Thriving in a Twin Pregnancy: TTTS and How to Avoid Preterm Labor

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.

Possible Fetal Complications

Once again, it’s important to remember that most babies do just fine. Not too long ago, babies born at a little more than 2 pounds had a slim chance of survival; these days they have an 85 percent survival rate, and new records are being broken all the time. The following fetal complications are listed merely to keep you informed.

Twin-to-Twin Transfusion Syndrome

Twin-to-twin transfusion syndrome (TTTS) is a rare but serious, progressive disorder that occurs in about 15 percent of monozygotic monochorionic twins, identical twins who share a common placenta. Identical twins with two placentas (dichorionic) and fraternal twins are not at risk of developing this condition. The earlier the onset of TTTS, the greater the risk of infant mortality. The cause is due to an abnormal vascular connection within their shared placenta—an uneven amount of blood flows between the two twins so that one receives too much blood while the other doesn’t receive enough. The disease is characterized by a fetal weight difference of more than 20 percent and a large discrepancy of amniotic fluid between the fetuses’ dividing membranes. Both babies suffer—the donor is often born underweight and anemic, while the recipient can experience jaundice, respiratory problems, or even heart failure.

Medical intervention has been successful. One method, amnioreduction, in which the excess fluid is removed from the recipient’s sac, shows promise. But critics point out that while it decreases the risk of a premature birth, the underlying cause of the disease continues. As the fluid returns to the recipient’s sac, several procedures may be necessary. For severe cases of TTTS, a recent Australian research study found that the use of laser therapy to correct the connecting blood vessel resulted in a significantly higher survival rate than amnioreduction.

For a mom with a monozygotic pregnancy, it’s important to identify and determine chorionicity early so that she can be closely monitored by her doctor to watch for any signs of TTTS.

If a family finds themselves with a TTTS diagnosis, knowledge is power. There are many wonderful resources offering information as well as support for parents expecting twins with TTTS, including the Twin-to-Twin Transfusion Syndrome Foundation and the message board available through the Twiniversity website. Two families from the surveys I collected experienced TTTS. Both sets of now three-year-old male twins are doing just fine!

“My pregnancy was complicated with TTTS. I had five amnioreductions to manage the fluid, and I was on bed rest for two months. I was monitored very closely. At 29 weeks I had an accidental septostomy (a hole was created in the membrane dividing the boys). Ultrasound then showed the membrane had actually been shredded and there was no longer anything separating the babies. From that point it was treated as a monoamniotic pregnancy. A different treatment could have brought a very different outcome, especially since Matthew had 70 percent of the placenta and Isaac only 30, which may not have been enough to sustain him if we had had laser surgery.” (Matthew and Isaac were born at 32 weeks and weighed 4 pounds, 4 ounces and 3 pounds, 3 ounces. They required a month-long stay in the NICU.)

Intrauterine Growth Restriction (IUGR)

Intrauterine growth restriction (sometimes referred to as low birth weight, or LBW) happens in about 15 percent of twin pregnancies when one or both fetuses are growing poorly and weigh below the 10th percentile for gestational age. The fetuses may not get enough nutrition due to maternal, fetal, or placental problems. Maternal smoking, alcohol and narcotic use, high blood pressure (preeclampsia), genetics, poor nutrition, and twin-to-twin transfusion syndrome are all contributing factors. While IUGR can occur in fraternal twins, it’s more common in identical twins (even those without TTTS) where one fetus gets a larger share of the placenta mass. Studies show that an early and proper diagnosis confirmed by ultrasound is paramount to a healthy outcome.

“There was a decent weight difference between the girls and that was identified early on but it wasn’t TTTS. There was a weight discrepancy from the first ultrasound at Week 16 but always just a little bit under [the 20 percent] where the doctors get nervous. At Week 33, the ultrasound showed an even bigger weight discrepancy, but the doctor redid the measurements a few times and got it closer. After delivery, they theorized that it was a cord placement issue that caused the weight difference. They’re a little closer in weight now, but the bigger twin at birth continues to be the bigger twin now.” (Kate and Sarah, identical girls, were delivered at Week 38 and weighed 5 pounds, 11 ounces and 8 pounds, 3 ounces.)


Preterm Labor

The number one problem of moms expecting twins, preterm labor happens when a pregnant mom goes into labor prior to Week 37 of gestation. Nearly 50 percent of mothers carrying twins experience preterm labor. The cause is not clear, but it’s speculated that poor weight gain through inadequate nutrition (so eat up!), an infection in the mother, a history of prior preterm labor, preeclampsia, smoking, maternal age (under age 16 or older than 35), benign uterine tumors, or simply overcrowding in the uterus due to multiple fetuses could contribute to preterm labor. In some cases, preterm labor can be stopped through drug therapy. Since it’s widely known that the cervical length decreases during the third trimester of a multiple pregnancy, which is a precursor to preterm labor, several studies recommend getting regular transvaginal ultrasounds starting the second trimester to measure cervical length for women who are at risk of developing preterm labor.

Seventeen out of 39 moms completing my survey went into preterm labor (before Week 37) and subsequently delivered early. Nine of those 17 missed Week 37 by just a few days, and their babies spent little or no time in the NICU. The mean, or average, week of delivery for the entire group of 39 moms was Week 36 and 2 days; the mode, or most common week of delivery, however, was Week 38. Even though one woman delivered at Week 35 and 4 days, her fraternal boys weighed in at 6 pounds each!

“I felt incredibly “wrong.” Something was not right, but I couldn’t really accurately describe it. I had my husband take me to the doctor’s despite everyone assuring me that it was Braxton-Hicks contractions. It didn’t feel like contractions though; it felt like the entire section of my lower back was in a huge back spasm. My head felt like lead, and I was having trouble keeping my mind and eyes focused.” (Although this mom was in full-blown labor, doctors were able to stop it, and she delivered at Week 36.)

Bullet list of preterm warning signs

Interventions to Help Prolong Pregnancy

Some of the complications women experience during a multiple pregnancy can be alleviated with proper and timely medical intervention. You can help prolong your pregnancy by managing risk factors such as diabetes or high blood pressure, loading up on calories and protein in your diet, limiting your stress level (maybe it’s time to take a leave of absence from that high-powered job), avoiding fatigue by getting plenty (and I mean plenty) of rest, and taking care of your dental health since gum disease is associated with preterm labor.

Bed Rest

Some doctors still routinely prescribe several weeks of bed rest to prevent premature delivery during a woman’s last trimester if she is expecting twins. The most common (and one of the most controversial) medical intervention, bed rest can mean anything from round-the-clock confinement to just a few hours a day, in a semireclining position or lying down completely. With bed rest, some physicians reason, the weight and stress of carrying more than one fetus are taken off the cervix. In addition, they say, more nutrients will reach the babies through the placenta because the mother’s blood fl ow increases.

But bed rest has its critics since there has been no large-scale double-blind research study indicating that bed rest prevents premature delivery (although another study found that while hospital bed rest didn’t prevent preterm labor, it did help increase fetal birth weight). Furthermore, critics note, complete bed rest will increase a woman’s chances of a blood clot and may actually increase her blood pressure, which often leads to preterm labor. The monotony of bed rest can also cause added stress, and a woman who is inactive frequently eats less and ultimately could harm her babies even more. Still, the benefits of resting in a reclined position are important for any pregnant woman as it reduces stress, rejuvenates mind and body, and helps lessen edema. A good compromise, therefore, is to rest often with your feet elevated—30-minute naps three times a day throughout pregnancy.

“I rested daily—usually for an hour at work—either in the sick room, out in my car, wherever I could find a place to lie down. I’m sure this made a difference. I also always kept my feet up a lot. I got plenty of funny looks during meetings, but I thought, Too bad, I’m having twins. I’m totally  swollen, and I’m putting my feet up. Deal with it!” (This mom’s tenacity paid off—she delivered her boys Week 37 and they weighed 6 pounds, 1 ounce and 7 pounds even.)

Drug Intervention

These days, doctors have an arsenal of medication to help slow or stop the onset of labor. Some women who experience preterm labor will be hospitalized and treated aggressively with a magnesium sulfate IV and an injection of a steroid to help the babies’ lungs mature more quickly and prevent respiratory problems after birth. Once labor has ceased for more than 12 hours, the expectant mother may be allowed to go home but must continue with drug therapy. Science is working hard at solving the problem, too. In 2007 there was a promising study done in Canada that suggests the topical use of nitroglycerin (yes, the heart medication!) helped reduce preterm labor. Authors of the study believe that it increases blood circulation in the placenta and relaxes the uterine muscles. But they caution that much more research needs to be done before it can be put into clinical use.

“My girls were in the NICU for seven long weeks. To cope with the stress, I focused all my attention on them, trying to stay informed of their situation. I tried to learn everything I could about the machines they were on—what the machines were doing for them. You just have to take it day by day. Some days we would rejoice in a milestone they accomplished, like getting off of a tube or a machine, or gaining a few ounces. Other days we would cry and worry because of a setback. I encourage moms and dads to just be there every day, even if it’s just for a few minutes. Look at your babies, take in every tiny inch of them and try to see the beauty of what you’ve created. Sitting at home later in that empty nursery those visions you’ve stored in your head will help you get by. Be strong and courageous for your children. My way of coping was to provide as much breast milk for them as possible. I focused myattention on pumping every few hours, and getting to see them every time I delivered the milk to the NICU. That really helped me.”

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A copy of the book Double Duty.