Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.
Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.
Ultrasound Obstet Gynecol. 2020 Dec;56(6):821-830. doi: 10.1002/uog.21975.
To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies.
This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3 centile in one twin or at least two of the following: EFW of one twin < 10 centile, abdominal circumference of one twin < 10 centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95 centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling.
We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival.
Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
根据新的德尔福共识定义，报告选择性胎儿生长受限（sFGR）的结局，并确定单绒毛膜双羊膜囊双胎妊娠中存活的潜在预测因素。
这是一项回顾性研究，对从孕早期开始连续监测的单绒毛膜双羊膜囊双胎妊娠进行研究，妊娠 16、20 或 30 周时根据新的德尔福共识标准诊断为 sFGR。sFGR 的定义为：一胎的估计胎儿体重（EFW）<第 3 百分位数，或至少存在以下两种情况：一胎的 EFW<第 10 百分位数、一胎的腹围<第 10 百分位数、EFW 差值≥25%或较小胎的脐动脉搏动指数>第 95 百分位数。主要结局是总体存活率（出生后 28 天）和一胎或双胎丢失的风险。我们进一步使用单变量和多变量广义估计方程模型来确定存活的可能预测因素。
我们分析了 675 例妊娠，其中 177 例（26%）在 16、20 或 30 周时被诊断为 sFGR。总的存活率为 313/354（88%），其中 146/177（82%）例妊娠的双胎存活，21/177（12%）例妊娠的一胎存活，10/177（6%）例妊娠的双胎丢失。随后有 6/177（3%）例发生双胎贫血-红细胞增多序列（TAPS），17/177（10%）例发生双胎输血综合征（TTTS）。所有 TAPS 胎儿均存活。随后发生 TTTS 的 sFGR 妊娠的存活率为 65%（22/34），而无后续 TAPS 或 TTTS 的孤立 sFGR 妊娠的存活率为 91%（279/308）（P<0.001）。大多数 sFGR 病例为 I 型（110/177（62%）），存活率为 96%（212/220），而 II 型（P<0.001）和 III 型（P=0.006）sFGR 的存活率分别为 55%（12/22）和 83%（55/66）。大多数 sFGR 妊娠（130/177（73%））在 16 或 20 周时首次诊断（早发型），存活率为 85%（221/260），而在 30 周时首次诊断（晚发型）的存活率为 98%（92/94）（P=0.04）。至少在一胎中存在主要畸形的 sFGR 病例为 28/177（16%）。在这些妊娠中，存活的有 39/56（70%），而无畸形的存活的有 274/298（92%）（P<0.001）。随后发生 TTTS（优势比（OR），0.18（95%CI，0.06-0.52））、II 型 sFGR（OR，0.06（95%CI，0.02-0.24））和 III 型 sFGR（OR，0.21（95%CI，0.07-0.60））以及至少一胎存在主要畸形（OR，0.12（95%CI，0.04-0.34））与存活率降低独立相关，但首次诊断时的胎龄与存活率无关。
孤立性 sFGR 与单绒毛膜双羊膜囊双胎妊娠 90%的存活率相关。随后发生 TTTS、较小胎的脐动脉舒张末期血流缺失或反转以及存在主要畸形会对 sFGR 的存活产生不利影响。版权所有 2020 ISUOG。由 John Wiley & Sons Ltd 出版。
