University of Colorado School of Medicine, Aurora, CO.
Colorado Fetal Care Center, Aurora, CO.
Am J Obstet Gynecol MFM. 2019 Mar;1(1):74-81. doi: 10.1016/j.ajogmf.2019.02.001. Epub 2019 Mar 27.
Despite improvements in fetal survival for pregnancies affected by twin-twin transfusion syndrome since the introduction of laser photocoagulation, prematurity remains a major source of neonatal morbidity and mortality.
To investigate the indications and factors influencing the timing of delivery following laser treatment, we collected delivery information regarding twin-twin transfusion syndrome cases in a large multicenter cohort.
Eleven North American Fetal Therapy Network (NAFTNet) centers conducted a retrospective review of twin-twin transfusion syndrome patients who underwent laser photocoagulation. Clinical, demographic and ultrasound variables including twin-twin transfusion syndrome stage, and gestational age at treatment and delivery were recorded. Primary and secondary maternal and fetal indications for delivery were identified. Univariate analysis was used to select candidate variables with significant correlation with latency and GA at delivery. Multivariable Cox regression with competing risk analysis was utilized to determine the independent associations.
A total of 847 pregnancies were analyzed. After laser, the average latency to delivery was 10.11 ± 4.8 weeks and the mean gestational age at delivery was 30.7 ± 4.5 weeks. Primary maternal indications for delivery comprised 79% of cases. The leading indications included spontaneous labor (46.8%), premature rupture of membranes (17.1%), and placental abruption (8.4%). Primary fetal indications accounted for 21% of cases and the most frequent indications included donor non-reassuring status (20.5%), abnormal donor Dopplers (15.1%), and donor growth restriction (14.5%). The most common secondary indications for delivery were premature rupture of membranes, spontaneous labor and donor growth restriction. Multivariate modeling found gestational age at diagnosis, stage, history of prior amnioreduction, cerclage, interwin membrane disruption, procedure complications and chorioamniotic membrane separation as predictors for both gestational age at delivery and latency.
Premature delivery after laser therapy for twin-twin transfusion syndrome is primarily due to spontaneous labor, preterm premature rupture of membranes and non-reassuring status of the donor fetus. Placental abruption was found to be a frequent complication resulting in early delivery. Future research should be directed toward the goal of prolonging gestation after laser photocoagulation to further reduce morbidity and mortality associated with twin-twin transfusion syndrome.
尽管自激光光凝术应用于双胎输血综合征以来，受影响妊娠胎儿的存活率有所提高，但早产仍是新生儿发病率和死亡率的主要原因。
为了研究激光治疗后分娩的适应证和影响分娩时机的因素，我们收集了一个大型多中心队列中双胎输血综合征病例的分娩信息。
北美胎儿治疗网络（NAFTNet）的 11 个中心对接受激光光凝治疗的双胎输血综合征患者进行了回顾性分析。记录了临床、人口统计学和超声变量，包括双胎输血综合征的分期，治疗和分娩时的孕周。确定了分娩的主要和次要母婴和胎儿适应证。采用单变量分析选择与潜伏期和分娩时孕周有显著相关性的候选变量。采用竞争风险分析的多变量 Cox 回归来确定独立关联。
共分析了 847 例妊娠。激光治疗后，平均分娩潜伏期为 10.11 ± 4.8 周，平均分娩孕周为 30.7 ± 4.5 周。分娩的主要母体适应证占 79%。主要适应证包括自发性分娩（46.8%）、胎膜早破（17.1%）和胎盘早剥（8.4%）。主要胎儿适应证占 21%，最常见的适应证包括供体状态不稳定（20.5%）、供体多普勒异常（15.1%）和供体生长受限（14.5%）。最常见的次要分娩适应证是胎膜早破、自发性分娩和供体生长受限。多变量模型发现诊断时的孕周、分期、既往羊水减量史、宫颈环扎术、双胎间胎膜破裂、手术并发症和羊膜绒毛膜分离是分娩时孕周和潜伏期的预测因素。
激光治疗双胎输血综合征后早产主要是由于自发性分娩、早产胎膜早破和供体胎儿状态不稳定。胎盘早剥是导致早产的常见并发症。未来的研究应致力于延长激光光凝术后的妊娠时间，以进一步降低与双胎输血综合征相关的发病率和死亡率。
