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Review
. 2016 Sep 6:354:i4353.
doi: 10.1136/bmj.i4353.

Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis

Fiona Cheong-See  1 , Ewoud Schuit  2 , David Arroyo-Manzano  3 , Asma Khalil  4 , Jon Barrett  5 , K S Joseph  6 , Elizabeth Asztalos  7 , Karien Hack  8 , Liesbeth Lewi  9 , Arianne Lim  10 , Sophie Liem  10 , Jane E Norman  11 , John Morrison  12 , C Andrew Combs  13 , Thomas J Garite  14 , Kimberly Maurel  13 , Vicente Serra  15 , Alfredo Perales  16 , Line Rode  17 , Katharina Worda  18 , Anwar Nassar  19 , Mona Aboulghar  20 , Dwight Rouse  21 , Elizabeth Thom  22 , Fionnuala Breathnach  22 , Soichiro Nakayama  23 , Francesca Maria Russo  24 , Julian N Robinson  25 , Jodie M Dodd  26 , Roger B Newman  27 , Sohinee Bhattacharya  28 , Selphee Tang  29 , Ben Willem J Mol  30 , Javier Zamora  31 , Basky Thilaganathan  4 , Shakila Thangaratinam  1 ; Global Obstetrics Network (GONet) Collaboration
Affiliations
Review

Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis

Fiona Cheong-See et al. BMJ. .

Abstract

Objective: To determine the risks of stillbirth and neonatal complications by gestational age in uncomplicated monochorionic and dichorionic twin pregnancies.

Design: Systematic review and meta-analysis.

Data sources: Medline, Embase, and Cochrane databases (until December 2015).

Review methods: Databases were searched without language restrictions for studies of women with uncomplicated twin pregnancies that reported rates of stillbirth and neonatal outcomes at various gestational ages. Pregnancies with unclear chorionicity, monoamnionicity, and twin to twin transfusion syndrome were excluded. Meta-analyses of observational studies and cohorts nested within randomised studies were undertaken. Prospective risk of stillbirth was computed for each study at a given week of gestation and compared with the risk of neonatal death among deliveries in the same week. Gestational age specific differences in risk were estimated for stillbirths and neonatal deaths in monochorionic and dichorionic twin pregnancies after 34 weeks' gestation.

Results: 32 studies (29 685 dichorionic, 5486 monochorionic pregnancies) were included. In dichorionic twin pregnancies beyond 34 weeks (15 studies, 17 830 pregnancies), the prospective weekly risk of stillbirths from expectant management and the risk of neonatal death from delivery were balanced at 37 weeks' gestation (risk difference 1.2/1000, 95% confidence interval -1.3 to 3.6; I(2)=0%). Delay in delivery by a week (to 38 weeks) led to an additional 8.8 perinatal deaths per 1000 pregnancies (95% confidence interval 3.6 to 14.0/1000; I(2)=0%) compared with the previous week. In monochorionic pregnancies beyond 34 weeks (13 studies, 2149 pregnancies), there was a trend towards an increase in stillbirths compared with neonatal deaths after 36 weeks, with an additional 2.5 per 1000 perinatal deaths, which was not significant (-12.4 to 17.4/1000; I(2)=0%). The rates of neonatal morbidity showed a consistent reduction with increasing gestational age in monochorionic and dichorionic pregnancies, and admission to the neonatal intensive care unit was the commonest neonatal complication. The actual risk of stillbirth near term might be higher than reported estimates because of the policy of planned delivery in twin pregnancies.

Conclusions: To minimise perinatal deaths, in uncomplicated dichorionic twin pregnancies delivery should be considered at 37 weeks' gestation; in monochorionic pregnancies delivery should be considered at 36 weeks.

Systematic review registration: PROSPERO CRD42014007538.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Study selection process in systematic review on prospective risk of stillbirth and neonatal complications in uncomplicated twin pregnancies (TTTT=twin to twin transfusion syndrome)
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Fig 2 Risk of bias in studies included in systematic review on prospective risk of stillbirth and neonatal complications in uncomplicated twin pregnancies
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Fig 3 Prospective risks of stillbirths from expectant management compared with risks of neonatal mortality from delivery at weekly intervals from 34 weeks’ gestation in twin pregnancies
See this image and copyright information in PMC

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