妊娠中晚期双绒毛膜双胎一胎胎死宫内妊娠结局分析

目的：比较双绒毛膜双胎之一选择性减胎与自发一胎胎死宫内（single intrauterine fetal death,SIUFD）的围生期结局,并比较不同减胎孕周对围生期结局的影响,探讨选择性减胎的临床应用。方法：纳入2011年1月—2019年12月在南京大学医学院附属鼓楼医院产科终止妊娠的55例双胎之一胎死宫内或行选择性减胎术将双胎减至单胎的临床资料,根据减胎或死胎原因将其分为选择性减胎组（39例）和自发SIUFD组（16例）,回顾性分析比较其围生期结局。结果：55例患者总妊娠丢失率为9.1%（5例流产）,活产率为90.9%。选择性减胎组的减胎/死胎孕周明显低于自发SIUFD组,总体终止孕周、活产率明显高于自发SIUFD组,而剖宫产率、流产率则低于自发SIUFD组,差异均有统计学意义（P<0.05）。2组的早产率、足月产率、存活儿出生体质量、出生体质量百分位数、新生儿健康出院率、新生儿重症监护病房（neonatal intensive care unit,NICU）入住率比较,差异均无统计学意义（均P>0.05）。根据选择性减胎的孕周将选择性减胎组再分为减胎孕周≤20周组（24例）和减胎孕周>20周组（15例）,2组新生儿出生体质量百分位数比较差异无统计学意义（P>0.05）,但与减胎孕周>20周组比较,减胎孕周≤20周组的早产率低、足月产率高,存活儿出生体质量更高,差异有统计学意义（均P<0.05）。结论：双胎妊娠发生SIUFD后会对存活儿围生期结局产生不良影响,对于有减胎指征者,选择性减胎有利于提高存活儿围生期的活产率及改善新生儿结局,对多胎妊娠的围生期结局有益。

Perinatal Outcomes of Single Intrauterine Fetal Death in Dichorionic Twins

Objective: Compare the perinatal outcomes of selective feticide and spontaneous single intrauterine fetal death (SIUFD) in dichorionic twins, analyze the perinatal outcomes of feticide at different gestational ages, and explore the clinical application of selective feticide. Methods: Fifty-five dichorionic twins pregnancies that underwent selective feticide or spontaneous SIUFD to reduce the twins to single birth in the Obstetrics Department of Nanjing Drum Tower Hospital from January 2011 to December 2019 were retrospectively reviewed. The patients were grouped into selective feticide group (N=39) and spontaneous SIUFD group (N=16) according to reasons of fetal reduction, analysis and compare the perinatal outcome retrospectively. Results: The total pregnancy loss rate in 55 cases was 9.1% (5 miscarriages), and the live birth rate was 90.9%. The gestational age of fetal reduction-death in the selective feticide group was significantly lower than that in the spontaneous SIUFD group, the overall termination of pregnancy gestational age and live birth rate in the selective feticide group were significantly higher than that of the spontaneous SIUFD group, and the cesarean section rate, miscarriage rate were lower than the spontaneous SIUFD group (P<0.05). There was no significant difference in preterm birth rate, full-term birth rate, birth weight, birth weight percentile, healthy discharge rate of newborns, and NICU rate of newborns between the two groups (both P>0.05). According to the gestational age at which selective feticide, there were 24 cases of gestational reduction of ≤20 weeks, and 15 cases of gestational reduction of >20 weeks. There was no statistically significant difference in the birth weight percentile between the two groups (P>0.05), but the preterm birth rate was lower, the full-term birth rate of gestational weeks was higher, and the birth weight of newborns was larger of ≤20 weeks (both P<0.05). Conclusions: Twin pregnancy will cause adverse effects on the perinatal outcomes of surviving children after SIUFD. For those with indications of fetal reduction, selective feticide in early pregnancy may be beneficial for the perinatal outcome in multiple pregnancy, improve the live birth rate of surviving children.