Consensus views arising from the 50th Study Group: Multiple Pregnancy
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Consensus expert views relating to clinical practice
- The risk of multiple pregnancy should be reduced by conservative use of ovarian stimulation with careful monitoring according to published guidelines (RCOG, 1999; NICE, 2004; Grade A).
- In view of the risks associated with multiple pregnancy, consideration should be given to transferring only a single embryo in women undergoing in vitro fertilisation (Grade A).
- In view of the changing effects of maternal age and fertility treatment on multiple pregnancy rates, there needs to be a mechanism for recording their impact on the rates of multiple pregnancy.
- Prepregnancy counselling regarding the risks of multiple pregnancy should be given to a woman undergoing fertility treatment (Grade C).
- Parents of high order multiple pregnancies (≥ 3) should be counselled and offered multifetal pregnancy reduction (MFPR) to twins in specialist centres (Grade B).
- Long-term neurodevelopmental follow-up studies are needed of survivors of multiple pregnancies who have undergone MFPR (Grade C).
- All women with a multiple pregnancy should be offered an ultrasound examination at 10–13weeks of gestation (Grade B) to assess:
- viability
- chorionicity
- major congenital malformation
- nuchal translucency for designation of risk of aneuploidy and twin-to-twin transfusion syndrome.
- All monochorionic twins should have a detailed ultrasound scan which includes extended views of the fetal heart (Grade B).
- Monochorionic twins require increased ultrasound surveillance from 16weeks of gestation onwards to detect twin-to-twin transfusion syndrome and growth discordance.This should be offered at an interval of 2 weeks (Grade C).
- Nuchal translucency based screening should be offered as the preferred method of aneuploidy screening in women with multiple pregnancy (Grade B).
- Monochorionic twins that are discordant for fetal anomaly must be referred at an early gestation for assessment and counselling in a regional fetal medicine centre (Grade B).
- Twins that are discordant for fetal anomaly should be managed in fetal medicine centres with specific expertise (Grade C).
- Hospitals should organise antenatal and postnatal care around specialist-led, multidisciplinary multiple pregnancy clinics (Grade C).
- The organisation of antenatal twin clinics should be facilitated by care pathways and allow referral to regional fetal medicine centres when appropriate (Grade C).
- The lead clinician for multiple pregnancy clinics should have expertise in ultrasound and in the intrapartum care of multiple pregnancies (Grade C).
- Twin-to-twin transfusion syndrome should be managed in conjunction with regional fetal medicine centres with recourse to specialist expertise (Grade C).
- Fetoscopic laser ablation is the treatment of choice in severe twin-to-twin transfusion syndrome presenting prior to 26weeks of gestation (Grade A).
- Single-twin demise in a monochorionic twin pregnancy should be referred and assessed in a regional fetal medicine centre (Grade B).
- The survivor after single-twin demise in monochorionic twins should have follow-up ultrasound and, if normal, an MRI examination of the fetal brain 2–3weeks after the co-twin death. Counselling should include the long-term morbidity in this condition (Grade C).
- Vaginal delivery of twins should be performed in a setting with continuous intrapartum monitoring, immediate recourse to caesarean section, appropriate analgesia and an obstetrician experienced in twin delivery (Grade B).
- In view of the increased risk of stillbirth in twin pregnancy, elective delivery is recommended between 37 and 38weeks of gestation (Grade C).
- Mothers with a multiple pregnancy have a need for specific information, including discussion of delivery and postnatal wellbeing, including breastfeeding (Grade C).
- The role of midwives and other healthcare specialists is integral to the management of multiple pregnancies within specialist clinics (Grade C).
- Additional support to women is available from TAMBA and the Multiple Births Foundation, and this should be encouraged (Grade C).
- There is a need to support women emotionally with multiple pregnancies (Grade A).
- There is a need to recognise early signs of perinatal psychological disturbance, which is increased after multiple births, and to offer treatment (Grade A).
Consensus expert views relating to future research
- The optimum method of delivery of twins at greater than 32weeks of gestation is unknown. Continuing research may inform this uncertainty.
- The optimum treatment of early-stage twin-to-twin transfusion syndrome is unclear.This needs to be informed by further research, preferably in the form of a randomised trial investigating conservative management, amnioreduction or laser ablation and their effects on disease progression.
- There is a need for further multicentre randomised controlled trials evaluating effectiveness and cost effectiveness of a single-embryo transfer policy in in vitro fertilisation.
- Further research is required to assess the outcome of the single surviving fetus in a monochorionic twin set where in utero therapy has been instigated.
- Because most epidemiological studies on cerebral palsy were performed before the impact of fertility treatment on multiple births, there is a need for updated surveys to establish the current prevalence of cerebral palsy following assisted conception.
- There is a need to understand mechanisms of prematurity in multiple pregnancies.
- There is a need to explore other interventions with the aim of reducing maternal psychological distress.
- Given the uncertainties about many interventions during multiple pregnancy, it is important to encourage clinical research aimed at improving pregnancy outcome.
Consensus expert views relating to health education/policy
- There is an urgent need for the establishment of a prospective registry of multiple pregnancies that relates chorionicity to outcome.
- A prospective cohort registry should evaluate the risks mediating neurological morbidity in multiple pregnancy.
- The UK regional congenital anomaly registers should collect information regarding plurality and chorionicity.
- The general health problems related to twinning should be brought more widely into the public domain.
- There is a need to enhance the provision of antenatal education for multiple pregnancies.This should facilitate realistic preparation for birth and parenting, and should aim to meet the needs of the father as well as the mother.
Key pre- and postnatal events to be offered in pregnancy
Dichorionic twins
- Multiples clinic: lead clinician with multidisciplinary team.
- Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy
- Structural anomaly scan at 20–22 weeks.
- Serial fetal growth scans e.g 24, 28, 32 and then two- to four-weekly.
- BP monitoring and urinalysis at 20, 24, 28 and then two-weekly.
- Discussion of woman’s/family needs relating to twins.
- 34–36 weeks: discussion of mode of delivery and intrapartum care.
- Elective delivery at 37–38 completed weeks.
- Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice
Monochorionic twins
- Multiples clinic: lead clinician with multidisciplinary team.
- Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy/TTTS
- Ultrasound surveillance for TTTS and discordant growth: at 16 weeks and then two-weekly.
- Structural anomaly scan at 20–22 weeks (including fetal ECHO).
- Fetal growth scans at two-weekly intervals until delivery.
- BP monitoring and urinalysis at 20, 24, 28 and then two-weekly.
- Discussion of woman’s/family needs relating to twins.
- 32–34 weeks: discussion of mode of delivery and intrapartum care.
- Elective delivery at 36–37 completed weeks (if uncomplicated).
- Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice.
