Wilson R Douglas, Johnson Mark P, Crombleholme Timothy M, Flake Alan W, Hedrick Holly L, King Mary, Howell Lori J, Adzick N Scott
Department of Surgery, Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
Fetal Diagn Ther. 2003 Sep-Oct;18(5):314-20. doi: 10.1159/000071972.
To review the incidence of posthysterotomy chorioamniotic membrane separation and delivery outcome following open fetal surgery [myelomeningocele (MMC); cystic adenomatoid malformation (CCAM); congenital diaphragmatic hernia (CDH); sacrococcygeal teratoma (SCT)].
Retrospective review of a maternal population undergoing open fetal surgery at a single tertiary level program (1998-2001) following the initiation of close postoperative ultrasound follow-up for membrane separation. Onset of membrane separation was coded as not present (NP), immediate (<2 weeks) or delayed (>2 weeks) from day of surgery.
Fifty-three charts were reviewed: MMC 43, CCAM 7, CDH 1, and SCT 2. In the MMC group there were 26 NP, 8 immediate, and 9 delayed. Preterm labor occurred in 4 patients with only 2 having had membrane separation. Risk of membrane separation is increased for surgery done at less than 23 weeks gestation (p < 0.005). Delay from MMC surgery to delivery was 11.0, 9.8, 12.0 weeks for NP, immediate, and delay, respectively. In the MMC group, there were 3 neonatal deaths (NND) at 9, 9, and 21 days post surgery (PROM/PTL; chorioamnionitis, PROM/PTL, respectively). No membrane separation was present in the CCAM, CDH, and SCT cases.
(1) Membrane separation was significantly more likely to occur if surgery was performed prior to 23 weeks. (2) Membrane separation post hysterotomy (17/50 = 34%) may be associated with an increased risk of PROM but not delivery before 30 weeks gestation. (3) Delivery prior to 33 weeks gestation for MMC groups was 12/43 (28%) with 3 NND (7%). (4) Elective delivery at 36-37 weeks gestation was possible for 43% of the fetal surgery population.
回顾开放性胎儿手术（脊髓脊膜膨出[MMC]；先天性囊性腺瘤样畸形[CCAM]；先天性膈疝[CDH]；骶尾部畸胎瘤[SCT]）后子宫切开术后绒毛羊膜分离的发生率及分娩结局。
对在单一三级医疗中心项目（1998 - 2001年）接受开放性胎儿手术的产妇群体进行回顾性研究，术后开始密切超声随访绒毛膜分离情况。绒毛膜分离的起始情况编码为不存在（NP）、即刻（<2周）或延迟（>2周，自手术日起）。
共查阅53份病历：MMC 43例，CCAM 7例，CDH 1例，SCT 2例。在MMC组中，26例为NP，8例即刻，9例延迟。4例患者发生早产，其中仅2例有绒毛膜分离。妊娠小于23周时进行手术，绒毛膜分离风险增加（p < 0.005）。MMC手术至分娩的延迟时间，NP组为11.0周，即刻组为9.8周，延迟组为12.0周。在MMC组中，术后9天、9天和21天分别有3例新生儿死亡（NND）（分别为胎膜早破/早产；绒毛膜羊膜炎、胎膜早破/早产）。CCAM、CDH和SCT病例中未出现绒毛膜分离。
（1）如果在23周前进行手术，绒毛膜分离的可能性显著更高。（2）子宫切开术后绒毛膜分离（17/50 = 34%）可能与胎膜早破风险增加有关，但与妊娠30周前分娩无关。（3）MMC组妊娠33周前分娩率为12/43（28%），有3例新生儿死亡（7%）。（4）43%的胎儿手术人群可在妊娠36 - 37周进行择期分娩。
