A University of Birmingham fetal medicine expert has helped to shape new advice from NICE on antenatal care for women pregnant with twins or triplets. Professor Mark Kilby says the new guideline, published today (September 28), charts the way forward for managing multiple pregnancy in the NHS.

The guideline says that women carrying twins or triplets should receive specialist care from an experienced multidisciplinary team to avoid higher than necessary rates of assisted birth and caesarean section, and so they receive appropriate neonatal risk assessment before birth. These women also need more monitoring and more frequent antenatal visits due to the higher risks which can be associated with twin and triplet pregnancies.

An increase in the number of women receiving specialist care for multiple pregnancies should also result in a lower number of preterm births and neonatal complications, resulting in potential cost savings for the NHS.

Current NHS antenatal care for women with a multiple pregnancy varies considerably, impacting on how a woman is cared for during her pregnancy and its outcome. This is the first time the National Institute for Health and Clinical Excellence (NICE) has published recommendations for health professionals on how antenatal services for women pregnant with twins or triplets can be improved.

Over the last thirty years, the number of multiple births has risen, mainly because of the introduction of assisted reproduction techniques including in vitro fertilisation [IVF]. Multiple births now account for 3% of live births.

Many women pregnant with twins or triplets will have an uncomplicated pregnancy which will result in a good outcome for both mother and babies. However it is well recognised that a multiple pregnancy does have higher risks compared with a singleton pregnancy. For the mother, there is an increased risk of miscarriage, anaemia, hypertension, vaginal bleeding, preterm delivery, and an assisted birth or caesarean. Risks to babies include low birth weight and prematurity which can result in admission to a neonatal intensive care unit, congenital malformations, cerebral palsy, and impaired physical and cognitive development. The stillbirth rate for twin births is also 2.5 times that for singleton births. It is therefore important for health professionals to be vigilant for complications to help manage these risks and provide the best possible outcome for mother and babies.

The NICE guideline recommends that a specialist team made up of obstetricians, midwives and ultrasonographers, with previous experience of caring for women with multiple pregnancies, should provide care for women with uncomplicated twin and triplet pregnancies. The core team should also offer women information and emotional support from first contact on topics such as the risks, symptoms and signs of preterm labour, and breastfeeding.

The importance of establishing the chorionicity of the babies (whether they share a placenta) for risk assessment is emphasized throughout the guideline. Babies who share a placenta are at higher risk of health problems such as feto-fetal transfusion syndrome, where two babies sharing a placenta receive an unequal amount of blood, and will require careful monitoring from a specialist team.

For that reason, NICE recommends women with twin and triplet pregnancies should be offered a first trimester ultrasound scan when crown-rump length[1] measures from 45mm to 84mm. This is the best time to determine if the babies do share a placenta and it is also useful for determining the risk of Down’s syndrome.

The guideline also includes an at-a-glance table which outlines the frequency and timing of antenatal care visits for women with multiple pregnancies, what should be done at each visit (that is, frequency of maternal blood pressure measurement, urinalysis and, most importantly, ultrasound scans), and what additional risk factors need to be monitored. This is the first time NICE has outlined what antenatal appointments women with a multiple pregnancy should receive.

Because there is a risk of going into labour early with a multiple pregnancy, women are currently sometimes advised to try bed rest or are offered cervical cerclage (a stitch to keep the cervix closed), intramuscular or vaginal progesterone or oral tocolytics (drugs to prevent labour). However, the new guidance recommends these should not be offered routinely as there is no evidence that these methods can prevent early labour.

To further reduce the variation within the NHS on timing of birth for a multiple pregnancy, the new NICE guideline also includes clear recommendations on when elective birth[2] should be offered to pregnant women expecting twins or triplets.

Women with uncomplicated monochorionic twin pregnancies (when the babies share a placenta) should be offered elective birth from 36 weeks, and women with dichorionic twin pregnancies (when each baby has a separate placenta) should be offered it from 37 weeks. This is because evidence suggests a higher fetal death rate in monochorionic twin pregnancies than in dichorionic twin pregnancies. For women with uncomplicated triplet pregnancies, evidence demonstrates elective birth should be offered from 35 weeks.

Mark Kilby, Guideline Development Group Chair and Professor of Fetal Medicine at the University of Birmingham and Birmingham Women’s Hospital, said: “This new evidence-based NICE guideline charts the way forward for managing twin and triplet pregnancies in the NHS.

“Evidence demonstrates more frequent contact with healthcare professionals and specialist care from an experienced multidisciplinary team can help reduce the risks for mother and babies. This is also the first time NICE has published clear recommendations to standardise the schedule for antenatal appointments, with modified protocols dependent upon pre-defined chorionicity, and provide clear guidance on when each visit should happen and what should be done.

“We discussed all the best available evidence when developing this guideline, and I am confident these recommendations will make a real difference to the management of twin and triplet pregnancies in England and Wales. If followed correctly, these new guidelines will result in fewer preterm births and neonatal complications, by providing mums-to-be with the highest quality of care.”

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE commented: “We know there is a real clinical need for this guideline because NHS antenatal care for women expecting twins or triplets appears to vary considerably across England and Wales. For example not all women with multiple pregnancies are cared for in dedicated settings such as `twin clinics’ or by multidisciplinary teams of healthcare professionals. This can lead to higher than necessary rates of assisted birth and caesarean sections and also means that women are not appropriately assessed for possible risks during pregnancy.

“Although many women will have a normal pregnancy and birth, it is well known that there are higher risks involved for these types of pregnancy and so it is important to get it right. This is the first time NICE has published recommendations for healthcare professionals on managing multiple pregnancy, based on the best available evidence.

“We hope this guideline will set the standard of high-quality care which should be provided to all women pregnant with twins or triplets. Implementing these clear recommendations will help women to feel supported and well looked after at a time when they can be feeling very anxious.”

Keith Reed, Chief Executive, Twins and Multiple Births Association (TAMBA) said:

“Tamba is delighted that NICE has published these important guidelines. Sadly the care some expectant multiple birth mothers currently receive does not meet their needs, occasionally with disastrous consequences. These guidelines will help ensure that clinical teams can focus on delivering evidence-based care whilst our families are better placed to know the standard of care they should be receiving.”

Jane Denton, Director of the Multiple Births Foundation said:

“The NICE Guideline on Multiple Pregnancy will transform the care for women expecting twins and triplets and is a significant milestone in the management of multiple pregnancies. The news of a twin or triplet pregnancy is often a great shock for parents and the risk of complications during the pregnancy and preterm birth, as well as the practical and financial implications for the family, can cause great anxiety.

“Although much of the care at present is very good, there are many inconsistencies and often poor co-ordination between healthcare professionals if mothers are referred to other hospitals.

“These recommendations address all of these concerns and will give mothers confidence that they are receiving the highest standard of care, appropriate to their individual needs. The Multiple Births Foundation welcomes the guideline and looks forward to supporting the full implementation of the recommendations.”

* Professor Kilby is available for telephone interview. To arrange please contact Jenni Ameghino, Press Office, University of Birmingham. 0121 415 8134. Mobile 07768 924156.

1. This guideline is available at www.nice.org.uk/CG129 from Wednesday 28 September 2011. Please contact the press office for embargoed copies.

2. It offers best practice advice on the management of twin and triplet pregnancies in the antenatal period. It does not look at women who are pregnant with four or more babies.

3. Over the last thirty years, the number of multiple births has risen mainly because of the introduction of assisted reproduction techniques including in vitro fertilisation [IVF]. In 2009, 16 women per 1000 giving birth in England and Wales had multiple births compared with 10 per 1,000 in 1980. Up to 24% of successful IVF procedures result in multiple pregnancies. Multiple births currently account for 3% of live births.

4. The overall stillbirth rate in multiple pregnancies is higher than in singleton pregnancies: in 2009 the stillbirth rate was 12.3 per 1,000 twin births and 31.1 per 1,000 triplet and higher-order multiple births, compared with 5 per 1,000 singleton births. The risk of preterm birth is also considerably higher in multiple pregnancies than in singleton pregnancies, occurring in 50% of twin pregnancies (10% of twin births take place before 32 weeks of gestation).

5. Duration of pregnancy becomes shorter with increasing numbers of fetuses. The higher incidence of preterm birth in multiple pregnancies is associated with an increased risk of neonatal mortality and long-term morbidity (especially neurodevelopmental disability and chronic lung disease). Prematurity accounts for 65% of neonatal deaths among multiple births, compared with 43% in singleton births. The significantly higher preterm delivery rates in twin and triplet pregnancies mean there is increased demand for neonatal intensive care resources.

6. Some risks to babies of multiple pregnancies are associated particularly with shared placentas. Feto-fetal transfusion syndrome (FFTS), most commonly occurring in twin pregnancies (where it is termed twin-to-twin transfusion syndrome; TTTS), is a condition associated with a shared placenta, affecting 15% of monochorionic pregnancies and accounting for about 20% of stillbirths in multiple pregnancies. A monochorionic pregnancy occurs when twins or triplets share a placenta. This complication (a shared placenta) may also occur in monochorionic and dichorionic triplet pregnancies. A monochorionic triplet pregnancy is when all three babies share a placenta; a dichorionic triplet pregnancy is when two of the three babies share a placenta and the third baby is separate. These are also associated with a significantly increased risk of neurodevelopmental morbidity.

7. Additional risks to the babies include intrauterine growth restriction (IUGR) and congenital abnormalities. In multiple pregnancies, 66% of unexplained stillbirths are associated with a birthweight of less than the tenth centile, compared with 39% for singleton births. Major congenital abnormalities are 4.9% more common in multiple pregnancies than in singleton pregnancies.


[1] Length from the top of the head to the bottom of the buttocks

[2] A birth that is planned, rather than occurring naturally

For more information contact:

Katie Williamson, NICE press office via 020 7045 2171 or katie.williamson@nice.org.uk.