Antenatal Management of Multiple Pregnancies within the UK - Submitted REVISION

1Antenatal Management of Multiple Pregnancies within the UK: A survey of practice Joanna Gent 1, Surabhi Nanda 2, Asma Khalil 3,4, Andrew Sharp 4Affiliations: Harris-Wellbeing Research Centre, Liverpool Women’s Hospital, University of Liverpool, UK Fetal Medicine Unit, Guy’s and St Thomas’s Hospital, London, UK Fetal Medicine Unit, St George's Hospital, University of London, London, UK Vascular Biology Research Centre, Molecular and Clinical Sciences Research 10 Institute, St George's University of London 11 12 13Correspondence: 14Dr Andrew Sharp asharp@liverpool.ac.uk 15Harris-Wellbeing Research Centre, Liverpool Women’s Hospital, Crown Street, Liverpool, L8 167SS, United Kingdom 17Tel: 01517959560 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45Abstract 46Objectives 47To identify variation in antenatal management of multiple pregnancy The UK has 10,000 48twin pregnancies per year There is established guidance on the management of dichorionic 49(DC) and monochorionic (MC) twin pregnancy from both the RCOG and NICE, however it is 50likely that the provision and practice of multiple pregnancy management varies amongst 51units 52Design 53Questionnaires were posted to 151 UK maternity units in rounds from May to November 542019 55Results 5660 responses were received (range 11500 to 501 deliveries), with annual multiple pregnancy 57rates of 190 to 25% of units did not offer a dedicated twin clinic and less than 15% of units 58provided dedicated multiple pregnancy midwifery staff for intrapartum and postnatal care 59Cervical length screening was performed in 24% of units with 84% of units offering treatment 60for a short cervix 15% of units prescribed Aspirin to all multiples, 47% prescribing 75mg and 6143% 150mg Monitoring of MC pregnancies varied with 18% of units not measuring Middle 62Cerebral Artery and 29% Ductus Venosus Dopplers Mean caesarean section rate was 6361.7% Delivery was offered from 37 weeks in 93% of DC twins and from 36 weeks in 90% 64MC twins 5% of MC twins were given non labouring prophylactic antenatal steroids 65Conclusion 66Despite well-established national guidance for twin pregnancy management there remains a 67wide variation in practice among units in the provision and antenatal management of multiple 68pregnancies throughout the UK The exact reasons for this variation require further 69exploration 70Key Words 71Multiple Pregnancy, Antenatal Care 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 951 Introduction 96The incidence of multiple pregnancies over the last 30 years has risen exponentially due to 97the use of assisted reproductive techniques, with rates doubling to 10,000 multiple 98pregnancy births in 2018 [1] Due to the substantial risks associated with multiple pregnancy 99and its largely preventable nature within IVF, the UK Human Fertilisation and Embryology 100Authority (HFEA) introduced a maximum live multiple birth rate target of 10% in 2008, 101reducing rates from 24% down to an average of 10% in 2017 [2] Despite this, multiple 102pregnancies still account for around 15 per 1000 women giving birth within England and 103Wales and up to 79 per 1000 in the over 45 age group [1] These pregnancies are 104associated with significant risk of adverse maternal and fetal outcomes, as well as significant 105costs to the National Health Service (NHS) 106Compared to singleton pregnancies, multiple pregnancies are associated with increased 107maternal morbidity (anaemia, hypertensive disorders, venous thromboembolism, obstetric 108cholestasis and gestational diabetes), and pregnancy complications such as; miscarriage, 109preterm birth, caesarean section and post-partum haemorrhage In addition, monochorionic 110twin pregnancies carry additional unique risks of twin to twin transfusion syndrome (TTTS), 111and/or selective fetal growth restriction (sFGR), approximately 15% each, and a 13% risk of 112twin anaemia-polycythaemia sequence (TAPS) in those who have undergone laser therapy 113as a treatment for TTTS [3,4,5] 114The fetal risks involved in twin pregnancies are also significant with in 12 multiple 115pregnancies ending in death or disability for one or more babies [6] The preterm birth rate is 11660% prior to 37 weeks with 10% delivering before 32 weeks and 11.5% of babies admitted to 117Neonatal Intensive Care Units (NICU) are from multiple pregnancies despite only accounting 118for 1.6% of live births [7,8,9] The significant adverse maternal and fetal outcomes pose 119significant challenges for clinicians and contribute to the average cost of caring for a multiple 120pregnancy being almost three times as much as a singleton pregnancy [6] 121Within the UK there are established guidelines for the management of twin and higher order 122pregnancies from The Royal College of Obstetricians and Gynaecologists (RCOG) on 123monochorionic twin pregnancies and The National Institute for Health and Care Excellence 124(NICE) which published revised multiple pregnancy guidelines in 2019 [7,10] 10 125Despite these well-established national guidelines, there has been concern about variations 126in practice A 2015 maternity services survey reported that only 10-18% of UK maternity 127units had been able to fully implement key quality standards within the previous 2011 NICE 128multiple pregnancy guideline - reflecting the complexities that multiple pregnancy present 129and the additional specialist services that they require [11-13] This prompted the Maternity 130Engagement Project by the Twins Trust charity, an initiative to improve outcomes within 131multiple pregnancies by promoting the NICE quality standard within targeted maternity units 132around the UK Over a 3-year period, selected units showed significant improvement in 133adherence to NICE quality standard as well as improved patient outcomes and associated 134cost saving [14] 135We designed this national survey to ascertain the current provision of antenatal care for 136multiple pregnancies in the UK and to identify any variations in practice to allow for targeted 137strategies to improve care universally 1382 Method 139The survey (Appendix A) with covering letter was mailed to the clinical lead for obstetrics in 140a 151 consultant led NHS trusts providing maternity servicesunits within the UK (England, 141Wales, Scotland, Northern Ireland, Channel Islands and Isle of Man (IOM)) including all 132 142NHS trusts within England, from a historic database from previously published surveys [15] 143The questionnaires were sent ininitially in two rounds in three rounds in May and, 144September 2019, with a 3rd added in and November 2019 due to the lower than anticipated 145response rate The questionnaire comprised of 34 questions, 16 of which covered general 146antenatal care and service provision for multiple pregnancy as well as protocols for 147screening and prevention of preterm birth A further 18 questions concerned the antenatal 148management of monochorionic and dichorionic pregnancies to explore local approaches to 149caring for these specific pregnancies Responses were analysed by question and expressed 150as a percentage of the total responses per question received in both exclusive and non151exclusive multiple-choice questions 11 12 1523 Results 15360/151 units responded giving a response rate of 40% and within England alone 49/132 154(37%) The size of the units ranged from 501 to 11,500 deliveries; 21 units had >5000 155deliveries, 34 units ranged from 2000-4999 and units had