INTERIM UPDATE

ACOG PRACTICE BULLETIN SUMMARY

Clinical Management Guidelines for Obstetrician–Gynecologists
NUMBER 231 (Replaces Practice Bulletin Number 169, October 2016)

For a comprehensive overview of these recommendations, the full-text Scan this QR code
version of this Practice Bulletin is available at 10.1097/ with your smartphone
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Practice Bulletin.

Committee on Practice Bulletins—Obstetrics and the Society for Maternal-Fetal Medicine. This Practice Bulletin was developed
by the Committee on Practice Bulletins—Obstetrics and the Society for Maternal-Fetal Medicine with the assistance of Edward J.
Hayes, MD, MSCP.

INTERIM UPDATE: The content in this Practice Bulletin has been updated as highlighted (or removed as necessary) to reflect
a limited, focused change to align with ACOG Committee Opinion 828, Indications for Outpatient Antenatal Fetal Surveil-
lance, and to provide additional information on screening for fetal chromosomal abnormalities in a multifetal gestation.

Multifetal Gestations: Twin, Triplet, and

Higher-Order Multifetal Pregnancies
The incidence of multifetal gestations in the United States has increased dramatically over the past several decades.
For example, the rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (1).
However, after more than three decades of increases, the twin birth rate declined 4% during 2014–2018 to 32.6 twins
per 1,000 total births in 2018 (2). The rate of triplet and higher-order multifetal gestations increased more than 400%
during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per
100,000 births by 2009 (3). The triplet and higher-order multiple birth rate was 93.0 per 100,000 births for 2018, an
8% decline from 2017 (101.6) and a 52% decline from the 1998 peak (193.5) (4). The long term changes in the
incidence of multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at
conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted
reproductive technology (ART), which is more likely to result in a multifetal gestation (5).
A number of perinatal complications are increased with multiple gestations, including fetal anomalies, preeclamp-
sia, and gestational diabetes. One of the most consequential complications encountered with multifetal gestations is
preterm birth and the resultant infant morbidity and mortality. Although multiple interventions have been evaluated in
the hope of prolonging these gestations and improving outcomes, none has had a substantial effect. The purpose of this
document is to review the issues and complications associated with twin, triplet, and higher-order multifetal gestations
and present an evidence-based approach to management.

Clinical Management Questions

< How is chorionicity determined?
< Can adjunctive tests be used to predict spontaneous preterm birth in women with multifetal gestations?

1140 VOL. 137, NO. 6, JUNE 2021 OBSTETRICS & GYNECOLOGY

© 2021 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
< Are there routine prophylactic interventions that can prolong pregnancy in women with multifetal
gestations?
< Does progesterone treatment decrease the risk of preterm birth in women with multifetal gestations?
< How is preterm labor managed in women with multifetal gestations?
< How is prenatal screening for fetal chromosomal abnormalities in women with multifetal gestations
different than for singleton pregnancies?
< What issues arise in prenatal diagnosis of fetal chromosomal abnormalities in women with multifetal
gestations?
< Are multifetal gestations with discordant fetal growth at risk of adverse outcomes?
< How is the death of one fetus managed?
< What is the role of antepartum fetal surveillance in dichorionic pregnancies?
< How are the complications caused by monochorionic placentation managed?
< Are there special considerations for timing and route of delivery in women with multifetal gestations?

Recommendations < The chorionicity of a multifetal pregnancy should be

established as early in pregnancy as possible, and the
and Conclusions optimal timing for determination of chorionicity by
ultrasonography is in the first trimester or early sec-
The following recommendations and conclusions are ond trimester.
based on good and consistent scientific evidence (Level A):
< Routine prophylactic interventions including cerc-
< There is no role for the prophylactic use of any to- lage, hospitalization, bedrest, tocolytics, and pes-
colytic agent in women with multifetal gestations, sary have not been proved to decrease neonatal
including the prolonged use of betamimetics for this morbidity or mortality, and therefore should not be
indication. used based solely on the indication of multifetal
< Progesterone treatment does not reduce the incidence gestation.
of spontaneous preterm birth in unselected women < Unless a contraindication exists, a course of antenatal
with twin or triplet gestations and, therefore, is not corticosteroids should be administered to all patients
recommended. who are at risk of delivery within 7 days and who are
< Serial ultrasonographic evaluation is recommended between 24 weeks and 34 weeks of gestation, irre-
approximately every 2 weeks beginning at approxi- spective of the fetal number.
mately 16 weeks of gestation in monochorionic ges- < Magnesium sulfate reduces the severity and risk of
tations to monitor for twin-to-twin transfusion cerebral palsy in surviving infants if administered
syndrome. when birth is anticipated before 32 weeks of gesta-
The following recommendations and conclusions are tion, regardless of fetal number.
based on limited or inconsistent scientific evidence < Women with one previous low transverse cesarean
(Level B): delivery, who are otherwise appropriate candidates
for twin vaginal delivery, may be considered candi-
< Women who underwent pregnancy reduction from dates for trial of labor after cesarean delivery.
triplets to twins, as compared with those who con-
The following recommendations and conclusions
tinued with triplets, were observed to have lower
are based primarily on consensus and expert opinion
frequencies of pregnancy loss, antenatal complica-
(Level C):
tions, preterm birth, low-birth-weight infants, cesar-
ean delivery, and neonatal deaths, with rates similar < All women with multifetal gestations, regardless of
to those observed in women with spontaneously age, are candidates for routine screening for fetal
conceived twin gestations. chromosomal abnormalities.

VOL. 137, NO. 6, JUNE 2021 Practice Bulletin No. 231 Summary 1141

© 2021 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
< The optimal gestational age for initiation of surveillance 3. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Kir-
in pregnant individuals with uncomplicated dichorionic meyer S, Mathews TJ, et al. Births: final data for 2009.
Natl Vital Rep 2011;60:1–70. (Level II-3)
twins is not known. However, for patients with uncom-
plicated dichorionic twin pregnancies, weekly antenatal 4. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK.
fetal surveillance may be considered at 36 0/7 weeks of Births: final data for 2018. Natl Vital Stat Rep 2019;
gestation. 68(13):1-47. (Level II-3)
5. Blondel B, Kaminski M. Trends in the occurrence, deter-
< For patients with a dichorionic twin pregnancy com- minants, and consequences of multiple births. Semin Peri-
plicated by maternal or fetal disorders such as fetal natol 2002;26:239–49. (Level III)
growth restriction, antenatal fetal surveillance should
be individualized and may be considered upon
diagnosis, or at a gestational age after which delivery
would be considered for abnormal testing.
< Women with uncomplicated monochorionic– Studies were reviewed and evaluated for quality
monoamniotic twin gestations can undergo delivery according to the method outlined by the U.S.
at 32 0/7–34 0/7 weeks of gestation. Preventive Services Task Force. Based on the highest
level of evidence found in the data, recommendations are
< Women with monoamniotic twin gestations should be provided and graded according to the following
delivered by cesarean birth to avoid an umbilical cord categories:
complication of the non-presenting twin at the time of Level A—Recommendations are based on good and
the initial twin’s delivery. consistent scientific evidence.
< In diamniotic twin pregnancies at 32 0/7 weeks of ges- Level B—Recommendations are based on limited or
tation or later with a presenting fetus that is vertex, inconsistent scientific evidence.
regardless of the presentation of the second twin, vaginal Level C—Recommendations are based primarily on
delivery is a reasonable option and should be considered, consensus and expert opinion.
provided that an obstetrician with experience in manag-
ing a nonvertex presenting second twin is available. Full-text document published online on May 20, 2021.
< The administration of neuraxial analgesia in women Copyright 2021 by the American College of Obstetricians and
with multifetal gestations facilitates operative vaginal Gynecologists. All rights reserved. No part of this publication
delivery, external or internal cephalic version, and may be reproduced, stored in a retrieval system, posted on the
total breech extraction. internet, or transmitted, in any form or by any means, elec-
tronic, mechanical, photocopying, recording, or otherwise,
without prior written permission from the publisher.
References American College of Obstetricians and Gynecologists
1. Martin JA, Hamilton BE, Osterman MJ. Three decades of 409 12th Street SW, Washington, DC 20024-2188
twin births in the United States, 1980-2009. NCHS Data Official Citation
Brief 2012;(80):1–8. (Level II-3) Multifetal gestations: twin, triplet, and higher-order multifetal
2. Martin JA, Osterman MJ. Is twin childbearing on the pregnancies. ACOG Practice Bulletin No. 231. American
decline? Twin births in the United States, 2014-2018. College of Obstetricians and Gynecologists. Obstet Gynecol
NCHS Data Brief 2019;(351):1–8. (Level II-3) 2021;137:e145–62.

1142 Practice Bulletin No. 231 Summary OBSTETRICS & GYNECOLOGY

© 2021 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use
of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of
care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the
treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such
course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or
technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its
publications may not reflect the most recent evidence. Any updates to this document can be found on acog.org or by calling
the ACOG Resource Center.
While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any
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content of this published product.

VOL. 137, NO. 6, JUNE 2021 Practice Bulletin No. 231 Summary 1143

© 2021 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.