Identical (Mono/Di) Size Discordance/Placenta Issues

[teamla]

Hi there,

I'll be 28 weeks on Tuesday and am on quite the emotional rollercoaster.

At my 26 week ultrasound (they do every two weeks to watch for growth discrepancies), they observed that my smaller twin (has always been a bit smaller) was up to 20% different, and was having blood flow issues from the cord. He's shown flatline diastolic flow ever since (once was actually reverse).

I'm being monitored by ultrasound every second day now and a non-stress test on the off days. The babies always do well on the NST and show good movement, however now that I am at 28 weeks I know they are going to deliver much more readily if we confirm that the smaller baby is not growing (did not show any growth in the one-week interval, which they disregard, but it is a sign), the reverse flow shows up again and persists, or the ductus flow is not good.

It looks like I will hit the 28 week mark that I have been striving for initially, but of course I'd like to wait much, much longer. Does anyone have experience either with this, IUGR, or delivery at 28 weeks? If so, how are your children doing now, and what would you advise?

Thanks in advance.

[Tigerchild]

Yes. My boys had TTTS (you don't mention if they have examined you for any markers of that, something you should demand if it's not already been done, BTW), but we had the additional complication of my smaller twin having a really crappy cord placement. He also had reverse flow, echogenic bowel, and blood flow issues in his brain, though there was more of a size discrepancy, as well as amniotic fluid discrepancies.

Are you seeing a perinatologist (hopefully one who specializes in twins?)? If not, if you can possibly afford it, it would be a good time to get a second opinion.

We were very touch and go from 20w - 34w, with daily monitoring, being told every day that we might need to "take them" the next day after week 26 (and almost daily offers of cord ligation for the smaller twin until I literally had a screaming fit about it).

The boys were born at 36 weeks, and are fine now. They still maintain their size difference even at 7, and to be honest we have seen some long term impacts with my smaller guy who suffered from IUGR as far as cognitive abilities go. (Wow, it hurts like hell to say that) However, that probably would not even be noticeable if we didn't have the twin without IUGR as a comparison. They are in wonderful health.

Stay strong. You are the babies best advocate. If you feel your provider is pushing you towards a very serious outcome (delivering at 28 weeks or even before 32 is high risk, at least IMO) then it is well within your rights to demand a second opinion, preferably at a different practice if you can all manage it--but often times especially with M-F medicine specialist practices there is enough indepenedance amongst the provders you may be able to get a genuine second opinion.

[teamla]

Thanks for the reply!

Yes, the reason for the bi-weekly ultrasounds were to keep an eye out for TTTS markers and any similar issues. My ultrasounds in the past were done at an MFM clinic by a sonographer, with an in-house peri who would go over the results with me after each one. He's the one who sent me to hospital at the 26-week mark.

Anyway, we've never met the diagnostic criteria for TTTS, as the fluid pockets have generally been within normal ranges and we can see two bladders, etc. Of course, TTTS could begin at any time, so they are keeping an eye out for that, but at the moment it simply looks like the smaller twin got a smaller portion of the placenta and is running out.

After the initial peri sent me to the hospital, the cord flow problem was verified, I was seen by my OB (who specializes in high-risk), given the lung development steroids, and sent home on modified bedrest (after having a neonatal consult and touring the NICU, which was frightening). I now go to the ultrasound room in the antenatal ward at the hospital every two days - my OB works out of there. These are all supervised directly by a peri (in the room with us) along with the sonographer, and then the peri discusses with my OB. On days that I don't go for an ultrasound, a nurse comes to my house to do a non-stress test and they report back to the same team.

I feel very much like you're saying - every day could be "the day". The team seems to be very reluctant to deliver before 28 weeks unless something grave happens (which is great), but they have already indicated they will be much less hesitant after that point. I think we all agree though that any time before 32 weeks involves quite serious risk. I haven't heard of a cord ligation - what is this, exactly?

I don't know exactly how to get a second opinion - I'm in Canada and our system is a bit different for that. I am already being seen by the best people in the city (this hospital is the centre for MFM in the area and has the highest level NICU, etc., and all the specialists work out of it already). My OB indicated that if things looked like they were going in the direction of delivery, the whole team (her, peris, neonatologist) would get together to agree before any action is taken, so I guess that's good.

I just feel like the whole thing is such a grey area, and I want to be absolutely sure we need to intervene before we do (obviously). I am trying to determine at what point IUGR actually harms the smaller baby. Right now he's very active and showing no signs of distress - possibly he is compensating well for the issues he's dealing with. I just don't want his life, long-term, to be compromised by anything I do or don't do, and dealing with that is really difficult.

Anyway, thank you so much for providing the information you did. I'm so happy to hear your pregnancy made it so long, and your boys are so healthy!