National Referral Centre for Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants-Malades, 75015, Paris, France.
Prenat Diagn. 2013 Feb;33(2):109-15. doi: 10.1002/pd.4031. Epub 2012 Dec 26.
This study aims to compare outcomes of active management of monochorionic diamniotic twin pregnancies complicated with severe intrauterine growth restriction (IUGR) of one twin before 24 weeks with continuous or intermittent absent or reversed end-diastolic flow (AREDF) in the umbilical artery, with or without twin-to-twin transfusion syndrome (TTTS).
This study is a retrospective comparison of 45 consecutive cases of severe selective IUGR (s-IUGR) defined as an estimated fetal weight at or below the fifth centile with a >25% weight discordance and AREDF in the umbilical artery before 24 weeks and 166 consecutive cases of TTTS stage III, with AREDF in the donor (TTTS3D) and also with s-IUGR. These were treated by either selective laser photocoagulation of chorionic vessels (SLPCV) or cord coagulation (CC).
The 166 cases of TTTS3D were treated by SLPCV, whereas 23 and 22 cases of s-IUGR were treated by SLPCV and CC, respectively. Overall survival was 52.17% or 45.45% in s-IUGR treated by SLPCV or CC, respectively, and 48.49% in TTTS3D. The survival of appropriately grown for gestational age (AGA) twins following CC (90.9%) was higher than that following SLPCV in s-IUGR (74%) or in recipient twins of TTTS3D (55.42%) (p = 0.001). Survival of the IUGR twin was 30% and 41.56% with SLPCV in s-IUGR and TTTS3D, respectively.
Active management of severe IUGR with AREDF in the umbilical artery seems beneficial. Survival rates with SLPCV were similar in s-IUGR and TTTS3D. However, there was a trend for higher survival rates in the AGA twin for CC. The choice of the technique should be driven by objective counseling on survival of both IUGR and AGA twins and therefore by the utility-based ethical values expressed by the pregnant woman.
本研究旨在比较 24 周前患有严重胎儿宫内生长受限（IUGR）的单绒毛膜双羊膜囊双胎中，脐动脉搏动指数（UA-PI）呈持续或间歇性无舒张末期血流（AREDF）或反向舒张末期血流（REDF）与存在或不存在双胎输血综合征（TTTS）的病例的结局。
本研究回顾性比较了 45 例严重选择性胎儿宫内生长受限（s-IUGR）病例（定义为估计胎儿体重低于第 5 百分位且体重差异大于 25%，且在 24 周前脐动脉出现 AREDF）和 166 例 TTTS Ⅲ期病例（脐动脉中存在 AREDF 的 TTTS3D），接受了选择性激光凝固胎盘血管（SLPCV）或脐带凝固（CC）治疗。
166 例 TTTS3D 接受了 SLPCV 治疗，而 23 例和 22 例 s-IUGR 分别接受了 SLPCV 和 CC 治疗。s-IUGR 接受 SLPCV 或 CC 治疗的总存活率分别为 52.17%和 45.45%，TTTS3D 为 48.49%。CC 治疗的 s-IUGR 中适当生长（AGA）双胞胎的存活率（90.9%）高于 SLPCV 治疗的 s-IUGR（74%）或 TTTS3D 中受血儿（55.42%）（p = 0.001）。s-IUGR 和 TTTS3D 中，SLPCV 治疗的 IUGR 双胞胎的存活率分别为 30%和 41.56%。
对伴有脐动脉 AREDF 的严重 IUGR 进行积极管理似乎是有益的。s-IUGR 和 TTTS3D 中 SLPCV 的生存率相似。然而，CC 治疗的 AGA 双胞胎的生存率有升高的趋势。技术的选择应基于对 IUGR 和 AGA 双胞胎的生存情况进行客观咨询，并基于孕妇表达的基于效用的伦理价值观。
