National and international guidelines on the management of twin pregnancies: a comparative review

Omer Weitzner, Jon Barrett, Kellie E. Murphy, John Kingdom, Amir Aviram, Elad Mei-Dan, Liran Hiersch, Greg Ryan, Tim Van Mieghem, Nimrah Abbasi, Nathan S. Fox, Andrei Rebarber, Vincenzo Berghella, Nir Melamed

Research output: Contribution to journalReview articlepeer-review

1 Scopus citations


Twin gestations are associated with increased risk of pregnancy complications. However, high-quality evidence regarding the management of twin pregnancies is limited, often resulting in inconsistencies in the recommendations of various national and international professional societies. In addition, some recommendations related to the management of twin gestations are often missing from the clinical guidelines dedicated to twin pregnancies and are instead included in the practice guidelines on specific pregnancy complications (eg, preterm birth) of the same professional society. This can make it challenging for care providers to easily identify and compare recommendations for the management of twin pregnancies. This study aimed to identify, summarize, and compare the recommendations of selected professional societies from high-income countries on the management of twin pregnancies, highlighting areas of both consensus and controversy. We reviewed clinical practice guidelines of selected major professional societies that were either specific to twin pregnancies or were focused on pregnancy complications or aspects of antenatal care that may be relevant for twin pregnancies. We decided a priori to include clinical guidelines from 7 high-income countries (United States, Canada, United Kingdom, France, Germany, and Australia and New Zealand grouped together) and from 2 international societies (International Society of Ultrasound in Obstetrics and Gynecology and the International Federation of Gynecology and Obstetrics). We identified recommendations regarding the following care areas: first-trimester care, antenatal surveillance, preterm birth and other pregnancy complications (preeclampsia, fetal growth restriction, and gestational diabetes mellitus), and timing and mode of delivery. We identified 28 guidelines published by 11 professional societies from the 7 countries and 2 international societies. Thirteen of these guidelines focus on twin pregnancies, whereas the other 16 focus on specific pregnancy complications predominantly in singletons but also include some recommendations for twin pregnancies. Most of the guidelines are recent, with 15 of the 29 guidelines published over the past 3 years. We identified considerable disagreement among guidelines, primarily in 4 key areas: screening and prevention of preterm birth, using aspirin to prevent preeclampsia, defining fetal growth restriction, and the timing of delivery. In addition, there is limited guidance on several important areas, including the implications of the “vanishing twin” phenomenon, technical aspects and risks of invasive procedures, nutrition and weight gain, physical and sexual activity, the optimal growth chart to be used in twin pregnancies, the diagnosis and management of gestational diabetes mellitus, and intrapartum care.This consolidation of key recommendations across several clinical practice guidelines can assist healthcare providers in accessing and comparing recommendations on the management of twin pregnancies and identifies high-priority areas for future research based on either continued disagreement among societies or limited current evidence to guide care.

Original languageEnglish
Pages (from-to)577-598
Number of pages22
JournalAmerican Journal of Obstetrics and Gynecology
Issue number6
StatePublished - Dec 2023


  • American College of Obstetricians and Gynecologists
  • International Federation of Gynecology and Obstetrics
  • International Society of Ultrasound in Obstetrics and Gynecology
  • National Institute for Health and Care Excellence
  • Royal College of Obstetricians and Gynaecologists
  • Society of Obstetricians and Gynaecologists of Canada
  • antenatal care
  • aspirin
  • clinical
  • comparison
  • delivery
  • expert
  • growth restriction
  • growth retardation
  • guidelines
  • management
  • multifetal
  • multiple
  • practice
  • preeclampsia
  • prenatal care
  • prenatal screening
  • preterm
  • professional
  • recommendations
  • review
  • societies
  • summary
  • twin
  • twins


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