背景:在双胎妊娠中,母体心血管适应被放大,以支持胎儿-胎盘单位的代谢需求。很少有研究评估常规使用激光手术治疗双胎输血综合征(TTTS)后母体的血流动力学变化。
目的:我们的研究目的是评估经胎儿镜激光手术治疗后并发TTTS的单绒毛膜双胎妊娠的血流动力学变化。
方法:一项2020年至2022年的前瞻性观察性研究,包括在妊娠16至26周期间接受激光手术的单绒毛膜双胎妊娠合并TTTS。为了评估胎盘功能和灌注,子宫动脉搏动指数,血红蛋白,血细胞比容,测量激光前和激光后24小时的可溶性fms样酪氨酸激酶-1/胎盘生长因子(sFlt1/PlGF)比率采样。一位心脏病专家的超声心动图评估了手术前的母体血流动力学,24小时,和激光术后1周这些数据与使用非参数检验在相同胎龄招募的无并发症单绒毛膜妊娠的心血管指数进行交叉比较。此外,我们拟合了随机-截距线性回归模型,以根据激光手术期间羊水引流量调查母体血流动力学变化.
结果:纳入42例TTTS妊娠,中位孕龄为19.1(17.4-20.9),15例无并发症的单绒毛膜妊娠。激光后的总生存率为72%,中位胎龄为31.5周(27-34)。在TTTS组中观察到血液化学和胎盘功能的显着变化,随着动脉压的改变,心率,心输出量,和心室应变,最终在激光后一周与这个不复杂的群体的价值观保持一致。羊膜引流的量,有1000毫升的截止值,对血流动力学参数无显著影响。最后,我们检测到一定百分比的激光手术并发症与国际文献一致,我们没有记录任何与产妇手术相关的问题.
结论:我们的分析强调,单绒毛膜双胎妊娠并发TTTS的母体心血管状况更具动态性,羊膜引流术完成胎盘吻合术后一周,母体血液动力学参数恢复到与单胎双胎妊娠相似的值。
Maternal cardiovascular adaptations are amplified in twin pregnancies to support the metabolic request of the feto-placental unit. Few studies have evaluated the maternal hemodynamics changes after routine use of laser surgery in the treatment of twin-twin transfusion syndrome.
The aim of our study was to evaluate hemodynamic changes in monochorionic twin pregnancies complicated by twin-twin transfusion syndrome before and after treatment with fetoscopic laser surgery.
A prospective observational study from 2020 to 2022, included monochorionic twin pregnancies complicated with twin-twin transfusion syndrome undergoing laser surgery between 16 and 26 weeks of gestation. To assess placental function and perfusion, uterine artery pulsatility index, hemoglobin, hematocrit, and soluble fms-like tyrosine kinase-1/placental growth factor ratio sampling prelaser and 24 hours postlaser were measured. Echocardiography by a single cardiologist evaluated maternal hemodynamics at presurgery, 24 hours, and 1 week postlaser. Those data were crosswise compared with cardiovascular indices of uncomplicated monochorionic pregnancies recruited at the same gestational age using nonparametric tests. Moreover, we fitted random-intercept linear regression models to investigate maternal hemodynamic changes according to the amount of amniotic fluid drained during laser surgery.
Forty-two twin-twin transfusion syndrome pregnancies with a median gestational age of 19.1 (17.4-20.9) weeks and 15 uncomplicated monochorionic pregnancies at the same gestational age were enrolled. Overall survival rate after laser was 72% with delivery at a median gestational age of 31.5 (27-34) weeks. Significant changes in blood chemistry and placental function were observed in the twin-twin transfusion syndrome group, along with alterations in arterial pressure, heart rate, cardiac output, and ventricular strain, eventually aligning with the uncomplicated group\'s values by 1 week postlaser. The amount of amniodrainage, with a 1000 ml cut-off, did not significantly impact hemodynamic parameters. Lastly, we detected a percentage of laser surgery complications in agreement with international literature and we did not record any maternal procedure-related problems.
Our analysis highlighted that maternal cardiovascular status in monochorionic twin pregnancy complicated by twin-twin transfusion syndrome was more dynamic and; 1 week after fetoscopic laser ablation of placental anastomosis completed by amniodrainage, maternal hemodynamic parameters restored to values similar to uncomplicated monochorionic twin pregnancies.