Kaufman Howard K, Hume Roderick F, Calhoun Byron C, Carlson Nancy, Yorke Victoria, Elliott Dawn, Evans Mark I
Maternal-Fetal Medicine, Rockford Memorial Hospital, Rockford, IL 61103, USA.
Fetal Diagn Ther. 2003 Nov-Dec;18(6):442-6. doi: 10.1159/000073140.
To evaluate the pathophysiology by which the in utero death of 1 twin might increase morbidity to its co-twin survivor and its mother. To assess previously reported risks for maternal disseminated intravascular coagulopathy, peripartal hemorrhage, retained placenta and infection, as well as the fetal risk of prematurity.
A retrospective analysis of the natural history of twin pregnancies from three institutions was performed. A total of 1,989 cases of twin pregnancy were identified, Wayne State University included 1,266 cases from 1984 to 1993; Madigan Army Medical Center 136 cases, 1995-2000, and Rockford Regional Perinatal Center, 587 cases, 1990-2000. The findings were classified by the presence or absence of fetal death in utero (IUFD) as follows: both IUFD (0/0); 1 IUFD (0/+), and both live born (+/+). A case-control study was performed on the subgroup of patients for whom complete records as to chorionicity, etc., were available.
Of the 1,989 cases reviewed there were 49 both IUFD (0/0), 61 complicated by 1 IUFD (0/+), and 1,879 with both live born (+/+). The overall fetal death rate for this twin cohort was 55/1,000. IUFD of 1 or both twins was related to an increased risk of previable delivery 55% in 0/0, and 28% in 0/+ versus 4% for +/+ with p<0.001. IUFD also was associated with early preterm delivery (mean gestational age at delivery of 23 (0/0) and 30 (0/+) versus 35 (+/+) weeks). Chorionicity as well as maternal risks were examined in the case-control study (24 (0/0), 43 (0/+), 134 (+/+)) with the following results: monochorionic placentation was more likely in pregnancies complicated by IUFD (54% (0/0), 51% (0/+) versus 14% (+/+); p<0.001). Retained placenta, requiring dilation and curettage, occurred more frequently when both twins died in utero, but may be related to the earlier gestational age at delivery.
Independent of retained placenta, there is no difference in the maternal risks for hemorrhage, abruption, coagulopathy or infection between groups. Immaturity at delivery and monochorionicity are more common in pregnancies complicated by fetal demise. Neonatal morbidity and developmental outcome will be the focus of a longitudinal study comparing cotwin survivors to twins matched for chorionicity and gestational age at delivery.
评估单胎宫内死亡可能增加其双胎存活者及母亲发病风险的病理生理机制。评估先前报道的母体弥散性血管内凝血、围产期出血、胎盘残留和感染的风险，以及胎儿早产风险。
对来自三个机构的双胎妊娠自然病史进行回顾性分析。共确定1989例双胎妊娠病例，韦恩州立大学包括1984年至1993年的1266例；马迪根陆军医疗中心1995年至2000年的136例，以及罗克福德地区围产期中心1990年至2000年的587例。根据宫内胎儿死亡（IUFD）的有无将结果分类如下：双胎均为IUFD（0/0）；1例IUFD（0/+），双胎均存活（+/+）。对绒毛膜性等有完整记录的患者亚组进行病例对照研究。
在1989例回顾病例中，49例双胎均为IUFD（0/0），61例合并1例IUFD（0/+），1879例双胎均存活（+/+）。该双胎队列的总体胎儿死亡率为55/1000。1例或双胎IUFD与未足月分娩风险增加相关，0/0组为55%，0/+组为28%，而+/+组为4%，p<0.001。IUFD还与早期早产相关（分娩时平均孕周分别为23周（0/0）、30周（0/+）和35周（+/+））。在病例对照研究（24例（0/0）、43例（0/+）、134例（+/+））中检查了绒毛膜性及母体风险，结果如下：合并IUFD的妊娠中，单绒毛膜胎盘形成更常见（54%（0/0）、51%（0/+）对14%（+/+）；p<0.001）。当双胎均在宫内死亡时，需要刮宫的胎盘残留更频繁出现，但可能与分娩时较早的孕周有关。
不考虑胎盘残留，各组间母体出血、胎盘早剥、凝血障碍或感染的风险无差异。分娩时不成熟和单绒毛膜性在合并胎儿死亡的妊娠中更常见。将双胎存活者与分娩时绒毛膜性和孕周匹配的双胎进行比较的纵向研究，将把新生儿发病率和发育结局作为重点。
