Twice the Luck

At some point in every twin pregnancy, you will make the transition to the high risk team, also known as maternal fetal medicine (MFM).  Even if you are fortunate enough to have a complication free pregnancy, all twin pregnancies are inherently higher risk (no pregnancy is without risk but carrying two babies has a whole lot more risk) and should necessitate a referral to MFM.

It can be overwhelming and scary to hear that your pregnancy is classified as high risk and to suddenly be referred to new doctors outside of the practitioners that you had selected and had imagined navigating your pregnancy with.  I want to spend some time talking about our experience with MFM and how we felt about the change.

First MFM Appointment

At first we fell through the cracks a bit and our referral to MFM was delayed by a few weeks.  This is something we came up against again and again The American medical system is just that – a system and in prenatal, it’s a system set up for singleton pregnancies. It can be frustrating and just plain difficult to try to get it to bend to fit a twin pregnancy.  Because of this delay, our referral to MFM felt a bit rushed and no one mentioned to us that this was standard procedure for a twin pregnancy so we went into it already on edge.

To be honest, that whole first appointment was a bit of a gut punch.  In reality, it was probably just bringing us back down to earth but from the “we’re having twins” buzz, but it was a tough wake up call.  Additionally, this doctor had a very blunt approach which did not make a gentle delivery.  We continued to see her as part of our MFM team and she did really improve once she got to know us.

The doctor went through all the possibilities of what could go wrong with twin pregnancies in general and our particular flavor of twin pregnancy specifically.  As the mother carrying a twin pregnancy, I was more likely to develop preeclampsia and gestational diabetes.  Twins are more likely to have one or both babies be growth restricted and then there is the particularly horrible nightmare that is vanishing twin syndrome.  

Our boys were monochorionic-diamnitic, also known a mono-di or mo-di, twins which means they shared a placenta but had their own amniotic sack.  Having their own separate amniotic sacks means that they were much less high risk than mo-mo twins, where both twins are in the same amniotic sack. However, sharing a placenta put them in a much higher risk category than if they had their own.  

One of the greatest risks to mo-di twin in utero is from twin to twin transfusion syndrome (TTTS).  This is where the shared placenta gets plumbed wrong.  When everything is working correctly, the placenta acts as a split funnel channeling equal amounts of blood and nutrients to each baby.  When TTTS comes on the scene, a route between these two opens so that the nutrients meant for one baby get siphoned into the other baby One baby thrives and the other starves.  There is treatment, a laser procedure that cauterizes that the vessels linking the babies, so frequent monitoring is necessary to make sure TTTS is caught early.  Translation – a lot of ultrasounds.

One of the last things the doctor talked about was more general, nebulous risk that I found the most frightening.  As mo-di twins, our twins started as a single fertilized egg that split into two soon after fertilization.  This is another one of those “pregnancy is the final frontier” moments.  We aren’t entirely sure why the egg splits.  Sure, there are a lot of theories, but just as many unknowns.  As a result, that split is considered a mutation and one mutation means the babies are more likely to have more mutations so their growth would have to be closely monitored.  Translation – a lot of ultrasounds and at least one echocardiogram on each baby while in utero.

Processing

It was definitely a quiet ride home after that appointment.  Even though the doctor had ended on a positive note, that everything with our babies looked good right now, the weight of all the possibilities was hard to carry around.  In the end, we did carry it.  There’s no hard and fast answer to how you handle the what ifs.  My husband and I talked a lot about how we were feeling and that made everything less lonely.  We did our own research and that made everything feel less unknowable and so more scary.  

PLEASE be careful what sites you use for research.  We stuck to names that we knew – Johns Hopkins, the Mayo Clinic.  Most large medical centers have very informative sites.  I found that the more I read, the more I had a framework in my mind that helped me filter out the crap because it simply didn’t make sense.

The single thing that helped the most with the lingering feeling for waiting for something to go wrong was, unfortunately, time.  The more appointments we went to, the more eyes that were on our babies, including ours, the better we felt.  I always felt a little nervous before each appointment, worrying that this would be the one where they found something.

The Logistics

As a high risk pregnancy, you will have lots of appointments.  So many appointments.  I have an ultrasound with a follow up appointment with one the MFM doctors every two weeks.  The poor schedulers at the hospital had quite the workout.   They had to find an opening with ultrasound immediately followed up an opening with one of four MFM doctors in the ball park of every two weeks.  This is where the hospital system really has a hard time with twin pregnancies – an ultrasound for multiples has to be longer than an ultrasound for a singleton.  It’s pretty common for hospital schedulers to forget that or really struggle to shoe horn the longer time slot into already packed hospital schedules.  Be nice to your schedulers – they have their work cut out for them!

While every ultrasound didn’t go the lengths of a full anatomy scan, they were pretty comprehensive.  Every two weeks, the techs measured the babies, the amount of amniotic fluid, the placenta, and checked the flow into and out of the placenta.  You start to get the pattern of everything – monitoring the babies’ growth and the flow from the placenta is checking for any signs of TTTS.  Any changes in the amount of amniotic fluid can also be a sign that something is not right with one of the babies.

Overall, we had a great experience with our MFM doctors.  I found them to be thoughtful, thorough, and above all, practical.  They told us up front when we should be worried about something and when we shouldn’t.  They were very practical about treating my symptoms and always had a pretty exhaustive list of any pros and cons when we needed to make a choice.  I know that my experience with my area hospital will not be the same for everyone, but I truly hope you have as positive experience as I did.