This document outlines protocols for managing multiple pregnancies, including twins and triplets. It discusses ultrasound monitoring schedules to assess chorionicity, growth, anatomy and complications. It recommends referral to specialist centers for complex or high-risk cases like monochorionic twins. Guidelines are provided for timing of delivery based on gestational age and chorionicity/amnionicity. Vaginal delivery is considered for uncomplicated dichorionic twins presenting vertex, while C-section is preferred for monochorionic twins. Postnatal support includes advice on breastfeeding and contraception.

1. Multiple Pregnancy:
protocol
RCOG, 2006
Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR

2. Dichorionic twins
Ultrasound
1. At 10–13 w:
(a) Viability
(b) Chorionicity: number of placental masses, the
lambda orT-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%
ABOUBAKR ELNASHAR

3. 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.
ABOUBAKR ELNASHAR

4. BP monitoring and urinalysis at 20, 24, 28 and
then two-weekly.
Treatment of co-twin death.
Expectant management .
Regular assessment of coagulation status
ABOUBAKR ELNASHAR

5. 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
ABOUBAKR ELNASHAR

6. 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
ABOUBAKR ELNASHAR

7. 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
ABOUBAKR ELNASHAR

8. 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.
ABOUBAKR ELNASHAR

9. 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.
ABOUBAKR ELNASHAR

10. 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.
ABOUBAKR ELNASHAR

11. 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
ABOUBAKR ELNASHAR

12. 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
ABOUBAKR ELNASHAR

13. BP monitoring and urinalysis at 20, 24, 28 and
then two-weekly.
ABOUBAKR ELNASHAR

14. 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.
ABOUBAKR ELNASHAR

15. ABOUBAKR ELNASHAR