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中华产科急救电子杂志 ›› 2022, Vol. 11 ›› Issue (04) : 246 -249. doi: 10.3877/cma.j.issn.2095-3259.2022.04.011

病例报告

双胎输血综合征三例
邱瑜1, 于威威1, 陈秋芳1, 张雪芹1,()   
  1. 1. 361000 厦门大学附属妇女儿童医院产科
  • 收稿日期:2022-05-08 出版日期:2022-11-18
  • 通信作者: 张雪芹
  • 基金资助:
    厦门市医疗卫生重点项目(3502Z20191102); 厦门市科学技术局项目(3502Z20214ZD1231)

Twin twin transfusion syndrome: 3 case reports

Yu Qiu1, Weiwei Yu1, Qiufang Chen1   

  • Received:2022-05-08 Published:2022-11-18
引用本文:

邱瑜, 于威威, 陈秋芳, 张雪芹. 双胎输血综合征三例[J]. 中华产科急救电子杂志, 2022, 11(04): 246-249.

Yu Qiu, Weiwei Yu, Qiufang Chen. Twin twin transfusion syndrome: 3 case reports[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2022, 11(04): 246-249.

例1 患者22岁,孕3产2,因"孕26+5周,双胎输血综合征(twin-twin transfusion syndrome,TTTS)Ⅱ期胎儿镜激光电凝术(fetoscopic laser photocoagulation,FLP)术后18 d"于2021年6月29日收入厦门大学附属妇女儿童医院产科。患者于2018年、2019年分别足月妊娠阴道分娩一女婴,目前体健。本次妊娠为自然受孕,末次月经2020年12月26日,孕12+5周超声提示单绒毛膜双羊膜囊(monochorionic diamniotic,MCDA)双胎,颈项透明层厚度分别为1.5 mm和1.3 mm。2021年6月5日(孕23+1周)超声检查发现两胎儿羊水最大暗区垂直径(amniotic fluid volume,AFV)分别为12.1 cm和2.0 cm,两胎儿膀胱可见,"受血儿胎儿肺动脉交叉起源,轻度三尖瓣返流,脐带边缘插入",宫颈管长度3.0 cm。考虑"MCDA、TTTS Ⅰ期",于6月8日(孕23+4周)行羊水减量术,过程顺利,术后每日复查超声,了解胎儿生长发育、羊水情况和胎儿大脑中动脉收缩期峰值速度(middle cerebral artery peak systolic velocity, MCA-PSV),6月11日超声提示"受血儿AFV 11.9 cm,膀胱明显充盈,供血儿羊水过少,膀胱未显示",病情进展为TTTSⅡ期,6月12日(孕24+1周)行胎儿镜FLP。术后予预防感染、抑制宫缩处理,6月15日查两胎儿羊水量正常,"原受血儿AFV 7.4 cm,原供血儿AFV 4.1 cm,两胎儿膀胱均显示"。术后1周和2周超声连续监测,提示两胎儿生长趋势良好,羊水正常,血流评估无异常。但6月19日(孕25+1周)超声提示:"羊膜松弛,原受血儿羊膜塌陷,需注意随访有无肢体缠绕等羊膜束带相关表现";6月29日(孕26+5周)复查超声,提示两胎"羊膜分隔带不连续、局部回声中断"(图1),且患者自觉腹部紧绷感,考虑"晚期先兆流产、MCDA双胎、TTTSⅡ期、羊水减量术后、FLP术后18 d,遂收入院。予倍他米松12 mg促胎肺成熟,1次/d,共2 d;利托君0.3 mg/min、阿托西班2~8 ml/h静脉滴注序贯抑制宫缩,低分子肝素4250 U(1次/d)皮下注射预防血栓治疗。7月9日(孕28+1周)因宫缩不能抑制行子宫下段剖宫产术,术中见一个胎盘,其间羊膜分隔可见小裂口,直径约1.0 cm;脐带2根,未见明显脐带缠绕打结。大子Apgar评分6-9-9分,体重1170 g;小子Apgar评分5-9-9分,体重1045 g。两早产儿均转新生儿科治疗,心脏彩色多普勒超声(彩超)及头颅磁共振成像(magnetic resonance imaging, MRI)检查示:小子双侧基底节区可见片状高信号,室旁见长T1、T2信号,心脏无明显异常;大子头颅MRI及心脏超声均无明显异常,予对症支持治疗,60 d后病情稳定出院。术后及出院诊断:(1)妊3产4;(2)孕28+1周,MCDA双胎,TTTS Ⅱ期;(3)剖宫产分娩,早产;(4)羊水减量术后,FLP术后;(5)双早产儿;(6)极低出生体重儿。之后儿童保健门诊随诊5次,目前大小子生长发育尚理想。

图1 双胎输血综合征患者孕26+5周超声查羊膜分隔情况图像。羊膜分隔带不连续,局部回声中断(箭头所示)
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