Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy.
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.
Ultrasound Obstet Gynecol. 2020 Dec;56(6):811-820. doi: 10.1002/uog.22054. Epub 2020 Nov 12.
To report the outcome of pregnancies complicated by twin-twin transfusion syndrome (TTTS) according to Quintero stage.
MEDLINE, EMBASE and CINAHL databases were searched for studies reporting the outcome of pregnancies complicated by TTTS stratified according to Quintero stage (I-V). The primary outcome was fetal survival rate according to Quintero stage. Secondary outcomes were gestational age at birth, preterm birth (PTB) before 34, 32 and 28 weeks' gestation and neonatal morbidity. Outcomes are reported according to the different management options (expectant management, laser therapy or amnioreduction) for pregnancies with Stage-I TTTS. Only cases treated with laser therapy were considered for those with Stages-II-IV TTTS and only cases managed expectantly were considered for those with Stage-V TTTS. Random-effects head-to-head meta-analysis was used to analyze the extracted data.
Twenty-six studies (2699 twin pregnancies) were included. Overall, 610 (22.6%) pregnancies were diagnosed with Quintero stage-I TTTS, 692 (25.6%) were Stage II, 1146 (42.5%) were Stage III, 247 (9.2%) were Stage IV and four (0.1%) were Stage V. Survival of at least one twin occurred in 86.9% (95% CI, 84.0-89.7%) (456/552) of pregnancies with Stage-I, in 85% (95% CI, 79.1-90.1%) (514/590) of those with Stage-II, in 81.5% (95% CI, 76.6-86.0%) (875/1040) of those with Stage-III, in 82.8% (95% CI, 73.6-90.4%) (172/205) of those with Stage-IV and in 54.6% (95% CI, 24.8-82.6%) (5/9) of those with Stage-V TTTS. The rate of a pregnancy with no survivor was 11.8% (95% CI, 8.4-15.8%) (69/564) in those with Stage-I, 15.0% (95% CI, 9.9-20.9%) (76/590) in those with Stage-II, 18.6% (95% CI, 14.2-23.4%) (165/1040) in those with Stage-III, 17.2% (95% CI, 9.6-26.4%) (33/205) in those with Stage-IV and in 45.4% (95% CI, 17.4-75.2%) (4/9) in those with Stage-V TTTS. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS. Overall, the incidence of PTB and neonatal morbidity increased as the severity of TTTS increased, but data on these two outcomes were limited by the small sample size of the included studies. When stratifying the analysis of pregnancies with Stage-I TTTS according to the type of intervention, the rate of fetal survival of at least one twin was 84.9% (95% CI, 70.4-95.1%) (94/112) in cases managed expectantly, 86.7% (95% CI, 82.6-90.4%) (249/285) in those undergoing laser therapy and 92.2% (95% CI, 84.2-97.6%) (56/60) in those after amnioreduction, while the rate of double survival was 67.9% (95% CI, 57.0-77.9%) (73/108), 69.7% (95% CI, 61.6-77.1%) (203/285) and 80.8% (95% CI, 62.0-94.2%) (49/60), respectively.
Overall survival in monochorionic diamniotic pregnancies affected by TTTS is higher for earlier Quintero stages (I and II), but fetal survival rates are moderately high even in those with Stage-III or -IV TTTS when treated with laser therapy. Gestational age at birth was similar in pregnancies with Stages-I-III TTTS, and gradually decreased in those with Stages-IV and -V TTTS treated with laser and expectant management, respectively. In pregnancies affected by Stage-I TTTS, amnioreduction was associated with slightly higher survival compared with laser therapy and expectant management, although these findings may be confirmed only by future head-to-head randomized trials. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
根据 Quintero 分期报告双胎输血综合征（TTTS）妊娠的结局。
检索 MEDLINE、EMBASE 和 CINAHL 数据库，以获取根据 Quintero 分期（I-V 期）分层报告 TTTS 妊娠结局的研究。主要结局是根据 Quintero 分期的胎儿存活率。次要结局是出生时的胎龄、34 周前、32 周前和 28 周前早产以及新生儿发病率。根据不同的管理选择（期待治疗、激光治疗或羊水减少）报告妊娠合并 I 期 TTTS 的结果。仅考虑对 II-IV 期 TTTS 进行激光治疗的病例，仅对 V 期 TTTS 进行期待治疗的病例进行处理。使用随机效应头对头荟萃分析对提取的数据进行分析。
纳入了 26 项研究（2699 对双胎妊娠）。总体而言，610 例（22.6%）妊娠被诊断为 Quintero 分期 I 期 TTTS，692 例（25.6%）为 II 期，1146 例（42.5%）为 III 期，247 例（9.2%）为 IV 期，4 例（0.1%）为 V 期。在 I 期 TTTS 中，至少有 1 个胎儿存活的发生率为 86.9%（95%CI，84.0-89.7%）（456/552），在 II 期 TTTS 中为 85%（95%CI，79.1-90.1%）（514/590），在 III 期 TTTS 中为 81.5%（95%CI，76.6-86.0%）（875/1040），在 IV 期 TTTS 中为 82.8%（95%CI，73.6-90.4%）（172/205），在 V 期 TTTS 中为 54.6%（95%CI，24.8-82.6%）（5/9）。在 I 期 TTTS 中，无存活胎儿的妊娠率为 11.8%（95%CI，8.4-15.8%）（69/564），在 II 期 TTTS 中为 15.0%（95%CI，9.9-20.9%）（76/590），在 III 期 TTTS 中为 18.6%（95%CI，14.2-23.4%）（165/1040），在 IV 期 TTTS 中为 17.2%（95%CI，9.6-26.4%）（33/205），在 V 期 TTTS 中为 45.4%（95%CI，17.4-75.2%）（4/9）。I-III 期 TTTS 妊娠的出生胎龄相似，而 IV-V 期 TTTS 妊娠的出生胎龄逐渐降低。总体而言，随着 TTTS 严重程度的增加，PTB 和新生儿发病率增加，但纳入研究的样本量较小，限制了这两个结局的数据。当根据干预类型对 I 期 TTTS 妊娠进行分层分析时，至少有 1 个胎儿存活的妊娠率为期待治疗者 84.9%（95%CI，70.4-95.1%）（94/112），激光治疗者 86.7%（95%CI，82.6-90.4%）（249/285），羊水减少者 92.2%（95%CI，84.2-97.6%）（56/60），而双胎存活的妊娠率分别为 67.9%（95%CI，57.0-77.9%）（73/108），69.7%（95%CI，61.6-77.1%）（203/285）和 80.8%（95%CI，62.0-94.2%）（49/60）。
总的来说，受 TTTS 影响的单绒毛膜双羊膜囊妊娠的整体存活率在早期 Quintero 分期（I 和 II）较高，但即使在接受激光治疗的 III 期或 IV 期 TTTS 中，胎儿存活率也相当高。I-III 期 TTTS 妊娠的出生胎龄相似，而分别接受激光治疗和期待治疗的 IV-V 期 TTTS 妊娠的出生胎龄逐渐降低。在 I 期 TTTS 中，与激光治疗和期待治疗相比，羊水减少与略高的存活率相关，尽管这些发现可能仅通过未来的头对头随机试验得到证实。版权所有©2020 ISUOG。由 John Wiley & Sons Ltd 出版。
