Ontario Fetal Centre, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
Fetal Medicine Unit &Prenatal Diagnosis Center, Shanghai 1st Maternity and Infant Hospital of Tongji University, Shanghai, China.
Ultrasound Obstet Gynecol. 2021 Jan;57(1):126-133. doi: 10.1002/uog.23515.
Type-III selective intrauterine growth restriction (sIUGR) is associated with a high and unpredictable risk of fetal death and fetal brain injury. The objective of this study was to describe the prospective risk of fetal death and the risk of adverse neonatal outcome in a cohort of twin pregnancies complicated by Type-III sIUGR and treated according to up-to-date guidelines.
We reviewed retrospectively all monochorionic diamniotic twin pregnancies complicated by Type-III sIUGR managed at nine fetal centers over a 12-year period. Higher-order multiple gestations and pregnancies with major fetal anomalies or other monochorionicity-related complications at initial presentation were excluded. Data on fetal and neonatal outcomes were collected and management strategies reviewed. Composite adverse neonatal outcome was defined as neonatal death, invasive ventilation beyond the resuscitation period, culture-proven sepsis, necrotizing enterocolitis requiring treatment, intraventricular hemorrhage Grade > I, retinopathy of prematurity Stage > II or cystic periventricular leukomalacia. The prospective risk of intrauterine death (IUD) and the risk of neonatal complications according to gestational age were evaluated.
We collected data on 328 pregnancies (656 fetuses). After exclusion of pregnancies that underwent selective reduction (n = 18 (5.5%)), there were 51/620 (8.2%) non-iatrogenic IUDs in 35/310 (11.3%) pregnancies. Single IUD occurred in 19/328 (5.8%) pregnancies and double IUD in 16/328 (4.9%). The prospective risk of non-iatrogenic IUD per fetus declined from 8.1% (95% CI, 5.95-10.26%) at 16 weeks, to less than 2% (95% CI, 0.59-2.79%) after 28.4 weeks and to less than 1% (95% CI, -0.30 to 1.89%) beyond 32.6 weeks. In otherwise uncomplicated pregnancies with Type-III sIUGR, delivery was generally planned at 32 weeks, at which time the risk of composite adverse neonatal outcome was 29.0% (31/107 neonates). In twin pregnancies that continued to 34 weeks, there was a very low risk of IUD (0.7%) and a low risk of composite adverse neonatal outcome (11%).
In this cohort of twin pregnancies complicated by Type-III sIUGR and treated at several tertiary fetal centers, the risk of fetal death was lower than that reported previously. Further efforts should be directed at identifying predictors of fetal death and optimal antenatal surveillance strategies to select a cohort of pregnancies that can continue safely beyond 33 weeks' gestation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
III 型选择性宫内生长受限（sIUGR）与胎儿死亡和胎儿脑损伤的高且不可预测的风险相关。本研究的目的是描述根据最新指南治疗的 III 型 sIUGR 合并双胎妊娠的胎儿死亡的前瞻性风险和不良新生儿结局的风险。
我们回顾性分析了在 12 年内 9 个胎儿中心管理的所有 III 型 sIUGR 合并双胎妊娠。排除多胎妊娠和初始表现存在主要胎儿异常或其他与单绒毛膜性相关并发症的妊娠。收集胎儿和新生儿结局的数据，并回顾管理策略。复合不良新生儿结局定义为新生儿死亡、复苏期后需要侵入性通气、培养证实的败血症、需要治疗的坏死性小肠结肠炎、颅内出血分级> I、早产儿视网膜病变分期> II 或囊性脑室周围白质软化症。评估了宫内死亡（IUD）的前瞻性风险和根据胎龄的新生儿并发症风险。
我们收集了 328 例妊娠（656 例胎儿）的数据。在排除选择性减少（n=18（5.5%））的妊娠后，310 例妊娠中有 51/620（8.2%）发生非医源性 IUD，35/310（11.3%）妊娠。328 例妊娠中，单发 IUD 19 例（5.8%），双发 IUD 16 例（4.9%）。每个胎儿的非医源性 IUD 前瞻性风险从 16 周时的 8.1%（95%CI，5.95-10.26%）下降到 28.4 周时的小于 2%（95%CI，0.59-2.79%），到 32.6 周时的小于 1%（95%CI，-0.30-1.89%）。在其他无并发症的 III 型 sIUGR 合并双胎妊娠中，通常计划在 32 周时分娩，此时复合不良新生儿结局的风险为 29.0%（31/107 例新生儿）。在继续到 34 周的双胎妊娠中，IUD 的风险非常低（0.7%），复合不良新生儿结局的风险较低（11%）。
在本队列中，III 型 sIUGR 合并双胎妊娠，并在多个三级胎儿中心治疗，胎儿死亡的风险低于之前报道的风险。应进一步努力确定胎儿死亡的预测因素和最佳产前监测策略，以选择可以安全继续妊娠至 33 周以上的妊娠。© 2020 年国际超声协会妇产科。
