Departments of Fetal Maternal Medicine, National Nagara Medical Center, Gifu City, Gifu, Japan.
Departments of Fetal Maternal Medicine, National Nagara Medical Center, Gifu City, Gifu, Japan.
Eur J Obstet Gynecol Reprod Biol. 2019 Oct;241:82-87. doi: 10.1016/j.ejogrb.2019.08.012. Epub 2019 Aug 23.
Some monochorionic twin pregnancies need intensive cardiac management even in the absence of twin-to-twin transfusion syndrome after birth. The purpose of this study was to investigate risk factors related to persistent hypotension requiring cardiotonic agent use among monochorionic twin pregnancies without twin-to-twin transfusion syndrome.
This was a retrospective study of 316 monochorionic twin pregnancies without twin-to-twin transfusion syndrome (632 babies). All cases were treated in the neonatal intensive care unit. Hypotension was defined as mean arterial blood pressure below the norm for gestational age. Decreased left ventricular ejection fraction was defined as a value <60%. Dopamine, dobutamine and phosphodiesterase III inhibitor were used as cardiotonic agents for hypotension persisting even after adequate infusion.
Among the 632 cases, 33 (5.2%) needed cardiotonic agents for persistent hypotension. The frequency of persistent hypotension with decreased left ventricular ejection fraction was significantly higher among larger twins (4.4%) than among smaller twins (0.6%, p = 0.0038). In larger twins, multivariate analysis showed that Z-score for cardiothoracic area ratio (odds ratio, 2.31; p < 0.001), tricuspid regurgitation (odds ratio, 6.34; p = 0.015) and gestational age at delivery (odds ratio, 0.66; p < 0.001) correlated with persistent hypotension. In smaller twins, univariate analysis showed gestational age at delivery, birth weight, Z-score for birth weight and Z-score for cardiothoracic area ratio of the larger twin were related to persistent hypotension. Concentration of brain natriuretic peptide in the umbilical vein in larger and smaller twins were significantly correlated (coefficient of correlation = 0.792, p < 0.001).
In monochorionic twin pregnancies, attention needs to be given to cardiac size along with amniotic fluid and fetal growth. Both larger and smaller twins carry risks of persistent hypotension after birth. Close observation is needed, especially in cases where the larger twin displays cardiomegaly despite absence of twin-to-twin transfusion syndrome.
即使在出生后没有双胎输血综合征的情况下，一些单绒毛膜双胞胎妊娠也需要进行强化心脏管理。本研究的目的是调查与无双胎输血综合征的单绒毛膜双胞胎妊娠中持续低血压需要使用强心剂相关的危险因素。
这是一项对 316 例无双胎输血综合征的单绒毛膜双胞胎妊娠（632 例婴儿）的回顾性研究。所有病例均在新生儿重症监护病房接受治疗。低血压定义为平均动脉血压低于胎龄正常范围。左心室射血分数降低定义为<60%。多巴胺、多巴酚丁胺和磷酸二酯酶 III 抑制剂被用作低血压持续存在（即使充分输液后）的强心剂。
在 632 例中，33 例（5.2%）因持续低血压需要使用强心剂。较大双胞胎（4.4%）中左心室射血分数降低的持续低血压发生率明显高于较小双胞胎（0.6%，p=0.0038）。在较大双胞胎中，多变量分析显示心胸面积比 Z 评分（比值比，2.31；p<0.001）、三尖瓣反流（比值比，6.34；p=0.015）和分娩时的胎龄（比值比，0.66；p<0.001）与持续低血压相关。在较小双胞胎中，单变量分析显示分娩时的胎龄、出生体重、较大双胞胎的出生体重 Z 评分和心胸面积比 Z 评分与持续低血压相关。较大和较小双胞胎的脐静脉脑利钠肽浓度呈显著相关（相关系数=0.792，p<0.001）。
在单绒毛膜双胞胎妊娠中，需要注意羊水和胎儿生长情况的同时注意心脏大小。较大和较小的双胞胎在出生后都有持续低血压的风险。需要密切观察，特别是在较大双胞胎尽管没有双胎输血综合征但出现心胸扩大的情况下。
