Weiner Eran, Dekalo Ann, Feldstein Ohad, Barber Elad, Schreiber Letizia, Bar Jacob, Kovo Michal
Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel(1).
Department of Obstetrics & Gynecology, The Edith Wolfson Medical Center, Holon, Israel(1).
Eur J Obstet Gynecol Reprod Biol. 2017 Jul;214:1-5. doi: 10.1016/j.ejogrb.2017.04.035. Epub 2017 Apr 22.
The association between infection and inflammatory response in singleton preterm birth (PTB) is well established, yet, less is known about PTB in twins. We aimed to compare the placental component and pregnancy outcome in pregnancies complicated with PTB of singletons vs. twin deliveries. We hypothesized that due to different underlying mechanisms, placental inflammatory lesions will be more prevalent in placentas derived from singleton pregnancies than twins.
Labor characteristics, neonatal outcome and placental histopathology reports of spontaneous PTB at 24-33/ weeks, from 1/2008-12/2015, were reviewed.
were compared between dichorionic-diamniotic twin deliveries (twins group) and singleton deliveries (singleton group) matched for gestational age. Excluded from the study medically indicated deliveries, due to preeclampsia or fetal growth restriction, and monochorionic twins. Placental lesions were classified to maternal vascular supply lesions, fetal vascular supply lesions, and maternal (MIR) and fetal (FIR) inflammatory responses. Composite neonatal outcome was defined as one or more of early complications: respiratory distress, necrotizing enterocolitis, sepsis, blood transfusion, ventilation, seizures, intra-ventricular hemorrhage, hypoglycemia, phototherapy, or death.
The twins group (n=72) was characterized by higher maternal BMI (p=0.009), and higher rates of assisted reproductive techniques (56.2% vs. 17.8%, p<0.001) and cesarean deliveries (75.3% vs. 32.8%, p<0.001) as compared to the singleton group (n=72). Placentas from the singleton group were characterized by higher rate of MIR, 58.9% vs. 19.2%, (p<0.001), FIR, 31.5% vs. 3.4%, (p<0.001), retro-placental hemorrhage, 26% vs. 8.9% (p<0.001), and vascular lesions related to maternal malperfusion, 28.8% vs. 9.6%, (p<0.001), as compared to placentas from the twins group. Higher rate of neonatal sepsis was observed in the singleton group as compared to the twins group, 24.7% vs. 4.1%, p<0.001, respectively. By logistic regression analyses retro-placental hemorrhage, placental maternal vascular malperfusion lesions, MIR, FIR and neonatal sepsis were found to be independently associated with singleton PTB: aOR 3.4, 95% CI 2.1-6.9, p<0.001, aOR=3.1, 95% CI 1.8-7.2, p<0.001, aOR=2.9, 95% CI 1.4-7.8, p<0.001, aOR=4.9, 95% CI 2.3-6.9, p<0.001, and aOR=4.8, 95% CI 2.3-6.7, p<0.001 respectively.
Placentas from singleton PTBs are characterized by higher rate of inflammatory and malperfusion lesions. The lack of these findings in twins PTBs suggests different factors that participate in the development of preterm birth in twins, such as over-distension of the uterus and up regulation of oxytocin receptors.
单胎早产(PTB)中感染与炎症反应之间的关联已得到充分证实,但双胎PTB的相关情况却知之甚少。我们旨在比较单胎与双胎分娩并发PTB时的胎盘成分及妊娠结局。我们推测,由于潜在机制不同,单胎妊娠胎盘的炎症性病变会比双胎妊娠胎盘更为普遍。
回顾了2008年1月至2015年12月期间24 - 33⁺/₇周自发性PTB的分娩特征、新生儿结局及胎盘组织病理学报告。
比较了双绒毛膜双羊膜囊双胎分娩(双胎组)与孕周匹配的单胎分娩(单胎组)。因子痫前期或胎儿生长受限而进行的医学指征分娩以及单绒毛膜双胎被排除在研究之外。胎盘病变分为母体血管供应病变、胎儿血管供应病变以及母体(MIR)和胎儿(FIR)炎症反应。综合新生儿结局定义为以下一种或多种早期并发症:呼吸窘迫、坏死性小肠结肠炎、败血症、输血、通气、惊厥、脑室内出血、低血糖、光疗或死亡。
与单胎组(n = 72)相比,双胎组(n = 72)的特征为母体BMI较高(p = 0.009),辅助生殖技术使用率较高(56.2%对17.8%,p < 0.001)以及剖宫产率较高(75.3%对32.8%,p < 0.001)。与双胎组胎盘相比,单胎组胎盘的特征为MIR发生率较高,分别为58.9%对19.2%(p < 0.001),FIR发生率较高,分别为31.5%对3.4%(p < 0.001),胎盘后出血发生率较高,分别为26%对8.9%(p < 0.001),以及与母体灌注不良相关的血管病变发生率较高,分别为28.8%对9.6%(p < 0.001)。与双胎组相比,单胎组新生儿败血症发生率较高,分别为24.7%对4.1%,p < 0.001。通过逻辑回归分析发现,胎盘后出血、胎盘母体血管灌注不良病变、MIR、FIR及新生儿败血症与单胎PTB独立相关:调整后比值比(aOR)分别为3.4,95%置信区间(CI)2.1 - 6.9,p < 0.001;aOR = 3.1,95% CI 1.8 - 7.2,p < 0.001;aOR = 2.9,95% CI 1.4 - 7.8,p < 0.001;aOR = 4.9,95% CI 2.3 - 6.9,p < 0.001;aOR = 4.8,95% CI 2.3 - 6.7,p < 0.001。
单胎PTB的胎盘具有较高的炎症和灌注不良病变发生率。双胎PTB中缺乏这些表现提示参与双胎早产发生发展的因素不同,如子宫过度扩张和催产素受体上调。