Taylor M J, Denbow M L, Duncan K R, Overton T G, Fisk N M
Centre for Fetal Care, Imperial College School of Medicine, London, United Kingdom.
Am J Obstet Gynecol. 2000 Oct;183(4):1023-8. doi: 10.1067/mob.2000.107368.
We sought to identify clinical factors at diagnosis that predict outcome in twin-twin transfusion syndrome.
In this retrospective series 23 patients with twin-twin transfusion syndrome were seen in a tertiary referral fetal medicine center over a 3-year period. Ten antenatal factors were assessed to determine their ability to predict outcome by use of ordered logistic regression. These factors were the following: (1) absent or reversed end-diastolic flow in the umbilical artery, nonvisible bladder, anhydramnios, and estimated fetal weight of <3rd percentile in the donor; (2) pulsatile umbilical vein, either absent or reversed end-diastolic flow in the ductus venosus, or both, and tricuspid-mitral valve regurgitation in the recipient; and (3) gestational age at presentation, estimated fetal weight discordancy, absent arterioarterial anastomosis, and spontaneous rupture of the membranes or cervical change as pregnancy factors. Management comprised serial amnioreduction (n = 10), selective feticide (n = 5; 4 also had amnioreduction), septostomy (n = 4; 1 also had amnioreduction), and delivery (n = 2). Two patients miscarried before treatment.
The chance of survival of both twins fell and double deaths increased linearly with increasing number of adverse factors (P =.026). A low chance of survival was independently associated with absent or reversed end-diastolic flow in the donor umbilical artery (P =.02) and with a pulsatile umbilical vein or absent or reversed end-diastolic flow in the ductus venosus (P =.03) of the recipient. The probability of at least one twin surviving was only 33% if there was absent or reversed end-diastolic flow in the donor umbilical artery or 37% when abnormal venous recordings were seen in the recipient. An arterioarterial anastomosis detected at diagnosis also influenced prognosis, with all twins surviving when an arterioarterial anastomosis was identified (P =.04).
Three factors identified at diagnosis independently predict poor survival in twin-twin transfusion syndrome-absent or reversed end-diastolic flow in the donor umbilical artery, abnormal pulsatility of the venous system in the recipient, and absence of an arterioarterial anastomosis. These may have a role in the counseling of parents and in selecting the appropriate treatment strategy.
我们试图确定双胎输血综合征诊断时可预测预后的临床因素。
在这项回顾性研究中，一家三级转诊胎儿医学中心在3年期间诊治了23例双胎输血综合征患者。评估了10项产前因素，通过有序逻辑回归分析来确定它们预测预后的能力。这些因素如下：（1）脐动脉舒张末期血流消失或反向、膀胱不可见、羊水过少以及供血儿估计胎儿体重低于第3百分位数；（2）脐静脉搏动、静脉导管舒张末期血流消失或反向或两者皆有，以及受血儿三尖瓣-二尖瓣反流；（3）就诊时的孕周、估计胎儿体重差异、动脉-动脉吻合支缺失以及胎膜自然破裂或宫颈变化等妊娠因素。治疗方法包括系列羊水减量术（n = 10）、选择性减胎术（n = 5；其中4例也进行了羊水减量术）、隔膜造口术（n = 4；其中1例也进行了羊水减量术）以及分娩（n = 2）。2例患者在治疗前流产。
随着不良因素数量的增加，双胎均存活的几率下降，双胎均死亡的情况呈线性增加（P = 0.026）。存活几率低与供血儿脐动脉舒张末期血流消失或反向独立相关（P = 0.02），也与受血儿脐静脉搏动或静脉导管舒张末期血流消失或反向独立相关（P = 0.03）。如果供血儿脐动脉舒张末期血流消失或反向，至少有一个胎儿存活的概率仅为33%；当受血儿出现异常静脉记录时，这一概率为37%。诊断时检测到的动脉-动脉吻合支也影响预后，当发现有动脉-动脉吻合支时，所有双胎均存活（P = 0.04）。
诊断时确定的三个因素可独立预测双胎输血综合征的不良存活结局，即供血儿脐动脉舒张末期血流消失或反向、受血儿静脉系统搏动异常以及动脉-动脉吻合支缺失。这些因素可能在为父母提供咨询以及选择合适的治疗策略方面发挥作用。
