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Twin and triplet pregnancy

About

What is covered

This NICE Pathway 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.
This NICE Pathway should be read in conjunction with the NICE Pathway on antenatal care for uncomplicated pregnancies.

Updates

Updates to this NICE Pathway

3 September 2019 Major update on publication of the twin and triplet pregnancy guideline (NG137). Renamed to reflect these changes (previously called multiple pregnancy). Multiple pregnancy: twin and triplet pregnancies (NICE quality standard 46) updated.
30 September 2016 Updated to include full guideline recommendations.
17 September 2013 Multiple pregnancy: twin and triplet pregnancies (NICE quality standard 46) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on managing twin and triplet pregnancies in the antenatal and intrapartum period in an interactive flowchart

What is covered

This NICE Pathway 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.
This NICE Pathway should be read in conjunction with the NICE Pathway on antenatal care for uncomplicated pregnancies.

Updates

Updates to this NICE Pathway

3 September 2019 Major update on publication of the twin and triplet pregnancy guideline (NG137). Renamed to reflect these changes (previously called multiple pregnancy). Multiple pregnancy: twin and triplet pregnancies (NICE quality standard 46) updated.
30 September 2016 Updated to include full guideline recommendations.
17 September 2013 Multiple pregnancy: twin and triplet pregnancies (NICE quality standard 46) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Twin and triplet pregnancy (2019) NICE guideline NG137
Multiple pregnancy: twin and triplet pregnancies (2013 updated 2019) NICE quality standard 46

Quality standards

Quality statements

Determining chorionicity and amnionicity

This quality statement is taken from the multiple pregnancy quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have the chorionicity and amnionicity of their pregnancy determined using ultrasound and recorded between 11+2 weeks and 14+1 weeks.

Rationale

If fetuses share a placenta, there is a greater risk of complications. Determining chorionicity and amnionicity allows women to be assigned the correct plan of care for their pregnancy.
Pregnancy risks, clinical management and subsequent outcomes are different for monochorionic and dichorionic twin pregnancies (and for monochorionic, dichorionic and trichorionic triplet pregnancies). Therefore, accurate determination of chorionicity is important.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have an ultrasound scan between 11+2 weeks and 14+1 weeks to determine and record the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who receive an ultrasound scan between 11+2 weeks and 14+1 weeks to determine and record the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who received an ultrasound scan between 11+2 weeks and 14+1 weeks to determine and record the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy of greater than 14+1 weeks’ gestation.
Data source: Local data collection. The Maternity Services Data Set collects data on:
  • Offer status – dating ultrasound scan (global number 17201960).
  • Gestation – dating ultrasound scan (global number 17202010).
  • Number of fetuses – dating ultrasound scan (global number 17202020).
Outcome
Determination of chorionicity and amnionicity.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to have an ultrasound scan between 11+2 weeks and 14+1 weeks to determine and record the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy have an ultrasound scan between 11+2 weeks and 14+1 weeks to determine and record the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission specialist services that provide ultrasound scanning between 11+2 weeks and 14+1 weeks for women with a multiple pregnancy to determine and record the chorionicity and amnionicity of their pregnancy.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 2 days and 14 weeks 1 day of their pregnancy. This is to see whether the babies share the same placenta (chorionicity) and amniotic sac (amnionicity). This information is recorded in the woman’s notes.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendations 1.1.1, 1.1.3 , and 1.3.7 to 1.3.10
The timing of the ultrasound scan is also shown in the multiple pregnancy antenatal care proforma and care pathways produced by the Twins and Multiple Births Association.

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Chorionicity
The number of chorionic (outer) membranes that surround babies in a multiple pregnancy. If there is only 1 membrane, the pregnancy is described as monochorionic; if there are 2, the pregnancy is described as dichorionic; and if there are 3, the pregnancy is trichorionic. Monochorionic twin pregnancies and monochorionic/dichorionic triplet pregnancies carry higher risks because babies share a placenta.
[NICE’s guideline on twin and triplet pregnancy, terms used in this guideline]

Amnionicity

The number of amnions (inner membranes) that surround babies in a multiple pregnancy. Pregnancies with 1 amnion (so that all babies share an amniotic sac) are described as monoamniotic; pregnancies with 2 amnions are diamniotic; and pregnancies with 3 amnions are triamniotic.
[NICE’s guideline on twin and triplet pregnancy, terms used in this guideline]

Ultrasound scan

An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and the presence of amniotic membrane(s) and membrane thickness.
[NICE’s guideline on twin and triplet pregnancy, recommendation 1.1.3]
Note: NICE’s guideline on antenatal care for uncomplicated pregnancies recommends determination of gestational age from 10 weeks 0 days. However, the aim in NICE’s guideline on twin and triplet pregnancy is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).

Recording the chorionicity and amnionicity

The chorionicity and amnionicity of the pregnancy should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image (of Lambda or T sign) should be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the woman’s hand-held maternity notes and their hospital notes.
[Expert opinion]

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. NICE’s guideline on pregnancy and complex social factors includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Labelling the fetuses

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have their fetuses labelled using ultrasound and recorded between 11+2 weeks and 14+1 weeks.

Rationale

Labelling the fetuses and recording this in the notes at the dating scan, using left and right, or upper and lower, allows the fetuses to be consistently identified throughout the pregnancy. It also takes into account that the ‘leading’ fetus may change as pregnancy progresses and labelling by number can cause confusion, particularly with left and right fetuses.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Numerator – the number of women in the denominator who have had their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Denominator – the number of women with a multiple pregnancy of greater than 14+1 weeks’ gestation.
Data source: Local data collection.
Outcome
Consistent identification of fetuses in multiple pregnancies.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Healthcare practitioners ensure that women with a multiple pregnancy have their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Commissioners ensure that that they commission specialist services for women with a multiple pregnancy to have their fetuses labelled using an ultrasound scan and recorded between 11+2 weeks and 14+1 weeks.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an ultrasound scan between 11 weeks 2 days and 14 weeks 1 day of their pregnancy to record the positions of their babies.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendations 1.1.4 and 1.3.7 to 1.3.10

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Ultrasound scan
An ultrasound scan is used to determine chorionicity based on the number of placental masses, the Lambda or T sign and the presence of amniotic membrane(s) and membrane thickness.
[NICE’s guideline on twin and triplet pregnancy, recommendation 1.1.3]
Note: NICE’s guideline on antenatal care for uncomplicated pregnancies recommends determination of gestational age from 10 weeks 0 days. However, the aim in NICE’s guideline on twin and triplet pregnancy is to minimise the number of scan appointments that women need to attend within a short time, especially if it is already known that a woman has a twin or triplet pregnancy (for example, as a result of IVF treatment).
Labelling the fetuses
Labelling of the fetuses should be documented in the ultrasound report. An electronic copy of the ultrasound report and an ultrasound image should also be stored on the radiology reporting and picture archiving system. Hard copies of the report should be printed out and placed in the women’s hand-held maternity notes and their hospital notes.
The fetuses should be labelled using either the lateral orientation (left and right) or the vertical orientation (upper and lower). Labelling of fetuses should be carried out at all ultrasound scans to ensure consistent identification throughout the pregnancy.
[Expert opinion]

Equality and diversity considerations

Some pregnant women have complex social needs and may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol or drugs)
  • have recently arrived in the UK as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that professionals give special consideration to women with complex social needs. NICE’s guideline on pregnancy and complex social factors includes recommendations on how to make antenatal care accessible to pregnant women with complex social needs and how to encourage women to maintain ongoing contact with maternity services.

Composition of the multidisciplinary core team

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are cared for by a multidisciplinary core team.

Rationale

Women with a multiple pregnancy should have their clinical care provided by a multidisciplinary core team because of the increased risks and complications associated with multiple births. Members of this team will have the expertise needed to provide high-quality care for women with a multiple pregnancy. It may be appropriate for the multidisciplinary core team to refer women to the community midwifery team for some of their additional antenatal appointments.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to be cared for by a multidisciplinary core team.
Healthcare practitioners ensure that women with a multiple pregnancy are cared for by a multidisciplinary core team.
Commissioners ensure that they commission services for women with a multiple pregnancy to be cared for by a multidisciplinary core team.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are cared for by a team of healthcare professionals with different skills and roles (for example, specialist doctors, specialist midwives and ultrasound operators).

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendation 1.3.1

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
The multidisciplinary core team should coordinate clinical care for women with twin and triplet pregnancies to:
  • minimise the number of hospital visits
  • provide care as close to the woman's home as possible
  • provide continuity of care within and between hospitals and the community; the community includes GPs in primary care, and community midwives and health visitors.
The multidisciplinary core team should offer information and emotional support specific to twin and triplet pregnancies at their first contact with the woman and provide ongoing opportunities for further discussion and advice including:
  • antenatal and postnatal mental health and wellbeing
  • antenatal nutrition
  • the risks, symptoms and signs of preterm labour and the potential need for corticosteroids for fetal lung maturation
  • likely timing and possible modes of delivery
  • breastfeeding
  • parenting.
[Adapted from NICE’s guideline on twin and triplet pregnancy, recommendations 1.3.1, 1.3.4, 1.3.5 and terms used in this guideline]

Care planning

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a care plan that specifies the timing of appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.

Rationale

Women with a multiple pregnancy should have most of their antenatal appointments with a member of the multidisciplinary core team. The number of appointments and ultrasound scans a woman should have depends on the chorionicity and amnionicity of her pregnancy and any associated risk factors or complications.
Women should have a record of the expected number of antenatal appointments they should attend, who they should have them with and where they will take place.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women with a multiple pregnancy have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
b) Evidence of local audit to monitor the completeness and accuracy of the antenatal care plan for women with a multiple pregnancy.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Numerator – the number of women in the denominator who have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Denominator – the number of women with a multiple pregnancy.
Data source: Local data collection.
Outcome
Women feel informed about their care and know which healthcare professionals they should see and when.
Data source: Local data collection. Data will also be collected against NHS outcomes framework 2013/14 indicator 4.5 ‘Women’s experience of maternity services’.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that provide women who have a multiple pregnancy with a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chorionicity and amnionicity of their pregnancy.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a care plan that has the dates and times of all their antenatal care appointments and details of who the appointments are with.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendations 1.1.13 and 1.3.7 to 1.3.10

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
[Adapted from NICE’s guideline on twin and triplet pregnancy, recommendations 1.3.1, 1.3.4, 1.3.5 and terms used in this guideline]
Care plan
A care plan should be provided at determination of chorionicity, which specifies the frequency and timing of antenatal care appointments. The care plan should contain the recommended schedule of specialist antenatal appointments according to the chorionicity and amnionicity of a pregnancy, as detailed in the NICE guideline on twin and triplet pregnancy. The schedule of specialist appointments is also shown as part of the multiple pregnancy antenatal care proforma and care pathways produced by the Twins and Multiple Births Association.
Women may be seen for additional antenatal appointments in the community with healthcare professionals outside the multidisciplinary core team, such as neonatal unit staff, community midwives and GPs. The scheduling of these appointments will be coordinated by the multidisciplinary core team.
[Expert opinion]

Monitoring for fetal complications

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.

Rationale

Multiple pregnancies are associated with increased risk of fetal complications. Fetal growth restriction is more likely to occur in monochorionic and dichorionic multiple pregnancies. There is a risk of feto-fetal transfusion syndrome with monochorionic multiple pregnancies. Therefore, it is important to monitor monochorionic and dichorionic multiple pregnancies closely for fetal complications in order to manage them effectively should they arise.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Data source: Local data collection.
Process
a) The proportion of women with a monochorionic multiple pregnancy who receive diagnostic monitoring for feto-fetal transfusion syndrome using ultrasound from 16 weeks and every 14 days until birth.
Numerator – the number of women in the denominator who received diagnostic monitoring for feto-fetal transfusion syndrome using ultrasound from 16 weeks and every 14 days until birth.
Denominator – the number of women who had a monochorionic multiple pregnancy and a gestational age greater than 16 weeks.
Data source: Local data collection.
b) The proportion of women with a monochorionic multiple pregnancy who receive diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters and amniotic fluid level assessment at each ultrasound scan from 16 weeks.
Numerator – the number of women in the denominator who received diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters and amniotic fluid level assessment at each ultrasound scan from 16 weeks.
Denominator – the number of women with a monochorionic multiple pregnancy and a gestational age greater than 16 weeks.
Data source: Local data collection.
c) The proportion of women with a dichorionic twin or trichorionic triplet pregnancy who receive diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters and amniotic fluid levels at each ultrasound scan from 24 weeks.
Numerator – the number of women in the denominator who received diagnostic monitoring for fetal weight discordance using 2 or more biometric parameters and amniotic fluid levels at each ultrasound scan from 24 weeks.
Denominator – the number of women with a dichorionic twin or trichorionic triplet pregnancy and a gestational age greater than 24 weeks.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place to ensure that women with a multiple pregnancy can be monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Healthcare practitioners ensure that women with a multiple pregnancy are monitored for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Commissioners ensure that they commission services that monitor women with a multiple pregnancy for fetal complications according to the chorionicity and amnionicity of their pregnancy.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) are monitored to check the babies for any complications (for example, to check the babies’ growth and blood flow) in a way that is appropriate for their pregnancy.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendations 1.4.18, 1.4.19, 1.4.22, 1.4.25 to 1.4.27, 1.4.31 and 1.4.35

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Fetal growth restriction
A difference in size of 25% or more between twins or triplets, known as fetal weight discordance, and an estimated fetal weight of any of the babies below the 10th centile for gestational age are clinically significant indicators of fetal growth restriction. The number of scans women receive to monitor for fetal growth restriction is determined by the amnionicity and chorionicity of the pregnancy and should follow the recommended schedule of specialist antenatal appointments, as detailed in the NICE guideline on twin and triplet pregnancy. The schedule of specialist appointments is also shown as part of the multiple pregnancy antenatal care proforma and care pathways produced by the Twins and Multiple Births Association.
[Adapted from NICE’s guideline on twin and triplet pregnancy, recommendation 1.4.23]
Fetal biometric parameters
Standard antenatal ultrasound measures to assess the growth and wellbeing of the fetus and monitor for fetal weight discordance, they include:
  • head circumference
  • abdominal circumference
  • femoral length.
[Expert opinion]
Feto-fetal transfusion syndrome
Feto-fetal transfusion syndrome occurs when blood moves from one baby to another. The baby that loses the blood is called the donor and the baby receiving the blood is called the recipient. Feto-fetal transfusion syndrome is a complication of monochorionic multiple pregnancies arising from shared placental circulation. It is also referred to as twin-to-twin transfusion syndrome in twin pregnancies.
[NICE’s guideline on twin and triplet pregnancy, terms used in this guideline]

Involving a consultant from a tertiary level fetal medicine centre

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

Rationale

Collaborative care between local services and tertiary level fetal medicine centres allows access to appropriate knowledge and expertise, and tertiary level neonatal and paediatric services when needed, while maintaining the focus on delivery of care locally.
A consultant from a tertiary level fetal medicine centre needs to be involved in some of the decisions about the care provided for women with a higher-risk multiple pregnancy, or if there are complications. It may be more suitable to involve the consultant in planning and managing care rather than referring a woman directly.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Data source: Local data collection.
Process
a) The proportion of women with a higher-risk multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a higher-risk multiple pregnancy.
Data source: Local data collection.
b) The proportion of women with a complicated multiple pregnancy who have a consultant from a tertiary level fetal medicine centre involved in their care.
Numerator – the number of women in the denominator who have a consultant from a tertiary level fetal medicine centre involved in their care.
Denominator – the number of women with a complicated multiple pregnancy.
Data source: Local data collection.
Outcome
Infant and maternal mortality and morbidity.
Data source: Local data collection. The Maternity Services Data Set collects data on neonatal death (global number 17209680). Mothers and babies: reducing risk through audits and confidential enquiries across the UK (MBRRACE-UK) collects data on: ‘all deaths of pregnant women and women up to one year following the end of the pregnancy’ and ‘neonatal deaths’.

What the quality statement means for different audiences

Service providers ensure that systems are in place to ensure women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Healthcare practitioners ensure that women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Commissioners ensure that they commission services for women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have an expert in fetal medicine involved in their care if their pregnancy is higher risk or if there are complications.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendation 1.7.1

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Tertiary level fetal medicine centre
A specialist regional (or supra-regional) fetal medicine centre that has a multidisciplinary team with the expertise and infrastructure to assess and manage complicated twin and triplet pregnancies. This includes providing complex fetal interventions or therapies, for example, fetoscopic laser ablation for feto-fetal transfusion syndrome; and selective termination of pregnancy using techniques such as fetoscopic cord occlusion or radiofrequency ablation.
[NICE’s guideline on twin and triplet pregnancy, terms used in this guideline]
Involving a consultant from a tertiary level fetal medicine centre
Involving a consultant from a tertiary level fetal medicine centre can either be through seeking an opinion and then recording the discussion in the woman’s notes, or referring a woman with a higher-risk or complicated multiple pregnancy to a tertiary level fetal medicine centre.
NICE’s guideline on twin and triplet pregnancy recommendation 1.7.1 advises the seeking of a consultant opinion from a tertiary level fetal medicine centre for higher-risk multiple pregnancies or complicated multiple pregnancies.
Higher-risk multiple pregnancies are defined as:
  • monochorionic monoamniotic twins
  • dichorionic diamniotic triplets.
  • monochorionic diamniotic triplets
  • monochorionic monoamniotic triplets.
Complicated multiple pregnancies are defined as those with:
  • fetal weight discordance (of 25% or more) and an estimated fetal weight 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 twin anaemia polycythaemia sequence.
[Adapted from NICE’s guideline on twin and triplet pregnancy, recommendation 1.7.1]

Equality and diversity considerations

The woman’s preferences should be taken into account when referring them for a consultant opinion at a tertiary level fetal medicine centre. An opinion may be sought from a consultant at a tertiary level fetal medicine centre if the centre is a long distance from the woman’s home and it is clinically appropriate to do so.
Care should be delivered locally where possible to minimise inconvenience and anxiety for women and their partners. But anxiety caused by travelling further for an appointment needs to be weighed against the anxiety of an unclear diagnosis or prognosis.
Women from some cultural backgrounds may prefer to have their antenatal examinations undertaken by female members of staff. NHS maternity services are organised so that such preferences can be accounted for and have arrangements in place for female chaperones if needed.

Advice and preparation for preterm birth

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.

Rationale

The multidisciplinary core team have expert knowledge in managing multiple pregnancies. Women with a multiple pregnancy are at increased risk of maternal and fetal complications in pregnancy and preterm birth. It is important that they are given advice on the possible risks, signs and symptoms of preterm labour so that they know what to expect and who to contact quickly if such symptoms arise. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Numerator – the number of women in the denominator who have had a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Denominator – the number of women with a multiple pregnancy that is greater than 24 weeks’ gestation.
Data source: Local data collection. NHS Maternity Statistics – 2010/2011:
  • ‘Complications during non-delivery obstetric episodes, 2010/11 (Table 24).
  • Singleton, twin and higher order multiple deliveries by gestation and birth status, 2010/11 (Table 26).’
Outcome
Levels of satisfaction with support and confidence to recognise the signs and symptoms of preterm labour.
Data source: Local data collection. Data will also be collected against NHS Outcomes Framework 2013/14: indicator 4.5 ‘Women’s experience of maternity services’.
The Care Quality Commission’s Maternity services survey 2018 collected data on singleton and multiple births and asked the questions ‘Thinking about your antenatal care, were you spoken to in a way that you could understand?’ and ‘Thinking about your antenatal care, were you involved enough in decisions about your care?’. The total number of respondents is also stated, although results are not broken down by singleton or multiple pregnancies.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Healthcare practitioners ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Commissioners ensure that they commission services in which women with a multiple pregnancy have a discussion by 24 weeks with one or more members of multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) discuss the risks and signs of an early (preterm) labour with one or more members of their healthcare team. The discussion should take place by 24 weeks of their pregnancy and also cover the possible problems associated with an early birth.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendations 1.3.5 and 1.9.3
The timeframe of ‘by 24 weeks’ is based on the multiple pregnancy antenatal care proforma and care pathways produced by the Twins and Multiple Births Association.

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Preterm labour
The risk of preterm birth is higher in multiple pregnancies. About 60 in 100 twin pregnancies are delivered by 37 weeks, and 75 in 100 triplet pregnancies are delivered by 35 weeks.
The benefits and risks of targeted corticosteroids for fetal lung maturation should be discussed when providing information about preterm labour.
The signs and symptoms of preterm labour include more frequent and regular contractions, ruptured membranes, unusual or severe backache or other pain.
The potential need for neonatal management and the role of neonatal networks, including the possibility of admission of babies to a neonatal unit after birth, should also be discussed. Where possible, staff from the neonatal unit should be involved in the discussion and women should be provided with appropriate information about the neonatal services.
[NICE’s guideline on twin and triplet pregnancy, recommendations 1.3.5 and 1.9.1 to 1.9.3]

Equality and diversity considerations

Information on the risks, signs and symptoms of preterm labour should be understood by all women so that they can feel fully informed. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).

Preparation for birth

This quality statement is taken from the multiple pregnancy: twin and triplet pregnancies quality standard. The quality standard defines clinical best practice for multiple pregnancy and should be read in full.

Quality statement

Women with a multiple pregnancy have a discussion by 28 weeks with one or more members of the multidisciplinary core team about the timing of birth and possible modes of delivery so that a birth plan can be agreed.

Rationale

Most women with multiple pregnancies deliver by 37 weeks either spontaneously or electively. This discussion should include the risks and benefits of different modes of birth and how they are managed to enable women to make an informed decision about their birth preference. Women should also be informed that a preterm birth is associated with an increased risk of admission to a neonatal unit.

Quality measures

Structure
Evidence of local arrangements to ensure that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 28 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Data source: Local data collection.
Process
The proportion of women with a multiple pregnancy who have a discussion with one or more members of the multidisciplinary core team by 28 weeks about the timing of birth and possible modes of delivery.
Numerator – the number of women in the denominator who have had a discussion with one or more members of the multidisciplinary core team by 28 weeks about the timing of birth and possible modes of delivery.
Denominator – the number of women with a multiple pregnancy of 28 weeks or more.
Data source: Local data collection.
Outcome
Women feel well informed and able to make decisions that reflect what is important to them about the options for delivery.
Data source: Local data collection. The Maternity Services Data Set collects data on delivery method (global number 2016160) and gestational age at birth (global number 17206120). Data will also be collected against NHS Outcomes Framework 2013/14: indicator 4.5 ‘Women’s experience of maternity services’.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a multiple pregnancy to have a discussion with one or more members of the multidisciplinary core team by 28 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Healthcare practitioners from the multidisciplinary core team ensure that the timing of birth and possible modes of delivery are discussed with women with a multiple pregnancy by 28 weeks so that a birth plan can be agreed.
Commissioners ensure that they commission services so that women with a multiple pregnancy have a discussion with one or more members of the multidisciplinary core team by 28 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed.
Women who are pregnant with twins or triplets (referred to as a multiple pregnancy) have a discussion with one or more members of their healthcare team about the timing of the birth and how they want their babies to be delivered. This discussion needs to take place by 28 weeks of their pregnancy and include agreement of their birth plan.

Source guidance

Twin and triplet pregnancy (2019) NICE guideline NG137, recommendation 1.8.2

Definitions of terms used in this quality statement

Multiple pregnancy
A multiple pregnancy is defined as a twin or triplet pregnancy.
[Expert opinion]
Multidisciplinary core team
A multidisciplinary core team of named specialists consists of specialist obstetricians, specialist midwives and ultrasonographers, all of whom have experience and knowledge of managing twin and triplet pregnancies.
A specialist obstetrician is an obstetrician with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
A specialist midwife is a midwife with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy.
An ultrasonographer is a healthcare professional with a postgraduate certificate in the performance and interpretation of obstetric ultrasound examinations.
[Adapted from NICE’s guideline on twin and triplet pregnancy, recommendations 1.3.1, 1.3.4, 1.3.5 and terms used in this guideline]

Equality and diversity considerations

Information on the timing of birth and possible modes of delivery should be understood by all women to enable them to make informed decisions. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities, and women who do not speak or read English).

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

This is a blood sampling process. It consists of a blood group and an antibody screen to determine the woman's blood group and whether she has atypical red cell antibodies in her blood. If atypical antibodies are present, the laboratory will do additional work to identify them. This will allow blood to be issued in an emergency very quickly.
Twin anaemia polycythaemia sequences is a complication affecting monochorionic twin or triplet pregnancies. It is a rare, chronic form of feto-fetal transfusion caused by the joining of fine blood vessels connecting the fetal circulations on the placenta. It presents when there are unequal blood counts between the twins in the womb. When TAPS occurs, the recipient twin is at risk for successively increasing blood count, called polycythaemia, and the donor twin for progressive blood loss, or anaemia. TAPS occurs without the differences in levels of amniotic fluids between the fetuses (polyhydramnios-oligohydramnios) that is usually seen in feto-fetal transfusion syndrome.
Explain sensitively the aims and possible outcomes of all screening and diagnostic tests to women with a twin or triplet pregnancy to minimise their anxiety.
Do not offer women with a twin or triplet pregnancy screening for fetal growth restriction or feto-fetal transfusion syndrome in the first trimester.

Glossary

(each baby has a separate placenta and amniotic sac)
(both babies share a placenta but have separate amniotic sacs)
(both babies share a placenta but have separate amniotic sacs)
(both babies share a placenta and amniotic sac)
(both babies share a placenta and amniotic sac)
(each baby has a separate placenta and amniotic sac)
(1 baby has a separate placenta and 2 of the babies share a placenta; all 3 babies have separate amniotic sacs)
(1 baby has a separate placenta and amniotic sac and 2 of the babies share a placenta and amniotic sac)
(all 3 babies share 1 placenta but each has its own amniotic sac)
(all 3 babies share 1 placenta. 1 baby has a separate amniotic sac and 2 babies share 1 sac)
(all 3 babies share 1 placenta. 1 baby has a separate amniotic sac and 2 babies share 1 sac)
(all 3 babies share a placenta and amniotic sac)
(a pregnancy in which any of the babies share a placenta and a chorionic (outer) membrane; this includes monochorionic twins and dichorionic and monochorionic triplets)
(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)
(in a vaginal birth, active management consists of 10 IU of oxytocin by intramuscular injection immediately after the birth of the last baby and before the cord is clamped and cut. In a caesarean section, it consists of 5 IU of oxytocin by intravenous injection immediately after the birth of the last baby and before the cord is clamped and cut)
(the number of amnions [inner membranes] that surround babies in a multiple pregnancy; pregnancies with 1 amnion [so that all babies share an amniotic sac] are described as monoamniotic; pregnancies with 2 amnions are diamniotic; and pregnancies with 3 amnions are triamniotic)
(the number of chorionic [outer] membranes that surround babies in a multiple pregnancy. If there is only 1 membrane, the pregnancy is described as monochorionic; if there are 2, the pregnancy is dichorionic; and if there are 3, the pregnancy is trichorionic; monochorionic twin pregnancies and monochorionic or dichorionic triplet pregnancies carry higher risks because babies share a placenta)
(occurs when blood moves from one baby to another: the baby that loses the blood is called the donor and the baby receiving the blood is called the recipient; feto-fetal transfusion syndrome is a complication of monochorionic multiple pregnancies arising from shared placental circulation; it is also referred to as twin-to-twin transfusion syndrome in twin pregnancies)
(an obstetrician with a special interest, experience and knowledge of managing multiple pregnancy, and who works regularly with women with a multiple pregnancy)
(obstetricians with a special interest, experience and knowledge of managing multiple pregnancy, and who work regularly with women with a multiple pregnancy)
(a specialist regional [or supra-regional] fetal medicine centre that has a multidisciplinary team with the expertise and infrastructure to assess and manage complicated twin and triplet pregnancies; this includes providing complex fetal interventions or therapies, for example, fetoscopic laser ablation for feto-fetal transfusion syndrome; and selective termination of pregnancy using techniques such as fetoscopic cord occlusion or radiofrequency ablation)
National Screening Committee
Fetal Anomaly Screening Programme
estimated fetal weight
deepest vertical pocket
middle cerebral artery peak systolic velocity
twin reverse arterial perfusion sequence
twin anaemia polycythaemia sequence
(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)

Paths in this pathway

Pathway created: November 2011 Last updated: September 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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