Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.
Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.
Ultrasound Obstet Gynecol. 2022 Jul;60(1):42-51. doi: 10.1002/uog.24887.
The aims of this study were to investigate the perinatal outcome of dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) in two academic fetal centers, and to conduct a systematic review of previously published data to investigate perinatal survival in this targeted population.
The first part of the study was a retrospective cohort study of prospectively collected data of consecutive triplet pregnancies with TTTS that underwent FLP at two fetal treatment centers between 2012 and 2020. Demographic, preoperative and operative variables and postoperative outcome were collected. Perinatal outcomes were investigated. The second part of the study was a systematic review and meta-analysis of studies evaluating the outcome of DCTA and/or MCTA triplet pregnancies, including our cohort study. PubMed, Web of Science and Scopus were searched from inception to September 2020. Primary outcomes were fetal survival (survival to birth), neonatal survival (survival to 28 days of age) and gestational age (GA) at birth.
A total of 31 sets of triplets with TTTS managed with FLP were included in the cohort study. Of these, 24 were DCTA and seven were MCTA. There were no significant differences in preoperative and operative variables between the two groups. There were also no significant differences between groups in GA at delivery or perinatal survival rate, including fetal and neonatal survival of at least one triplet, at least two triplets and all three triplets. Nine studies, including our cohort study, were included in the systematic review (156 DCTA and 37 MCTA triplet pregnancies treated with FLP). The overall fetal and neonatal survival was 79% (95% CI, 75-83%) and 75% (95% CI, 71-79%), respectively, in DCTA cases and 74% (95% CI, 52-92%) and 71% (95% CI, 49-89%), respectively, in MCTA cases. The rate of preterm birth before 28 weeks and before 32 weeks' gestation was 14% (95% CI, 4-29%) and 61% (95% CI, 50-72%), respectively, in DCTA triplets and 21% (95% CI, 3-45%) and 82% (95% CI, 62-96%), respectively, in MCTA triplets.
Triplet pregnancies with TTTS are at high risk of adverse perinatal outcome and preterm birth, regardless of chorionicity. The rate of survival after FLP in MCTA triplets was higher in our study than that reported in previous studies and is currently comparable with survival in DCTA triplets, which could be due to improved surgical skills. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
本研究旨在调查 2 家学术胎儿治疗中心采用胎儿镜激光凝固术（FLP）治疗的双绒毛膜三羊膜（DCTA）和单绒毛膜三羊膜（MCTA）三胎妊娠合并双胎输血综合征（TTTS）的围产结局，并对之前发表的数据进行系统回顾，以调查该目标人群的围产生存情况。
研究的第一部分是对 2012 年至 2020 年期间在 2 家胎儿治疗中心接受 FLP 治疗的连续三胎妊娠 TTTS 患者的前瞻性收集数据进行回顾性队列研究。收集人口统计学、术前和手术变量以及术后结果。研究围产结局。研究的第二部分是对评估 DCTA 和/或 MCTA 三胎妊娠结局的研究进行系统回顾和荟萃分析，包括我们的队列研究。从开始到 2020 年 9 月，检索了 PubMed、Web of Science 和 Scopus。主要结局是胎儿存活率（存活至出生）、新生儿存活率（存活至 28 天）和出生时的胎龄（GA）。
共纳入了 31 组接受 FLP 治疗的 TTTS 三胎妊娠队列研究。其中 24 组为 DCTA，7 组为 MCTA。两组术前和手术变量无显著差异。两组在分娩时的 GA 或围产儿存活率（至少存活一个、至少两个和所有三个三胞胎）方面也无显著差异。包括我们的队列研究在内的 9 项研究被纳入系统回顾（156 例 DCTA 和 37 例 MCTA 三胎妊娠接受 FLP 治疗）。DCTA 病例的总体胎儿和新生儿存活率分别为 79%（95%CI，75-83%）和 75%（95%CI，71-79%），MCTA 病例分别为 74%（95%CI，52-92%）和 71%（95%CI，49-89%）。DCTA 三胎妊娠的早产发生率（28 周前和 32 周前）分别为 14%（95%CI，4-29%）和 61%（95%CI，50-72%），MCTA 三胎妊娠分别为 21%（95%CI，3-45%）和 82%（95%CI，62-96%）。
TTTS 的三胎妊娠围产结局和早产风险均较高，与绒毛膜性无关。本研究中 MCTA 三胎妊娠接受 FLP 后的存活率高于以往研究报道，目前与 DCTA 三胎妊娠的存活率相当，这可能是由于手术技术的提高。
