单绒毛膜双羊膜囊双胎妊娠双胎之一胎死宫内对妊娠结局的影响

doi:10.19723/j.issn.1671-167X.2025.03.025

摘要/Abstract

摘要：

目的: 比较单绒毛膜双羊膜囊(monochorionic diamniotic，MCDA)双胎妊娠选择性减胎和自发双胎之一胎死宫内(single intrauterine fetal demise，sIUFD)后的存活儿妊娠结局，并探索预后的影响因素。方法: 收集2010年9月至2021年8月北京大学第三医院收治的219例MCDA双胎妊娠中一胎宫内死亡病例，根据胎死方式分为自发sIUFD组(120例)和选择性减胎组(99例)，采集孕期母体情况、宫内死亡胎儿情况和妊娠结局资料进行回顾性病例分析。结果: 自发sIUFD组和选择性减胎组的存活儿活产率分别为85.0%及81.8%，存活儿总围生期存活率则分别为73.3%及81.8%，差异均无统计学意义。与自发sIUFD组相比，选择性减胎组的分娩孕周更大， < 37周早产率、新生儿窒息率和早期新生儿死亡率更低。以分娩孕周为结局变量，采用Cox回归分析发现，胎死方式并非影响存活儿分娩孕周的风险因素，而妊娠期高血压和胎死孕周为影响存活儿分娩孕周的独立风险因素；分别以是否出现 < 37周早产、存活儿宫内死亡和新生儿颅脑B超异常为结局变量，采用非条件Logistics回归分析发现，胎死方式、胎死孕周、死胎位置和胎儿并发症等为影响上述存活儿结局的独立风险因素；根据单因素分析结果，将上述风险因素纳入多因素回归分析，结果与单因素分析相同。结论: 对于存在严重双胎并发症的MCDA双胎妊娠患者，进行选择性减胎术后的存活儿预后更好，积极的宫内干预治疗对于改善存活儿预后具有重要的意义。

关键词: 单绒毛膜双羊膜囊, 胎死宫内, 选择性减胎术, 妊娠结局

Abstract:

Objective: To compare the pregnancy outcomes of surviving fetuses in monochorionic diamniotic (MCDA) twin pregnancies after selective feticide or spontaneous single intrauterine fetal demise (sIUFD), and to explore the influencing factors of prognosis. Methods: A total of 219 cases of intra-uterine death of one fetus in MCDA twin pregnancies admitted to Peking University Third Hospital from September 2010 to August 2021 were collected. According to the mode of fetal death, they were divided into the spontaneous sIUFD group (120 cases) and the selective feticide group (99 cases). Data on the maternal conditions during pregnancy, the situation of the intrauterine-dead fetus, and pregnancy outcomes were collected for retrospective case-analysis. Results: The live-birth rates of surviving fetuses in the spontaneous sIUFD group and the selective feticide group were 85.0% and 81.8% respectively, and the total perinatal survival rates of surviving fetuses were 73.3% and 81.8% respectively, and there were no statistically significant differences. Compared with the spontaneous sIUFD group, the selective feticide group had a greater gestational week at delivery, and lower rate of preterm birth before 37 weeks, neonatal asphyxia, and early neonatal mortality. Using the gestational week at delivery as the outcome variable, Cox regression analysis showed that the mode of fetal death was not a risk factor affecting the gestational week at delivery of the surviving fetus, while gestational hypertension and the gestational week of fetal death were independent risk factors affecting the gestational week at delivery of the surviving fetus. Using preterm birth before 37 weeks, intrauterine death of the surviving fetus, and abnormal neonatal cranial ultrasound as outcome variables respectively, unconditional logistic regression analysis showed that the mode of fetal death, the gestational week of fetal death, the position of the dead fetus, and fetal complications were independent risk factors affecting the outcomes of the above-mentioned surviving fetuses. According to the results of the univariate analysis, the above risk factors were included in the multivariate regression analysis, and the results were the same as those of the univariate analysis. Conclusion: For MCDA twin pregnancy patients with severe twin-related complications, the prognosis of surviving fetuses after selective feticide is better. The proactive intrauterine intervention and treatment are of great significance for improving the prognosis of surviving fetuses.

Key words: Monochorionic diamniotic, Intrauterine fetal demise, Selective feticide, Pregnancy outcome

中图分类号:

R714.2

卞雯, 周文君, 吴天晨, 朱培静, 陈一诺, 原鹏波, 王学举, 王颖, 魏瑗, 赵扬玉. 单绒毛膜双羊膜囊双胎妊娠双胎之一胎死宫内对妊娠结局的影响[J]. 北京大学学报（医学版）, 2025, 57(3): 592-598.

Wen BIAN, Wenjun ZHOU, Tianchen WU, Peijing ZHU, Yinuo CHEN, Pengbo YUAN, Xueju WANG, Ying WANG, Yuan WEI, Yangyu ZHAO. Perinatal outcomes of single intrauterine fetal demise in monochorionic diamniotic twins[J]. Journal of Peking University (Health Sciences), 2025, 57(3): 592-598.

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参考文献 30

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Variables	Spontaneous sIUFD group (n=120)	Selective feticide group (n=99)	P
Age/years, M (P₂₅, P₇₅)	30.00 (27.00, 32.75)	31.00 (29.00, 34.00)	0.013^a
BMI/(kg/m²), M (P₂₅, P₇₅)	21.89 (19.52, 24.83)	21.88 (19.96, 24.22)	0.968^a
Conception method, n (%)			0.669^b
Spontaneous pregnancy	107 (89.2)	90 (90.9)
Assisted reproduction	13 (10.8)	9 (9.1)
Parity, n (%)			0.130^b
Primipara	90 (75.0)	65 (65.7)
Multipara	30 (25.0)	34 (34.3)
Hypertensive disorders of pregnancy, n (%)	18 (15.0)	18 (18.2)	0.527^b
Gestational diabetes mellitus, n (%)	11 (9.2)	19 (19.2)	0.032^b
Other comorbidities, n (%)	23 (19.2)	21 (21.2)	0.707^b

Variables	Spontaneous sIUFD group (n=120)	Selective feticide group (n=99)	P
Fetal complications, n (%)			< 0.001^a
TTTS	41 (34.2)	14 (14.1)
sIUGR	23 (19.2)	29 (29.3)
TRAPs	2 (1.7)	19 (19.2)
MTFDA	4 (3.3)	15 (15.2)
Multiple	19 (15.8)	19 (19.2)
None	31 (25.8)	3 (3.0)
Gestational weeks of sIUFD/feticide/weeks, M(P_25，P₇₅)	26.78 (22.71, 30.57)	21.64 (18.96, 24.71)	< 0.001^b
< 28 gestational weeks, n (%)	71 (59.2)	98 (99.0)	< 0.001^a
Location of the dead fetus, n (%)			0.213^a
Lower	77 (66.4)	72 (74.2)
Higher	39 (33.6)	25 (25.8)

Variables	Spontaneous sIUFD group (n=102)	Selective feticide group (n=81)	P
Cesarean section, n (%)	45 (44.1)	39 (48.1)	0.587^a
Gestational week of delivery/weeks, M (P₂₅, P₇₅)	35.71 (32.36, 38.04)	37.43 (33.86, 38.93)	0.014^b
PPROM, n (%)	18 (17.5)	19 (21.8)	0.449^c
Preterm birth/weeks, n (%)
< 30	10 (9.8)	5 (6.2)	0.374^a
< 32	24 (23.5)	13 (16.0)	0.211^a
< 33	37 (36.3)	21 (25.9)	0.135^a
< 37	60 (58.8)	34 (42.0)	0.024^a
Transferred to NICU, n (%)	42 (41.2)	33 (40.7)	0.953^a
Neonatal asphyxia, n (%)	14 (13.7)	1 (1.2)	0.002^a
Neonatal birth weight/g, M (P₂₅, P₇₅)	2 295.00 (1 660.00, 2 962.50)	2 690.00 (1 880.00, 3 090.00)	0.064^b
Small for gestational age infant, n (%)	35 (34.3)	22 (27.2)	0.299^a
Early neonatal death, n (%)	14 (13.7)	0 (0)	0.001^a
Abnormal neonatal cranial ultrasound, n (%)	25 (24.5)	19 (23.5)	0.868^a

Variables	Gestational weeks of delivery, HR (95%CI)	Preterm birth (< 37 weeks), OR (95%CI)	Viable fetus died in utero, OR (95%CI)	Abnormal neonatal cranial ultrasound, OR (95%CI)
Age		0.984(0.911-1.062)
Hypertensive disorders of pregnancy	1.644 (1.116-2.423)^*			2.072 (0.839-5.117)
Gestational diabetes mellitus			0.564 (0.177-1.799)
Selective feticide	1.102 (0.727-1.672)	2.298 (0.912-5.791)	0.333 (0.141-0.788)^*	2.505 (0.906-6.924)
Gestational weeks of fetal death	1.070 (1.034-1.107)^▲	1.204 (1.107-1.310)^▲	0.934 (0.863-1.009)	1.129 (1.034-1.232)^#
Dead fetus lies lower		2.232 (1.047-4.760)^*
TTTS	1.359 (0.842-2.193)	1.838 (0.648-5.213)	9.524 (2.025-44.798)^#	1.840 (0.600-5.645)
TRAPs	0.789 (0.399-1.558)	0.400 (0.085-1.884)	8.964 (1.369-58.681)^*	0.234 (0.022-2.450)
sIUGR	0.783 (0.264-2.322)	0.706 (0.233-2.141)	7.138 (1.364-37.342)^*	0.642 (0.189-2.176)
MTFDA	0.627 (0.130-3.028)	0.727 (0.144-3.671)	10.506 (1.638-67.394)^*	1.027 (0.195-5.397)
Multiple complications	1.464 (0.467-4.592)	1.322 (0.414-4.223)	7.292 (1.401-37.943)^*	0.765 (0.210-2.785)

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