Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK.
Department of Biomedical, Metabolic and Neural Sciences, International Doctorate School in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy.
Acta Obstet Gynecol Scand. 2021 May;100(5):832-842. doi: 10.1111/aogs.14066. Epub 2021 Jan 12.
Untreated twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity. Laser surgery is recommended before 26 weeks of gestation. However, the optimal management in case of late TTTS (occurring after 26 weeks of gestation) is yet to be established.
We conducted a systematic review and meta-analysis to evaluate the outcomes of monochorionic-diamniotic twin pregnancies complicated by late TTTS according to different management options (expectant, laser therapy, amnioreduction, or delivery). The primary outcome was mortality, including single and double intrauterine, neonatal, and perinatal death. Secondary outcomes were composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (ie, free from neurological complications), and preterm birth before <32 weeks of gestation. Outcomes were reviewed according to the management and reported for the overall population of twins and disease status (ie, donor and recipient separately). Random-effect meta-analyses of proportions were used to analyze the data.
Nine studies including 796 twin pregnancies affected by TTTS were included. No randomized controlled trials were available for inclusion. TTTS occurred at ≥26 weeks of gestation in 8.7% (95% CI 6.9%-10.9%; 67/769) of cases reporting TTTS at all gestations. Intrauterine death occurred in 17.7% (95% CI 4.9%-36.2%) of pregnancies managed expectantly, 5.3% (95% CI 0.9%-12.9%) of pregnancies treated with laser, and 0% (95% CI 0%-9%) after amnioreduction. Neonatal death occurred in 42.5% (95% CI 17.5%-69.7%) of pregnancies managed expectantly, in 2.8% (95% CI 0.3%-7.7%) of cases treated with laser, and in 20.2% (95% CI 6%-40%) after amnioreduction. Only one study (10 cases) reported data on immediate delivery after diagnosis with no perinatal deaths. Perinatal death incidence was 55.7% (95% CI 31.4%-78.6%) in twin pregnancies managed expectantly, 5.6% (95% CI 0.5%-15.3%) in those treated with laser, and 20.2% (95% CI 6%-40%) in those after amnioreduction. Intact survival was reported in 44.4%, 96.4%, and 78% of fetuses managed expectantly, with laser or amnioreduction, respectively.
Evidence regarding perinatal mortality and morbidity in twin pregnancies complicated by late TTTS according to the different managements was of very low quality. Therefore further high-quality research in this field is needed to elucidate the optimal management of these pregnancies.
未经治疗的双胎输血综合征（TTTS）与围产儿死亡率和发病率高有关。建议在 26 孕周前进行激光手术。然而，对于晚期 TTTS（发生在 26 孕周后）的最佳管理尚待确定。
我们进行了系统评价和荟萃分析，以评估根据不同管理选择（期待治疗、激光治疗、羊水减少或分娩）治疗的晚期 TTTS（发生在 26 孕周后）的单绒毛膜-双羊膜双胞胎妊娠的结局。主要结局是死亡率，包括单胎和双胎宫内、新生儿和围产期死亡。次要结局包括复合发病率、神经病变发病率、呼吸窘迫综合征、新生儿重症监护病房入院、完整存活率（即无神经并发症）和 32 孕周前早产。根据管理方法对结局进行了回顾，并按双胞胎的总体人群和疾病状况（即供体和受体分别）进行了报告。使用随机效应荟萃分析对比例数据进行了分析。
纳入了 9 项研究，共纳入了 796 例 TTTS 受影响的双胞胎妊娠。由于所有妊娠报告的 TTTS 均在所有妊娠中占 8.7%（95%CI 6.9%-10.9%；67/769），因此没有纳入随机对照试验。期待治疗的妊娠中宫内死亡发生率为 17.7%（95%CI 4.9%-36.2%），激光治疗的妊娠中宫内死亡发生率为 5.3%（95%CI 0.9%-12.9%），羊水减少治疗的妊娠中宫内死亡发生率为 0%（95%CI 0%-9%）。期待治疗的妊娠中新生儿死亡发生率为 42.5%（95%CI 17.5%-69.7%），激光治疗的妊娠中新生儿死亡发生率为 2.8%（95%CI 0.3%-7.7%），羊水减少治疗的妊娠中新生儿死亡发生率为 20.2%（95%CI 6%-40%）。只有一项研究（10 例）报告了在诊断后立即分娩而无围产儿死亡的资料。期待治疗的妊娠中围产儿死亡率为 55.7%（95%CI 31.4%-78.6%），激光治疗的妊娠中围产儿死亡率为 5.6%（95%CI 0.5%-15.3%），羊水减少治疗的妊娠中围产儿死亡率为 20.2%（95%CI 6%-40%）。期待治疗、激光治疗和羊水减少治疗的胎儿完整存活率分别为 44.4%、96.4%和 78%。
根据不同治疗方法，晚期 TTTS 双胞胎妊娠围产儿死亡率和发病率的证据质量非常低。因此，需要进一步开展高质量的研究，以阐明这些妊娠的最佳管理方法。
