NICE consults on draft antenatal care guideline for women pregnant with twins or triplets

The National Institute for Health and Care Excellence (NICE) is today (9 February) opening a consultation to address the antenatal care needs of women in England and Wales who are pregnant with twins or triplets. Multiple pregnancies carry a higher risk of numerous health-related complications for both the mother and her babies and, with the number of multiple births in England and Wales increasing steadily over the last 30 years[1], there is increasing pressure for maternity services to provide timely, efficient and effective care.

NICE is developing a clinical guideline to help the whole of the NHS in England and Wales provide high-quality antenatal care for women pregnant with twins or triplets. As part of this process, NICE is asking organisations with a registered interest in this guideline to comment on the document's proposed content. This consultation will run for eight weeks.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: “Multiple pregnancies are associated with higher rates of miscarriage, stillbirth and premature birth. These women are also at increased risk of developing a hypertensive disorder like pre-eclampsia, or having a haemorrhage or postnatal illness, while their babies are more likely to develop congenital abnormalities such as Down's syndrome or cerebral palsy. Because of the increased likelihood of complications, pregnant women carrying multiple babies need closer monitoring by healthcare professionals and, in some cases, specialist care.

“Access to specialist care for women and their babies can vary across the country, which is why we are encouraging organisations to register as stakeholders and provide helpful feedback on this draft guideline during this consultation period. We want to do all we can to ensure this guideline will enable all women who are expecting twins or triplets to receive high-quality, consistent care regardless of where they live.”

This draft guideline looks at a wide range of issues relating to the antenatal care of women carrying twins or triplets such as general care and information, determining gestational age, providing care in specialist settings, screening for fetal complications and timing of birth. Recommendations on which NICE is asking organisations to comment include:

  • Determining the chorionicity[2]of the pregnancy (whether the babies share a placenta) at the time of diagnosis of twin and triplet pregnancies by ultrasound using the number of placental masses and the presence of a Lambda[3]or T-sign[4].
  • Providing regular training so that ultrasonographers can identify the presence of a Lambda or T-sign accurately and confidently.
  • Clinical care for women with twin and triplet pregnancies should be provided by a nominated multidisciplinary specialist team. The core team should comprise named specialist obstetricians, midwives and ultrasonographers with experience and knowledge of managing twin and triplet pregnancies.
  • Estimating fetal weight discordance based on two or more biometric parameters at each ultrasound scan from 20 weeks. Do not undertake scans more than 28 days apart. A 25% or greater difference between twins or triplets should be regarded as a clinically significant indicator of intrauterine growth restriction.
  • Seeking a consultant opinion from a tertiary level fetal medicine centre for monochorionic monoamniotic twin pregnancies (where each baby has its own placenta and sac of amniotic fluid), monochorionic monoamniotic, monochorionic triamniotic (where triplets all share the same placenta but have separate sacs of amniotic fluid) and dichorionic monoamniotic triplet pregnancies (where two of the babies share one placenta and all three share amniotic fluid), and for pregnancies complicated by any of the following:
    • discordant fetal growth
    • fetal anomaly
    • discordant fetal death
    • feto-fetal transfusion syndrome[5].

Stakeholders have until 6 April 2011 to comment on the recommendations in the draft guideline. Organisations can register as stakeholders at any time during the development of the guideline and comments must be submitted via the NICE website; Until the final guideline is published, recommendations could change depending on feedback received during the development of this guideline.


Notes to Editors

  • Read the draft guideline on multiple pregnancy (from Wednesday 9 February 2011)
  • This draft guideline follows a series of documents published by NICE last year that aim to reduce complications in pregnancy. These include guidelines for healthcare professionals on caring for pregnant women with complex social factors, preventing, diagnosing and managing hypertension (high blood pressure) in pregnancy and public health guidance on quitting smoking in pregnancy and following childbirth and also weight management before, during and after pregnancy. These are all available to download from the NICE website at

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.



[2] Chorionicity refers to whether or not the babies share one placenta while in the womb. In twin and triplet pregnancies, the babies will either be ‘trichorionic' (when triplets each have separate placentas), ‘dichorionic' (two babies have separate placentas), or ‘monochorionic', which is when all babies share one placenta.

[3] If the babies have separate placentas, the membranes separating them are normally easy to see, making it obvious that there is more than one placenta. Sometimes, the placentas can be close together and it may look like there is only one. In these cases, ultrasonographers should look for a ‘lambda' - a triangular shape where the membranes meet the two placentas.

[4] When babies share a placenta, there will be a ‘T-sign' where the membranes meet the single shared placenta. This is shaped like a ‘T' hence the name.

[5] Feto-fetal transfusion syndrome mainly occurs when multiple babies share one placenta. In twins, it is also called twin-to-twin syndrome. It involves one baby drawing blood directly from another in order to grow. Around one in five stillbirths in multiple pregnancies is due to this condition.

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This page was last updated: 08 February 2011

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.

Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.