Women with multi-fetal pregnancies (twins, triplets and more) face the issue of pregnancy loss just as women with singletons do; however, they also face issues involving losses in which certain aspects are unique to their multiple gestations. In the simplest case, women with twins suffer fetal losses through the “vanishing twin syndrome.” The advent of widespread ultrasound use has shown us that many twin pregnancies suffer the loss of one twin quite early in pregnancy, and were ultrasound not available, neither the patient nor caregiver would have recognized the pregnancy as anything but a singleton pregnancy. Sebire et al evaluated pregnancies at 10–14 weeks with transvaginal ultrasound and determined that about 5% of all twin pregnancies have a demise of one (3.5%) or both (1.5%) twins at that time. Obviously, unrecognized losses do not causing families to “suffer” loss. In cases in which the losses are recognized, feelings of loss often seem muted compared to cases of loss of a singleton. The reason for the milder reaction may be due to a feeling that the “pregnancy” hasn’t miscarried and there is still a viable fetus, due to ambivalent feelings about having “twins” or simply due to the fact that these losses are very early and in many cases a fetus (or even fetal heart beat) was never seen so the sense of “bonding” was lessened. Beyond the case of the vanishing twin, women with multiple gestations may be faced with three other broad categories of fetal loss with special implications: the elective reduction of a high-order (arguably triplets or more) pregnancy to a low-order one to improve outcome for the fetuses, the potential loss of a normal fetus when the selective termination of an abnormal twin is considered, the issues of fetal and neonatal loss surrounding preterm interventions when one twin is severely compromised in utero and the other is healthy. It is probably generally known that, in general, twins deliver earlier than singletons, triplets earlier than twins, and the more fetuses in the womb, the earlier the average delivery. Likewise, while many preterm and extremely preterm infants survive, the earlier one delivers, the higher the risk of serious and possibly life-long complications. In recent years, the increased use of assisted-reproduction technologies has resulted in a rise in the number of triplets and higher-order multiple gestations. While it is clear that this has been a godsend to many couples with long histories of infertility, it has also placed many in the uncomfortable circumstance of carrying triplets and quadruplets with a high potential to have one, two or more children with major, life-long handicaps including lung disease, mental retardation, seizure disorders, blindness and cerebral palsy. Consequently as early as 1986, physicians were reporting on attempts to perform reductions of high-order pregnancies to low-order ones. This procedure has been refined and become more widely available. Studies have been fairly convincing that quadruplet pregnancies which are reduced do better than those which are not. While he data for triplets is not as clear, early evidence suggests there is some improvement in outcomes. It does not appear that triplets reduced to twins do quite as well as natural twins though. Thus couples now are routinely informed of this procedure with two obvious issues. First, they have been trying very hard to get pregnant and gone to the extremes of high-tech interventions only to be faced with a decision to terminate one of their much-desired fetuses in order to improve the chances for the others. Many women who choose to undergo reduction experience feelings of loss. Berkowitz et al found 65% of women had acute feels of emotional pain and stress, 70% mourned for their lost fetuses and 37% had an anniversary grief reaction. Although persistent depressive symptoms were mild, nearly 18% experienced lingering guilt or sadness and anger. Despite these feelings, 93% of the women said they would make the same choice to undergo reduction again. A second consideration is that the procedure it self does carry a risk of causing a miscarriage of the whole pregnancy. Fortunately, this complication is uncommon in experienced hands. In a recent series of 400 patients undergoing reductions, 92% delivered one or more infants after 24 weeks’ gestation. The risk of miscarriage was 7.3% in triplets, 8.4% in quadruplets, 6.1% in quintuplets and 17.6% in those with 6 or more fetuses. Nonetheless, when a miscarriage occurs, the reactions of grief and anger may be significant given that the patient’s decision to undergo reduction has led to the loss of a much desired and worked for pregnancy. A similarly complicated decision faces parents with multiple gestations in which one fetus has an abnormality and the other(s) is(are) normal. While women carrying singleton pregnancies may face the decision to terminate an abnormal pregnancy, women with twins must consider the possibility that their decisions could affect the normal fetus. It has been shown that the selective termination of the abnormal fetus is associated with a 3–8% risk of miscarriage. The emotional strain on a couple brought about by the discovery of an abnormality in their fetus is complicated by the findings that selective termination of the non-presenting twin (the one furthest from the cervix) actually lowers the risk of preterm delivery compared to twins. Should the couple terminate to improve the chances for the normal one? What if they miscarry and lose both? What it they choose not to terminate and then the abnormal twin induces a complication which results in a preterm delivery with damage to or loss of the healthy one? No matter what decision they make, they may look back on it with regret if they suffer a loss of both children—on top of the feeling of loss itself. Finally parents of twins may face circumstances in which complications results in the compromise of one twin and decisions must be made on how to manage the pregnancy. As with all of our previously listed circumstances, patients are called upon to make decisions which may result in the death or compromise of a normal fetus, making the emotions relating to the loss more difficult compared to the case when extraneous factors bring about the loss. There are two subsets of this situation, the cases of identical twins with a shared placenta, and the case of non-identical twins or identical twins with separate placentas. It is sometimes hard to distinguish between the two groups during pregnancy, particularly if a patient’s first visit is relatively late in gestation. In the first case, a situation arises in which one twin becomes severely compromised, such as when an abnormal placenta leads to poor feeding and oxygenation. The compromised fetus can be “starved” to the point of damage and, ultimately, death. Cesarean delivery may be the only option offered to improve the outcome for that fetus; however, delivery of both twins would be performed. Depending on gestational age, this could expose the healthy twin to the complications of prematurity. Parents may be faced with a decision to risk the life of the healthy twin in an attempt to save the sick one or to sacrifice the sick twin so as not to expose the healthy twin to unnecessary risks. In the subset of cases with identical twins having shared placentas, it can be more complicated. Investigators have reported numerous cases of identical twin pregnancies (with shared placentas) in which the demise of one twin caused damage to the other. While the early hypothesis was that something was released from the dead fetus which damaged the other one, more recently it has been hypothesized that the loss of blood pressure in the dead twin results in the live twin pumping blood across to the other one with a transient loss in blood pressure causing the damage. Unfortunately, studies have not clearly established the level of concern we should have. Estimates on the risk of major morbidity or mortality to the surviving fetus range from very low to 46%. In one report, while there were no cases of damage to the surviving fetus, a high incidence of fetal distress was noted among women retaining a living fetus in utero for at a week or more. A final consideration is that the markers for damage don’t appear until weeks after the damage has occurred. Unless an impending demise is expected and occurs while a patient is being monitored, there is no way to know whether the healthy fetus suffered a hypotensive crisis, which should produce changes in the fetal heart rate, or not. Thus, parents are sometimes asked to be involved in making decisions with limited data available to guide them. As when consider the issues surrounding loss in the multiple pregnancy, one other factor separates this from the singleton. When couples suffer a fetal demise in a singleton pregnancy, they either miscarry or undergo a procedure to end the pregnancy. Few mothers desire to carry the dead fetus for more than a few days, and most desire to end the pregnancy quickly. In the case of the multiple gestation with one demise, the mother is often called upon to continue carrying the dead fetus for weeks to months. This may have implications for her grieving process as well as for her feelings toward the surviving twin. Caregivers must recognize that even the birth of a healthy baby will be a time of sorrow as well as joy. We must be careful not to adopt the attitude of “don’t complain, be grateful—at least you got one healthy baby.” We must take the time to acknowledge and affirm the appropriateness of the couple’s emotions of loss while letting them see that they have much to be thankful for. Thus, the issues
surrounding the losses incurred in multiple gestations are frequently more complicated
than losses in the singleton, but the emotions are the same. The primary difference is
that in many cases, parents are forced to make decisions which have a direct impact on and
sometimes bring about damage or death to one or more of the fetuses. This may alter the
normal feelings of pain, stress and anger which occur when fetal losses occur completely
outside the control of the parents. |