Increased Stillbirth in Uncomplicated Monochorionic Twin Pregnancies

Danon, D.; Sekar, Renuka; Hack, K.E.A.; Fisk, Nicholas M.

doi:10.1097/aog.0b013e318292766b

Cited by 61 publications

(60 citation statements)

References 41 publications

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“…Monochorionicity is associated with about 3-to 4-fold higher risk of IUD than dichorionicity [12,13,29]. The above relationship was also observed in our study.…”

Section: Discussionsupporting

confidence: 88%

Perinatal outcome according to chorionicity in twins — a Polish multicenter study

et al. 2016

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Objectives: The aim of the study was to analyze the perinatal outcome of twin gestations and estimate the influence of chorionicity on the outcome in a large cohort of twin pregnancies in Poland. Material and methods:A retrospective analysis of 465 twin deliveries in 6 Polish centers in 2012 was conducted. Baseline characteristics, the course of pregnancy and labor, as well as the neonatal outcome were analyzed in the study group and according to chorionicity. Results:A total of 356 twin pregnancies were dichorionic (DC group) (76.6%), and 109 were monochorionic (MC group) (23.4%). There were no differences in the occurrence of pregnancy complications according to chorionicity, except for IUGR of at least one fetus (MC 43.1% vs. DC 34.6%; p = 0.003). 66.5% of the women delivered preterm, significantly more in the MC group (78% vs. 62.9%; p = 0.004). Cesarean delivery was performed in 432 patients (92.9%). Mean neonatal birthweight was statistically lower in the MC group (2074 g vs. 2370 g; p < 0.001). Perinatal mortality of at least one twin was 4.3% (2.8% in the DC group vs. 9.2% in the MC group; p = 0.004). Neonatal complications, including NICU admission, respiratory disorders, and infections requiring antibiotic therapy, were significantly more often observed among the MC twins. Conclusions:The overall perinatal outcome in the presented subpopulation of Polish twins and its dependence on chorionicity is similar to the reports in the literature. Nevertheless, the rates of preterm and cesarean deliveries remain higher. It seems that proper counselling of pregnant women and education of obstetricians may result in reduction of these rates.

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“…Monochorionicity is associated with about 3-to 4-fold higher risk of IUD than dichorionicity [12,13,29]. The above relationship was also observed in our study.…”

Section: Discussionsupporting

confidence: 88%

Perinatal outcome according to chorionicity in twins — a Polish multicenter study

et al. 2016

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“…Primary studies,15 16 29 39 62 systematic reviews,13 and guideline bodies9 63 have been limited in their interpretation of evidence on the timing of delivery in twin pregnancies because of paucity of data and inadequate methods. Firstly, they compared the risks of stillbirth in twin pregnancies at various gestational weeks with those at, or near, term, without considering the inherent longitudinal design with women repeatedly observed during the pregnancy 64.…”

Section: Discussionmentioning

confidence: 99%

“…Thirdly, studies did not provide gestational age specific pooled estimates for significant neonatal morbidity 1366 Fourthly, existing recommendations on the timing of delivery are based on gestational age specific risk of stillbirth and do not formally take into account the benefit gained by reducing neonatal deaths 1367 Finally, the risks of fetal death in twins were not assessed beyond 36 weeks’ gestation, and the rationale behind the choice of the gestational ages for elective delivery is not clear 9.…”

Section: Discussionmentioning

confidence: 99%

“…10 11 12 Women and their partners, clinicians, and guideline makers need robust estimates of the risk of stillbirth from continuing the pregnancy and the neonatal risk from early delivery to decide on the optimal timing of delivery. Existing reviews have focused mainly on the risk of stillbirth, without taking neonatal outcomes into account 13. There are no published data on perinatal mortality and morbidity for specific gestations and chorionicity in twins to guide decision making on the timing of delivery 14.…”

Section: Introductionmentioning

confidence: 99%

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

Cheong-See

Schuit

Arroyo-Manzano

et al. 2016

BMJ

194

150

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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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“…Compared with uncomplicated dichorionic gestations, the odds ratio for stillbirth per pregnancy at 32, 34, and 36 weeks of gestation was 4.2 (95% CI, 1.4-12.6), 3.7 (95% CI, 1.1-12.0), and 8.5 (95% CI, 1.6-44.7), respectively. 31 However, this meta-analysis did not include many of the more recent studies revealing a lower risk of intrauterine fetal demise in monochorionic, diamniotic twins. The most recent paper published is our own data, a retrospective cohort study of all twins (601 dichorionic and 167 monochorionic pregnancies) who delivered at or after 34 weeks at a single tertiary care center from 1987 to 2010.…”

Section: Delivery Timing Considerations In Uncomplicated Monochorionimentioning

confidence: 99%

Fetal Surveillance and Timing of Delivery for Multiples

Unal¹

2015

Clinical Obstetrics &Amp; Gynecology

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This chapter describes the current evidence and recommendations for surveillance and delivery timing for multifetal gestations. Ultrasound surveillance should include early determination of chorionicity, anatomic survey for all twins with fetal echocardiography for monochorionic twins, and growth assessment every 4 weeks. Monochorionic twins should also undergo ultrasound surveillance for twin-twin transfusion syndrome every 2 weeks starting at 16 weeks. Weekly testing with nonstress tests or biophysical profiles is recommended at 32 weeks for monochorionic, diamniotic twins, and 34 weeks for dichorionic twins. If this surveillance is reassuring, optimal delivery timing is 36 weeks 0 days to 37 weeks 0 days for monochorionic, diamniotic twins, and 37 week 0 days to 38 weeks 0 days for dichorionic twins.

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Increased Stillbirth in Uncomplicated Monochorionic Twin Pregnancies

Cited by 61 publications

References 41 publications

Perinatal outcome according to chorionicity in twins — a Polish multicenter study

Perinatal outcome according to chorionicity in twins — a Polish multicenter study

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

Fetal Surveillance and Timing of Delivery for Multiples

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