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Abstract：
To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies.
This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks\' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling.
We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival.
Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks\' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling.
We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival.
Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
摘要：
报告根据新的Delphi共识定义诊断的选择性胎儿生长受限（sFGR）的结局。并确定潜在的生存预测因子，在一组未经选择的单绒毛膜双胎妊娠中。
这是一项从头三个月开始的单绒毛膜双胎妊娠的回顾性研究，在妊娠16、20或30周被诊断为sFGR。根据新的Delphi共识标准将sFGR定义为在一个双胞胎中存在估计的胎儿体重（EFW）<3百分位数或以下至少两个：一个双胞胎的EFW<10百分位数，一对双胞胎的腹围<10百分位数，EFW不一致≥25％或较小双胞胎的脐动脉搏动指数>95百分位。主要结果是总体生存率（直到出生后第28天）和失去一个或两个双胞胎的风险。我们使用单和多变量广义估计方程模型进一步确定了可能的生存预测因子。
我们分析了675例怀孕,其中177例（26%）在16、20或30周时被诊断为sFGR。总体生存率为313/354（88％）和146/177（82％）怀孕导致两个双胞胎的存活。一对双胞胎的存活率为21/177（12％），而两个双胞胎的存活率为10/177（6％）。随后的双胎贫血-红细胞增多症序列（TAPS）在6/177（3％）妊娠中发生，双胎-双胎输血综合征（TTTS）在17/177（10％）妊娠中发生。所有TAPS胎儿都存活了下来。随后发展为TTTS的sFGR妊娠的存活率为65％（22/34），与分离的sFGR（没有随后的TAPS或TTTS）的91％（279/308）相比（P<0.001）。大多数sFGR病例为I型（110/177（62％）），生存率为96％（212/220），与II型（P<0.001）和III型（P=0.006）sFGR患者的生存率分别为55％（12/22）和83％（55/66）。大多数sFGR妊娠（130/177（73％））在16或20周（早期发作）首次诊断。存活率为85%(221/260)，与首次诊断为30周（迟发）的sFGR的98％（92/94）生存率相比（P=0.04）。在28/177（16％）sFGR病例中，至少有一个双胞胎存在重大异常。在这些怀孕中，生存率为39/56（70％），无异常者为274/298（92%）（P<0.001）。TTTS的后续发展(比值比(OR)，0.18（95%CI，0.06-0.52）），II型sFGR(或,0.06（95%CI，0.02-0.24））和III型sFGR（OR，0.21(95%CI，0.07-0.60))和至少一个双胞胎中存在重大异常(OR，0.12（95%CI，0.04-0.34）），但不是第一次诊断时的胎龄，与生存率下降独立相关。
在单绒毛膜双胎妊娠中，分离的sFGR与90％的存活率相关。TTTS的后续发展，较小的双胞胎的脐动脉中缺乏或逆转的舒张末期血流以及主要异常的存在对sFGR的存活率产生不利影响。版权所有©2020ISUOG。由JohnWiley&SonsLtd.发布.
这是一项从头三个月开始的单绒毛膜双胎妊娠的回顾性研究，在妊娠16、20或30周被诊断为sFGR。根据新的Delphi共识标准将sFGR定义为在一个双胞胎中存在估计的胎儿体重（EFW）<3百分位数或以下至少两个：一个双胞胎的EFW<10百分位数，一对双胞胎的腹围<10百分位数，EFW不一致≥25％或较小双胞胎的脐动脉搏动指数>95百分位。主要结果是总体生存率（直到出生后第28天）和失去一个或两个双胞胎的风险。我们使用单和多变量广义估计方程模型进一步确定了可能的生存预测因子。
我们分析了675例怀孕,其中177例（26%）在16、20或30周时被诊断为sFGR。总体生存率为313/354（88％）和146/177（82％）怀孕导致两个双胞胎的存活。一对双胞胎的存活率为21/177（12％），而两个双胞胎的存活率为10/177（6％）。随后的双胎贫血-红细胞增多症序列（TAPS）在6/177（3％）妊娠中发生，双胎-双胎输血综合征（TTTS）在17/177（10％）妊娠中发生。所有TAPS胎儿都存活了下来。随后发展为TTTS的sFGR妊娠的存活率为65％（22/34），与分离的sFGR（没有随后的TAPS或TTTS）的91％（279/308）相比（P<0.001）。大多数sFGR病例为I型（110/177（62％）），生存率为96％（212/220），与II型（P<0.001）和III型（P=0.006）sFGR患者的生存率分别为55％（12/22）和83％（55/66）。大多数sFGR妊娠（130/177（73％））在16或20周（早期发作）首次诊断。存活率为85%(221/260)，与首次诊断为30周（迟发）的sFGR的98％（92/94）生存率相比（P=0.04）。在28/177（16％）sFGR病例中，至少有一个双胞胎存在重大异常。在这些怀孕中，生存率为39/56（70％），无异常者为274/298（92%）（P<0.001）。TTTS的后续发展(比值比(OR)，0.18（95%CI，0.06-0.52）），II型sFGR(或,0.06（95%CI，0.02-0.24））和III型sFGR（OR，0.21(95%CI，0.07-0.60))和至少一个双胞胎中存在重大异常(OR，0.12（95%CI，0.04-0.34）），但不是第一次诊断时的胎龄，与生存率下降独立相关。
在单绒毛膜双胎妊娠中，分离的sFGR与90％的存活率相关。TTTS的后续发展，较小的双胞胎的脐动脉中缺乏或逆转的舒张末期血流以及主要异常的存在对sFGR的存活率产生不利影响。版权所有©2020ISUOG。由JohnWiley&SonsLtd.发布.
