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Abstract：
Fetal growth restriction is associated with an increased risk for adverse neonatal outcomes. The Hadlock singleton growth reference is widely used to determine the estimated fetal weight percentile for both twin and singleton gestations. The Eunice Kennedy Shriver National Institute of Child Health and Human Development\'s twin-specific growth reference accounts for the different growth trajectory that twins follow during gestation. There is a lack of research comparing these different growth references in their ability to identify fetal growth restriction that is associated with adverse neonatal outcomes in dichorionic twin gestations.
This study aimed to compare a twin-specific growth reference (the Eunice Kennedy Shriver National Institute of Child Health and Human Development\'s twin-specific growth reference) and a singleton growth reference (Hadlock) in their ability to identify fetal growth restriction associated with adverse neonatal outcomes in dichorionic twin gestations.
This was a retrospective cohort study of dichorionic twin gestations at ≥32 weeks\' gestation delivered at a single institution between 2004 and 2019 with the serial growth ultrasounds and neonatal outcomes data available for analysis. Using their last growth ultrasound before delivery, twins were classified into the following 3 categories: fetal growth restriction according to both the Hadlock and Eunice Kennedy Shriver National Institute of Child Health and Human Development references, fetal growth restriction according to the Hadlock reference only, and no fetal growth restriction according to either reference, with fetal growth restriction defined as an estimated fetal weight of <10th percentile for gestational age. Multivariable generalized linear mixed models were used to assess the adverse neonatal outcomes via pair-wise comparisons between the groups, with a random-effects component to account for twin-pair correlations.
A total of 1460 dichorionic twin infants were included with 8.1% (n=118) of cases classified as fetal growth restricted by both the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Hadlock references, 8.8% (n=129) of cases classified as fetal growth restricted by the Hadlock reference only, and 83.1% (n=1213) of cases classified as no fetal growth restriction by either reference. Compared with twins with no fetal growth restriction by either reference, twins with fetal growth restriction by both references were more likely to experience mild (adjusted odds ratio, 2.38; confidence interval, 1.38-4.13) or severe (adjusted odds ratio, 2.82; confidence interval, 1.16-6.88) composite neonatal morbidity. Compared with twins with fetal growth restriction according to the Hadlock reference only, twins with fetal growth restriction according to both references were more likely to experience mild (adjusted odds ratio, 2.03; confidence interval, 1.00-4.14) but not severe (adjusted odds ratio, 3.70; confidence interval, 0.72-18.90) composite neonatal morbidity. Composite neonatal morbidity was not different between twins with fetal growth restriction according to the Hadlock reference only and those with no fetal growth restriction by either growth reference.
The Eunice Kennedy Shriver National Institute of Child Health and Human Development\'s twin-specific growth reference better identifies the risk for adverse neonatal outcomes in dichorionic twin gestations diagnosed with fetal growth restriction. The use of the Hadlock singleton growth reference more than doubles the number of dichorionic twins identified with fetal growth restriction who seem to be at a low-risk for neonatal morbidity, leading to unnecessary maternal anxiety, increased antenatal testing, and possibly iatrogenic preterm delivery.
This study aimed to compare a twin-specific growth reference (the Eunice Kennedy Shriver National Institute of Child Health and Human Development\'s twin-specific growth reference) and a singleton growth reference (Hadlock) in their ability to identify fetal growth restriction associated with adverse neonatal outcomes in dichorionic twin gestations.
This was a retrospective cohort study of dichorionic twin gestations at ≥32 weeks\' gestation delivered at a single institution between 2004 and 2019 with the serial growth ultrasounds and neonatal outcomes data available for analysis. Using their last growth ultrasound before delivery, twins were classified into the following 3 categories: fetal growth restriction according to both the Hadlock and Eunice Kennedy Shriver National Institute of Child Health and Human Development references, fetal growth restriction according to the Hadlock reference only, and no fetal growth restriction according to either reference, with fetal growth restriction defined as an estimated fetal weight of <10th percentile for gestational age. Multivariable generalized linear mixed models were used to assess the adverse neonatal outcomes via pair-wise comparisons between the groups, with a random-effects component to account for twin-pair correlations.
A total of 1460 dichorionic twin infants were included with 8.1% (n=118) of cases classified as fetal growth restricted by both the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Hadlock references, 8.8% (n=129) of cases classified as fetal growth restricted by the Hadlock reference only, and 83.1% (n=1213) of cases classified as no fetal growth restriction by either reference. Compared with twins with no fetal growth restriction by either reference, twins with fetal growth restriction by both references were more likely to experience mild (adjusted odds ratio, 2.38; confidence interval, 1.38-4.13) or severe (adjusted odds ratio, 2.82; confidence interval, 1.16-6.88) composite neonatal morbidity. Compared with twins with fetal growth restriction according to the Hadlock reference only, twins with fetal growth restriction according to both references were more likely to experience mild (adjusted odds ratio, 2.03; confidence interval, 1.00-4.14) but not severe (adjusted odds ratio, 3.70; confidence interval, 0.72-18.90) composite neonatal morbidity. Composite neonatal morbidity was not different between twins with fetal growth restriction according to the Hadlock reference only and those with no fetal growth restriction by either growth reference.
The Eunice Kennedy Shriver National Institute of Child Health and Human Development\'s twin-specific growth reference better identifies the risk for adverse neonatal outcomes in dichorionic twin gestations diagnosed with fetal growth restriction. The use of the Hadlock singleton growth reference more than doubles the number of dichorionic twins identified with fetal growth restriction who seem to be at a low-risk for neonatal morbidity, leading to unnecessary maternal anxiety, increased antenatal testing, and possibly iatrogenic preterm delivery.
摘要：
胎儿生长受限与不良新生儿结局的风险增加有关。Hadlock单胎生长参考广泛用于确定双胎和单胎妊娠的估计胎儿体重百分位数。EuniceKennedyShriver国家儿童健康与人类发展研究所的双胞胎特定生长参考说明了双胞胎在妊娠期间遵循的不同生长轨迹。缺乏研究比较这些不同的生长参考，以确定与双胎妊娠不良新生儿结局相关的胎儿生长受限。
本研究旨在比较双胎特异性生长参考（EuniceKennedyShriver国家儿童健康与人类发展研究所的双胎特异性生长参考）和单胎生长参考（Hadlock）的能力，以确定与二胎双胎妊娠不良新生儿结局相关的胎儿生长限制。
这是一项回顾性队列研究，研究了2004年至2019年期间在单一机构分娩的≥32周的双胎双胎妊娠，并提供了系列生长超声和新生儿结局数据可供分析。使用分娩前的最后一次生长超声，根据Hadlock和EuniceKennedyShriver国家儿童健康与人类发育研究所的参考文献，将双胞胎分为以下3类：胎儿生长受限。胎儿生长受限仅根据Hadlock参考，根据任一参考文献，没有胎儿生长受限，胎儿生长受限定义为估计胎儿体重<胎龄的10百分位数。使用多变量广义线性混合模型通过组间的成对比较来评估不良新生儿结局。具有随机效应分量来解释双对相关性。
共有1460名二胎双胞胎婴儿，其中8.1％（n=118）的病例被EuniceKennedyShriver国家儿童健康与人类发育研究所和Hadlock参考文献归类为胎儿生长受限，8.8%（n=129）的病例被归类为胎儿生长限制仅由Hadlock参考，83.1%(n=1213)的病例被任一参考分类为无胎儿生长受限。与没有胎儿生长限制的双胞胎相比，两个参考文献的胎儿生长受限的双胞胎更有可能经历轻度(调整后的优势比，2.38；置信区间，1.38-4.13)或严重(调整后的赔率比，2.82；置信区间，1.16-6.88）复合新生儿发病率。与仅根据Hadlock参考文献的胎儿生长受限的双胞胎相比，根据两个参考文献，胎儿生长受限的双胞胎更有可能经历轻度(调整后的优势比，2.03；置信区间，1.00-4.14)但不严重(调整后的赔率比，3.70；置信区间，0.72-18.90）复合新生儿发病率。仅根据Hadlock参考有胎儿生长受限的双胞胎与根据任一生长参考没有胎儿生长受限的双胞胎之间的复合新生儿发病率没有差异。
EuniceKennedyShriver国家儿童健康和人类发育研究所的双胎特异性生长参考更好地识别了诊断为胎儿生长受限的双胎妊娠中不良新生儿结局的风险。使用Hadlock单例生长参考使确定为胎儿生长受限的二胎双胞胎的数量增加一倍以上，这些双胞胎似乎对新生儿发病的风险较低。导致不必要的母性焦虑，增加产前检查，可能还有医源性早产.
本研究旨在比较双胎特异性生长参考（EuniceKennedyShriver国家儿童健康与人类发展研究所的双胎特异性生长参考）和单胎生长参考（Hadlock）的能力，以确定与二胎双胎妊娠不良新生儿结局相关的胎儿生长限制。
这是一项回顾性队列研究，研究了2004年至2019年期间在单一机构分娩的≥32周的双胎双胎妊娠，并提供了系列生长超声和新生儿结局数据可供分析。使用分娩前的最后一次生长超声，根据Hadlock和EuniceKennedyShriver国家儿童健康与人类发育研究所的参考文献，将双胞胎分为以下3类：胎儿生长受限。胎儿生长受限仅根据Hadlock参考，根据任一参考文献，没有胎儿生长受限，胎儿生长受限定义为估计胎儿体重<胎龄的10百分位数。使用多变量广义线性混合模型通过组间的成对比较来评估不良新生儿结局。具有随机效应分量来解释双对相关性。
共有1460名二胎双胞胎婴儿，其中8.1％（n=118）的病例被EuniceKennedyShriver国家儿童健康与人类发育研究所和Hadlock参考文献归类为胎儿生长受限，8.8%（n=129）的病例被归类为胎儿生长限制仅由Hadlock参考，83.1%(n=1213)的病例被任一参考分类为无胎儿生长受限。与没有胎儿生长限制的双胞胎相比，两个参考文献的胎儿生长受限的双胞胎更有可能经历轻度(调整后的优势比，2.38；置信区间，1.38-4.13)或严重(调整后的赔率比，2.82；置信区间，1.16-6.88）复合新生儿发病率。与仅根据Hadlock参考文献的胎儿生长受限的双胞胎相比，根据两个参考文献，胎儿生长受限的双胞胎更有可能经历轻度(调整后的优势比，2.03；置信区间，1.00-4.14)但不严重(调整后的赔率比，3.70；置信区间，0.72-18.90）复合新生儿发病率。仅根据Hadlock参考有胎儿生长受限的双胞胎与根据任一生长参考没有胎儿生长受限的双胞胎之间的复合新生儿发病率没有差异。
EuniceKennedyShriver国家儿童健康和人类发育研究所的双胎特异性生长参考更好地识别了诊断为胎儿生长受限的双胎妊娠中不良新生儿结局的风险。使用Hadlock单例生长参考使确定为胎儿生长受限的二胎双胞胎的数量增加一倍以上，这些双胞胎似乎对新生儿发病的风险较低。导致不必要的母性焦虑，增加产前检查，可能还有医源性早产.
