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After Ronaldo loses newborn, UAE doctors weigh in on twin pregnancy risks

Planning can help avoid complications, expert advises

On Monday, Cristiano Ronaldo revealed to the world the devastating news that he and his partner Georgina Rodríguez, who was pregnant with twins, had lost one of their newborns, a boy.

The couple described the grief as the “greatest pain”, adding: ‘Only the birth of our baby girl gives us the strength to live this moment with some hope and happiness.”

While the reasons why the baby failed to survive have not been revealed, but given the fact that it was a twin pregnancy, the risk factors were higher and there could have been a number of reasons behind the tragedy.

Twin pregnancy, or a higher order multiple gestation brings its own set of risks, experts in the UAE told Khaleej Times what could go wrong, and why, and if there was a way to avoid complications and even stillbirth.

Dr Shamsa Al Awar, consultant obstetrics and gynaecology, chair of ObGyn Department at College of Medicine and Health Sciences at UAE University, said one reason why a twin pregnancy is considered high risk is because the biological norm for the human species is a single pregnancy and two or more growing embryos can cause significant stress on the body. “Every species is different when it comes to the number of embryos it is able to grow safely, and with humans, the default is a singleton pregnancy — any more than that is considered exceptional,” she said.

“Twins carry an increased risk of prematurity. The pressure on the uterus increases, as well as other issues that could occur if the foetuses are sharing the same placenta as in the case of some identical twins, which carries an even bigger risk,” she said, adding that is why a twin pregnancy is considered full term at 37 weeks, while a singleton is 40 weeks.

Dr Al Awar added that in twin pregnancies, the mother is also more prone to infections such as urinary tract infections (UTI) and chorioamnionitis (infection of the placenta and the amniotic fluid), which may also increase the risk of stillbirth.

“Stillbirth increases in multiple gestation,” Dr Al Awar stated. “The risk in twins is 3-6 times compared to a singleton, and in triplets its 10 times more.”

“Some of the reasons for stillbirth include preexisting maternal diseases such as diabetes, hypertension and pre-eclampsia; umbilical cord problems, intrauterine infections, birth defect from congenital abnormalities (like heart defects and defects in the abdominal wall),” she explained.

Al Awar said that planning can help avoid complications in any type of pregnancy.

“The best way to avoid complications is to plan your pregnancy. Start with preconception health counselling before you become pregnant. See a doctor and check what you can make better so that you minimise risks and maximise chances of a healthy pregnancy.

She continued: “Take folic acid at least three months before you plan to get pregnant. If you are obese, lose weight. Improve your lifestyle —if you are a smoker, for example, quit smoking, and ensure you have good nutrition and good sleep. You should prepare for the best journey ever.”

Dr Mandeep Singh, MD MRCOG, sub-specialist and consultant in foetal maternal medicine and CEO at Burjeel Farha (Women’s and Children) said that two of the most important decisions to make during pregnancy is to get access to healthcare as early as possible and to find the right doctor who specialises in multiple pregnancy.

“There are two things: one is early access to care, and getting access to the right centre,” he said, adding that it is important to understand that not every obstetrician can manage a twin pregnancy.

“Twin pregnancies need to be managed by centres that have experience in managing multiple pregnancies.

“Twin pregnancy is different from singleton pregnancy, and both the patients and doctors need to recognise that. Somehow, there has always been this culture that every doctor can manage the pregnancy. I think we need to move away from that.

“Twin pregnancy complications are very different from single term pregnancy. So screening for these problems and picking up problems at the right time and managing them in an appropriate way is the key to safe deliveries and safe outcomes.”

So how can one avoid complications that may lead to a stillbirth?

Dr Singh said one way is by “educating yourself, adopting a healthy lifestyle, access to the right doctors and proper plan of management are the three main factors.”

“So when you get access to good medical facilities, they will put all the things that are needed to make sure that the pregnancy is going well. These include booking a screening for chromosomal abnormalities, a screening for infectious diseases, a screening for diabetes, screening for pre-eclampsia, because these are the things that if found in someone at high risk, you can treat and make sure that they don’t have a poor outcome.

“There are things that we can do to prevent complications, and then, as the pregnancy advances, it is vital to keep looking for complications that may happen and managing labour appropriately. Labour cannot just be managed by one person. You need trained doctors, you need trained midwives, you need trained nurses looking after the patient.”

The specialist added that a scan is carried out every four weeks after 20 weeks gestation for non-identical (dichorionic twins) and every two weeks for identical twins (mono-chorionic twins) to rule out any complications.

Furthermore, he said factors that can make a pregnancy high risk include the mother having heart disease, having complications with the lungs or complications with the placenta, or suffering from high blood pressure in pregnancy or had some previous history. Other factors include the mother having suffered a previous loss of a child, or if she the previous delivery resulted in a baby below normal size and weight, or if the baby was born with some defect.

What is a stillbirth?

According to Cleveland Clinic a stillbirth is the death of a baby in the womb after week 20 of the mother’s pregnancy. The reasons go unexplained for 1/3 of cases. The other 2/3 may be caused by problems with the placenta or umbilical cord, high blood pressure, infections, birth defects, or poor lifestyle choices. Stillbirth happens in one out of 160 pregnancies yearly in the U.S.

Dr Singh: “We do not know all the reasons why these babies die but the most common reason is because of problems with growth.

He added that some of the risk factors include gestational diabetes, high blood pressure in pregnancy or preeclampsia which can all cause stillbirth.

“Then there are certain blood disorders that can cause stillbirth. So it's a very complex field,” he noted.

“The risk of stillbirth in identical twin pregnancies is 9 times higher than singleton pregnancies, and 4 times for non-identical (fraternal) twins.”

Furthermore, Dr. Kalavathy Subramaniam, Consultant Obstetrician & Gynaecologist at Corniche Hospital said other complications in twin pregnancy include breathing difficulty at later gestation due to an overdistended uterus/abdomen. "Twin pregnancy also carries higher changes of premature deliveries, twin-to-twin transfusion syndrome, selective intrauterine growth restriction of a twin, polyhydramnios and increased fetal anomalies."

Furthermore, Dr Subramaniam noted that "twin pregnancy is associated with higher cesarean section rates , post-partum hemorrhage and anemia in the mother."

rasha@khaleejtimes.com