A tale of two twins: A detailed case presentation of preterm neonates with divergent clinical courses
Selvi. S1*, Shanmuga Priya 2, Divya. E2
1Senior Registered Nurse, NICU, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu
2Registered Nurse, NICU, Kauvery Hospital, Vadapalani, Chennai, Tamil Nadu
*Correspondence
Abstract
Background: The management of preterm twins in the Neonatal Intensive Care Unit (NICU) presents a complex interplay of shared gestational risks and individual postnatal challenges. This case report details the clinical journeys of dichorionic diamniotic twins born at 31 weeks gestation.
Cases Presentation: Twin A and Twin B were born via emergency Lower Segment Cesarean Section (LSCS) for maternal anemia. Both presented with severe respiratory distress syndrome (RDS) requiring intubation, surfactant administration, and mechanical ventilation. Twin A’s course was typical for a preterm infant, complicated by apnea of prematurity and managed with non-invasive ventilation and caffeine citrate. In stark contrast, Twin B’s neonatal period was dominated by a surgical crisis: an acute intestinal volvulus on day of life (DOL) 8, requiring emergent bowel resection. This was further complicated by post-operative sepsis, a patent ductus arteriosus (PDA), and prolonged respiratory support.
Conclusion: These cases highlight the necessity for vigilant, system-based nursing assessment and intervention in the NICU. They underscore the importance of recognizing subtle clinical changes from abdominal distension to oxygen desaturations that can signify life-threatening events. The report provides a detailed chronology of care, emphasizing the critical role of the neonatal nurse in respiratory management, surgical post-operative care, infection control, nutritional support, and family-centered discharge planning.
Key words: Neonatal Intensive Care Unit (NICU); Lower Segment Cesarean Section (LSCS); Respiratory Distress Syndrome (RDS)
Introduction
Prematurity remains a leading cause of neonatal morbidity and mortality. Infants born before 32 weeks gestation are at heightened risk for a cascade of complications, including respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), and sepsis. The birth of preterm twins compounds these risks, requiring a highly coordinated and specialized nursing approach. This case presentation follows two preterm twins from their delivery through their complex and ultimately divergent hospital courses, offering a comprehensive look at the multifaceted role of the NICU nurse.
Case Presentation
Maternal and Birth History
- Mother: G2P1L1, with a history of anemia in the current pregnancy.
- Delivery: Emergency Lower Segment Cesarean Section (LSCS) was performed at 31 weeks gestation due to maternal anemia.
- Placenta/Membranes: Clear liquor noted. Dichorionic diamniotic twins.
Infant Demographics and Immediate Postnatal Period
| Characteristics | Twin A | Twin B |
|---|---|---|
| Date of Birth & Time of Birth | 31/7/25 at 9.13 am | 31/7/25 at 9.14 am |
| Birth Weight | 1.01 kg | 1.178 kg |
| APGAR Score | 4 at 1 min; 7 at 5 min | 4 at 1 min; 7 at 5 min |
Nursing Note (Delivery Room): Both infants required immediate intervention. Resuscitation was initiated per NRP guidelines. The nurse’s role included preparing and checking the radiant warmer, suction equipment, and T-piece resuscitator, and assisting the medical team during high-risk delivery.
Respiratory Course: A Shared Beginning
Both infants followed an identical path in the first hours of life, consistent with RDS in preterm infants.
- Initial Resuscitation: Both were placed on T-piece resuscitation (PEEP 5 cm H₂O, PIP 20 cm H₂O) for poor respiratory effort.
- Deterioration & Intubation: Due to worsening respiratory distress, both were intubated with a 3.0 mm endotracheal tube (ETT) within the first hour. A chest X-ray for both confirmed low lung volumes, suggestive of surfactant deficiency.
- Surfactant Administration: Under strict aseptic precautions, both received a first dose of surfactant (Neosulf). Twin A showed moderate improvement. Twin B remained pale with persistent acrocyanosis and showed no clinical improvement, necessitating a second dose of surfactants.
Nursing Considerations (Respiratory – Initial Phase)
- Preparation: Priming and checking the T-piece resuscitator, preparing the ventilator, and ensuring surfactant is readily available and properly warmed.
- Procedure: Assist with intubation, ensuring correct ETT placement (auscultation and Et CO₂ detector). Administer surfactant via the ETT as per protocol, while continuously monitoring heart rate and oxygen saturation.
- Ongoing Assessment: Frequent assessment of breath sounds, chest movement, vital signs, and oxygen saturation. Monitoring complications of RDS and surfactant administration, such as pulmonary hemorrhage or pneumothorax.
The Divergent Path: Twin A’s Progress
Weaning and Apnea of Prematurity
Twin A’s respiratory status improved. He was extubated to High-Flow Nasal Cannula (HFNC) 24 hours of life. However, he developed classic apnea of prematurity with episodes of desaturation and bradycardia, which resolved with gentle tactile stimulation.
- Intervention: A loading dose of Caffeine Citrate (20 mg/kg) was given, followed by a daily maintenance dose (5 mg/kg/day). This respiratory stimulant is a cornerstone of nursing care for prematurity apnea.
- Cardiovascular: Acrocyanosis gradually improved. Peripheral pulses were well felt. There was no pre-ductal/post-ductal saturation difference. A screening 2D Echo on day 16 was normal.
- Infection: A peripheral intravenous line was secured on DOL 3. A 5-day course of empirical antibiotics (Piperacillin-Tazobactam & Amikacin) was completed after a negative sepsis workup (CRP and blood culture).
- Feeding: Total Parenteral Nutrition (TPN) was initiated and gradually transitioned to enteral feeds as tolerated. He had one episode of asymptomatic hypoglycemia which resolved with adjustment of intravenous fluids.
The Divergent Path: Twin B’s Surgical Crisis
Acute Abdomen: Volvulus
On Day of Life 8, Twin B’s condition took a dramatic turn. The infant, who was being weaned from respiratory support, developed:
- Subject: Irritability increased gastric residuals.
- Objective: Persistent, localized upper abdominal distension, bilious aspirates from the orogastric tube.
Nursing Assessment & Action: The bedside nurse immediately recognized bilious aspirates as a cardinal sign of intestinal obstruction until proven otherwise. The infant was made NPO (nil per os), and the medical team was notified STAT.
- Diagnostic Workup.
- Abdominal X-ray: Showed dilated bowel loops.
- Stool for occult blood: Positive.
- Consultation: Pediatric Surgery was consulted immediately.
- Diagnosis: Terminal ileal obstruction, suspected volvulus.
Surgical Intervention and Post-Operative Care
On DOL 10, Twin B underwent an exploratory laparotomy.
- Intra-operative Findings: A distal ileum volvulus with gangrenous changes was found. A 20×25 cm segment of non-viable bowel was resected, and a primary anastomosis was created.
- Histopathology: Biopsy revealed transmural necrosis and muscular hypertrophy, compatible with gangrenous bowel secondary to intestinal obstruction.
- Post-Operative Course: The infant returned to the NICU intubated (Mode A/C/PC, PIP 20, PEEP 5, FiO₂ 50%).
Nursing Considerations (Post-Operative)
- Handover: A thorough handover from the operating room team was obtained, including details of the surgery, intra-operative blood loss, and current lines/drains.
Systems Assessment
- Respiratory: Meticulous ventilator management, monitoring for atelectasis (common post-op), and pain-related splinting. Chest X-rays revealed evolving infiltrates in the right middle/lower lobe, later involving the left, suggestive of pneumonia/atelectasis. The nurse administered nebulization and chest physiotherapy to aid in secretion clearance.
- Surgical Site: Monitoring the abdominal incision for bleeding, infection (redness, swelling, discharge), and dehiscence.
- Gastrointestinal: The infant remained NPO with an orogastric tube to low intermittent suction. Meticulous measurement of output. The nurse monitored for return of bowel sounds and passage of meconium.
- Pain: Frequent pain assessment using a validated neonatal pain scale (e.g., NIPS or PIPP). Administration of analgesics as ordered.
- Cardiovascular: The infant developed tachycardia with fluctuating oxygen requirements. He was noted to be anemic (Hb – 9.98 g/dl) and was transfused with 20ml of Packed Red Blood Cells. A 2D Echo revealed a Patent Ductus Arteriosus (PDA) with pulmonary hypertension, managed with a 3-day course of oral Paracetamol.
- Respiratory Weaning: Ventilator support gradually weaned. On DOL 14, he was successfully extubated back to HFNC, which was eventually weaned to nasal pillows on day of life 19.
Complications Common to Both Infants
Sepsis and Infection Control
Both infants were at high risk for hospital-acquired infections.
- Twin A: Received and completed a course of antibiotics for suspected early-onset sepsis, which was later ruled out.
- Twin B: Had a more complex course. Initial antibiotics were stopped, but a blood culture drawn on DOL 16 later grew Candida parapsilosis (a fungal infection) on DOL 20, requiring targeted antifungal therapy.
Nursing Interventions
- Meticulous Hand Hygiene: The single most important intervention.
- Line Care: Strict aseptic technique for accessing and maintaining central and peripheral lines.
- Surveillance: Daily assessment for subtle signs of sepsis (temperature instability, lethargy, glucose intolerance, increased apnea). Monitoring lab values, especially C-reactive protein (CRP), which was markedly elevated (CRP > 29 mg/L).
Nutritional Management and Feed Intolerance
- Twin A: Progressed well, with feeds gradually advanced.
- Twin B: Faced significant challenges.
- Parenteral Nutrition: Required TPN for an extended period pre- and post-surgery. The nurse monitored for complications like line infection and cholestasis.
- Re-introducing Feeds: Feeds were carefully re-introduced post-surgery and advanced slowly, monitoring closely for signs of intolerance (abdominal distension, emesis, increased gastric residuals). He required supportive medications, including anti-reflux agents and prokinetics.
- Weight Gain: Daily weights were crucial to track growth and ensure adequate caloric intake.
Hyperbilirubinemia and Neurological Status
- Jaundice: Both infants developed hyperbilirubinemia, a common issue in preterm infants. Total bilirubin levels were monitored, and phototherapy was initiated as per protocol. For Twin B, the peak was T. Bilirubin 31.5 mg/dL, which decreased to 8.3 mg/dL with treatment.
- Cranial Surveillance: Serial cranial ultrasounds were performed on both infants to screen for intraventricular hemorrhage (IVH), a major concern in preterm. All scans were reported as normal. Head circumference and anterior fontanelle were assessed daily.
Screenings for Prematurity
- Retinopathy of Prematurity (ROP): Screening was performed at the appropriate chronological age. Twin A (Zone 2, Stage 1) and Twin B (Zone 2A, Stage I) both showed early ROP, requiring follow-up in 2 weeks.
- Hearing: Otoacoustic Emissions (OAE) screening was passed by both infants.
Family-Centered Care and Discharge Planning
- Communication: The nursing team played a vital role in communicating the twins’ progress to the parents, explaining complex medical terms, and preparing them for the possibility of surgery for Twin B. The emotional support provided during the crisis was invaluable.
- Kangaroo Mother Care (KMC): Once stable, both infants were initiated on KMC. The nurse trained the mother in proper positioning, duration, and the benefits of skin-to-skin contact for thermoregulation, bonding, and breastfeeding support.
- Feeding Education: The mother was taught Paladai (spoon) feeding as a bridge to direct breastfeeding, ensuring the infants received expressed breast milk.
Discharge Coordination
- Medications: Parents were educated on administering iron supplements and other discharge medications.
- Follow-up: Appointments were scheduled for ROP re-screening, neurodevelopmental follow-up, and routine vaccinations.
- “Rooming-in”: If available, a period of rooming-in allows parents to provide all care under nursing supervision before going home.
Outcome
Twin A was discharged home on day 26 of life with a weight of 1.42 kg. Twin B, after a more protracted 38-day stay, was discharged home weighing 2.25 kg, with head circumference 29.27 cm. Both were referred to as ongoing high-risk follow-up.
Discussion & Learning Points for Neonatal Nurses
This case presentation offers several key learning points for NICU nurses:
- The Unpredictability of Prematurity: Even twins with identical beginnings can have vastly different outcomes. The nurse must maintain a high index of suspicion for complications in every infant.
- The Critical Importance of Assessment: The early recognition of bilious aspirates in Twin B was a life-saving nursing intervention. It exemplifies the need for thorough, system-by-system daily assessments and the ability to differentiate between benign and pathological findings.
- Mastery of Respiratory Support: From T-piece resuscitation to conventional ventilation and HFNC, the NICU nurse must be proficient in all modes of respiratory support, understanding the principles behind each and the subtle signs that indicate improvement or deterioration.
- Comprehensive Post-Operative Care: The care of a surgical neonate requires specialized knowledge in pain management, wound care, fluid and electrolyte balance, and the gradual reintroduction of enteral feeds.
- Infection Prevention is Paramount: Constant vigilance and adherence to aseptic protocols are the primary defenses against hospital-acquired infections in this vulnerable population.
- The Nurse as a Bridge to Home: The transition from the NICU to home is a major milestone. The nurse is central to preparing the family, building their confidence, and ensuring a safe discharge.
This detailed case presentation underscores that the practice of neonatal nursing is a dynamic blend of high-technology care, astute clinical judgment, and profound human connection.
