Multiple Pregnancy: protocol RCOG, 2006

Aboubakr Elnashar Benha University Hospital, Egypt

ABOUBAKR ELNASHAR

Dichorionic twins

Ultrasound

1. At 10–13 w:

(a) Viability (b) Chorionicity: number of placental masses, the

lambda or T-sign and membrane thickness, discordant fetal sex.

(c) NT: method of choice for aneuploidy screening

2. Cervical length measurement may be useful in

predicting PTL:

25 mm at 23 w predicts about 80% of women who

deliver spontaneously at <30 w, with a false positive

rate 11%

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3. Structural anomaly scan at 20–22 w.

4. Ultrasound

/4 w from 20 w in DC twins and

/2 w from 16 w in MC twins.

5. Serial fetal growth scans

e.g 24, 28, 32 and then two- to four-weekly:

Twins that are wt discordant: using two or more biometric

parameters at each ultrasound scan. a 25% or greater

difference in size between twins or triplets as a clinically

important indicator of intrauterine growth restriction

or fetal anomaly should be managed in fetal

medicine centres with specific expertise.

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BP monitoring and urinalysis at 20, 24, 28 and

then two-weekly.

Treatment of co-twin death.

Expectant management .

Regular assessment of coagulation status

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The mode of delivery

1. At 34–36 w: discussion of mode of delivery and

intrapartum care.

2. Prerequisites for vaginal delivery

continuous intrapartum monitoring

appropriate analgesia

an obstetrician experienced in twin delivery

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3. Presentation of the first twin.

A. Vertex-vertex: Vaginal delivery .

B. 2nd non-vertex: The optimal mode is unknown

with retrospective reviews providing support for

both CS and vaginal birth

4. Very low birth weight infant (1500 g): CS

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Time of delivery:

Elective delivery at 37–38 completed weeks.

Postnatal advice and support (hospital- and

community-based) to include breast feeding and

contraceptive advice

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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 pregnancies

monochorionic monoamniotic triplet pregnancies

monochorionic diamniotic triplet pregnancies

dichorionic diamniotic triplet pregnancies

pregnancies complicated by any of the following:

discordant fetal growth

fetal anomaly

discordant fetal death

feto-fetal transfusion syndrome.

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Timing of birth

Offer women with uncomplicated:

monochorionic twin pregnancies elective birth[2]

from 36 weeks 0 days, after a course

of antenatal corticosteroids has been offered

dichorionic twin pregnancies elective birth[2] from

37 weeks 0 days

triplet pregnancies elective birth[2]from 35 weeks

0 days, after a course of antenatal

corticosteroids has been offered.

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Monochorionic twins

Ultrasound

1. At 10–13 weeks:

(a) Viability

(b) Chorionicity

(c) NT: aneuploidy/TTTS

2. Ultrasound surveillance for TTTS and discordant

growth: at 16 weeks and then two-weekly.

3. Structural anomaly scan at 20–22 weeks

(including fetal ECHO).

4. Fetal growth scans at two-weekly intervals until

delivery.

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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

Twin-to-twin transfusion syndrome should be

managed in conjunction with regional fetal medicine

centres with recourse to specialist expertise

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Single-twin demise in a monochorionic twin

pregnancy should be referred and assessed in a

regional fetal medicine centre

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

Delivery at 34 W

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BP monitoring and urinalysis at 20, 24, 28 and

then two-weekly.

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Delivery

1. At 32–34 weeks: discussion of mode of delivery

and intrapartum care.

2. For MCMA twins, delivery should be around 32

weeks by caesarean section

3. Elective delivery at 36–37 completed weeks (if

uncomplicated).

Postnatal advice and support (hospital- and

community-based) to include breastfeeding and

contraceptive advice.

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