Twin pregnancy - complications and causes of claims for compensation

According to the NHS, twin and multiple pregnancies are becoming more common. Today, 1 in 65 births in the UK are twins or multiple babies, compared with 1 in 100 in 1984.

Twin pregnancies carry greater risks for the mother and baby than ‘singleton’ pregnancies. Twin pregnancy is in itself one of the risk factors for many possible complications of any pregnancy, such as pre-eclampsia, intrauterine growth restriction (IUGR) and gestational diabetes, but twins also have complications of their own.

For this reason, twin pregnancies must be treated as high risk. This means they need careful monitoring for early signs of complications and planning ahead to ensure that skilled obstetric care is available at the time of birth. Regular scanning and monitoring in pregnancy, correct advice and planning about mode of delivery, skilled maternity care in labour including electronic fetal heart-rate monitoring, and experienced management of the delivery are essential to avoid injury to the mother and babies.

What are the different types of twin pregnancy?

Different types of twins need different levels of care, including the number of antenatal appointments, tests and scans that should take place. The parents can find out what type of twins they have, as well as checks for dates and Down Syndrome screening, at the antenatal ultrasound scan appointment which usually takes place at between 11 to 14 weeks of pregnancy.

The three types of twins are:

• DCDA - dichorionic diamniotic twins – where each baby has their own placenta with its own separate inner membrane (amnion) and outer membrane (chorion). All non-identical twins and one third of identical twins are DCDA. DCDA twins have the lowest risk of all twins.
• MCDA - monochorionic diamniotic twins – where the twins share a single placenta with a single outer membrane and 2 inner membranes. Two thirds of identical twins are MCDA. MCDA twins have the highest risk of developing a dangerous abnormality of the placenta called twin-to-twin transfusion syndrome or TTTS. MCDA twins need more frequent scans and monitoring. The mother may be referred in pregnancy to a fetal medicine centre for specialist care.
• MCMA - monochorionic monoamniotic twins – where the twins share both the inner and outer membranes. Only 1 in 100 pairs of identical twins are MCMA. These rare twins need specialist care with frequent scans and close monitoring as they have an increased risk of cord entanglement, which can be life-threatening for the babies.

Complications of twin pregnancy

Twin or multiple pregnancies have a higher risk of pregnancy complications, such as:

• Anaemia

Iron deficiency anaemia can usually be treated with iron tablets, folic acid supplements and diet. If left untreated, anaemia increases the risk of serious injuries, such as maternal and fetal death, intrauterine growth restriction (IUGR) and developmental problems, infection, heart failure, and the body’s ability to tolerate bleeding.

• High blood pressure (hypertension), pre-eclampsia and HELLP syndrome

Women carrying twins are more than twice as likely as other pregnant women to develop high blood pressure. Hypertension often develops earlier and becomes worse in twin pregnancies than in those with a single baby. High blood pressure can be a sign of other serious conditions. It also increases the risk of detachment of the placenta (placental abruption).

High blood pressure and protein in the urine (proteinuria) are symptoms of pre-eclampsia, a pregnancy-related condition which can be dangerous for both mother and baby if left untreated. Other symptoms may include swelling (oedema)of the face, ankles or hands, severe headaches, visual disturbance and abdominal pain. Treatment usually involves admission to hospital and bedrest to lower the mother’s blood pressure, but sometimes the only way to avoid the risk of serious injury from the condition is early (often premature) delivery.

HELLP syndrome is a very dangerous condition which needs urgent treatment. It is similar to pre-eclampsia but is often mistaken for other conditions, leading to delays in vital treatment. The name HELLP is an acronym describing key features of the condition: Haemolysis (breaking down of red blood cells; ELevated liver enzymes; and Low Platelet count (which affects blood clotting). Symptoms include high blood pressure, proteinuria, swelling, visual disturbance, headache, nausea and vomiting or indigestion after eating, and pain in the abdomen or upper body on deep breathing.

Like pre-eclampsia, HELLP syndrome develops in the later stages of pregnancy and often can only be treated by delivery of the baby, with or without a blood transfusion for the mother. Untreated, women with HELLP syndrome can become critically ill or die from liver rupture or stroke. Unborn babies are at risk of stillbirth or brain injury from placental failure or abruption.

• Intrauterine growth restriction (IUGR)

Twins are often slightly smaller than single babies, but restricted growth of one or both twins can also indicate problems with the placenta or umbilical cord or other conditions which, if undetected, can put the babies’ lives at risk. Unborn twins’ growth should be monitored regularly by ultrasound scans so that problems with growth can be detected early and the babies delivered prematurely if necessary.

• Gestational diabetes

Gestational (pregnancy-related) diabetes can often be controlled by diet and exercise but may need treatment with tablets or insulin injections to keep the mother’s blood sugar levels under control. Where diabetes is uncontrolled it increases the risk of other complications of pregnancy, including high blood pressure and pre-eclampsia, shoulder dystocia, stillbirth, prematurity, neonatal problems including breathing difficulties, hypoglycaemia and jaundice.

• Premature birth

Premature birth (before 37 weeks of pregnancy) and low birth weight (below 5.5lb) are the most common complication which affects twins and other multiple pregnancies. 60% of twins are born before 37 weeks. The figure increases to 80% for triplets.

Babies who are born prematurely may not have fully developed organs at birth. They may need help with breathing and feeding and may find it difficult to control their body temperature or fight off infection. They are at risk of other serious conditions, such as retinopathy of prematurity which can lead to permanent blindness if not diagnosed and treated early. They usually need care in a neonatal intensive care unit after birth.

• Twin to twin transfusion syndrome (TTTS)

TTTS is a rare but serious complication that affects 10-15% of identical twins who share a placenta (monochorionic). MCDA twins are at highest risk but TTTS also affects MCMA twins. It can also affect triplets and other multiple births. TTTS is caused by abnormal blood vessel connections in the placenta which allow more of the blood supply to flow to one twin than the other. This can leave the ‘donor twin’ undernourished and anaemic without enough blood. Meanwhile, the ‘recipient twin’ risks heart failure from its cardiovascular system being overloaded with too much blood and complications from too much amniotic fluid.

When twin pregnancy is complicated by TTTS, careful monitoring with frequent ultrasound scanning is required to monitor the growth and wellbeing of the babies. Urgent referral to a fetal medicine centre may be needed for specialist treatment. Delays in diagnosis of TTTS or referral to a specialist fetal medicine centre for treatment can cause death or brain damage to the unborn babies.

• Unplanned vaginal breech delivery

The method and timing of the birth of twins, triplets or other multiples must be carefully planned with the mother and an experienced obstetrician, as the risk of placental failure and other complications increases if the pregnancy is allowed to go on for too long. Twin deliveries usually take place in hospital in the presence of a multi-disciplinary team of maternity professionals, including midwives, an obstetrician and paediatricians. Throughout labour and delivery, the unborn twins must be carefully monitored, using electronic fetal heart monitoring.

In the UK, more than half of all twins and nearly all triplets are delivered by caesarean section. This is particularly important for the babies’ safety where:

• the first baby is in the breech position (bottom, feet or knees first);
• one of the twins is in the transverse position (lying sideways);
• the placenta’s position makes safe vaginal delivery difficult;
• the twins share a placenta;
• the mother has had a previous caesarean section or difficult delivery. 

Around 40% of twin births take place by vaginal delivery. Sometimes, even if a caesarean section was planned, vaginal delivery may become the safer option once the mother has gone into labour spontaneously. These births need careful management by obstetricians who are skilled in handling the complications of twin births, including unplanned vaginal breech delivery. Serious birth-related brain injury claims often arise from emergency situations in which inexperienced or unskilled junior obstetricians are faced with having to manage an unplanned vaginal breech delivery.

Boyes Turner helps twins obtain compensation after birth injury

Where negligent management of twin pregnancy, labour or delivery has caused brain injuries, such as cerebral palsy, or severe neurological disability, we help their family recover substantial compensation to meet the child’s needs arising from their disability.

Some of our recent cases include:

• A liability settlement (with damages to be assessed) and an early £250,000 interim (part) payment for a child whose brain was severely damaged as a result of delay in referring his mother to a specialist fetal medicine centre for laser ablation treatment for twin to twin transfusion syndrome;
• £24 million equivalent settlement for a second twin who suffered devastating brain damage and cerebral palsy from hyperstimulation of her mother’s uterus during induction of labour.
• £2.9 million settlement for a second twin who suffered a severe hypoxic brain injury and cerebral palsy when his oxygen supply was cut off by the umbilical cord around his neck during a negligently delayed delivery.

If you or your child have suffered severe injury as a result of negligent maternity care, and you would like to find out more about making a claim, contact us by email at cerebralpalsy@boyesturner.com.