Antenatal care for women with a multiple pregnancy

It is recommended that antenatal care to women with a multiple pregnancy should be provided in a dedicated service, whether it be in a clinic staffed by a dedicated multidisciplinary team or delivered by a core team in a specialized model.

Some previous (non-randomized) studies have showed that spe­cialist care might have an impact on some of the important outcomes including fewer women with pre- eclampsia, less preterm birth, fewer low birthweight babies, fewer perinatal deaths, less major neonatal morbidity, and lower infant mortality (103). A Cochrane review of only 162 women with a multiple pregnancy, however, did not show any significant difference in improving maternal and infant health outcomes in women seen in ‘specialized’ antenatal clinics com­pared with ‘standard’ antenatal care (13). A recent retrospective co­hort study in 286 women in a single centre showed lower caesarean section rates and fewer late preterm births, in women with antenatal care in a dedicated twins clinic compared to standard care (104).

The United Kingdom NICE guideline recommends that ‘clinical care for women with twin and triplet pregnancies should be provided by a nominated multidisciplinary team consisting of a core team of named specialist obstetricians, specialist midwives and ultrasonog- raphers, all of whom have experience and knowledge of managing twin and triplet pregnancies’ (11). NICE specifies a schedule of ap­pointments including timing of ultrasound scans depending on whether there are twin or triplets and based on chorionicity and amnionicity (Table 20.2). The guidance also covers recommended timing and place of delivery (11).

For higher-order multiple pregnancy, it is recommended that antenatal care should be delivered by fetal medicine specialists and should involve regular serial ultrasound but there is no published literature to guide this care and it would need to be individualized.

Nutritional supplements, diet, and lifestyle advice

A pregnant woman with a multiple pregnancy has a higher meta­bolic rate compared to a pregnant woman with a singleton preg­nancy. However, there are no randomized controlled trials to advise whether specific dietary advice is recommended for women with a multiple pregnancy (105). It needs to be emphasized that women with a multiple pregnancy have a higher incidence of anaemia and it is recommended checking the full blood count at 20-24 weeks’ ges­tation to identify women who may need iron and folic acid supple­mentation (11). There is no evidence to suggest any advice specific for multiple pregnancy in relation to lifestyle issues, for example, work patterns, sexual activity, and exercise.

Use of corticosteroids

It is well known that antenatal corticosteroids reduce neonatal com­plications in preterm babies. However, it is better to avoid untargeted routine single or multiple courses of steroids and to advocate tar­geted steroids when indicated, that is, when preterm labour or birth is imminent, and therefore to shift the focus towards informing all women with twin and triplet pregnancies of the increased risk of preterm birth and the benefits of targeted steroids, and provide in­formation about symptoms and signs to be aware of so that they can present in a timely manner (11).