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To assess the rate of fetal loss following amniocentesis or chorionic villus sampling (CVS) in twin pregnancy.MEDLINE, EMBASE and Cochrane databases were searched for studies reporting procedure-related complications following amniocentesis or CVS in twin pregnancy. The primary outcome was the rate of procedure-related fetal loss. The secondary outcomes were fetal loss occurring before 24 weeks of gestation and fetal loss occurring within 4 weeks after the procedure. Head-to-head meta-analyses were used to compare directly each outcome, between women undergoing amniocentesis and those not undergoing amniocentesis and between women undergoing CVS and those not undergoing CVS, and to compute pooled risk differences (RD) between women exposed and those not exposed to each invasive procedure. Additionally, meta-analyses of proportions were used to estimate the pooled rates of each of the three outcomes in women undergoing amniocentesis or CVS and in controls.Sixteen studies (3419 twin pregnancies undergoing and 2517 not undergoing an invasive procedure) were included. Head-to-head meta-analyses comparing directly twin pregnancies undergoing and those not undergoing amniocentesis showed a higher risk for overall fetal loss in those undergoing amniocentesis (odds ratio (OR), 1.46 (P = 0.04); RD, 0.013 (P = 0.04)), while there was no difference in the risk of either fetal loss before 24 weeks of gestation (OR, 1.59 (P = 0.06); RD, 0.010 (P = 0.11)) or fetal loss within 4 weeks after the procedure (OR, 1.38 (P = 0.3); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.4% (95% CI, 1.4-3.6%) in twin pregnancies undergoing amniocentesis compared with 2.4% (95% CI, 0.9-4.6%) in those not undergoing amniocentesis. Head-to-head meta-analyses directly comparing twin pregnancies undergoing and those not undergoing CVS showed no significant difference in either overall fetal loss (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)) or fetal loss before 24 weeks of gestation (OR, 1.61 (P = 0.5); RD, 0.003 (P = 0.8)). Overall, the pooled rate of fetal loss was 2.0% (95% CI, 0.0-6.5%) in twin pregnancies undergoing CVS compared with 1.8% (95% CI, 0.3-4.2%) in those not undergoing CVS.The risk of fetal loss following amniocentesis and CVS in twins is lower than reported previously and the rate of fetal loss before 24 weeks of gestation, or within 4 weeks after the procedure, did not differ from the background risk in twin pregnancy not undergoing invasive prenatal testing. These data can guide prenatal counseling for twin pregnancies undergoing invasive procedures. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.Riesgo de pérdida del feto tras una amniocentesis o una biopsia de vellosidades coriónicas en un embarazo de gemelos: revisión sistemática y metaanálisis OBJETIVO: Evaluar la tasa de pérdida del feto tras una amniocentesis o una biopsia de vellosidades coriónicas (BVC) en un embarazo de gemelos. MÉTODOS: Se hizo una búsqueda en las bases de datos MEDLINE, EMBASE y Cochrane de estudios que habían reportado complicaciones relacionadas con el procedimiento después de una amniocentesis o una BVC en un embarazo de gemelos. El resultado primario fue la tasa de pérdida del feto relacionada con el procedimiento. Los resultados secundarios fueron la pérdida del feto producida antes de las 24 semanas de gestación y la pérdida del feto producida dentro de las 4 semanas posteriores al procedimiento. Se utilizaron metaanálisis cara a cara para comparar cada resultado directamente, entre las mujeres que se sometieron a una amniocentesis y las que no se sometieron a ella, y entre las mujeres que se sometieron a una BVC y las que no se sometieron a ella, así como para calcular las diferencias de riesgo (DR) combinadas entre las mujeres expuestas y las no expuestas a cada procedimiento agresivo. Además, se utilizaron los metaanálisis de proporciones para estimar las tasas combinadas de cada uno de los tres resultados en las mujeres que se sometieron a amniocentesis o a BVC y en los controles. RESULTADOS: Se incluyeron 16 estudios (3.419 embarazos de gemelos sometidos a un procedimiento agresivo y 2.517 no sometidos). Los metaanálisis cara a cara que compararon directamente los embarazos de gemelos sometidos y no sometidos a amniocentesis mostraron un mayor riesgo de pérdida general del feto en total en los sometidos a amniocentesis (Razón de Momios (RM), 1,46 (P=0,04); DR, 0,013 (P=0,04)), mientras que no hubo diferencias en el riesgo de pérdida del feto antes de las 24 semanas de gestación (RM, 1,59 (P=0,06); DR, 0,010 (P=0,11)) ni en el de las 4 semanas posteriores al procedimiento (RM, 1,38 (P=0,3); DR, 0,003 (P=0,8)). En general, la tasa conjunta de pérdida del feto fue del 2,4% (IC 95%, 1,4-3,6%) en los embarazos de gemelos sometidos a amniocentesis, en comparación con el 2,4% (IC 95%, 0,9-4,6%) en los que no se sometieron a amniocentesis. Los metaanálisis cara a cara que compararon directamente los embarazos de gemelos que se sometieron y que no se sometieron a una BVC no mostraron diferencias significativas ni en la pérdida del feto en total (RM, 1,61 (P=0,5); DR, 0,003 (P=0,8)) ni en la pérdida del feto antes de las 24 semanas de gestación (RM, 1,61 (P=0,5); DR, 0,003 (P=0,8)). En general, la tasa combinada de pérdida del feto fue del 2,0% (IC 95%, 0,0-6,5%) de los embarazos de gemelos sometidos a BVC, comparada con el 1,8% (IC 95%, 0,3-4,2%) de los que no se sometieron a BVC. CONCLUSIÓN: El riesgo de pérdida del feto tras la amniocentesis y la BVC en gemelos es menor que lo reportado en el pasado y la tasa de pérdida del feto antes de las 24 semanas de gestación, o dentro de las 4 semanas posteriores al procedimiento, no difiere de la del riesgo de contexto en los embarazos de gemelos que no se someten a pruebas prenatales agresivas. Estos datos pueden servir de guía para el asesoramiento prenatal de los embarazos de gemelos que se someten a procedimientos agresivos.双胎妊娠中继羊膜穿刺术或绒膜绒毛取样后发生流产的风险:系统评价和荟萃分析 目的: 评估双胎妊娠中继羊膜穿刺术或绒膜绒毛取样(CVS)后发生的流产率。 方法: 在MEDLINE(美国医学文献联机数据库)、EMBASE(荷兰医学文摘数据库)和实证医学资料库中针对报告双胎妊娠中继羊膜穿刺术或CVS后发生与医疗程序相关的并发症进行了搜索。主要结果是与医疗程序相关的流产率。次要结果是发生在孕期24周前的流产和疗程后4周内发生的流产。采用头对头荟萃分析来直接对比每个结果，在已进行过羊膜穿刺术的孕妇与未进行羊膜穿刺术的孕妇之间，并在已经历CVS的孕妇和未经历CVS的孕妇之间进行对比，以计算出暴露于每种侵入性疗程和未暴露于每种侵入性疗程的孕妇之间的汇总风险差异。此外，采用按比例的荟萃分析来评估经历羊膜穿刺术或CVS的孕妇及对照组中三种预后的 每个汇总比率。 结果: 包含了16项研究(经历过侵入性医疗程序的3419个双胎妊娠和未经历侵入性医疗程序的2517个 双胎妊娠)。直接对比经历和未经历羊膜穿刺术的双胎妊娠的头对头荟萃分析，表明经历了羊膜穿刺术的双胎孕妇发生流产的总体风险更高(比值比(OR)，1.46 (P=0.04)；RD, 0.013 (P=0.04))，在孕期24周前(OR, 1.59 (P=0.06); RD, 0.010 (P=0.11))或疗程后四周内(OR, 1.38(P=0.3); RD, 0.003 (P=0.8))，这两种情况的流产风险没有差别。总体来看，经历羊膜穿刺术的双胎妊娠的流产汇总比率为2.4%(95% CI, 1.4-3.6%)，相比之下，未经历羊膜穿刺术的双胎妊娠的流产汇总比率为2.4%(95% CI, 0.9-4.6%)。直接对比经历过和未经历CVS的双胎妊娠的头对头荟萃分析，表明总体流产情况(OR, 1.61 (P=0.5); RD, 0.003 (P=0.8))和孕期24周前的流产情况(OR, 1.61 (P=0.5); RD, 0.003 (P=0.8))无显著差异。总体来看，经历过CVS的双胎妊娠的流产汇总比率为2.0%(95% CI, 0.0-6.5%)，相比之下，未经历CVS的双胎妊娠的流产汇总比率为1.8%(95% CI, 0.3-4.2%)。 结论: 双胎妊娠中继羊膜穿刺术或绒膜绒毛取样(CVS)后发生流产的风险低于以前的报告，而且孕期24周前或疗程后四周内的流产率与未经历侵入性产前检查的双胎妊娠中的背景风险没有差异。这些数据能够为双胎妊娠进行侵入性检查提供产前咨询指导。© 2020 国际妇产科超声学会.

Objectives: A third-trimester fetal weight discordance of 25% has been proposed as an independent predictor of fetal loss in twin pregnancies. As fetal weight gain at this stage of pregnancy increases exponentially, it is not entirely certain whether a single cut-off for inter-twin weight discordance is appropriate. The aim of this study was to investigate whether a single weight discordance cut-off can be used or whether different cut-offs should be adopted according to the gestational age at assessment. Methods: This was a retrospective study of all twin pregnancies of known chorionicity from a large regional cohort over a 10-year period. Receiver operating characteristic curve and logistic regression analyses were used to explore the relation between estimated fetal weight (EFW) discordance detected within 4 weeks from the occurrence of the outcome and single fetal loss at different gestational age windows. Results: 957 twin pregnancies (173 monochorionic and 784 dichorionic) were included in the analysis. EFW discordance was independently associated with the occurrence of single fetal loss in twin pregnancies in each gestational age window. Ultrasound EFW discordance had an area under the curve of 0.77 (95% CI: 0.67-0.87) for the prediction of single fetal loss in the third trimester of pregnancy, with an optimal cut-off of around 25% (23.2%). The optimal cut-offs of EFW discordance for the prediction of single fetal loss were different in each gestational age window. Conclusion: The accuracy of EFW discordance in predicting single fetal loss in twin pregnancies varies during the third trimester of pregnancy. The degree of fetal weight discordance associated with fetal loss decreases during the third trimester, suggesting that the weight discordance threshold for intervention should vary according to gestational age.