identical twins - planned c-section - Mothering Forums

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#1 of 17 Old 05-26-2008, 06:38 AM - Thread Starter
 
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Just curious. I don't have twins and am not pregnant. I met my neighbor, who is having a planned c-section in week 38. She has a 18 mo who was born vaginally. She said the c-section was because the twins share the same moderkage (mother cake - what is this word in english!? Sorry for the brain fart - I hope you know what I mean!) Anyway, this can cause problems for the 2nd twin. (I guess if it seperates from the uterus before the 2nd has time to be born? Not sure, she didn't go into details.) Just FYI: non-identical twins are not scheduled for cesarean, but a mother of twins can choose that.

Can someone enlighten me?
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#2 of 17 Old 05-26-2008, 11:27 AM
 
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They share the same placenta? That's no big deal. My girls were a hospital vaginal birth and they also shared the same placenta.

Is she bothered by the c-section? If she really thinks it's necessary then I doubt anyone is going to talk her out of it.
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#3 of 17 Old 05-26-2008, 02:44 PM
 
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If they're monoamniotic, they do need to be delivered by c-section, and she should be in the hospital on monitors as soon as they're viable. 50-60% of monoamniotic twins used to die, before those standard procedures were put in place, and now most of them live. (The problem is that in monoamniotic pregnancies, there's nothing separating the babies, and so their cords can, and almost always do, form true knots, which tighten either in utero or during delivery - why most of them used to not make it.) I think it's on of those rare exceptions where c-sections really are best, but it is a really rare condition.

I lucked out but monoamniotic twins are a rarity even among identicals. They're 1 in 60,000 pregnancies (at least, that's the statistic I've heard) and I believe they're less than 1% among identical twin pregnancies. Didi and dimo are a lot more common.

But if they're waiting till 38 weeks, I doubt they're monoamniotic. Most momo twins are delivered by week 34.

Maybe they're worried about acute TTS? I don't know much about that, but I've heard it mentioned. Maybe one of the dimo moms knows more?
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#4 of 17 Old 05-26-2008, 05:07 PM
 
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I assumed they weren't monoamniotic because she'd be in the hospital on monitors.

It seems as if they're worried that after baby A is born the placenta will seperate before baby B is out. I'm not sure about the statistics on this but it can't be high because there are lots of baby's here born that either share a placenta of have fused placentas. Sounds to me like an easy excuse to section twins instead of putting in the time to let her birth vaginally. And if she doesn't know any better, it sounds like a good reason to her.
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#5 of 17 Old 05-26-2008, 06:03 PM
 
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I'm guessing they share a placenta? Both of my sets of twins have shared a placenta and I had a homebirth at 39+ weeks with the first set and am planning the same this time. I believe the risk of the placenta detaching before the second baby is born is very small.

Heather, Army wife & Mama to M (10), J (9), L & S (my HBAC babies are 7!), N & R (5), and A (born 11/30/12 UBA2C)
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#6 of 17 Old 05-27-2008, 04:18 AM - Thread Starter
 
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Thank you all for your posts. It clarified things. I guess she was told planned cesarean would be OK, and she just went with it. She said it was good to know the exact b'day, so she could schedule someone to take care of her 18mo DD. I feel she doesn't know the facts, but it isn't my business to tell her, as we are not friends, just neighbors, so I didn't say much. I'd like to be friendly with her though, as our DDs are the same age. I did want to know my facts though, if we ever talked again - which is unlikely, as she would have to bring the conversation up, and the c-section is only 2 weeks from now.
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#7 of 17 Old 05-27-2008, 08:42 PM
 
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I love that a placenta is called a mother cake!

Blessed mama of four
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#8 of 17 Old 05-27-2008, 08:48 PM
 
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Sorry I just had to : at the idea of mother cake :

Twin boys 04/2005 : Support breastfeeding rights at FirstRight.Org : warrior
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#9 of 17 Old 05-28-2008, 04:20 AM - Thread Starter
 
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Quote:
Originally Posted by gemelos View Post
I love that a placenta is called a mother cake!
Off topic: Me too. And that's what it really is, isn't it? Danish is a VERY LITERAL language. Most everything is called exactly what it is. Some other funny examples:

umbilical cord translates as "belly button rope"
nipple is "breast wart"
midwife is "earth mother"
airplane is "flying machine"
morning rolls are "round pieces"
penis is "peeing man"
yoni is "peeing wife"
brow/face presentation at birth is "star gazing"
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#10 of 17 Old 05-28-2008, 06:50 PM
 
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Also, with id twins with 1 placenta, there is about 1 in 1,000,000 chance of having accute TTTS also. They are now pushing people to have c-sections with ALL twins that share a placenta (even if they are in different amnionic sacks). it is more of an insurance issue, but one that OB's are pushing more and more.

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#11 of 17 Old 05-28-2008, 11:01 PM
 
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This practice is so disturbing to me. If I'd been pushed into a c-section at 36 weeks for my double breech presentation they would have been here 3 weeks early as I carried them to 39 weeks by my 'obstetrical due date'. Claire was only 6.6--can you imagine how tiny and undercooked she would have been?
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#12 of 17 Old 05-29-2008, 12:30 PM
 
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Quote:
Originally Posted by cdahlgrd View Post
Also, with id twins with 1 placenta, there is about 1 in 1,000,000 chance of having accute TTTS also. They are now pushing people to have c-sections with ALL twins that share a placenta (even if they are in different amnionic sacks). it is more of an insurance issue, but one that OB's are pushing more and more.
I'm curious where that figure comes from. Do you have any links? I have had the hardest time finding ANY info on acute TTTS. My girls had it last time. No c-section-had a HBAC. This time my boys' cord insertions are very close and the OB is sure they share vascular connections. I've been trying to find out the actual odds of acute TTTS but have never seen anything, even on the TTTS website. My OB is fully supportive of a VBAC again (he doesn't know I'm planning another HBAC) even though he believes the babies share vascular connections. And he's hardly a "good" OB, if you know what I mean.

Heather, Army wife & Mama to M (10), J (9), L & S (my HBAC babies are 7!), N & R (5), and A (born 11/30/12 UBA2C)
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#13 of 17 Old 05-29-2008, 04:12 PM
 
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I have had a hard time finding info on acute TTTS, as well. It's definitely mentioned on the TTTS Foundation website, but the bulk of the info seems to be on chronic TTTS. (Which is where our focus has been to this point, anyway.) I admit I haven't (yet) gone over every inch of that website and I haven't searched exhaustively on the general issue of acute TTTS, but I've done some looking.

In thinking about the birth and what I would or wouldn't feel comfortable in refusing, in terms of monitoring, etc., I would like to know more about acute TTTS. Like, the odds, what seems to set it up or increase the likelihood of it being a problem, what might be risky (delayed clamping of baby A's cord, for example?), and how they monitor it or know it's a factor. (That last one is a big question mark in my mind.)

purpleheather, I think (this is just my understanding) the shared vascular connections often are virtually a given with a monochorionic pregnancy, regardless. It's the imbalance or disequilibrium that may or may not result that is the problem (with chronic TTTS). I'm sure you know that, but I wanted to mention it. Unless you think the OB is talking specifically about cord placement and likelihood of developing ACUTE TTTS, not just TTTS in general at any point in the pregnancy?

I still think that the low protein & tendency toward anemia have a lot to do with the TTTS dynamic, and that you can bolster your odds against it (despite any shared vascular connections) with a good weightgain early on and excellent nutrition. They (even the Foundation) always say there's no known cause, but their first responses after diagnosis seem to be boosting your protein intake (with Boost drinks, of course) and resting, etc.

Anyway, sorry to go careening off-topic, but I wanted to add that I too am curious about that figure for acute TTTS.

And yes, I've read papers recommending elective delivery of uncomplicated mono/di pregnancies after 37 weeks. I guess the rationalization is that, even with the possibility of near-term issues, the likelihood is that respiratory distress isn't a big risk and avoiding onset of acute TTTS (which moves quickly and can result in fetal death, as well as brain damage in the surviving twin even if sectioned in minutes) is worth the possible tradeoff.

I read that article when I was 14 weeks along and had just found out about the twins, their monochorionic status, and was trying to figure out what I'd be facing in terms of momentum and opinions. It was very depressing....
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#14 of 17 Old 05-29-2008, 04:18 PM
 
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Quote:
Originally Posted by Intertwined View Post
This practice is so disturbing to me. If I'd been pushed into a c-section at 36 weeks for my double breech presentation they would have been here 3 weeks early as I carried them to 39 weeks by my 'obstetrical due date'. Claire was only 6.6--can you imagine how tiny and undercooked she would have been?
It wouldn't have happened in your case (at least not for the acute TTTS risk) because your twins didn't share a placenta. But yeah, the near-term and pre-term issues exist and are daunting. I think the issue specifically is weighing those risks against the possibility of a vastly negative outcome in uncomplicated (non-TTTS, etc.) monochorionic pregnancies, though. I desperately want a vaginal birth and I want a spontaneous vaginal birth, but I do think about the acute TTTS thing and wish for more information.

I can't imagine being pushed at 36 weeks for double breech presentation, though. And really, that would be an apples and oranges situation. After all, what's the harm in waiting a bit longer, even if the plan is to section if they don't flip? Where's the compelling reason to section that early?! There, the risks of sectioning weighed against the "risks" of waiting don't add up compellingly at all (as far as I can see...)

I'm glad yours came when they did!
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#15 of 17 Old 05-29-2008, 04:33 PM
 
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[QUOTE=AmyC;11344614]Like, the odds, what seems to set it up or increase the likelihood of it being a problem, what might be risky (delayed clamping of baby A's cord, for example?), and how they monitor it or know it's a factor. (That last one is a big question mark in my mind.)

purpleheather, I think (this is just my understanding) the shared vascular connections often are virtually a given with a monochorionic pregnancy, regardless. It's the imbalance or disequilibrium that may or may not result that is the problem (with chronic TTTS). I'm sure you know that, but I wanted to mention it. Unless you think the OB is talking specifically about cord placement and likelihood of developing ACUTE TTTS, not just TTTS in general at any point in the pregnancy?
QUOTE]

There isn't much information out there, unfortunately. I have the big books that the TTTS Foundation gives out and it does not state the risk or protocol for acute TTTS in there at all.

My OB is specifically concerned about the risk of a acute TTTS as he thinks chronic TTTS would likely have presented itself by now. Given the fact that, thus far, this pregnancy has been identical to my last one (right down to placenta and cord placement) I guess that is the reason.

There really isn't anything you can do to prevent acute TTTS or even to know it is happening in some cases. You definitely don't want to delay cord clamping in Baby A because the risk of transfusion is so high. But we were monitoring both babies via doppler and never had any indication that there was acute TTTS until after the birth. Then it was obvious, as one baby was anemic and one was polycythemic.

I have read before that acute TTTS can be deadly, but I'm wondering the details on that. Even Dr. DeLia didn't elaborate on that aspect when I talked to him. My girls had no lasting complications whatsoever. I guess if it becomes severe enough you would see fluctuations in FHTs but by that point would it be too late? I honestly don't know. I've yet to see anything that shows a clear benefit in delivering monochorionic twins by cesarean.

Heather, Army wife & Mama to M (10), J (9), L & S (my HBAC babies are 7!), N & R (5), and A (born 11/30/12 UBA2C)
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#16 of 17 Old 05-30-2008, 06:50 PM
 
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When I was pg, I found a couple studies about the frequency of acute TTTS and it was roughly 1 in 1,000,000. There was a high mortality with those affected, but I still didn't agree to an elective cesarian. I felt my risks of other complications, etc. were much higher than that, so I chose to labor and try for vaginal delivery.

The risk of chronic TTTS is much higher, I think up to about 20% of all monochorionic twins. We didn't experience this either, thankfully.

It isn't easy being a twin mom!!

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#17 of 17 Old 06-02-2008, 10:11 AM
 
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There really isn't anything you can do to prevent acute TTTS or even to know it is happening in some cases. You definitely don't want to delay cord clamping in Baby A because the risk of transfusion is so high. But we were monitoring both babies via doppler and never had any indication that there was acute TTTS until after the birth. Then it was obvious, as one baby was anemic and one was polycythemic.

This was exactly the case with my mono/di twin boys. Born at 40wks, in a hospital, spontaneous labor, med-free vaginal birth (just so you know ). Baby A came out WHITE and lethargic and floppy, Baby B came out like a freight train (7mins later), red in color and screaming. Labor was short < 5 hours total. Baby A was anemic and Baby B was polycythemic.

My understanding is that the change in blood pressure (from contractions) can kick the Acute TTTS in gear. It must take a bit for heart tones to reflect that the donor baby is not getting proper blood supply. Acute TTTS can be very fast and fatal. If you have a long labor, I would assume that eventually donor baby's heart tones would slow way down while recipient baby's heart tones would speed way up (trying to accommodate for extra blood) but at that point - will it be too late? So, this is where the recommendation of c-sec at 36-37 weeks comes into play. If you make it to this point w/out regular TTTS, their theory is that avoiding labor will avoid Acute TTTS (again - labor can kick in the Acute TTTS). They also feel that for every week you are still pregnant after 36 weeks, you have another week where Acute TTTS can come into play (this was the explanation given to me by a HUGE supporter of mono-di c-secs at 36/37 weeks)

At some point I came across a study showing that there is about a 1% chance of Acute TTTS - but I did not save the link (pity). As others have said, there is not a lot of info. out there on Acute TTTS because there is not a lot of research. So, technically, the percentage could be a lot higher because there could be a whole lot of unreported cases out there (mine was not reported). While it disturbs me also to recommend all mono-di twin pregnancies to have a c-sec at 36-37 weeks, I don't think it can be completely dismissed as the OB's having an excuse to section.

Imagine - this is a new area of study. We don't know the actual facts and statistics of how many twins developed and were damaged/dead due to Acute TTTS. Personally, I know that if I didn't bring home two healthy boys due to Acute TTTS, I would have been wishing that I could have done something to change the outcome. FWIW - my boys (2 1/2) are fine too, with no lasting effects from the Acute TTTS - but my perspective has changed a bit now. I'm not sure where I stand on the c-sec recommendation, but I do see where it comes from.

~Andrea

**I also love that the placenta is called the mothercake, and think I will start using that
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