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Regimens of ultrasound surveillance for twin pregnancies for improving outcomes

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Referencias

References to studies included in this review

Ir a:

Giles 2003 {published data only}

Giles W, Bisits A, O'Callaghan S. The Doppler assessment in multiple pregnancy study (DAMP) and meta analyses of Doppler and twins. American Journal of Obstetrics and Gynecology 2000;182(1 Pt 2):S17. CENTRAL
Giles W, Bisits A, O'Callaghan S, Gill A. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. BJOG 2003;110(6):593‐7. CENTRAL

References to studies excluded from this review

Ir a:

Holohan 1987 {published data only}

Holohan M. Doppler studies of umbilical and utero‐placental blood flow in twin pregnancies [Trial abandoned]. Personal communication1992. CENTRAL

ACOG Practice Bulletin 2004

ACOG Practice Bulletin #56. Multiple gestation: complicated twin, triplet, and higher‐order multifetal pregnancy. Obstetrics and Gynecology 2004;104(4):869‐83.

Baud 2014

Baud D, Windrim R, Van Mieghem T, Keunen J, Seaward G, Ryan G. Twin‐twin transfusion syndrome; a frequently missed diagnosis with important consequences. Ultrasound in Obstetrics & Gynecology 2014;44(2):205‐9.

Blondel 2002

Blondel B, Kogan MD, Alexander GR, Dattani N, Kramer MS, Macfarlane A, et al. The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: an international study. American Journal of Public Health 2002;92(8):1323‐30.

Branum 2003

Branum AM, Schoendorf KC. The effect of birth weight discordance on twin neonatal mortality. Obstetrics & Gynecology 2003;101(3):570‐4.

Chauhan 2010

Chauhan SP, Scardo JA, Hayes E, Abuhamad AZ, Berghella V. Twins: prevalence, problems, and preterm births. American Journal of Obstetrics and Gynecology 2010;203(4):305‐15.

Chittacharoen 2000

Chittacharoen A, Leelapattana P, Rangsiprakarn R. Prediction of discordant twins by real‐time ultrasonography combined with umbilical artery velocimetry. Ultrasound in Obstetrics & Gynecology 2000;15(2):118‐21.

Deeks 2011

Deeks JJ, Higgins JPT, Altman DG (editors). Chapter 9: Analysing data and undertaking meta‐analyses. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.

Dodd 2005

Dodd JM, Grivell RM, Crowther CA. Evidence based care for women with a multiple pregnancy. Best Practice & Research. Clinical Obstetrics and Gynaecology 2005;19(1):131‐53.

Dodd 2010

Dodd JM, Grivell RM, Crowther CA. Multiple pregnancy. In: James DK, Steer PJ, Weiner CP, Crowther CA, Gonik G editor(s). High Risk Pregnancy: Management Options. 4th Edition. Edinburgh, UK: Elsevier Saunders, 2010.

Dube 2002

Dube J, Dodds L, Armson B. Does chorionicity or zygosity predict adverse perinatal outcomes in twins?. American Journal of Obstetrics and Gynecology 2002;186(3):579‐83.

Emery 2015

Emery SP, Bahtiyar MO, Dashe JS, Wilkins‐Haug, Johnson A, Paek BW, et al. The North American Fetal Therapy Network consensus statement prenatal management of uncomplicated monochorionic gestations. Obstetrics & Gynecology 2015;125(5):1236‐43.

GRADEpro GDT 2015 [Computer program]

McMaster University (developed by Evidence Prime). GRADEpro GDT. Hamilton (ON): McMaster University (developed by Evidence Prime), 2015.

Guyatt 2008

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck‐Ytter Y, Alonso‐Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924‐6.

Hack 2008

Hack K, Derks J, Elias S, Franx A, Roos E, Voerman S, et al. Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study. BJOG 2008;115(1):58‐67.

Higgins 2003

Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327:557‐60.

Higgins 2011a

Higgins JPT, Altman DG, Sterne JAC (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.

Higgins 2011b

Higgins JPT, Deeks JJ, Altman DG (editors). Chapter 16: Special topics in statistics. In: Higgins JPT, Green S (editors), Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.

Kilby 2016

Kilby MD, Bricker L, on behalf of the Royal College of Obstetricians and Gynaecologists. Management of monochorionic twin pregnancy. BJOG 2016;124:e1‐e45.

NICE 2011

National Collaborating Centre for Women's and Children's Health. Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period. NICE Clinical Guideline. London: RCOG Press, 2011.

RevMan 2014 [Computer program]

Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Russell 2003

Russell RB, Petrini JR, Damus K, Mattison DR, Schwarz RH. The changing epidemiology of multiple births in the United States. Obstetrics & Gynecology 2003;101(1):129‐35.

Su 2002

Su LL. Monoamniotic twins: diagnosis and management. Acta Obstetricia et Gynecologica Scandinavica 2002;81(11):995‐1000.

Taylor 2002

Taylor MJ, Govender L, Jolly M, Wee L, Fisk NM. Validation of the Quintero staging system for twin‐twin transfusion syndrome. Obstetrics & Gynecology 2002;100(6):1257‐65.

References to other published versions of this review

Ir a:

Woolcock 2014

Woolcock JG, Grivell RM, Dodd JM. Regimens of ultrasound surveillance for twin pregnancies for improving outcomes. Cochrane Database of Systematic Reviews 2014, Issue 11. [DOI: 10.1002/14651858.CD011371]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Ir a:

Giles 2003

Methods

RCT

Participants

539 women were randomised (271 to the standard care group and 268 to the intervention group) in a twin pregnancy with two viable, apparently normally formed twins on ultrasound, at 25 weeks' gestation. The trial recruited women from March 1993 through until March 1997. DC and MC twin pregnancies were not differentiated when including women in the study.

Interventions

Doppler and biometry (intervention) versus biometry (growth) alone (standard care). Women were randomised to receive Doppler and biometry (growth) at 25, 30 and 35 weeks' gestation or to receive biometry only at the same time points.

Outcomes

Primary was perinatal mortality, secondary were maternal and fetal ‐ birthweight, Apgar scores, admission to neonatal intensive care unit, admission to special care unit, requirement for ventilation and neonatal death up to 28 days of life.

Notes

Setting: the study was conducted in tertiary level referral hospitals in Australia, New Zealand and South West Asia.

Sources of trial funding and information relating to declarations of interest were not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomisation code in blocks of 20

Allocation concealment (selection bias)

Low risk

Opaque, sealed envelope, opened by personnel remote from participant's care

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not stated

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Not stated

Incomplete outcome data (attrition bias)
All outcomes

Low risk

13 out of 539 lost to follow‐up and not included in results. 7/271 women were lost in the no Doppler group (standard care) (2.58%) and 6/268 were lost in the Doppler (intervention) group (2.24%)

Selective reporting (reporting bias)

Low risk

No apparent reporting bias

Other bias

Low risk

None evident

DC: dichorionic
MC: monochorionic
RCT: randomised controlled trial

Characteristics of excluded studies [ordered by study ID]

Ir a:

Study

Reason for exclusion

Holohan 1987

No data available, trial abandoned. Was planning to assess continuous wave Doppler in twin pregnancies but was discontinued before reaching the stage of being a RCT

RCT: randomised controlled trial

Data and analyses

Open in table viewer
Comparison 1. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Perinatal mortality (post randomisation) Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.32, 2.41]
Analysis 1.1
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 1 Perinatal mortality (post randomisation).

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 1 Perinatal mortality (post randomisation).

2 Stillbirth Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.11, 3.99]
Analysis 1.2
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 2 Stillbirth.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 2 Stillbirth.

3 Neonatal death Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.29, 3.46]
Analysis 1.3
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 3 Neonatal death.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 3 Neonatal death.

4 Gestational age at birth Show forest plot

1

526

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.39, 0.59]
Analysis 1.4
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 4 Gestational age at birth.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 4 Gestational age at birth.

5 Infant requiring ventilation Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.59, 1.25]
Analysis 1.5
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 5 Infant requiring ventilation.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 5 Infant requiring ventilation.

6 Admission to special care or intensive care units Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.88, 1.05]
Analysis 1.6
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 6 Admission to special care or intensive care units.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 6 Admission to special care or intensive care units.

7 Caesarean section any Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.81, 1.23]
Analysis 1.7
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 7 Caesarean section any.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 7 Caesarean section any.

8 Elective caesarean section Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.77, 1.47]
Analysis 1.8
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 8 Elective caesarean section.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 8 Elective caesarean section.

9 Emergency caesarean section Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.66, 1.32]
Analysis 1.9
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 9 Emergency caesarean section.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 9 Emergency caesarean section.

10 Induction of labour Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.80, 1.50]
Analysis 1.10
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 10 Induction of labour.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 10 Induction of labour.

11 Antenatal admission to hospital Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.80, 1.15]
Analysis 1.11
Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 11 Antenatal admission to hospital.

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 11 Antenatal admission to hospital.

Study flow diagram
Figuras y tablas -
Figure 1

Study flow diagram

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 1 Perinatal mortality (post randomisation).
Figuras y tablas -
Analysis 1.1

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 1 Perinatal mortality (post randomisation).

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 2 Stillbirth.
Figuras y tablas -
Analysis 1.2

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 2 Stillbirth.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 3 Neonatal death.
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Analysis 1.3

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 3 Neonatal death.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 4 Gestational age at birth.
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Analysis 1.4

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 4 Gestational age at birth.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 5 Infant requiring ventilation.
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Analysis 1.5

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 5 Infant requiring ventilation.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 6 Admission to special care or intensive care units.
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Analysis 1.6

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 6 Admission to special care or intensive care units.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 7 Caesarean section any.
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Analysis 1.7

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 7 Caesarean section any.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 8 Elective caesarean section.
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Analysis 1.8

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 8 Elective caesarean section.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 9 Emergency caesarean section.
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Analysis 1.9

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 9 Emergency caesarean section.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 10 Induction of labour.
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Analysis 1.10

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 10 Induction of labour.

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Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 11 Antenatal admission to hospital.
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Analysis 1.11

Comparison 1 Fetal growth (biometry) + umbilical artery Doppler versus fetal growth, Outcome 11 Antenatal admission to hospital.

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Summary of findings for the main comparison. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth for twin pregnancies for improving outcomes

Fetal growth + umbilical artery Doppler versus fetal growth for twin pregnancies for improving outcomes

Patient or population: women with twin pregnancies were randomised from 25 weeks
Setting: tertiary level referral hospitals in Australia, New Zealand and South West Asia
Intervention: fetal growth plus Doppler
Comparison: fetal growth

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with fetal growth + umbilical artery Doppler

Risk with fetal growth

Perinatal mortality

(after randomisation)

Study population

RR 0.88
(0.32 to 2.41)

1052
(1 RCT)

⊕⊕⊝⊝
Low1

15 per 1000

13 per 1000
(5 to 37)

Neonatal death

Study population

RR 1.01
(0.29 to 3.46)

1052
(1 RCT)

⊕⊕⊝⊝
Low1

9 per 1000

10 per 1000
(3 to 33)

Birth less than 28 weeks

‐

‐

‐

‐

‐

The trial included in this review did not report this outcome.

Gestational age at birth (weeks)

The mean gestational age at birth was 35.8 weeks

The mean gestational age at birth was 35.7 weeks

MD 0.10 weeks longer with growth plus Doppler
(0.39 shorter to 0.59 longer)

526
(1 RCT)

⊕⊕⊕⊝
Moderate2

Caesarean section (any)

Study population

RR 1.00
(0.81 to 1.23)

526
(1 RCT)

⊕⊕⊕⊕
High

409 per 1000

409 per 1000
(331 to 503)

Induction of labour

Study population

RR 1.10
(0.80 to 1.50)

526
(1 RCT)

⊕⊕⊕⊝
Moderate3

216 per 1000

238 per 1000
(173 to 324)

Antenatal admission to hospital

Study population

RR 0.96
(0.80 to 1.15)

526
(1 RCT)

⊕⊕⊕⊕
High

477 per 1000

458 per 1000
(382 to 549)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High quality: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect
Very low quality: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1 Events are rare and wide confidence intervals cross line of no effect (‐2).
2 Confidence limits cross line of no effect and 0.5 in both directions (‐1).
3 Wide confidence intervals crossing line of no effect (‐1).

Figuras y tablas -
Summary of findings for the main comparison. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth for twin pregnancies for improving outcomes
Ir a la tabla de la revisión
Comparison 1. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Perinatal mortality (post randomisation) Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.88 [0.32, 2.41]

2 Stillbirth Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.11, 3.99]

3 Neonatal death Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

1.01 [0.29, 3.46]

4 Gestational age at birth Show forest plot

1

526

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.39, 0.59]

5 Infant requiring ventilation Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.59, 1.25]

6 Admission to special care or intensive care units Show forest plot

1

1052

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.88, 1.05]

7 Caesarean section any Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.81, 1.23]

8 Elective caesarean section Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.06 [0.77, 1.47]

9 Emergency caesarean section Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.66, 1.32]

10 Induction of labour Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

1.10 [0.80, 1.50]

11 Antenatal admission to hospital Show forest plot

1

526

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.80, 1.15]
Figuras y tablas -
Comparison 1. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth
Ir a la tabla de la revisión