Life Support

Cooper Freedman's Day Off
By Nancy Kiu, Director of Medical Research

IVF procedures have increased the amount of multiples being born, and in a world full of Jon and Kate Plus 8 and Octomoms, it would appear as if carrying multiples to term safely has become commonplace. But as Charlotte and Cooper find out in this episode, that's far from the truth.

According to studies published on the medical research database UpToDate, the two biggest risks for complications in a pregnancy of multiples is either complete pregnancy loss or preterm birth. In cases of preterm birth, about 95% of triplets have low birth weights, and 35% have very low birth weight, and preterm birth is very common in the case of multiples – the average length of gestation for triplets is around 32 weeks.

All this means that there's a lot for Charlotte and Cooper to consider in the case of the CoopLettes – should they attempt to carry all three babies to term, and increase the risk for both Charlotte and the unborn babies? Or should they consider selectively reducing from triplets to twins?

Studies show that carrying triplets to term doubles the risk of developing severe pregnancy diseases and complications, but that by reducing from triplets to twins, the risk of severe prematurity is decreased, as well as fewer pregnancy losses. In addition, selective termination can be a safe and effective means for termination for abnormal or normal fetuses in a pregnancy of multiples. And medical outcomes aren't the only consideration – many parents don't understand the economic and psychological impact of births of multiples, including the intensity of care that infants can require – preterm and low birth weight infants often require costly neonatal care and long-term developmental follow up.

In addition, studies also show that there's a large risk of spontaneous loss of one or more of the fetuses between when a triplet pregnancy is diagnosed through when they are delivered; in fact, over 50% of triplet pregnancies result in a spontaneous reduction and oftentimes the embryo is re-absorbed back into the womb or by one of the other fetuses.

A debate about selective reduction brings up all sorts of tricky areas surrounding pregnancy in general - an argument could be made that if a pregnant woman's body allows for a natural spontaneous loss in over half of triplet pregnancies, by selectively reducing, are we not doing what nature might have intended already? And should financial consideration be a factor in having children? If there is no medically indicated reason to do it, is there a difference between selective reduction and abortion, even though in the cases of selective reduction, the entire pregnancy isn't being ended, just a reduction of the numbers in the womb? Would considering selective reduction be different if the multiples were conceived naturally vs. via IVF?

Each couple facing a pregnancy of multiples must make this decision for themselves, and they must make it fast – the time frame to have the selective reduction debate is usually around 10-14 weeks. Any later, and it starts becoming risky. While Cooper accurately points out the dangers of carrying triplets to his pregnant wife, Charlotte counters that they can't reduce now – they've already told Mason that he's going to be a big brother to triplets. Will this decision come back to haunt them?

Charlotte ends up going into labor early, at 26 weeks, which means that the babies could be at risk for cognitive and neurological impairments, and many organs, like their lungs, aren't fully developed. Addison safely delivers the first baby, but the baby's not without complications as she has ectopia cordis, which means that her chest wall isn't fully formed and cannot protect her heart. Sam rushes into surgery and saves her, but what about the other two babies?

Addison hatches upon the plan of a delayed interval birth, which involves delivering one of the multiples prematurely and then halting Charlotte's labor and keeping the other two babies in her womb so that they'll have time to continue to develop. In cases of delayed interval births, some of the babies can be born days, weeks, or even months apart; every extra day in the womb means a better chance at survival. Delayed interval births aren't without dangers, though – statistics show that maternal morbidity in a delayed interval birth is over 30%. Charlotte tells Addison to chance it and give her girls more time to cook, so Addison stitches up Charlotte's cervix and places Charlotte in the Trendelenburg position, which means that Charlotte's bed is angled thirty degrees so that when lying down, Charlotte's head is below her feet, which hopefully will help relieve some of the pressure.

Fun Fact: when breaking this episode, the writers were curious about the effects of being in the Trendelenburg position, and created a mock bed in a thirty degree position to lie in. The many side effects of being in this position include headaches, as the blood rushes to your head. In short – it's not comfortable, and we weren't even pregnant!

Charlotte must now remain on bed rest for the duration of her pregnancy – given how ornery Charlotte has been already, will being on permanent bed rest break the normally unbreakable Charlotte King? Will CoopLette #1 survive in the NICU? And will these extreme measures help give the remaining two CoopLettes a fighting chance at survival? Needless to say, with everything going on, it's the last day off Cooper Freedman will have for a long time.