Biology concepts – twins, dizygotic, delayed interval
delivery, steroid hormones, lung development, time of birth
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Leonardo DiCaprio starred as
the twins Louis and Philipe in
the latest iteration of The Man In The Iron Mask. I’m partial
to Gabriel Byrne, Gerard
Depardieu and Jeremy Irons as the
three musketeers. Louis and
Philipe were monozygotic
twins, and they are more
often born in close proximity,
but not always.
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This isn’t the first time twins have thrown a cog in the
works of succession. Consider the case of The
Man In The Iron Mask. Alexandre Dumas gives us a story of intrigue, murder,
revenge and affairs of state in 17th century France. King Louis XIV isn’t the
ruler that France deserves, but he’s the one in power and he is cruel.
The musketeers obey him, but begrudgingly. When it comes to
be known in the halls of the palace that a young man in the country looks just
like the king, we learn that Louis XIV is a twin. The prior king had sent the
younger twin (by minutes) to the country to avoid the problems of succession. Louis
XIV finds him, imprisons him and forces him to wear the iron mask.
Needless to say, everything turns out just fine. Philipe,
the younger twin replaces Louis on the throne with the help of the musketeers
and saves the populace from starvation. So, yes, in the end it seems that twins
can be a bother on succession.
The real story of the iron mask most likely includes an
older brother, not a twin. No one really knows who he was, but he was a
prisoner of Louis XIV and was hidden behind a mask. He died in 1703, and his
treatment while in prison suggests that he was a royal. Hence, the idea that he
may have been a brother of the king.
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This is the birth of a baby
orca at Sea World in San Diego
last year. When is the baby
born? Some people say it’s when
the baby takes its first
breath. This is tough to judge for a
whale; it is born underwater,
but it has to breathe air. The
first thing mom does is lead baby to the surface. So, the
most common determination is
when the whole body
is outside mama.
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The first thing to consider is what defines time of birth.
Because certain actions, like delivering the body after the head is out, or
cutting the umbilicus after delivery can be delayed by complications, time of
birth is usually defined as when the complete body hits the air. For a natural
birth, this means a decent time gap between twins. They’re coming down a one
lane road and there’s no room to pass or drive side by side. In C-sections,
it’s almost always just a minute or two difference, but with natural delivery
the average is 17 minutes.
If that time gap comes at the right moment, twins can be
born with different birthdates. How many twins this affects in the US is low –
and here’s why. About 98% of US births take place in the hospital, and this is
probably higher for twins because the risks during delivery are higher.
Hospitals like to deliver babies when it is more convenient
for doctors and staff, so they induce labor plan caesarian section births for
day time. Therefore, the hours of the day when most babies are born in the
United States are between 8:00 am and 9:00 am and between noon and 1:00 pm.
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Most mammals are born during
the inactive period for
their species – diurnal
animas are born at night and
nocturnal animals are most
often born in the day. Pigs, for
example are born in the
nighttime, so are horses – just
ask any veterinarian.
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The time of midnight is an artificial construct, made by man
to order his day, so having one twin born on the left of midnight and the other
born on the right side doesn’t really make a difference. Their birthdays differ
by one digit and mom and dad might feel compelled to plan two different
parties, but that’s about it.
Likewise, if the twins are born across a midnight that
occurs on the last day of a month, then twins could be born in different months
– astrologists might consider this important, but I don’t know who else would.
Your accountant might point out that if the two children were born across the
midnight hour on December 31st, then you’ll get the tax exemption on
just one of your two kids for that first year. OK, now I’m listening.
Aaron and Luke Hegenberger were born on the night of
December 31st, 1999. Aaron was born at 11:53 pm, while Luke was born
just a few seconds after midnight. So, even though they entered the world separated
by only eight minutes, the boys were born on different days of different months
of different years of two different millennia!
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Twins born by C-section have
shorter gaps between births
for obvious reason. The short
time to second birth is
important, as second twins do
better with shorter gaps. One
study showed how much more
stressed the second
twins are while another discussed the idea that
C-section is suggested if the
time between births is getting
low, even though C-section
has its own risks.
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There can be growth discordance, where one fetus just
matures faster than the other. Delivering twin A might be warranted, but twin B
could use another few days of maturation. This brings us to the idea of delayed interval delivery (DID) of
multiples. Medical professionals now have ways to deliver one baby and delay
the birth of the second.
It is a sad thing to contemplate, but twin pregnancies are
associated with higher rates of miscarriage. When one twin dies in utero and
must be delivered, all efforts are made to save the second twin. This would
include delaying its delivery until it is past the 25th week. Just a
few days can make all the difference.
The lungs are the primary concern when delivering preterm
infants. At about 25 weeks of gestation, the lungs begin to change morphology.
They go from the canalicular stage (tubal) to the saccular stage, meaning they
start to develop alveoli, the air exchanging sacs of the lung.
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Retinopathy of prematurity is
caused by using high tension
oxygen with preemies. The
high pressure oxygen helps with
immature lungs, but it causes
overgrowth of blood vessels
in the retina and can lead to
complete blindness. This
occurred a lot in the 1960’s
before they realized the risks.
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A six year study in a different birthing center
showed a 14.3% survival for 22-25 week first twins, but delaying the birth of
the second twin by just nine days on average improved their survival to 57.1%.
This is astonishing.
I can think of two main issues when delaying birth of the
second twin; 1) how to stop the second twin from coming out, and 2) how to make
the most of the delay time. Both are critical and both can be managed in some
cases.
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Oxytocin is the hormone that
induces labor contractions. They
are described as wave-like.
They start at the top and contract
down the sides of the uterus.
This forces the baby’s head
toward the birth canal.
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Doctors can close the birth canal with sutures (called cervical cerclage); this often has the
same effect on contraction production, or they can use an endometrial loop.
But the main issue is to get the second baby’s lungs to
mature so that they can survive on the outside. You could just wait as long a
possible to deliver the second baby, but giving them a push is better. Antenatal corticosteroids (ante =
before and natal = birth) corticosteroids are a way to help out.
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Baby Stewie from Family Guy
got into some steroids and bulked
up in one episode. These
steroids are different from the
glucocorticoids used to
induce lung maturation. Stewie took
anabolic steroids, but both
are lipid and have receptors inside
the cells, not on the surface.
Warning, steroids DO NOT give you
big muscles, they just let
you recover faster, so you can work
harder to get big muscles –
and they cause major health problems.
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Just a few days of steroids will
significantly improve the outcomes of premature births, and all of these
techniques together allow for some amazing delays in twin delivery. The record?
Well, the longest ones I could find in the literature were 104 days in one case
and 101 days in another (that's 3.5 months!) – these were with cervical cerclage and tocolytic treatment. But it also occurs in natural deliveries. A 2012 case in Ireland
occurred where the contractions just stopped after the delivery of a first
premature twin. Eighty seven days later her sister was born. So – do we still define twins as babies born
about the same time?
Next week – let’s shatter the last of the twins definitions.
Do they have to come from the same father? Do they have to be conceived at the
same time? No and no.
Reinhard, J., Reichenbach, L., Ernst, T., Reitter, A., Antwerpen, I., Herrmann, E., Schlösser, R., & Louwen, F. (2012). Delayed interval delivery in twin and triplet pregnancies: 6 years of experience in one perinatal center Journal of Perinatal Medicine, 40 (5) DOI: 10.1515/jpm-2011-0267
Padilla-Iserte, P., Vila-Vives, J., Ferri, B., Gómez-Portero, R., Diago, V., & Perales-Marín, A. (2014). Delayed Interval Delivery of the Second Twin: Obstetric Management, Neonatal Outcomes, and 2-Year Follow-Up The Journal of Obstetrics and Gynecology of India, 64 (5), 344-348 DOI: 10.1007/s13224-014-0544-1
Lewi, L., Devlieger, R., De Catte, L., & Deprest, J. (2014). Growth discordance Best Practice & Research Clinical Obstetrics & Gynaecology, 28 (2), 295-303 DOI: 10.1016/j.bpobgyn.2013.12.003
Hjortø, S., Nickelsen, C., Petersen, J., & Secher, N. (2014). The effect of chorionicity and twin-to-twin delivery time interval on short-term outcome of the second twin Journal of Maternal-Fetal and Neonatal Medicine, 27 (1), 42-47 DOI: 10.3109/14767058.2013.799657
For more information or classroom activities, see:
Delayed interval delivery -