BOSIRE: Double bundles of joy come with risk

Karen* was my first ever multiple birth experience. She waddled into the labour ward at one in the morning, and declared that she was in labour. She was infectiously cheerful for someone in pain. She had been attending our antenatal clinic and was well-prepared for delivery.

As the nurse settled Karen in bed, I prepared to review her as we waited for her file to arrive from the records department. She told me all the key things I needed to know in one sentence.

She knew she was carrying twins whose due date was in two days, and that they were both positioned head first, so she was scheduled for a normal delivery.

It was refreshing to meet a patient who was so involved in her care and privy to all her relevant medical information. She had been woken up about an hour before by what felt like labour pains, but noted that despite the short duration, her contractions were quite regular and only about three minutes apart.

As I jotted this down, she had a contraction that interrupted the conversation. It was a big one that got me concerned. I suspended taking the medical history to examine her.

My decision was well informed because her babies were ready to come there and then. The race to wheel her bed to the delivery suit was hilarious. I shouted to the midwife to bring the delivery tray while everyone scattered out of our way.

We did make it to the delivery suite but certainly not onto the delivery couch. The babies were well on their way. The first twin arrived without much effort. Mummy needed no encouragement. She gave a single push and the little fellow came out yelling as he took his first breath. I never even got a chance to wear the sterile delivery gown.

No sooner had we cut the umbilical cord and settled him in the resursitare (the receiving bed for new-borns) than his brother quickly made his entry into the world. He was equally loud.

The two came out minutes apart, identical in every way except for their birth weights. At 3,700 grams and 3,900 grams, they were really big for a twin pregnancy. Karen was ecstatic.

COMPLICATIONS

Worldwide, monozygotic (identical) twins occur at a rate of four per 1,000 births. They result from fertilisation of one egg by one ovum. Once the fertilised egg starts to divide into many cells that form the eventual baby, somewhere along the way they cleave into two separate entities, each independently developing into a baby. The babies are same gender and will look very much alike.

Fraternal (non-identical, dizygotic) twins on the other hand result from two separate eggs that are fertilised at the same time and develop into two separate babies who are not identical and may even be different sexes.

Incidence varies for these twins, and is dependent on the age of mother, race and interventions such as assisted fertility. The rate is about 10 to 40 per 1,000 births in blacks, seven to 10 per 1,000 births in whites, and approximately three per 1,000 births in Asians. It is also more common in older women.

Multiple pregnancies (twins, triplets and other high order births) come with increased complications.

There is associated higher rate of neonatal morbidity and mortality, risk of preterm delivery, low birth weight, congenital abnormalities and other high-risk morbidities.

Maternal morbidity and mortality are also increased with complications such as anaemia, pre-eclampsia and post-partum haemorrhage.

With each extra baby in the womb, the pregnancy duration is reduced by approximately two weeks. Therefore, the higher the number of multiples, the higher the expected rate of prematurity and resultant low birth weight.

The large placenta to cater for multiple babies increases the risk of the mother developing pregnancy-induced hypertension, pre-eclampsia and eclampsia. This sets in earlier in the pregnancy, increasing the need to deliver earlier.

The excessive stretch on the uterus makes it difficult to contract after the babies come out, allowing for heavy bleeding that could be life-threatening.

Mothers delivering twins are marked from the out-set as high alert for bleeding and their management is aggressively geared towards preventing post-partum haemorrhage. They are more likely to undergo a Caesarean section, especially because of the position of the babies in the womb.

Karen’s babies avoided prematurity and low birth weight, much to our relief, but Karen wasn’t so lucky. Within the first hour of delivery, she got eclampsia that sent her straight to the intensive care unit for three days.

When she got better, and was discharged, she had to adjust to motherhood and the demands of the new babies. The demands of one baby can be overwhelming, let alone multiples. This can be difficult for the new mother, leading to increased risk of post-natal depression.

*Name has been changed to protect identity.