Routine hospital admission in twin pregnancy between 26 and 30 weeks' gestation. Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions. Clinical trial of induction of labor versus expectant management in twin pregnancy. The effects of hospital admission for bed rest on the duration of twin pregnancy: a randomised trial. Randomized management of the second nonvertex twin: vaginal delivery or cesarean section. A randomized trial of psychosocial support during high-risk pregnancies. The Latin American Network for Perinatal and Reproductive Research. Preterm labour in twin pregnancies: can it be prevented by hospital admission? Aiming to increase birth weight: a randomised trial of pre-pregnancy information, advice and counselling in inner-urban Melbourne. Is routine hospitalization needed in antenatal care of twin pregnancy?
Of 141 women with twin pregnancies, 72 were randomly assigned to outpatient care and 69 to hospital admission between 26 and 30 weeks' gestation. There were no differences between the groups in the frequencies of major maternal complications in pregnancy and labour but more of those admitted to hospital than of the outpatient group had to be admitted after 30 weeks. There were no differences between the groups in the mean birthweights of the twins by birth order, or in their mean gestation at birth whether analysed by intention to treat or by the treatment given. 22 infants were delivered before 32 weeks' gestation in the inpatient group compared with 10 in the outpatient group. With the exception of small-for-dates infants, any trend towards greater morbidity or mortality was seen in the inpatient group. The policy of routine hospital admission of women with twin pregnancies from 26 weeks' gestation is not beneficial to mother or babies and should be abandoned. Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
                Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
                Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs: Two interventions prevent preterm births--smoking cessation and progesterone. Eight interventions prevent stillbirths--balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery. Eleven interventions improve survival of preterm newborns--prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
                The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions. The appropriate date of delivery in twin pregnancies is supposed to be earlier than that in singleton pregnancy. The aim of this study was to compare two strategies for managing twin pregnancies (i.e., immediate induction and expectant management).
                Seventeen patients underwent immediately induced labor by administration of oral prostaglandin E(2) at 37 weeks, while 19 patients underwent expectant management.
                The average gestational age at delivery in the induction group was 37.5 +/- 0.4 weeks, significantly earlier than that in the expectant management group (39.0 +/- 1.1 weeks). However, there were no significant differences in the average birth weight between the two groups (2, 700 +/- 330 g in the induction group vs. 2,672 +/- 392 g in the expectant management group). The cesarean delivery rate in the induction group was 18%, not significantly different from that in the expectant management group (32%). The most common indication for cesarean section in the expectant management group was maternal infection, while there was no maternal infection in the induction group (p = 0.08).
                It may be acceptable do intervene in twin pregnancies earlier than in singleton pregnancies during term.
                Copyright 2000 S. Karger AG, Basel 212 women with twin pregnancies were randomly allocated either to receive advice to rest in hospital from 32 weeks' gestation until delivery, or to be part of a control group in which hospital admission was offered selectively (and, on average, 5 weeks later). Preterm delivery was more common among women admitted routinely for bed rest than among controls, and this difference was unlikely to have occurred by chance. There is at present no scientifically acceptable evidence that this common, disruptive, and expensive obstetric policy does more good than harm. Sixty twin deliveries after the thirty-fifth gestational week with vertex-breech and vertex-transverse presentations were managed according to a randomization protocol. Thirty-three parturient women (21 vertex-breech and 12 vertex-transverse presentations) were allocated for vaginal delivery and 27 for cesarean section (18 vertex-breech and nine vertex-transverse). Six pairs of twins in the vaginal delivery group were delivered in a different mode than requested by the protocol (two women underwent cesarean section; in four cases the second twin spontaneously changed to vertex presentation). There were no significant differences between 1- and 5-minute Apgar scores and incidence of neonatal morbidity between the second-born twins in both study groups. Firstborn twins had higher 1-minute Apgar scores than the second-born infants irrespective of route of delivery (p less than 0.05). No case of birth trauma or neonatal death was recorded. Maternal febrile morbidity was significantly higher in the cesarean section group than in the vaginal delivery group (40.7% versus 11.1%, p less than 0.05). These results suggest that in twins with vertex-breech or vertex-transverse presentations after the thirty-fifth week of gestational age the neonatal outcome of the second twin was not significantly influenced by the route of delivery. It is often suggested that psychological and social support and health education for women at high risk for delivering a low-birth-weight infant can improve the outcomes of pregnancy, but the evidence is inconclusive. We undertook this prospective trial to evaluate a program of home visits designed to provide psychosocial support during pregnancy.
                At four centers in Latin America, 2235 women at higher-than-average risk for delivering a low-birth-weight infant were recruited before the 20th week of pregnancy. The women were randomly assigned either to an intervention group (n = 1115) that received four to six home visits from a nurse or social worker in addition to routine prenatal care or to a control group (n = 1120) that received only routine prenatal care (with a mean of eight prenatal visits). The principal measures of outcome were low birth weight (< 2500 g), preterm delivery (< 37 weeks of gestation), and specified categories of maternal and neonatal morbidity.
                The women who received the home visits as well as routine prenatal care had outcomes that differed little from those of the women who received only routine care. The risks of low birth weight (odds ratio for the intervention group as compared with the control group, 0.93; 95 percent confidence interval, 0.68 to 1.28), preterm delivery (odds ratio, 0.88; 95 percent confidence interval, 0.67 to 1.16), and intrauterine growth retardation (odds ratio, 1.08; 95 percent confidence interval, 0.83 to 1.40) were similar in the two groups. There was no evidence that the intervention had any significant effect on the type of delivery, the length of hospital stay, perinatal mortality, or neonatal morbidity in the first 40 days. There was no protective effect of the psychosocial-support program even among the mothers at highest risk.
                Interventions designed to provide psychosocial support and health education during high-risk pregnancies are unlikely to improve maternal health or to reduce the incidence of low birth weight among infants. Women attending a twin pregnancy antenatal clinic underwent cervical palpation to calculate a cervical score by subtracting dilatation from length. Those with a score of -2 or less at or before 34 weeks are at especially high risk of preterm labour. A total of 139 such women were randomly allocated either to receive bed-rest in hospital or to continue conventional outpatient management. No beneficial effect of bed-rest could be identified in prolonging twin pregnancy or improving fetal outcome. In the 1980s there was substantial interest in early pregnancy and pre-pregnancy interventions to increase birth weight and reduce preterm birth. We developed an inter-pregnancy intervention, implemented in a randomised controlled trial, to be provided by midwives at home soon after women's first birth.
                MCH nurses invited women to take part during their home visit to new mothers. Women's contact details, with their permission, were passed to the study midwife. She had a randomisation schedule to which women's names were added before she met the women or their partners. All women recruited had a home visit from the study midwife with a discussion of their first pregnancy, labour and birth and the postpartum experience. Women in the intervention arm received in addition a pre-pregnancy intervention with discussion of social, health or lifestyle problems, preparation and timing for pregnancy, family history, rubella immunisation, referrals for health problems, and a reminder card. The primary outcome was defined as a birth weight difference in the second birth of 100 g (one-sided) in favour of the intervention. Additional data collected were gestational age, perinatal deaths and birth defects. Analyses used EPI-INFO and STATA.
                Intervention and comparison groups were comparable on socioeconomic factors, prior reproductive history and first birth outcomes. Infant birth weight in the second birth was lower (-97.4 g,)) among infants in the intervention arm. There were no significant differences between intervention and comparison arms in the proportion of women having a preterm birth, an infant with low birthweight, or an infant with a birth weight <10th percentile. There were more adverse outcomes in the intervention arm: ten births <32 weeks), compared with one in standard care, and more infants with a birth weight <2000 g, 16 compared with two in standard care
                As the primary outcome was envisaged to be either improved birth weight or no effect, the study was not designed to identify the alternative outcome with confidence. Despite widespread support for pre-pregnancy interventions to improve maternal and perinatal health, this first randomised controlled trial of a multi-component intervention provided at home, did not have a beneficial outcome. A prospective study was carried out to evaluate the significance and efficacy of routine hospital bed rest in prevention of premature birth and pregnancy complications compared to specialized antenatal care at the outpatient clinic of 73 twin pregnancies. The twin pregnancies were screened in health centers by means of symphysis-fundus measurement, and the diagnosis was confirmed by ultrasound examination at the outpatient clinic. On the average the ultrasonic diagnosis was performed during the 23rd gestational week; at this visit the women were divided into two groups with similar follow-up to the end of the 29th gestational week. At this stage one of the groups was hospitalized unless there had been indications for earlier admission. In the hospital group, the mean for gestational week at delivery was 36.7 (+/- 2.4) and in the outpatient group 37.4 (+/- 1.8) respectively (N.S.). There was no difference in the rate of pregnancy complications between the groups too. No statistical differences in the perinatal mortality (7.1% and 1.1% respectively) or birthweights of the newborns were found, either. Present results do not support the idea of using routine hospital bed rest. It could not be proved to have positive effects on the gestational age, birth weight and perinatal mortality of the newborns, nor to the pregnancy complications. In our opinion early diagnosis of twin pregnancy is of decisive importance and specialized ambulatory follow-up could be employed instead of routine bed rest in antenatal care of twin pregnancy.
There is a lack of robust evidence to guide clinical advice regarding the method of birth for twin pregnancies. Women should be informed of possible benefits and risks of either approach, including short-term and long-term consequences for both mother and babies. Future research should aim to provide unbiased evidence, including long-term outcomes.