单绒毛膜双胎伴选择性胎儿生长受限及舒张末期血流间歇性消失或反向（III型）：胎儿镜下胎盘激光凝固术的可行性及围产期结局

Monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic flow (Type III): feasibility and perinatal outcome of fetoscopic placental laser coagulation.

作者信息

Gratacós E, Antolin E, Lewi L, Martínez J M, Hernandez-Andrade E, Acosta-Rojas R, Enríquez G, Cabero L, Deprest J

机构信息

Department of Maternal-Fetal Medicine (ICGON) and Fetal and Perinatal Research Group (IDIBAPS), Hospital Clinic, University of Barcelona, Spain.

出版信息

Ultrasound Obstet Gynecol. 2008 Jun;31(6):669-75. doi: 10.1002/uog.5362.

DOI:10.1002/uog.5362

PMID:18504780

Abstract

OBJECTIVES

To assess the feasibility and impact on perinatal outcome of fetoscopic laser coagulation of placental anastomoses in monochorionic twins with selective intrauterine growth restriction (sIUGR) and intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery (Type III), in comparison with expectant management.

METHODS

This is a descriptive study of the outcome of 18 cases of monochorionic twins with Type III sIUGR treated with laser, and 31 pregnancies managed expectantly over the same period. All newborns underwent neonatal brain ultrasound scans. Perinatal outcome and the incidence of neurological damage were compared between the two groups.

RESULTS

Laser coagulation could be performed in only 88.9% (16/18) of cases owing to technical difficulties, and in 12.5% (2/16) a second procedure was required to achieve complete coagulation of the large artery-to-artery anastomosis. Mean gestational age at delivery was 31.0 (range, 26-33) weeks in the expectant management group and 32.6 (range, 23-38) weeks in the laser group (P = 0.32). Overall perinatal survival was 85.5% (53/62) and 63.9% (23/36), respectively (P = 0.02). Intrauterine demise of the smaller twin occurred in 19.4% (6/31) and 66.7% (12/18), respectively (P = 0.001), and was associated with death of the cotwin in 50% (3/6) and 0% (0/12) of these cases, respectively (P = 0.02). The prevalence of periventricular leukomalacia in the larger fetus was 4/28 (14.3%) in the expectant management group and 1/17 (5.9%) in the laser group (P = 0.63).

CONCLUSIONS

Laser coagulation in sIUGR-iAREDF pregnancies is technically difficult and not always feasible. Placental dichorionization significantly increases the proportion of fetuses with intrauterine death of the growth-restricted twin, but it protects the normal twin from its cotwin's death in the event of demise of the growth-restricted twin.

摘要

目的

评估对于单绒毛膜双胎妊娠合并选择性胎儿生长受限（sIUGR）及脐动脉舒张末期血流间歇性缺失或反向（iAREDF，III型）的情况，与期待治疗相比，胎儿镜下激光凝固胎盘吻合支的可行性及其对围产期结局的影响。

方法

这是一项描述性研究，纳入18例接受激光治疗的III型sIUGR单绒毛膜双胎妊娠病例及同期31例接受期待治疗的妊娠病例。所有新生儿均接受了新生儿脑部超声检查。比较两组的围产期结局及神经损伤发生率。

结果

由于技术困难，仅88.9%（16/18）的病例能够进行激光凝固，其中12.5%（2/16）的病例需要进行第二次操作以实现大动脉-动脉吻合支的完全凝固。期待治疗组的平均分娩孕周为31.0（范围26 - 33）周，激光治疗组为32.6（范围23 - 38）周（P = 0.32）。总体围产期存活率分别为85.5%（53/62）和63.9%（23/36）（P = 0.02）。较小胎儿的宫内死亡发生率分别为19.4%（6/31）和66.7%（12/18）（P = 0.001），其中分别有50%（3/6）和0%（0/12）的病例合并另一胎儿死亡（P = 0.02）。期待治疗组较大胎儿脑室周围白质软化症的发生率为4/28（14.3%），激光治疗组为1/17（5.9%）（P = 0.63）。