© CLIMB and Dr. PectorJune 2007ISTS A Potpourri of Multiple-Birth Loss Elizabeth A. Pector, M.D. Spectrum Family Medicine, S.C. & Jean Kollantai President

June 2007 ISTS © CLIMB and Dr. Pector

A Potpourri of Multiple-Birth Loss

Elizabeth A. Pector, M.D.Spectrum Family Medicine, S.C.

& Jean Kollantai

President and Founder, Center for Loss in Multiple Birth


Maternal & Perinatal MortalityUnited States live plural births are still rising

1989 92,9162002 132,549 (nearly 1/4 of all LBW are multiples)2003 136,3282004 139,495 (50% increase over 1989)

U.S. maternal deaths: multiple was 3.6 times singleton rate, 1979-2000.U.S. 1989-99. Twin neonatal mortality dropped 37%, stillbirth dropped 48%. U.S. 2004: Twins have 5 times, triplets 9 times, and quadruplets 28 times, higher

infant mortality than singletons. 4,249 deaths of liveborn multiples

U.S. 2004: Multiples had 3% of live births, 15% of infant deaths. U.S. 2003: Multiples had 3% of live births but 9% (2,336) of fetal deaths. U.S 2003: Twins have 3 times, triplets 4 times, higher fetal mortality than

singletons. African-American multiple loss rates much greater than white. Sweden 1991-2001: Twins have 2.4 times, triplets 5.8 times, higher stillbirth

than singletons.Absolute number of perinatal multiple deaths roughly stable for 20 years.

Intact sets will suffer loss as they age in decades to come.

April 21, 2006 NAPSW © CLIMB and Dr. Pector

Types of Multiple-Birth Loss First to Second Trimester (before viability)

Spontaneous loss of all fetuses Spontaneous loss of some fetuses: “going longer”

Intrauterine demise Delayed interval delivery

Adverse prenatal diagnosis: “knowing ahead” Anomaly Monochorionic complications…TTTS, MCMA, conjoined

Iatrogenic: “best of difficult choices” Multifetal pregnancy reduction (MFPR) Selective termination

Third trimester & neonatal-stillbirth Complicated delivery, prematurity, anomaly

Later Infancy & childhood Late effects: birth event, prematurity or anomaly SIDS, SUDC Accidental, illness, rare intentional harm to child

Teen or adult losses Combinations of any or all of the above


Fetal loss: prognosis for survivor

Co-twin prognosis following 1 twin’s demise after 14 weeks: 2nd twin demise: Monochorionic 12%, dichorionic 4% Survivor neurologic abnormality: Monochorionic 18%,

dichorionic 1% Ong et al, BJOG 2006 113(9):992-8.

Survivor cerebral palsy: possible slight increase after vanishing twin Newton et al, Twin Res 2003 6(2):83-4. Pinborg et al, Hum Reprod 2005 20(10)2821-9.


Grief with multiples

6 key concepts (CLIMB) Complicated, simultaneous Essential to acknowledge all multiples

Loss of once-in-a-lifetime parenting opportunity or unique sibling relationship.

Entire experience colors every part Long process of putting pieces into a whole Care as for singleton bereavement, + multiple-specific Overwhelming confusion & uncertainty


Grief with multiples Loss of all multiples: (35% of CLIMB membership)

Longer, more intense than singleton. Most go on to become parents through own pregnancy or adoption.

Loss of some multiples: Longer, as intense as singleton. Often consider survivors

part of the original group. 2 surviving triplets are NOT twins! Toddler-age, childhood bereavement:

Influence of age, stage, ? zygosity Teen bereavement:

Influence of age, development, multiple relationship Adult bereavement:

Equal or greater than for other family, spouse (MZ); Influence of gender & zygosity

Risk of complicated grief for parents and for surviving siblings at all ages


Perinatal/child grief complicating factors

Infertility, multiples, medical trauma to mother, prematurity, disability, all increase depression risk for parents.

Medical & ethical questions, second-guessing “Did we & the doctors do the right thing?” Little guidance. Rare situations, exploring medical literature.

“Multiple encounters” Encounters with multiples in medical settings, family, friends,

public, media: parents recall the loss of “my multiples” Comments from those who are unaware or will not

acknowledge loss (especially 2+ survivors) Raising survivors, relating to their loss


Family & social issues in loss

Family = co-multiple, parents, grandparents, siblings, friends. Communication is critical; relationships are strained. Importance of child/adult co-multiple involvement in funerals

Isolating factors: Multiple-loss itself is rare, poorly understood Unusual family/s (same-gender, surrogacy, adoption) Disenfranchisement: “You still have one.” “Two out of three

is ok.” “You lost too many.” “That’s what you get for playing God.”

Later functioning High risk for complicated grief (perinatal and later) Risk for suicidality in adult surviving twin after co-twin

suicide What is “OK” after 3-5 years, 5-10 years, & later?


Response: VOICES of griefEach loss is unique. Respect differences, privacy. Validate: Acknowledge loss of individual(s) AND of group identity.

Verbalize: Ask the bereaved about feelings, desires & choices. Orient, inform: Offer information on all grief/disposition options. Involve: Encourage memories & keepsakes of each multiple &

the set together. (14-15 wk demised fetus visible at term) Viewing, holding, photos, clinical mementos, sketches Matching items for each multiple, living and dead Caregiver letters for each multiple Ask about cultural or religious desires, prohibitions.

Community/Counseling Offer counseling & peer support…more than once

Exit strategy: Help with decisions, logistics (transfer mom/stable neonates/deceased), out-of-hospital care.

Support: After the hospital Creative ideas for remembrance Support options


Progress in loss support since 2002

CLIMB website Other Internet support groups & sites Collaboration with COMBO organizations Translations of CLIMB & other loss information (i.e. Multiple

Births Canada) French, Spanish, Chinese, Russian…German to come

Dependable support for bereaved parents and adult survivors in many countries US, UK, Canada, Australia, New Zealand

Empiric research (MPR, Dr. Pector’s perinatal loss surveys) Grief is still profound, but can proceed without anger over lost

opportunities when parents get appropriate mementos. Parents inform survivors of loss, respect their level of grief (or

lack of grief), recognize it will differ from their own.


Multiple multiples: 2 sets of identical twins“Nothing will ever replace or make up for it…mementos are critical.”

having twins again has gone a long way to healing. At times I feel selfish that there is a void &…no matter what joy we have with B. & R. it can never replace what has been lost. -- dad who lost the first set of identical twin boys, had a second set of identical boys 2-3 yr later.

11% of CLIMBfamilies who have had a loss in one multiple pregnancyhave another, intact set of multiples.


More work remains! Research is needed on:

Loss of all multiples Outcome of survivors of co-twin fetal loss (all trimesters) Loss of some high-order multiples with 2+ survivors Parent needs & support in NICU after multiple loss Effective outreach to ethnic minorities for multiple loss Support for repeat multiple gestation (“multiple multiples”) Late follow-up of MPR families, and communication with living

children about MPR Loss of a multiple to SIDS: specific support for parents and

survivors Loss of a multiple as a toddler or young child: specific support

for parents and survivors Results of counseling & support groups for parents &

survivors (including adult survivors of vanishing twins) Research using the pair method of twin mortality (Rebecca

Hartman, PhD)


Cultural factors

Varied beliefs about multiples’ origins & traits Desired, good luck, godly, returning ancestors Evil, bad luck, devil/animal, result of infidelity Shared soul, one’s death may lead to other’s death without

proper precautions; both lonely Treat multiples reverently or equally to avoid death

Faith & religious tenets don’t always comfort. Suggest all bereavement options, including those not

ordinarily accepted in one’s faith background. Some have prohibitions on seeing, naming. Some African

cultures avoid grief for one twin’s death. Some faiths require prompt burial; limited time to obtain

memories & mementos.


Cultural factors

Alternative health and belief systems “Myth of the vanishing twin” (Schwartz)

Postulated lifelong impact of early fetal loss Prenatal psychology, alternative psychotherapy Support groups, or minorities, may reject “medical model” of

grief. Internet culture

International, multilingual support Information available anonymously Easily accessible support for unusual losses

Rapid intimacy in discussing difficult topics Some information of dubious quality Potential deception, anger, rants


Contact info & resources

[email protected], Jean Kollantai

Synspectrum.com/[email protected], Beth Pector

Documents

© CLIMB and Dr. PectorJune 2007ISTS A Potpourri of Multiple-Birth Loss Elizabeth A. Pector, M.D. Spectrum Family Medicine, S.C. & Jean Kollantai President