BACKGROUND:

A gestational age of 32 weeks is categorized under moderately pre-term gestation. Advances in medical sciences have now permitted easy survival of infants born during this period with no long-term complications. However, the probability of possible anomalies cannot be nullified, especially in case of multiple viable foetuses, weighing 2090g and 1590g respectively. (Refer Table 1:Anthropometric Data)

PURPOSE OF WORK:

Through this case study, we strive for a brief exploration into one of the many aspects of Paediatrics: Twin Pregnancy. The case emphasizes on pre requisites, outcomes and complications of a preterm twin pregnancy, discussing its various aspects, connections with other fields of study, at the same time, encouraging Research and Innovations so as to improve the expectancy and quality of life.

CASE REPORT:

Foreword: Special thanks to Lozhkina Valentina Dmitrieva, Senior Teacher at Tambov Regional Children's Clinical Hospital, Tambov, 82 Ryleeva Street (ГБУЗ Тамбовская областная детская клиническая больница, Г.Тамбов, Улица Рылеева 82) for permitting us to carry out this case study and for immense co-operation in making ample of resources available for the same.

The study has been conducted with complete consent of Subjects of Discussion as well as their Guardians. All measures to ensure protection of Privacy were undertaken.

CASE:

A 27-year-old, primigravida women who was pregnant with diamniotic dichorionic twins, through assisted reproductive technique (In-Vitro Fertilization) was examined at 4 weeks of gestation for high risk of Termination of Pregnancy.

Isthemicocervical insufficiency pertaining to Cervical Dilatation without marked contractions was diagnosed and Obstetric Pessary was performed at 28 weeks of gestation, to treat the same. A successful Caesarean delivery, preceded by outpouring of amniotic fluid, of twins was reported at 32 weeks of gestation, a boy (twin A) and a girl (Twin B) were delivered. Their anthropometric parameters are as follows:

Anthropometric Data Table 1

1.Post Delivery Complications:

In Twin B: Ischemic haemorrhagic lesions of Central Nervous System and ephemeral Central Nervous System depression pertaining to Respiratory Failure of 2nd degree were observed. Additionally, Suppressed /Weakened Reflexes and mild motor dystonia were observed.

Reflex Analysis Table 2

A haemangioma of digits was also reported accompanied by mild degree of neonatal Jaundice (Bilirubin level: 200 mol/l).

(Normal bilirubin in pre-term infants: up to 170 mol/l)

Echocardiography revealed Failure of Closure of Foramen Ovale and a Patent Ductus Arteriosus with muffled heart sounds. No other anomalies were detected under Ultrasound.

Twin A: Similar complications were also observed in the second twin; however, some exceptional changes in bilirubin levels were as follows:

Bilirubin Levels Table 3

Inferences: Persistently elevated levels of Bilirubin in Twin A up until 5 weeks post delivery

Comparative Analysis of Neurological Complications, under Neurosonography in Twin A and Twin B

Comparison of Neurological Signs Table 4

Observation: Presence of Severe Degree of Neurological Disorders in Twin A over Twin

1. Probable Reasons for Central Nervous System disorder:

· Secondary Chronic Absolute Placental Insufficiency

· Hypoxia as a result of Respiratory Insufficiency of 2nd degree

· Persistently elevated levels of Bilirubin causing Neonatal Jaundice

INTERVENTIONS:

To combat Respiratory Insufficiency, Initially, suction for both the twins was performed using the nasopharyngeal tube. The twins were later injected with a minimally invasive method of Kursoff. Antibacterial Therapy with Ampicillin, Gentamicin, and Amoxicillin was given for respiratory infections like congenital pneumonia.

DISCUSSION:

On persistent follow up of the subjects and their health status, the following observations were made in a period of 4 years (2019-2023):

· Spastic Diplegia: A mild muscle dystonia was observed in both the twins post-delivery however a progressive exacerbation of the condition in the form of muscle stiffness of the lower extremities was observed with increasing age. Parents reported difficulty in crawling and late initiation of stable walking. The cause and progression of this Diplegia can be attributed to the above-mentioned neurological complications at birth.

· Placental Complications: Secondary Absolute Placental Insufficiency

Theory: Placental insufficiency generally occurs due to inadequate blood flow to the placenta and usually develops post 20 weeks of Gestation. Reasons may be attributed to the anomalies of placental vascular remodelling i.e., failure of transformation of the uterine arteries to large placental vessels in order to secure adequate blood supply of the placenta. As a result, placental functioning progressively deteriorates. This process affects the placental blood flow, leading to fetal hypoxemia, or low levels of oxygen in the blood, and restriction of fetal growth.

Inference: Presence of Neurological anomalies in twins can be as a result of insufficient blood supply to the brain leading to the development of Hypoxic ischemic Encephalopathy

· Elevated Bilirubin Levels (Refer Table 3:Bilirubin Levels)

Theory: During pregnancy, the mother’s liver removes bilirubin for the baby through glucuronidation but after birth, this function is gradually taken over by the baby’s liver. However, Neonates have limited ability to metabolize and excrete bilirubin. In some babies, the liver might not be developed enough to efficiently get rid of bilirubin. When too much bilirubin builds up in a new baby’s body, the skin and whites of the eyes might look yellow, which is known as Neonatal Jaundice. A mild form of Jaundice is fairly common. However, the case reports persistently elevated levels of Bilirubin up to 5 weeks post-delivery.

Such high levels Of Bilirubin may cause bilirubin to accumulate in the grey matter of the central nervous system, potentially causing irreversible neurological damage manifested as Cerebral Palsy in evidently in Twin A, in accordance with our case study. Bilirubin is known to accumulate in the grey of neurological tissue where it exerts direct neurotoxic effects. It appears that its neurotoxicity is due to mass-destruction of neurons by apoptosis and necrosis such severe form of hyperbilirubinemia puts the neonate at a high risk of kernicterus When severe jaundice goes untreated for too long, it can cause a condition called kernicterus. Kernicterus is a type of brain damage that can result from high levels of bilirubin in the baby’s blood

New-borns are especially vulnerable to hyperbilirubinemia-induced neurological damage, because in the earliest days of life, the still-developing liver is heavily exercised by the breakdown of fetal hemoglobin as it is replaced with adult hemoglobin and the blood–brain barrier is not as developed, further increasing the risk of Kernicterus. Therefore bilirubin levels must be carefully monitored in case they start to climb, in which case more aggressive therapy is needed, usually via light therapy but sometimes even via exchange transfusion.

Kernicterus frequently affects an area of the brain called the basal ganglia. When this area of the brain is damaged before, during, or shortly after birth, it can lead to cerebral palsy.

Inference: Persistently elevated Bilirubin levels in Twin A can be a cause of Cerebral Palsy

CONCLUSION: It can be concluded that pre-term Neurological complications can have multifactorial etiologies. Therefore, in order to make an accurate diagnosis and devise an accurate line of treatment, all of these factors should be taken into consideration.

Research so as to promote development of techniques for early detection of such complications and an in depth understanding of their occurrence is the need of the hour.

Efforts to eliminate iatrogenicity in such delicate cases should be undertaken and special training of doctors and nurses to manage such cases should be done at a massive scale.

Information about the Authors:

Dr. Gajendran Velmurugan

Student-Master’s Degree

Tambov State Medical University named after G.R. Derzhavin

Email - vegan.gj@gmail.com

Lonikar Samruddhi Anirudha

6th year at Tambov State Medical University named after G.R. Derzhavin

Email - samruddhi604@gmail.com

Singh Sonal Rajkumar

6th year at Tambov State Medical University named after G.R. Derzhavin

Email - sonalsingh1029@gmail.com

Shinde Sahil Umesh

6th year at Tambov State Medical University named after G.R. Derzhavin

Email – sahilshinde170899@gmail.com