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What can cause the loss of a baby during pregnancy?Sadly, pregnancy loss in the first 12 weeks (early miscarriage) is common. It usually happens because the embryo is not developing as it should.
The risk of losing a baby in the first two trimesters of a twin pregnancy is slightly higher than with a single pregnancy. And this risk is increased for twins who share a placenta and/or an amniotic sac (identical twins) (NCCWCH 2011: 28).
A miscarriage after 12 weeks and before 24 weeks (late miscarriage) is much less likely to happen. A late miscarriage may be caused by a problem with the uterus (womb) or cervix (NHS Choices 2011), but this is not always the case.
For many parents who have suffered a late pregnancy loss, the word "miscarriage" doesn't properly capture the gravity and impact of their bereavement. Grieving parents sometimes feel that what they have suffered is the loss of a baby, or a stillborn baby. The medical definition of a stillborn baby is one who is lost at or after 24 weeks of pregnancy (NHS Choices 2009a).
In many cases, the reason or cause of a miscarriage cannot be found, and nothing could have been done to prevent it.
The loss of a baby at any stage is hard to bear, both for you and your loved ones. As well as being painful, it is often a frightening and bewildering experience. Although it can be hard to know where to begin, it can help to talk to loved ones, or to other parents who have been through the same experience.
Is loss more common for twins than single babies?Unfortunately, the loss of a baby is slightly more common (Sands 2009). About 12 out of every 1,000 twin births and 31 out of 1,000 triplet births result in a baby who is stillborn. This is compared with about five in 1,000 singleton births (NCCWCH 2011: 27).
The risk of stillbirth in twins increases slightly after 38 weeks. So if a mum hasn't already had twins by the time she is 38 weeks pregnant, a caesarean or induced labour is usually suggested (NCCWCH 2011: 138, 174, 188). This is especially the case with identical twins, as sharing a placenta increases the risk of a baby being stillborn. That's why it's often recommended that twins are born by 37 weeks (MBF 2010, NCCWCH 2011: 28, RCOG 2008).
What happens when one twin dies in the uterus?The loss of a twin during the first trimester of pregnancy doesn't usually affect the development of the remaining baby (Anderson-Berry 2010). This is called vanishing twin syndrome, and happens when a twin pregnancy is found at a very early scan but only one baby is seen at your dating scan.
You may experience few or no symptoms, apart from some mild cramping and spotting or light bleeding (Anderson-Berry 2010). But if you've had an early scan and were excited about expecting twins, you may feel bereft when you find out you're expecting one baby.
With the loss of twin in the second or third trimester, complications with the remaining twin are more likely. Your doctor will carefully monitor you and your baby. She'll strive to get the right balance between giving your baby a little longer in your uterus, and assessing if it's safer for him to be born early.
Most babies whose co-twin is lost in the second or third trimester are born healthy. However, there is an increased risk of problems such as cerebral palsy, particularly for identical twins (Anderson-Berry 2010, NCCWCH 2011: 150, Ong et al 2006, Pharoah 2001). There is also an increased risk of going into labour early.
You may feel distressed by the idea of the twin who has died remaining in your uterus with his surviving twin. On the other hand, some mums feel comforted by the fact that their twins are together. You may even feel guilty about any happiness you feel about your surviving baby. All these feelings are perfectly understandable. Hospital staff can help you to plan a birth that respects your loss, while meeting the needs of your surviving baby.
How will losing a twin affect us?Losing a baby is a tragedy that affects you, your partner, and those close to you in many ways (RCOG 2011, NHS Choices 2009).
You may feel a range of difficult emotions. This may include:
- Denial, holding on to the belief that doctors have made a mistake, and that both your babies will be born alive and healthy.
- Guilt, feeling that you caused your loss through being fearful of having twins. Or because you wanted a baby of a different sex, or didn't want two babies.
- Anxiety, worrying that your grieving may affect your ability to bond with your surviving baby.
- Fear that your surviving baby will become ill, or even die.
- Failure or disappointment, as expecting twins felt special, and the birth of the single, surviving baby may feel like an anticlimax.
Your grief may be not only for the loss of a precious baby, but also for the loss of being a parent of more than one baby (Tamba nd). Your doctor can refer you to a bereavement counsellor if you feel it would help.
Depending on the stage of your pregnancy loss, there may also be practical matters to deal with, such as organising a funeral. You may not be able to focus on your surviving baby as much you'd like to at this difficult time.
Your grief may emerge or re-emerge later than when you first heard of your loss. Celebrations such as Christmas may be hard to cope with. And when your surviving twin reaches a childhood milestone, such as when he takes his first steps, it may bring your grief to the fore again.
How can we remember our baby?You may gain comfort from a memory box which contains ultrasound scans or other mementoes that remind you of your baby. Your surviving twin can also look through this box when he is old enough (Tamba nd).
If your surviving twin is able to learn about his twin, it may help with his sense of identity (Schott et al 2007).
You and your partner may want to know if your babies were identical. This may help you to be aware of your genetic profile for future pregnancies (Schott et al 2007). Knowing this may also be important to your surviving twin.
How will it affect my wider family?Your friends and family may find it difficult to say the right thing. Being aware of this may help you to cope with, or be prepared for, any unintentionally hurtful comments when they happen.
In the future, you will need to decide if and how to tell your surviving child about the loss of their twin. It is usually recommended that you do this early on (Schott et al 2007).
If you make your loss part of everyday conversation then it's likely that your friends and relatives will too, rather than avoiding the issue. Your friends and family can help by not focusing solely on the surviving baby. Mentioning by name the twin who has been lost gives you the opportunity to express your grief.
The grandparents of your lost twin may feel sadness for your loss as well as for losing their own grandchild. They may also feel sad about the loss of the special status associated with having twin grandchildren.
Where can I get support?The Twins and Multiple Births Foundation (Tamba) bereavement support group offers advice and support for families who have lost one or more children. And you can talk to other parents about the loss of a twin in our community.
The Stillbirth and Neonatal Death Charity (Sands) offers support for anyone who is affected by the death of a baby.
If, after a few months, you feel as if you're not coping with everyday life, or things are getting worse, talk to your doctor or midwife. They'll be able to refer you for bereavement counselling or reflection sessions at your local hospital. These sessions allow you to return to the hospital, talk about what happened, and ask for any information you may need.
Anderson-Berry AL. 2010. Vanishing twin syndrome. eMedicine. emedicine.medscape.com [Accessed May 2012]
Glinianaia SV, Pharoah PO, Wright C,et al. 2002. Northern Region Perinatal Mortality Survey Steering Group. Fetal or infant death in twin pregnancy: neurodevelopmental consequence for the survivor. Arch Dis Child Fetal Neonatal Ed. 86(1): F9-15
Kohner N and Henley A. 2001. When a baby dies: the experience of late miscarriage, stillbirth and neonatal death. London: Routledge
NCCWCH. 2011. Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period. National Collaborating Centre for Women's and Children's Health, NICE Clinical Guideline. www.nice.org.uk [pdf file, accessed May 2012]
NHS Choices. 2011. Miscarriage. NHS Choices, Health A-Z. www.nhs.uk [Accessed May 2012]
NICE. 2011. Antenatal care for women who are pregnant with twins or triplets: understanding NICE guidance. www.nice.org.uk [Accessed May 2012]
Ong SS, Zamora J, Khan KS, et al. 2006. Prognosis for the co-twin following single-twin death: a systematic review. BJOG. 113(9):9 92-8
RCOG. 2008. Management of monochorionic twin pregnancy. www.rcog.org.uk [pdf file, accessed May 2012]
Sands. 2009. Saving babies' lives: report 2009. London: Sands
Schott J, Henley A, Kohner N. 2007. Pregnancy loss and the death of a baby: guidelines for professionals. 3rd edition. London: Sands
Tamba. 2012. Tamba twins and multiples healthcare survey. Guildford: Twins and multiple births association