Regimens of ultrasound surveillance for twin pregnancies for improving outcomes

Jane G Woolcock; Rosalie M Grivell; Jodie M Dodd

doi:10.1002/14651858.CD011371.pub2

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Figure 1

Study flow diagram

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Figure 2

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

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Analysis 1.1

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

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Analysis 1.2

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

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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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Analysis 1.4

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

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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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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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Analysis 1.7

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

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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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Analysis 1.9

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

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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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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).

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

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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]

Comparison 1. Fetal growth (biometry) + umbilical artery Doppler versus fetal growth

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