Vayssière C
SIHCUS-CMCO, 19, rue Louis-Pasteur, 67303 Schiltigheim, France.
J Gynecol Obstet Biol Reprod (Paris). 2002 Nov;31(7 Suppl):5S114-23.
Spontaneous prematurity is more frequent in multiple than singleton pregnancies. It is estimated that 72% of the multiple pregnancies delivered before 33 weeks are spontaneous births, compared with 58% among singletons (NP3). As in singleton pregnancies, uterine contractions, close together, often precede preterm delivery by several days (NP2). The benefits of home tocodynamometry for patients who have already been hospitalized for threatened preterm delivery (TPD) (NP4) is difficult to assess from the data currently available, but it has not been shown to provide any benefits in a population of asymptomatic twin pregnancies (NP1). Cervical ultrasound appears to have good predictive value for preterm delivery when performed for TPD (NP3), although again few data are available. The efficacy of tocolysis appears similar to that for singleton pregnancies (NP3). Although the lack of data prevents us from judging the efficacy of tocolytics such as calcium channel blockers or oxytocin antagonists, it seems logical to use them as first-line drugs, especially because of the increased risk of pulmonary edema in multiple pregnancies with Bmimetics (NP3). Antenatal corticosteroid therapy appears to be less beneficial in multiple than singleton pregnancies (NP3). Pharmacological studies suggest that the dose currently used may be insufficient for multiple pregnancies (NP3). While awaiting results from clinical studies comparing the efficacy of higher doses, we must for now recommend antenatal corticosteroid therapy only at the usual doses. While the rate of in utero transfers to level III facilities is nearly 85% in the case of severe TPD (NP4), this practice must be encouraged still more in view of the benefits of inborn status compared with postnatal transfer. Finally, delayed-interval delivery is a relatively rare obstetrical practice that should be considered on a case-by-case basis when the first fetus is born before 26 weeks. This approach requires tocolysis and antibiotic therapy. The usefulness of cerclage in this situation has yet to be demonstrated. A delayed-interval delivery can prolong the pregnancy by an average of 15 to 30 days (NP4).
多胎妊娠中自然早产比单胎妊娠更常见。据估计，33周前分娩的多胎妊娠中有72%是自然分娩，而单胎妊娠中这一比例为58%（NP3）。与单胎妊娠一样，子宫收缩频繁往往在早产前几天出现（NP2）。对于已经因先兆早产（TPD）住院的患者，家庭宫缩监测的益处（NP4）很难从现有数据中评估，但在无症状双胎妊娠人群中尚未显示其有任何益处（NP1）。对于TPD进行宫颈超声检查时，似乎对早产有较好的预测价值（NP3），不过同样数据较少。宫缩抑制剂的疗效似乎与单胎妊娠相似（NP3）。尽管缺乏数据使我们无法判断钙通道阻滞剂或催产素拮抗剂等宫缩抑制剂的疗效，但将它们用作一线药物似乎是合理的，特别是因为使用β-拟交感神经药物的多胎妊娠发生肺水肿的风险增加（NP3）。产前糖皮质激素治疗在多胎妊娠中的益处似乎比单胎妊娠少（NP3）。药理学研究表明，目前使用的剂量可能对多胎妊娠不足（NP3）。在等待比较更高剂量疗效的临床研究结果期间，目前我们必须仅推荐按常规剂量进行产前糖皮质激素治疗。虽然在严重TPD的情况下，宫内转运至三级医疗机构的比例接近85%（NP4），但鉴于与产后转运相比出生时状态的益处，这种做法仍应进一步鼓励。最后，延迟间隔分娩是一种相对罕见的产科做法，当第一个胎儿在26周前出生时，应根据具体情况考虑。这种方法需要使用宫缩抑制剂和抗生素治疗。在这种情况下宫颈环扎术的有效性尚未得到证实。延迟间隔分娩可使妊娠平均延长15至30天（NP4）。
