comprehensive study of twinning rates in the developing world .
Many people romanticize about having twins but I ’ m quite sure if one was to ask parents with twins , having them is not as glamorous as it sounds and some parents have even been overheard saying “ I cannot wish twins on my worst enemy !!”
Regina ( not her real name ) was a wonderful lady on her first pregnancy and like many first-time mothers full of excitement , started clinic pretty early . She had symptoms very early , nausea , vomiting with loads of hyperacidity not to mention the breast tenderness . As is standard we did her baseline scan and she was pleasantly surprised when we told her that she was actually carrying twins . Thus began our journey or should I say long walk to freedom ….
As with most first timers , she always came in with her husband Jeremy ( not his real name ) and they were a very pleasant couple to work with . I think you have to be pleasant to withstand my jokes and laughter . Anyway , other than the twin gestation the pregnancy was proceeding as normal and suddenly out of the blue at about 28 weeks Regina rushes to the clinic saying she has contractions .
Being a paranoid , I had to do a vaginal exam and low and behold she was already 6 cm dilated . Being at 28 weeks she did not have to get to full dilatation before she expelled the baby . These are the cases that make you think should we routinely give steroids to mothers at 28 weeks gestation . We quickly swung into action . As my office is very near the hospital , we rushed directly to the labor unit . I called the nurses and requested them to be ready with terbutaline injection , Magnesium sulphate and the steroids , whichever was available , dexamethasone or betamethasone .
The terbutaline was to knock off the labor , despite the fact that it was very advanced . At this point we had reached the point of no return but I wanted to have as much time as possible to administer the Magnesium which we use to protect the brain of the foetus ( minimize the risk of postnatal cerebral palsy ) and the steroids help with advancing the lung maturity which in turn reduces risk of death due to breathing problems in the neonate . Steroids also reduce the risk of bleeding in the babies brain and a serious problem with the babies gut / intestines called Necrotizing enterocolitis .
At this point the highest priority was trying to ensure we get even if it was only one extra hour so that the interventions would have time to act . For those who know how labor progresses once in active labor the cervix dilates 1cm / hour . Another challenge is that these are small babies due to the gestation and smaller for gestation due to the multiple pregnancy . This meant the babies could come any time . Due to the lightning swift action of all the actors , we were in the labor ward and on treatment in under 15 minutes . Fortunately , we were able to stop the labor with the terbutaline , however she progressed and delivered vaginally in the morning to twin girls Jewel and Jeanette ( not their real names ), 850 and 890 grams respectively .
Regina had just undergone one of the complications of twin gestations - preterm labor and delivery . Fortunately , we had managed to discuss this during her antenatal period but discussing and having the problem are not necessarily the same thing . I usually tell my patients that at 28 weeks if they are able to listen to me and we chose a reasonable hospital and they let me chose a neonatologist ( paediatrician who has specialized in complications of newborn and especially preterm babies ), if the baby does not have a severe complication the chances of going home are pretty high . Fortunately , in this case my theory ran true and the neonatologist worked with them very well .
They obviously had to be admitted to the neonatal intensive care unit ( NICU ) and that would be their home for the next six weeks . Whether it was the antenatal interventions or the best care in the NICU we don ’ t know , but we are all in agreement that there was definitely some divine intervention . If all else remains constant for well preterm babies all that is needed is just warmth and adequate nutrition . We don ’ t weigh the babies frequently as they will initially lose weight which tends to stress the mothers . With the grace of God Jewel and Jeanette left the hospital at approximately 1800g each .
Regina along with her bundles of joy had just become statistics , as survivors of preterm birth . 60 % of twin pregnancies end up with a preterm birth . Unfortunately , not everyone has this success story due to the ravages of prematurity .
There are several other complications that can be attributed to twin gestation and in most cases twin pregnancies increase the risk which are twice as likely to occur than in singleton pregnancies .
Complications due to twin pregnancy can be to the mother ( maternal ) and or to the foetus . For the mother the complications can occur during the antenatal period , during labor and after delivery .
Some of the other complication from having twin gestation include exaggerated nausea and vomiting , miscarriages / abortions , malpresentation ( when the baby comes legs or arms first ), anemia , Placenta praevia , Preterm labor and delivery , Risk of hypertensive disease , and Antepartum haemorrhage .
Maternal risks during labor include Premature rupture of membranes ( PROM ), cord prolapse , operative delivery , Post-partum haemorrhage and so on . Maternal risks after delivery could be due to subinvolution of the uterus leading to bleeding , infection and lactation failure .
Twin fetuses have double the risk of still births or miscarriages , intrauterine growth restriction , small fore gestational age , congenital anomalies , cord accidents , asphyxia , operative delivery and sometimes twin entrapment during delivery .
Twins have double the risk of Congenital anomalies such as Neural tube defects , cardiac anomalies , bowel atresia . Conjoined twins , Twin , Twin transfusion syndrome and TRAP sequence ( twin reversed arterial perfusion ), would be unique to twins , resulting in severe morbidity and mortality for affected babies .
From this we can see twins are not as wonderful as we all imagine and we have not even started on issues of raising them . If time and space allow , I may decide to write on the individual complications in later editorials .
Dr . Maureen Owiti is a practicing Obstetrician Gynaecologist and fertility consultant based in Nairobi . You can commune with her on this or related matters via email at : Drmaureenowiti @ gmail . com .