Reduction in twin stillbirth following implementation of NICE guidance.
Khalil A., Giallongo E., Bhide A., Papageorghiou A., Thilaganathan B.
BACKGROUND:There has been an unprecedented fall in stillbirth in twin pregnancies in the UK. It is contested whether implementation of the National Institute for Health and Care Excellence (NICE) guidance on the antenatal management of uncomplicated twin pregnancies may have contributed to this change. The aim of this study was to investigate whether the implementation of NICE guidance is associated with a reduction in stillbirth in twin pregnancy. METHODS:This was a cohort study including all twin pregnancies at St George's Hospital, London, UK. Data were analysed according to two time periods: Group 1 (before June 2013) before implementation of NICE twin guidance, and Group 2 (after June 2013) after this implementation. The exclusion criteria were higher order multiple gestations, pregnancies of unknown chorionicity, pregnancies complicated by miscarriage, undergoing termination and pregnancies diagnosed with vanishing twin. The main outcome was stillbirth. Other outcomes include neonatal death (NND), admission to the neonatal unit (NNU) and emergency Caesarean section. Chi-square test and Mann-Whitney U-test were used to compare between the study groups. We planned a priori sensitivity analysis according to chorionicity. RESULTS:We included 1666 twin pregnancies (3332 fetuses), with 1114 pregnancies (2228 fetuses) before June 2013 and 552 pregnancies (1104 fetuses) from June 2013, in the analysis. Of those, 1299 were dichorionic and 354 were monochorionic diamniotic. The incidence of stillbirth was significantly lower in group 2 compared to the group 1 (3.6 per 1000 births vs 13.5 per 1000 births, p=0.008). The reduction in stillbirth rates was from 8.5 to 3.6 per 1000 births in dichorionic and from 33.6 to 3.8 per 1000 births in monochorionic twin pregnancies. There was no significant difference in the rates of neonatal death (p=0.625), NNU admission (p=0.506) or emergency Caesarean section (p=0.820) between the two groups. The median gestational age at delivery was significantly lower in the post-NICE compared to the pre-NICE twin pregnancies (median 36.9 vs 36.3 weeks, p<0.001), as a consequence of an increase in preterm birth (PTB) between 34 and 37 weeks (27.0% vs 39.3%, p=0.002), but not before 34 weeks' gestation (p=0.562). CONCLUSIONS:A large and significant reduction (>70%) in stillbirth has been noted in twin pregnancies and associated with implementation of NICE guidance. This reduction was statistically significant in monochorionic, but not dichorionic, twin pregnancies. The improvement in twin pregnancy outcome was achieved without a concomitant increase in neonatal mortality, admission to the neonatal unit or emergency Caesarean section. This article is protected by copyright. All rights reserved.