In an ironic twist, after recently writing about an insensitive sketch entitled “Saturday Night Live” Skit Mocks Infertility, it was just reported sextuplets were born to parents “overcome with joy” who tried to conceive for 17 years.
Though my previous article reflects my dismay over Dwayne “The Rock” Johnson’s skit making fun of those struggling with infertility, this one will shift the discussion to the risks of multiple birth gestations in general—spontaneous or otherwise. This current example, however, serves to underscore the wide spectrum of challenges individuals with fertility difficulties face when desiring to conceive.
Referencing Adeboye Taiwo’s delight over the news of multiples, Virginia Commonwealth University (VCU) Medical Center released this from the father, “I was excited. For the very first time we were expecting.” Imagine that after 17 years of effort.
Because the sextuplet reality was known, a coordinated medical team and delivery plan could be put together and optimally implemented. According to Susan Lanni, M.D.—the medical director of labor and delivery who is a maternal-fetal specialist at VCU Medical Center, pre-delivery drills and resuscitation exercises were employed due to the expected intensity of a near simultaneous six premature infant delivery.
On May 11, 2017 a team of 40 people—integrated between obstetric and neonatal fields— successfully delivered by cesarean section six premature babies—three boys and three girls. They were of 30 weeks and 2 days gestation, ranging from 1 pound 10 ounces to 2 pounds 15 ounces. The hospital states “all six are doing well and continue to thrive in the Children’s Hospital of Richmond (CHoR) at VCU neonatal intensive care unit (NICU).”
According to Russell Moores, M.D.—medical director of the NICU at ChoR at VCU, “Given their prematurity, they are doing exceptionally well.” Mr. Taiwo adds, “I hope for the smallest of my six children to grow up and say ‘I was so small, and look at me now.’ I want my kids [to] come back to VCU to study and learn to care for others with the same people who cared for me and my family.”
His gratitude shows his appreciation for the large team involved and invested in the best possible outcome for his children. When it comes to multiples or prematurity or medical issues in the newborn period, the number of caregivers expeditiously rises. Thankfully, the reports indicate a success story for this family.
As per the Centers for Disease Control and Prevention (CDC), of the nearly 4 million live births in 2015, 133,155 were twins and 24 were quintuplets or higher. There are many more in-between exposing further the relevance of the topic.
Now, let’s shift gears to understanding the science behind multiple births in general.
The risks of multiple births…
The issue with twin or higher order gestation is usually a space-occupying one. Due to overcrowding, the higher the number you go, the more intrauterine growth restriction can develop. Depending upon the distribution of placenta and amniotic sacs, meaning what is or isn’t shared, twin-to-twin transfusion can result where one steals another’s blood and nutrient supply. This discordant situation causes problems. Amniotic fluid can diminish in volume, so for these and more reasons including maternal health status like increased blood pressure or preeclampsia, mothers of multiples will typically not be delivered at full term.
Even in an uneventfully developing pregnancy, the balance of when the infants’ varying organ systems—in particular the lungs—have reached optimal maturity and staving off untoward events is a delicate one constantly considered. Delivery is usually by cesarean section in these higher ordered births given the rarity of a well-positioned infant for vaginal delivery, let alone four or five.
Prematurity and Low to Extremely Low Birth Weight (ELBW)…
Since it is more likely such infants will be delivered preterm, the medical issues that can arise are more often due to the extremely low or very low birth weight and degree of prematurity. Fortunately, if birth can’t be delayed, then giving antenatal steroids is an option to promote infant lung maturity and when they are premature we know what to watch for and how to intervene.
The degree of low weight and earlier gestation contributes much to the ultimate outcome. The more an infant weighs and the older they are in weeks, the better their chances are of less or no issues. Female gender is also an advantage.
Once delivered, the lung status and the degree of intervention for respiratory support says the most about longer term problems. The sooner an infant can be sustained on room air, the better he will do. Intubation and mechanical ventilation can be required and complicate the clinical and future picture. Too much oxygen for a long time can cause issues as well.
So, the delicate dance continues between being helpful and contributing to further difficulty.
In this population and during the hospitalization period especially, diligent monitoring of all organ systems is necessary as there are a constellation of symptoms that can arise. Hypothermia or issues with regulating temperature warrant close surveillance as these infants can lose a lot of heat per body surface area. Hypoglycemia due to loss of maternal source and reduced glycogen stores. Due to immature liver and kidney systems, jaundice from hyperbilirubinemia and electrolyte imbalances are closely followed. Oral feeds versus intravenous nutrition are strategically initiated given the risk of necrotizing enterocolitis (NEC), the emergent disease process that can take place in the premature gastrointestinal (GI) tract.
Anemia is common. Apnea (episodes where breathing stops) can result from a reduced central respiratory drive to be an indicator of infection. These babies are at greater risk of infection from a more vulnerable immunity. Preemies, in particular those of ELBW are at risk of intraventricular hemorrhage (IVH) so head— or cranial —ultrasounds are routinely performed early on to catch any evolving bleeds in the brain. Many don’t have this issue, but if they do and depending on the extent longer term problems can result. That said, when a milder bleed occurs, the infants tend to do quite well and are resilient often leading to no developmental problems. Certain holes in the heart needed in utero but not in post-birth air remain open in the premature infant, for some this becomes an issue that requires addressing.
The litany continues beyond what is mentioned here of checks vital to ensuring the well-being of the baby. Since we know what to look for, we can avoid many problems and catch others before they progress. Just because these situations can take place, does not mean that they always do. The individual is always the variable.
Like in most babies full term or premature, the goal is to be feeding, voiding and stooling well on room air while vigorous and alert. Plenty of premature infants demonstrate these parameters immediately, just simply need to gain weight and grow enough to be safely discharged.
To sum up…
For babies with challenges at birth, the NICU is the ideal environment replete with those properly trained to know what to look for and how to manage it. Multiples can do quite well and thrive. Expertise in this area is essential to securing their long-term health and growth. Though premature and low birth weight infants are more prone to obstacles, medical advances and dedicated care teams have made wondrous strides.
