Updated NICE Guideline on Twin and Triplet pregnancy

The National Institute for Health and Care Excellence (NICE) have released guideline on Twin and Triplet Pregnancy, developed by the National Guideline Alliance (NGA).

This guideline covers the care that should be offered to women with a twin or triplet pregnancy in addition to the routine care that is offered to all women during pregnancy. It aims to reduce the risk of complications and improve outcomes for women and their babies.

Twins or triplets occur in approximately 1 in 60 pregnancies (16 in every 1,000 women giving birth in 2015 had a multiple birth), and 3% of live-born babies are from multiple gestations. Women with a twin or triplet pregnancy are at higher risk compared with women with a singleton pregnancy. Adverse outcomes are more likely, both for the woman and her babies, during the prenatal and intrapartum periods. Because of this, women need increased monitoring and more contact with healthcare professionals during their pregnancy.

This guideline contains new and updated recommendations on: on fetal complications, screening and preventing preterm birth, timing of birth, mode of birth, fetal monitoring during labour, analgesia, managing the third stage of labor, maternal complications, general care and indications for referral to a tertiary level fetal medicine centre.

Determining gestational age and chorionicity

Gestational age

• Offer women with a twin or triplet pregnancy a first-trimester ultrasound scan to estimate gestational age and determine chorionicity and amnionicity (ideally, these should all be performed at the same scan.

Chorionicity and amnionicity

• Determine chorionicity and amnionicity at the time of detecting a twin or triplet pregnancy by ultrasound using:
  
  
  
  • the number of placental masses
  
  
  • the presence of amniotic membrane(s) and membrane thickness
  
  
  • the lambda or T‑sign.
  
  
  
  


• If a woman with a twin or triplet pregnancy presents after 14⁺⁰ weeks, determine chorionicity and amnionicity at the earliest opportunity by ultrasound using all of the following:
  
  
  
  • the number of placental masses
  
  
  • the presence of amniotic membrane(s) and membrane thickness
  
  
  • the lambda or T-sign
  
  
  • discordant fetal sex.
  
  
  
  


• If it is not possible to determine chorionicity or amnionicity by ultrasound at the time of detecting the twin or triplet pregnancy, seek a second opinion from a senior sonographer or refer the woman to a healthcare professional who is competent in determining chorionicity and amnionicity by ultrasound scan as soon as possible.


• Conduct regular clinical audits to evaluate the accuracy of determining chorionicity and amnionicity.


• If transabdominal ultrasound scan views are poor because of a retroverted uterus or a high BMI, use a transvaginal ultrasound scan to determine chorionicity and amnionicity.


• Do not use 3‑dimensional (3‑D) ultrasound scans to determine chorionicity and amnionicity.


• Networks should agree care pathways for managing all twin and triplet pregnancies to ensure that each woman has a care plan in place that is appropriate for the chorionicity and amnionicity of her pregnancy.

Delivery of antenatal and intrapartum care

Antenatal care

• Antenatal clinical care for women with a twin or triplet pregnancy should be provided by a nominated multidisciplinary team consisting of:
  
  
  
  • a core team of named specialist obstetricians, specialist midwives and sonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies
  
  
  • an enhanced team for referrals, which should include:
    
    
    
    • a perinatal mental health professional
    
    
    • a women's health physiotherapist
    
    
    • an infant feeding specialist
    
    
    
    
  
  
  • a dietitian.
  
  
  
  

Intrapartum care

• Intrapartum care for women with a twin or triplet pregnancy should be provided by a multidisciplinary team of obstetricians and midwives who have experience and knowledge of managing twin and triplet pregnancies in the intrapartum period.

Dichorionic diamniotic twin pregnancy

• Offer women with an uncomplicated dichorionic diamniotic twin pregnancy at least 8 antenatal appointments with a healthcare professional from the core team. At least 2 of these appointments should be with the specialist obstetrician.
  
  
  
  • Combine appointments with scans when crown-rump length measures from 45.0 mm to 84.0 mm (at approximately 11⁺² weeks to 14⁺¹ weeks) and then at estimated gestations of 20, 24, 28, 32 and 36 weeks.
  
  
  • Offer additional appointments without scans at 16 and 34 weeks.
  
  
  
  

Monochorionic diamniotic twin pregnancy

• Offer women with an uncomplicated monochorionic diamniotic twin pregnancy at least 11 antenatal appointments with a healthcare professional from the core team. At least 2 of these appointments should be with the specialist obstetrician.
  
  
  
  • Combine appointments with scans when crown-rump length measures from 45.0 mm to 84.0 mm (at approximately 11⁺² weeks to 14⁺¹ weeks) and then at estimated gestations of 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 weeks.
  
  
  
  

Triamniotic triplet pregnancy (trichorionic, dichorionic or monochorionic)

• Offer women with an uncomplicated trichorionic triamniotic triplet pregnancy at least 9 antenatal appointments with a healthcare professional from the core team.

Fetal complications

Information about screening

• A healthcare professional with experience of caring for women with twin and triplet pregnancies should offer information and counselling to women before and after every screening test.


• Inform women with a twin or triplet pregnancy about the complexity of decisions they may need to make depending on the outcomes of screening, including different options according to the chorionicity and amnionicity of the pregnancy.

Screening for chromosomal conditions

• Offer women with a twin pregnancy information on and screening for Down's syndrome, Edwards' syndrome and Patau's syndrome.


• Refer women with a dichorionic and monochorionic triplet pregnancy who want to have screening for Down's syndrome, Edwards' syndrome and Patau's syndrome to a tertiary level fetal medicine centre.


• Do not use second-trimester serum screening for Down's syndrome in triplet pregnancies.


• Refer women with any type of triplet pregnancy who have a higher chance of Down's syndrome, Edwards' syndrome or Patau's syndrome (use a threshold of 1 in 150 at term) to a fetal medicine specialist in a tertiary-level fetal medicine centre.

Screening for preterm birth

• Explain to women and their family members or carers (as appropriate) that:
  
  
  
  • they have a higher risk of spontaneous preterm birth than women with a singleton pregnancy and
  
  
  • this risk is further increased if they have other risk factors, such as a spontaneous preterm birth in a previous pregnancy.
  
  
  
  


• Do not use fetal fibronectin testing alone to predict the risk of spontaneous preterm birth in twin and triplet pregnancy.


• Do not use home uterine activity monitoring to predict the risk of spontaneous preterm birth in twin and triplet pregnancy.

Screening for fetal growth restriction and feto-fetal transfusion syndrome in the first trimester

• Do not offer women with a twin or triplet pregnancy screening for fetal growth restriction or feto-fetal transfusion syndrome in the first trimester.

Preventing preterm birth

• Do not offer intramuscular progesterone to prevent spontaneous preterm birth in women with a twin or triplet pregnancy.


• Do not offer the following interventions (alone or in combination) routinely to prevent spontaneous preterm birth in women with a twin or triplet pregnancy:
  
  
  
  • arabin pessary
  
  
  • bed rest
  
  
  • cervical cerclage
  
  
  • oral tocolytics.
  
  
  
  

Maternal complications

• Advise women with a twin or triplet pregnancy to take low-dose aspirin daily from 12 weeks until the birth of the babies.

Indications for referral to a tertiary level fetal medicine centre

• Seek a consultant opinion from a tertiary level fetal medicine centre for:
  
  
  
  • pregnancies with a shared amnion
  
  
  • pregnancies complicated by any of the following:
    
    
    
    • fetal weight discordance (of 25% or more) and an EFW of any of the babies below the 10th centile for gestational age
    
    
    • fetal anomaly (structural or chromosomal)
    
    
    • discordant fetal death
    
    
    • feto-fetal transfusion syndrome
    
    
    • twin reverse arterial perfusion sequence (TRAP)
    
    
    • conjoined twins or triplets
    
    
    • suspected TAPS
    
    
    
    
  
  
  
  

Planning birth: information and support

• From 24 weeks in a twin or triplet pregnancy, discuss with the woman (and her family members or carers, as appropriate) her plans and wishes for the birth of her babies. Provide information that is tailored to each woman's pregnancy, taking into account her needs and preferences. Revisit these conversations whenever clinically indicated and whenever the woman wants to.


• Ensure the following has been discussed by 28 weeks at the latest:
  
  
  
  • analgesia during labour (or for caesarean birth
  
  
  • intrapartum fetal heart monitoring
  
  
  • management of the third stage of labour.Ensure the following has been discussed by 28 weeks at the latest:
  
  
  
  

Timing of birth

Antenatal information for women

• Explain to women with a twin pregnancy that about 60 in 100 twin pregnancies result in spontaneous birth before 37 weeks.


• Explain to women with a triplet pregnancy that about 75 in 100 triplet pregnancies result in spontaneous birth before 35 weeks.


• Explain to women with a twin or triplet pregnancy that spontaneous preterm birth and planned preterm birth are associated with an increased risk of admission to a neonatal unit.

When to offer planned birth

• Offer planned birth at 37 weeks to women with an uncomplicated dichorionic diamniotic twin pregnancy.


• For women who decline planned birth at the timing recommended in recommendations 1.9.9 and 1.9.10, offer weekly appointments with the specialist obstetrician. At each appointment, offer an ultrasound scan and perform assessments of amniotic fluid level and doppler of the umbilical artery flow for each baby in addition to fortnightly fetal growth scans.

Mode of birth

Twin pregnancy: dichorionic diamniotic or monochorionic diamniotic

• Explain to women with an uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply:
  
  
  
  • the pregnancy remains uncomplicated and has progressed beyond 32 weeks
  
  
  • there are no obstetric contraindications to labour
  
  
  • the first baby is in a cephalic (head-first) presentation
  
  
  • there is no significant size discordance between the twins.
  
  
  
  


• Offer caesarean section to women if the first twin is not cephalic at the time of planned birth.


• Offer caesarean section to women in established preterm labour between 26 and 32 weeks if the first twin is not cephalic.


• Offer an individualised assessment of mode of birth to women in suspected, diagnosed or established preterm labour before 26 weeks. Take into account the risks of caesarean section and the chance of survival of the babies.

Twin pregnancy: monochorionic monoamniotic

• Offer a caesarean section to women with a monochorionic monoamniotic twin pregnancy:
  
  
  
  • at the time of planned birth (between 32⁺⁰ and 33⁺⁶ weeks) or
  
  
  • after any complication is diagnosed in her pregnancy requiring earlier delivery or
  
  
  • if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies (unless the first twin is close to vaginal birth and a senior obstetrician advises continuing to vaginal birth).
  
  
  
  

Triplet pregnancy

• Offer a caesarean section to women with a triplet pregnancy:
  
  
  
  • at the time of planned birth (35 weeks) or
  
  
  • after any complication is diagnosed in her pregnancy requiring earlier delivery or
  
  
  • if she is in established preterm labour, and gestational age suggests there is a reasonable chance of survival of the babies.
  
  
  
  

Fetal monitoring during labour in twin pregnancy

Antenatal information for women

• By 28 weeks of pregnancy, discuss continuous cardiotocography with women with a twin pregnancy and their family members or carers (as appropriate) and address any concerns. Explain that the recommendations on cardiotocography are based on evidence from women with a singleton pregnancy because there is a lack of evidence specific to twin pregnancy or preterm babies.

Intrapartum monitoring

• Offer continuous cardiotocography to women with a twin pregnancy who are in established labour and are more than 26 weeks pregnant.


• Perform a portable ultrasound scan when established labour starts, to confirm which twin is which, the presentation of each twin, and to locate the fetal hearts.

Analgesia

• Discuss options for analgesia and anaesthesia with women (and their family members or carers, as appropriate), whether they are planning a vaginal birth or caesarean section. Ensure this discussion takes place by 28 weeks at the latest.


• Offer regional anaesthesia to women with a twin or triplet pregnancy who are having a caesarean section.

Managing the third stage of labour

• Start assessing the risk of postpartum haemorrhage in women with a twin or triplet pregnancy in the antenatal period and continue throughout labour and the third stage.


• Do not offer physiological management of the third stage to women with a twin or triplet pregnancy.


• By 28 weeks of pregnancy, discuss with women with a twin or triplet pregnancy the potential need for blood transfusion, including the need for intravenous access. Document this discussion in the woman's notes.

To read the guidelines in detail follow the link: www.nice.org