Journal of Medical Sciences and Health

Introduction

Multiple pregnancies are associated with markedly high risks during pregnancy and the neonatal period compared to singleton gestations. These include an increased chance of preterm birth, low birth weight, and birth defects like congenital hydrocephalus [1-3]. Hydrocephalus, which is characterized by excess cerebrospinal fluid within the brain's ventricles, is recognized as a devastating complication—one that further amplifies the risk profile for preterm twins. The inherently shortened gestation of twin pregnancies exposes neonates to the dual threats of organ immaturity and the sequelae of any underlying congenital anomalies [4, 5].

Infants who are born at the edge of survival, particularly twins, are vulnerable not just to immediate perinatal complications but also to chronic health challenges that extend into infancy and beyond [2]. Within these, the coexistence of severe hydrocephalus and malnutrition

represents especially an unfavourable clinical trajectory, as each condition feeds into the other in a cycle of growth failure and neurodevelopmental delay [6]. Rural healthcare disparities, with their attendant barriers to care and nutrition, can further compound these risks.

This report presents a premature twin delivery where the surviving infant in a twin pregnancy developed congenital hydrocephalus and severe acute malnutrition soon after birth. Through this case, the interplay of biological vulnerability and social determinants in shaping outcomes among high-risk neonates is being reported.

Case Report

A female child was born after a lower-segment caesarean section (LSCS) at 30 weeks' gestation, as part of a twin pregnancy, in a rural health care setting. Weighing 1.08 kg at birth (25th percentile for gestational age), she cried shortly after delivery and registered healthy APGAR scores of 7 and above at both 1 and 5 minutes. Tragically, her co-twin died within the first hours of life, reflecting the acute perinatal hazards associated with prematurity in multiple gestations [1, 2].

The early postnatal period was marked by an absence of breastfeeding within the first hour—an opportunity often missed in low-resource settings. Surviving initial respiratory and metabolic adaptation, the baby required a prolonged two-month stay in a tertiary Neonatal

Intensive Care Unit (NICU) to support stabilisation and further maturation.

At six months, her caregivers noted progressive cranial enlargement [Fig. 1]. Medical evaluation and imaging revealed congenital hydrocephalus, attributed to aqueductal stenosis [Fig. 2]. The child underwent a ventriculoperitoneal shunt surgery [Fig. 1] to relieve raised intracranial pressure. However, over the subsequent months, despite successful shunt placement, she continued to exhibit severe undernutrition.

At one year of age, the infant's anthropometric measures showed an evident picture: a weight of 5.8 kg (well below the median of 8.4 kg for age), stunted length at 62 cm (against a median of 72 cm), and a MUAC of only 9 cm—all indicative of severe acute malnutrition per WHO criteria [Table. 1]. Head circumference gradually reduced post-operatively from 51 cm to 47 cm, yet remained above normal, reflecting residual hydrocephalus. Developmental milestones were significantly delayed—likely the cumulative result of prematurity, neurological dysfunction, and nutritional deprivation.

Dietary history revealed exclusive dependence on milk powder beyond the age of six months, with no introduction of appropriate complementary foods, contrary to recommended infant feeding guidelines. Immunisation documentation showed early doses administered [Table. 2], but subsequent critical vaccines—including Rotavirus, PCV, MR and Vitamin A—had been missed, increasing vulnerability to infectious morbidity.

Socioeconomic evaluation placed the family in Class IV under the Modified BG Prasad scale: the father earned a daily wage of approximately Rs. 400, supporting five dependents, with limited access to both healthcare and social safety nets. Though the family successfully registered for the Ayushman Bharat scheme, utilisation of these benefits was minimal. 

Discussion

This case exemplifies the grave compounding of vulnerabilities—prematurity, congenital hydrocephalus, severe malnutrition, and insufficient immunisation—in the context of rural poverty. Each factor, independently a driver of child morbidity and mortality, interacts synergistically in this setting, amplifying the risk to survival and healthy development.

Preterm delivery, especially in twin pregnancies, brings inherent perinatal hazards. Twins often have shorter gestations and more frequent complications due to organ immaturity compared to singletons, resulting in less favourable outcomes, especially when congenital anomalies like hydrocephalus are present [1, 2, 3]. Congenital hydrocephalus, particularly from aqueductal stenosis, poses critical risks: unchecked, it causes progressive intracranial hypertension, developmental delay, and, frequently, early death unless neurosurgical intervention—such as ventriculoperitoneal (VP) shunting—is performed in time. In this case, although shunt surgery was completed, the persistent neurological and nutritional challenges underscored gaps in continuity of care and systemic resource limitations [7].

Severe acute malnutrition (SAM), as reflected by the child's clearly low anthropometric scores (weight, length, and MUAC) which originates from inadequate feeding but also perpetuates a cycle of delayed recovery, repeated infections, and impaired neurodevelopment. Malnutrition directly diminishes immune function, further heightening susceptibility to common and vaccine-preventable illnesses [8]. In infants contending with a neurological disorder, these risks are magnified; up to a third of children with hydrocephalus in similar sub-Saharan settings are malnourished, leading to heightened morbidity and slower recovery [6].

Socioeconomic constraints, such as poverty, low paternal earnings, and large family size, are central to understanding the adverse trajectory in this case. The family's position in BG Prasad Class IV is suggestive of broader social and economic determinants that recur in reports of preventable child deaths in low-resource contexts [9]. Lack of parental awareness, health literacy, limited engagement with social safety nets, and geographic isolation from advanced care facilities make timely intervention difficult.

Immunization gap of PCV, Rotavirus, and MR, vitamin A (all crucial for infection prevention), reflect not only individual oversight but also structural deficits in primary healthcare reach and parental education. Immunization is globally recognized as among the most cost-effective public health tools, yet incomplete coverage remains a persistent problem in rural settings and contributes directly to excess mortality and severe illness in children like the one described here [10].

From a health systems vantage, this case demonstrates the urgent need to reinforce the continuum of antenatal and postnatal care—especially in regions where congenital anomalies, prematurity, and malnutrition converge but diagnostic and referral infrastructure are weak.

 In order to address the needs of such patients, a coordinated strategy is essential which include systematic antenatal screening for anomalies, robust community nutrition, feeding programs, and widespread immunization. The role of community health workers and public health teams in early identification and consistent follow-up of at-risk infants cannot be overstated. Only with integrated efforts—melding clinical excellence with social and public health interventions—can similar tragic outcomes be prevented moving forward.

Conclusion

Premature birth in a twin pregnancy, complicated by congenital hydrocephalus and severe malnutrition, presents an extreme challenge in rural and low-resource settings. This case re-emphasises the need for early detection, aggressive nutritional and neurological management, completion of immunisation, and the strengthening of rural public health systems. Moreover, taking care of socioeconomic and educational barriers alongside medical care is crucial to preventing similar tragedies and promoting holistic child health.

Disclosure

Authorship declaration: All authors are in agreement with the content of the manuscript. SR and RK designed the study. SR and SP has primarily collected data for this study. SR wrote the majority of the manuscript. SR, SP, JM, RK contributed to the analysis. SR, SP, JM and RK provided critical feedback and revision on the manuscript. All authors have read and approved the final version of the manuscript. 

Declarations of Ethics and Consent to Participate: All the ethical and consent process guidelines have been followed during the publication of this manuscript.

Funding: The authors received no financial support for the research, authorship, and/or publication of this manuscript.

Conflict of Interest: The authors declare that they have no conflict of interest.