中国实用妇科与产科杂志

中国实用妇科与产科杂志

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单绒毛膜双胎选择性生长受限对新生儿脑损伤的影响

李静芝，张海鹰，蔡丽平，王立晶，袁红   

  1. 作者单位：暨南大学第二临床医学院妇产科，广东 深圳518020
  • 出版日期:2015-04-02 发布日期:2015-04-02
  • 通讯作者: 张海鹰
  • 基金资助:

    深圳市科技计划项目（201202122）

The influence of selective intrauterine growth restriction on neonatal cerebral injury in monochorionic twins.

LI Jing-zhi，ZHANG Hai-ying，CAI Li-ping，WANG Li-jing，YUAN Hong.   

  1. Department of Obstetrics and Gynecology，the Second School of Clinical Medicine of Jinan University，Shenzhen 518020，China
  • Online:2015-04-02 Published:2015-04-02

摘要：

目的 探讨单绒毛膜（MC）双胎选择性宫内生长受限（sIUGR）对新生儿脑损伤的影响。方法 选择2011年6月至2014年6月在暨南大学第二临床医学院就诊及分娩的MC双胎并发sIUGR产妇24例和其48个胎儿为sIUGR组，并根据sIUGR儿脐动脉血流多普勒波形将sIUGR组分为Ⅰ型11例、Ⅱ型10例、Ⅲ型3例。同期分娩的无并发症的MC双胎56例及其112个胎儿作为对照组。分娩后对新生儿头颅进行超声检查，如有异常则用超声或磁共振（MRI）复查，随访至新生儿出院。新生儿脑损伤分为轻度：（1）Ⅰ级、Ⅱ级脑室内出血（IVH）。（2）豆状核纹状体血管病变和（或）室管膜下假性囊肿。重度：（1）Ⅲ、Ⅳ级IVH。（2）Ⅱ级以上脑室周围白质软化囊性变（PVL）。（3）脑穿通囊肿和（或）脑室扩张。分析比较两组及3种类型sIUGR之间新生儿结局及脑损伤情况。结果 sIUGR组新生儿重度、轻度脑损伤率分别为（4.2%，1/24）、（10.4%，5/48）；而对照组分别为（0）、（6.2%，7/112）。两组比较差异无统计学意义（P>0.05）。轻度脑损伤12例，均无明显神经系统受损的临床表现，其中11例（11/12，91.7%）复查头颅超声或MRI见影像学明显改善。sIUGR组Ⅰ型有2例（2/22，9.1%）而Ⅱ、Ⅲ型有3例（3/26，11.5%）出现轻度脑损伤，两两比较，差异无统计学意义（P>0.05）。sIUGR组Ⅱ、Ⅲ型各有1例新生儿死亡及1例重度脑损伤，而sIUGRⅠ型无新生儿死亡和重度脑损伤，虽然差异未达统计学意义（P>0.05），但其预后明显差于Ⅰ型。结论 与正常MC双胎比较， MC双胎并发sIUGR新生儿近期重度、轻度脑损伤发生率无明显差异，且绝大多数轻度脑损伤为暂时性，但sIUGRⅡ、Ⅲ型比Ⅰ型预后差，应加强监测，适时终止妊娠。

关键词: 双胎, 单绒毛膜, 选择性宫内生长受限, 脑损伤

Abstract:

Abstract： Objective To investigate the influence of selective intrauterine growth restriction (sIUGR) on neonatal cerebral injury in monochorionic twins. Methods From June 2011 to June 2014，clinical data of 24 cases of monochorionic diamniotic (MCDA) twins (48 fetuses) with sIUGR and 56 cases of normal MCDA twins (112 fetuses) in the same period were analyzed retrospectively in the Second School of Clinical Medicine of Jinan University. Fetuses with sIUGR were classified into three types according to umbilical artery Doppler flow pattern. There were 11 cases of typeⅠ, 10 cases of typeⅡand 3 cases of type Ⅲ. The babies received transcranial ultrasound scan after delivery and serial ultrasound scanning or MRI were followed-up in cases with abnormal ultrasound findings. Mild cerebral injury was defined with one of the following abnormal cranial scan finding:intraventricular hemorrhage(IVH) gradeⅠor gradeⅡ,lenticulostiate vasculopathy and/or subependymal pseudocysts; while severe cerebral injury was defined as IVH grade Ⅲ or grade Ⅳ, cystic periventricular hemorrhage (PVL) gradeⅡor higher, porencephalic cysts and/or ventricular dilatation. The neonatal cerebral injury was compared between sIUGR and normal MCDA twins, and among the three types of sIUGR as well. Results The incidence of severe and mild cerebral injury was 4.2% (1/24) and 10.4% (5/48) respectively in the sIUGR group, and 0% and 6.3% (7/112) in the control group. No significant difference was noted between the proportion of cerebral injury in two groups (P>0.05). No clinical neural injury symptom was observed in the 12 cases with minor brain scan anomalies. All of them received serial brain scan or MRI. Except for one case without ultrasonography change, the majority (11/12, 91.6%) of cases had signs of improvement. There were 2 cases (2/22，9.1%) in typeⅠand 3 cases (3/26，11.5%) in typeⅡ/Ⅲ presenting minor cerebral injury (P>0.05). There was one neonatal death and one major brain injury in typeⅡ/Ⅲ, while there was no neonatal death and severe brain injury in typeⅠ(P>0.05). Conclusion The incidence of severe and mild cerebral injury rate in neonates of MC twins with sIUGR is not significantly different from that in normal MCDA twins. The majority of cases with mild cerebral injury is transient. But the prognosis is poorer in typeⅡ/Ⅲ. Therefore, it is important to monitor the intrauterine situation closely and terminate the pregnancy in time in order to decrease the rate of major cerebral injury.

Key words: twins, monochorionic, selective intrauterine growth restriction, cerebral injury

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