Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA,
Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA.
Fetal Diagn Ther. 2022;49(4):180-189. doi: 10.1159/000524162. Epub 2022 Apr 4.
We aimed to investigate the prevalence and clinical outcomes of twin-to-twin transfusion syndrome (TTTS) with proximate cord insertions.
This was retrospective cohort study of TTTS cases managed at single fetal center between 2012 and 2020. Presence of proximate cord insertions was defined as a distance of equal or less than 4 cm between placental cord insertions that was recorded based on sonographic and fetoscopic examinations. Clinical outcomes were investigated compared to unmatched cohort and to 1:2 matched controls using preoperative variables including Quintero staging, selective fetal growth restriction, anterior placenta, preoperative cervical length, and gestational age at fetal intervention. Systematic review and meta-analysis were conducted following PRSMA guidelines through searching PubMed, Scopus, CINAHL, and Medline databases from inception until January 2021.
The prevalence of proximate cord insertions in monochorionic placentas with TTTS was 2% (5/246). All 5 cases were managed by fetoscopic laser surgery (FLS). Procedure time was significantly longer (mean: 61.4 min in proximate cord vs. 37.5 min in nonproximate cord, p < 0.001), and amnioinfusion was significantly more common (100% in proximate cord vs. 43% in nonproximate cord, p = 0.01). Perinatal survival and neonatal outcomes were not different between groups. Similar findings were seen following 1:2 control matching. Systematic review yielded total of 19 case reports of which different management options were applied including FLS (n = 13), amniodrainage (n = 3), and selective reduction (n = 3). Clinical outcomes results were mixed and inconsistent. FLS was described as technically challenging and residual anastomosis was common. Overall fetal and neonatal survival following FLS was 85% and 80%, respectively.
Presence of proximate cords in TTTS cases poses serious technical challenges even for highly experienced surgeons. Feasibility should be only determined by fetoscopic examination.
本研究旨在探讨脐带附着位置相近的双胎输血综合征（TTTS）的发生率和临床结局。
这是一项回顾性队列研究，纳入了 2012 年至 2020 年在单胎胎儿中心接受治疗的 TTTS 病例。脐带附着位置相近定义为胎盘脐带附着位置之间的距离相等或小于 4cm，这是通过超声和胎儿镜检查记录的。与未匹配队列和 1:2 匹配对照组相比，使用术前变量（包括 Quintero 分期、选择性胎儿生长受限、前置胎盘、术前宫颈长度和胎儿干预时的孕周）比较临床结局。采用 PRISMA 指南进行系统评价和荟萃分析，通过检索 PubMed、Scopus、CINAHL 和 Medline 数据库，从建库至 2021 年 1 月进行检索。
在 TTTS 合并的单绒毛膜胎盘病例中，脐带附着位置相近的发生率为 2%（5/246）。所有 5 例均通过胎儿镜激光手术（FLS）治疗。手术时间明显延长（附着位置相近组为 61.4 分钟，非附着位置相近组为 37.5 分钟，p<0.001），羊水灌注更为常见（附着位置相近组为 100%，非附着位置相近组为 43%，p=0.01）。两组围产儿存活率和新生儿结局无差异。经 1:2 匹配对照后也得出了相似的结果。系统评价共纳入 19 例病例报告，其中应用了不同的治疗方法，包括 FLS（n=13）、羊水引流（n=3）和选择性减胎（n=3）。临床结局结果不一致。FLS 被描述为具有技术挑战性，且吻合口残留常见。FLS 治疗后的总体胎儿和新生儿存活率分别为 85%和 80%。
即使对于经验丰富的外科医生来说，TTTS 病例中存在脐带附着位置相近也会带来严重的技术挑战。可行性只能通过胎儿镜检查来确定。
