双胎妊娠选择性胎儿生长受限不同分型的妊娠期分型转化及围产结局

Analysis of typing conversion and perinatal outcomes in twins with selective intrauterine growth restriction of different subtypes

目的观察不同分型选择性胎儿生长受限(sIUGR)孕妇的自然病程、分型变化及围产结局。方法收集浙江大学医学院附属妇产科医院2014年1月至2018年12月收治的153例期待治疗的sIUGR孕妇的临床资料,依据舒张末期脐动脉血流多普勒超声检查分为3型(Ⅰ型:正常;Ⅱ型:持续性消失或反向;Ⅲ型:间歇性消失或反向),回顾性分析并比较各分型孕妇的年龄、孕产次、受孕方式、诊断孕周、妊娠期合并症或并发症、分娩孕周、分娩指征、分娩方式、新生儿性别和出生体重、胎死宫内、新生儿死亡和新生儿严重并发症,特别比较基于首诊分型的sIUGR的妊娠期分型变化及其围产结局的差异。结果(1)临床特征及妊娠结局:153例sIUGR孕妇中,初次诊断时Ⅰ型100例(65.3%),Ⅱ型35例(22.9%),Ⅲ型18例(11.8%)。各分型sIUGR孕妇的年龄、受孕方式、妊娠并发症、初次诊断孕周、脐带插入特征、分娩指征、胎儿宫内死亡率和新生儿死亡率分别比较,差异均无统计学意义(P均>0.05)。Ⅰ型sIUGR孕妇的分娩孕周为(33.5±1.9)周,显著晚于Ⅱ型和Ⅲ型sIUGR孕妇[分别为(31.3±1.8)、(31.2±1.1)周,P<0.001]。Ⅰ型sIUGR双胎估测胎儿体重(EFW)差显著低于Ⅱ型、Ⅲ型sIUGR(P均<0.001)。Ⅰ型sIUGR大、小胎儿的新生儿重症监护病房(NICU)入住率、脑白质软化、肺部并发症发生率,以及大胎儿坏死性小肠结肠炎的发生率均明显低于Ⅱ型和Ⅲ型(P均<0.05)。(2)分型转化:Ⅰ型sIUGR中,28例(28.0%,28/100)孕妇分娩前的分型发生进展,其中18例进展为Ⅱ型,10例进展为Ⅲ型。与持续Ⅰ型sIUGR相比,进展为Ⅱ型或Ⅲ型sIUGR者大、小胎儿NICU入住率和肺部并发症发生率,以及大胎儿脑白质软化和坏死性小肠结肠炎发生率均较高,差异均有统计学意义(P均<0.05)。Ⅰ型进展为Ⅲ型sIUGR孕妇双胎脐带插入呈不一致型的比例(6/10)显著高于持续Ⅰ型和Ⅰ型进展为Ⅱ型者[分别为19.4%(14/72)、0(0/18),P=0.001]。初次诊断为Ⅱ型sIUGR者35例,其中分娩前逆转为Ⅰ型者4例(11.4%),持续Ⅱ型者25例(71.4%),逆转为Ⅲ型者6例(17.1%);持续Ⅱ型、逆转为Ⅲ型sIUGR者大胎儿NICU入住率显著高于逆转为Ⅰ型者(P<0.05)。初次诊断为Ⅲ型sIUGR者18例,其中分娩前逆转为Ⅰ型者2例(2/18),进展为Ⅱ型者6例(6/18),持续Ⅲ型者10例(10/18)。Ⅲ型转化为各分型sIUGR者大小胎儿严重并发症的发生率无显著差异(P均>0.05)。结论初诊不同分型sIUGR间存在分型转化现象,包括进展或逆转。对于Ⅰ型sIUGR,当双胎EFW差较大、脐带插入呈不一致型时,应适当增加超声评估频率。

Objective To retrospectively analyze the clinical data of different types of selective intrauterine growth restriction(sIUGR)pregnant women under expectant management,including the natural evolution,typing conversion and perinatal outcomes.Methods The clinical data of 153 pregnant women with sIUGR under expected treatment in Women′s Hospital,Zhejiang University School of Medicine from January 2014 to December 2018 were collected.Maternal characteristics including maternal age,gravidity,parity,method of conception,pregnancy complication,gestational age at delivery,indication for delivery,birth weight,the rate of intrauterine and neonatal death and neonatal outcomes were recorded.Pregnant women with sIUGR were divided into three types according to end-diastolic umbilical artery flow Doppler ultrasonography,and the differences of typing conversion and perinatal outcomes of sIUGR pregnant women based on the first diagnosis were compared.Results(1)Clinical characteristics and pregnancy outcomes:among 153 pregnant women with sIUGR,100 cases(65.3%)were diagnosed with typeⅠ,35 cases(22.9%)with typeⅡ,and 18 cases(11.8%)with typeⅢ.There were no significant differences in age,conception mode,pregnancy complications,first diagnosis gestational age,characteristics of umbilical cord insertion,delivery indications,fetal intrauterine mortality and neonatal mortality among three types of sIUGR pregnant women(all P>0.05).The average gestational age at delivery of typeⅠsIUGR was(33.5±1.9)weeks,which was significantly later than those of typeⅡandⅢ[(31.3±1.8),(31.2±1.1)weeks,P<0.001].The percentage disordance in estimated fetal weight(EFW)of typeⅠsIUGR was significantly lower than those of typeⅡand typeⅢ(P<0.001).The incidence rate of neonatal intensive care unit(NICU)admission,cerebral leukomalacia and respiratory complications of both fetus and necrotizing enterocolitis of large fetus in typeⅠwere significantly lower than those in typeⅡand typeⅢ(all P<0.05).(2)Typing conversion:in 100 cases of typeⅠsIUGR,18 cases progressed to typeⅡand 10 cases progressed to typeⅢ.Compared with 72 stable typeⅠsIUGR,those with progressed typeⅠsIUGR had higher incidence of NICU admission and lung disease in both fetuses,and cerebral leukomalacia and necrotizing enterocolitis in large fetus(all P<0.05).The proportion of inconsistent cord insertion was significantly higher in those typeⅠprogressed to typeⅢ(6/10)than in those with stable typeⅠ(19.4%,14/72)and typeⅠprogressed to typeⅡsIUGR[0(0/18),P=0.001].Four cases of typeⅡsIUGR reversed to typeⅠand 6 cases reversed to typeⅢ.Compared with typeⅡreversed to typeⅠsIUGR,those stable typeⅡand typeⅡreversed to typeⅢsIUGR had a higher incidence of NICU admission in large fetus(P<0.05).Two cases of typeⅢsIUGR reversed to typeⅠand 6 cases progressed to typeⅡ.There were no significant differences in fetal serious complications in typeⅢsIUGR with or without doppler changes(all P>0.05).Conclusions The different types of sIUGR could convert to each other.The frequency of ultrasound examinations should be increased for patients with the typeⅠsIUGR,especially when the percentage discordance in EFW is substantial or with discordant cord insersion.