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

Fiona Cheong-See, Ewoud Schuit, David Arroyo-Manzano, Asma Khalil, Jon Barrett, K. S. Joseph, Elizabeth Asztalos , Karien Hack, Liesbeth Lewi, Arianne Lim, Sophie Liem, Jane E. Norman, John Morrison, C. Andrew Combs, Thomas J. Garite, Kimberly Maurel, Vicente Serra, Alfredo Perales, Line Rode, Katharina Worda & 17 others Anwar Nassar , Mona Aboulghar , Dwight Rouse, Elizabeth Thom, Fionnuala Breathnach , Soichiro Nakayama , Francesca Maria Russo, Julian N. Robinson , Jodie M. Dodd, Roger B. Newman, Sohinee Bhattacharya, Selphee Tang, Ben Willem J. Mol, Javier Zamora, Basky Thilaganathan, Shakila Thangaratinam, A Global Obstetrics Network (GONet) Collaboration

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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; I2=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; I2=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; I2=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.
Original languageEnglish
Article numberi4353
Pages (from-to)1-9
Number of pages9
JournalBMJ
Volume354
DOIs
Publication statusPublished - 6 Sep 2016

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Twin Pregnancy
Stillbirth
Meta-Analysis
Pregnancy
Gestational Age
Databases
Fetofetal Transfusion
Confidence Intervals
Information Storage and Retrieval
Neonatal Intensive Care Units
Risk Management
Pregnancy Rate
Perinatal Death
Observational Studies
Language

Cite this

Cheong-See, F., Schuit, E., Arroyo-Manzano, D., Khalil, A., Barrett, J., Joseph, K. S., ... A Global Obstetrics Network (GONet) Collaboration (2016). Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ, 354, 1-9. [i4353]. https://doi.org/10.1136/bmj.i4353

Prospective risk of stillbirth and neonatal complications in twin pregnancies : systematic review and meta-analysis. / Cheong-See, Fiona; Schuit, Ewoud; Arroyo-Manzano, David; Khalil, Asma; Barrett, Jon; Joseph, K. S.; Asztalos , Elizabeth ; Hack, Karien ; Lewi, Liesbeth; Lim, Arianne; Liem, Sophie; Norman, Jane E.; Morrison, John ; Combs, C. Andrew; Garite, Thomas J.; Maurel, Kimberly; Serra, Vicente; Perales, Alfredo ; Rode, Line; Worda, Katharina; Nassar , Anwar ; Aboulghar , Mona; Rouse, Dwight; Thom, Elizabeth; Breathnach , Fionnuala; Nakayama , Soichiro; Russo, Francesca Maria; Robinson , Julian N.; Dodd, Jodie M.; Newman, Roger B.; Bhattacharya, Sohinee; Tang, Selphee; Mol, Ben Willem J.; Zamora, Javier; Thilaganathan, Basky; Thangaratinam, Shakila ; A Global Obstetrics Network (GONet) Collaboration.

In: BMJ, Vol. 354, i4353, 06.09.2016, p. 1-9.

Research output: Contribution to journalArticle

Cheong-See, F, Schuit, E, Arroyo-Manzano, D, Khalil, A, Barrett, J, Joseph, KS, Asztalos , E, Hack, K, Lewi, L, Lim, A, Liem, S, Norman, JE, Morrison, J, Combs, CA, Garite, TJ, Maurel, K, Serra, V, Perales, A, Rode, L, Worda, K, Nassar , A, Aboulghar , M, Rouse, D, Thom, E, Breathnach , F, Nakayama , S, Russo, FM, Robinson , JN, Dodd, JM, Newman, RB, Bhattacharya, S, Tang, S, Mol, BWJ, Zamora, J, Thilaganathan, B, Thangaratinam, S & A Global Obstetrics Network (GONet) Collaboration 2016, 'Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis' BMJ, vol. 354, i4353, pp. 1-9. https://doi.org/10.1136/bmj.i4353
Cheong-See F, Schuit E, Arroyo-Manzano D, Khalil A, Barrett J, Joseph KS et al. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ. 2016 Sep 6;354:1-9. i4353. https://doi.org/10.1136/bmj.i4353
Cheong-See, Fiona ; Schuit, Ewoud ; Arroyo-Manzano, David ; Khalil, Asma ; Barrett, Jon ; Joseph, K. S. ; Asztalos , Elizabeth ; Hack, Karien ; Lewi, Liesbeth ; Lim, Arianne ; Liem, Sophie ; Norman, Jane E. ; Morrison, John ; Combs, C. Andrew ; Garite, Thomas J. ; Maurel, Kimberly ; Serra, Vicente ; Perales, Alfredo ; Rode, Line ; Worda, Katharina ; Nassar , Anwar ; Aboulghar , Mona ; Rouse, Dwight ; Thom, Elizabeth ; Breathnach , Fionnuala ; Nakayama , Soichiro ; Russo, Francesca Maria ; Robinson , Julian N. ; Dodd, Jodie M. ; Newman, Roger B. ; Bhattacharya, Sohinee ; Tang, Selphee ; Mol, Ben Willem J. ; Zamora, Javier ; Thilaganathan, Basky ; Thangaratinam, Shakila ; A Global Obstetrics Network (GONet) Collaboration. / Prospective risk of stillbirth and neonatal complications in twin pregnancies : systematic review and meta-analysis. In: BMJ. 2016 ; Vol. 354. pp. 1-9.
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title = "Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis",
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; I2=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; I2=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; I2=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.",
author = "Fiona Cheong-See and Ewoud Schuit and David Arroyo-Manzano and Asma Khalil and Jon Barrett and Joseph, {K. S.} and Elizabeth Asztalos and Karien Hack and Liesbeth Lewi and Arianne Lim and Sophie Liem and Norman, {Jane E.} and John Morrison and Combs, {C. Andrew} and Garite, {Thomas J.} and Kimberly Maurel and Vicente Serra and Alfredo Perales and Line Rode and Katharina Worda and Anwar Nassar and Mona Aboulghar and Dwight Rouse and Elizabeth Thom and Fionnuala Breathnach and Soichiro Nakayama and Russo, {Francesca Maria} and Robinson, {Julian N.} and Dodd, {Jodie M.} and Newman, {Roger B.} and Sohinee Bhattacharya and Selphee Tang and Mol, {Ben Willem J.} and Javier Zamora and Basky Thilaganathan and Shakila Thangaratinam and {A Global Obstetrics Network (GONet) Collaboration}",
note = "Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.",
year = "2016",
month = "9",
day = "6",
doi = "10.1136/bmj.i4353",
language = "English",
volume = "354",
pages = "1--9",
journal = "BMJ",
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TY - JOUR

T1 - Prospective risk of stillbirth and neonatal complications in twin pregnancies

T2 - systematic review and meta-analysis

AU - Cheong-See, Fiona

AU - Schuit, Ewoud

AU - Arroyo-Manzano, David

AU - Khalil, Asma

AU - Barrett, Jon

AU - Joseph, K. S.

AU - Asztalos , Elizabeth

AU - Hack, Karien

AU - Lewi, Liesbeth

AU - Lim, Arianne

AU - Liem, Sophie

AU - Norman, Jane E.

AU - Morrison, John

AU - Combs, C. Andrew

AU - Garite, Thomas J.

AU - Maurel, Kimberly

AU - Serra, Vicente

AU - Perales, Alfredo

AU - Rode, Line

AU - Worda, Katharina

AU - Nassar , Anwar

AU - Aboulghar , Mona

AU - Rouse, Dwight

AU - Thom, Elizabeth

AU - Breathnach , Fionnuala

AU - Nakayama , Soichiro

AU - Russo, Francesca Maria

AU - Robinson , Julian N.

AU - Dodd, Jodie M.

AU - Newman, Roger B.

AU - Bhattacharya, Sohinee

AU - Tang, Selphee

AU - Mol, Ben Willem J.

AU - Zamora, Javier

AU - Thilaganathan, Basky

AU - Thangaratinam, Shakila

AU - A Global Obstetrics Network (GONet) Collaboration

N1 - Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

PY - 2016/9/6

Y1 - 2016/9/6

N2 - 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; I2=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; I2=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; I2=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.

AB - 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; I2=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; I2=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; I2=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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DO - 10.1136/bmj.i4353

M3 - Article

VL - 354

SP - 1

EP - 9

JO - BMJ

JF - BMJ

SN - 0959-8146

M1 - i4353

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