Eltaweel N, D'Antonio F, Prasad S, Mustafa H, Khalil A
Division of Biomedical Science, Warwick Medical School, University of Warwick, University Hospital of Coventry and Warwickshire, Coventry, UK.
Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy.
Ultrasound Obstet Gynecol. 2025 Jun 5. doi: 10.1002/uog.29230.
To assess the impact of intervention with cervical cerclage, cervical pessary or vaginal progesterone on the risk of preterm birth (PTB) in monochorionic diamniotic (MCDA) twin pregnancies undergoing fetoscopic laser surgery (FLS) for twin-to-twin transfusion syndrome (TTTS).
The MEDLINE, Embase and Cochrane databases were searched from inception to November 2023. The inclusion criteria were studies on MCDA twin pregnancies undergoing FLS for TTTS, comparing those receiving with those not receiving an intervention to prevent PTB, including vaginal progesterone, cervical cerclage and cervical pessary. The primary outcome was gestational age (GA) at birth. The secondary outcomes included the interval between FLS and birth, PTB prior to 34, 32, 28 and 24 weeks' gestation, delivery within 2 and 4 weeks after FLS, preterm prelabor rupture of membranes, chorioamnionitis, double survival, survival of at least one twin, no survival, overall fetal or perinatal loss, and overall fetal or perinatal survival. All outcomes were explored in the overall population of MCDA twin pregnancies undergoing FLS for TTTS according to different cut-offs of cervical length (CL) for intervention. Random-effects meta-analysis was used to directly compare the risk of each outcome. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology was used to assess the quality of the retrieved evidence.
Ten studies (1159 MCDA pregnancies) were included in the systematic review, of which seven were included in the meta-analysis. There was no significant difference in mean gestational age at birth in MCDA twin pregnancies undergoing FLS for TTTS in women receiving vs not receiving cervical cerclage, with CL < 30, < 25, < 20 or < 15 mm. There was also no significant difference in the mean interval between FLS and delivery, and in the risk of fetal or perinatal loss between women receiving vs not receiving cervical cerclage. Similarly, intervention with cervical pessary was not associated with a higher gestational age at birth compared with no intervention. It was not possible to perform any comprehensive pooled data synthesis for women receiving progesterone. In women with CL < 30 mm, intervention with cervical pessary was not associated with a reduced risk of PTB < 32, < 28 or < 24 weeks' gestation, or with delivery within 2 or 4 weeks after FLS or perinatal loss. Finally, in women with CL < 25 mm, cervical pessary did not reduce the risk of PTB < 32 weeks or perinatal loss. On GRADE assessment, the quality of evidence was very low in showing that cervical cerclage and cervical pessary can affect gestational age at birth in MCDA twin pregnancies that underwent FLS for TTTS, irrespective of the degree of cervical shortening.
There is currently no evidence that intervention with cervical cerclage or pessary leads to a greater gestational age at birth or reduces the risk of PTB in MCDA twin pregnancies complicated by TTTS and undergoing FLS in women with a short CL, while the level of evidence for intervention with vaginal progesterone is insufficient for evaluation. However, the small sample sizes of the included studies, lack of comparison in the original publications and lack of stratification of the observed outcomes according to Quintero stage, gestational age at FLS and CL cut-off highlight the need for appropriately powered studies. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
评估宫颈环扎术、宫颈托或阴道用黄体酮干预对接受胎儿镜激光手术（FLS）治疗双胎输血综合征（TTTS）的单绒毛膜双羊膜囊（MCDA）双胎妊娠早产（PTB）风险的影响。
检索MEDLINE、Embase和Cochrane数据库，检索时间从建库至2023年11月。纳入标准为关于接受FLS治疗TTTS的MCDA双胎妊娠的研究，比较接受与未接受预防PTB干预措施（包括阴道用黄体酮、宫颈环扎术和宫颈托）的情况。主要结局为出生时的孕周（GA）。次要结局包括FLS与出生之间的间隔、孕34、32、28和24周之前的PTB、FLS后2周和4周内分娩、早产前胎膜早破、绒毛膜羊膜炎、双胎均存活、至少一个胎儿存活、无存活、总体胎儿或围产期丢失以及总体胎儿或围产期存活。根据不同的宫颈长度（CL）干预临界值，在接受FLS治疗TTTS的MCDA双胎妊娠总体人群中探讨所有结局。采用随机效应荟萃分析直接比较各结局的风险。使用推荐分级、评估、制定和评价（GRADE）方法评估检索到的证据质量。
系统评价纳入了10项研究（1159例MCDA妊娠），其中7项纳入荟萃分析。对于CL<30、<25、<20或<15mm的接受FLS治疗TTTS的MCDA双胎妊娠女性，接受与未接受宫颈环扎术者出生时的平均孕周无显著差异。接受与未接受宫颈环扎术的女性在FLS与分娩之间的平均间隔以及胎儿或围产期丢失风险方面也无显著差异。同样，与未干预相比，使用宫颈托干预与出生时更高的孕周无关。对于接受黄体酮治疗的女性，无法进行任何全面的汇总数据综合分析。对于CL<30mm的女性，使用宫颈托干预与孕<32、<28或<24周时的PTB风险降低、FLS后2周或4周内分娩或围产期丢失无关。最后，对于CL<25mm的女性，宫颈托并未降低孕<32周时的PTB风险或围产期丢失风险。根据GRADE评估，无论宫颈缩短程度如何，证据质量极低，表明宫颈环扎术和宫颈托可影响接受FLS治疗TTTS的MCDA双胎妊娠的出生孕周。
目前没有证据表明宫颈环扎术或宫颈托干预可使接受FLS治疗且CL较短的合并TTTS的MCDA双胎妊娠女性出生时孕周更大或降低PTB风险，而阴道用黄体酮干预的证据水平不足以进行评估。然而，纳入研究的样本量较小、原始出版物中缺乏比较以及未根据Quintero分期、FLS时的孕周和CL临界值对观察到结局进行分层，凸显了开展有足够效力研究的必要性。©2025作者。《妇产科超声》由John Wiley & Sons Ltd代表国际妇产科超声学会出版。
