The Carles Sisters
Julia and Jose Carles are expecting quadruplets, and only five sets of quadruplets are born in the UK each year. However, monochorionic quadruplets are almost unheard of, with only one other set of them in the world alive today. It will be a miracle if all four babies make it to the full nine months of pregnancy.
Professor Nick Fisk is one of the UK’s leading obstetricians and he tells us “It’s almost impossible to give an accurate statistic for the chance of four quadruplets surviving intact and healthy; it’s well less than 50% for having four healthy quads”.
Conventional quads, with one placenta each, are usually born at least nine weeks premature. Monochorionic quads, sharing just the one placenta, have a high risk of being born even earlier. In normal pregnancies, mother and baby are scanned only twice; at twelve and twenty weeks. Julia and Jose must come to London every week to ensure the babies are healthy and growing. Everyone knows these are one in a billion babies, but until they are born they are simply referred to as baby A, B, C and D.
Registrar Dr Kielan O’Donoghue reveals, following the latest scan, that the babies are girls. Their joy may be short-lived, as the first in a series of difficult decisions must now be tackled. With multiple pregnancies, a reduction of embryos is often suggested. With all four girls sharing the same placenta, competition for nutrients is stiff. A selective reduction results in the termination of one or more of the embryos, so that the stronger ones survive. The choice is stark. Jose tries to explain “How can we pick one life to end. It would be different if they could tell us that one was severely disabled and unlikely to survive, then we would discuss the possibility of having a reduction”.
Julia is six months into her pregnancy and the health of one of the babies, known as baby A, is causing alarm. Julia and Jose travel to Queen Charlotte’s Hospital in Chelsea, a centre of excellence in the care of multiple births. Dr Kielan O’Donoghue details the condition of the quads. She’ll only be certain all the girls are alive when she can identify four beating hearts. The good news is that all four are alive and moving.
Professor Fisk “All four babies are in reasonable condition, although we’ve had some slight concerns about the growth of one or two of them, but that’s a situation in these single-placenta, multiple-births which can go on for several weeks before it gets worse”. The babies are all OK but, because of the increased risk to baby A, Professor Fisk and his team have decided that Julia must stay in hospital for round-the-clock monitoring, so that any further complications are picked up.
No-one cane predict when Julia might go into labour, so Jose returns home and waits for news. While Julia counts the days, Jose is counting boxes. With four new babies on the way, the Carles family need a bigger house.
The move to the new house has kept Jose busy for a week and just when he was least expecting it, he receives a ‘phone call; Julia is having contractions. Julia’s still only 7 months pregnant, far too soon for the quads to survive if they were delivered now. Julia is given drugs to slow the contractions and steroids to help the development of the babies’ lungs.
Professor Fisk has a word with her “You’ve had these for about 14 hours and they haven’t done an awful lot to the neck of the womb and that’s the ultimate arbiter we use for what’s happening. If you were 34 weeks, we’d say go ahead and deliver, but you’re not. The survival rate increases by about 1% each day, so every day counts”.
Next morning, Professor Fisk returns to assess Julia’s condition. The swab that would indicate real labour was normal, so things should settle down. The fact that the babies are girls is in their favour as the survival rate for girls is about two weeks better for girls than for boys.
She is now at 27 weeks, the contractions have stopped and the survival rate is up to about 80%.
Another week and the quad’s growth is again giving Professor Fisk cause for concern. Babies C and D are fine at about a kilogram each, baby B is smaller, but baby A has not grown in the last two weeks. They have to be cautious as baby A is at the front of the womb making it harder to measure accurately.
Professor Fisk is desperate for Julia to hang on for at least two more weeks and he knows that while babies B, C and D will gain vital weight, baby A may not grow any more. Julia and Jose are determined to give them all the same fighting chance of survival. But, this life or death decision is taken out of everyone’s hands by the results of more tests.
The latest scan shows a decline in baby A’s blood flow; the sign Professor Fisk has been waiting for. The babies will be delivered now; 11 weeks premature. Delivery has to be by caesarean section.
Everyone in theatre is on high alert, the last set of monochorionic quads delivered in the world were all born with life-threatening complications.
Baby D is born first and taken away by the paediatric team. Although the quads share one large sac, they have each been developing within their own smaller protective sac made of a thin membrane. All the babies are placed in incubators and taken to the special care unit. The girls lungs have only developed to the size of a thumbnail so the first 48 hours will be crucial.
Baby D, Ellie, weighs just over a kilogram, baby C, Georgina, is slightly heavier, baby C, Holly, comes in under 900 grams but baby A, Jessica, weighs only 770 grams; that’s 1.5 pounds.
The Carles quads are now 3 days old. They each weigh less than 2.5 lbs and their lungs are barely functioning. They’ll spend the first few weeks of their life in intensive care until they’re out of danger.
Knowing that their babies are in the best possible hands, Julia and Jose must, reluctantly, leave their little girls and return home. Weeks of anxiety lie ahead. If the quads can put on weight and manage their own breathing, they will be well enough to go home. The girls lungs are still too weak to suck a bottle or nipple, so they are fed via a tube to their stomachs. As a precaution, tubes in their noses deliver oxygen by continuous positive airway pressure or CPAP.
A month on and Holly, Jessica, Georgina and Ellie have gained weight and their lungs have developed so they no longer need to be in intensive care. They are being moved to a local special care baby unit, not far from their new home. This means that mum and dad can visit much more frequently.
After 7 months of traumatic pregnancy and weeks of intensive care, at 8 weeks and 5 days old, the day that nobody thought would ever happen has arrived. The Carles sisters are on their way home.
