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Increased Stillbirth in Uncomplicated Monochorionic Twin Pregnancies: A Systematic Review and Meta-analysis

Danon, David MD; Sekar, Renuka MD; Hack, Karien E. A. MD; Fisk, Nicholas M. PhD, MBA, FRCOG

doi: 10.1097/AOG.0b013e318292766b

OBJECTIVE: To estimate the risk of stillbirth in apparently uncomplicated monochorionic–diamniotic twin pregnancies by systematic review and meta-analysis and compare it with that in uncomplicated dichorionic pregnancies.

DATA SOURCES: We performed an electronic search (January 1985 to April 2012) of Medline, PubMed, Embase, and databases.

METHODS OF STUDY SELECTION: Studies detailing gestational-age specific stillbirth rates after 24 weeks of gestation in monochorionic–diamniotic twin pregnancies uncomplicated by twin–twin transfusion syndrome, growth restriction, or major anomalies. The rate and risk of stillbirth were calculated in 2-week gestational age blocks and compared in controlled studies with dichorionic pregnancies.

TABULATION, INTEGRATION, AND RESULTS: We evaluated 361 studies to include nine informative studies, four after additional data from the investigators. The rate of stillbirth per 1,000 uncomplicated monochorionic–diamniotic pregnancies at 32–33, 34–35, and 36–37 weeks of gestation was 5.1, 6.8, and 6.2, respectively. The risk of stillbirth per pregnancy at 32, 34, and 36 weeks of gestation was 1.6%, 1.3% and 0.9%, respectively. Compared with uncomplicated dichorionic pregnancies, the odds ratio for stillbirth per pregnancy at 32, 34, and 36 weeks of gestation was 4.2 (95% confidence interval [CI] 1.4–12.6), 3.7 (CI 1.1–12.0), and 8.5 (CI 1.6–44.7), respectively.

CONCLUSION: Uncomplicated monochorionic twin pregnancies are at substantial risk of stillbirth throughout the third trimester, which is severalfold higher than in dichorionic twin pregnancies. Given the risk of fetal death to the cotwin, these data should inform decisions around timing of delivery in seemingly normal monochorionic twin pregnancies.

Supplemental Digital Content is Available in the Text.Apparently uncomplicated monochorionic twin pregnancies have a substantial risk of third-trimester stillbirth compared with uncomplicated dichorionic pregnancies.

The University of Queensland, UQ Centre for Clinical Research, and the Centre for Advanced Prenatal Care, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; and the Diakonessenhuis, Department of Obstetrics and Gynecology, Utrecht, The Netherlands.

Corresponding author: David Danon, MD, Centre for Advanced Prenatal Care, Level 6, Ned Hanlon Building, Royal Brisbane & Women's Hospital, Herston, 4029, Queensland, Australia; e-mail:

Dr. Danon is supported by the Richard & Jack Wiseman Trust.

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the International Fetal Medicine and Surgery Society Annual Meeting, March 30–April 3, 2012, Queenstown, New Zealand.

The authors thank Ms. Lee Jones for statistical support.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.