目的:本研究旨在确定单绒毛膜双胎(MCT)妊娠的选择性胎儿生长受限(sFGR)。
方法:回顾性分析北京大学第三医院2015年1月至2019年12月sFGR病例。我们根据国际妇产科超声学会诊断标准纳入sFGR。我们排除了那些严重胎儿结构异常的病例,双反向动脉灌注(TRAP),遗传综合征或非整倍性;因产妇并发症或个人原因而终止的病例;有胎儿干预的怀孕,例如用于血管吻合的胎儿镜激光光凝(FLP),通过射频消融(RFA)和微波消融(MVA)减少胎儿。我们没有排除那些接受羊膜减灭术治疗的病例。根据发病时的胎龄(24周之前或之后),我们对数据进行了分析,以确定与胎儿预后结局相关的危险因素.主要结果包括至少一个双胞胎和两个双胞胎的存活。次要结局包括分娩的胎龄,活产体重,Apgar<7in5min,入院新生儿病房和新生儿死亡。Kruskal-Wallis秩检验用于比较非正态分布数据,而分类数据使用Fisher精确检验或χ2检验进行匹配。方差分析用于比较正态分布数据,接下来是事后Bonferroni分析。采用多元二元logistic回归分析确定与宫内死亡相关的因素。
结果:有119例怀孕符合调查条件,75(63.0%)被归类为早发性sFGR,44(37.0%)被归类为晚发性sFGR。至少一个双胞胎的存活率(82.7%vs.95.5%),双胞胎的存活率(73.3%vs.88.6%)在早发性sFGR组均降低,与晚发型sFGR组相比。胎儿生长受限(FGR)和适当的胎龄生长(AGA)胎儿存活的婴儿在两组出生体重方面表现出相似的结果,5分钟Apgar评分<7,新生儿死亡,和28天生存率。多变量模型用于预测至少一个双胞胎的宫内死亡。重叠双胎输血综合征(TTTS)的比值比(OR17.915,95CI3.699~86.756)和Ⅱ/Ⅲ型sFGR(OR4.619,95CI1.074~19.869)明显更高。
结论:在MCT妊娠中,早发性sFGR至少有一个或两个双胞胎的存活率较差,但是活产后的预后没有统计学差异,无论是FGR婴儿还是AGA婴儿。叠加TTTS和Ⅱ/Ⅲ型sFGR的围产期结局较差。这些信息可以在产前咨询期间提供给父母。
OBJECTIVE: This study aimed to identify selective fetal growth restriction (sFGR) in monochorionic twin (MCT) pregnancy with expectant management.
METHODS: We retrospectively analyzed cases of sFGR between January 2015 and December 2019 in Peking University Third Hospital. We included sFGR according to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria. We excluded those cases where a significant fetal structural abnormality, twin reversed arterial perfusion (TRAP), genetic syndrome or aneuploidy; cases terminated for maternal complications or for personal reasons; pregnancies that had a fetal intervention, such as fetoscopic laser photocoagulation (FLP) for vascular anastomoses, fetal reduction by radiofrequency ablation (RFA) and microwave ablation (MVA). We didn\'t excluded those cases that had amnioreduction therapy. According to the gestational age at onset (before 24 weeks or after), data were analyzed to identify the risk factors associated with fetal prognostic outcomes. Primary outcomes included survival of at least one twin and both twins. Secondary outcomes included gestational age of delivery, live birth weight, Apgar <7 in 5 min, admission to the neonatal unit and neonatal death. Kruskal-Wallis rank tests were used to compare non-normally distributed data, whereas categorical data were matched using Fisher\'s exact test or χ2 tests. ANOVA was used to compare normally distributed data, followed by a post-hoc Bonferroni analysis. Multivariate binary logistic regression was used to identify the factors connected with intrauterine death.
RESULTS: There were 119 pregnancies that qualified for investigation, 75 (63.0%) were categorized as early-onset sFGR and 44 (37.0%) as late-onset sFGR. The rate of survival of at least one twin (82.7% vs. 95.5%), survival of both twins (73.3% vs. 88.6%) were all reduced in the early-onset sFGR group, compared to the late-onset sFGR group. Babies born alive of fetal growth restriction (FGR) and appropriate growth for gestational age (AGA) fetuses showed similar results in the two groups regarding birth weight, 5-min Apgar score <7, neonatal death, and 28-day survival rate. A multivariable model was used to predict the intrauterine death of at least one twin. The odds ratio were significantly higher for superimposed twin-twin transfusion syndrome (TTTS) (OR 17.915, 95%CI 3.699∼86.756) and Types Ⅱ/Ⅲ sFGR (OR 4.619, 95%CI 1.074∼19.869).
CONCLUSIONS: In MCT pregnancies, early-onset sFGR had a poorer survival of at least one or both twins, but there was no statistical difference in the prognosis after live birth, neither for FGR babies nor those of AGA. Superimposed TTTS and Types Ⅱ/Ⅲ sFGR had a worse perinatal outcome. This information could be provided to the parents during prenatal counselling.