妊娠11~13^(+6)周胎儿超声指标在双胎胎儿心脏畸形筛查中的价值

Value of fetal ultrasonography index in twin fetal heart malformation screening at 11-13^(+6) weeks of gestation

目的探讨双胎妊娠11~13+6周胎儿超声指标在筛查双胎先天性心脏畸形中的临床价值。方法采用回顾性队列研究方法,在首都医科大学附属北京妇产医院(2012年1月至2016年12月)和石家庄市第四医院(2014年1月至2018年12月)建档病例中,筛选出双胎之一或双胎发生心脏畸形的病例作为心脏畸形组,并将同时期正常分娩的双胎胎儿作为对照组,对两组11~13+6周超声的颈项透明层(NT)厚度、头臀长(CRL)、绒毛膜性、受孕方式,以及双胎间NT差异、CRL差异、NT差异≥20%发生率、CRL差异≥10%发生率等超声数据进行对比分析。结果①心脏畸形组共30例(其中双胎之一心脏畸形者27例,两胎儿均心脏畸形者3例),对照组共1906例。②一胎或两胎NT值≥第95百分位及NT值≥第99百分位在心脏畸形组中发生率明显高于对照组(20.00%比2.20%,P<0.001;10.00%比0.63%,P=0.002),二者筛查心脏畸形的ROC曲线下面积(AUC)分别为0.589、0.549;心脏畸形组CRL差异高于对照组(P=0.018),CRL差异≥10%在心脏畸形组中发生率高于对照组(26.67%比12.70%,P=0.024),CRL差异≥10%发生率筛查心脏畸形的AUC为0.570;两组间NT差异、NT差异≥20%发生率、受孕方式及绒毛膜性差异无统计学意义(均P>0.05)。③以双胎NT值≥第95百分位及NT值≥第99百分位发生率、CRL差异≥10%发生率、NT差异≥20%发生率为指标进行多因素Logistic回归分析发现,双胎NT值≥第95百分位及NT值≥第99百分位发生率均是双胎心脏畸形发生的危险因素(OR=1.095、105.778,95%CI=4.311~28.558、16.984~658.796)。结论妊娠11~13+6周超声发现一胎或两胎NT值增厚、两胎儿间CRL差异≥10%,提示双胎发生心脏畸形的风险增加;NT值≥第95百分位及NT值≥第99百分位是双胎发生心脏畸形的危险因素。

Objective To investigate the clinical value of fetal ultrasonography in the screening of congenital heart malformations in twins at 11-13+6 weeks of gestation.Methods A retrospective cohort study method was used.Cases were collected from Beijing Obstetrics and Gynecology Hospital,Capital Medical University,Beijing Maternal and Child Health Care Hospital(January 2012 to December 2016)and the Fourth Hospital of Shijiazhuang City(January 2014 to December 2018).The twins with singleton or twins with cardiac malformation were screened out as the cardiac malformation group,and the twins with normal delivery during the same period were selected as the control group.Ultrasound data such as the nuchal translucency(NT),crown-rump-length(CRL),chorionicity,conception method,NT discordance,CRL discordance,NT discordance≥20%incidence rate between twins,and the CRL discordance≥10%incidence rate between twins in the two groups at 11-13+6 weeks were compared and analyzed.Results①There were 30 cases in the cardiac malformation group(including 27 twins with singleton cardiac malformation and 3 twins with twin cardiac malformation)and 1906 cases in the control group.②The incidence rates of NT value≥95th percentile and NT value≥99th percentile in one or two pregnancies were significantly higher in the cardiac malformation group than in the control group(20.00%vs 2.20%,P<0.001;10.00%vs 0.63%,P=0.002),the area under the ROC curve(AUC)for cardiac malformation screening was 0.589 and 0.549,respectively;CRL discordance in cardiac malformation group was higher than that in control group(P=0.018),the incidence of CRL discordance≥10%in the cardiac malformation group was higher than that in the control group(26.67%vs 12.70%,P=0.024),the AUC of cardiac malformation screening was 0.570;there were no significant differences in the incidence of NT discordance,the incidence of NT discordance≥20%,pregnancy pattern and chorionicity between the two groups(all P>0.05).③Multivariate Logistic regression analysis was performed using the incidence rates of NT value≥95%and NT value≥99%,CRL discordance≥10%,and NT discordance≥20%.The incidences of fetal NT value≥95%and NT value≥99%were risk factors for cardiac malformation in twins(OR=11.095,105.778;95%CI=4.311-28.558,16.984-658.796).Conclusions Ultrasound at 11-13+6 weeks of gestation showing thickened value of one or two fetuses,and the CRL discordance≥10%,indicates an increased risk of cardiac malformation in the twins;NT value≥95%and NT value≥99%is a risk factor for heart defects in twins.