目的:关于胎盘吻合术(FLP)的胎儿镜下激光光凝治疗双胎对双胎输血综合征(TTTS)是否与较低的总生存率相关的数据存在矛盾。这项研究的目的是表征FLP后跨FLP胎龄的生存率和其他相关发病率。
方法:这是对2011年至2022年在两个中心进行TTTSFLP的单绒毛膜-羊膜双胎患者前瞻性收集的数据的二次分析。在18周之前将患者分为FLP的胎龄阶段,180/7-196/7周,200/7-216/7周,220/7-236/7周,240/7-256/7周和26周之后。人口特征,比较了整个孕龄时期TTTS的超声特征和手术特征。结果包括总体生存率,早产,早产胎膜破裂(PPROM),还比较了不同胎龄时期的宫内胎儿死亡(IUFD)和新生儿死亡(NND)。通过拟合这些结果的逻辑回归模型进行多变量分析。构建Kaplan-Mejer曲线以比较每个胎龄时期从PPROM到分娩的间隔。
结果:有768例患者符合纳入标准。在18周之前进行FLP的双重生存率为61.3%,而在整个孕龄后期为78.0%-86.7%。这似乎与之前进行FLP后供体IUFD的比率增加有关,与18周后(28.0%vs.9.3%-14.1%)。无论FLP的胎龄如何,受体IUFD/NND和供体NND的比率相似。早期FLP的PPROM率较高,从18周前FLP的45.6%到24-26周胎龄FLP的11.9%不等。然而,不同孕龄时期的分娩年龄相似,中位数为31.7周.在多变量分析中,在调整选择性胎儿生长受限后18周前,供者丢失与FLP独立相关,Quintero阶段和其他协变量。PPROM和PTD也与FLP前18周调整宫颈长度,胎盘位置,套管针尺寸,激光能量和羊膜输液。
结论:胎龄较早的FLP与较低的总生存率相关,这是由捐赠者IUFD的高风险驱动的,与PPROM或PTD的差异相反。关于生存的咨询应说明出现的胎龄。本文受版权保护。保留所有权利。
OBJECTIVE: There are conflicting data on whether fetoscopic laser photocoagulation of placental anastomoses (FLP) for treating twin-to-twin transfusion syndrome (TTTS) is associated with lower rates of overall survival. The objective of this study is to characterize survival and other associated morbidity after FLP across gestational ages of FLP.
METHODS: This is a secondary analysis of prospectively collected data on patients with monochorionic-diamniotic twins that had FLP for TTTS at two centers between 2011 and 2022. Patients were divided into gestational age epochs for FLP before 18 wks, 18 0/7 - 19 6/7 wks, 20 0/7 - 21 6/7 wks, 22 0/7 - 23 6/7 wks, 24 0/7 - 25 6/7 wks and after 26 wks. Demographic characteristics, sonographic characteristics of TTTS and operative characteristics were compared across the gestational age epochs. Outcomes including overall survival, preterm delivery, preterm prelabor rupture of membranes (PPROM), intrauterine fetal demise (IUFD) and neonatal demise (NND) were also compared across gestational age epochs. Multivariate analysis was performed by fitting logistic regression models for these outcomes. Kaplan-Mejer curves were constructed to compare the interval from PPROM to delivery for each gestational age epoch.
RESULTS: There were 768 patients that met inclusion criteria. The dual survival rate was 61.3% for FLP performed prior to 18 weeks compared to 78.0% - 86.7% across later gestational age epochs. This appears to be related to increased rates of donor IUFD following FLP performed before, versus after 18 weeks (28.0% vs. 9.3% - 14.1%). Rates of recipient IUFD/NND and donor NND were similar regardless of gestational age of FLP. Rates of PPROM were higher for earlier FLP, ranging from 45.6% for FLP before 18 weeks to 11.9% for FLP at 24 - 26 weeks gestational age. However, the gestational age of delivery was similar across gestational age epochs with a median of 31.7 weeks. In multivariate analysis, donor loss was independently associated with FLP before 18 weeks after adjusting for selective fetal growth restriction, Quintero stage and other covariates. PPROM and PTD were also associated with FLP before 18 weeks after adjusting for cervical length, placental location, trocar size, laser energy and amnioinfusion.
CONCLUSIONS: FLP performed at earlier gestational ages is associated with lower overall survival, which is driven by higher risk of donor IUFD, as opposed to differences in PPROM or PTD. Counseling regarding survival should account for gestational age of presentation. This article is protected by copyright. All rights reserved.