Practice Guidelines

Antenatal care for twin and triplet pregnancies: summary of NICE guidance

BMJ 2011; 343 doi: (Published 28 September 2011) Cite this as: BMJ 2011;343:d5714
  1. Cristina Visintin, project manager1,
  2. Moira A Mugglestone, director of guideline development1,
  3. David James, clinical codirector1,
  4. Mark D Kilby, professor of fetal medicine and clinical lead in fetal medicine 23
  5. on behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA, UK
  2. 2University of Birmingham, Birmingham B15 2TT, UK
  3. 3Birmingham Women’s Foundation Trust, Birmingham B15 2TG
  1. Correspondence to: M A Mugglestone mmugglestone{at}

In the past 30 years the incidence of twin and triplet pregnancies has increased, mainly because of increasing use of assisted reproduction techniques, such as in vitro fertilisation. Multiple births currently account for 3% of live births in England and Wales.1 Twin and triplet pregnancies are associated with higher maternal and fetal mortality and morbidity than singleton pregnancies. Women with twin and triplet pregnancies therefore need more frequent contact with healthcare professionals and specialised care from a multidisciplinary team. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on antenatal care for women with twin and triplet pregnancies.2


NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Determining gestational age and chorionicity

  • Offer women with twin and triplet pregnancies an estimation of gestational age, determination of chorionicity (box), and screening for Down’s syndrome using first trimester ultrasonography when the “crown to rump” length (length from the top of the head to the bottom of the buttocks) measures from 45 mm to 84 mm (at about 11 weeks 0 days to 13 weeks 6 days). Ideally, these should all be performed at the same scan.

  • Screening for Down’s syndrome should involve nuchal translucency measurement and maternal biochemical testing in the first trimester. [Based on very low quality evidence from observational studies and on the experience and opinion of the Guideline Development Group (GDG)]

  • Determine chorionicity in twin and triplet pregnancies with ultrasonography using the number of placental masses, the “lambda” or the “T” sign (describing the appearance of the dividing membrane comprising one …

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