双胎输血综合征的预测和诊治进展

doi:10.12280/gjfckx.20200676

摘要/Abstract

摘要：

双胎输血综合征（twin-twin transfusion syndrome,TTTS）是单绒毛膜双胎妊娠的严重并发症,目前仍然是全球胎儿医学专家面临的主要挑战。在TTTS中,通过共享胎盘中的血管吻合支进行双胎输血会引起严重的血液动力学失衡,是导致围生儿死亡的主要原因。所有单绒毛膜双胎中约有10%~15%会发展成TTTS,通常发生在妊娠的第16周至第26周之间,其严重程度取决于胎盘内血管吻合支的类型、数量和直径。产前管理的进步使胎儿围生期、生存期延长,新生儿并发症（包括脑损伤和神经发育障碍）的发生率降低。因此,早期发现,严密监测,选择合适的治疗方法,尽量延长孕周,选择合适的时机终止妊娠,是降低单绒毛膜双胎围生儿死亡的关键。对TTTS的发病机制、预测、诊断和治疗进行综合分析,同时对激光治疗后存活胎儿远期神经系统损伤问题进行总结。

关键词: 双胎输血综合征, 预测, 诊断, 治疗, 预后

Abstract:

Twin-twin transfusion syndrome (TTTS) is a devastating complication of monochorionic twin pregnancy and remains a major challenge for worldwide fetal medicine specialists. In TTTS, intertwin transfusion through vascular anastomoses in the shared placenta leads to severe hemodynamic imbalance, which is the main cause of perinatal death. Approximately 10%-15% of all monochorionic diamniotic twins develop TTTS, which usually occurs between the 16th and 26th weeks of gestation, the type, number and diameter of these anastomoses determines the risk profile. Advancements in antenatal management have led to increased perinatal survival and a decreased incidence of neonatal complications, including brain injury and neurodevelopmental impairment. Therefore, early detection, rigorous monitoring, appropriate treatment, prolonging the gestational age as much as possible, and choosing the right time to terminate the pregnancy are the keys to reducing the mortality of monochorionic diamniotic twin. This article analyzes the pathogenesis, prediction, diagnosis and treatment of TTTS, and summarizes the long-term nervous system damage of surviving fetuses after laser treatment.

Key words: Fetofetal transfusion, Forecasting, Diagnosis, Therapy, Prognosis

赵晓敏, 陈叙. 双胎输血综合征的预测和诊治进展[J]. 国际妇产科学杂志, 2021, 48(2): 186-190.

ZHAO Xiao-min, CHEN Xu. Progress of Prediction, Diagnosis and Treatment in Twin-Twin Transfusion Syndrome[J]. Journal of International Obstetrics and Gynecology, 2021, 48(2): 186-190.

图/表 1

参考文献 26

[1]	Mackie FL, Whittle R, Morris RK, et al. First-trimester ultrasound measurements and maternal serum biomarkers as prognostic factors in monochorionic twins: a cohort study[J]. Diagn Progn Res, 2019,3:9. doi: 10.1186/s41512-019-0054-9. doi: 10.1186/s41512-019-0054-9 pmid: 31093579
[2]	Murgano D, Khalil A, Prefumo F, et al. Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis[J]. Ultrasound Obstet Gynecol, 2020,55(3):310-317. doi: 10.1002/uog.21889. doi: 10.1002/uog.21889 pmid: 31595578
[3]	Bamberg C, Hecher K. Update on twin-to-twin transfusion syndrome[J]. Best Pract Res Clin Obstet Gynaecol, 2019,58:55-65. doi: 10.1016/j.bpobgyn.2018.12.011. pmid: 30850326
[4]	Spruijt MS, Lopriore E, J Steggerda S, et al. Twin-twin transfusion syndrome in the era of fetoscopic laser surgery: antenatal management, neonatal outcome and beyond[J]. Expert Rev Hematol, 2020,13(3):259-267. doi: 10.1080/17474086.2020.1720643. pmid: 31971028
[5]	刘娜. 双胎输血综合征的诊治及争议[J]. 实用妇产科杂志, 2019,35(10):743-746. doi: 1003-6946(2019)10-0743-04.
[6]	Mogra R, Saaid R, Tooher J, et al. Prospective Validation of First-Trimester Ultrasound Characteristics as Predictive Tools for Twin-Twin Transfusion Syndrome and Selective Intrauterine Growth Restriction in Monochorionic Diamniotic Twin Pregnancies[J]. Fetal Diagn Ther, 2020,47(4):321-327. doi: 10.1159/000504049. pmid: 31962341
[7]	Stagnati V, Zanardini C, Fichera A, et al. Early prediction of twin-to-twin transfusion syndrome: systematic review and meta-analysis[J]. Ultrasound Obstet Gynecol, 2017,49(5):573-582. doi: 10.1002/uog.15989. doi: 10.1002/uog.15989 pmid: 27270878
[8]	Sinkovskaya E, Klassen A, Abuhamad A. A novel systematic approach to the evaluation of the fetal venous system[J]. Semin Fetal Neonatal Med, 2013,18(5):269-278. doi: 10.1016/j.siny.2013.05.009. doi: 10.1016/j.siny.2013.05.009 pmid: 23800449
[9]	徐琦, 周祎, 黄冬冰, 等. 早孕期超声指标对复杂性单绒毛膜双胎的预测价值[J]. 中华围产医学杂志, 2019,22(10):744-750. doi: 10.3760/cma.j.issn.1007-9408.2019.10.011.
[10]	Chon AH, Chavira ER, Wilson ML, et al. The impact of laser surgery on angiogenic and anti-angiogenic factors in twin-twin transfusion syndrome: a prospective study[J]. J Matern Fetal Neonatal Med, 2018,31(8):1085-1091. doi: 10.1080/14767058.2017.1309020. pmid: 28320252
[11]	Taylor MJ, Denbow ML, Tanawattanacharoen S, et al. Doppler detection of arterio-arterial anastomoses in monochorionic twins: feasibility and clinical application[J]. Hum Reprod, 2000,15(7):1632-1636. doi: 10.1093/humrep/15.7.1632. doi: 10.1093/humrep/15.7.1632 pmid: 10875880
[12]	Khalil A. Modified diagnostic criteria for twin-to-twin transfusion syndrome prior to 18 weeks’ gestation: time to change?[J]. Ultrasound Obstet Gynecol, 2017,49(6):804-805. doi: 10.1002/uog.17443. doi: 10.1002/uog.17443 pmid: 28236371
[13]	Dekoninck P, Deprest J, Lewi P, et al. Gestational age-specific reference ranges for amniotic fluid assessment in monochorionic diamniotic twin pregnancies[J]. Ultrasound Obstet Gynecol, 2013,41(6):649-652. doi: 10.1002/uog.12387. doi: 10.1002/uog.12387 pmid: 23292907
[14]	Gijtenbeek M, Haak MC, Huberts T, et al. Perioperative fetal hemodynamic changes in twin-twin transfusion syndrome and neurodevelopmental outcome at two years of age[J]. Prenat Diagn, 2020,40(7):825-830. doi: 10.1002/pd.5690. pmid: 32266998
[15]	Wohlmuth C, Gardiner HM, Diehl W, et al. Fetal cardiovascular hemodynamics in twin-twin transfusion syndrome[J]. Acta Obstet Gynecol Scand, 2016,95(6):664-671. doi: 10.1111/aogs.12871. doi: 10.1111/aogs.12871 pmid: 26872246
[16]	Society for Maternal-Fetal Medicine, Simpson LL. Twin-twin transfusion syndrome[J]. Am J Obstet Gynecol, 2013,208(1):3-18. doi: 10.1016/j.ajog.2012.10.880. pmid: 23200164
[17]	Van Der Veeken L, Couck I, Van Der Merwe J, et al. Laser for twin-to-twin transfusion syndrome: a guide for endoscopic surgeons[J]. Facts Views Vis Obgyn, 2019,11(3):197-205. pmid: 32082525
[18]	国家卫生和计划生育委员会公益性行业科研专项《常见高危胎儿诊治技术标准及规范的建立与优化》项目组. 胎儿镜激光治疗双胎输血综合征技术规范(2017)[J]. 中国实用妇科与产科杂志, 2017,33(7):695-698. doi: 10.19538/j.fk2017070109.
[19]	D′Antonio F, Benlioglu C, et al. Perinatal outcomes of twin pregnancies affected by early twin-twin transfusion syndrome: A systematic review and meta-analysis[J]. Acta Obstet Gynecol Scand, 2020,99(9):1121-1134. doi: 10.1111/aogs.13840. doi: 10.1111/aogs.13840 pmid: 32162305
[20]	Melhem NZ, Ledermann S, Rees L. Chronic kidney disease following twin-to-twin transfusion syndrome-long-term outcomes[J]. Pediatr Nephrol, 2019,34(5):883-888. doi: 10.1007/s00467-018-4176-z. pmid: 30560449
[21]	Bolch C, Fahey M, Reddihough D, et al. Twin-to-twin transfusion syndrome neurodevelopmental follow-up study (neurodevelopmental outcomes for children whose twin-to-twin transfusion syndrome was treated with placental laser photocoagulation)[J]. BMC Pediatr, 2018,18(1):256. doi: 10.1186/s12887-018-1230-8. doi: 10.1186/s12887-018-1230-8 pmid: 30068295
[22]	Cho H, Shin SH, Jun JK, et al. Early postnatal cardiac manifestations are associated with perinatal brain injury in preterm infants with twin to twin transfusion syndrome[J]. Sci Rep, 2019,9(1):18505. doi: 10.1038/s41598-019-54951-z. doi: 10.1038/s41598-019-54951-z pmid: 31811241
[23]	Bolch C, Fahey M, Reddihough D, et al. Twin-to-twin transfusion syndrome neurodevelopmental follow-up study (neurodevelopmental outcomes for children whose twin-to-twin transfusion syndrome was treated with placental laser photocoagulation)[J]. BMC Pediatr, 2018,18(1):256. doi: 10.1186/s12887-018-1230-8. doi: 10.1186/s12887-018-1230-8 pmid: 30068295
[24]	Brandsma FL, Spruijt MS, Rijken M, et al. Behavioural outcome in twin-twin transfusion syndrome survivors treated with laser surgery[J]. Arch Dis Child Fetal Neonatal Ed, 2020,105(3):304-309. doi: 10.1136/archdischild-2019-317080. doi: 10.1136/archdischild-2019-317080 pmid: 31371433
[25]	van Klink JM, Koopman HM, Rijken M, et al. Long-Term Neurodevelopmental Outcome in Survivors of Twin-to-Twin Transfusion Syndrome[J]. Twin Res Hum Genet, 2016,19(3):255-261. doi: 10.1017/thg.2016.26. doi: 10.1017/thg.2016.26 pmid: 27137794
[26]	Spruijt MS, Lopriore E, Tan R, et al. Long-Term Neurodevelopmental Outcome in Twin-to-Twin Transfusion Syndrome: Is there still Room for Improvement?[J]. J Clin Med, 2019,8(8):1226. doi: 10.3390/jcm8081226.

分期	指标
Ⅰ期	羊水过少,羊水过多,供血儿膀胱可见
Ⅱ期	羊水过少,羊水过多,供血儿膀胱不可见,多普勒超声扫描正常
Ⅲ期	羊水过少,羊水过多,供血儿膀胱不可见,多普勒超声扫描异常（脐动脉舒张末期血流消失或反向,静脉导管血流反向,脐静脉搏动血流）
Ⅳ期	一胎或双胎胎儿水肿
Ⅴ期	一胎或双胎胎儿死亡

分期	指标
Ⅰ期	羊水过少,羊水过多,供血儿膀胱可见
Ⅱ期	羊水过少,羊水过多,供血儿膀胱不可见,多普勒超声扫描正常
Ⅲ期	羊水过少,羊水过多,供血儿膀胱不可见,多普勒超声扫描异常（脐动脉舒张末期血流消失或反向,静脉导管血流反向,脐静脉搏动血流）
Ⅳ期	一胎或双胎胎儿水肿
Ⅴ期	一胎或双胎胎儿死亡