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Homebirth and Chorionicity

post #1 of 27
Thread Starter 
Good day all,
I'm 18weeks into my first pregnancy and the two little ones I'm carrying are doing well. It appears that they are sharing a placenta but are separated by a thin band in the amnion, so two amnions. However, the ultrasound did not determine if they share a chorion. I am planning a homebirth with my midwives and have been told that there are increased risks with delivery of twins sharing a chorion. Does anyone have any positive experience with this kind of scenario? Would love to hear about it.
post #2 of 27
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post #3 of 27
I agree with the above and wanted to add that the BIG deal is that they have their own amniotic sacks to decrease issues with cord entanglement. I am planning a HB as well and my twins are Di/Di (they think although one US report said they were mono-di. but it doesn't really matter b/c everything can be fused anyhow.... I can't wait to find out if they are ID or fraternal. I hope they can tell at the birth and i don't have to wait for testing.
post #4 of 27
From what I understand, if your twins each have their own amniotic sacs, but do share a chorion, the risks are not that much greater during delivery. But if your twins had shared an amniotic sac, the risks during delivery increase for things like cord entanglement and cord prolapse. Like a PP said TTTS can be a risk factor, so that is something to be aware of. Also if your twins are monochorionic, then you will have to clamp the cord right away, or at least pretty quickly, when the first baby comes out. My twins were born at home and we had no complications, but they were di/di. I wish you the best in your homebirthing plans. :
post #5 of 27
My Id girls birth was in the hospital and were born in an hour, no problem the easiest birth ever. They were 4 min apart. One had some low blood sugar issues, but that's it. I'm happy I had a Obgyn who supported me w/non-medicated vaginal birth.
post #6 of 27
According to my peri-natologist (and I didn't do any fact checkin on this, so you may want to research it yourself), if you babes share a placenta, then there is a 1 in 1,000,000 chance that during delivery that they will develop some kind of TTS, even if it didn't show up before. And when it does occur, it is usually fatal for both babies. So now, docs are trying to c-section those kids to avoid the huge liability costs.

My boys shared a placenta and I refused a routine c-section. We labored and then ended up with a c-section, but they were fine.
post #7 of 27
Find out about the TTTS. Mine had it and it was a lot of drama and a lot of concern during my pregnancy. There are markers that can be identified by u/s. This site has more info on TTTS.
post #8 of 27
Thread Starter 

Thanks to all for your suggestions

I knew about the TTTS but had the impression that one chorion may cause other issues in delivery. I'm continuing to think positive, eat healthy, rest, see my naturopath and midwives and listen to my body! Keep your fingers crossed for me.
post #9 of 27
Yes, if your twins share a placenta, you cannot rule out TTTS with a few ultrasounds. It doesn't work that way.

That being said, even amongst MZ twins, it's rare. And the longer you go without problems the less likely it is that your twins will develop it (although there is a risk of it developing even during delivery, which is why it is VERY important to be monitored for signs of distress--but that's something that hopefully a midwife would do anyway especially with twins).

Just because they share a placenta and have a thin membrane separating them does NOT doom them to suffering from TTTS. I don't want to scare you. But I also think that it's wise to be cautious. And I would definitely want a doctor or midwife who's aware of the other symptoms of TTTS that don't need a U/S to detect (like rapid increase in amniotic fluid for one, which will result in a lot of pain and when you see it...it's most definitely obvious). If you are diagnosed with it, get second and third opinions, preferably from some of the national experts, particularly if you're in an area that doesn't have a doctor that's a specialist for it.

My boys had TTTS. It was diagnosed at the 20 week level II u/s. It was a very hellish experience, and I hope that you are among the majority that don't have to deal with it. You shouldn't be bullied from having a non-medical birth, but please be aware and be your own advocate for monitoring for this. There are a lot of things that can be done now that save a lot of babies' lives.
post #10 of 27
Yes, mine who had TTTS were monochorionic/diamniotic. I still had a nice vaginal birth.
post #11 of 27

reply

TTTS does not occur during delivery. It isn't an acute condition, it is a chronic one. I'm not an expert on it, but do know that it occurs weeks or months before you deliver and some signs of it are one twin having an enlarged bladder and heart and being much larger than the other (the recipient twin). The other twin will be much smaller have a small or no noticable kidney or bladder(the donor twin). TTTS is very serious, but it will not suddenly develop during delivery. TTTS is also sometimes treatable. Not to the point where your pregnancy will be problem free, but there are a few things a maternal fetal medicine specialist can do to buy the twins some extra time to spend in-utero. I don't know of any problems related to delivering monochorionic/diamniotic twins vaginally, but one poster earlier said,

"But if your twins had shared an amniotic sac, the risks during delivery increase for things like cord entanglement and cord prolapse."

This statement is 100% wrong. I am currently pregnant with monochorionic/monoamniotic twins and when you have "momo's" (that's what they're called) you DO NOT deliver them vaginally, ever. They are c-sectioned no later than 35.0 weeks (although, not many make it that far...fetal distress usually occurs before then and the babies are delivered quickly). With monoamniotic twins, their cords WILL BE entangled. If you are lucky, there will be no true knots, but that's only if you are really lucky. With a monoamniotic twin pregnancy, you are admitted to the hospital somewhere between 24-28 weeks and you are monitored either 3X a day or 24/7 (depending on your doctor). Most momo's are then delivered at 32-33 weeks because that's what the research says is safest. That time frame has the least risk of fetal death. Attempting to carry them to 35.0 weeks is acceptable only if you are on 24/7 monitoring. Cord entanglement is indeed a problem. So much so that if you attempt to carry them past 35.0 weeks, the chance of one or both dying skyrockets since after 35 weeks, the main thing that babies do is put on fat. Yes, their lungs develop the ability to produce enough surfactant to allow them to breathe air easily, but those carrying momo's are given one dose of steroids to help the babies' lungs develop quicker...which is yet another stressful part of the momo experience for those of us who are "medical model of care" adverse. Anyway, the fat that the babies put on after 35.0 weeks takes up a lot of space in-utero and causes cord compression. Its the compression that kills, not the tangles or necessarily the knots. So thinking you can deliver momo's vaginally is wrong. Even if you made it to 38-40 weeks with them both still alive (the chance of which is less than 50%), the chances of them surviving a vaginal delivery is slim due to the shortened cord length because of the tangles and knots. As one baby enters the birth canal, the tangles and knots would be pulled tight cutting off circulation to both. However, most at risk would be twin B, if still alive at this point. I don't have to say the rest. So, if you are interested in knowing more about monoamniotic twins or have been diagnosed with momo's, visit www.monoamniotic.org. Its a support group web site for momo moms and it also has a lot of current information about monoamniotic twin pregnancy. The members there are either currently pregnant with momo's or have already gone through it, so they are a wealth of information and support. Its a scary pregnancy, but with the right doctor and the right monitoring, both babies can be born healthy. Just not at term and not vaginally.
Jen
post #12 of 27
Quote:
"But if your twins had shared an amniotic sac, the risks during delivery increase for things like cord entanglement and cord prolapse."

This statement is 100% wrong.
Ok, I'm sorry.
post #13 of 27
Quote:
Originally Posted by JenPL View Post
TTTS does not occur during delivery. Jen
http://www.greenjournal.org/cgi/cont...tract/94/5/819 This talks about TTTS occuring during delivery and that it hasn't been studied much. Normally TTTS is chronic, but 1 in about 1,000,000 cases, it is accute.


Quote:
Originally Posted by JenPL View Post
"But if your twins had shared an amniotic sac, the risks during delivery increase for things like cord entanglement and cord prolapse."

This statement is 100% wrong. I am currently pregnant with monochorionic/monoamniotic twins and when you have "momo's" (that's what they're called) you DO NOT deliver them vaginally, ever. Jen
Actually they are delivered vaginally occasionally. Usually when Mom hasn't had any ultrasounds (which doesn't happen very often). I have recently heard of a case in the Seattle area, and both twins survived. HOWEVER, of course, MANY MANY more haven't survived. And all the complications you stated are very true and very real.
post #14 of 27
Quote:
Originally Posted by JenPL View Post
TTTS does not occur during delivery. It isn't an acute condition, it is a chronic one.

May I ask where you got this information? According to the research I have seen from the TTTS Foundation and in talking to several international experts, while it is *rare* for TTTS complications to suddenly present during delivery, it *can* happen. What's more likely is that very mild transfusion had been happening for quite some time (that was not detected), and sometimes things can happen during delivery that can cause bleeding out and other potentially dangerous things to happen. (Again, unless the twins are not being watched during delivery, it's likely to be salvageable.)

Luckily these days we have better monitoring and finer-tuned detection of TTTS to begin with. But I would hate to see false information get out about this. I suppose it's true on a fine point that TTT doesn't 'develop' during delivery (and thus, you wouldn't have the syndrome bit). But the complications can, rarely, if those connections are there or have the potential to cause one twin to donate blood to the other through the placenta.

TTTS survival rates have gone up significantly, with the advent and access to laser surgery in utero that can close off the blood vessels that link the twins, with more understanding so that doctors don't perforate the sac (essentially creating a one-sac environment) as a 'solution', with the additional nutritional information we know to boost survival for the donor twin, and the fact that there's a good chance to allow babies delivered very early to survive. There are many, many things that can be done.

However, it doesn't make for a fun pregnancy. It can make for a rather traumatic one. But the end result is that with proper care and a bit of luck chances are good that even if you're diagnosed with TTTS and the placenta is shared at least 30+ percent by one twin, the hopes for both surviving are good. And in most cases (except undetected serious cases) at least one will survive.
post #15 of 27
They are not vaginally delivered occasionally. They are vaginally delivered very very rarely. And yes, it would be because no ultrasound was done or the doctor or midwife didn't know to make sure a seperating membrane was visible on the u/s (which would be negligent care). When no membrane is visible, a high-resolution u/s should be done to verify if there is a membrane or not. If still no membrane, it is an extremely high-risk pregnancy and only a perinatologist or MFM should manage the pregnancy. I have heard of some OB's managing the care but consulting with a peri or MFM, but this is not the norm and usually only happens when the momo mom is in a rural area where there is no peri or MFM nearby. Monoamniotic twin pregnancies are very rare. They only occur in 1% of all twin pregnancies and the misdiagnosis rate is very high because often a "regular" ultrasound machine cannot detect the membrane. That's why often a woman will have an initial diagnosis from an OB, but then find that after the high-resolution u/s from a peri or MFM the membrane is actually there. That is the best scenario and one that everyone hopes for when first diagnosed with a monoamniotic twin pregnancy. Anyway, I have read of only one woman who delivered momo's vaginally, but only with the help of an experienced perinatologist who monitored her very closely with NST's and dopplers. I am extremely skeptical of your account of the Seattle woman. I'm not saying you are lying or something, i'm just saying that i'd want to know the facts before i am willing to believe she really had a monoamniotic twin pregnancy and a successful vaginal delivery. I've had women argue with me that they had monoamniotic twins when all they meant was that their twins were identical, so there is some misunderstanding out there about what monoamniotic means. Perhaps one or two women in that situation (delivering momo's vaginally at term) would have their babies survive the ordeal; after all, the chances of both babies reaching term and being delivered safely is less than 50%, but it is not 0%. So, it can happen. But the vast majority of the babies would die or suffer from complications due to a birth delay. Any doctor who offered a vaginal birth for mom's pregnant with monoamniotic twins would be opening him/herself up for a malpractice lawsuit nowadays given that the research shows that a vaginal delivery is negligent care and therefore, grounds for malpractice. There are no perinatologists or specialists in maternal fetal medicine that i know of anywhere in the country who offer a vaginal birth for momo's. Its just not done. Take a look at this picture of one momo mom's umbilical cords. Do you think this would facilitate a safe vaginal delivery? http://s114.photobucket.com/albums/n...t=ourcords.jpg

Jen
post #16 of 27
Like i said, i'm not an expert with TTTS...but as far as i know, the syndrome does not suddenly develop during delivery. If it can occur acutely and cause complications during delivery in one out of a million cases (like Courtney said above), then that's kind of like saying the chances of it are close to non-existent. Its certainly not something i'd worry about. What you are saying sounds more likely, that it has been occurring undetected for some time, but that delivery can present complications (which would still make it chronic, not acute). I don't know the details about TTTS, so perhaps i shouldn't have said anything about it at all. I just know the basics, the symptoms and some treatments (laser surgery, fluid reduction). You sound like you have researched the topic and are therefore much more knowledgeable about it than i am. So if you say it can occur as an acute condition, then I apologize for being incorrect about that statement.
Jen
post #17 of 27
Thread Starter 

Just to clarify

I see a lot of discussion about mono's but my twins are not monoamniotic, they are diamniotic but possibly monochorionic (still to be confirmed) and appear to share one placenta. I know that TTTS can happen in cases where twins share one placenta, but I know that there is no chance of cord entanglement during pregnancy since they do not share an amniotic sac. Just wondering what the chances of that happening were in delivery since I don't know if a chorion can break but an amnion (one or both) remain intact....Hope that clarifies.
post #18 of 27
I don't think you have to worry about cord entanglement between the twins with a sac. Like in any birth, there is a small chance that one cord could prolapse or something, but with an attentive midwife or assistant or doctor that should be detected right away.

I'm sure there's some really strange thing that could happen, but I really don't think you have to worry about it!

I think you have to be careful about home delivery of twins that you know share a placenta (not that it's just fused or something), but if you've been receiving adequate care, and there's no special need for alarm (TTTS, huge size discrepancy due to very unbalanced placenta sharing/IUGR of one of the twins, early labor and delivery, blah blah blah), I don't see why that would affect your delivery.

I know so many mamas that have delivered their MZ twins vaginally! I'm not sure how many of them shared a placenta, but since the majority of MZ twins do to some degree, I assume that most of them did!

As long as there's no problems, I'd anticipate having smooth sailing for birth. Having MZ twins that share a placenta does NOT rule out vaginal birth or minimal medical intervention! Until my boys developed TTTS, my ob was all for me going for VBAC and was encouraging me to go unmedicated (as I did during my first labor). So it absolutely does not rule out a 'natural' birth. If they're MoMo, though, I think the safest route to go is to accept more interventions and give more weight/thought to cesarean because there are some pretty serious things that can happen there that are far less likely with other births.

And if my twins were found to have MoMo on a regular ultrasound, I would very seriously consider getting a level II for a second opinion!
post #19 of 27

Let's clarify about Acute TTTS

From the TTTS Foundation website:

Acute TTTS describes those cases that occur suddenly, whenever there is a major difference in the blood pressures between the twins. This may occur in labor at term, or during the last third of pregnancy whenever one twin becomes gravely ill or even passes away as a result of the abnormalities in their shared placenta. Acute TTTS twins may have a better chance to survive based on their gestational age, but may have a greater chance of surviving with handicaps.

There are markers for chronic TTTS, which your doc will look for. As Tigerchild mentioned: IUGR, size discrepancy, oligo/hydro amnio fluid. TTTS is pretty rare, but I would definitely get checked for it.
post #20 of 27
I am new to these boards - and just started browsing through threads.

I have 1yr old twins that were born in a hospital (vag, med-free, low-intervention). My OB didn't *know* a lot about chorionicity, but since my research after the babies - I believe that my twins were diamniotic / monochorionic. First ultrasound was at 8wks, babies look like they were in one "big black circle" (chorionic sac) but had the thin membrane separating them (amniotic). When born, the placenta came out as one - but they neglected to have it tested...so we don't know 100% if it was indeed one, or fused (I believe it was one because of 1st ultrasound and the following info). Now that I got all that out of the way - I wanted to share my story with you regarding possible Acute TTTS.

Quote:
Originally Posted by Tigerchild View Post
I suppose it's true on a fine point that TTT doesn't 'develop' during delivery (and thus, you wouldn't have the syndrome bit). But the complications can, rarely, if those connections are there or have the potential to cause one twin to donate blood to the other through the placenta.
Pregnancy & delivery was great - free of complications. Labor was fast (5 hrs), but I suspected it would be - my first was only 7 hours. Got to the hospital and was 7cm. Was monitored off and on, but I took the "belts" off often to go to the bathroom (claimed I was peeing but really to labor away from nurses). When I started bearing down they wheeled me to the OR to birth the babies. I can't remember if they monitored them at this point, I'm sure they probably did but I'll have to watch the video or ask DH....anyway...Baby A was born and was very lethargic and white. They cut A's cord right-away. I held on to him while I started pushing B out (they were 7 minutes apart). When they took A's blood pressure, it was different between his arm & leg (and low). They suspected a heart defect. Oh - birth weight was only 2oz difference. To make a long story short - after taking Baby A to a NICU and running various tests, his hemoglobin was low, they came back and tested Baby B's hemoglobin and it was high. Soooo...they diagnosed them with Acute TTTS. I had no symptoms during pregnancy, and even during labor the babies showed no signs of distress. Thankfully it was a fast labor - I don't want to imagine what could have happened.

I wish I would have kept better track of the placenta, but I was told it was going to the pathologist for testing. When at 8 weeks post-partum I didn't get any reports on it I tried tracking it down....and did not succeed. So, technically, we don't know for-sure if they had Acute TTTS, but I have tried to do research to find other reasons why Baby A's hemoglobin would be high and B's low and have not come up with anything (yet) other than Baby A was the donor and B was the recipient.

So, I know this veered off homebirth and Chorionicity, but the poster that said that TTTS is not acute - I just wanted to reinstate that is not true. Although it is rare, it is something to consider when choosing to have identical twins at home vs. the hospital. However, what would they have done to help me deliver faster? My babies showed no signs of distress...if it was Acute TTTS, then it kicked in at the very end of my labor**** - and they were born fast so I don't think having them at the hospital made it any safer for this particular situation.

****from what I understand - Acute TTTS lays dormant until labor begins and at some point the contractions and mother's change in blood pressure kicks it into gear. Obviously, the blood vessels were formed when the placenta formed, but distribute blood correctly until some point in labor.

Sorry about the novel!
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