to the editor: This letter was written in reaction to the “Diary from a Week in Practice” feature published in the May 1, 1998, issue of American Family Physician.¹ It was with a mixture of surprise, pleasure, anxiety and grief that I read the news that Dr. Frisbie is expecting twins. I have followed “Diary” closely since I learned in September 1996 that I was pregnant with twins. Although I felt overwhelmed by the news at the time, I took some comfort in knowing that Dr. Shupe had successfully completed a twin pregnancy and seemed to have achieved a healthy balance between her family responsibilities and an active, interesting practice. Her associates seem to be uncommonly supportive, and I'm fortunate to be affiliated with a similarly understanding group of family physicians. I'm sure Dr. Frisbie will enjoy the same support, professionally and personally, that Dr. Shupe was privileged to have.

My own story took a tragic turn with the intrauterine demise of my son Bryan. His death was discovered during a routine prenatal visit, and his surviving identical twin, Jared, was urgently delivered that day at 33 weeks' gestation. I am grateful that my now 15-month-old survivor is doing well. My sorrow for the brother he and I will never know leaves me with ambivalent feelings when I read about other multiple pregnancies, such as the well-publicized McCaughey septuplets.

I wish to remind my colleagues that multiple pregnancies carry a significantly higher risk of morbidity and mortality for both the mother and the infants, and that issues in grieving the loss of pregnancy in multiple gestations are misunderstood. With the rising number of twin pregnancies, as noted in “Diary,” it is important that physicians not minimize the grief process that parents undergo when either a “selective reduction” procedure is undertaken or an accidental loss occurs early or late in a multiple pregnancy. In particular, attempts to reassure parents that they “at least” have one or more survivors from the pregnancy will damage the physician's relationship with them.

Properly grieving the loss of the equally desired child promotes healthy development of surviving children from the same pregnancy, in addition to children who were born previously or subsequently. Parents want and need to hear that their physician is concerned about their adjustment to such a loss. Simple gestures, such as asking how they're coping when they bring surviving children to the physician's office for well-child examinations or mentioning the deceased child by name at a well-woman examination after delivery or even a year or two later, will greatly enhance the quality of your professional relationship with these families.

Support networks are available for families facing these complex situations. Centers for Loss in Multiple Birth (CLIMB), Inc. (P.O. Box 1064, Palmer, AK 99645; telephone: 907-746-6123; e-mail: climb@pobox.alaska.net) has helpful materials for both parents and professionals dealing with the loss of one, more or all of the children in a multiple pregnancy, including prenatal loss, loss by selective reduction or loss later during childhood.

Second, an organization is available to help surviving twins whose loss occurred at any time from before birth through adulthood. This organization provides information and support for both the surviving twins and the people who are close to them: Twinless Twins (c/o Dr. Raymond Brandt, 11220 St. Joe Road, Fort Wayne, IN 46835; telephone: 219-627-5414; e-mail: brandt@fwi.com; Web site: www.fwi.com/twinless). I have no connection with these organizations other than as a mother who has received valuable support from them.

I wish Dr. Frisbie the best of health during her pregnancy and a happy, successful delivery with minimal discomfort or disability preceding it. I'm sure Dr. Shupe will adequately prepare her for the inevitable questions from patients about whether twins run in her family or if she used fertility drugs. Part of the art of family practice is learning how to disclose an appropriate amount of personal information while keeping the encounter focused on the needs of the patient. I wish Dr. Frisbie good luck in her own journey through this territory. My patients were among my greatest supporters during my emotional recovery process, and by sharing my story, I've been able to empathetically assist other patients who have experienced their own unfortunate losses of pregnancy.