Please help me make a decision « Back to Group Discussions

[EonJourney]

I am pregnant with 2 identical boys and currently 34 weeks and 4 days. The risk for carrying identical twins who share 1 placenta is death to 1 or both twins during vaginal deliveries or later term (past 35 weeks pregnant) is about 4.6%. I have always wanted a vbac natural birth but my high risk ob says I should deliver at 35 weeks via c-sect. I will be closely monitored during labor for this to happen but the studies say even with closely monitoring 1 or both twins could die during labor or during weeks 34+. What would you do if you were in my shoes? Is it worth the 4.6% risk to wait until my body goes into labor on its own and then perhaps consider a csect if warranted? Anyone else have a planned c sect and then a natural birth with a later child and notice any differences?

[Ablemec]

I haven't given birth before, either vaginally or by c-section, but if it were me, I think I would get the c-section.  4.6% is a fairly substantial risk, one that seems to outweigh the benefits of a natural birth.  Based on your post, it seems like your OB isn't just practicing defensive medicine, but really thinks there's a risk here.  Natural birth is obviously something very important to you, but would you be able to handle the stress of staying pregnant every day knowing the risks you're facing?  That in and of itself probably isn't very good for you or the babies.  

Many of us have been heard to say that we are for natural birth, but are thankful that hospitals and surgeries are available when necessary.  It seems to my (uninformed, untrained) eyes that this is one of those times.

[Abraisme]

I agree with Ablemec.  I'm very, very pro natural birth, but a 4.6% chance of death is pretty high!  That's 1 out of 20, which is a very real statistic.  There is a good time and place for medical intervention.  I hope that you're able to make the best decision for your family and come to peace with the outcome. 

[MrsKatie]

I agree with the above posters.  I am also VERY pro-natural birth, and am extremely skeptical of most, if not all, modern western medical practices.  But if I were faced with that statistic I'd get the twins out as soon as my doctor recommended.

I'm so sorry you have to make this decision at all.  I wish the best for you and your twins!

[Jaimee]

Did you read the studies yourself or did your doctor communicate that stat to you?  I'm always a bit skeptical and personally would want a second professional opinion stat!  Specifically what is the risk?  Carrying longer than 35 weeks?  Laboring?  Both?  What are the stats for laboring at say 36 weeks?  Or carrying to 36 weeks?  Obviously the longer they can grow the better for their lungs, feeding, etc.  I guess I would want to weigh all the information carefully.  Then, if other professionals confirm the risks involved then I think I would agree with the pp's as well.  There is a time and place for medical intervention and this may be it.  I know you don't have a lot of time to make this decision and I hope you can find peace and resolution quickly.   

[meesh933]

My knee-jerk reaction would probably be to go for the c-section, but Jaimee makes some good points, too.  A second opinion probably wouldn't hurt. I, too, and curious about when the actual risk is - during labor, or just continuing to remain pregnant?

As far as a later vbac, it is possible to find providers who will attend a vba2c. Maybe not in the hospital, though. There are homebirth midwives around here who will attend births after several c-sections. It doesn't completely eliminate the possibility, but a second section will make it harder to find a provider.

[Jaimee]

Are your twins di or mono amniotic?  I would be happy to search for some studies for you...  I did a really brief search and did find a few studies, though some excluded TTTS, which I know you do have and most likely make this decision more complex.  I don't want to overwhelm you or overstep your comfort level so let me know how I can help!

Perinatal mortality and mode of delivery in monochorionic diamniotic twin pregnancies ≥32 weeks of gestation: A multicentre retrospective cohort study

Hack, K.E.A.^a, Derks, J.B.^a, Elias, S.G.^b, Van Mameren, F.A.^a, Koopman-Esseboom, C.^c, Mol, B.W.J.^d, Lopriore, E.^e, Schaap, A.H.P.^f, Arabin, B.^g, Duvekot, J.J.^h, Go, A.T.J.I.ⁱ, Wieselmann, E.^j, Eggink, A.J.^k, Willekes, C.^l, Vandenbussche, F.P.H.A.^m, Visser, G.H.A.^a

Abstract

Objective To study perinatal mortality rates in a cohort of 465 monochorionic (MC) twins without twin-twin transfusion syndrome (TTS) born at 32 weeks of gestation or later since reported interauterine fetal death (IUFD) rates >32 weeks of gestations in the literature vary, leading to varying recommendations on the optimal timing of delivery, and to investigate the relation between perinatal mortality and mode of delivery. Design Multicentre retrospective cohort study. Setting Ten perinatal referral centres in the Netherlands. Population All MC twin pregnancies without TTTS delivered at ≥32 weeks of gestation between January 2000 and December 2005. Methods The medical records of all MC twin pregnancies without TTTS delivered at the ten perinatal referral centres in the Netherlands between January 2000 and December 2005 were reviewed. Main outcome measures Perinatal mortality in relation to gestational age and mode of delivery at ≥32 weeks of gestation. Results After 32 weeks of gestation, five out of 930 fetuses died in utero and there were six neonatal deaths (6 per 1000 infants). In women who delivered ≥37 weeks, perinatal mortality was 7 per 1000 infants. Trial of labour was attempted in 376 women and was successful in 77%. There were three deaths in deliveries with a trial of labour (8 per 1000 deliveries), of which two were related to mode of delivery. Infants born by caesarean section without labour had an increased risk of neonatal morbidity and respiratory distress syndrome. Conclusions In MC twin pregnancies the incidence of intrauterine fetal death is low ≥32 weeks of gestation. Therefore, planned preterm delivery before 36 weeks does not seem to be justified. The risk of intrapartum death is also low, at least in tertiary centres. © 2011 RCOG.

[LiLStar]

One question is, how fast would things go south, if they did? If everything looked great on an NST/BPP on Monday, is it safe to assume that on Tuesday they'd still be doing fine? Or can situations go from looking great to dangerous over night? Could frequent monitoring buy you a few days/weeks? 

[EonJourney]

Thank you everyone for your responses. I am swaying toward being induced at 36 weeks for the safety of the twins. I have mono-diamniotic twins and would love more studies Jaimee if you have time. So far I have found 2 compelling studies for delivery between 35 and 36 weeks.

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2007.01556.x/full

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1160580/

LilStar- from what I have been researching is Acute TTTS can occur in the womb and the next day 1 or both twins could be found to have passed. I was diagnosed with chronic TTTS at 19 weeks but no interventions were needed. (with these type of twins sharing a placenta TTTS or twin to twin transfusion syndrome causes 1 or both of the twins to pass and usually fetal surgery to save the twins is needed) The incidence of TTTS for mono-di twins is 15%. Anyway yes the fact that I was diagnosed is on my mind and is worrisome but also everything looks completely stable and normal right now and has been that way for about 10 weeks.

I delivered DS at 39 weeks and my gut tells me that if I were to allow for natural delivery I would deliver at 37.5 to 38 weeks. Maybe 1 week is not that big of a deal to go early? I don't know and wish things were just simple like it was with a singleton :)

My best to you all.

Thanks

[Gemini529]

Hi,

I would personally err on the side of caution on this one.   If the 4-5% number is accurate, it's not a risk I would personally take.  A close friend just lost her twins (It was a combo between TTTTS and cord entanglement...they were mo-mo) Also, there was nothing she could have done, as they were only 23 weeks along when it was discovered. But now that I've seen how quickly it can happen, I have become sort of paranoid and wouldn't want to chance that I could lose them, especially having made it as far as you have.  

Sorry, I know it's a tough decision.  My friend was actually toying with the idea of asking to go longer (the protocol was to give her a C section no later than 32 weeks) but the docs convinced her that the sooner they get out of their dangerous situation, the better. In her case, I guess they were right.  I don't want to scare you or freak you out.  My friend was told right from the start that the pregnancy was really high risk and they had a 50% survival rate for mo mo twins. So your situation isn't the same.  I'd get a second or even third opinion, and if they all seem to agree, then I'd go with that.  Good luck and I hope you are able to come to a decision you are comfortable with.  

[crazykittymomma]

I'm with Jaimee on definitely doing as much independent research as possible and maybe even get a second opinion just to be really sure before I make any decisions. Have you contacted your local ICAN for twin resources? I know my midwife delivered VBAC twins at home not too long ago, though I don't know the rest of the circumstances.

[Jaimee]

I looked over those studies you posted, Eon and the second one is particularly convincing, though admits the need for further study as the cohort was quite small.  I picked this quote out as the main point that I saw:

Another preventative approach might be earlier delivery. Complicated MCDA twin pregnancies, such as those with TTTS or abnormal umbilical artery Doppler, are already delivered in many centres at 32 wk. At this stage neonatal survival is now comparable to that at term [30,31]. Minor neonatal morbidity is still likely at 32 wk, but the chance of major respiratory and neurological problems is reduced substantially by administration of antenatal steroids [32]. Elective vaginal delivery would increase the chance of failed induction, but there is an increasing view that elective caesarean section is preferable to preterm induction of labour in MCDA twin pregnancies, both to avoid a caesarean section being performed as an emergency and to obviate the risks of acute intertwin transfusion during labour [33]. Accepting that elective delivery of all MC twins at 32 wk would carry an attendant neonatal morbidity, the complications of iatrogenic prematurity could be lessened if an intermediate gestation were chosen, e.g., 34 wk. Although neonatal morbidity would be reduced, so would the number of fetal deaths prevented. Acknowledging the limitation of small numbers in this study, 80% of fetal deaths at 32 wk or greater and 60% at 34 wk or greater, respectively, would have been prevented if fetuses were delivered before these gestation time points. When expressed per pregnancy, one case of IUD would be prevented for every 23 MC pregnancies delivered at 32 wk and one for every 30 pregnancies at 34 wk. The above figures underestimate the potential gain of such strategy, because single IUD in MCDA pregnancy also exposes the surviving co-twin to a substantial risk of brain injury and thus long-term handicap from acute intertwin transfusion [6–8].

The first study seemed to imply that delivery prior to 37 weeks was indicated, but not necessarily before then.  With these conflicting data, I really would seek more professional opinions.

The first study, also mentioned the incidences of premature complications and that these are actually quite low in fetuses delivered after 32 weeks, so that's encouraging at least.  And it also talked about vaginal vs. cesarean delivery and the risk of intertwin transfusion, so that's definitely something to keep in mind as well.

[Jaimee]

Here's another conflicting study regarding the risk of fetal death in MCDA twins:

Prospective risk of intrauterine death of monochorionic-diamniotic twins

Simões, T.^a, Amaral, N.^a, Lerman, R.^a, Ribeiro, F.^a, Dias, E.^a, Blickstein, I.^bc

^a  Department of Maternal-Fetal Medicine Maternity Dr Alfredo da Costa, Lisbon, Portugal
^b  Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
^c  Hadassah-Hebrew University School of Medicine, Jerusalem, Israel

Abstract

Objective: The purpose of this study was to calculate the prospective risk of fetal death in monochorionic-diamniotic twins. Study design: We evaluated 193 monochorionic diamniotic twin pregnancies that were followed and delivered after 24 weeks. Surveillance included cardiotocography and sonography performed at least once weekly. The prospective risk of fetal death was calculated as the total number of deaths at the beginning of the gestational period divided by the number of continuing pregnancies at or beyond that period. Results: The fetal death rate was 5 of 193 pregnancies (2.6%; 95% CI, 1.1, 5.9); the prospective risk of stillbirth per pregnancy after 32 weeks of gestation was 1.2% (95% CI, 0.3% - 4.2%). Conclusion: Under intensive surveillance, the prospective risk of fetal death in monochorionic-diamniotic pregnancies after 32 weeks of gestation is much lower than reported and does not support a policy of elective preterm delivery. © 2006 Mosby, Inc. All rights reserved.

But then here's one that supports it and only includes uncomplicated twins...

Multiple Gestations: Timing of Indicated Late Preterm and Early-Term Births in Uncomplicated Dichorionic, Monochorionic, and Monoamniotic Twins

Newman, R.B., Unal, E.R.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical University of South Carolina, Charleston, SC, United States

Abstract

In this work we review the indications for late preterm and early-term birth in uncomplicated dichorionic, monochorionic, and monoamniotic twin gestations. Uncomplicated dichorionic twins have optimal outcomes when delivered at 38 weeks' gestation. Monochorionic twins, however, are at greater risk for unexpected stillbirth, and a management plan of late preterm delivery (34-37 weeks) after informed consent is reasonable. Monoamniotic twins are at even greater risk for sudden intrauterine fetal demise, and it is recommended that these expectant mothers be managed by inpatient hospitalization with fetal testing 1-3 times per day and delivery between 32 and 34 weeks' gestation. Recommendations are also provided for the circumstance of single intrauterine fetal demise in a twin gestation. © 2011 Elsevier Inc.

How much does your care provider say the TTTS is likely to affect the statistics since it appears that your TTTS is not severe considering you did not need any interventions..? 

Okay more studies...

Contemporary management of monochorionic diamniotic twins: Outcomes and delivery recommendations revisited

Smith, N.A.^a, Wilkins-Haug, L.^a, Santolaya-Forgas, J.^a, Acker, D.^a, Economy, K.E.^a, Benson, C.B.^b, Robinson, J.N.^a

^a  Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, United States
^b  Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States

Abstract

Objective: We sought to investigate outcomes of contemporaneously managed monochorionic diamniotic (MCDA) twins, stratified by pregnancy complication. Study design: Four hundred eighteen MCDA pregnancies from 2001 through 2008 were retrospectively reviewed. Results: There were 236 ongoing pregnancies at 24 weeks' gestation. The likelihood of progressing from 24 weeks to 2 live births was 98.7% in uncomplicated pregnancies, 89.7% with twin-twin transfusion syndrome, and 100% with growth discordance, increasing at 32 weeks to 99.5%, 93.8%, and 100%, respectively. The relative risk (RR) of birth <32 weeks was significantly greater in twin-twin transfusion syndrome (RR, 4.1; 95% confidence interval, 2.7-6.1) and growth discordant (RR, 2.1; 95% confidence interval, 1.8-3.8) pregnancies than in uncomplicated pregnancies (P < .0001). Conclusion: This represents one of the largest cohorts of MCDA twins. The risk of third-trimester fetal loss was low. The likelihood of both intrauterine fetal demise and preterm birth were greater in complicated pregnancies. In the absence of a clinical indication for delivery, these data do not support elective preterm delivery for prevention of intrauterine fetal demise in uncomplicated MCDA twins. © 2010 Mosby, Inc.

Mode of delivery study...

Acute intrapartum placentofetal or fetoplacental transfusion in monochorionic twin pregnancy

Suzuki, S., Igarashi, M., Takeshita, T.

Department of Obstetrics and Gynecology, Japanese Red Cross Katsushika Maternity Hospital, 5-11-12 Tateishi, Katsushika-ku, Tokyo 124-0012, Japan

 

Planned caesarean section may be the only preventive
measure of the acute transfusion during a trial of vaginal delivery in
monochorionic-diamniotic twin pregnancy. In Scotland, for
example, it has been reported to reduce the risk of perinatal death
of second twins due to intrapartum anoxia at term (Smith et al.
2005). However, some investigations have concluded that there is
no clinically relevant difference in neonatal mortality due to
delivery of monochorionic-diamniotic twin pregnancies near term
(Sau et al. 2006; Harbst and Kallen 2008). Although the placental
vascular anastomoses, such as in these two cases, are nearly always
present in monochorionic twin pregnancies, in addition, the
incidence of the acute transfusion may be rare. For example, we
have encountered only these two cases (0.7%) in 282 monochorionic-
diamniotic twin vaginal labours during the recent 10-year
period. Therefore, the mode of delivery for monochorionicdiamniotic
twin pregnancies may need much debate along with
the accumulation of similar case reports.

 

References

 

		Dodd, J.M., Crowther, C.A. Elective delivery of women with a twin pregnancy from 37 weeks' gestation. (2003) Cochrane database of systematic reviews (Online : Update Software), (1), pp. CD003582. Cited 8 times.
2		Herbst, A., Källén, K. Influence of mode of delivery on neonatal mortality in the second twin, at and before term (2008) BJOG: An International Journal of Obstetrics and Gynaecology, 115 (12), pp. 1512-1517. Cited 10 times. doi: 10.1111/j.1471-0528.2008.01899.x   View at publisher
3		Lopriore, E., Oepkes, D. Fetal and neonatal haematological complications in monochorionic twins (2008) Seminars in Fetal and Neonatal Medicine, 13 (4), pp. 231-238. Cited 13 times. doi: 10.1016/j.siny.2008.02.002   View at publisher
4		Machin, G.A., Keith, L.G. Can twin-to-twin transfusion syndrome be explained, and how is it treated? (1998) Clinical Obstetrics and Gynecology, 41 (1), pp. 105-113. Cited 26 times. doi: 10.1097/00003081-199803000-00016   View at publisher
5		Minakami, H., Sato, I. Reestimating date of delivery in multifetal pregnancies (1996) Journal of the American Medical Association, 275 (18), pp. 1432-1434. Cited 77 times. doi: 10.1001/jama.275.18.1432   View at publisher
6		Sau, A., Chalmers, S., Shennan, A.H., Fox, G., Maxwell, D. Vaginal delivery can be considered in monochorionic diamniotic twins (2006) BJOG: An International Journal of Obstetrics and Gynaecology, 113 (5), pp. 602-604. Cited 4 times. doi: 10.1111/j.1471-0528.2006.00887.x   View at publisher
7		Smith, G.C.S., Shah, I., White, I.R., Pell, J.P., Dobbie, R. Mode of delivery and the risk of delivery-related perinatal death among twins at term: A retrospective cohort study of 8073 births (2005) BJOG: An International Journal of Obstetrics and Gynaecology, 112 (8), pp. 1139-1144. Cited 47 times. doi: 10.1111/j.1471-0528.2005.00631.x   View at publisher
8		Uotila, J., Tammela, O. Acute intrapartum fetoplacental transfusion in monochorionic twin pregnancy (1999) Obstetrics and Gynecology, 94 (5 SUPPL. 1), pp. 819-821. Cited 14 times. doi: 10.1016/S0029-7844(99)00441-X   View at publisher

Most of the above references look promising, please let me know if you'd like details on any of those.

[EonJourney]

Thank YOU so much Jaimee! You have given me so much to read about and think about and discuss with my ob. I really really appreciate the time you put into this search. I am not sure how you did this but it is certainly helpful for me. My next ob visit is Monday and I am looking forward to our discussion.

My best to you and everyone else. You all gave me helpful insights that will guide my decision.

[Jaimee]

You're very welcome.  It's nice to be able to use my brain for things other than resolving disputes between my children over the bouncy horse.    Plus, my dh has access to online journal libraries since he is faculty at the University of Illinois... a nice perk.  Please don't hesitate to ask if you'd like the abstracts, etc. for any of the above references or any other studies you find online that you cannot access or if you'd like me to do a specific search for something other than what has already been done.  This is a big decision and I'm really very happy to help.

[Jaimee]

Eon, please update us after your appointment today!

[Abraisme]

Yes, please do!
 

Originally Posted by Jaimee 

Eon, please update us after your appointment today!

[EonJourney]

Oh I am so conflicted still. I wish this was an easy decision but its not for me. My high risk doc and and my regular ob both are pushing for planned csect at 35 weeks or latest at 36 .2 weeks. Reading all those studies I now feel like I would like to go at least to 36.5 days but neither think that is a good idea. Measurements were all normal and weigths were 5lbs and 5lbs 12 oz. Yes the science states delivery at 35-36 weeks is optimal but I have to think that those women might not be as healthy as me. My BP is very low, no swelling no complications, I eat really really healthy and exercise every day. I like to believe that the human body is born to birth healthy babies and not be influenced by ob's who are only familiar with women who are not athletic and as healthy as me. Oh what to do? All comments/advice are appreciated. I certainly don't want to look back and say what if...but I never thought it would be me who is ok with a planned c sect.

[Abraisme]

I think it's a good compromise to go to 36w2d.  It's so hard to say and there does seem to be a real risk here.  Good luck!  What you really want are healthy babies.
 

Originally Posted by EonJourney 

Oh I am so conflicted still. I wish this was an easy decision but its not for me. My high risk doc and and my regular ob both are pushing for planned csect at 35 weeks or latest at 36 .2 weeks. Reading all those studies I now feel like I would like to go at least to 36.5 days but neither think that is a good idea. Measurements were all normal and weigths were 5lbs and 5lbs 12 oz. Yes the science states delivery at 35-36 weeks is optimal but I have to think that those women might not be as healthy as me. My BP is very low, no swelling no complications, I eat really really healthy and exercise every day. I like to believe that the human body is born to birth healthy babies and not be influenced by ob's who are only familiar with women who are not athletic and as healthy as me. Oh what to do? All comments/advice are appreciated. I certainly don't want to look back and say what if...but I never thought it would be me who is ok with a planned c sect.

[jbk21]

Originally Posted by Abraisme 

I think it's a good compromise to go to 36w2d.  It's so hard to say and there does seem to be a real risk here.  Good luck!  What you really want are healthy babies. 

I think so, too.  And thankfully they are at really great weights from what they are estimating, so even though it's still pretty early they seem like they will be pretty strong!