Prevention of preterm birth in twin-to-twin transfusion syndrome: a systematic review and network meta-analysis

Henrique G. Provinciatto; Maria E. Barbalho; Laura F. Crosara; Pedro V.B. Orsini; Alexandre Provinciatto; Chris E. Philip; Rodrigo Ruano; Edward Araujo Júnior

doi:10.1515/jpm-2024-0119

Article

Prevention of preterm birth in twin-to-twin transfusion syndrome: a systematic review and network meta-analysis

Henrique G. Provinciatto , Maria E. Barbalho , Laura F. Crosara , Pedro V.B. Orsini , Alexandre Provinciatto , Chris E. Philip , Rodrigo Ruano and Edward Araujo Júnior

Published/Copyright: June 21, 2024

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From the journal Journal of Perinatal Medicine Volume 52 Issue 7

Abstract

Objectives

We aimed to perform a systematic review and network meta-analysis to evaluate the preventive strategies for preterm birth in twin-to-twin transfusion syndrome.

Methods

PubMed, Embase and Cochrane Central were searched from inception to December 2023 with no filters. Additionally, the reference lists of the included studies were manually examined to identify any supplementary studies. We selected randomized controlled trials and cohorts comparing interventions to prevent preterm birth in twin pregnancies complicated by twin-to-twin transfusion syndrome. A random-effects frequentist network meta-analysis was performed using RStudio version 4.3.1. Randomized controlled trials and cohorts were assessed respectively using the Risk of Bias in Non-randomized Studies of interventions tool and Cochrane Collaboration’s tool for assessing risk of bias in randomized trials.

Results

In this systematic review and meta-analysis, we included eight studies comprising a total of 719 patients. Compared with expectant management, cerclage stood out as the only intervention associated with an increase in the survival of at least one twin (risk ratio 1.12; 95 % confidence interval 1.01–1.23). Our subgroup analysis based on different thresholds for short cervix demonstrated a significant reduction in the risk of preterm birth before 32 weeks with ultrasound-indicated cerclage using a 15 mm criterion (risk ratio 0.65; 95 % confidence interval 0.47–0.92).

Conclusions

Our study suggests the potential benefit of cerclage as a preventive strategy for preterm birth in pregnancies complicated by twin-to-twin transfusion syndrome. These findings highlight the necessity for further investigation to corroborate our results and address the optimal threshold for ultrasound-indicated cerclage.

Keywords: twin pregnancy; twin-to-twin transfusion syndrome; prematurity; cerclage; pessary; progesterone

Corresponding author: Prof. Edward Araujo Júnior, PhD, Department of Obstetrics, Paulista School of Medicine – Federal University of São Paulo (EPM-UNIFESP), Rua Belchior de Azevedo, 156 apto. 111 Torre Vitoria, Vila Leopoldina, São Paulo, SP, CEP 05089-030, Brazil, E-mail: araujojred@terra.com.br

Research ethics: Our investigations were carried out following the rules of the Declaration of Helsinki of 1975, revised in 2013. As this is a review article, it was not necessary Ethics Committee approval.
Informed consent: Not applicable, because the study is a review.
Author contributions: Conceptualization, HP; methodology, MEB and LCF; validation, PVBO; formal analysis, HP; investigation, MEB and LCF; resources, HP; data curation, AP and CEP; writing – original draft preparation, EAJ; writing – review and editing, RR; visualization, HP, MEB, LCF, PVBO, AP, CEP, EAL, and RR; supervision, EAJ; project administration, RR. All authors have read and agreed to the published version of the manuscript.
Competing interests: The authors state no conflict of interest.
Research funding: None declared.
Data availability: The data presented in this study are available on request from the corresponding author.

Appendix 1

PubMed

(“Fetofetal Transfusion”[mh] OR “fetal transfusion syndrome” OR “twin-to-twin transfusion syndrome” OR “twin-to-twin transfusion” OR “twin transfusion” OR “twin transfusion syndrome” OR “twin twin transfusion syndrome” OR TTTS) AND (“Pessaries”[mh] OR pessary OR “Cerclage, Cervical”[mh] OR cerclage OR “cervical stitch” OR “Progesterone”[mh] OR progesterone)

Embase

(‘twin twin transfusion syndrome’/exp OR “fetal transfusion syndrome” OR “twin-to-twin transfusion syndrome” OR “twin-to-twin transfusion” OR “twin transfusion” OR “twin transfusion syndrome” OR “twin twin transfusion syndrome” OR TTTS) AND (‘vagina pessary’/exp OR pessary OR pessaries OR ‘cerclage’/exp OR cerclage OR “cervical stitch” OR ‘progesterone’/exp OR progesterone)

Cochrane

(“Fetofetal Transfusion” OR “fetal transfusion syndrome” OR “twin-to-twin transfusion syndrome” OR “twin-to-twin transfusion” OR “twin transfusion” OR “twin transfusion syndrome” OR “twin twin transfusion syndrome” OR TTTS) AND (pessary OR pessaries OR cerclage OR “cervical stitch” OR progesterone)

Appendix 2

Study	Reasons for exclusion
Aboudiab 2017	A cohort involving 17 twin pregnancies complicated by TTTS who received cerclage. There was no control group, and the period comprises Chavira 2009 study, having the possibility of overlapping.
Loh 2020	A cohort comprising 15 twin pregnancies complicated by TTTS. Of these, only one patient had a short cervix and was submitted to cerclage. There was no control group.
Robyr 2005	This observational study involved 10 patients with a cervical length of up to 20 mm. Of these, 9 patients received cerclage. The only patient who received expectant management had a miscarriage. Moreover, the period comprises Chavira 2009 study, having the possibility of overlapping.
Youssefzadeh 2021	A case-control study evaluating causes for dual demise in 52 pregnancies. This study consist in a wrong study design based on eligibility criteria.
Zaretsky 2018	A study comprising 169 patients with diagnosis of TTTS. This study do not provide data of patients with short cervix who received cerclage and those who received expectant management.

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/jpm-2024-0119).

Received: 2024-03-15

Accepted: 2024-06-07

Published Online: 2024-06-21

Published in Print: 2024-09-25

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Articles in the same Issue

https://doi.org/10.1515/jpm-2024-0119

Keywords for this article

twin pregnancy; twin-to-twin transfusion syndrome; prematurity; cerclage; pessary; progesterone