Expert Commentary

What is the ideal gestational age for twin delivery to minimize perinatal deaths?

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Q. What is the ideal gestational age for twin delivery to minimize perinatal deaths?

A. Results of a large, robust meta-analysis of 32 studies (including 35,171 women with uncomplicated twin gestations) indicated that 37 weeks’ gestation be considered ideal timing in uncomplicated dichorionic twin pregnancies, and not before 36 weeks for monochorionic twin pregnancies, to minimize perinatal deaths. Researchers examined the risks of stillbirth and neonatal death at weekly intervals (eg, pooled risk difference per 1,000 pregnancies for stillbirth and neonatal death at 37 0-6 weeks, 1.2; 95% confidence interval [CI], −1.3 to 3.6; I2 = 0%), as well as morbidity outcomes in preterm infants. Unclear factors in the meta-analysis data, however, including the accuracy of chorionicity determination and the lack of information on fetal surveillance at the study centers, among others, preclude recommending a change in current practice from society-supported guidelines, which indicate that ideal delivery should fall within a gestational-age range, with delivery decisions within that range depending on numerous factors.

Cheong-See F, Schuit E, Arroyo-Manzano D, et al; Global Obstetrics Network (GONet) Collaboration. Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ. 2016;354:i4353. doi:10.1136/bmj.i4353.




Cheong-See and colleagues conducted a comprehensive review and analysis of 32 studies of uncomplicated dichorionic and monochorionic twin pregnancies to determine the risks of stillbirth and neonatal complications by gestational age.

Details of the study

The authors searched major databases for studies on twin pregnancies that reported rates of stillbirth as well as neonatal outcomes (neonatal mortality was defined as death up to 28 days after delivery). A total of 32 studies were included in the analysis, with 29,685 dichorionic and 5,486 monochorionic pregnancies in 35,171 women. The authors estimated the gestational-age specific differences in risk for stillbirths and neonatal deaths after 34 weeks’ gestation.

In dichorionic pregnancies, the prospective weekly pooled risk of stillbirths from expectant management and the risk of neonatal mortality from delivery were balanced at 37 weeks of gestation (risk difference, 1.2/1,000, 95% CI, −1.3 to 3.6; I2 = 0%). In monochorionic pregnancies, after 36 weeks there was a trend toward an increase in stillbirths compared with neonatal deaths, with a pooled risk difference of 2.5/1,000 (95% CI, −12.4 to 17.4; I2 = 0%). Neonatal morbidity rates were consistently reduced with increasing gestational age in both monochorionic and dichorionic pregnancies.

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