单绒毛膜双羊膜囊双胎选择性胎儿生长受限的研究进展

单绒毛膜双羊膜囊(monochorionic diamniotic,MCDA)双胎选择性胎儿生长受限(selective fetal growth restriction,sFGR)是指一胎的估重在正常胎儿体重的第10百分位数以下,这是MCDA双胎sFGR确诊的必要条件,其在单绒毛膜双胎妊娠中的发生率为11％～14％[1],常伴发显著的双胎体重不一致.     

双绒毛膜及单绒毛膜双胎与妊娠期并发症及围生儿结局分析

目的:探讨双胎妊娠绒毛膜性对孕妇妊娠期并发症及围生儿预后的影响及意义。方法:对我院定期随诊并分娩的472例双胎临床资料进行回顾性分析,根据绒毛膜性分为单绒毛膜双羊膜囊组(MCDA组)和双绒毛膜双羊膜囊组(DCDA组),对两组孕妇的分娩孕周、并发症以及围生儿预后等进行比较分析。结果:两组孕产妇妊娠并发症的发生率比较,差异无统计学意义(P>0.05)。MCDA组低出生体重儿、极低出生体重儿、新生儿窒息及围生儿死亡的发生率均明显高于DCDA组,其差异有统计学意义(P<0.05),MCDA组中双胎输血综合征发生率为7.32%。结论:绒毛膜性对孕妇妊娠并发症的发生无明显影响,而双胎孕妇于孕早期行B超检查诊断单绒毛膜或双绒毛膜对预测围生儿预后具有重要意义。尽早确定双胎类型,加强对单绒毛膜双胎的监护及干预,是改善胎儿和新生儿预后的关键。     

双胎妊娠分娩时机与分娩方式的选择

近年来,双胎妊娠发生率急剧上升,双胎分娩的处理是具有挑战性的临床问题。双胎妊娠分娩方式与分娩时机应结合母胎情况、当地医疗机构医疗水平和医疗条件进行综合考虑。无并发症单绒毛膜双羊膜囊(monochorionic-diamniotic,MCDA)双胎分娩不超过37周为宜,双绒毛膜双羊膜囊(dichorionic-diamniotic,DCDA)双胎可妊娠至38周,单绒毛膜单羊膜囊(monochorionic-monoamniotic,MCMA)双胎为32～33周分娩。对于无并发症MCDA双胎与DCDA双胎可考虑阴道试产,MCMA双胎则建议剖宫产手术终止妊娠。     

孕中晚期双胎之一胎死宫内存活儿预后分析

目的:分析双胎之一胎死宫内(sIUFD)后存活儿的预后。方法:回顾分析2017年1月至2019年11月在郑州大学第三附属医院分娩的sIUFD病例58例,包括sIUFD发生孕周、胎死原因、不同孕周及不同绒毛膜性存活儿的新生儿结局及脑损伤情况,并随访其神经发育情况。结果:58例孕中晚期发生sIUFD的病例中单绒毛膜双羊膜囊双胎(MCDA)27例,双绒毛膜双羊膜囊双胎(DCDA)31例。死亡原因中脐带、胎盘异常占25.9%(15/58),胎儿发育异常占5.2%(3/58);存活儿的早产率为70.7%(41/58),其中最小孕周28+1周。与DCDA双胎组比较,MCDA双胎组分娩胎龄、出生体重、Apgar评分均较低。与孕中期比较,孕晚期发生sIUFD的早产率、MCDA双胎数及急诊剖宫产率更高,新生儿出生体重、Apgar评分更低。新生儿出生后头颅超声脑异常9例,其中新生儿脑损伤3例(5.2%,3/58),分别为2例脑软化,1例脑室内出血Ⅲ级。存活儿目前的存活率为91.4%(53/58),随访时间平均28个月,3例婴幼儿智能发育量表(CDCC)监测可疑。结论:绒毛膜性、死胎发生孕周、终止妊娠的孕周是影响妊娠结局的主要因素,需加强产前、产后神经影像学检查及远期标准化随访。     

辅助生殖技术受孕单绒毛膜双羊膜囊双胎妊娠特殊并发症的分析

目的:探讨辅助生殖技术(ART)受孕单绒毛膜双羊膜囊(MCDA)双胎妊娠特殊并发症及胎儿的结构异常发生情况。方法:回顾性分析2010.06~2013.09期间由ART受孕在本院产检及分娩的44例MCDA双胎妊娠患者的临床资料(ART受孕组),分析MCDA双胎的特殊并发症及胎儿结构异常,并与同期的自然受孕的MCDA双胎组(自然受孕组,n=360)进行比较。结果:ART受孕组母体平均年龄及BMI均较自然受孕组明显增高(P0.01),组间初产妇比例无统计学差异(P0.05)。MCDA双胎妊娠中双胎输血综合征(TTTS)81例,占20.0%;选择性宫内生长受限(sIUGR)47例,占11.6%,双胎反向动脉灌注序列(TRAPS)10例,占2.5%;胎儿结构异常25例,占6.2%。ART受孕组与自然受孕组MCDA双胎特殊并发症及胎儿结构异常的发生风险无统计学差异(P0.05)。结论:ART受孕对MCDA双胎妊娠特殊并发症及胎儿结构异常的发生无明显影响。     

双胎妊娠中一胎异常的筛查诊断与处理

双胎妊娠比单胎妊娠容易出现母胎并发症。单绒毛膜双羊膜囊双胎（MCDA）和双绒毛膜双羊膜囊双胎（DCDA）均可发生一胎异常。双胎之一异常在临床上主要表现为双胎生长发育不一致、染色体或基因异常和结构异常。为提高双胎妊娠的临床咨询与管理水平,文章就双胎妊娠中一胎异常的筛查、诊断与处理进行阐述。     

含单绒毛膜多胎妊娠的产前管理

含单绒毛膜的多胎妊娠情况复杂,孕妇的孕期监测及宫内干预尤为重要。含单绒毛膜双胎的双绒毛膜三羊膜囊三胎妊娠可以在孕11~14周采用氯化钾心脏注射减去同绒毛膜双胎之一,保留单绒毛膜单胎,也可以选择孕16周后射频消融减胎术保留双绒毛膜双羊膜囊双胎,2种减胎方式妊娠结局无明显差异。胎儿镜激光手术能显著改善多胎妊娠合并双胎输血综...     

双胎妊娠一胎宫内死亡34例临床分析

目的:探讨双胎妊娠一胎宫内死亡的原因、临床处理及预后。方法:回顾性分析2005年1月至2009年12月,我院双胎妊娠一胎宫内死亡34例患者的临床资料。结果:双胎妊娠一胎宫内死亡占我院双胎妊娠的5.2%,34例中单羊膜囊双胎3例,单绒毛膜双胎23例,双绒毛膜双胎8例;及时终止妊娠23例(单羊膜囊双胎均及时终止妊娠),期待治疗11例,平均期待时间单绒毛膜双胎为4.7±5.6周,双绒毛膜双胎为8.6±1.2周;单绒毛膜双胎发现死胎时的孕周、分娩孕周及存活儿的出生体重均小于双绒毛膜双胎。除引产外的30例存活儿发生围生儿死亡6例,随访24例存活新生儿中,2例失访,22例随访中发生脑瘫(四肢瘫,语言障碍)3例,存在其他脑损害(语言或运动发育延迟)4例,余健康存活。结论:单绒毛膜双胎更易发生双胎妊娠一胎宫内死亡,绒毛膜性质和孕周是影响围生儿结局和远期预后的重要因素,存活儿无胎儿窘迫,孕妇无严重妊娠并发症及合并症情况下,期待治疗是一种有效的处理方式。     

选择性胎儿生长受限的诊治

<正>随着中国二孩政策的放开,辅助生殖技术的发展,双胎妊娠的发生率有上升趋势。双胎妊娠、尤其单绒毛膜双羊膜囊(MCDA)双胎可以发生一系列特有的并发症,包括双胎输血综合征(TTTS)、选择性胎儿生长受限(sFGR)、双胎反向动脉灌注序列征(TRAPS)、双胎贫血-多血序列征(TAPS),严重影响妊娠结局[1]。其中sFGR较常见[2],具有潜在的胎死宫内及新生儿神经系统损伤的风险,被认为是重要的MCDA双胎并发症,越来越受到临床医生的重视。本     

双胎之一胎死宫内的母儿结局分析

目的:探讨双胎之一胎死宫内(sIUFD)患者绒毛膜性和孕周对母儿结局的影响。方法:选取近5年我院产科分娩的sIUFD者73例,将患者按绒毛膜性分为双绒毛膜双羊膜囊双胎(DCDA)及单绒毛膜双羊膜囊双胎(MCDA)两组。收集相关临床资料,包括孕妇一般资料、发生sIUFD孕周、影像学检查、妊娠并发症、分娩情况及新生儿结局等。结果:我院sIUFD发生率为3.24%(98/3025),DCDA组sIUFD发生率为2.50%(56/2239),MCDA组sIUFD发生率为5.50%(37/673),二者相比,差异有统计学意义。与DCDA组相比,MCDA组另一胎的死亡率、新生儿贫血发生率、新生儿重度脑损伤发生率高(P0.05)。比较两组早产、胎膜早破、胎儿生长受限、子痫前期、新生儿窒息、新生儿呼吸窘迫综合征(ARDS)、新生儿凝血功能异常发生率,差异无统计学意义(P0.05)。孕28周后发生sIUFD者早产发生率高于在孕28周之前者,差异有统计学意义(P0.05);MCDA组孕28周后发生sIUFD者其新生儿重症监护病房(NICU)入住率、新生儿贫血发生率高于孕28周前发生sIUFD者,而重度脑损伤率低于孕28周前发生sIUFD者,差异有统计学意义(P0.05);DCDA组发生sIUFD的孕周与新生儿结局无明显相关性。结论:在sIUFD发生后,新生儿早产的发生率均显著升高,另一胎的严重不良结局,如宫内死亡、重度脑损伤等,与双胎绒毛膜性密切相关。在MCDA双胎中,sIUFD的发生孕周与另一胎不良预后有相关性。应重视产前产后的影像学检查,对另一胎的预后、妊娠抉择起重要作用。     

Stillbirths in singletons,dichorionic and monochorionic twins: a comparison of risks and causes

Objectives

To estimate the risk of stillbirth in dichorionic and monochorionic twins compared with singletons, and to evaluate the relevant causes of stillbirth in each group.

Study design

A retrospective cohort analysis of all pregnancies ≥22 weeks of gestation was performed at a tertiary care center from January 1995 to June 2011. The overall fetal survival and the prospective risk of stillbirth were compared in monochorionic diamniotic (MCDA) twins, dichorionic diamniotic (DCDA) twins, and singletons. Causes of stillbirth were classified using the ReCoDe classification and were compared among the three study groups.

Results

A total of 46,200 singletons, 462 MCDA twins and 1108 DCDA twins were included in the study. Both Kaplan–Meier analysis and prospective risk calculation showed that MCDA twins had the highest risk of stillbirth (OR ranging between 13.5 95% CI 8.7–20.7 at 22.0–24.6 weeks and 4.0 95% CI 1.1–13.1 at 31.0–33.6 weeks, compared to singletons), while singletons had the lowest. Main causes of stillbirth were major congenital malformations in singletons (25.1%) and in DCDA twins (75%), and twin–twin transfusion syndrome in MCDA twins (81.5%). When excluding fetuses affected by major congenital anomalies, MCDA twins (p < 0.001) but not DCDA twins (p = 0.2) remained at increased risk for stillbirth compared with singletons.

Conclusion

The risk of stillbirth is significantly higher both in MCDA and DCDA twins compared with singletons. Stillbirths are mainly due to twin–twin transfusion syndrome in MCDA twins and major congenital anomalies in DCDA twins. When major congenital anomalies are excluded, DCDA twins have a similar in utero mortality to singletons.     

The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies – 20 years of experience from one tertiary perinatal center

ObjectiveTwin pregnancies are associated with higher neonatal mortality and morbidity. Growth discordance and monochorionicity are among the factors that worsen the course of pregnancy. The study aimed to assess neonatal conditions and mortality in relation to growth type and chorionicity.Materials and methodsData from 820 pregnant women with twin pregnancies and their 1640 newborns were analyzed. The Apgar score and umbilical artery blood pH, as well as the rate of complications, were compared between dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twins with symmetric and discordant growth. The Student's t-test and the Pearson chi-square test were used for comparisons.ResultsThere were 576 (70.2%) DCDA pregnancies, including 421 (73.1%) with symmetric growth and 155 (26.9%) with discordant growth, and 244 (29.8%) MCDA pregnancies, including 110 (45.1%) with symmetric growth and 134 (54.9%) with discordant growth. A significantly greater percentage of twins with discordant growth occurred in women older than 34 years than in those that were younger. An Apgar score of ≤7 was significantly more common among MCDA discordant twins, while an arterial umbilical blood pH of <7.2 was more common among MCDA twins with symmetric growth. Early neonatal deaths (n = 29; 1.8%), respiratory disorders, and a birth weight of <1500 g were significantly more common in MCDA twins than in DCDA twins.ConclusionMCDA twins with growth discordance are burdened with a higher risk of neonatal morbidity and mortality than symmetric DCDA twins. Chorionicity and growth discordancy are important determinants of the outcome of twin pregnancy.     

Prospective risk of fetal death in uncomplicated monochorionic twins

A retrospective cohort study was carried out in a university teaching hospital to determine the prospective risk of unexpected fetal death in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies after viability. All MCDA twins delivered at or after 24 weeks' gestation from July 1999 to July 2007 were included. Pregnancies with twin-twin transfusion syndrome, growth restriction, structural abnormalities, or twin reversed arterial perfusion sequence were excluded. Of the 144 MCDA twin pregnancies included in our analysis, the risk of intrauterine death was 4.9%. The prospective risk of unexpected intrauterine death was 1 in 43 after 32 weeks' gestation and 1 in 37 after 34 weeks' gestation. Our results demonstrate that despite close surveillance, the unexpected intrauterine death rate in uncomplicated MCDA twin pregnancies is high. This rate seems to increase after 34 weeks' gestation, suggesting that a policy of elective preterm delivery warrants evaluation.     

An Analysis of Pregnancy Outcome in Dichorionic and Monochorionic Twins Given Special Antenatal and Intranatal Care: A Four-Year Survey

Objective

The present study aims to analyze perinatal outcomes in twins given special care during pregnancy and labor and to compare fetal and neonatal outcomes in dichorionic twins with monochorionic twins.

Study Design

Eighty eight (88) twin pregnancies booked for care at a tertiary care Fetal Medicine centre were included in this study. The maternal demographic variables, course of pregnancy, fetal problems, and specialized fetal therapeutic and diagnostic interventions were noted. The above parameters were compared in the sub-groups of dichorionic and monochorionic twin pregnancies and related to the perinatal outcome. Statistical analysis was done using the student’s t test and the two-tailed chi sqaure tests with Yate’s continuity correction. A p value <0.05 was considered as significant.

Results

Mean maternal age was 30.34 + 4.81 years (range 19–48). 81 % of the twins were DCDA, and 19 % were MCDA. The mean gestational age at delivery was 34.4 ± 3.5 weeks, and this was not significantly different in MCDA and DCDA groups. Serious fetal problems warranting intervention at the time of initial referral were significantly higher in MCDA twins although overall perinatal outcome in both groups were not different.

Conclusion

Specialized care during pregnancy and labor including active fetal surveillance and therapeutic intervention when indicated improves the perinatal outcome in twin pregnancies and ensured at least one healthy live birth in over 90 % cases, although with an increase in late prematurity.     

Vaginal delivery can be considered in monochorionic diamniotic twins

The outcomes of 60 sets of monochorionic diamniotic (MCDA) twins were compared with 218 sets of dichorionic diamniotic (DCDA) twins. The caesarean section rates for MCDA were similar to those for DCDA twins (56.6 versus 53.6%, P > 0.1). Although the number of babies with 5-minute Apgar score of <7 was significantly higher for vaginally delivered MCDA twins compared with that of DCDA twins (12 versus 3.5%, P < 0.001), the umbilical artery pH of <7.2 was similar (20 versus 13%, P > 0.05). Admission to neonatal intensive care unit (NICU) and neonatal mortality were also similar in both groups. Delivery by caesarean section was associated with increased admission to the NICU and neonatal mortality for MCDA twins when compared with vaginal delivery group. From this retrospective cohort study, we can conclude that vaginal delivery for MCDA twins appeared to be a reasonable management option when similar selection criteria for vaginal delivery of DCDA twins were applied.     

Use of the Foetal Myocardial Performance Index in monochorionic,diamniotic twin pregnancy: a prospective cohort and nested case-control study

Aims: Assess clinical utility of the foetal Myocardial Performance Index (MPI) in evaluation and management of monochorionic, diamniotic twin (MCDA) pregnancies.

Methods: Prospective cohort of (a) initially uncomplicated MCDA (b) Complicated MCDA, including twin–twin transfusion syndrome (TTTS), selective intrauterine growth restriction (sIUGR), and liquor and/or growth discordance (L/GD) not meeting TTTS or sIUGR criteria. TTTS and sIUGR were case-control matched. Routine Dopplers and MPI were taken and correlated to diagnosis and final outcome.

Results: Twenty-six always uncomplicated pairs, 51 always complicated pairs, and seven uncomplicated to pathological pairs were included. TTTS recipient (n?=?25) left and right MPI and intertwin difference (ITD) were significantly elevated, however, were already elevated in Stage I (n?=?10), and did not predict progression or pregnancy outcome. sIUGR MPI (n?=?11) did not differ significantly from control. Of 15-L/GD pairs, two that progressed to TTTS had significantly higher left and right MPI values in the future recipient (0.61 and 0.72) versus future sIUGR larger twins (0.48 and 0.51) or stable L/GD (0.47 and 0.52): p?Conclusions: In this cohort, MPI did not add substantial diagnostic/prognostic information to current routine evaluation in established TTTS or sIUGR though potentially differentiated L/GD cases progressing to TTTS.     

Perinatal outcomes of twin pregnancies discordant for major fetal anomalies

OBJECTIVE: The aim of this study was to determine perinatal outcomes of twin pregnancies discordant for a major fetal anomaly and to compare with twins without anomaly. METHODS: All twin pregnancies admitted or referred to the maternal-fetal unit were prospectively entered into a computer database. Chorionicity, fetal anomaly, mean gestational age at delivery, birth weight and perinatal survival rate were reviewed. MAIN OUTCOME MEASURES: Mean gestational age at delivery, birth weight and perinatal survival rate of twins with and without anomaly. RESULTS: There were 48 cases of monochorionic diamniotic (MCDA), 2 cases of monochorionic monoamniotic (MCMA) and 217 twins with dichorionic (DC) placentation. Out of 267 twin pregnancies, there were 17 (6.3%) twins with fetal anomaly. Twins discordant for a major fetal anomaly were diagnosed in 13 cases (4.8%). We observed 3 cases with MCDA and 10 cases with DC placentation and the incidence of discordance for a major fetal anomaly as 4.6% (10/217) in DC and 6.0% (3/50) in MC twin pregnancies. We identified 8 cases (62%) with craniospinal, 2 (15%) with gastrointestinal, 2 (15%) with urinary system, and 1 case (8%) with both craniospinal and gastrointestinal anomalies. There were significant differences between the normal co-twin of the major anomaly group (n = 13) and twins without anomaly group (n = 235) in mean gestational age at delivery (32 vs. 34 weeks; p = 0.029), mean birth weight (1,640 vs. 2,030 g; p = 0.022) and perinatal survival rate (69.2 vs. 91.1%; p = 0.018), respectively. CONCLUSION: The presence of a fetus with a major anomaly in a twin gestation increases the risk of preterm delivery, low birth weight and perinatal mortality of the normal co-twin.