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Cited by 645Assisted Reproductive Technology and Twin PregnancyPrenatal Screening and DiagnosticsMaternal and Perinatal Health Interventions

ISUOG Practice Guidelines: role of ultrasound in twin pregnancy

Khalil, A., Rodgers, M., Baschat, A., Bhide, A., Gratacos, E., Hecher, K., Kilby, M. D., Lewi, L. +8 more·2016·Ultrasound in Obstetrics & Gynecology
DOI 10.1002/uog.15821
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Abstract

The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) is a scientific organization that encourages sound clinical practice, and high-quality teaching and research related to diagnostic imaging in women's healthcare. The ISUOG Clinical Standards Committee (CSC) has a remit to develop Practice Guidelines and Consensus Statements as educational recommendations that provide healthcare practitioners with a consensus-based approach, from experts, for diagnostic imaging. They are intended to reflect what is considered by ISUOG to be the best practice at the time at which they are issued. Although ISUOG has made every effort to ensure that Guidelines are accurate when issued, neither the Society nor any of its employees or members accepts any liability for the consequences of any inaccurate or misleading data, opinions or statements issued by the CSC. The ISUOG CSC documents are not intended to establish a legal standard of care because interpretation of the evidence that underpins the Guidelines may be influenced by individual circumstances, local protocol and available resources. Approved Guidelines can be distributed freely with the permission of ISUOG ([email protected]). The incidence of multiple pregnancy is rising, mainly due to delayed childbirth and advanced maternal age at conception and the resultant widespread use of assisted reproduction techniques1. The twin birth rate increased by just under 70% between 1980 (19 per 1000 live births) and 2006 (32 per 1000 live births)2. Twin pregnancy is associated with a high risk of perinatal mortality and morbidity3-6. In 2009, the associated stillbirth rate was 12 per 1000 twin births and 31 per 1000 triplet and higher-order multiple births, compared with five per 1000 singleton births7, 8. Preterm birth prior to 37 weeks' gestation occurs in up to 60% of multiple pregnancies, contributing to the increased risk of neonatal mortality (65% of neonatal deaths among multiple births are preterm, compared with 43% of neonatal deaths in singletons) and long-term morbidity9-12. Of course, such complications rise with a reduction in gestational age at birth. In addition, compared with singletons, twins are at increased risk of iatrogenic preterm delivery due to the greater incidence of maternal and fetal complications. The risk is significantly higher in monochorionic compared with dichorionic pregnancy3-6. Ultrasound assessment of fetal biometry, anatomy, Doppler velocimetry and amniotic fluid volume is used to identify and monitor twin pregnancies at risk of adverse outcomes such as twin-to-twin transfusion syndrome (TTTS) and fetal growth restriction (FGR). As in singletons, impaired fetal growth can be assessed in twins by comparing biometry and Doppler velocimetry parameters against standards for uncomplicated pregnancy. This guidance will address the role of ultrasound in the care of uncomplicated twin pregnancy and those complicated by TTTS, selective FGR (sFGR), twin anemia–polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence, conjoined twins and single intrauterine death (IUD). The document provides guidance on the methods used to determine gestational age and chorionicity, screening for chromosomal and structural abnormalities, and screening for TTTS, TAPS, growth abnormalities and preterm birth. The management of higher-order multiple pregnancy will be covered in a separate document. The Cochrane Library and Cochrane Register of Controlled Trials were searched for relevant randomized controlled trials, systematic reviews and meta-analyses and a search of MEDLINE from 1966 to 2014 was carried out. The date of the last search was 15 November 2014. In addition, relevant conference proceedings and abstracts were searched. Databases were searched using the relevant MeSH terms including all sub-headings. This was combined with a keyword search using ‘twin’, ‘multiple’, ‘pregnancy’, ‘ultrasound’, ‘twin-to-twin transfusion syndrome’, ‘fetal growth restriction’, ‘twin anemia polycythemia sequence’, ‘twin reversed arterial perfusion’, ‘acardiac twin’, ‘monochorionic monoamniotic’, ‘conjoined’, ‘demise’. The National Library for Health and the National Guidelines Clearing House were also searched for relevant guidelines and reviews. Gray (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections and clinical trial registries. The search was limited to the English language. When possible, recommendations are based on, and explicitly linked to, the evidence that supports them, while areas lacking evidence are annotated as ‘good practice points’. Details of the grades of recommendations and levels of evidence used in these Guidelines are given in Appendix 1. Other studies have recommended the use of the smaller CRL or the mean CRL, which takes into account both fetuses13-15. The disadvantage of

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Authors
Khalil, A., Rodgers, M., Baschat, A., Bhide, A., Gratacos, E., Hecher, K., Kilby, M. D., Lewi, L., Nicolaides, K. H., Oepkes, D., Raine‐Fenning, N., Reed, K., Salomon, L. J., Sotiriadis, A., Thilaganathan, B., & Ville, Y.
Affiliations
  • St George's Hospital (GB)
  • Johns Hopkins University (US)
  • University Medical Center Hamburg-Eppendorf (DE)
  • Birmingham Women’s and Children’s NHS Foundation Trust (GB)
  • Universitair Ziekenhuis Leuven (BE)
  • Harris Birthright Research Centre for Fetal Medicine (GB)
  • Leiden University Medical Center (NL)
  • University of Nottingham (GB)
  • Tamba (GB)
  • Hôpital Necker-Enfants Malades (FR)
  • Aristotle University of Thessaloniki (GR)
Corresponding author
Khalil, A.
ORCID
Venue
Ultrasound in Obstetrics & Gynecology
Publisher
Wiley
Published
2016-02
Volume
47
Issue
2
Pages
247-263
ISSN
  • 0960-7692 (ISSN-L)
  • 1469-0705
DOI
10.1002/uog.15821
OpenAlex
W2206449147
Cited by
645
References
134
Citations by year
2026: 44 · 2025: 58 · 2024: 66 · 2023: 99 · 2022: 77 · 2021: 96 · 2020: 96 · 2019: 32 · 2018: 42 · 2017: 17 · 2016: 14 · 2014: 1
FWCI
24.23
Type
journal article
Language
en
Update notices
erratum (2018-07-04)
Open access
closed
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor, 1 d)
Locations
  • Ultrasound in Obstetrics and Gynecology (publishedVersion)
  • PubMed (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • Leiden Repository (Leiden University) (submittedVersion)
  • University of Birmingham Research Portal (University of Birmingham) (submittedVersion)
Topics
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Assisted Reproductive Technology and Twin Pregnancy
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Prenatal Screening and Diagnostics
  • Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
Keywords
twin pregnancy, prenatal ultrasound, multiple pregnancy, monochorionic twins, dichorionic twins, fetal biometry, fetal anatomy, Doppler velocimetry, amniotic fluid volume, fetal growth restriction, macrosomia, preterm birth, stillbirth, perinatal mortality, assisted reproduction, fetal heart rate monitoring
MeSH terms
Chorion, Female, Fetal Diseases, Fetal Growth Retardation, Gestational Age, Humans, Pregnancy, Pregnancy Complications, Risk Factors, Ultrasonography, Prenatal, Premature Birth, Pregnancy, Twin

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