Twin pregnancy: MBRRACE-UK’s Perinatal Confidential Enquiry into stillbirth and neonatal death in twin pregnancies

MBRRACE-UK have published a report on the themes arising from the care of 50 women whose pregnancies ended with the death of one or both twins.

Echoing the findings of so many recent maternity safety reports, MBRRACE-UK Perinatal Confidential Enquiry: Stillbirths and Neonatal deaths in Twin Pregnancies identifies failings, including lack of senior or specialist involvement, poor multidisciplinary teamwork, risk management and communication, which were common throughout these women’s and their babies’ care. The report also highlights a worrying lack of awareness, risk management, recognition of the ‘red flag’ signs and treatment of twin-to-twin transfusion syndrome (TTTS). In many cases, MBRRACE-UK found that this was lacking, and concluded that the outcome would have been different for 54% of the babies and 64% of the mothers if they had received better care.

Twin pregnancy: more complex, greater risk, more specialist care 

Twin (and other multiple) pregnancies are more complex and carry greater risks than singleton (one baby) pregnancies. Twins have double the stillbirth rate and three times the neonatal (newborn) death rate of singleton babies. Twin pregnancies are safer when they are managed more closely at all stages by multidisciplinary teams of midwives, obstetricians, sonographers and neonatologists, led by senior clinicians, and in good communication with the parents.

Different types of twins have different types of risk, depending on whether the unborn babies share a placenta. This is known as their chorionicity. Early ultrasound scanning to check the babies’ chorionicity helps reduce risk by planning appropriate care. All women with twin pregnancies, but especially those with monochorionic twin pregnancies (where the babies share one placenta and are at risk of TTTS) should be advised of the risks of their type of pregnancy, how to recognise important symptoms and get help. They should be involved in the planning of the birth and pregnancy care.

Findings of the MBRRACE-UK twin pregnancies report

The report focussed on the late fetal loss, stillbirth or neonatal death of 80 babies from 50 twin pregnancies. The care that they received was compared with relevant guidelines and standards available at the time of their births, in 2017. The MBRRACE-UK panels believed the outcomes would have been different for 54% of the babies and 64% of the mothers if they had received better care.

• Antenatal care

Many of the women did not receive the recommended standard of specialist multidisciplinary antenatal care with a named specialist midwife, a named sonographer and led by a lead consultant specialist within a dedicated team. Over half of the women were not advised of the risks of pre-term birth or the symptoms of pre-term labour. Three quarters of the women with monochorionic pregnancies were not advised of the potential complications of monochorionicity, including TTTS, before 16 weeks of pregnancy. The lack of a specialist core team led to a reduced level of recognition and management of risk in individual pregnancies, contributing to the loss of the pregnancy.

The report highlighted that its most concerning finding was in relation to antenatal care given to women with monochorionic twin pregnancy whose ‘red flag’ warning symptoms of TTTs were not recognised by emergency triage (prioritising of care) in maternity services.

The panel found that in six cases, undiagnosed TTTS was the most likely cause of injury to the unborn baby and that the outcome might have been altered by timely recognition of TTTS and laser ablation therapy. 

• Scanning

Ultrasound scanning has a key role in the care of twin pregnancies, where it helps with diagnosis, establishing chorionicity, risk assessment, screening for problems and growth-related complications. In monochorionic (shared placenta) pregnancies regular, specialist scanning by skilled senior clinicians is even more important in identifying potentially dangerous complications for the unborn babies, including twin-to-twin transfusion syndrome (TTTS).

The MBRRACE-UK report found that two thirds of the women who lost one or both twins had received sub-optimal care in their antenatal scanning which, in some cases, may have made a difference to the outcome. Areas of substandard care related to the lack of frequency of scans, inconsistent labelling of the twins (affecting accuracy of monitoring), failure to monitor the growth and estimated weight of each unborn baby or act on signs of abnormal growth or amniotic fluid volume. There were delays in referring women with complex monochorionic twin pregnancy to a specialist fetal medicine centre. There were also significant failures to recognise and diagnose TTTS, leading to delays in referral for timely specialist treatment.

• Labour and birth

19 out of the 50 women received substandard care during labour and birth. The panels found that in many cases when the woman was admitted in labour, there was a lack of preparation for the birth of her twins and she did not receive senior or multidisciplinary (obstetric and neonatal specialist) review. In a third of pre-term labours, there was a failure to administer antenatal steroids and magnesium sulphate which are known to improve the outcome for the newborn premature baby. In some cases, after the premature vaginal birth of the first twin had taken place, the delivery of the second twin was expedited immediately without good clinical reason.

• Neonatal resuscitation and care

16 women received substandard resuscitation or neonatal unit care which affected the outcome for one or both of their babies. The MBRRACE panel found instances where there was a lack of specific skills needed to manage the baby’s airway (ability to breathe) at birth, and differing resuscitation practises of babies born before 26 weeks of pregnancy.

• Communication with parents and within healthcare teams

Poor communication was a theme which ran throughout these women’s care. In addition to the previously mentioned lack of discussions with parents during their antenatal care, parents were not advised before and after birth about their babies’ chances of survival, or involved in decisions about resuscitation. After the death of their baby there was a shocking lack of bereavement support with some bereaved parents waiting up to 35 weeks for a follow up visit. None of the parents were involved in the investigations which followed their babies’ deaths.

Communication failures within the healthcare teams included lack of supervision and leadership in half of the twin pregnancies, which affected the outcome for the babies or the mother.

Boyes Turner can help recover compensation for mothers and babies injured during twin pregnancy

As yet another national audit highlights the tragic harm that babies and their families are suffering from negligent maternity care, our specialist birth and neonatal injury team remain committed to helping injured families recover their entitlement to compensation. Whilst nothing can undo the harm that has been done, our clients value the support that compensation can provide in paying for the needs of a disabled child and counselling for psychological injury to the bereaved parent. We are experienced in claims involving negligent management of complicated twin pregnancies and deliveries, such as TTTS, late second twin and vaginal breech deliveries.

If you or a member of your family have suffered serious injury as a result of negligent maternity or neonatal care, and you would like to find out more about claiming compensation, contact us by email at mednegclaims@boyesturner.com.