目的 探讨不同分型选择性宫内生长受限（selective intrauterine growth restriction，sIUGR）的发育正常胎儿（大胎儿）围产期特点及生后早期循环功能的变化。 方法 回顾性纳入2018年2月至2022年8月于北京大学第三医院宫内诊断sIUGR，且生后转入新生儿重症监护病房的sIUGR大胎儿91例。比较不同分型sIUGR大胎儿的围产期情况、临床指标及超声心动图评估的心功能变化。采用单因素方差分析和LSD检验、Kruskal-Wallis H检验、χ2检验及Bonferroni校正检验进行统计学分析。 结果 出生胎龄、出生体重和胎盘重量在Ⅱ型sIUGR大胎儿中分别为（30.6±1.5）周、（1 503.9±286.4）g和（548±120）g，在Ⅲ型中分别为（30.5±2.3）周、（1 523.5±424.4）g和（560±109）g，均小于Ⅰ型患儿［分别为（33.0±1.7）周、（2 022.1±372.3）g和（630±131）g］（LSD检验，P值均<0.05）；Ⅱ型和Ⅲ型患儿生后住院时间均长于Ⅰ型［36.0 d（27.0～43.0 d）和32.0 d（15.0～47.0 d）与17.0 d（9.5～22.0 d）］，因胎儿窘迫导致早产的比例均高于Ⅰ型［63.6%（21/33）和75.0%（15/20）与31.6%（12/38），χ2值分别为7.30和9.93］（Bonferroni校正，all P<0.017）；Ⅱ型生后使用血管活性药物的比例高于Ⅰ型［45.5%（15/33）与18.4%（7/38），χ2=6.04，P=0.014］。室间隔厚度在Ⅲ型大于Ⅰ型和Ⅱ型［（4.4±1.4）与（3.8±0.9）和（3.3±0.9）mm］；Ⅲ型左心室游离壁厚度大于Ⅰ型［（4.6±1.3）与（3.1±0.7）mm］，Ⅰ型大于Ⅱ型［（2.7±0.6）mm］；左心室舒张末期内径、右心室流出道内径、右心室前后径和肺动脉内径在Ⅰ型均大于Ⅱ型和Ⅲ型［左心室舒张末期内径：（15.0±2.1）与（13.4±2.3）和（12.3±3.2）mm；右心室流出道内径：（8.7±1.4）与（7.3±1.4）和（7.1±0.8）mm；右心室前后径：（7.1±1.5）与（6.5±0.9）和（6.4±1.0）mm；肺动脉内径：（6.8±1.1）与（6.3±0.9）和（6.3±0.8）mm］（LSD检验，P值均<0.05）。 结论 与Ⅰ型sIUGR大胎儿相比，Ⅱ型和Ⅲ型sIUGR中的大胎儿出生胎龄及体重小，胎儿窘迫比例高，需加强围产期及生后早期的动态监测和循环支持。Ⅲ型患儿生后早期存在左心室壁及室间隔增厚，可能导致心室舒张功能储备力减低，故应对Ⅲ型患儿生后早期的心肌舒张功能进行重点评估和监测。 Objective To explore the perinatal characteristics and early postnatal circulatory function of the larger fetus in monochorionic diamniotic twin pregnancy complicated with selective intrauterine growth restriction (sIUGR). Methods From February 2018 to August 2022, a total of 91 larger fetuses of the sIUGR pregnancies who were hospitalized in the neonatal intensive care unit of Peking University Third Hospital were retrospectively included. The perinatal factors, clinical monitoring indicators, and echocardiographic data of the larger twins in pregnancies with three types of sIUGR were compared using one-way analysis of variance and LSD test, Kruskal-Wallis H test, Chi-square test, and Bonferroni correction. Results The gestational age, birth weight, and placental weight were (30.6±1.5) weeks, (1 503.9±286.4) g, and (548±120) g in the type Ⅱ sIUGR larger twins and were (30.5±2.3) weeks, (1 523.5±424.4) g, and (560±109) g in type Ⅲ, which were all smaller, lower, and lighter than those in the type Ⅰ[(33.0±1.7) weeks, (2 022.1±372.3) g, and (630±131) g, respectively] (LSD test, all P<0.05). Compared with type Ⅰ sIUGR larger twins, type Ⅱ and Ⅲ sIUGR larger twins had longer hospital stay [36.0 d (27.0-43.0 d) and 32.0 d (15.0-47.0 d)vs. 17.0 d (9.5-22.0 d)], higher proportion of preterm births due to fetal distress [63.6% (21/33) and 75.0% (15/20) vs. 31.6% (12/38), χ2=7.30 and 9.93] (Bonferroni correction, all P<0.017) Compared with type Ⅰ sIUGR larger twins, type Ⅱ sIUGR larger twins had higher proportion of postnatal use of vasoactive drugs [45.5% (15/33)vs. 18.4% (7/38), χ2=6.04, P=0.014]. The interventricular septum thickness was larger in the type Ⅲ sIUGR larger twins than those in the type Ⅰ and Ⅱ twins [(4.4±1.4) vs. (3.8±0.9) and (3.3±0.9) mm] the thickness of left ventricular free wall was the largest in the type Ⅲ larger twins, followed by those in the type Ⅰ and type Ⅱ [(4.6±1.3) vs. (3.1±0.7) vs. (2.7±0.6) mm] the left ventricular end-diastolic diameter, right ventricular outflow tract diameter, right ventricular anteroposterior diameter, and pulmonary artery diameter in type Ⅰ larger twins were increased comparing with those in type Ⅱ and Ⅲ [left ventricular end-diastolic diameter: (15.0±2.1) vs. (13.4±2.3) and (12.3±3.2) mm right ventricular outflow tract diameter: (8.7±1.4) vs. (7.3±1.4) and (7.1±0.8) mm right ventricular anteroposterior diameter: (7.1±1.5) vs. (6.5±0.9) and (6.4±1.0) mm pulmonary artery diameter: (6.8±1.1) vs. (6.3±0.9) and (6.3±0.8) mm] (LSD test, all P<0.05). Conclusion The larger fetuses of type Ⅱ and Ⅲ sIUGR pregnancies had smaller gestational age and lighter birth weight who are more prone to have fetal distress, so it is necessary to strengthen dynamic monitoring and circulatory support for such neonates during the perinatal period and early postnatal period. The thickening of the left ventricular wall and interventricular septum in the early postnatal period of type Ⅲ larger fetuses may lead to the decrease of ventricular diastolic function reserve, thereby the evaluation and monitoring of the myocardial diastolic function of these neonates in the early postnatal period are critical.
Perinatal characteristics and early postnatal circulatory function changes in the larger fetus in twin pregnancy with selective intrauterine growth restriction
Objective To explore the perinatal characteristics and early postnatal circulatory function of the larger fetus in monochorionic diamniotic twin pregnancy complicated with selective intrauterine growth restriction (sIUGR). Methods From February 2018 to August 2022, a total of 91 larger fetuses of the sIUGR pregnancies who were hospitalized in the neonatal intensive care unit of Peking University Third Hospital were retrospectively included. The perinatal factors, clinical monitoring indicators, and echocardiographic data of the larger twins in pregnancies with three types of sIUGR were compared using one-way analysis of variance and LSD test, Kruskal-Wallis H test, Chi-square test, and Bonferroni correction. Results The gestational age, birth weight, and placental weight were (30.6±1.5) weeks, (1 503.9±286.4) g, and (548±120) g in the type Ⅱ sIUGR larger twins and were (30.5±2.3) weeks, (1 523.5±424.4) g, and (560±109) g in type Ⅲ, which were all smaller, lower, and lighter than those in the type Ⅰ[(33.0±1.7) weeks, (2 022.1±372.3) g, and (630±131) g, respectively] (LSD test, all P<0.05). Compared with type Ⅰ sIUGR larger twins, type Ⅱ and Ⅲ sIUGR larger twins had longer hospital stay [36.0 d (27.0-43.0 d) and 32.0 d (15.0-47.0 d)vs. 17.0 d (9.5-22.0 d)], higher proportion of preterm births due to fetal distress [63.6% (21/33) and 75.0% (15/20) vs. 31.6% (12/38), χ2=7.30 and 9.93] (Bonferroni correction, all P<0.017) Compared with type Ⅰ sIUGR larger twins, type Ⅱ sIUGR larger twins had higher proportion of postnatal use of vasoactive drugs [45.5% (15/33)vs. 18.4% (7/38), χ2=6.04, P=0.014]. The interventricular septum thickness was larger in the type Ⅲ sIUGR larger twins than those in the type Ⅰ and Ⅱ twins [(4.4±1.4) vs. (3.8±0.9) and (3.3±0.9) mm] the thickness of left ventricular free wall was the largest in the type Ⅲ larger twins, followed by those in the type Ⅰ and type Ⅱ [(4.6±1.3) vs. (3.1±0.7) vs. (2.7±0.6) mm] the left ventricular end-diastolic diameter, right ventricular outflow tract diameter, right ventricular anteroposterior diameter, and pulmonary artery diameter in type Ⅰ larger twins were increased comparing with those in type Ⅱ and Ⅲ [left ventricular end-diastolic diameter: (15.0±2.1) vs. (13.4±2.3) and (12.3±3.2) mm right ventricular outflow tract diameter: (8.7±1.4) vs. (7.3±1.4) and (7.1±0.8) mm right ventricular anteroposterior diameter: (7.1±1.5) vs. (6.5±0.9) and (6.4±1.0) mm pulmonary artery diameter: (6.8±1.1) vs. (6.3±0.9) and (6.3±0.8) mm] (LSD test, all P<0.05). Conclusion The larger fetuses of type Ⅱ and Ⅲ sIUGR pregnancies had smaller gestational age and lighter birth weight who are more prone to have fetal distress, so it is necessary to strengthen dynamic monitoring and circulatory support for such neonates during the perinatal period and early postnatal period. The thickening of the left ventricular wall and interventricular septum in the early postnatal period of type Ⅲ larger fetuses may lead to the decrease of ventricular diastolic function reserve, thereby the evaluation and monitoring of the myocardial diastolic function of these neonates in the early postnatal period are critical.
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