目的 分析双胎输血综合征(twin-twin transfusion syndrome,TTTS)胎儿脑-胎盘血流参数和生物学指标差异在围产结局中的预测价值.方法 回顾性分析2014年1月至2023年1月在郑州大学第一附属医院诊断的53例未行任何宫内治疗的TITS,其中不良结局组30例,良好结局组23例.分析两组脐动脉搏动指数差异(dis-cordance of umbilical arterial pulsatility index,UA-PIdisc)、大脑中动脉收缩期峰值流速 MoM 值差异(discordance of middle cerebral artery-peak systolic velocity of multiples of the median,MCA-PSV MoMdisc)、大脑中动脉搏动指数差异(discordance of middle cerebral artery pulsatility index,MCA-PIdisc)、脑-胎盘率差异(discordance of cerebro-placental ratio,CPRdisc)、估测体重差异(estimated fetal weight,EFWdisc)和诊断孕周、分娩孕周、Quintero 分期的差异,采用单因素及多因素logistics回归分析识别围产儿丢失的危险因素,进而采用ROC曲线评估各指标预测不良围产结局的诊断效能.结果 不良结局组TTTS诊断孕周[23.4(21.0～26.6)与30(28.2～31.0)]和分娩孕周[24.2(21.1～26.8)与30.4(29.5～32.4)]均较良好围产结局组早(P＜0.05),且不良结局组Quintero分期[Ⅰ期 13.3％(4/30)与 56.5％(13/23)、Ⅱ 期 13.3％(4/30)与 8.7％(2/23)、Ⅲ 期 36.7％(11/30)与 21.7％(5/23)、Ⅳ期 36.7％(11/30)与 13.0％(3/23)]更重(P＜0.05).不良结局组供血儿 UA-PI[1.34(1.09～2.12)与1.13(0.96～1.46)]、MCA-PSV MOM[1.10(0.87～1.29)与0.94(0.70～1.13)]较良好结局组高(P＜0.05);不良结局组 UA-PIdisc[38.42(17.90～55.47)与 7.87(4.00～22.67)]、MCA-PIdi.sc[29.71(13.82～46.99)与16.58(7.69～28.06)]和 CPRdisc[51.25(34.52～67.86)与 16.28(5.63～34.86)]高于良好结局组(P＜0.05).多因素回归分析显示,CPRdisc(OR=1.072,95％CI 1.032～1.114)和分娩孕周(OR=0.445,95％CI 0.284～0.695)是TTTS围产儿丢失的危险因素(P＜0.05).ROC曲线显示,CPRdisc+分娩孕周两者结合预测不良围产结局的曲线下面积为0.965,敏感性为97％,特异性为87％(P＜0.05).结论 不良结局组TTTS诊断孕周和分娩孕周早,且Quintero分期更重.CPRdisc增高和分娩孕周≤28周是TTTS不良围产结局的危险因素,两者结合可以更好的预测围产结局.
Predictive value of cerebroplacental ratio and gestational age at delivery for perinatal outcome in twin-twin transfusion syndrome
Objective To analyze the predictive value of the difference of cerebroplacental blood flow parameters and fe-tal biometry in perinatal outcomes in twin-twin transfusion syndrome(TTTS).Methods A retrospective study was conducted to study 53 cases of TTTS diagnosed at the First Affiliated Hospital of Zhengzhou University during January 2014 to January 2023,in which no intrauterine treatment was performed.Among them,23 cases had good outcomes,while 30 cases had adverse outcomes.The discordance of umbilical arterial pulsatility index(UA-PIdisc),the middle cere-bral artery-peak systolic velocity of multiples of the median(MCA-PSVM.M disc),middle cerebral artery pulsatility in-dex(MCA-PIdisc),cerebroplacental ratio(CPRdisc),estimated fetal weight(EFWdisc),gestational ages at diagnosis,gestational ages at delivery,and Quintero staging between the two groups were analyzed.A logistic regression analysis was employed to identify and adjust for risk factors.The accuracy of prediction was evaluated through the analysis of the receiver-operating characteristic curve.Results The adverse outcome group had earlier gestational age at diagnosis[23.4(21.0-26.6)vs 30(28.2-31.0)]and gestational age at delivery[24.2(21.1-26.8)vs 30.4(29.5-32.4)]in TTTS than the good outcome group(P＜0.05),and the Quintero stage[stage Ⅰ 13.3％(4/30)vs 56.5％(13/23);stage Ⅱ 13.3％(4/30)vs 8.7％(2/23);stage Ⅲ 36.7％(11/30)vs 21.7％(5/23);stage Ⅳ 36.7％(11/30)vs 13.0％(3/23)]was severe in the adverse outcome group(P＜0.05).The adverse outcome group donor twins had higher UA-PI[1.34(1.09-2.12)vs 1.13(0.96-1.46)]and MCA-PSV MOM values[1.10(0.87-1.29)vs0.94(0.70-1.13)]than those in the good outcome group(P＜0.05).Compared to the good outcome group,the difference values of UA-PIdisc[38.42(17.90-55.47)vs 7.87(4.00-22.67)],MCA-PIdisc[29.71(13.82-46.99)vs 16.58(7.69-28.06)],and CPRdisc[51.25(34.52-67.86)vs 16.28(5.63-34.86)]were higher than those in the adverse outcome group(P＜0.05).Multivariable regression analyses showed that CPRdisi(OR=1.072,95％CI:1.032-1.114)and gestational age at delivery(OR=0.445,95％CI:0.284-0.695)were risk factors of perinatal loss in TTTS(P＜0.05).The ROC curve showed that the combined use of CPRdisc and gesta-tional age at delivery had an area under the curve of 0.965,sensitivity of 97％,and specificity of 87％in predicting ad-verse perinatal outcomes(P＜0.05).Conclusion The adverse outcome group had earlier gestational age at diagnosis,gestational age at delivery and Quintero stage more severe in TTTS.Higher CPRdisc ordance and gestational age at delivery≤28 weeks are risk predictors for adverse perinatal outcomes in TTTS,and the combination of both can better predict perinatal outcome.
UltrasonographyTwin-twin transfusion syndromeMonochorionic-diamniotic twinCerebroplacental ratioGestational age
NETL
NSTL
万方数据
