태아간 체중 차이가 큰 쌍태 임신의 주산기 예후

김금재(Keum Jae Kim),김미경(Mi Kyung Kim),유혜경(Hye Kyung Yoo),오혜은(Hye Eun Oh),원혜성(Hye Sung Won),이필량(Pil Ryang Lee),이인식(In Sik Lee),김암(Ahm Kim),남주현(Joo Hyun Nam) 대한산부인과학회 1999 Obstetrics & Gynecology Science Vol.42 No.9

Objective: To evaluate whether twin discordancy is a risk factor for adverse perinatal and neonatal outcomes. Methods: Three hundred and seventy-five twin gestations over 28 weeks of gestation were included in this retrospective study. Medical records of mothers and infants were reviewed. Pregnancies were divided into 2 groups according to the birth weight discordancy(%) between twin neonates(group I;less than 25%, group II;25% or more). Birth weight discordancy was calculated from following formula; (birth weight of larger twin-birth weight of smaller twin)/ birth weight of larger twin x 100. Perinatal and neonatal outcomes in group I and II were compared with each other. Also, difference in the outcomes between the smaller and larger twins of group II was evaluated. To evaluate whether birth weight discordancy is an independent variable in predicting poor perinatal and neonatal outcomes, multiple logistic regression analysis was used. Results: Thirty-seven gestations(9.9%) were documented to belong to group II. Group II showed significantly higher incidence of preeclampsia, placenta previa, and small for gestational age infants(p<0.01, p<0.05 and p<0.001, respectively). The group also showed higher incidence of adverse neonatal outcomes(admission to neonatal intensive care unit, respiratory distress syndrome, pneumonia, bronchopulmonary dysplasia, patent ductus arteriosus, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, sepsis, congenital anomaly, neonatal death, p<0.01). Outcomes of the larger and smaller twins of group II were not significantly different with each other except small for gestational age infants(p<0.005). However, birth weight discordancy was not an independent variable in predicting adverse perinatal and neonatal outcomes. Conclusion: Fetal growth discordancy of 25% or more should be regarded as a risk factor for adverse perinatal and neonatal outcomes in twin gestations. However it is not an independent factor in predicting adverse perinatal and neonatal outcomes.

우리나라 쌍태아의 출생체중 불일치 수준과 조기분만에 관한 연구; 2009-2013

박상화 ( Sang Hwa Park ),한정호 ( Jung Ho Han ),임달오 ( Dar Oh Lim ) 한국보건정보통계학회 2015 보건정보통계학회지 Vol.40 No.2

Objectives: To compare the relationship between intra-twin birth weight discordance and preterm birth (PTB; ≤36 weeks) by analyzing the birth certificated data of Koera Statistics. Methods: The 2009-2013 birth certificated data of Korea Statistics was used for this analysis. There were 31,998 completely matched twin pairs from 67,557 twin birth data. The data of unmatched twin cases, teenage birth, extra-marital birth, non-hospital birth cases, and gestational age and birth weight information missing cases were excluded. Odds ratio and 95 percent confidence intervals were calculated from logistic regression analyses to describe the risk of PTB by the degree of intra twin birth weight discordance (birth weight difference/ birth weight of heavier twin x 100) adjusted for infantile sex, birth order, maternal age, year of birth, and maternal education & occupation. Results: The incidence of intra-twin birth weight discordance was 55.3 percent in discordance level of ≤9 percent, and 4.4 percent in discordance level of ≥30 percent. The mean gestational age was getting shorter from 35.9 weeks in discordance level of ≤9 percent to 34.8 weeks in discordance level of ≥30 percent. The rate of PTB in twins was increased with increasing degree of birth weight discordance. The PTB rates were 52.1 percent and 70.8 percent, respectively, in subjects with a birth weight discordance of ≤9 percent and in those ≥30 percent. Compared with birth weight discordance of ≤9 percent, odds ratio of PTB was 1.15 (95% confidence interval: 1.07-1.24) in birth weight discordance (20%), and 2.28 (2.02-2.57) in birth weight discordance of ≥30 percent. Conclusions: The risk of PTB was significantly increased with higher degree of intra-twin birth weight discordance of ≥20 percent.

우리나라 쌍태아의 출생체중 불일치에 관한 연구

박상화 ( Sang Hwa Park ),김종석 ( Jong Seok Kim ) 서울대학교 인구의학연구소 2015 人口醫學硏究論集 Vol.28 No.-

The objective of the study was to com pare the inter-twin birth weight discordance by analyzing birth certificated data of Korea Statistics, There were 26,325 pairs of twins, born from 2010 to 2013, according to the birth certificated data of Korea Statistics (excluded extra-marital birth, teenage birth, and non-hospital birth cases). Odds ratio and 95% confidence intervals were calculated from logistic regression analyses to describe the birth weight discordance by maternal age, year of birth, gestational age and infantile gender. Birth weight discordance rate (%) was calculated as 100 x (birth weight difference of inter-twin/birth weight of heavier twin). Overall rate of birth weight discordance was 11.1 percent, and mean difference of inter-twin birth weight was 0.281kg. The frequency of discordance level was 55.3 percent, 29.4 percent, 10.8 percent, and 4.5 percent, respectively, and in twin with a birth weight discordance level of :0; 9 percent, 10-19 percent, 20-29 percent, and ~ 30 percent. 1ncidence of birth weight discordance more than 25 percent was 8.3 percent. Compared with women aged 20-29 years, odds ratio of ~ 25 percent discordance was 1.157 (95 % confidence interval: 1.017-1.317) in aged 35 years and older. Birth weight discordance of ~ 25 percent was significantly increased with earlier gestational age. Odds ratio of ~ 25 percent discordance was 2.272 (1.997-2.584) in early preterm birth (:0; 33 weeks), and 1.405 (1.276-1.548) in post preterm birth (34-36 weeks) as compared to full term birth (~37 weeks). Odds ratio of ~ 25 percent discordance for the different-sexed twins was 1.122 0.008-1.249), compared with same-sexed twins (female-female). Birth weight discordance of ~ 25 percent was associated with earlier gestational age, and women aged 35 years & older, and different-sexed twin. There was a need to understand the contributing birth weight discordance and to reduce the discordance for high risk women.

성장불일치를 초래하는 쌍태아에서 태반의 난막성, 태반무게, 제대부착부위에 따른 도플러혈류의 변화

김석영 ( Kim Seog Yeong ),김광준 ( Kim Gwang Jun ),윤성준 ( Yun Seong Jun ),이순표 ( Lee Sun Pyo ),이지성 ( Lee Ji Seong ) 대한산부인과학회 2004 Obstetrics & Gynecology Science Vol.47 No.2

Objective : To evaluate hemodynamic change in growth discordant twins using a ratio of middle cerebral artery/umbilical artery resistance index and to assess the relationship between Doppler hemodynamic and the influence of placental chorionisity and umbilical cord insertion. Methods : 118 live born twin pairs whose birthweight discordance below or above 20% between March 2000 and March 2002 were included in our study. And we divided the two groups in which above 20% of growth discordance (GD) group was GD and below 20% of GD group was control. Chorionisity and umbilical cord insertion in all study subjects within 24 hours after delivery were investigated. And then we classified to monochorionic (MONO), and dichorionic (DI) placenta and the type of insertion of umbilical cord were also classified central, marginal and velamentous type. 56 of twin pairs were performed 153 Doppler flow velocimetry between smaller and larger fetus prenatally. Resistance index (RI) of middle cerebral artery and umbilical artery in each fetus were measured and standardized as a ratio of middle cerebral artery/umbilical artery (MCA/UmA). ANOVA, Mann-Whitney U test, and chi-square test, were performed and p<0.05 was considered as statistically significant. Results : Mean birthweight in monochorionic twins had lighter than those of dichorionic twins (p<0.01). The mean growth discordant ratios were 14.1% in monochorionic twin and 12.1% in dichorionic twins. In monochorionic twin, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than those of the larger fetus, significantly (1.09 vs. 1.28 p<0.05). And in monochorionic twins, the smaller fetus in GD group showed lower value of MCA/UmA RI ratio than the smaller fetus in control group, significantly (1.09 vs. 1.27 p<0.05). The placental weight in dichorionic twin was correlated the birthweight in infants in GD group, positively. Monochorionic twins in GD group had a significantly higher incidence of peripheral cord insertion than those of dichorionic twins in GD group (50.0% vs. 35.7% p<0.01). But dichorionic twins had a significantly higher incidence of central cord insertion than those of monochorionic twins in control group (69.2 vs. 57.4 p<0.05). Conclusion : The higher middle cerebral artery blood flows in smaller fetuses of monochorionic twins proved to be circulatory redistribution of the fetus in inadequate intrauterine condition. And these change of middle cerebral blood flow might be understood the part of mechanisms fetal growth and adaptation. Placental weight, number and umbilical cord insertion were also important factors which affected to develop the growth discordance of twin pregnancy.

출생 체중 불일치를 보이는 쌍태임신의 주산기 예후

이희종(Hee Jong Lee),이준서(June Seo Lee),김행수(Haeng Soo Kim),양정인(Jeong In Yang),오준환(Jun Hwan Oh),한기수(Ki Su Han),오기석(Kie Suk Oh) 대한산부인과학회 2001 Obstetrics & Gynecology Science Vol.44 No.3

Objective : To evaluate the perinatal outcomes of twin pregnancies with birth weight discordancy and to determine factors affecting on the outcomes. Methods : We studied 367 pairs of twin delivered after 28 weeks of gestation at the Ajou University Hospital between June 1994 and June 2000. Twins were stratified into three groups according to the percent difference of birth weight. Birth weight difference less than 15%(concordant) was classified into control group(268 pairs), between 15% and 25% into group 1(72 pairs), and more than 25% into group 2(27 pairs). Perinatal outcomes of each group were assessed retrospectively. Results : In smaller twins, mean birth weight(control vs group 1 vs. group 2 : 2274.3±424.9 gm vs. 2012.9±303.2 gm vs. 1635.2±440.8 gm, p<0.05), duration of neonatal intensive care unit admission(7.6±11.5 days vs. 11.6±10.8 days vs. 18.6±14.4 days, p<0.05), and the frequency of neonatal jaundice(8.6% vs. 12.5% vs. 29.6%, p<0.05), the frequency of small for gestational age infant(8.2% vs. 40.3% vs. 74.1%, p<0.05), and perinatal mortality(2.6% vs. 2.8% vs. 11.1%, p<0.05) in group 2 showed statistically significant difference from control group. No difference was found in larger twins. In multiple logistic regression analysis, independent prognostic factors of discordant twin were gestational age and birth weight. Conclusion : In twin pregnancies with birth weight discordancy, larger twins showed no difference in perinatal outcomes but smaller twins with birth weight discordancy more than 25% showed significantly higher perinatal mortality and morbidity. However independent prognostic factor was not discordancy itself but gestational age and birth weight.

최신임상강좌 : Discordant twin의 처치

김석영 ( Suk Young Kim ) 대한산부인과학회 2008 Obstetrics & Gynecology Science Vol.51 No.6

In twins, growth restriction is found in up to 25%, and intertwin birth weight discordance of more than 20% is frequently recorded. The discordance is usually measured as intrapair weight difference, expressed as a percentage of the larger twin`s weight. Monochorionic twins represent a high-risk group for adverse pregnancy outcome. Although unequal placental sharing may lead to selective intrauterine growth restriction of one twin, unequal blood flow by placental may cause twin-to-twin transfusion syndrome (TTTS). TTTS will develop in around 15% of monochorionic twins and constitutes one of the major causes of fetal growth discordance in monochorionic twins. The two main available treatments for TTTS are laser therapy and amnioreduction. A recent randomized controlled trial provided strong evidence suggesting that laser therapy is superior to amnioreduction in term of survival and neurologic outcomes diagnosed before 26 weeks of the severe cases of TTTS. Laser photocoagulation is an anatomical correctional treatment that aims at interrupting the vascular anastomoses responsible for the hemodynamic decompensation, whereas amnioreduction is a palliative treatment that reduces the effects of the increased amniotic fluid pressure. So we must have alternative strategy to predict early sign and symptoms of TTTS and make the available referral network to management of these discordant twins.

쌍태아 간의 출생체중 불일치율 분포 및 기준에 관한 연구

박상화 ( Sang Hwa Park ),임달오 ( Dar Oh Lim ) 한국보건정보통계학회 2019 보건정보통계학회지 Vol.44 No.3

Objectives: To compare the frequency of inter twin birth weight discordance, and degree of discordance rate in twin births by gestational age. Methods: There were 51,783 pairs of twins from 2007-2014 of birth certificated data of Korea Statistics. We excluded extra-marital and non-hospital birth cases. Birth weight discordance rate (%) was calculated as (birth weight of larger twin-birth weight of smaller twin)/birth weight of larger twin and multiplied with 100. Birth weight discordance values was calculated to describe the degree of discordance by 50th, 90th, and 95th percentile, and two standard deviations above the mean, and frequency of severe birth weight discordancy (birth weight discordancy equal to or more than 25%) at each gestational age. Results: The mean discordance rate for inter twin was 11.0%±9.3%. The discordance values was not a normal (Gaussian) distribution (Kolmogorov-Smirnov test: p-value=0.01), and the best-fit function was exponential model (R²=0.94, p<0.01). The cumulative frequency of discordance values had cubic model (R²=0.99, p<0.01). The 50th percentile of birth weight discordancy was 8.8% discordance, the 90th was 23.4%, and the 95th was 29.1%. At earlier gestational age, the percentage discordant according to the 95th percentile of birth weight discordance was higher (37.0% at 28-33 weeks) than at older gestational age (approximately 26.0% at ≥37 weeks). The values of 95th percentile represented approximately the severe birth weight discordancy (≥25%) in gestational age at 37 weeks and older. Conclusions: The 95th percentile corresponded to a birth weight discordancy of approximately 25 percent at older gestational age (≥37 weeks). The degree of twin births weight discordance should be categorized with respect to gestational age since the degree of discordance may vary in different gestational age.

임신 제1 삼분기 불일치 쌍태임신의 임상적 결과

송승은 ( Seung Eun Song ),고옥진 ( Ok Jin Ko ),조현지 ( Hyun Ji Cho ),서은성 ( Eun Sung Seo ),정경란 ( Kyung Lan Jung ),최석주 ( Suk Joo Choi ),오수영 ( Soo Young Oh ),노정래 ( Cheong Rae Roh ),김종화 ( Jong Hwa Kim ) 대한산부인과학회 2007 Obstetrics & Gynecology Science Vol.50 No.12

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 ≥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.

융모막성에 따른 쌍태아 체중 불일치의 주산기 예후

길기철 ( Ki Chul Kil ),이귀세라 ( Gui Se Ra Lee ),강영화 ( Young Hwa Kang ),김연희 ( Yeon Hee Kim ),김사진 ( Sa Jin Kim ),신종철 ( Jong Chul Shin ) 대한산부인과학회 2008 Obstetrics & Gynecology Science Vol.51 No.11

Objective: The purpose of this study was to examine the association between intrapair birth weight discordance and perinatal outcomes according to the chorionicity. Methods: Twin births in St. Vincent`s Hospital of Catholic University of Korea for the period 2000~2007 were retrospectively studied. Discordance was defined as an intertwin birth weight difference ≥20% and concordance was defined as weight difference <20% calculated from the larger newborn. Perinatal outcomes were compared between discordant and concordant pairs in monochorio-diamnionic and dichorionic twins. Results: Among 38 monochorionic twin births, 34.2% was discordant and 66.8% was concordant. Among 144 dichorionic twin birth, 9.9% was discordant and 91.9% was concordant. The incidences of intrauterine fetal death (FDIU), twin-to-twin transfusion syndrome (TTTS), intrauterine growth restriction (IUGR) and neonatal hypoglycemia of discordant group of monochorionic twins were statistically increased compared with concordant group of monochorionic twins. The incidences of IUGR and neonatal hypoglycemia were statistically increased in the discordant group of dichorionic twins compared with concordant group of dichorionic twins. The others were not shown statistically significant between two groups in the both chorionic twins. Conclusions: Birth weight discordance in monochorionicity seems to predict fetal death, TTTS, IUGR and newborn hypoglycemia. Birth weight discordance in dichorionicity does not seem to be good predictor of adverse perinatal outcomes except IUGR and neonatal hypoglycemia.

우리나라 쌍태아의 임신기간별 출생체중 불일치 수준에 관한 연구; 2007-2014

박상화 ( Sang Hwa Park ),조진만 ( Jean Man Jo ),임달오 ( Dar Oh Lim ) 한국보건정보통계학회 2016 보건정보통계학회지 Vol.41 No.3

Objectives: To compare the relationship between gestational age and inter twin birth weight discordance level. Methods: We used the 2007-2014 birth certificated data of Statistics Korea 51,783 pairs of twins. The data of unmatched twin cases, extra-marital birth and non-hospital birth cases were excluded. Birth weight discordance rate was calculated as (birth weight difference between larger and smaller birth weight/birth weight of heavier twin) x 100. Odds ratio and 95% confidence intervals were calculated from logistic regression analyses to describe the birth weight discordance (≥25%) of gestational age adjusted by year of birth, infantile gender, maternal age, maternal education, and age difference between couples. Results: The inci-dence of inter twin birth weight discordance was 55.3 percent in discordance of ≤9 percent, 10.9 percent in discordance of 20-29 percent, and 4.4 per-cent in discordance of ≥30 percent. The frequency of more than 25 percent discordant set demonstrated polynomial relationship to gestational age (Y=-82.294+6.226X-0.101X², R²=0.77, p<0.01). Overall incidence of birth weight discordance more than 25 percent was 8.3 percent. The frequency of discordance level (≥25%) by gestational age was 10.7 percent in extremely preterm (≤27 weeks), 14.3 percent in very preterm (28-31 weeks), 13.1 per-cent in moderate preterm (32-33 weeks), 8.7 percent in late preterm (34-36 weeks), and 5.8 percent in full and late term (≥39 weeks). The rate of discor-dance level of ≥25 percent decreased with increasing gestational age. Compared with discordance level (≥25%) of full and late term, odds ratio of dis-cordance level (≥25%) was 2.76 (95% confidence interval; 2.05-3.70) in very preterm, 2.48 (1.86-3.31) in moderate preterm, 1.97 (1.37-2.83) in extremely preterm, and 1.56 (1.19-2.05) in late preterm. Conclusions: The risk of discordance level of ≥25 percent increased significantly with very preterm and moderate preterm birth. There is a need to understand the contributing factors and close attention to reduce the risk of discordance level of ≥25 per-cent in gestational age from 28 to 33 weeks.