Restricción de crecimiento aumenta el riesgo de displasia broncopulmonar, muerte y sepsis en gemelos de 30 o menos semanas de gestación / Growth restriction increases the risk of bronchopulmonary dysplasia, death, and sepsis in twins of 30 weeks or less of gestation

INTRODUCCIÓN: Múltiples factores influyen en el riesgo de morbimortalidad del prematuro con restricción del crecimiento intrauterino (RCIU). La comparación de gemelos con crecimiento intrauterino discordante permite evaluar su efecto, excluyendo factores maternos y manejo prenatal. Nuestro objetivo fue evaluar el efecto de la RCIU sobre la morbilidad aguda, crónica y mortalidad, en parejas de recién nacidos gemelares prematuros extremos. PACIENTES Y MÉTODO: Gemelos menores de 1500 g y 30 semanas de gestación, de la Red Neocosur. Se realizaron análisis separados de pares de gemelos concordantes, discordantes leves y severos, evaluando el efecto de la RCIU sobre morbi-mortalidad. Se realizó análisis multivariado para establecer magnitud del efecto. RESULTADOS: 459 pares de gemelos, 227 concordantes, 110 discordantes leves y 122 severos. Entre los concordantes solo hubo diferencia en uso de oxígeno a las 36 semanas. En discordantes leves, el menor tuvo menos enfermedad de membrana hialina y requirió menos dosis de surfactante, pero tuvo un mayor riesgo de Displasia broncopulmonar (DBP) o muerte. En discordantes severos, el menor presentó mayor mortalidad, sepsis, utilización y permanencia en ventilación mecánica, pese a menor frecuencia de enfermedad de membrana hialina. En regresión múltiple, el riesgo combinado de DBP o muerte fue mayor en gemelo menor y discordante severo. CONCLUSIÓN: En gemelos discordantes, la patología respiratoria aguda fue más frecuente en el gemelo mayor, aunque el riesgo de DBP o muerte fue mayor en el gemelo con RCIU.

INTRODUCTION: Multiple factors influence the risk of morbidity and mortality of premature infants with intrauterine growth restriction (IUGR). The comparison of twins with different intrauterine growth allows evaluating the effect of the restriction, excluding maternal factors and prenatal mana gement. Our objective was to assess the effect of IUGR on acute and chronic morbidity, and mortality of extreme preterm twins. PATIENTS AND METHOD: Twins weighing less than 1500 grams and gesta tion equal to or less than 30 weeks, of the Neocosur Network. Separate analyses were performed on concordant twin pairs, and on mild and severe discordant twins, evaluating the effect of IUGR on morbidity and mortality. A multivariate analysis was performed in order to establish the impact of this effect. RESULTS: 459 twin pairs, 227 concordant twins, 110 of mild discordance, and 122 of severe discordance. Among the concordant ones, there was only a difference in oxygen uptake at 36 weeks. In those of mild discordance, the smaller twin presented a lower frequency of hyaline membrane disease and required fewer doses of surfactant, but had a higher risk of bronchopulmonary dysplasia (BPD) or death. In severe discordant twins, the smaller one presented higher mortality, sepsis, use and permanence in mechanical ventilation, despite the lower frequency of hyaline membrane disease. In multiple regression analysis, the combined risk of BPD or death was higher in the smaller twin and of severe discordance. CONCLUSION: In discordant twins, the acute respiratory pathology was more frequent in the larger one, although the risk of BPD or death was higher in the one with IUGR.

Clinical study on independent risk factors and neonatal complications in discordant twins / 中华实用儿科临床杂志

Objective To investigate the perinatal independent risk factors and neonatal complications of discordant twins.Methods Clinical data of 152 (76 pairs) discordant twins and 552 (276 pairs) concordant twins were enrolled at the Obstetrics of Peking University People's Hospital from November 1,2011 to October 31,2016.The perinatal characteristics and the neonatal complications in 2 groups were analyzed and compared.Binary Logistic regression analysis was used to identify the independent risk factors associated with the occurrence of discordant twins.Results (1) The gestational age,the incidence of term infants and birth weight of the discordant twins were significantly lower than those of the concordant twins[(35.8 ±2.5) weeks vs.(36.7 ± 1.8) weeks,48.7％ vs.60.2％,(2 277.1 ± 575.7) g vs.(2 545.0 ± 413.4) g],and the differences were statistically significant (all P ＜ 0.05).The incidence of premature infants,the incidence of infants small for gestational age and the rate of transferring discordant twins to pediatric department were significantly higher than that of concordant twins (51.3％ vs.39.9％,40.8％ vs.13.2％,46.1％ vs.26.8％),and the differences were statistically significant (all P ＜ 0.05).(2) The incidence of neonatal asphyxia,neonatal respiratory distress syndrome,neonatal pneumonia,neonatal apnea,bronchopulmonary dysplasia,neonatal sepsis and neonatal intracranial hemorrhage were significantly higher than those of concordant twins (6.6％ vs.2.5％,7.2％ vs.3.1％,5.3％ vs.1.3％,9.2％ vs.3.3％,3.9％ vs.0.9％,3.3％ vs.0.7％,4.6％ vs.O.7％),and the differences were statistically significant(all P ＜ 0.05).(3) The birth weight in the twins with low body weight group was significantly lower than that in the twins with high body weight group [(1 926.7 ± 414.1) g vs.(2 618.7 ± 504.6) g],and the differences were statistically significant (P ＜ 0.05).The incidence of small for gestational age,the rate of conversion to pediatrics and the incidence of neonatal intracranial hemorrhage in the twins with low body weight group were significantly higher than those in the twins with high body weight group (65.8％ vs.6.6％,56.6％ vs.35.5 ％,9.2％ vs.0),and the differences were statistically significant (all P ＜ 0.05).(4) Logistic regression analysis showed that hypertensive disorder during pregnancy (OR =2.127,95％ CI:1.392-3.253) and gestational diabetes mellitus (OR =1.684,95％ CI:1.112-2.552) were independent risk factors for the occurrence of discordant twins.Conclusions Hypertensive disorder during pregnancy and gestational diabetes mellitus are independent risk factors for the occurrence of discordant twins,who are much more likely to develop various neonatal complications,particularly low-birth-weight infants.Timely surveillance and treatment of short-term complications and long-time follow-up are essential to discordant twins.

Clinical outcomes of first trimester discordant twins / 대한산부인과학회지

OBJECTIVE: To compare the clinical outcomes of first trimester discordant twins with second or third trimester discordant twins and concordant twins. METHODS: Pregnancy outcomes of twin pregnancies delivered from October 1994 to February 2006 were analyzed retrospectively. Subjects were categorized into following three groups: 1) group 1, first trimester discordant twins defined as intertwin CRL difference > or =5 days at 10-14 weeks of gestation (n=32), 2) group 2, second or third trimester discordant twins defined as intertwin AC difference >20 mm at 20-28 weeks of gestation or intertwin fetal weight difference >25% beyond 29 weeks of gestation (n=42), 3) group 3, concordant twins with no discordancy throughout the whole gestation (n=723). Perinatal complications analyzed for were congenital anomaly, fetal growth restriction (FGR), fetal death in utero (FDIU). RESULTS: The three groups were similar with respect to maternal characteristics and chorionicity. Overall, the group 2 had higher perinatal complications compared to the group 3. Congenital anomaly was more common in the group 1 than the group 2 (21.9% vs. 11.9%, p<0.001). However, FGR rate was higher in the group 2 than the group 1 (32.3% vs. 71.8%, p<0.01). Congenital anomaly, FGR and FDIU were more common in the group 1 compared to the group 3 (21.9% vs. 3.5%, p<0.001, 32.3% vs. 9.1%, p<0.01, 6.3% vs. 1.0%, p<0.05, respectively). CONCLUSIONS: First trimester discordant twins have an increased risk of congenital anomaly, FGR and FDIU, and therefore, they should be regarded as a high-risk pregnancy likewise second or third trimester discordant twins.