Cervical-length as a screening for spontaneous preterm birth in uncomplicated twins: one vs. serial measurements
Cervical-length as a screening for spontaneous preterm birth in uncomplicated twins: one vs. serial measurements
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宫颈长度作为无并发症双胞胎自发性早产的筛查：单次测量与系列测量
DOI：
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发表时间：
2020
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
摘要目的虽然宫颈长度(CL)为单胎自然早产提供了有效的筛查手段，但双胞胎的表现仍存在争议。我们的目标是双重的。首先，比较妊娠中期单次CL测量(∼20 周)和连续测量作为无并发症双胎自然早产和34 周的预测指标的表现。其次，描述单个CL在∼24、∼28和∼32 Week的表现。材料和方法对2013年至2017年在布宜诺斯艾利斯意大利医院进行的双胞胎队列研究。纳入标准为双绒毛膜或单绒毛膜双胎，其CL测量范围为18至33 + 6 周，并有分娩资料。排除标准包括以下任何并发症：医源性早产和34 周、环扎术、胎儿生长受限、胎儿死亡、结构异常、羊水过多、双胞胎输血综合征、选择性胎儿生长受限、双胞胎贫血-红细胞增多症序列和双胎动脉反向灌注序列。自然早产定义为自然分娩<34 周。用两种不同的界值将CL分为短小(阳性筛查)或正常(阴性筛查)：(A)任何胎龄(GA)的固定界值为25 mm。如果任何CL测量为-lt；25 mm；和(B)GA调整的截止值为10%的假阳性率，则筛查被认为是阳性。计算每个GA的10%的FPR，如果任何CL测量低于10%的FPR截止值，则筛查被认为是阳性的。我们报告敏感度、特异度、阳性和阴性预测值、阳性和阴性似然比和ROC曲线下面积。结果在本单位随访的777对双胞胎中，381例符合排除标准，18例因未完成随访而被排除。我们纳入了378例患者，其中双绒毛膜早破284例(75%)，单绒毛膜早孕94例(25%)。20 时，单个CL的敏感性≤为20%，ROC曲线下面积为0.58(95%CI，0.45~0.70)，而连续测量的敏感性为58.8%(95%CI，40.7~75.4)，ROC曲线下面积为0.70(95%CI，0.61~0.79)(p <； .001)。对单个CL在∼24、∼28和∼32 周的表现的分析显示，与连续测量的结果相似，当FFP R=10%时，一次测量在24和32 周的敏感性分别为30%(95%CI，14.7~49.4)和31.6%(95%CI，12.6~56.6)，而28 周的敏感性为48.3%(95%CI，(29.4~67.5))。结论妊娠中期连续测量较单次测量有更好的表现。此外，在单项测量中，中期的CL表现最差，而28 周的评估检测到了一半的早产。然而，所有的策略都表现平平。
Abstract Objective While cervical length (CL) provides an effective screening tool for spontaneous preterm birth in singletons, the performance in twins is still controversial. Our aim was twofold. First, to compare the performance of a single CL measurement at mid-gestation (∼20 weeks) versus serial measurements as a predictor of spontaneous preterm birth < 34 weeks in uncomplicated twin pregnancies. Second, to describe the performance of a single CL at ∼24, ∼28 and ∼32 weeks. Material and methods cohort study of twins followed 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. Two different cutoffs were used to classify CL as short (positive screening) or normal (negative screening): (a) a fixed cutoff of 25 mm at any gestational age (GA). The screening was considered positive if any CL measurement was <25 mm; and (b) a GA adjusted cutoff to a 10% false positive rate (FPR). The 10% FPR for each GA was calculated and the screening was considered positive if any of the CL measurements were below this 10% FPR cutoff. We report sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio and area under the ROC curve. Results Among 777 twins followed in our Unit, 381 met exclusion criteria and 18 were excluded due to incomplete follow-up. We included 378 patients, 284 (75%) dichorionic and 94 (25%) monochorionic. The performance of one CL at 20 weeks showed a sensitivity ≤ 20% with an area under the ROC curve of 0.58 (95% CI, 0.45–0.70), while the performance of serial measurements showed a sensitivity of 58.8% (95% CI, 40.7–75.4) with an area under the ROC curve of 0.70 (95% CI, 0.61–0.79) (p < .001). The analyses of the performance of a single CL at ∼24, ∼28 and ∼32 weeks showed similar AUC than the serial measurements and, for a FPR = 10%, the performance of one measurement at 24 and 32 weeks showed a sensitivity of 30% (95% CI, 14.7–49.4) and 31.6% (95% CI, (12.6–56.6), while the measurement at 28 weeks showed a sensitivity of 48.3% (95% CI, (29.4–67.5). Conclusion Serial measurements showed a better performance than a single one in mid-gestation. Moreover, among single measurements the CL in mid-gestation showed the poorest performance, while the 28 weeks assessment detected half of the preterm deliveries. However, all the strategies showed modest performances.