Abstract:

Objective: To verify the source of brain injury in premature infants with twin-twin transfusion syndrome (TTTS) from fetal period or postnatal factors. Methods: A prospective cohort study with TTTS twins was performed whose mothers received fetal ultrasound before the delivery at 34 weeks, and postnatal brain ultrasound was performed within 2 d at the same hospital by ultrasound to diagnose intracranial hemorrhage and(PIVH) cystic periventricular leukomalacia (PVL). The brain injury was scored on fetal and postnatal ultrasounds. The pregnant women with twins died and chromosomal abnormality of one of the twins were excluded.Results: A total of 94 fetuses of the 47 pregnant women with TTTS were analyzed in the study. The median age of the pregnant women was 31 (18-46) years old, and the TTTS were diagnosed between 16 and 28 weeks of gestational age, and the gestational age of 28 ~ 33 + 5 weeks was terminated. 7, 9, 17, 8 and 6 cases were in Quintero Ⅰ, Ⅱ, Ⅲ, Ⅳ and Ⅴ periods respectively, in stage Ⅴ 6 cases of fetal death happened, the partners of 6 cases occurred PIVH and PVL. In all, 19/88 (21.6%) fetuses had brain injury seen on fetal ultrasound, 5 recipients, 14 donors(26.3% vs 73.6 %, P＜ 0.05). 17 fetuses were with Quintero Ⅲ, Ⅳand Ⅴ brain injury and 2 fetuses with Quintero Ⅰ,Ⅱbrain injury (30.3% vs 6.2 %, P＜0.05). Twins of 13/47 cases(27.7%) were not found new patients with brain injury after the treatment of amniotic fluid reduction at 19 ~ 28 weeks of gestation. The gestational age of all 88 cases was (30.5± 4.5) weeks. Recipients weight was (1 607±438) g, donors (1 257±403) g, 4 cases died caused by neonatal asphyxia. In all, 24/84 infants (28.6%) had brain injury seen on postnatal ultrasound. 9 recipients, 15 donors were found (37.5% vs 62.5 %, P＜0.05). There were 5 cases with PIVH Ⅰ, all of them were diagnosed without PVL. PIVH Ⅱ, 11 cases involved fetal stage, and in neonatal stage 4 cases were increased ,including 1 case with PVL. 3 cases developed to PIVH Ⅲ with soften cerebral white matter, no death case. During PIVH Ⅲ, 5 cases in fetal stage were combined with PVL, there were 5 cases at neonatal stage, 3 cases developed from PIVH Ⅱ , and 1 case died. All of the 3 fetuses involved PIVH Ⅳ were with PVL, and 2 cases in neonatal stage were caused by PVIH Ⅲ with PVL, and died.Conclusion: The risk of cerebral injury and neurologic morbidity increased in fetuses and infants TTTS. Severe cerebral lesions detected in TTTS included cystic periventricular leukomalacia (PVL), severe intraventricular hemorrhage (IVH). In view of the increased risk of cerebral injury, cranial ultrasound scans should be performed routinely in all TTTS survivors at birth.