单绒毛膜单羊膜囊双胎脐带缠绕1例并文献复习

张菲菲　陈莉　杨延冬

[关键词] 单绒毛膜单羊膜囊;双胎妊娠;脐带缠绕;分娩时机

[中图分类号] R714.4          [文献标识码] C          [文章编号] 1673-9701（2021）27-0161-03

Monochorionic monoamniotic twin umbilical cord tangling of a case report and literature review

ZHANG Feifei   CHEN Li   YANG Yandong

Department of Obstetrics and Gynecology，Binzhou Medical University Hospital， Binzhou   256600， China

[Abstract] This paper reports a pregnant woman who had irregular prenatal examination during pregnancy and first visited our hospital at 32+1 weeks of gestation due to threatened preterm labor.She was diagnosed with monochorionic twins， combined with the results of ultrasound in the first trimester. After admission， magnesium sulfate was given to protect the fetal nervous system and induce lung maturation. Cesarean section was performed at 32+3 weeks of gestation. Two live infants were delivered during surgery. The eldest daughter was delivered in the head position， weighing 1600 g，and Apgar score at 1 minute was 9 （skin color was reduced by 1 point）.The second daughter was delivered in the hip position，weighing 1700 g， with an Apgar score of 7 at 1 minute（breath，muscle tension，skin color reduced by one point each） and nine at 5 minutes（skin color reduced by one point）. There was no diaphragm between the two fetuses.After delivery of the placenta， the two umbilical cords were about 50/55 cm in length.The root of the umbilical cord was immediately adjacent. The two umbilical cords were complex entangled for six circles showed proper knots of the umbilical cord，and the operation was uneventful. The patient recovered well after surgery and was discharged as scheduled. The eldest daughter was hospitalized in pediatrics because of DIC secondary to neonatal necrotizing enterocolitis. After 36 days of hospitalization，family members gave up treatment.The second daughter was discharged after hospitalizing in the Department of Pediatrics for 52 days.The growth and development were good.

[Key words] Monochorionic monoamniotic sac; Twin pregnancy; Umbilical cord entanglement; Timing of delivery

雙胎妊娠因母胎并发症多，属高危妊娠范畴。其类型可分为双绒毛膜双羊膜囊双胎、双绒毛膜单羊膜囊双胎、单绒毛膜单羊膜囊双胎。其中，单绒毛膜单羊膜囊（Monochorionic monoamniotic，MCMA）双胎胎儿及新生儿病率和死亡率更高，为极高危妊娠，因受精卵在受精后第9～13天分裂，两个胎儿共存于一个羊膜腔内，共用一个胎盘。两胎儿之间无胎膜分隔，脐带相互缠绕及打结发生率高，存在发生宫内意外的风险，孕期需加强监测。目前普遍认为，MCMA双胎妊娠终止妊娠的孕周以孕32～34周为宜。本文报道1例孕妇，孕期未规律产检，结合孕早期超声结果，诊断为单绒双胎，于孕32+3周行剖宫产，术中发现两根脐带复杂缠绕并呈脐带真结，两早产儿出生后反应好，其一于出生后36 d因早产儿并发症最终放弃治疗。对于不合并结构异常和并发症的MCMA双胎，临床处理应结合孕妇及胎儿宫内状况，在遵循治疗原则的基础上，制定个体化的治疗方案。

1 临床资料

患者，33岁，孕1产0，末次月经2020年1月25日，自然受孕，自述孕1个多月于外院行彩超检查提示一个宫内妊娠囊，两个原始心管搏动。孕期未规律产检，孕32+1周因自觉下腹紧缩感首次就诊于我院。入院查体：宫高：35 cm，腹围：117 cm，头先露，胎心：150/146次/min，宫口未开，宫颈管长2 cm，先露高，骨盆内外测量正常。入院彩超（2020年9月6日）：宫内双活胎，头位/头位。一胎儿：双顶径8.1 cm，股骨长6.0 cm，脐动脉S/D 2.3，羊水较大前后径：4.8 cm;另一胎儿：双顶径7.9 cm，股骨长6.1 cm，脐动脉S/D 2.9，羊水较大前后径：4.5 cm。……