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Tag Archives: premature birth

When One of the Twins Die In Utero

Did you always think that when a mother conceives twins, triplets, quadruplets or more, all of the fetus will be born alive? As morbid as it maybe, some fetus/fetuses die prematurely even before being born. Some may die within the first, 2nd or 3rd trimester (3 months). And their death can bring about complication/s not only to the mother, but to the remaining twin as well.
The effect of the fetal death to the surviving twin may vary according to the timing of the death. In a data published 1994, loss of one twin at the first trimester does not impair the development of the surviving fetus. (Some are completely resorbed in a condition termed as “vanishing twin syndrome.”) In the second trimester however, this is associated with increased risk for the survivor as reflected by a high incidence of growth retardation, premature labor and perinatal mortality.
An observation of twin pregnancies where single fetal death occurred after 20 weeks of gestation, the mothers were known to have preeclampsia which may also prompt babies to be delivered prematurely. The surviving twin aside from being delivered prematurely, they are also observed to be with intrauterine growth restriction. This could be an effect of the death of the other twin, or that and the effect of preeclampsia wherein the blood flow to the fetus may become diminished. This in turn causes diminished delivery of oxygen and nutrients to the baby thus. Head MRI and ultrasound of these survivors revealed some neurologic injury. Fortunately, in these mothers, there was no detected abnormality on coagulation profile.
A similar observational study was also done among twin pregnancies where a single fetal death occurred after 20 weeks of gestation. The study showed that the main cause of the fetal death was twin-to-twin transfusion syndrome. The survivors were also delivered prematurely and later also died after birth because of the same cause. (TTTS is due to abnormal communication between the blood vessels supplying the placenta of both, leading to shunting of more blood to the other twin while deprivation of the other one. One may die immediately while still in utero, while the other may survive or end up hydropic; or both may survive with severe physical discrepancy — see my other blogs on hydrops fetalis). 
Another in depth observation was done among twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation. Chorionicity of the twin pregnancies was noted (see illustration below on the types of twin pregnancy according to chorionicity).
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(Image courtesy of  http://www.health.sa.gov.au/ppg/Default.aspx?PageContentMode=1&tabid=75)
Often times, the surviving twin was delivered prematurely, and that baby ended up with intrauterine growth restriction. The mother on the other hand had preeclampsia and gestational diabetes, both of which may also lead to the growth restriction of the surviving twin. In cases of monochorionic pregnancies, again twin-to-twin transfusion syndrome afflicted the babies. Some of the twin eventually died as well in utero (before being delivered), while others after birth. Also, ultrasound of the baby’s head should cerebral anomalies in some.
Even if one of the twins survive after the death of the other, and gets delivered, it is not reassuring that he will live and be discharged as well baby as his outcome may be compromised by the complications of premature birth, or presence of neurologic injury.

References:

1. Prömpeler HJMadjar HKlosa Wdu Bois AZahradnik HPSchillinger HBreckwoldt M. Twin pregnancies with single fetal death. Acta Obstet Gynecol Scand. 1994 Mar;73(3):205-8.

2. Axt RMink DHendrik JErtan Kvon Blohn MSchmidt W. Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.J Perinat Med. 1999;27(3):221-7.

3. Aslan HGul ACebeci APolat ICeylan Y. The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation. Twin Res. 2004 Feb;7(1):1-4.

4. Chelli DMethni ABoudaya FMarzouki YZouaoui BJabnoun SSfar EChennoufi MBChelli H. Twin pregnancy with single fetal death: etiology, management and outcome. J Gynecol Obstet Biol Reprod (Paris). 2009 Nov;38(7):580-7. Epub 2009 Oct 14.

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A Mother’s Day Story – Part 1

I was a faculty of a neonatal resuscitation program provider’s course when one afternoon I received a call to attend to the delivery of a preterm baby. The mother was 34 years old, on her second pregnancy, her first being 15 years ago. She was apparently alright except for her hypertension which was at 220/110 (we call these mothers, a walking time bomb). She was admitted for control as her baby is still premature but to no avail hence the emergency cesarean section. I was hoping that the hypertensive period and the current crisis hadn’t been occurring for a long time as it may greatly affect the well being of her baby. Minutes gone, and baby finally was delivered. He was a strong 1.5-kgs 32 weeks old (6 1/2 months by layman’s counting). But he had difficulty breathing spontaneously so I had to rush him to the NICU for intensive care. I provided mechanical ventilator and administer surfactant to ease his breathing. He went fine. Meanwhile, I learned that while the mother was in the recovery room the mother had seizure creating a commotion and series of procedures to keep her up…

–o0o–  –o0o– –o0o–

Few days passed, baby was now able to breath on his own. The respirator was already discontinued. He was already being fully fed via tube, meaning no more intravenous line (commonly called “dextrose”). He was now on low flow oxygen as respiratory support, still inside an incubator.

On his 10th day of life, baby suddenly crashed — his color was turning purplish, he was not breathing, the monitor indicated his blood oxygen saturation is low, and his heart has fallen below the normal. Suddenly, the nurse went to his rescue. She immediately provided bag-mask ventilation. Slowly, baby’s heart rate increase, he was turning pink back again and he resumed his breathing. While doing so, his mother was beside him, watching, caressing his head. 

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(photo credit: http://www.rch.org.au/paed_trauma/manual.cfm?doc_id=12610)

Baby got stabilized thereafter… After about two days, similar incident happened. Baby again had near arrest (his heart beat fell to less than 60/min, bluish in color and not breathing spontaneously). Again, bag-mask ventilation was provided until he was pulled out. He regained consciousness and was crying as if he didn’t almost die. At the time the nurse was attending to him, his mother was again there providing comfort. She wasn’t talking but her facial expression said she wanted to be with her son always, caress him, comfort him, hug him, hold him, bathe him, nurse him forever. IF ONLY she could…

 –o0o– –o0o– –o0o–

At the recovery room when the mother had seizures, her BP shoot up causing rupture of blood vessels inside her head. She suffered what we call a hemorrhagic stroke (a stroke caused by hemorrhage in her brain from a rupture of blood vessels). She had to be operated on… She fell into coma… She laid there at the ICU with all the machines keeping her live… She arrested – her heartbeat stopped 10 days after she gave birth. Despite heroic measures, she didn’t make it. At that very same time she was being revived, the nurse in the NICU was reviving the baby… while the mother was caressing him…

The second time that baby was arresting, the nurse who saw mother caressing the baby while he was being resuscitated came from a leave, and had no idea that the mother passed away2 days ago …

 –o0o– –o0o– –o0o–

After discharged from the hospital, I saw baby for a few times for some vaccinations. But as days went, I noticed that baby hardly interacted. His face was becoming more and more expression-less unless he cried. He would never smile no matter how hard I try to make him. Deprived of maternal care… He was being passed from grandmother to grandmother, aunt to aunt depending on who’s free and available. This costs him inconsistencies of affection and care– something that confused his premature brain, which required consistency of maternal presence and care…

Few months more, I didn’t see baby anymore… I wonder how he is now…

As for the mother… she missed the chance of being a mother to her son. He was a vibrant boy until his emotional regression. She could have nursed him, bathed him, sent him to sleep, fed him. She could have watched him roll over, crawl, learn to stand and walk. She could have heard him say “mama” as his first word. She could have brought him to the park. She could stopped him crying. She could have… Only if death hadn’t stole him away from his son and family.

 

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