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Timing of Delivery for Twins With Growth Discordance and Growth Restriction: An Individual Participant Data
Ashlee K Koch1, Renée J Burger, Ewoud Schuit
1Flinders Medical Centre, Adelaide, South Australia, and the Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia; the Department of Obstetrics, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Julius Center for Health Sciences and Primary Care & Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Department of Gynaecology and Obstetrics, GROW School of Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Department of Obstetrics and Gynecology, Haga Hospital, The Hague, the Department of Obstetrics and Gynecology, Gelre Hospitals Apeldoorn, Apeldoorn, and the Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Atrium Health, Charlotte, North Carolina; the Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; the Department of Obstetrics and Gynecology, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil; the Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, and the Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, the Departments of Obstetrics and Gynecology, Medicine, Community Health Sciences, and Pediatrics, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, and the Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada; the Department of Obstetrics and Gynecology, ASST-Spedali Civili, and the Department of Clinical and Experimental Sciences, University of Brescia, Brescia, and the Fetal Therapy Unit "Umberto Nicolini" and the Department of Women, Mother and Newborn, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy; the Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan; the Department of Fetal Medicine, The Aga Khan University, Karachi, Pakistan; the Department of Obstetrics and Gynecology, University Hospitals of Leuven, Leuven, Belgium; the Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon; the Departments of Clinical Biochemistry and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; the Epidemiology Branch, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Rockville, Maryland; the Mednax Center for Research, Education, Quality, and Safety, Sunrise, Florida; the Obstetrix Medical Group, Campbell, California; Unidad de Medicina Materno-Fetal, Instituto Valenciano de Infertilidad, Departamento de Pediatría, Obstetricia y Ginecología, and Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Departamento de Pediatría, Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain; and the Fetal Medicine Unit, St George's Hospital, the Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, and the Twins Trust Centre for Research and Clinical Excellence, London, the Institute of Applied Health Research, University of Birmingham, Birmingham, and the Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, United Kingdom.
Growth discordance in twin pregnancies increases stillbirth and neonatal death risks. However, optimal delivery timing remains unchanged, balancing risks around 37 weeks gestation for dichorionic and monochorionic twins.
Area of Science:
- Perinatal Medicine
- Maternal-Fetal Medicine
- Obstetrics
Background:
- Twin pregnancies face unique risks, including stillbirth and neonatal death.
- Fetal growth restriction and discordance significantly impact perinatal outcomes.
Purpose of the Study:
- To evaluate stillbirth and neonatal death risks by gestational age in twin pregnancies with varying growth discordance and small for gestational age (SGA).
- To establish optimal delivery gestational ages based on these risks.
- To compare these optimal ages with those for uncomplicated twin pregnancies.
Main Methods:
- Individual participant data meta-analysis of 20 cohort studies (7,474 dichorionic, 2,281 monochorionic twin pairs).
- Searched MEDLINE, EMBASE, ClinicalTrials.gov, Ovid (2015-2018), combined with prior meta-analysis data (inception-2015).
- Excluded monoamniotic twin pregnancies; analyses stratified by chorionicity, growth discordance, and SGA.
Main Results:
- Higher risks of stillbirth and neonatal death observed with SGA and increased growth discordance in both dichorionic and monochorionic twins.
- Perinatal risk balanced between 36 0/7 and 37 6/7 weeks gestation for both types of twin pregnancies.
- Risk of stillbirth likely exceeded neonatal death risk from 37 6/7 weeks onward.
Conclusions:
- Growth discordance and SGA elevate absolute risks of stillbirth and neonatal death.
- Despite increased risks, the optimal timing for delivery in twin pregnancies is not altered by growth disorders alone.
- Current optimal delivery recommendations for uncomplicated twins appear applicable even with growth disturbances.
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