Multiple Pregnancy

1. Multiple Pregnancy Implementing NICE guidance September 2011 NICE clinical guideline 129

2. What this presentation covers • Epidemiology • Definitions • Scope • Key priorities for implementation • Costs and savings • Discussion • NICE pathway • NHS Evidence • Find out more

3. Epidemiology • Multiple births currently account for 3% of live births • In 2009, 16 women per 1000 giving birth in England and Wales had multiple births compared with 10 per 1000 in 1980 • Maternal mortality associated with multiple births is 2.5 times that for single births • Stillbirths and pre-term births are more common in twins and triplets than in singletons

4. Definitions: Key terms • Chorionicity • Amnionicity

5. Scope • The guideline covers antenatal care for twin and triplet pregnancies and timing of birth but does not cover mode of delivery. • The guideline should be read in conjunction with ‘Antenatal Care’ (NICE clinical guideline 62).

6. Key priorities for implementation The areas identified as key priorities are: • Determining gestational age and chorionicity • Specialist care • Monitoring for intrauterine growth restriction • Indications for referral to a tertiary level fetal medicine centre • Timing of birth

7. Determining gestational age and chorionicity • An ultrasound scan should be offered when crown–rump length measures from 45 mm to 84 mm to: • Estimate gestational age • Screen for Down’s syndrome • Determine chorionicity • Assign nomenclature to fetuses to ensure consistency throughout pregnancy a: the lambda sign b: the T-sign Images reproduced with kind permission of: Centre for Fetal Care, Queen Charlotte’s & Chelsea Hospital, Imperial College Healthcare NHS Trust

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

9. Specialist care • Clinical care for women with twin and triplet pregnancies should be provided by a nominated multidisciplinary team consisting of: • a core team of named specialist obstetricians, specialist midwives and ultrasonographers with experience of managing multiple pregnancies • an enhanced team for referrals who have experience and knowledge relevant to multiple pregnancies

10. Specialist care • 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

11. Specialist care • At first contact provide information and emotional support specific to twin and triplet pregnancy • Provide ongoing opportunities for further discussion and advice including: • antenatal and postnatal mental health and wellbeing • antenatal nutrition • risks, symptoms and signs of preterm labour • potential need for corticosteroids • likely timing and possible modes of delivery • breastfeeding • parenting

12. Monitoring for intrauterine growth restriction • Estimate fetal weight discordance using two or more biometric parameters at each ultrasound scan from 20 weeks. • Aim to undertake scans at intervals of less than 28 days. • A 25% or greater difference in size between twins or triplets should be considered as a clinically important indicator of intrauterine growth restriction

13. Monitoring for intrauterine growth restriction For twin and triplet pregnancies: • Do not use abdominal palpation or symphysis-fundal height measurements to predict intrauterine growth restriction • Do not use umbilical artery Doppler ultrasound to screen for intrauterine growth restriction or birthweight differences

14. Indications for referral to a tertiary level fetal medicine centre • Seek a consultant opinion from a tertiary level fetal medicine centre for: • monochorionic monoamniotic twin or triplet pregnancies • monochorionic diamniotic triplet pregnancies • dichorionic diamniotic triplet pregnancies • pregnancies complicated by discordant fetal growth, fetal anomaly, discordant fetal death or feto-fetal transfusion syndrome

15. Timing of birth • *after a course of corticosteroids has been offered

16. Costs and savings • Costs and savings will vary on a local level, and according to local need • Where existing resources can be reallocated to meet the recommendations, no additional cost is expected • Training may be necessary to improve specialist knowledge of the core team • Improved clinical outcomes, arising from specialised care, may result in potential savings and enhanced patient experience

17. Discussion • What information and support do we provide for women with a multiple pregnancy? • What information do we currently give women regarding nutrition? • How can we support continuity of care? • What are the training implications for staff to support implementation of this guideline?

18. NICE Pathway Click here to go to NICE Pathways website

19. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of maternity care. Click here to go to the NHS Evidence website

20. Find out more • Visit www.nice.org.uk/guidance/CG129 for: • the guideline • the NICE pathway • ‘Understanding NICE guidance’ • costing report and template • audit support • implementation advice

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