背景:双胎输血综合征(TTTS)使大约10%-15%的单绒毛膜双胎妊娠复杂化。这篇综述的目的是评估激光后TTTS双胞胎的胎盘结构特征,并阐明其对胎儿结局和手术成功的影响。
方法:从开始到2023年8月搜索了5个数据库。包括详细说明激光后TTTS双胞胎分娩后胎盘分析的研究。研究分为两大类:(1)激光后的残余吻合和(2)异常的脐带插入:帆状和/或边缘或近端。主要结果是确定激光后残余吻合和异常脐带插入的TTTS胎盘的比例。次要结果包括评估激光后胎儿结局的残余吻合,并评估异常脐带插入与TTTS发育之间的关系。使用JoannaBriggs研究所检查表和Cochrane偏差风险工具对研究偏差进行了批评。使用随机效应荟萃分析,结果报告为合并比例或比值比(OR),95%置信区间(CI).PROSPERO注册:CRD42023476875。
结果:26项研究,包括4013个单绒毛膜双胞胎,被纳入分析。激光后残余吻合的TTTS胎盘比例为24%(95%CI,0.12-0.41),每个胎盘吻合的平均值和标准偏差为4.03±2.95。激光后残余吻合与宫内胎儿死亡显着相关(OR,2.38[95%CI,1.33-4.26]),新生儿死亡(或,3.37[95%CI,1.65-6.88]),复发性TTTS(或,24.33[95%CI,6.64-89.12]),和双胞胎贫血红细胞增多症序列(OR,13.54[95%CI,6.36-28.85])。合并异常索(绒毛和边缘),绒毛绳,据报道,激光后一个或两个双胞胎的边缘脐带插入率为49%(95%CI,0.39-0.59),27%(95%CI,0.18-0.38),和28%(95%CI,0.21-0.36),分别。合并,与非TTTS单绒毛膜双胞胎相比,要求激光的TTTS双胞胎(分别为p=0.72,p=0.38和p=0.71)没有显着相关。
结论:据我们所知,这是首次联合探讨激光术后TTTS双胞胎残余吻合和异常脐带插入结局的综述.需要进行大规模的前瞻性研究来评估异常脐带插入与激光后残余吻合发展之间的关系。
BACKGROUND: Twin-twin transfusion syndrome (TTTS) complicates approximately 10%-15% of all monochorionic twin pregnancies. The aim of this
review was to evaluate the placental architectural characteristics within TTTS twins following laser and elucidate their impact on fetal outcomes and operative success.
METHODS: Five databases were searched from inception to August 2023. Studies detailing post-delivery placental analysis within TTTS twins post-laser were included. Studies were categorized into two main groups: (1) residual anastomoses following laser and (2) abnormal cord insertion: either velamentous and/or marginal or proximate. The primary outcome was to determine the proportion of TTTS placentas with residual anastomoses and abnormal cord insertions post-laser. Secondary outcomes included assessing residual anastomoses on post-laser fetal outcomes and assessing the relationship between abnormal cord insertion and TTTS development. Study bias was critiqued using the Joanna Briggs Institute checklists and Cochrane risk of bias tool. Random-effects meta-analysis was used, and results were reported as pooled proportions or odds ratio (OR) with 95% confidence interval (CI). PROSPERO registration: CRD42023476875.
RESULTS: Twenty-six studies, comprising 4013 monochorionic twins, were included for analysis. The proportion of TTTS placentas with residual anastomoses following laser was 24% (95% CI, 0.12-0.41), with a mean and standard deviation of 4.03 ± 2.95 anastomoses per
placenta. Post-laser residual anastomoses were significantly associated with intrauterine fetal death (OR, 2.38 [95% CI, 1.33-4.26]), neonatal death (OR, 3.37 [95% CI, 1.65-6.88]), recurrent TTTS (OR, 24.33 [95% CI, 6.64-89.12]), and twin anemia polycythemia sequence (OR, 13.54 [95% CI, 6.36-28.85]). Combined abnormal cord (velamentous and marginal), velamentous cord, and marginal cord insertions within one or both twins following laser were reported at rates of 49% (95% CI, 0.39-0.59), 27% (95% CI, 0.18-0.38), and 28% (95% CI, 0.21-0.36), respectively. Combined, velamentous and marginal cord insertions were not significantly associated with TTTS twins requiring laser (p = 0.72, p = 0.38, and p = 0.71, respectively) versus non-TTTS monochorionic twins.
CONCLUSIONS: To the best of our knowledge, this is the first
review to conjointly explore outcomes of residual anastomoses and abnormal cord insertions within TTTS twins following laser. A large prospective study is necessitated to assess the relationship between abnormal cord insertion and residual anastomoses development post-laser.