经阴道早期妊娠减胎术安全性研究

目的探讨早孕期（≤12周）经阴道超声引导下多胎妊娠胚胎减灭术的方法、安全性及有效性。方法回顾性分析1999年6月~2008年7月我院早孕期经阴道减胎341例资料,应用超声引导胚胎抽吸减胎法181例,KCl心搏区注射减胎法160例。选择2007年7月~2008年7月新鲜周期体外受精-胚胎移植（IVF-ET）助孕后双活胎妊娠215例和单活胎妊娠538例作为对照,与减胎后双胎及单胎妊娠者妊娠结局进行比较。结果胚胎抽吸减胎法与KCl心搏区注射减胎法相比,减胎孕周小[（47.8±3.1）d vs.（60.0±8.0）d,t=-10.249,P=0.000],流产率低[7.7%（14/181）vs.15.6%（25/160）,χ2=5.220,P=0.022],两种方法术后未流产病例分娩孕周、早产率、新生儿出生体重及胎儿畸形率相似（P〉0.05）。三胎减为双胎妊娠者与IVF-ET术后双胎妊娠者比较,流产率高[13.7%（22/161）vs.7.0%（15/215）,χ2=4.641,P=0.031],新生儿出生体重低[（2479.4±579.9）g vs.（2594.2±464.6）g,t=-2.011,P=0.045],但早期流产率、分娩孕周及早产率差异均无显著性（P〉0.05）。双胎减为单胎妊娠者与IVF-ET术后单胎妊娠者比较,流产率、早期早产率差异均无显著性（P〉0.05）,双胎减胎组早产率增高[14.8%（9/61）vs.6.6%（31/472）,χ2=4.103,P=0.043],分娩孕周及新生儿体重显著低于IVF-ET术后单胎妊娠者[分娩孕周（38.0±2.1）周vs.（38.5±1.4）周,t=-2.662,P=0.008;新生儿体重（3042.9±527.6）g vs.（3340.8±478.9）g,t=-4.801,P=0.000],但减胎组平均分娩孕周也达到38周,新生儿平均体重〉3000 g。而双胎减为单胎组与未减胎双胎比较,分娩孕周明显增加[（38.0±2.1）周vs.（36.6±1.7）周,t=5.270,P=0.000],早产率明显降低[14.8%（9/61）vs.44.5%（89/200）,χ2=17.638,P=0.000],新生儿出生体重显著增高[（3042.9±527.6）g vs.（2594.2±464.6）g,t=6.744,P=0.000]。结论早孕期可以行经阴道抽吸减胎法者较须KCl胎心搏动区注射法减胎者结局更优,选择适当的减胎时机对保证手术安全至关重要。早孕期经阴道超声引导下多胎妊娠胚胎减灭术是多胎妊娠安全、有效的治疗手段,可改善母儿妊娠结局。

Safety of Transvaginal Multi-fetal Pregnancy Reduction in Early Stage

Objective To evaluate the safety and effectiveness of different methods of transvaginal pregnancy multi-fetal reduction for women with early pregnancy（≤ 12 weeks）. Methods Totally 341 consecutive cases of transvaginal early pregnancy multi-fetal reduction in Peking University Third Hospital Reproductive Medicine Center from June 1999 to July 2008 were reviewed.In the patients,embryo aspiration was employed in 181 cases,and fetal cardiac activity area injection of KCl in the other 160 patients.215 twin pregnancy cases and 538 single pregnancy cases during July 2007 to July 2008 after fresh cycle of IVF-ET were studied as a control group. Results Embryo aspiration group had shorter pregnancy period [（47.8±3.1） d vs.（60.0±8.0） d,t=-10.249,P=0.000] and lower miscarriage rate [7.7%（14/181） vs.15.6%（25/160）,χ2=5.220,P=0.022] than the fetal cardiac activity area injection group;but similar early abortion rate,delivery weeks,new born weights,premature delivery and fetal abnormality rates（P0.05）.Triplet to twin cases had higher abortion rate [13.7%（22/161） vs.7.0%（15/215）,χ2=4.641,P=0.031] and lower new born weights [（2479.4±579.9） g vs.（2594.2±464.6） g,t=-2.011,P=0.045] than post-IVF-ET twin pregnancy group,but early abortion rates,delivery weeks,and premature delivery rates between these two groups were similar（P0.05）.Although twin to singleton cases had higher premature delivery rate [14.8%（9/61） vs.6.6%（31/472）,χ2=4.103,P=0.043],lower new born weight [（3042.9±527.6） g vs.（3340.8±478.9） g,t=-4.801,P=0.000] and earlier delivery weeks [（38.0±2.1） w vs.（38.5±1.4） w,t=-2.662,P=0.008] than post-IVF-ET singleton cases,their average labor weeks were above 38 and new born weight was over 3000 g post reduction;the abortion and early premature delivery rates were similar between the two groups（P0.05）.Twin to singleton cases showed lower premature delivery rate [14.8%（9/61） vs.44.5%（89/200）,χ2=17.638,P=0.000],higher new born weights [（3042.9±527.6） g vs.（2594.2±464.6） g,t=6.744,P=0.000] and higher delivery weeks [（38.0±2.1） w vs.（36.6±1.7） w,t=5.270,P=0.000] than non-reduction twin cases.Conclusions For transvaginal early pregnancy fetal reduction,embryo aspiration,whenever applicable,had better pregnancy results than fetal cardiac activity area injection,and fetal reduction is a safe and effective way to cure multiple pregnancies.