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OBSTETRICS
The risk of stillbirth and infant death by each
additional week of expectant management in
twin pregnancies
Jessica M. Page, MD; Rachel A. Pilliod, MD; Jonathan M. Snowden, PhD;
Aaron B. Caughey, MD, PhD
OBJECTIVE: The objective of the study was to compare the fetal/infant 10,000 vs 22.5 per 10,000; P < .05). As expected, the risk of infant
mortality risk associated with each additional week of expectant death following delivery gradually decreased as pregnancies
management with the mortality risk of immediate delivery in women approached term gestation. Week-by-week differences were statisti-
with twin gestations. cally significant (P < .05) between 32 and 36 weeks with decreasing
risk of infant death at advancing gestational ages. The composite risk
STUDY DESIGN: A retrospective cohort study was performed utilizing
of stillbirth and infant death associated with an additional week of
2006e2008 National linked birth certificate and death certificate
pregnancy had a significant increase from 37 to 38 weeks gestation
data. The incidence of stillbirth and infant death were determined for
(43.9 per 10,000 vs 59.2 per 10,000; P < .05). At 37 weeks
each week of pregnancy from 32 0/7 weeks through 40 6/7 weeks
gestation, the relative risk of mortality was statistically significantly
gestation. Pregnancies complicated by fetal anomalies were excluded.
lower with immediate delivery as compared with expectant manage-
These measures were combined to estimate the theoretic risk of
ment (relative risk, 0.87; 95% confidence interval, 0.77e0.99).
remaining pregnant an additional week by adding the risk of stillbirth
during the extra week of pregnancy with the risk of infant death CONCLUSION: Our results suggest that fetal/infant death risk is
encountered with delivery during the following week. This composite minimized at 37 weeks gestation; however, individual maternal and
fetal/infant mortality risk was compared with the risk of infant death fetal characteristics must also be taken into account when determining
associated with delivery at the corresponding gestational age. the optimal timing of delivery for twin pregnancies.
RESULTS: The risk of stillbirth increased with increasing gestational Key words: expectant management, infant death, stillbirth, twin
age, for example, between 37 and 38 weeks gestation (12.5 per pregnancy
Cite this article as: Page JM, Pilliod RA, Snowden JM, et al. The risk of stillbirth and infant death by each additional week of expectant management in twin pregnancies.
Am J Obstet Gynecol 2015;212:630.e1-7.
FIGURE 2 TABLE 2
Risk of fetal/infant death per week of expectant management vs delivery Relative risk of fetal/infant
in 10,000 twins mortality with each additional
week of expectant management
vs delivery
GA RR 95% CI
34 1.28 (1.15e1.44)
35 1.05 (0.94e1.18)
36 0.88 (0.79e1.00)
37 0.87 (0.77e0.99)
38 0.53 (0.45e0.63)
39 0.49 (0.36e0.67)
40 0.27 (0.18e0.43)
CI, confidence interval; GA, gestational age; RR, relative
risk.
Page. Fetal/infant mortality risk in twin pregnancies
by gestational age at delivery. Am J Obstet Gynecol
2015.
The risk of infant death following delivery and composite fetal/infant mortality risk with expectant
management are shown by gestational age in twin pregnancies from 32 through 40 weeks
poorly identied, the 37 vs 38 week issue is
gestation.
not fully answered by this analysis in
Page. Fetal/infant mortality risk in twin pregnancies by gestational age at delivery. Am J Obstet Gynecol 2015.
which most SGA/IUGR was identied by
birthweight.
Even with these analyses, the decision
by gestational diabetes, hypertensive incidence of seizures, there were no sig- between delivery at 37 vs 38 weeks is
disorders, and IUGR was performed to nicant differences found by gestational unclear. Although the risk of stillbirth
ascertain the comparison in a low-risk age at delivery. The need for ventilation would be reduced by delivery at 37
twin cohort. Table 4 displays the ratio for greater than 6 hours of time was used weeks, the risk of complications of pre-
of stillbirths, rate of infant death, and as a marker for neonatal respiratory maturity with subsequent increased
composite risk estimate by gestational complications. Signicantly fewer cases likelihood of infant death at this
age in this group. Figure 3 displays the of mechanical ventilation were found
rate of infant death vs mortality risk of with advancing gestational age from
expectant management. This compares 32 through 38 weeks.
the mortality risk of immediate delivery TABLE 3
vs continued pregnancy for 1 additional C OMMENT Number needed to deliver to
week. The result was similar with that Our work demonstrates that the risk of prevent 1 fetal/infant death in
found in our primary study group, but immediate delivery is lower than the additional week of expectant
now 38 weeks gestation is when a sta- expectant management at 37 weeks management
tistically signicantly lower mortality gestation for unselected twin pregnan- GA NNT
rate is produced by delivery as compared cies in the absence of fetal anomalies. 34 606
with expectant management. This corresponds with prior studies that 35 4071
Analysis of neonatal complications have also recommended this timing of
by gestational age at delivery is shown delivery for uncomplicated dichorionic 36 1811
in Table 5. The NICU admission rate pregnancies.4,9,13 37 1689
was lowest following delivery at 38 When limited to the lower-risk twin 38 360
weeks gestation, and the NICU admis- pregnancies, excluding gestational dia-
39 259
sion rate decreased signicantly with betes, hypertension, and small-for-
each additional week of pregnancy from gestational-age (SGA)/IUGR pregnancies, 40 72
32 through 38 weeks gestational age. 38 weeks became the threshold above GA, gestational age; NNT, number needed to treat.
Additional outcomes studied included which mortality only increased. Although Page. Fetal/infant mortality risk in twin pregnancies
by gestational age at delivery. Am J Obstet Gynecol
neonatal seizures and a need for me- this analysis suggests 38 weeks in the 2015.
chanical ventilation. Because of the low lowest-risk group because SGA/IUGR is so
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