Fetal Medicine Unit, Department of Obstetrics and Gynecology, La Paz Hospital, La Paz Hospital, Medical Faculty of Autónoma University, Madrid, Spain.
J Matern Fetal Neonatal Med. 2021 Dec;34(23):3838-3843. doi: 10.1080/14767058.2019.1698030. Epub 2019 Dec 3.
Selective intrauterine growth restriction (sIUGR) is a complication observed in about 10-15% of all monochorionic (MC) pregnancies, causing a significant increase in perinatal mortality and morbidity.
To evaluate clinical management options and perinatal outcomes of sIUGR in MC pregnancies monitored in a single tertiary center.
A retrospective study was performed on 55-MC pregnancies with sIUGR between January 2012 and May 2018 at the Fetal Medicine Unit of La Paz Hospital. Cases were classified according to the umbilical artery (UA) Doppler pattern as type I (positive end-diastolic flow; = 25), type II [persistently absent or reversed end-diastolic flow (AREDF); = 5] and type III [intermittently absent or reversed end-diastolic flow (iAREDF); = 25]. Types II and III were then merged together as severe sIUGR cases. Subsequently, two possible approaches were considered: expectant management (EM) with elective preterm delivery in case of fetal deterioration, or in-utero therapy fetoscopic laser photocoagulation (FLP) of intertwin anastomosis or selective umbilical cord occlusion (CO) of the growth-restricted fetus.
Gestational age (GA) at diagnosis was progressively lower with each type. Severe sIUGR cases delivered significantly earlier than type I, showing lower birth weights and higher intertwin biometric discordance. Unintended fetal demise occurred in 14% (6/25) of severe sIUGR pregnancies as opposed to 0% (0/19) in type I, = .028. A significantly higher proportion of twins was admitted in NICU in severe cases when compared to type I [87% (33/38) versus 47% (18/38), < .001]. In addition, brain damage at birth was also found to be more prevalent in this group [21% (8/38) versus 11% (4/38), = .346], especially in the larger twin, when comparing any short-term neurological sequel [30% (7/23) versus 0% (0/19), = .011] or specifically periventricular leukomalacia [PVL; 22% (5/23) versus 0% (0/19), = .053]. Although the overall mortality rate was significantly higher in severe sIUGR that underwent CO instead of EM [58% (7/12) versus 11% (4/36), = .002], NICU admissions were higher in the latter [94% (17/18) versus 40% (2/5), = .021]. Neurological sequels at birth were similar in both groups [39% (7/18) versus 40% (2/5), = 1.000], similarly when considering only the larger twin for any brain lesion [28% (5/18) versus 40% (2/5), = .621] or just PVL [22% (4/18) versus 20% (1/5), = 1.000].
Given the good prognosis of type I sIUGR, expectant management is the first approach to consider. However, due to the poorer clinical evolution of types II and III sIUGR, the decision-making is challenging and needs to be individualized depending on the UA Doppler pattern, GA at diagnosis, severity of growth restriction and biometric discordance, technical issues and parents' preferences.
选择性宫内生长受限（sIUGR）是约 10-15%的单绒毛膜（MC）妊娠中观察到的一种并发症，导致围产期死亡率和发病率显著增加。
评估在单一三级中心监测的 MC 妊娠中 sIUGR 的临床管理选择和围产结局。
对 2012 年 1 月至 2018 年 5 月在拉巴斯医院胎儿医学科接受 sIUGR 的 55 例 MC 妊娠进行回顾性研究。根据脐动脉（UA）多普勒模式将病例分类为 I 型（正末期血流；=25）、II 型[持续无或反向末期血流（AREDF）；=5]和 III 型[间歇性无或反向末期血流（iAREDF）；=25]。然后，将 II 型和 III 型合并为严重 sIUGR 病例。随后，考虑了两种可能的方法：择期早产的期待管理（EM），以防胎儿恶化，或宫内治疗 胎儿镜激光凝固术（FLP）治疗双胎间吻合口或选择性脐带闭塞（CO）限制胎儿生长。
每种类型的诊断时的孕龄（GA）逐渐降低。严重 sIUGR 病例的分娩时间明显早于 I 型，出生体重较低，双胎间生物计量差异较大。意外胎儿死亡发生在 14%（6/25）的严重 sIUGR 妊娠中，而 I 型为 0%（0/19），=0.028。与 I 型相比，严重病例中更多的双胞胎被收治在 NICU [87%（33/38）与 47%（18/38），<0.001]。此外，出生时脑损伤在该组中也更为常见[21%（8/38）与 11%（4/38），=0.346]，尤其是在较大的双胞胎中，当比较任何短期神经后遗症时 [30%（7/23）与 0%（0/19），=0.011]或特定的脑室周围白质软化症[PVL；22%（5/23）与 0%（0/19），=0.053]。尽管接受 CO 而不是 EM 的严重 sIUGR 的总体死亡率显著更高[58%（7/12）与 11%（4/36），=0.002]，但后者的 NICU 入住率更高[94%（17/18）与 40%（2/5），=0.021]。两组出生时的神经后遗症相似[39%（7/18）与 40%（2/5），=1.000]，当仅考虑较大的双胞胎时，任何脑部病变也相似[28%（5/18）与 40%（2/5），=0.621]或仅为 PVL[22%（4/18）与 20%（1/5），=1.000]。
鉴于 I 型 sIUGR 的良好预后，期待管理是首先要考虑的方法。然而，由于 II 型和 III 型 sIUGR 的临床演变较差，决策具有挑战性，需要根据 UA 多普勒模式、诊断时的 GA、生长受限的严重程度和生物计量差异、技术问题和父母的偏好进行个体化。
