尽管自从引入激光光凝术以来,受双双胞胎输血综合征影响的妊娠的胎儿存活率有所改善,早产仍然是新生儿发病率和死亡率的主要来源。
为了研究激光治疗后的适应症和影响分娩时间的因素,我们在大型多中心队列中收集了双胎-双胎输血综合征病例的分娩信息.
11个北美胎儿治疗网络(NAFTNet)中心对接受激光光凝治疗的双胎-双胎输血综合征患者进行了回顾性研究。临床,人口统计学和超声变量,包括双胎输血综合征阶段,记录治疗和分娩时的胎龄.确定了主要和次要的母体和胎儿分娩指征。单变量分析用于选择与潜伏期和分娩时的GA显著相关的候选变量。使用具有竞争风险分析的多变量Cox回归来确定独立关联。
总共分析了847例妊娠。激光后,平均分娩潜伏期为10.11±4.8周,平均分娩胎龄为30.7±4.5周.主要的产妇分娩指征占病例的79%。主要适应症包括自发分娩(46.8%),胎膜早破(17.1%),和胎盘早剥(8.4%)。主要胎儿适应症占病例的21%,最常见的适应症包括供体不放心状态(20.5%),异常供体多普勒(15.1%),和供体生长限制(14.5%)。最常见的次要分娩指征是胎膜早破,自发劳动和供体生长限制。多变量建模在诊断时发现胎龄,舞台,先前羊膜减少的历史,环扎术,共赢膜破坏,手术并发症和绒毛膜羊膜分离可预测分娩时的胎龄和潜伏期。
双胎输血综合征激光治疗后早产主要是由于自发分娩,早产胎膜早破和供体胎儿的不放心状态。发现胎盘早剥是导致早期分娩的常见并发症。未来的研究应针对激光光凝后延长妊娠的目标,以进一步降低与双胎输血综合征相关的发病率和死亡率。
Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality.
To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort.
Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations.
A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency.
Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.