双胎反向动脉灌注序列征胎儿产前超声评估及特征分析

doi:10.12280/gjszjk.20210098

摘要/Abstract

摘要：

目的: 分析双胎反向动脉灌注序列征（twin reversed arterial perfusion sequence,TRAPS）胎儿产前超声的特征。方法: 回顾性分析2015年1月—2020年10月共22例在西北妇女儿童医院诊断的TRAPS超声特征。结果: ①无心无头13例,表现为无心无头,无上肢,仅可见部分脊柱及下肢;有头无心5例,可见颅骨光环或者部分颅骨,可见四肢及脊柱,未见心脏结构,此5例胎儿颅内结构均显示不清或仅见部分脑组织,或有严重颅内畸形;不定形无心4例,均表现为不规则组织的团状回声,未见明显身体结构。②无心胎儿伴随畸形：无心胎儿共有13例伴发全身水肿,其中有4例表现为淋巴水囊瘤;有1例表现为全前脑,1例表现为全前脑合并脐膨出,2例脑积水。③泵血胎儿中22例均可见胎心,其中仅1例表现为颈项透明层增厚、双肺回声增强、心内结构紊乱、心胸比增大、胸腔积液、单脐动脉,1例帆状胎盘,1例心包积液,其余胎儿均未见明显异常。④彩色多普勒显示,无心畸形胎儿均可在脐部测及脐动脉血流反向进入腹腔。结论: 产前超声是诊断TRAPS的重要手段,尽早确诊有助于判断预后,为治疗方式的选择提供可靠的依据。

关键词: 超声检查,产前, 先天畸形, 双胎疾病, 超声检查, 多普勒,彩色, 产前诊断

Abstract:

Objective: To analyze the characteristics of prenatal ultrasound in twin reversed arterial perfusion sequence (TRAPS). Methods: Retrospective analysis was conducted on the ultrasound characteristics of 22 cases of the TRAPS diagnosed in Northwest Women and Children′s Hospital from January 2015 to October 2020. Results: ①There were 13 cases with no heart and no head, no upper limbs, only part of the spine and lower limbs; 5 cases with head but no heart. The halo of skull or part of skull, limbs and spine could be seen, and no heart structure was found. The intracranial structure of these 5 cases was not clear or only part of brain tissue could be seen, or there were serious intracranial malformations; 4 cases of unformed centerlessness showed mass echo of irregular tissue without body structure. ②Concomitant deformity of centerlessness: 13 cases were accompanied with systemic edema, including 4 cases of lymphangioma, 1 case of whole forebrain, 1 case of forebrain with omphalocele, and 2 cases of hydrocephalus. ③In those pump twins, all of 22 cases were found fetal heart by ultrasound. One case showed NT thickening, double lung echo enhancement, intracardiac structural disorder, cardiothoracic ratio increase, pleural effusion, single umbilical artery, and no obvious abnormality was found in other fetuses. ④Color Doppler showed that those fetuses without cardiac malformation had the umbilical artery blood flow and reverse into the abdominal cavity. Conclusions: Prenatal ultrasound is an important means of TRAPS diagnosis. The early diagnosis of TRAPS is helpful to determine the prognosis and provide reliable reference for the treatment.

Key words: Ultrasonography, prenatal, Congenital abnormalities, Diseases in twins, Ultrasonography, Doppler, color, Prenatal diagnosis

周浔丹, 张文婷, 安培莉, 杨芳, 侯小霞. 双胎反向动脉灌注序列征胎儿产前超声评估及特征分析[J]. 国际生殖健康/计划生育, 2021, 40(5): 372-376.

ZHOU Xun-dan, ZHANG Wen-ting, AN Pei-li, YANG Fang, HOU Xiao-xia. Prenatal Ultrasound Evaluation and Characteristic Analysis of Twin Reverse Arterial Perfusion Sequence[J]. Journal of International Reproductive Health/Family Planning, 2021, 40(5): 372-376.

图/表 6

表1 22例TRAPS临床资料

病例	年龄	孕周	绒毛膜性	TRAPS分型	合并其他畸形
病例1	26	22	单绒双羊	无心无头型	全身水肿
病例2	26	27	单绒单羊	无心无头型	泵血儿单脐动脉,受血儿全身水肿
病例3	25	18⁺⁶	单绒单羊	不定形无心型	无
病例4	27	15	单绒双羊	无心无头型	受血儿淋巴水囊瘤
病例5	31	20	单绒单羊	无心无头型	无
病例6	29	12	单绒单羊	无心无头型	受血儿全身水肿
病例7	32	16	单绒双羊	有头无心型	泵血儿左心室强光点,受血儿脑积水,淋巴水囊瘤
病例8	24	21⁺⁵	单绒双羊	不定形无心型	受血儿全身水肿
病例9	28	16	单绒单羊	无心无头型	受血儿全身水肿
病例10	27	19	单卵三胎	有头无心型	受血儿全前脑,全身水肿,腹腔积液
病例11	33	27	单绒双羊	有头无心型	泵血儿球拍胎盘,受血儿脑积水
病例12	34	30	单绒双羊	不定形无心型	无
病例13	31	11	单绒双羊	无心无头型	受血儿淋巴水囊瘤
病例14	30	17	单绒双羊	无心无头型	受血儿全身水肿
病例15	37	12	单绒双羊	无心无头型	泵血儿NT增厚、双肺回声增强、心内结构紊乱、心胸比增大、胸腔积液、单脐动脉;受血儿全身水肿
病例16	30	13	单绒双羊	有头无心型	受血儿全前脑、脐膨出
病例17	30	13	单绒双羊	不定形无心型	泵血儿单脐动脉,羊水过少;受血儿淋巴水囊瘤
病例18	24	16	单卵三胎	有头无心型	受血儿全前脑,左上肢桡骨短小,左手呈“钩状”
病例19	23	14	单绒双羊	无心无头型	无
病例20	23	22	单绒双羊	无心无头型	泵血儿心包积液
病例21	25	26	单绒双羊	无心无头型	受血儿全身水肿
病例22	37	20	单绒双羊	无心无头型	泵血儿帆状胎盘

图1 病例13无心无头型胎儿超声图注：图A显示宫腔右侧胎儿未见胎儿头颅及心脏结构,胎儿背部呈水肿状,呈“铠甲征”,内为无回声区;图B彩色多普勒显示该胎儿腹腔段脐动脉内可见反向血流入腹。

图2 病例15无心无头型胎儿超声图注：图A胎儿1双肺回声增强,心脏增大,结构模糊,胸腔内可见前后径3 mm无回声区;图B胎儿2膀胱横切面显示：仅见一根脐动脉,右侧可见,左侧缺如;图C胎儿2未见正常头颅结构显示,仅见躯干及部分四肢结构,躯干皮肤下方可见无回声区;图D 胎儿2频谱及彩色多普勒血流显示,其内可见一支纤细血流信号,血流方向与另一胎儿脐血流相反。

图3 病例16有头无心型胎儿超声图注：图A显示胎儿2可见较小的颅骨光环,颅内可见单一脑室,双侧丘脑似融合;图B可见双下肢,未见双上肢,胸腔内未见明显的心脏回声,频谱及彩色多普勒血流显示,可见一搏动性血管,经脐孔进入胎儿体内,与胎儿1搏动频率相同;胎儿2全身皮肤水肿,头颈部水肿明显。

图4 病例18有头无心型合并全前脑超声图注：图A显示胎儿颅部及躯干皮肤周围可见低至无回声环绕;图B显示该胎儿颅内可见大片状无回声,脑中线结构消失,丘脑融合;图C显示未见明显心脏结构回声;频谱及彩色多普勒血流显示该胎儿腹腔段脐动脉内可见反向血流入腹,为脐动脉反向血流频谱;图D显示双下肢及右上肢发育尚可,左上肢桡骨短小,左手呈“钩状”。

图5 病例12不定形无心型胎儿超声图注：图A 显示宫内未见另一正常胎儿影像,宫腔底部内见一强弱不均回声肿块,似可见骨样组织回声,未见正常心脏结构及腹腔脏器回声,未见明确心脏搏动;图B彩色多普勒显示：其胎体内可见一粗大血管回声,可见其搏动,其脐带入胎盘血流频谱与正常胎儿脐带入胎盘血流频谱反向。

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