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Войти в исследования Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis.
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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, Global Obstetrics Network (GONet) Collaboration
Аннотация
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.