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Multiple pregnancy
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Introduction
This pathway covers the management of twin and triplet pregnancies in the antenatal period. The incidence of multiple births is rising, due mainly to increasing use of assisted reproduction techniques. Multiple pregnancy is associated with higher risks for both mother and babies. Because of this, women with multiple pregnancies need more antenatal contact with healthcare professionals than women with singleton pregnancies. In addition, their higher risk of preterm delivery places greater demand on specialist neonatal resources.
This pathway should be used in conjunction with the antenatal care pathway. The multiple pregnancy pathway specifies the care that women with twin and triplet pregnancies should receive that is additional to or different from routine antenatal care for women with singleton pregnancies. For many women the twin or triplet pregnancy will be detected only after the first (booking) appointment in routine antenatal care. Women should then be offered the specialist antenatal appointments described in this pathway.
Source guidance
The NICE guidance that was used to create the pathway.
Multiple pregnancy. NICE clinical guideline 129 (2011)
Quality standards
Quality statements
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Implementation
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Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
8 February 2013 Minor maintenance updates
Supporting information
Glossary
The inner membrane that surrounds the baby. Pregnancies with one amnion (so that all babies share an amniotic sac) are monoamniotic; pregnancies with two amnions are diamniotic; and pregnancies with three amnions are triamniotic.
Antenatal ultrasound evaluation of fetal wellbeing based on fetal movement, fetal tone, fetal breathing, amniotic fluid volume, and the nonstress test of the fetal heart rate (or cardiotocography).
The number of chorionic (outer) membranes surrounding babies in a multiple pregnancy, indicating whether babies share a placenta. In monochorionic pregnancies babies share one placenta; in dichorionic pregnancies there are two placentas; in trichorionic triplet pregnancies each baby has a separate placenta.
One baby has a separate placenta and amniotic sac and two of the babies share a placenta and amniotic sac.
In dichorionic triplets one of the babies has a separate placenta and two of the babies share one placenta. All three babies have separate amniotic sacs.
Dichorionic twins each have a separate placenta.
Feto-fetal transfusion syndrome occurs when blood moves from one baby to another. It is a complication of monochorionic multiple pregnancies arising from shared placental circulation. Also referred to as twin-to-twin transfusion syndrome in twin pregnancies.
Monochorionic diamniotic twins share a placenta but have separate amniotic sacs.
Twin or triplet pregnancies in which all babies share a placenta and amniotic sac.
All three babies share one placenta. One baby has a separate amniotic sac and two babies share one sac.
In monochorionic triamniotic triplets all three babies share one placenta but each has its own amniotic sac.
Obstetricians with a special interest, experience and knowledge of managing multiple pregnancies, who work regularly with women with multiple pregnancies.
In trichorionic triplets all three babies have separate placentas and amniotic sacs.
A regionally commissioned centre with the experience and expertise for managing complicated twin and triplet pregnancies.
See 'Feto-fetal transfusion syndrome'.
Pregnancies are either monozygous (arising from one fertilised egg) or dizygous (arising from two separate fertilised eggs). Monozygous twins are identical; dizygous twins are non-identical.
Woman with a multiple (twin or triplet) pregnancy
Woman with a multiple (twin or triplet) pregnancy
Woman with a multiple (twin or triplet) pregnancy
This pathway should be used in conjunction with the antenatal care pathway. The multiple pregnancy pathway specifies the care that women with twin and triplet pregnancies should receive that is additional to or different from routine antenatal care for women with singleton pregnancies. For many women the twin or triplet pregnancy will be detected only after the first (booking) appointment in routine antenatal care. Women should then be offered the specialist antenatal appointments described in this pathway.
Organisation of care
Organisation of care
Organisation of care
Clinical care should be provided by a nominated multidisciplinary team consisting of:
- a core team of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies
- an enhanced team for referrals, including:
- a perinatal mental health professional
- a women's health physiotherapist
- an infant feeding specialist
- a dietitian.
The enhanced team should have experience and knowledge relevant to twin and triplet pregnancies.
Do not refer women routinely to the enhanced team; refer only when needed.
Coordinate care to:
- minimise hospital visits
- provide care as close to the woman's home as possible
- provide continuity within and between hospitals and the community.
For pregnancies involving a shared amnion, offer individualised care from a consultant in a tertiary level fetal medicine centre.
Networks should agree care pathways so that each woman has a care plan appropriate for the chorionicity of her pregnancy.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTraining for ultrasonographers
Training for ultrasonographers
Training for ultrasonographers
Provide regular training in identifying the lambda or T-sign. Senior colleagues should support less experienced ultrasonographers.
Training should cover ultrasound measurements needed for women who book after 14 weeks 0 days (see early scan and chorionicity) and should emphasise that risks are determined by chorionicity and not zygosity.
Conduct regular audits of the accuracy of determining chorionicity.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeInformation, support and nutritional advice
Information, support and nutritional advice
Information, support and nutritional advice
Explain sensitively the aims and possible outcomes of screening and diagnostic tests to minimise anxiety.
The core team (see organisation of care) should offer information and support specific to twin and triplet pregnancies at first contact and provide ongoing opportunities for discussion covering:
- antenatal and postnatal mental health and wellbeing
- antenatal nutrition (see below)
- the risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation
- likely timing and possible modes of deliverySpecific recommendations about mode of delivery are outside the scope of this pathway.
- breastfeeding
- parenting.
NICE has written information for the public explaining the guidance on multiple pregnancy.
Nutritional supplement, diet and lifestyle advice
Give the same advice about diet, lifestyle and nutritional supplements as in routine antenatal care (see the antenatal care pathway).
Be aware of the higher incidence of anaemia in women with twin and triplet pregnancies. Perform a full blood count at 20–24 weeks to identify a need for early supplementation with iron or folic acid, and repeat at 28 weeks as in routine antenatal careThis is in addition to the test for anaemia at the routine booking appointment; see the antenatal care pathway.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeSchedule of specialist antenatal appointments
Schedule of specialist antenatal appointments
Schedule of specialist antenatal appointments
This information is also available in an appointments chart on the NICE website.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeDetermining chorionicity and planning care
View the 'Determining chorionicity and planning care' pathScreening and management of fetal complications
View the 'Screening and management of fetal complications' pathRefer to a tertiary level fetal medicine centre
Refer to a tertiary level fetal medicine centre
Refer to a tertiary level fetal medicine centre
Seek a consultant opinion from a tertiary level fetal medicine centre for:
- monochorionic monoamniotic twin pregnancies
- monochorionic monoamniotic triplet pregnancies
- monochorionic diamniotic triplet pregnancies
- dichorionic diamniotic triplet pregnancies.
- pregnancies complicated by any of the following:
- discordant fetal growth (also see monitoring for intrauterine growth restriction)
- fetal anomaly
- discordant fetal death
- feto-fetal transfusion syndrome (also see screening and treatment for feto-fetal transfusion syndrome)
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeMaternal complications: hypertension
Maternal complications: hypertension
Maternal complications: hypertension
Measure blood pressure and test urine for proteinuria at each appointment, as in routine antenatal care (see the antenatal care pathway).
Advise women to take 75 mg of aspirinAt the time this pathway was created (November 2011) this drug did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented. [This recommendation is adapted from recommendation 1.1.2.2 in 'Hypertension in pregnancy', NICE clinical guideline 107] daily from 12 weeks until the birth of the babies if they have one or more of the following risk factors for hypertension:
- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- BMI of 35 kg/m2 or more at first visit
- family history of pre-eclampsia.
See the hypertension in pregnancy guideline for more information.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeRisk of preterm birth
Risk of preterm birth
Risk of preterm birth
Inform women that spontaneous preterm birth and elective preterm birth are associated with an increased risk of admission to a special care baby unit.
Predicting the risk of preterm birth
Be aware that women with twin pregnancies have a higher risk of spontaneous preterm birth if they have had a spontaneous preterm birth in a previous singleton pregnancy.
Do not use cervical length (with or without fetal fibronectin) routinely to predict the risk of preterm birth.
Do not use the following to predict the risk of preterm birth:
- fetal fibronectin testing alone
- home uterine activity monitoring.
Preventing preterm birth
Do not use the following (alone or in combination) routinely to prevent spontaneous preterm birth:
- bed rest at home or in hospital
- intramuscular or vaginal progesterone
- cervical cerclage
- oral tocolytics.
Untargeted corticosteroids
Inform women:
- of their increased risk of preterm birth
- about the benefits of targeted corticosteroids
- that there is no benefit in using untargeted administration of corticosteroids.
Do not use single or multiple untargeted (routine) courses of corticosteroids.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTiming of birth
Timing of birth
Timing of birth
Discuss with the woman timing of birth and possible modes of deliverySpecific recommendations about mode of delivery are outside the scope of this pathway. early in the third trimester.
Inform women that spontaneous preterm birth and elective preterm birth are associated with an increased risk of admission to a special care baby unit.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTiming of birth for uncomplicated twin pregnancies
Timing of birth for uncomplicated twin pregnancies
Timing of birth for uncomplicated twin pregnancies
Inform women that:
- about 60% of twin pregnancies result in spontaneous birth before 37 weeks 0 days and
- elective birthSpecific recommendations about mode of delivery are outside the scope of this pathway. from 36 weeks 0 days for monochorionic twins and 37 weeks 0 days for dichorionic twins does not appear to be associated with increased risk of serious adverse outcomes and
- continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk of fetal death.
- 36 weeks 0 days for monochorionic twin pregnancies, after a course of corticosteroids has been offered
- 37 weeks 0 days for dichorionic twin pregnancies.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeTiming of birth for uncomplicated triplet pregnancies
Timing of birth for uncomplicated triplet pregnancies
Timing of birth for uncomplicated triplet pregnancies
Inform women that:
- about 75% of triplet pregnancies result in spontaneous birth before 35 weeks 0 days and
- continuing uncomplicated triplet pregnancies beyond 36 weeks 0 days increases the risk of fetal death.
Offer elective birthSpecific recommendations about mode of delivery are outside the scope of this pathway. from 35 weeks 0 days, after a course of corticosteroids has been offered.
Implementation tools
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Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeIf elective birth is declined
If elective birth is declined
If elective birth is declined
Offer weekly appointments with a consultant obstetrician. Offer an ultrasound scan at each appointment (perform fortnightly fetal growth scans and weekly biophysical profile assessments).
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
Pathway created: November 2011 Last updated: February 2013
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