Excerpted from Double Duty: The Parents’ Guide to Raising Twins, from Pregnancy through the School Years (2nd Edition) by Christina Baglivi Tinglof Copyright © 2009 by Christina Baglivi Tinglof. Excerpted by permission of McGraw-Hill. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Chorionic Villus Sampling
What? Chorionic villus sampling (CVS) is relatively new in the medical community. With the aid of ultrasound, a catheter (thin tube) is inserted into a woman’s cervix (transcervical) or a thin needle is inserted through her abdomen (transabdominal) and a small amount of the developing placenta cells are extracted and then cultured in a laboratory. There’s very little discomfort to the patient who undergoes transcervical CVS, the feeling is similar to a pap smear; transabdominal CVS patients may find the pinch of the needle slightly more uncomfortable.
Why? The test can detect chromosomal abnormalities such as Down syndrome, cystic fibrosis, and Tay-Sachs disease, among others.
When and How Often? Chorionic villus sampling is usually performed once between Weeks 10 and 12.
Pros and Cons. Since CVS can be performed early in pregnancy, some couples choose it instead of amniocentesis. Primary results are available within 48 hours (compared to the standard two weeks for amniocentesis results). There’s a lower complication rate—both physically and psychologically—if selective termination is chosen when one fetus has an abnormal result. The downside of CVS, though, is its slightly higher risk of spontaneous abortion (approximately 1 percent for singleton pregnancies; about 4 percent for multiple pregnancies) as well as the possibility of fetal limb defects (documented in patients who had the procedure done prior to 10 weeks). There’s also a chance of amniotic leakage. In addition, the test can’t detect neural tube defects such as spina bifida.
Maternal Serum Alpha-Fetoprotein
What? Maternal serum alpha-fetoprotein (MSAFP) is a painless blood test used to measure a specific protein made by the baby (or babies) and circulated in the mother’s bloodstream.
Why? The test offers a noninvasive way to analyze the health of the fetus. High levels of alpha-fetoprotein (AFP) can indicate a neural tube defect such as spina bifida, or it can simply mean a multiple pregnancy. Low levels may indicate Down syndrome.
When and How Often? The test is usually given once between Weeks 16 and 20.
Pros and Cons. Considered by some to be a controversial test, MSAFP’s biggest drawback is its sometimes inaccurate results in the form of false positives and false negatives. Women with false positive results require additional tests, worrying them needlessly. If levels of AFP are low, an expensive amniocentesis may be prescribed to confirm or deny the existence of Down syndrome. If levels are high, parents might jump to the wrong conclusion that their baby has a neural tube defect, only to discover later through ultrasound that the blood results simply mean that the couple is expecting twins. This blood test is not necessary for women who already plan on having an amniocentesis.
“I received a call from the doctor’s office stating that the alpha-fetoprotein numbers were abnormal. They told me I needed to head straight in for an emergency sonogram. Terror is an accurate word for what was going through my mind. My husband and I went together to the office, and I told him I was fully prepared for the worst. When the technician started the sonogram, she said, “Well, there’s your answer. You have twins!” My husband and I cried. We were so relieved.”
What? For a nonstress test (NST), external ultrasound monitors are attached to a woman’s abdomen in order to monitor the fetal heartbeat, fetal movement, and possible uterine activity. The results are printed out and then evaluated by a physician.
Why? The test is usually used during the third trimester to assess fetal well-being due to stress from maternal high blood pressure, overcrowding in the uterus due to multiples, or other medical problems associated with a high-risk pregnancy.
When and How Often? When deemed necessary by a physician, a NST is administered weekly during the last trimester, usually after Week 30, and sometimes twice weekly after Week 32 (approximately Week 28 for women expecting identical twins).
Pros and Cons. This is a painless and safe procedure. There are no immediate drawbacks, except that it can take up to an hour to perform.
Possible Maternal Complications
The following are complications that may happen during pregnancy, but chances are they won’t happen. Statistically, mothers carrying twins do experience more problems, but keep in mind that statistics are only as reliable as the population they study. Since most research is carried out at major medical centers, many participants are already deemed high risk. The odds are that if you take good care of yourself by eating right (increase those calories and protein!), getting enough rest (put those feet up!), heeding the “warning signs,” and visiting your doctor regularly, your babies will be born big and healthy. But be proactive and always call your doctor if you experience any unusual symptoms.
Spotting is common in early pregnancy and seems more serious than it usually is. In fact, of the moms I interviewed, four experienced bleeding in the early weeks, prompting a visit to their doctors and the ultimate discovery of their twin pregnancies. One mom spotted at Week 14 but carried her babies all the way to Week 38!
While the causes of spotting are not always clear (some women bleed on and off throughout their entire pregnancies without any ill effects to their babies), a woman experiencing vaginal bleeding should err on the side of caution and notify her physician. In some cases, bleeding in the early months could mean an impending miscarriage of one or both babies, an ectopic pregnancy, or an incompetent cervix in which the cervix prematurely dilates (if caught early enough the cervix can be sutured closed and later opened nearer to delivery). In late pregnancy, bleeding may mean that the placenta is separating from the uterus (placental abruption) or partially covering the cervix (placenta previa), both require immediate medical attention. Bleeding during sexual intercourse may indicate a cervical polyp or vaginal infection.
During pregnancy, the amount of fluid increases in your body. As the babies grow and crowd the pelvis, circulation slows, causing a swelling of the ankles and hands. Standing for long periods of time exacerbates the situation. When this happens, it’s best to lie down with your feet propped up. Wearing support hose that’s not too tight at the waist can also counter the effects of mild edema. However, if your hands continue to swell and your face becomes swollen, it could be a sign of toxemia and should be reported to the doctor immediately.
Preeclampsia, or toxemia, is characterized by extremely high blood pressure. The cause is not known, but it affects about 5 percent of all pregnancies, and nearly 20 percent of twin pregnancies. Careful screening of blood pressure, monitoring swelling of the hands and feet, and testing for protein in the urine, especially during the third trimester, are the best ways to assess whether a woman is at risk for developing preeclampsia. Other signs include headaches, blurred vision, rapid weight gain (a pound or more in a day), and abdominal pain. In recent years, with improved screening and the use of magnesium sulfate as a routine treatment, the incidence of preeclampsia is lower. Still, if it goes unchecked and untreated, it can develop into eclampsia, a dangerous condition for both mothers and babies.
Gestational diabetes develops during the latter half of the second trimester or early part of the third trimester and then can resolve itself after the babies are born. The condition occurs when there is a change in a pregnant woman’s glucose metabolism as her body puts more demands on the pancreas to produce more insulin, resulting in insulin resistance. If a woman develops gestational diabetes, her chances of preeclampsia increase. She may also experience complications during delivery and might be at risk for developing adult-onset diabetes later in life. A glucose tolerance test is given during the second or third trimester to screen for the disease. Women with borderline gestational diabetes are put on a strict diet high in protein and low in carbohydrates, while women who develop the condition require insulin during the remainder of their pregnancies. Unfortunately, women expecting multiples increase their chances of developing gestational diabetes. (Seven moms interviewed developed the condition. All were able to keep their insulin levels under control, and five delivered past Week 34.)
Anemia occurs when a woman’s body isn’t producing enough red blood cells to transport oxygen to her babies. As the babies grow, they deplete the mother’s iron supply. In severe cases, anemia can cause preterm labor. A diet rich in iron and folic acid may not be enough to prevent anemia, and often a doctor will prescribe additional iron supplements—especially if a woman develops a mild dilutional anemia after 28 weeks of pregnancy, as most do.
Placenta Previa and Abruptio Placenta
A condition where the placenta covers part of or the entire cervix, placenta previa is twice as likely to happen to a mother expecting twins as a woman carrying a singleton. Usually, the only symptom of this condition is slight bleeding without any discomfort. After the mother’s and babies’ conditions have been assessed through ultrasound, bed rest is usually recommended. If placenta previa occurs during the early months of pregnancy, the placenta often grows up and away from the cervix, but if it occurs later in pregnancy, and the condition does not correct itself, then cesarean delivery is required.
Abruptio placenta (placental abruption), on the other hand, is when the placenta begins to peel away from the uterine wall, usually during the third trimester. Symptoms include vaginal bleeding and abdominal pain, sometimes quite severe. If the abruption is mild, the doctor may admit the mom-to-be to the hospital for observation. If the babies are in distress, however, the doctor may choose to deliver them immediately by cesarean.
Nearly 50 percent of twins are delivered by cesarean, due in large part to added complications associated with a multiple delivery and to a medical community that shies away from breech (baby in feet-first position) or transverse (baby in horizontal position) deliveries. In about half of all twin pregnancies, both infants will be in the vertex (head-down) position—but in the remaining 50 percent, one or both babies are either in the breech or transverse position. Sometimes after the first baby is born vaginally, the physician can manually massage the mother’s abdomen to turn the second baby into the head-down position, thereby avoiding a cesarean delivery.
To many moms, the thought of delivering their babies under the harsh lights of an operating room is scary, especially to those who have never spent a day in the hospital. You can ease your anxiety by understanding the procedure and knowing what to expect and when.
The procedure itself is quite quick—only about 30 minutes. Post-op—suturing the uterus and abdomen and monitoring your vital signs—takes a bit longer, about an hour or two. After your abdomen has been shaved and cleaned with an antibacterial solution, a catheter is inserted into your bladder to keep it empty during surgery, and an IV is inserted, usually on the back of your hand, to administer both fluids and regional anesthesia (either a spinal or epidural so you can be fully awake but not feel anything below your waist). A curtain is raised just below your chest so both you and your husband or birthing partner (who’s seated right next to your head) won’t have to watch the procedure. Next, a transverse (horizontal) incision is made just above the bikini line. The doctors then remove both babies and placentas, and carefully stitch up the uterus as well as the abdomen. Although you won’t feel any pain, you’ll feel a slight tugging during the whole operation.
Usually both babies will be cleaned and weighed right there in the operating room (my husband even had the opportunity to cut their umbilical cords there as well), and you’ll get a chance to finally say hello to your bundles for the first time. Immediately following the operation, you’ll be sent to a post-op room where a nurse will watch your vital signs while your babies will be sent temporarily to the nursery for evaluation. You’ll meet up again either in the post-op room or in your hospital room (some moms choose to have their babies stay in the nursery a while longer so they can get a bit of sleep following surgery).
Once the anesthesia wears off, many moms require additional medication to help ease the discomfort from the surgery. Once your doctor gives the OK, getting out of bed and walking the halls (I pushed both bassinets up and down the corridors twice a day while in the hospital—they acted as a makeshift walker) helps promote the healing process, making recovery time much faster. Stitches are usually removed in seven days; you won’t be able to do any heavy lifting or driving for several weeks.