Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Pasadena, CA, USA.
Childbirth Research Associates, North Hollywood, CA, USA.
J Matern Fetal Neonatal Med. 2022 Mar;35(6):1184-1191. doi: 10.1080/14767058.2020.1745177. Epub 2020 Mar 31.
Optimal surgical management of monochorionic diamniotic twins complicated by selective intrauterine growth restriction (SIUGR) type II is unknown. Surgical management may involve selective laser photocoagulation of communicating vessels (SLPCV), which offers the possibility of dual twin survivors versus umbilical cord occlusion (UCO) of the SIUGR twin.
To identify patient characteristics associated with SIUGR twin survival for those undergoing SLPCV.
All patients studied were those who underwent fetal treatment for SIUGR type II at our center from 2006-2018. SIUGR type II was defined as an estimated fetal weight <10th percentile with persistent absent and/or reversed end diastolic flow in the umbilical artery of the SIUGR twin, in the absence of twin-twin transfusion syndrome. Patients were offered SLPCV versus UCO, and those undergoing SLPCV, patient characteristics associated with 30-day survival of the SIUGR twin were examined using bivariate analysis and multiple logistic regression models.
Fifty-four consecutive SIUGR type II patients were treated, 45 SLPCV and nine UCO. Of the 45 SLPCV cases, there were 16 (35.6%) with SIUGR twin (and dual) survival. SIUGR twin survival appeared associated with middle cerebral artery (MCA) peak systolic velocity (psv) <1.5 multiples of the median, and forward atrial systolic flow in the ductus venosus (DV). In a analysis, we subsequently categorized patients as: SIUGR type IIa ( = 32 (71.1%)): normal MCA psv, and normal DV waveform, versus SIUGR type IIb ( = 13 (28.9%)): MCA psv ≥1.5 multiples of the median, and/or DV with absent or reversed atrial systolic flow. Thirty-day survival of the SIUGR twin was 50% for type IIa and 0% for type IIb.
Over one-third of SIUGR type II patients experienced dual survival after treatment with laser surgery. Normal MCA psv and normal DV waveforms were associated with SIUGR type II survival of the SIUGR twin. exploration and subclassification of SIUGR type II patients by preoperative Doppler indices created two groups, one (type IIa) with 50% survival and one (type IIb) with 0% survival of the SIUGR twin after laser surgery. Upon further confirmation, these findings may provide guidance for counseling patients and conducting fetal therapy.
患有选择性胎儿宫内生长受限（SIUGR）Ⅱ型的单绒毛膜双羊膜囊双胎的最佳手术治疗方法尚不清楚。手术治疗可能涉及交通血管选择性激光凝固术（SLPCV），该手术有双重存活的可能性，而 SIUGR 胎儿的脐带阻塞（UCO）则没有。
确定接受 SLPCV 的 SIUGR 胎儿存活相关的患者特征。
所有接受研究的患者均为 2006 年至 2018 年在本中心接受 SIUGR Ⅱ型胎儿治疗的患者。SIUGR Ⅱ型定义为估计胎儿体重低于第 10 百分位，且 SIUGR 胎儿的脐动脉中持续存在无和/或反向舒张末期血流，而无双胎输血综合征。为患者提供 SLPCV 与 UCO 治疗，对接受 SLPCV 的患者，使用双变量分析和多变量逻辑回归模型检查与 SIUGR 胎儿 30 天存活相关的患者特征。
54 例连续的 SIUGR Ⅱ型患者接受了治疗，其中 45 例接受了 SLPCV，9 例接受了 UCO。在 45 例 SLPCV 病例中，有 16 例（35.6%）SIUGR 胎儿（和双重）存活。SIUGR 胎儿存活似乎与大脑中动脉（MCA）收缩期峰值速度（psv）<1.5 个中位数倍数和卵圆孔未闭（DV）中的前房收缩期血流有关。在 分析中，我们随后将患者分为以下两类：SIUGR Ⅱ a（ = 32（71.1%））：MCA psv 正常，DV 波型正常，与 SIUGR Ⅱ b（ = 13（28.9%））：MCA psv≥1.5 个中位数倍数，和/或 DV 存在无或反向房收缩期血流。SIUGR 胎儿的 30 天存活率为 SIUGR Ⅱ a 组的 50%，SIUGR Ⅱ b 组的 0%。
超过三分之一的 SIUGR Ⅱ型患者在接受激光手术后经历了双重存活。正常的 MCA psv 和正常的 DV 波型与 SIUGR 胎儿的存活有关。通过术前多普勒指数对 SIUGR Ⅱ型患者进行探索和分类，创建了两个组，一个（Ⅱ a 型）的 SIUGR 胎儿存活率为 50%，另一个（Ⅱ b 型）的 SIUGR 胎儿存活率为 0%。在进一步确认后，这些发现可能为患者咨询和胎儿治疗提供指导。
