1、Multiple Pregnancy多胎妊娠多胎妊娠 Definition(定义)一次妊娠宫腔内同时有两个或两个以上胎儿时称为多胎妊娠(Multiple Pregnancy)u妊娠期高血压疾病Hypertensive disorder in pregnancyu妊娠期肝内胆汁淤积症Intrahepatic cholestasis of pregnancyu贫血 Anemiau胎膜早破uPremature rupture of membranceu早产preterm laboru胎儿发育异常fetal development abnormal Twin Pregnancy双胎妊娠双胎妊娠?Cla
2、ssification(分类)(分类)Dizygotic (Fraternal)twin -70%双卵双胎双卵双胎(两个卵子分别受精形成的两个卵子分别受精形成的)Monozygotic (Identical)twin -30%单卵双胎(由一个受精卵分裂形成的)单卵双胎(由一个受精卵分裂形成的)Dizygotic Twin(双卵双胎)(双卵双胎)由两个受精卵同时发育而成。Monozygotic Twin(单卵双(单卵双胎)胎)一个受精卵发育出两个胚泡,分别植入。单卵双胎由于受精卵在早期发育阶段发生分裂的时间不同,形成下述4种类型。Monozygotic Twin I type双绒双绒毛膜毛膜双羊
3、双羊膜囊单卵双胎膜囊单卵双胎Dichorionic diamnionicSplit time:in fertilization 3 days 受精卵受精卵分裂时间分裂时间 :受精后:受精后3 3日内日内Incidence rate:30%发生率:发生率:30%30%This diagram shows 2chorion;2 amnia and 2 placenta.Monozygotic Twin type单绒单绒毛膜毛膜双羊双羊膜囊单卵双胎膜囊单卵双胎 Monochorionic diamnionicSplit time:fertilization 4-8 days 受精卵受精卵分裂时间分裂
4、时间 :受精后:受精后4-84-8天内天内Incidence rate:68%发生率:发生率:68%68%This diagram shows 1 chorion;2 amnia and a single placenta.Monozygotic Twin type单绒单绒毛膜毛膜单羊单羊膜囊单卵双胎膜囊单卵双胎 Monochorionic monoamnionic Split time:fertilization 9-13 days 受精卵受精卵分裂时间分裂时间 :受精后:受精后9-139-13天内天内Incidence rate:1-2%发生率:发生率:1-2%1-2%This diagr
5、am shows 1 chorion,1 amnia and a single placentaMonozygotic Twin type联体双胎联体双胎 Monochorionic monoamnionic conjoined twinsSplit time:after fertilization 13 days 受精卵受精卵分裂时间分裂时间 :受精:受精13 13天后天后Conjoined twins incidence rate:rare 联体双胎联体双胎 发生率:罕见发生率:罕见 双绒双羊双绒双羊 单绒双羊单绒双羊 单绒单羊单绒单羊 联体双胎联体双胎DIAGNOSIS(诊断)(诊断)H
6、istory(病史)(病史)Clinical Manifestation(临床表现)(临床表现)Obstetrics Examination(产科检查)(产科检查)Auxiliary Examination(辅助检查)(辅助检查)Familial (家族史)(家族史)Induction of ovulation (妊娠前曾促排卵)(妊娠前曾促排卵)Assisted reproductive technology ART (体外受精多个胚胎移植)(体外受精多个胚胎移植)History Clinical Manifestation more nausea and/or morning sickne
7、ss 恶心、呕吐等早孕反应加重恶心、呕吐等早孕反应加重 exaggerated other normal pregnancy symptoms 其他正常怀孕症状明显其他正常怀孕症状明显 abdominal enlargement 腹部增大腹部增大 unusual rate of weight gain 体重迅速增加体重迅速增加 swelling(edema)下肢水肿下肢水肿 breath difficulty 呼吸困难呼吸困难34 weeks pregnant with twins 36 weeks Singleton pregnant Obstetrics Examination 子宫大于停
8、经周数,腹部触及多个小肢体;不同部位可听到两个胎心。Auxiliary Examination Ultrasound Examination(超声检查)(超声检查)Fetal Heart Doppler Detector (胎心多普勒监测仪)(胎心多普勒监测仪)Ultrasound Examination (超声检查)(超声检查)Singleton pregnantUltrasound Examination8 weeks twins pregnancyUltrasound Examination11 weeks twinsUltrasound Examination绒毛膜性的判断 单绒毛膜性
9、双胎特有的双胎并发症较多。6-10周之间,宫腔内两个孕囊,为双绒毛膜双胎;仅见一个孕囊,单绒毛膜双胎可能性大。绒毛膜性的判断 11-13周之间,胎膜与胎盘插入点呈“双胎峰”的为双绒毛膜性 胎膜与胎盘插入点呈“T”字征的为单绒毛膜性病病 例例 1 1l 孕妇,25岁,G1P0,自然受孕。双胎妊娠,停经7周超声提示宫腔内可见2个胎囊,头臀长均符合停经孕周。l 妊娠24周系统排畸超声检查未见异常。l 定期孕检,妊娠31周,复查超声提示胎儿1:腹围26.9cm,羊水池最大深度6.5cm,脐动脉S/D2.5,预测体重1871g;胎儿2:腹围24.2cm,羊水池最大深度5.5cm,脐动脉S/D3.3,预测
10、体重1356g。l此次双胎妊娠是哪种类型此次双胎妊娠是哪种类型?会有几个胎盘?新生儿具有同样的基会有几个胎盘?新生儿具有同样的基因、性别、血型、外貌特征吗?因、性别、血型、外貌特征吗?Complication(并发症)(并发症)5P 2A U I Hypertensive Disorder in Pregnancy 3-4 times (妊娠期高血压疾病)(妊娠期高血压疾病)Anaemia 2.4 times (贫血)(贫血)Intrahepatic Cholestasis of Pregnancy 2 times (妊娠期肝内胆汁淤积症)(妊娠期肝内胆汁淤积症)Polyhydramnios
11、12%10 times (羊水过多)(羊水过多)Premature Rupture of Membrane 14%(胎膜早破)(胎膜早破)孕妇的并发症 Uterine Inertia(宫缩乏力(宫缩乏力 )Placental Abruption(胎盘早剥)(胎盘早剥)Postpartum Hemorrhage(产后出血)(产后出血)Abortion(流流 产产 )2-3 2-3 倍倍 1%;2%/10%孕妇的并发症 Premature Delivery(早早 产产)50%7-10倍倍 Prolapse or Twist of Umbilical Cord (脐带脱垂及脐带扭转)(脐带脱垂及脐带
12、扭转)Fetal Head Locking、Fetal Head Crash (胎头绞索及胎头碰撞)(胎头绞索及胎头碰撞)Fetal Malformation 2 倍倍 (胎胎 儿儿 畸畸 形形)围产儿并发症 1.Twin to Twin Transfusion Syndrom TTTS 双胎输血综合症双胎输血综合症 2.Selective IUGR 选择性胎儿生长受限选择性胎儿生长受限 3.Twin reversed arterial perfusion sequence,TRAPS 动脉反向灌注序列,一胎无心畸形动脉反向灌注序列,一胎无心畸形 4.单绒毛膜单羊膜囊双胎单绒毛膜单羊膜囊双胎
13、单绒毛膜双胎特有并发症单绒毛膜双胎特有并发症 1.Twin to Twin Transfusion Syndrom TTTS单绒单绒毛膜毛膜双羊双羊膜囊单卵双胎膜囊单卵双胎胎盘间的动静脉吻合支,胎盘间的动静脉吻合支,血液从动脉向静脉单向分流血液从动脉向静脉单向分流Donor Twin:(供血儿)(供血儿)smaller not enough blood oligohydramnios(羊水过少)(羊水过少)Recipient Twin:(受血儿)(受血儿)larger too much blood polyhydramnios(羊水过多)(羊水过多)Weight 20%HB 50g/L目前TT
14、TS的诊断依据 单绒毛膜性双胎 双胎出现羊水量改变,一胎羊水池最大深度大于cm,另一胎小于cm供血儿羊水过少,被挤压到子宫的一侧,“贴附儿stuck-twin”5期:仅羊水量异常 超声不能显示供血儿膀胱 出现脐动脉、静脉导管、脐静脉多普勒血流的异常 任何一胎水肿或腹腔积液 任何一胎死亡病病 例例 2 2l 孕妇,33岁,G3P0,试管双胎妊娠,停经13周行NT超声双胎儿大小分别为12+1周、12+6周。l 妊娠25+3周系统排畸超声检查提示胎儿1:腹围21.5cm,羊水10.5cm,S/D3.1,胎儿结构未见异常;胎儿2:腹围18.1cm,羊水1.9cm,S/D6.5,胎儿结构未见异常。l此次
15、双胎妊娠是哪种类型此次双胎妊娠是哪种类型?会有几个胎盘?新生儿具有同样的基会有几个胎盘?新生儿具有同样的基因、性别、血型、外貌特征吗?为什么会存在一个羊水多,一个因、性别、血型、外貌特征吗?为什么会存在一个羊水多,一个羊水少的现象?羊水少的现象?2.Selective IUGR(选择性胎儿生长受限)(选择性胎儿生长受限)FGR胎儿体重估测位于该孕周第10百分位以下,两胎儿体重相差25%以上。FGR胎儿通常存在脐带边缘附着或帆状插入 分为3型 仅出现体重相差 小胎儿出现脐血流舒张期缺失或倒置 小胎儿出现间歇性脐血流舒张期改变。3.Twin reversed arterial perfusion
16、sequence,TRAPS动脉反向灌注序列,一胎无心畸形动脉反向灌注序列,一胎无心畸形 双胎之一心脏缺如、残留或无功能。最显著的特征是结构正常的泵血胎通过一根胎盘表面动脉-动脉吻合向寄生的无心胎供血。如不治疗,正常胎儿可发生心力衰竭而死亡。Management Nutrition(营养)(营养)Prevent Preterm Labor:Adequate Rest(充分休息)(充分休息)Detect and Treat the Complications(防治并发症)(防治并发症)Ultrasound Monitor(超声监测)(超声监测)During Pregnancy Fetal Mal
17、formation(胎儿畸形)(胎儿畸形)Complated Acute Polyhydramnios(合并急性羊水过多)(合并急性羊水过多)Critical Complication(严重的并发症)(严重的并发症)Placenta Function Decrement(胎盘功能减退)(胎盘功能减退)Pregnancy Termination Indication (终止妊娠的指征)(终止妊娠的指征)双胎妊娠分娩的时限有特殊考虑吗?双胎妊娠分娩的时限有特殊考虑吗?若无并发症,单绒毛膜性双胎的分娩孕周一般为35-37周,通常不超过37周。严重的sIUGR和TTTS在严密监护下可期待至32-34周
18、分娩。单绒毛膜单羊膜囊的分娩孕周亦为32-34周 双胎临产时应想到的问题:阴道分娩?剖宫分娩?额外的准备?多胎妊娠的分娩途径有特殊考虑吗?多胎妊娠的分娩途径有特殊考虑吗?Vaginal Delivery(经阴道分娩)(经阴道分娩)Caesarean Section(剖宫产)(剖宫产)Prevent Postpartum Hemorrhage(预防产后出血)(预防产后出血)Delivery Pattern(分娩方式)(分娩方式)Vaginal Delivery(经阴道分娩)(经阴道分娩)F1Cephalic Presentation F2 Cephalic Presentation (F1 F1
19、 头先露,头先露,F2F2头先露)头先露)F1Cephalic Presentation F2 Breech Presentation (F1 F1 头先露,头先露,F2F2臀先露)臀先露)F1Cephalic Presentation F2 Transverse Presentation(F1 F1 头先露,头先露,F2F2横位)横位)分娩期处理 产妇足够的摄入量和睡眠 观察胎心 注意宫缩和产程进展 第二产程必要时会阴后-侧切开 第一胎儿娩出后,胎盘侧脐带必须夹紧,以防第二胎儿失血。助手应在腹部固定第二胎儿为纵产式,观察胎心、宫缩及阴道流血情况,阴道检查了解胎位及排除脐带脱垂,静脉滴注低浓度
20、缩宫素,促宫缩。发现脐带脱垂、胎盘早剥,立即产钳助产或臀牵引。如第二胎儿为肩先露,必要时第二胎儿剖宫分娩。Caesarean Section Indication剖宫产指征剖宫产指征 Shoulder presentation、Breech presentation(肩、臀先露)(肩、臀先露)Uterine Inertia Prolonged labor(宫缩乏力、产程延长)(宫缩乏力、产程延长)Fetal Distress(胎儿窘迫)(胎儿窘迫)Conjoined Twins 26 weeks(联体双胎孕周(联体双胎孕周 2626周周 Critical Complication(严重并发症)
21、(严重并发症)Selective laser ablation of the placental anastomotic vessels Fetal Distress 胎儿窘迫胎儿窘迫 Definition:胎儿在子宫内因急性或慢性缺胎儿在子宫内因急性或慢性缺氧危及其健康和生命的综合症状。氧危及其健康和生命的综合症状。Hypoxia(缺氧)(缺氧)Morbidity :2.7%-38.5%Classification:acute fetal distress chronic fetal distressEtiology (病(病 因)因)Acute Fetal Distress Chronic
22、 Fetal Distress 母体血液含氧量不足、母胎间血氧运输及交换障碍、胎儿自身因素异常Fetal Acute Hypoxia 母胎间血氧运输及交换障碍或脐带血循环障碍 前置胎盘、胎盘早剥 脐带异常:绕颈、真节、扭转、脱垂、血肿、过短、附着于胎膜 母体休克(心源性、感染性、失血性)缩宫素使用不当 孕妇应用麻醉药,抑制呼吸Fetal Chronic Distress 母体血液含氧量不足:先心病、慢肺不全 哮喘发作、重度贫血 子宫胎盘血管硬化、狭窄、梗死,绒毛间隙血液灌注不足:妊娠期高血压疾病、慢性肾炎、糖尿病、过期妊娠 胎儿严重的心血管疾病、呼吸系统疾病Pathophysiology(病理
23、生理)(病理生理)mild hypoxia轻度缺氧轻度缺氧CO2 respiratory acidosis呼吸性酸中毒呼吸性酸中毒sympathetic nerve exciting神经兴奋症状神经兴奋症状BPHRsevere hypoxia 严重缺氧严重缺氧vagus nerve exciting迷走神经兴奋迷走神经兴奋HR meconium in themeconium in the amnionic fluid amnionic fluid(羊水胎粪污染)(羊水胎粪污染)PH 肛门括约肌松驰肛门括约肌松驰混合性酸中毒混合性酸中毒Diagnosis -Acute Fetal Distres
24、s(急性胎儿窘迫)(急性胎儿窘迫)Abnormal fetal heart rate (胎心率异常)(胎心率异常)Meconium in the amnionic fluid(羊水粪染)(羊水粪染)Abnormal fetal movement (胎动异常)(胎动异常)Acidosis (酸中毒)(酸中毒)Diagnosis -Acute Fetal Distress Abnormal fetal heart rate(胎心率异常)(胎心率异常)变异减速:胎心率减速与宫缩无固定关系,下降迅速且下降幅度大,持续时间长短不一,回复也迅速。晚期减速:胎心率下降的起点多在宫缩波峰处开始,胎心率减速曲线
25、的波谷落后于宫缩曲线的波峰,幅度小于50bpm,回复时间长Diagnosis -Acute Fetal Distress Meconium in the amnionic fluid(羊水胎粪污染)(羊水胎粪污染)Meconium-Stained Amniotic Fluid (MSAF)(羊水粪染分度)(羊水粪染分度):light green(浅绿色)(浅绿色):dark green or yellowgreen(深绿色、黄绿色)(深绿色、黄绿色):brown madder(棕黄色、稠厚)(棕黄色、稠厚)Diagnosis -Acute Fetal Distress Abnormal fet
26、al movement(胎动异常)(胎动异常)Diagnosis -Acute Fetal Distress Acidosis(酸中毒)(酸中毒)PH 7.20 PO2 60mmHgManagement -Acute Fetal Distress Left lateral position oxygen uptake(左侧卧位,增加供氧)(左侧卧位,增加供氧)Cause remove(病因治疗)(病因治疗)Acute termination(尽快终止妊娠)(尽快终止妊娠)Diagnosis -Chronic Fetal Distress Fetal movement decrease or d
27、isappear(胎动减少或消失)(胎动减少或消失)Abnormal fetal heart monitor (胎心监测异常)(胎心监测异常)Abnormal fetal Manning score (胎儿生物物理评分异常)(胎儿生物物理评分异常)Placenta function decrease (胎盘功能低下)(胎盘功能低下)Meconium in the amnionic fluid (羊水胎粪污染)(羊水胎粪污染)Diagnosis -Chronic Fetal Distress Fetal movement decrease or disappear 10 times/12h 胎动
28、减少或消失胎动减少或消失 Diagnosis -Chronic Fetal Distress Abnormal fetal monitor (胎心监测异常)(胎心监测异常)Non-stress test(NST)-non-reactive(NST无反应型)无反应型)Baseline varibility 5bpm (基线变异频率(基线变异频率180 or 10min)NST有反应型:20-40分钟,3次以上胎动时伴有胎心率加速大于15bpm,持续时间大于15秒Diagnosis -Chronic Fetal Distress Abnormal fetal Manning score (胎儿生物
29、物理评分异常)(胎儿生物物理评分异常)6分 可疑 4分 缺氧 Diagnosis -Chronic Fetal Distress Placenta function decrease(胎盘功能低下)(胎盘功能低下)urine E310mg 雌三醇 urine E3/CRE 10 雌三醇/肌酐 SP1 100mg/L 妊娠特异糖蛋白 HPL 4mg/L 胎盘生乳素 Blood E340nmol/LDiagnosis -Chronic Fetal Distress Meconium in the amnionic fluid(羊水粪染)(羊水粪染)Management -Chronic Fetal
30、 Distress Left lateral position oxygen uptake Cause management Expectant management Termination Premature Rupture of MembranePROM 胎膜早破胎膜早破 Definition:before onset of labor(临产前)(临产前)Classification:PROM of term:10%(足月胎膜早破(足月胎膜早破37周)周)Preterm PROM:2.0-3.5%(足月前胎膜早破(足月前胎膜早破20-37周)周)Etiology Genital tract
31、 Infection(感染)(感染)Nutrition(营养因素)(营养因素)Cytokine(细胞因子)(细胞因子)Amnio cavity pressure (羊膜腔压力升高)(羊膜腔压力升高)Fetal membrane stress asymmetry(胎膜压力不均)(胎膜压力不均)Cervical loose(宫颈内口松弛)(宫颈内口松弛)Diagnosis Clinical Manifestation Clinical Manifestation 突感较多液体从阴道流出,无腹痛等其他产兆。阴道窥器检查见阴道后穹窿有羊水积聚或有羊水自宫口流出,即可确诊胎膜早破。羊膜腔感染,阴道流液有
32、臭味,发热、母胎心率增快、子宫压痛、白细胞计数增多、C-反应蛋白与降钙素原(procalcitonin,PCT)升高。Auxiliary ExaminationPH 6.5 (正常阴道PH4.5-5.5)Smear (阴道液涂片检查)(阴道液涂片检查)Amnioscope (羊膜镜检查)(羊膜镜检查)Fetal fibronectin(fFN)0.05mg/L (分泌物胎儿纤连蛋白)(分泌物胎儿纤连蛋白)Insulin-like growth factor binding protein IGFBP-1Amnio cavity infection detect (羊膜腔感染检查)(羊膜腔感染检
33、查)C-reactive protein 8mg/L (母血(母血C反应蛋白)反应蛋白)Blood test (母血常规)母血常规)amniotic fluid bacteria culture (羊水细菌培养)(羊水细菌培养)amniotic fluid smear exam Bacteria(+)WBC30/ml(羊水涂片)(羊水涂片)amniotic fluid IL-6 7.9ng/ml 降钙素原分为3级(正常:0.5ng/ml;轻度升高:0.5-2ng/ml;明显升高:10ng/ml),轻度升高表示感染存在。羊膜镜检查 Ultrasound 绒毛膜羊膜炎 母体心动过速100次/分 胎
34、儿心动过速160次/分 母体发热38 子宫激惹 羊水恶臭 母体白细胞计数15109/L 中性粒细胞90%Maternal risksInfection Placental abruptionPostpartum hemorrhageFever and endomyometritis in puerperium Fetal risksPreterm birth Respiratory distress syndromContractures and deformitiesInfection Prolapse of umbilical cordPregnancy Termination Gesta
35、tional age24week pregnancy termination Gestationla age35week wait for labor Infection pregnancy termination Pregnancy Termination Vaginal delivery:35week,fetal lung mature,cervical ripe Caesarean section:Fetal presentation abnormal Cervical unripe Obvious amniotic cavity infection Fetal distressMana
36、gement expectant management(期待治疗)(期待治疗)28-35 week;no infection;羊水池深度3cmCommunication (医患沟通)(医患沟通)-Informed consent Lie in bed (卧床)(卧床)-deep venous thrombosis Monitor fetal condition (胎儿状况胎儿状况)Antibiotic (12h)(预防感染治疗)(预防感染治疗)Inhibit uterine contraction (抑制宫缩)(抑制宫缩)Promote lung mature (促胎肺成熟)(促胎肺成熟)Improve oligoamnios (纠正羊水过少纠正羊水过少)betamethasone(倍地米松)(倍地米松)12mg iv qd(12h)2times dexamethasone(地塞米松)(地塞米松)10mg iv qd 2times 6mg im 12h 4times 每天生命体征检查:体温、心率、宫缩、阴道流液形状 每周2次血常规及C反应蛋白 每天胎动计数 每天2次胎心监测 每周2次Manning评分 每周1次超声检测