Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA.
Ultrasound Obstet Gynecol. 2024 Aug;64(2):222-227. doi: 10.1002/uog.27629. Epub 2024 Jun 22.
To determine the association between elevated (> 1.5 multiples of the median (MoM)) middle cerebral artery (MCA) peak systolic velocity (PSV) and fetal demise of the donor twin in pregnancies complicated by twin-twin transfusion syndrome (TTTS) in the absence of twin anemia-polycythemia sequence (TAPS). Secondary objectives were to evaluate if donor or recipient MCA-PSV is associated with a risk for their corresponding fetal death, and to compare the proportion of donor fetuses with low MCA pulsatility index (PI) among donor twins with high MCA-PSV and those with normal MCA-PSV to evaluate the contribution of blood-flow redistribution to the fetal brain in donor twins with high MCA-PSV.
This prospective cohort study included TTTS cases that underwent laser surgery between 2011 and 2022 at a single center. TAPS cases were excluded from the study. Multivariable and Poisson regression analysis were performed to explore the association between isolated elevated donor MCA-PSV and fetal demise, adjusted for TTTS stage, selective fetal growth restriction (sFGR) and other confounders.
Of 660 TTTS cases, donor MCA-PSV was not recorded in 48 (7.3%) cases. Of the remaining 612 patients, nine (1.5%) were lost to follow-up and 96 TAPS cases were excluded; thus, 507 cases were included in the study. High donor MCA-PSV was seen in 6.5% (33/507) of cases and was an independent risk factor for donor fetal demise (adjusted relative risk (aRR), 4.52 (95% CI, 2.72-7.50)), after adjusting for confounders. Regression analysis restricted to each Quintero TTTS stage demonstrated that high donor MCA-PSV was an independent risk factor for fetal demise of the donor in Quintero Stage II (aRR, 14.21 (95% CI, 1.09-186.2)) and Quintero Stage III (aRR, 3.41 (95% CI, 1.82-6.41)). Donor MCA-PSV in MoM was associated with fetal demise of the donor (area under the receiver-operating-characteristics curve (AUC), 0.69; P < 0.001), but recipient MCA-PSV in MoM was not associated with fetal demise of the recipient (AUC, 0.54; P = 0.44). A higher proportion of donor twins in the group with high MCA-PSV had a low MCA-PI compared to the group with normal MCA-PSV (33.3% vs 15.5%; P = 0.016).
Elevated donor MCA-PSV without TAPS prior to laser surgery for TTTS is associated with a 4-fold increased risk for donor fetal demise, adjusted for sFGR, TTTS stage and other confounders. Doppler evaluation of donor MCA-PSV prior to laser surgery may help stratify TTTS staging to evaluate the risk of donor fetal demise. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
确定在无双胎贫血-多血症序列（TAPS）的情况下，患有双胎输血综合征（TTTS）的妊娠中，高于中动脉（MCA）收缩期峰值速度（PSV）中位数（MoM）的倍数（> 1.5）与供体双胞胎胎儿死亡之间的关联。次要目标是评估供体或受体 MCA-PSV 是否与相应胎儿死亡的风险相关，以及比较高 MCA-PSV 供体双胞胎中低 MCA 搏动指数（PI）的比例与正常 MCA-PSV 的供体双胞胎，以评估血流再分配对高 MCA-PSV 供体双胞胎胎儿大脑的贡献。
本前瞻性队列研究纳入了 2011 年至 2022 年在一家中心接受激光手术的 TTTS 病例。将 TAPS 病例排除在研究之外。多变量和泊松回归分析用于探索孤立的高供体 MCA-PSV 与胎儿死亡之间的关联，调整了 TTTS 分期、选择性胎儿生长受限（sFGR）和其他混杂因素。
在 660 例 TTTS 病例中，48 例（7.3%）未记录供体 MCA-PSV。在其余 612 例患者中，9 例（1.5%）失访，96 例 TAPS 病例被排除；因此，507 例患者纳入研究。高供体 MCA-PSV 见于 6.5%（33/507）的病例，在调整混杂因素后，是供体胎儿死亡的独立危险因素（调整相对风险（aRR），4.52（95%CI，2.72-7.50））。回归分析仅限于每个 Quintero TTTS 分期，表明高供体 MCA-PSV 是 Quintero 分期 II（aRR，14.21（95%CI，1.09-186.2））和 Quintero 分期 III（aRR，3.41（95%CI，1.82-6.41））供体胎儿死亡的独立危险因素。MoM 中的供体 MCA-PSV 与供体胎儿死亡相关（接受者操作特征曲线（ROC）下面积（AUC），0.69；P < 0.001），但 MoM 中的受体 MCA-PSV 与受体胎儿死亡无关（AUC，0.54；P = 0.44）。与正常 MCA-PSV 相比，MCA-PSV 较高的供体双胞胎中，MCA-PI 较低的供体双胞胎比例更高（33.3%比 15.5%；P = 0.016）。
在 TTTS 激光手术前，无 TAPS 的高供体 MCA-PSV 与供体胎儿死亡的风险增加 4 倍相关，调整了 sFGR、TTTS 分期和其他混杂因素。MCA-PSV 的多普勒评估供体 MCA-PSV 可帮助分层 TTTS 分期，以评估供体胎儿死亡的风险。
