Practice Bulletin No 144

Gynecologists,

doi:10.1097/01.aog.0000446856.51061.3e

Cited by 164 publications

(32 citation statements)

References 118 publications

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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%

“…Although we observed a change in the direction of the difference in risk, with more stillbirths than neonatal deaths beyond 36 weeks in monochorionic twin pregnancies, the difference was not significant. The variation in policies for management of monochorionic twin pregnancies, with some advocating delivery as early as 34+0-6 weeks,8 10 have contributed to the fall in number of pregnancies available for analysis in later gestation. Based on our findings, there is no clear evidence to recommend early preterm delivery routinely before 36 weeks in monochorionic pregnancies.…”

Section: Discussionmentioning

confidence: 99%

“…Current recommendations vary on the timing of delivery, starting from 34 up to 37 weeks’ gestation in monochorionic twin pregnancies8 and from 37 up to 39 weeks in dichorionic twin pregnancies 910 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.…”

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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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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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“…22, 26, 66, 124, 130, 131 Still, it should be emphasized that there is currently no level-I evidence that routine monitoring of cervical length in women with twin pregnancies improves pregnancy outcome, 132 and therefore current recommendations do not support such a practice. 133 …”

Section: Commentsmentioning

confidence: 99%

Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations?

Melamed

Pittini

Hiersch

et al. 2016

American Journal of Obstetrics and Gynecology

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Objective To determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at mid-gestation. Materials and Methods This was a retrospective cohort study of women with twin pregnancies followed in a tertiary medical center between 2012 and 2014. All participants underwent routine measurement of cervical length at mid-gestation and every 2–3 weeks thereafter until 28–32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (Period 1, routine exam), 22+0 to 24+6 weeks (Period 2), 25+0 to 27+6 weeks (Period 3) and 28+0 to 32+0 weeks (Period 4). Measurements of cervical length at Periods 2–4 were analyzed in the form of either absolute length (in mm) or percent shortening relative to cervical length at Period 1. The performance of a stepwise algorithm that incorporates serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at Period 1. Results Overall 441 women with twin pregnancies who were eligible for the study underwent a total of 2,374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the four periods of gestation [Odds ratio (95%-confidence interval): 7.2 (3.1–16.5), 15.3 (6.4–36.7), 10.3 (4.4–24.3) and 23.1(8.3–64.1), respectively]. Compared with a single measurement of cervical length at mid-gestation (Period 1), a stepwise algorithm integrating serial cervical length measurements from all four successive gestational age periods resulted in a significant increase in the area under the ROC curve (0.917 vs. 0.613, p<0.001). Similarly, when a target false positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs. 28%, p<0.001), higher positive likelihood ratio (14.54 vs. 5.12) and a lower negative likelihood ratio (0.32 vs. 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at Period 1. Conclusions Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements.

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“…We also identified 70 specific situations guidelines published between 2002 and 2014. Of these, 91% were from the USA,25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59 UK60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76 and Canada 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88. The remaining were from Australia,89 Brazil,90 Mexico,91 Poland,92 Spain93 and Uruguay 94…”

Section: Resultsmentioning

confidence: 99%

Antenatal care for healthy pregnant women: a mapping of interventions from existing guidelines to inform the development of new WHO guidance on antenatal care

Ábalos

Chamillard

Díaz

et al. 2015

BJOG

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BackgroundThe World Health Organization (WHO) is in the process of updating antenatal care (ANC) guidelines.ObjectivesTo map the existing clinical practice guidelines related to routine ANC for healthy women and to summarise all practices considered during routine ANC.Search strategyA systematic search in four databases for all clinical practice guidelines published after January 2000.Selection criteriaTwo researchers independently assessed the list of potentially eligible publications.Data collection and analysisInformation on scope of the guideline, type of practice, associated gestational age, recommendation type and the source of evidence were mapped.Main resultsOf 1866 references, we identified 85 guidelines focusing on the ANC period: 15 pertaining to routine ANC and 70 pertaining to specific situations. A total of 135 interventions from routine ANC guidelines were extracted, and categorised as clinical interventions (n = 80), screening/diagnostic procedures (n = 47) and health systems related (n = 8). Screening interventions, (syphilis, anaemia) were the most common practices. Within the 70 specific situation guidelines, 102 recommendations were identified. Overall, for 33 (out of 171) interventions there were conflicting recommendations provided by the different guidelines.ConclusionMapping the current guidelines including practices related to routine ANC informed the scoping phase for the WHO guideline for ANC. Our analysis indicates that guideline development processes may lead to different recommendations, due to context, evidence base or assessment of evidence. It would be useful for guideline developers to map and refer to other similar guidelines and, where relevant, explore the discrepancies in recommendations and others.Tweetable abstractWe identified existing ANC guidelines and mapped scope, practices, recommendations and source of evidence.

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Practice Bulletin No 144

Cited by 164 publications

References 118 publications

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

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

Do serial measurements of cervical length improve the prediction of preterm birth in asymptomatic women with twin gestations?

Antenatal care for healthy pregnant women: a mapping of interventions from existing guidelines to inform the development of new WHO guidance on antenatal care

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