We will plan an update of the following sections of the guideline:
An extension to the scope will be needed to incorporate intrapartum care.
We will amend the guideline in the following clinical area:
When and how should screening be used to identify chromosomal abnormalities in multiple pregnancy?
The proposed amendment is to cross refer to National Screening Committee (NSC) recommendations on cfDNA screening.
We found 122 new studies through surveillance of this guideline. New evidence that could affect recommendations was identified. Topic experts, including those who helped to develop the guideline, advised us about whether the following sections of the guideline should be updated and any new sections added:
When and how should screening be used to identify feto-fetal transfusion syndrome (FFTS) in multiple pregnancy?
Topic experts advised that the update of this question needs to be considered with the review question: What is the optimal screening programme to detect intrauterine growth restriction in multiple pregnancies?
Topic experts recommended that this question should be updated to consider monitoring for FFTS beyond the 24 weeks recommended by NICE guideline CG129 in monochorionic pregnancies. NICE guideline CG129 differs from the RCOG Green Top Guideline 51 (2016) 'Management of monochorionic twin pregnancy' which recommends ultrasound surveillance from 16 weeks until delivery at two weekly intervals.
Further expert advice indicated that detection of twin anaemia polycythemia sequence (TAPS) is too specialised for inclusion in the scope of this guideline and should not be covered in the update.
Decision: This question should be updated.
What is the optimal screening programme to detect intrauterine growth restriction in multiple pregnancies?
Topic experts advised that the update of this question needs to be considered with the review question:
When and how should screening be used to identify FFTS in multiple pregnancy?
Topic experts advised a review of the recommended threshold of estimated fetal weight (EFW) discordance. In the updated RCOG Green Top Guideline a new EFW discordance threshold of 20% has been advised for monochorionic pregnancies. There is therefore a potential impact on NICE guideline CG129, to review the currently recommended threshold of 25%.
Topic expert feedback and new evidence indicated the need to review the recommended frequency of ultrasound surveillance for growth restriction. NICE guideline CG129 recommends aiming to undertake ultrasound scans at intervals of less than 28 days to estimate fetal weight discordance. It was considered possible to split out recommendations to the different types of multiple pregnancies (monochorionic, dichorionic and trichorionic) for ultrasound surveillance.
Topic experts also indicated that there is insufficient evidence to include the use of growth charts for twins in the guideline, and it was agreed that these should be excluded from the current update.
Decision: This question should be updated.
Predicting the risk of preterm birth: What is the optimal screening programme to predict the risks of spontaneous preterm delivery?
Topic experts advised that abdominal circumference will not predict spontaneous preterm birth. The evidence on measuring abdominal circumference is therefore unlikely to impact on the review question for spontaneous preterm delivery.
Decision: This question should not be updated.
NICE guideline CG129 does not include recommendations on intrapartum care because this area was not included in the original guideline scope.
Topic experts advised that a significant proportion of multiple pregnancy losses occur intrapartum and cited evidence that the risk of adverse perinatal outcomes is greater than in singleton pregnancies. Therefore this area was recommended for inclusion in an update of the guideline.
Although new guidance is being developed by NICE on high risk intrapartum care, it was decided during scoping for this guideline that this will not cover multiple pregnancy. It was proposed that intrapartum care should be incorporated into the scope of NICE guideline CG129 at its next update. This is potentially a large piece of work, and a scoping exercise will be needed to establish:
areas of intrapartum care specific to multiple pregnancies
recommendations from related guidelines to be considered in the update for potential cross referral or incorporation in NICE guideline CG129.
Decision: This area should be included.
Interventions for FFTS
Topic experts advised that interventions for FFTS and TAPS are specialist areas with little variation in the small number of centres that provide treatment. Topic experts did not feel it was necessary to extend the scope to include interventions for FFTS in an update of NICE guideline CG129.
Decision: This review question should not be included.
We also found new evidence that was not thought to have an effect on current recommendations. This evidence related to determining gestational age and chorionicity, general care, maternal complications, indications for referral to a tertiary level fetal medicine centre, and timing of birth.
After considering all the new evidence and views of topic experts, we decided that a partial update with modified scope is necessary for this guideline.
See how we made the decision for further information.
This page was last updated: 09 January 2017