一些研究已经评估了与激光TTTS后胎儿死亡相关的术前和手术因素,然而,这些发现并不完全是决定性的。
本研究旨在确定胎儿镜下激光光凝术治疗双胞胎对双胞胎输血综合征后单个胎儿死亡(受体和供体双胞胎)的危险因素。
我们搜索了PubMed,Scopus,从数据库成立到2020年6月,系统地和WebofScience。我们对研究单绒毛膜妊娠合并双胎至双胎输血综合征的胎儿镜激光光凝后胎儿死亡(供体和/或受体)的危险因素进行了系统评价。最初,我们调查了2012年至2020年在我们的2个高容量胎儿中心接受胎儿镜激光光凝治疗的双胎-双胎输血综合征女性队列,以确定供者死亡和受者死亡的危险因素.此外,为了更好地描述这些因素,我们对文献进行了系统回顾.在符合进入标准的研究中,对多种术前因素和手术因素进行了分析.随机效应模型用于汇集标准化的平均差或比值比以及相应的95%置信区间。使用I2值评估异质性。
在最终分析中,共有514例使用胎儿镜激光光凝治疗的双胎对双胎输血综合征。在逻辑回归之后,供体死亡的重要因素是选择性胎儿生长受限(比值比,1.9;95%置信区间,1.3-2.8;P=.001)和脐动脉血流,供体舒张末期速度缺失或逆转(比值比,2.06;95%置信区间,1.2-3.4;P=.004)。与受体死亡相关的一个重要因素是受体静脉导管中不存在或逆转了a波(比值比,1.74;95%置信区间,1.07-3.13;P=.04)。包括来自23项研究和我们当前队列的数据。分析了4892例使用胎儿镜激光光凝治疗的双胎对双胎输血综合征的妊娠,以了解供体死亡的危险因素。分析了4594例有双胎对双胎输血综合征的妊娠患者的受者死亡情况.在研究中,供者死亡的总发生率为10.9%~35.8%,受者死亡的总发生率为7.3%~24.5%.供者死亡的重要危险因素是双胎估计胎儿体重不一致>25%(比值比,1.86;95%置信区间,1.44-2.4;I2,0.0%),选择性胎儿生长受限(比值比,1.78;95%置信区间,1.4-2.27;I2,0.0%),双胎对双胎输血综合征III期(优势比,2.18;95%置信区间,1.53-3.12;I2,0.0%),供体的脐动脉血流缺乏或舒张末期速度逆转(比值比,2.31;95%置信区间,1.9-2.8;I2,23.7%),供体静脉导管中不存在或逆转a波(赔率比,1.83;95%置信区间,1.45-2.3;I2,0.0%),和动脉吻合的存在(比值比,2.81;95%置信区间,1.35-5.85;I2,90.7%)。序贯选择性凝血对供体死亡具有保护作用(优势比,0.31;95%置信区间,0.16-0.58;I2,0.0%)。受者死亡的重要危险因素是双胞胎对双胞胎输血综合征IV期(优势比,2.18;95%置信区间,1.01-4.6;I2,16.5%),接受者的脐动脉血流缺乏或舒张末期速度逆转(比值比,2.68;95%置信区间,1.91-3.74;I2,0.0%),接受者静脉导管中不存在或逆转a波(赔率比,2.37;95%置信区间,1.55-3.64;I2,60.2%),和大脑中动脉峰值收缩期速度>1.5倍的中位数(比值比,3.06;95%置信区间,1.36-6.88;I2,0.0%)。
在接受激光治疗的双胎对双胎输血综合征的妇女中,以多普勒研究异常为代表的异常血流模式和低胎儿体重与单胎死亡有关。尽管顺序选择性凝血可以防止供体死亡,动脉吻合的存在与供体死亡密切相关。这项荟萃分析广泛调查了术前和手术因素与胎儿死亡的关联。这些发现可能是重要的住院咨询,为了进一步了解这种疾病,也许在改进手术技术方面。
Several studies have assessed preoperative and operative factors associated with fetal demise after laser for TTTS, yet these findings are not completely conclusive.
This study aimed to identify risk factors for single fetal demise (recipient and donor twins) after fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome.
We searched PubMed, Scopus, and Web of Science systematically from the inception of the database to June 2020. We conducted a systemic
review on studies investigating risk factors for fetal demise (donor and/or recipient) after fetoscopic laser photocoagulation in monochorionic pregnancies complicated with twin-to-twin transfusion syndrome. Initially, we investigated the cohort of women with twin-to-twin transfusion syndrome that underwent fetoscopic laser photocoagulation at our 2 high-volume fetal centers between 2012 and 2020 to identify risk factors for donor demise and recipient demise. Furthermore, we conducted a systematic
review of the literature to better characterize these factors. Among studies that met the entry criteria, multiple preoperative and operative factors were tabulated. The random-effect model was used to pool the standardized mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value.
A total of 514 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were included in the final analysis. Following the logistic regression, factors that remained significant for donor demise were selective fetal growth restriction (odds ratio, 1.9; 95% confidence interval, 1.3-2.8; P=.001) and umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.06; 95% confidence interval, 1.2-3.4; P=.004). A significant factor associated with recipient demise was absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 1.74; 95% confidence interval, 1.07-3.13; P=.04). Data from 23 studies and our current cohort were included. A total of 4892 pregnancies with twin-to-twin transfusion syndrome managed with fetoscopic laser photocoagulation were analyzed for risk factors for donor demise, and 4594 pregnancies with twin-to-twin transfusion syndrome were analyzed for recipient demise. Among studies, the overall incidence rates ranged from 10.9% to 35.8% for donor demise and 7.3% to 24.5% for recipient demise. Significant risk factors for donor demise were intertwin estimated fetal weight discordance of >25% (odds ratio, 1.86; 95% confidence interval, 1.44-2.4; I2, 0.0%), selective fetal growth restriction (odds ratio, 1.78; 95% confidence interval, 1.4-2.27; I2, 0.0%), twin-to-twin transfusion syndrome stage III (odds ratio, 2.18; 95% confidence interval, 1.53-3.12; I2, 0.0%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the donor (odds ratio, 2.31; 95% confidence interval, 1.9-2.8; I2, 23.7%), absent or reversed a-wave in the ductus venosus of the donor (odds ratio, 1.83; 95% confidence interval, 1.45-2.3; I2, 0.0%), and presence of arterioarterial anastomoses (odds ratio, 2.81; 95% confidence interval, 1.35-5.85; I2, 90.7%). Sequential selective coagulation was protective against donor demise (odds ratio, 0.31; 95% confidence interval, 0.16-0.58; I2, 0.0%). Significant risk factors for recipient demise were twin-to-twin transfusion syndrome stage IV (odds ratio, 2.18; 95% confidence interval, 1.01-4.6; I2, 16.5%), umbilical artery blood flow with absent or reversed end-diastolic velocity of the recipient (odds ratio, 2.68; 95% confidence interval, 1.91-3.74; I2, 0.0%), absent or reversed a-wave in the ductus venosus of the recipient (odds ratio, 2.37; 95% confidence interval, 1.55-3.64; I2, 60.2%), and middle cerebral artery peak systolic velocity of >1.5 multiple of the median (odds ratio, 3.06; 95% confidence interval, 1.36-6.88; I2, 0.0%).
Abnormal blood flow patterns represented by abnormal Doppler studies and low fetal weight were associated with single fetal demise in women with twin-to-twin transfusion syndrome undergoing laser therapy. Although sequential selective coagulation was protective against donor demise, the presence of arterioarterial anastomoses was considerably associated with donor demise. This meta-analysis extensively investigated the association of a wide range of preoperative and operative factors with fetal demise. These findings may be important inpatient counseling, in further understanding the disease, and perhaps in improving surgical techniques.