Spontaneous preterm birth prevention in multiple pregnancy 2018 TOG

Question 1

Twins are associated with how much greater risk of perinatal mortality than singletons?

Answer 1

3 x - prematurity main contributor

Question 2

Risk of twins delivering before 37 weeks and 32 weeks

Answer 2

<37 50%
<32 10%

Question 3

Asymptomatic women with twins
Cervical length < 25, risk delivery <28/40
Cervical < 20 risk delivery <32 weeks and 34 weeks

Answer 3

Cervical length < 25mm, risk delivery <28/40 25%

Cervical < 20mm risk delivery <32 weeks 42% and 34 weeks 62%

Conclusion - measure CL at 18 weeks in twin pregnancy

Question 4

Does NICE recommend FFN in twin pregnancy?

Answer 4

‘Do not use FFN alone’

Although 1 study found positive and negative likelihood ratios 85% and 75%, respectively for FFN in symptomatic twin pregnancy

Question 5

Can cervical cerclage be used in twin pregnancy?

Answer 5

Not advised - some studies found harm (preterm)

Question 6

NICE advises not to use the following to prevent preterm birth in twin pregnancy

Answer 6

Arabin pessary
Bedrest
Cerclage
Oral tocolytics

Does not comment on vaginal progesterone - more evidence needed

Note tocolysis can be given if to allow time for steroid or in utero transfer