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(Abstracted from BJOG2022;129:29–41)Decreased fetal movement (DFM) can indicate that a pregnancy is at risk for stillbirth. Maternal awareness and monitoring of fetal movement have been considered to be a simple, low-cost stillbirth prevention strategy.

(Abstracted from Health Technol Assess2021;25:1–66)In England and Wales, approximately 16 of every 1000 women have a multiple gestation. Multiple pregnancies are associated with higher rates of stillbirth and neonatal and infant mortality, as well as child disability compared with singleton pregnancies.

Preterm birth complicates approximately 10% of pregnancies worldwide. It can lead to neonatal mortality or lifelong complications for those babies who survive. One cause of preterm birth is cervical insufficiency, which affects up to 1% of pregnant women and can be treated with the placement of vaginal cervical cerclage. There are 2 techniques for cervical cerclage: the modified Shirodkar cerclage, which involves dissecting the bladder and placing a suture around the supravaginal cervix with the suture thread buried, and the McDonald cerclage, which involves inserting the suture thread as high as possible around the upper section of the cervix. The effectiveness of either technique is dependent on perioperative decisions, such as suture thread choice. One UK survey found that 87% of clinicians prefer to use braided thread, with 13% preferring monofilament thread. The preference for braided thread was due to its easy handling and concerns that monofilament thread is difficult to remove if it becomes embedded in the cervix. However, an observational, nonrandomized systemic review suggested that monofilament thread was better than braided thread to prevent pregnancy loss (7% vs 18.9%; risk ratio [RR], 0.34; 95% confidence interval [CI], 0.18–0.63). Additional evidence suggests that monofilament thread is superior because braided thread could serve as a reservoir for bacteria, causing vaginal dysbiosis and increasing the risk of pregnancy loss. There are no randomized clinical trials to inform the choice of suture thread to prevent pregnancy loss. The aim of this study was to compare the effectiveness of monofilament suture thread to braided suture thread on pregnancy loss in women undergoing cervical cerclage.This was a superiority randomized clinical trial, conducted at 75 obstetric units in the United Kingdom between August 21, 2015, and January 28, 2021. Included were women aged 18 years and older with singleton pregnancies, who required vaginal cervical cerclage. Excluded were women who required emergency or rescue cerclage, needed immediate suture insertion, or had ruptured or visible membranes, as well as those who did not have a cerclage placed vaginally. Eligible women were randomized to receive either monofilament thread or braided thread. Women were followed up until 28 days postdelivery or hospital discharge, whichever came first. Preterm neonates were followed up until delivery or discharge, and babies born at term were followed up 28 days postdelivery or hospital discharge, whichever came first.A total of 2049 women were randomized to the monofilament suture thread group (n = 1025) or the braided suture thread group (1024). The intention-to-treat analysis included 1003 women in the monofilament group and 993 women in the braided group. No significant differences were observed in the rate of pregnancy loss between the monofilament group and braided group (8% vs 7.6%, respectively; RR, 1.05; 95% CI, 0.79–1.40; adjusted risk difference, 0.002; 95% CI, −0.02 to 0.03; P= 0.73). Insertion complications occurred in 4% of women in the monofilament group and 3% in the braided suture group. Women in the monofilament group experienced more removal complications than the braided group (RR, 1.25; 95% CI, 1.15–1.36). No significant differences were observed in maternal secondary outcomes or neonatal outcomes.In conclusion, there was no difference in the rate of pregnancy loss when using monofilament suture thread or braided suture thread in women undergoing cervical cerclage.

(Abstracted from Lancet2018;392:1629–1638)Two to 6 million pregnancies were estimated to have ended in stillbirth in 2015. The aim of the AFFIRM study was to test the hypothesis that introduction of a reduced fetal movement care package for pregnant women and clinicians that increased women's awareness of the need for prompt reporting of RFM and that standardized management, including timely delivery, would alter the incidence of stillbirth.

(Abstracted from BMJ2016;354:i4353)Twin pregnancies are at increased risk of stillbirth. Uncomplicated twin pregnancies are commonly delivered earlier to prevent stillbirth; however, there is a risk of neonatal complications associated with being born prior to 39 weeks’ gestation.

(Abstracted from N Engl J Med2019;380:1815–1824)The hormone progesterone plays a critical role in preparing the endometrium for implantation of the embryo and continues to be produced throughout pregnancy. Historically, progesterone supplementation has been initiated during early pregnancies to prevent miscarriages in asymptomatic women who have a history of recurrent miscarriages or to rescue a pregnancy in women who have started to bleed during early pregnancy.

Women with twin pregnancy are at high risk of spontaneous preterm delivery. Three large randomized trials have shown that progesterone reduces the rate of preterm delivery in high-risk singleton pregnancies, although evidence of significant reduction in perinatal mortality or clear neonatal benefit in singleton women is lacking. The STOPPIT study was a randomized, double-blind, placebo-controlled trial designed to evaluate the potential benefit of progesterone for prevention of preterm birth in women with twin pregnancy. Between 2004 and 2008, 500 women with twin pregnancy were enrolled from 9 antenatal clinics at hospitals in the United Kingdom. At 24 weeks of gestation, the study subjects were randomized to either 90 mg of vaginal progesterone gel (n 250) or placebo gel (n 250) daily for 10 weeks. The primary study outcome was delivery or intrauterine death before 34 weeks of gestation. Analysis was performed according to intention to treat. The investigators also performed a meta-analysis of all published and unpublished studies in which women with twin pregnancy were randomly allocated to treatment with a progesterone (including progesterone).

Intrauterine fetal demise increases progressively beyond 37 weeks of gestation. However, neonatal death rates continue to improve up to 39 or 40 weeks of gestation. Previous studies have suggested that elective induction of labor (induced labor in the absence of medical indications) for prolonged pregnancies of more than 42 weeks may reduce perinatal mortality without increasing rates of cesarean delivery. Few well-designed studies have compared maternal and neonatal outcomes among women with prolonged labor undergoing induction with those expectantly managed.

Several investigators have hypothesized that outpatient preinduction cervical ripening with nitric oxide donors such as isosorbide mononitrate (IMN) would reduce the elapsed time from hospital admission to delivery and improve women's experience of induction of labor. This double-blind randomized placebo-controlled trial investigated whether vaginal self-administration at home by woman at term would improve the process of induction of labor. The study subjects were 350 nulliparous singleton women with cephalic presentation at ≥37 weeks' gestation, requiring cervical ripening before induction of labor. The participants self-administered IMN (n 177) or placebo (n 173) vaginally at home without fetal monitoring at 48, 32, and 16 hours before the scheduled time of admission for induction of labor. The primary study outcome measures were the elapsed time interval from hospital admission to delivery and the women's experience of home treatment for cervical ripening. Maternal satisfaction was determined with a questionnaire, using a 10 point scale with 1 extremely good and 10 not at all good.