Performance of the cervical shortening for prediction of spontaneous preterm birth in uncomplicated twins
Performance of the cervical shortening for prediction of spontaneous preterm birth in uncomplicated twins
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宫颈缩短术在预测无并发症双胞胎自发性早产中的表现
DOI：
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发表时间：
2021
影响因子：
1.8
通讯作者：
L. Otaño
中科院分区：
文献类型：
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作者：
C. Meller;G. Izbizky;H. Aiello;L. Otaño
【摘要】目的对宫颈明显缩短的双胞胎，尤其是宫颈长度大于25mm的双胞胎的处理缺乏共识。因此，重要的是定义随时间变化的“异常”CL变化，并比较不同策略的性能。本研究的目的是双重的，描述颈椎缩短的性能和综合策略的性能，包括颈椎缩短和固定CL截断在任何测量中<25 mm作为无并发症双胎妊娠自发性PTB (sPTB) < 34周的预测因子。材料与方法对2013 - 2017年在布宜诺斯艾利斯意大利医院双胞胎诊所随访的双胞胎进行回顾性队列研究。纳入标准是双绒毛膜或单绒毛膜双羊膜双胞胎，CL测量在18至33 + 6周之间，并有分娩资料。排除标准包括以下并发症：医院源性早产<34周、子宫环扎、胎儿生长受限、胎儿死亡、结构异常、羊水过多、双胎输血综合征、选择性胎儿生长受限、双胎贫血-红细胞增多症序列、双胎动脉灌注逆转序列。自发性早产定义为自发性分娩<34周。分析20-24周、20-28周、24-28周、24-32周和28-32周颈椎缩短情况。分析颈椎变化随时间缩短的速度（mm/周）和随时间缩短的比率（%/周）。构建每个时期的ROC曲线，并使用两个不同的截止点将CL的变化分类为阳性或阴性筛选：a)与约登指数最高值相关的CL缩短和b)固定10%的假阳性率（FPR）。对于第二个目标，我们分析了一种综合策略，考虑在任何GA和/或显著缩短的固定截止时间为25 mm。如果任何GA的任何CL测量值<25 mm，或者每个时期的CL缩短≥临界值，则认为筛选呈阳性。我们报告了敏感性、特异性、阳性和阴性预测值、阳性和阴性似然比和ROC曲线下面积。结果纳入378例患者，1417次测量，284例（75%）双绒毛膜，94例（25%）单绒毛膜。20 ~ 28周时，CL截断值分别为1.6 mm/周和4.1%/周，检出率为54.2%(32.8 ~ 74.4%)，特异性为80.5%（75.1 ~ 85.1%）和83.5%（78.5 ~ 87.8%）。综合策略的检出率为65.7%(47.8 ~ 80.9%)，特异性为69（63.7 ~ 74）。所有研究时期的ROC曲线均显示AUC < 0.7。在早产患者组中，初始平均CL短于足月组，分别为39（±12）mm和43（±7.7）mm (p = 0.02)，最重要的CL变化发生在20-24周，无论是速度还是随时间缩短的比例。相反，足月分娩的患者在妊娠晚期的CL变化更高。结论所有策略对sPTB <34周的预测作用均为中等。在20-28周期间，检测到一半的风险患者，FPR约为10-20%，综合策略将灵敏度提高到检测到三分之二的风险患者，但FPR为30%。未来的分析需要探索其他策略来提高性能，并真正识别高风险患者。
Abstract Objective There is a lack of consensus about the management of twins with significant cervical length (CL) shortening, especially if CL is above 25 mm. Therefore, it is important to define “abnormal” CL change over time, and to compare the performance of different strategies. The aim of this study was twofold, to describe the performance of the cervical shortening and that of an integrated strategy that includes both the cervical shortening and a fixed CL cutoff <25 mm in any measurement as predictor of spontaneous PTB (sPTB) < 34 weeks in uncomplicated twin pregnancies. Material and methods Retrospective cohort study of twins followed in our Twins Clinic at Hospital Italiano de Buenos Aires from 2013 to 2017. Inclusion criteria were dichorionic or monochorionic diamniotic twins with CL measurement between 18 and 33 + 6 weeks with available data of the delivery. Exclusion criteria included any of the following complications: iatrogenic preterm delivery <34 weeks, cerclage, fetal growth restriction, fetal death, structural anomalies, polyhydramnios, twin–twin transfusion syndrome, selective fetal growth restriction, twin anemia–polycythemia sequence, and twin reversed arterial perfusion sequence. Spontaneous preterm birth was defined as spontaneous delivery <34 weeks. Cervical shortening was analyzed in the following periods: 20–24 weeks, 20–28 weeks, 24–28 weeks, 24–32 weeks and 28–32 weeks. Cervical changes were analyzed as velocity of shortening over time (mm/week) and as the ratio of shortening over time (%/week). ROC curves for each period were constructed and two different cutoffs were used to classify changes of the CL as positive or negative screening: a) the shortening of CL associated to the highest value of the Youden Index and b) fixing a 10% false positive rate (FPR). For the second objective, we analyzed an integrated strategy considering a fixed cutoff of 25 mm at any GA and/or a significant shortening. The screening was considered positive if any CL measurement was <25 mm at any GA or there was a shortening of the CL ≥ the cutoff obtained for each period. We report sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio and area under the ROC curve. Results We included 378 patients and 1417 measurements, 284 (75%) dichorionic and 94 (25%) monochorionic. Between 20 and 28 weeks, with a change in CL cutoff = 1.6 mm/week or 4.1%/week the detection rate was 54.2% (32.8–74.4%) and the specificity 80.5% (75.1–85.1%) and 83.5% (78.5–87.8%) respectively. In the integrated strategy, the detection rate was 65.7% (47.8–80.9%) and the specificity 69 (63.7–74). All the ROC curves of the periods studied showed an AUC < 0.7. In the group of patients that delivered preterm the initial mean CL was shorter than in the term group, 39 (±12) mm vs. 43 (± 7.7) mm (p = .02) and the most important change in CL was at 20–24 weeks both in the velocity and in the ratio of shortening over time. Conversely, patients that delivered at term showed a higher change in CL in the third trimester. Conclusion The performance of all the strategies analyzed as a predictor of sPTB <34 weeks was moderate. The period 20–28 weeks detected half of the patients at risk with a FPR around 10–20% and the integrated strategy increased the sensitivity up to a detection of two thirds of the patients at risk but with a FPR of ∼30%. Future analyses need to explore other strategies to improve the performance and to really identify the patients at higher risk.