gestational diabetes ramble, twin size - Mothering Forums

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#1 of 29 Old 06-04-2008, 10:44 PM - Thread Starter
 
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Okay, I'm a little frazzled and not completely up to speed with my gestational diabetes information since I haven't thought about it since I took the GD screen awhile back, so this may not be the best time to post. But I am upset and wanted to make a query, or vent, or something.

I am 32 weeks along with mono/di boys. I had our monthly perinatologist consult yesterday morning. (My husband also had surgery yesterday afternoon for bladder cancer which we first found out about maybe 1.5 weeks ago. So that accounts for some of the "frazzled" I'm feeling....)

I ended up getting the "GD-happy" peri we saw 8 weeks ago...the one who told me, "Your babies are growing big, and twins don't do that" and immediately started talking about gestational diabetes and whether I'd been screened, and that I needed to be screened. I managed to speak up about the possibility of twins gaining good size and going to term if mothers were able to have a good early weight gain by following something like a Brewer-type diet, or the nutritional profile recommended by Barbara Luke. I also described my diet a bit. He just looked at me for a moment (this was at our first meeting 8 weeks ago) and then said, "Just get tested."

So I did consent to the screen, although I didn't end up taking it until 29 weeks. I passed. My OB's office didn't mention the score (and I didn't ask), but they just called and said everything was fine with the results and things looked great.

Well, at our last peri consult/ultrasound, we had a different doctor. The twins were, as always, tracking "big," but this doctor didn't mention anything about GD. (I had just taken the test but hadn't gotten the results yet, anyway.)

There is a disparity between their sizes (they've maintained about an 18-20% difference over the last 3 months or so, if I recall correctly) but it has never seemed to indicate any "issues" or problems such as chronic TTTS. It is not like one is growing big at the expense of the other....BOTH are growing ahead of the average, even though one is bigger than his brother.

This time (yesterday), the larger twin jumped ahead. If I look at their estimated stats and compare their growth to the previous scans & particularly the one two weeks ago, it's really a matter of the smaller twin measuring significantly smaller, or growing less than he usually has. He's still "ahead" of average, but only by a week or so this time. And because of that, this time there was a 25% difference in size between the twins.

They examined fluid levels & cord flow (via doppler) twice, and neither were abnormal. (I think this was them ruling out TTTS symptoms?) They could see the bladders of both twins. I think the larger twin had more fluid, but the peri seemed satisfied with those stats.

I was a little bothered right off the bat because I had their estimates from a scan two weeks ago, and I was mentally prepped for a ~7 oz. gain per baby per week, so I was watching for them to be 14 to 16 oz heavier. The larger twin made that, and beat it by a little. The smaller twin gained 9 oz.

This doctor immediately asked whether I'd been tested for GD, and whether I'd been tested "again." I told him I was screened at 29 weeks and passed. And I got a call from my OB's office this afternoon, saying that they'd received the report from my appointment yesterday and that the specialists are recommending that I take the 3 hour test this week, "because one twin is bigger than the other."

My mind is spinning from this. I did question the peri about the whole plus/minus factor with ultrasounds, and he acknowledged that (I think he said 15% either way), but basically harped on GD.

I'm going in for a NST tomorrow so I'll see my OB. She is pretty reasonable, though she seems always to defer to the recommendations of the perinatologist team. I'm wondering what issues to cover with her.

I really don't know how it is that u/s estimates are off....if it's that the measurements themselves are subjective when it comes to generalizing to guess weight (i.e., you can't really get an accurate idea of size from measuring the head, abdomen, leg bone & arm bone?), or that degree of fat/weight varies quite a bit baby to baby and that skews estimates, or if it's that some techs are less accurate in their measuring and the results will vary a lot because they rely on whatever the techs capture.

I look at the techs when they freeze the image (of the head or abdomen) on the screen and then create the dotted circle and size it over the image. They adjust it, adjust, adjust, then click. It finalizes and the computer spits out the circumference and the gestational age that relates.

So....if their circle is just slightly inside the outline, or just a little over, that could account for some error or difference? Or the point at which they click on each end of the femur accounts for that specific measurement, so if they're off a little bit on where they clicked on the image, it throws things off a little?

I was wondering if there is a chance that the measurements were basically accurate for one twin while less accurate for the other. And if that could account for the increase in difference between them.

Also, I'm wondering if GD even would make sense in "explaining" why one twin would nose ahead of the other (or why one twin would slack off.) Wouldn't they both just grow bigger? Is one twin going from 20% to 25% bigger (because the smaller twin grew more slowly than usual) some kind of indication of GD?

I just want to have a good reason to take the test. "Twins don't grow big" doesn't feel very compelling to me. "One twin is bigger than the other" doesn't seem clearly to indicate likelihood of GD. What could explain one twin starting to grow less, and the other maintaining his usual growth curve? GD?

And I am torn about the test. On the one hand, I feel it's just a big stress to the system to go through. Fasting, then drinking "glucola," then sitting in a lab waiting room for 3 hours. So unnatural. And I never have believed that I have GD, so I am loathe to subject myself to that test just because some perinatologist is convinced that twins "don't grow big." On the other hand, I feel spooked and nervous and superstitious, like "what if I fail this time?" Is there even a "certain way" to eat in the days ahead to promote passing, or is it purely a matter of how your body metabolizes sugar?

Is the test even warranted? Could the diagnosis of gestational diabetes explain why one twin didn't grow as much (which is the only difference noted this week)?

I'm sorry my thoughts are so scattered and rambly. I hope my issues and questions are clear.

Here are some measurement estimates over the last few months, for reference:

20 weeks, 4 days
Twin A: 13 oz
Twin B: 1 lb. 2 oz.

24 weeks, 4 days
twin A: 1 lb 13 oz
twin B: 2 lbs 3 oz.

28 weeks, 4 days
Twin A: 3 lbs, 4 oz.
Twin B: 4 lbs, 1 oz.

30 weeks, 5 days
Twin A: 4 lb, 3 oz
Twin B: 5 lb, 2 oz

32 weeks, 4 days
Twin A: 4 lb, 12 oz
Twin B: 6 lb, 6 oz

Can anyone give me any feedback? What questions would you raise with the doctor, tomorrow? And do you think the "issue" is more big babies, the one baby being bigger, or the smaller baby seeming to gain less and letting the gap widen? Does gestational diabetes speak to the issue? And what could explain such a change?

Thanks for bearing with me....
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#2 of 29 Old 06-04-2008, 11:01 PM
 
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Ok, for the first part of your post I thought you were talking about Gentle Discipline and I was getting really confused. Anyway, I personally would not get tested for GD just because the twins are measuring big. Ultrasounds are not accurate and big twins are a good thing, anyway! My twins had very significant weight differences at birth (6 lbs 10 oz, 8 lbs 4 oz) but both were totally healthy. I never got any tests or anything done while I was pregnant, but I also had a homebirth midwife. You just need to do what you feel comfortable with and don't feel pressured to do something because the doctors are trying to scare you.

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#3 of 29 Old 06-04-2008, 11:31 PM
 
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That sounds so weird to me. With everything I was told when I was dxed with GD at 27 weeks, the possibility of growth disparity related to GD was never mentioned.

Could you perhaps request another 1-hour test, and if those numbers are off, then decide about the 3 hour? It still sucks to have to drink the stuff AGAIN and sit there, but better that than the 3-hour. Though really, I'd be tempted to get a second opinion from another peri.

Betsy, mama to beautiful, strong MZ twins Lillian and Kate, born 11 weeks early on January 10, 2006.
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#4 of 29 Old 06-04-2008, 11:35 PM - Thread Starter
 
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Quote:
Originally Posted by gemelos
Anyway, I personally would not get tested for GD just because the twins are measuring big. Ultrasounds are not accurate and big twins are a good thing, anyway! My twins had very significant weight differences at birth (6 lbs 10 oz, 8 lbs 4 oz) but both were totally healthy. I never got any tests or anything done while I was pregnant, but I also had a homebirth midwife. You just need to do what you feel comfortable with and don't feel pressured to do something because the doctors are trying to scare you.
Thanks. I think the size difference is more a matter of concern, or at least of "watching," when the twins are MZ and share a placenta. Because with that scenario, the twins don't have completely separate circulatory systems, and a disparity of size (accompanied by other conditions) can indicate that their shared vascular connections are getting out of balance and that one (the recipient) may have begun to grow at the expense of the other (the donor.)

To this point, they never have suspected TTTS even with the size difference, because BOTH twins were tracking bigger than average and other than the difference between them (which has been relatively consistent), there were no other indications of TTTS.

This one doctor suspected gestational diabetes simply because they were growing big. Then all was quiet on that front, and when I took the screen I passed. Now he's making noise again, and the reason I heard was that "one twin was bigger than the other" but I'm wondering if it's just the "big babies" again.

This burns me because I take deep pride & satisfaction in growing them big....and no perinatologist seems to recognize it as possibly good or positive. I mean, wasn't this the GOAL?! And tracking in the 90th percentile or whatever should not be reason for alarm....after all, somebody's got to be tracking there, right? Why not a healthy twin?

Not one single doctor has mentioned anything about diet, calories, protein, or nutrition to me. And none of them have talked about weight gain--overall weightgain or target goals along the way. Not once. Having read the recommendations on my own time, that simply blows my mind! Of course, I found my doctor mid-stream and all, and I haven't asked any questions on the subject, but still..... They don't seem terribly informed or concerned about those issues, or the goals that seem so obvious and well-known online & in books. It's strange.
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#5 of 29 Old 06-04-2008, 11:37 PM
 
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I had mono-di twins, and would not worry one bit about the GD thing. Even if you had GD, why would that make one twin grow more than the other? That just doesn't make sense.

The differences in weight gain would actually worry me a bit more -- my OB said if they got to 20 percent we would be screening with even more regularity and 25 percent would probably mean action (I think...). Maybe mamas who had babes with TTTS will be able to offer more reassurance there -- but I would be asking about that.

Do you see the same person for your U/S? We had the same tech for our three-week scans and so I (and the OB) took his readings more seriously than the quickie scans at the hospital in the last weeks as I figured whatever quirks he had in measuring, they would at least be consistent quirks.

HTH. Sending good thoughts your way!

P.S. Extra hugs to you and your husband as he recovers from surgery. I can imagine the state of frazzledness. I hope he recovers quickly and that all is well.
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#6 of 29 Old 06-05-2008, 12:29 AM - Thread Starter
 
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Originally Posted by OGirlieMama View Post
That sounds so weird to me. With everything I was told when I was dxed with GD at 27 weeks, the possibility of growth disparity related to GD was never mentioned.
Thanks for that comment. That is the kind of thing I was skeptical about....that this test is recommended because of growth disparity. I am thinking that this test is being recommended because of "big babies," and the increase in growth disparity is what was setting off my alarms, but screening for GD isn't likely to address that issue.

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Originally Posted by LoisLane View Post


I had mono-di twins, and would not worry one bit about the GD thing. Even if you had GD, why would that make one twin grow more than the other? That just doesn't make sense.
Okay, another person who agrees this doesn't make sense. (GD suspected because of disparity.) I'll raise this issue with my OB and see what she says.

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Originally Posted by LoisLane
The differences in weight gain would actually worry me a bit more -- my OB said if they got to 20 percent we would be screening with even more regularity and 25 percent would probably mean action (I think...). Maybe mamas who had babes with TTTS will be able to offer more reassurance there -- but I would be asking about that.
Yes, I know. I have seen different standards, with the TTTS Foundation website having the more conservative ones, I think. The team of peris we've been consulting with have been comfortable with 18-20% disparity between my twins in particular, but I think it's because they're observing the situation in context. Alarm bells could go off with the same level of disparity in a different twin pair, but they've been pretty good about evaluating in a kind of holistic way.

So looking beyond the disparity, they've recognized that both twins are tracking above average for size (one is not bigger while one is small for gestational age...both measure "ahead"), their disparity has been fairly consistent with both gaining well, their fluid levels have been in a good range and roughly equal, the membrane between them always has been loose & sort of fluttering easy (not billowing out to one side like a sail because there's more fluid on one side than the other), both twins have visible bladders and are swallowing fluid/producing urine, the Doppler studies of umbilical flow have showed normal rates of flow & good consistency between the twins. Both umbilical cords have decent implantation sites (one is not off with a peripheral implantation and getting less of the "good stuff.")

They've had one NST and both performed well; I got out of there in 20 minutes.

So....I think the 20% disparity hasn't been considered a big deal.

I'm not sure if the new 25% disparity is a big deal as far as TTTS is concerned. I mean, they scrutinized all the same things that typically are factors, and no red flags went up. And the bigger twin basically grew at the predictable rate (a normal gain) while the smaller twin didn't. Which is what gave rise to the increased disparity.

Quote:
Originally Posted by LoisLane
Do you see the same person for your U/S? We had the same tech for our three-week scans and so I (and the OB) took his readings more seriously than the quickie scans at the hospital in the last weeks as I figured whatever quirks he had in measuring, they would at least be consistent quirks.

HTH. Sending good thoughts your way!


No, I think we have seen a different tech every time we've gone for our peri consults. I guess this is another point to raise with my doctor tomorrow. I really wonder if we were to have a scan tomorrow, how the twin A measurements might come out. Is there this sudden lag, or was it a measuring quirk? And is there anything serious going on? And what the heck does GD have to do with any of it?!

Maybe I'm more prepared for this exchange with my OB tomorrow than I thought I'd be when I started writing this message. Thank you so much for the feedback here. When I finished the message (I'd left it sitting on my computer unfinished for hours), I figured I was posting too late to get any responses tonight....

Quote:
Originally Posted by LoisLane
P.S. Extra hugs to you and your husband as he recovers from surgery. I can imagine the state of frazzledness. I hope he recovers quickly and that all is well.
Thanks for the hugs. The timing of the news seemed crazy (but it could have been worse) and we are getting support & help with food. Which is huge, because I am getting less and less productive and had been leaning more and more on him. He's recovering well and thankfully has no incision to heal from, since the surgery was trans-urethral. What a mind blow to have to shift to thoughts of cancer right in the third trimester of a twin pregnancy, though. It has messed with both of us.
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#7 of 29 Old 06-05-2008, 12:40 AM
 
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I think you are right in not worrying eariler because their growth and disparity had been consistent (the 18-20 percent measurements) -- just like after a babe is born, as long as she remains basically on her curve (even if it's the 3rd percentile), that's fine -- someone has to be on the tiny end (and the big end). I do think the fact that they have possibly changed their growth pattern (16 vs 9 ounces) is something to ask about, though. That's the whole reason why mono-di twins get all these U/S anyway!

And I think you deserves CHEERS for doing so much to support nutrition and good growth for those babes these last months! That's a ton of work and not easy, especially as the belly starts to get SO big. So even if your docs aren't saying it, I will -- YAY you!

Glad to hear you have people taking care of you. I wish I could bring you a lasagne, too!
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#8 of 29 Old 06-05-2008, 06:00 AM
 
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BIG HUGS and you're doing an **awesome** job!!!!!

Michel Odent doesn't generally recommend the GD screening as far as I understand - you could google his ideas/ approach, but basically he says that everybody should be eating the diet they recommend for GD, so why test.
You could ask what they would want to do if they found a 'worrying to them' result? If it is diet change then you can feel more confident assuring them you are making any relevant changes. I don't suppose you actually *need* to make any changes though!

TTTS - do you know what they share in terms of amnion/ chorion? If they were early split monos it might be they wouldn't be able to be affected iyswim. Maybe more clarification on that point from the OB would help....

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#9 of 29 Old 06-05-2008, 08:01 AM
 
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I very reluctantly took the 3 hr after failing the 1 hr. My di/di twins were measured big though not 6 lbs at 32 wks big . I gave them a hard time about it -- asking what would I do differently at 32 wks if it came for GD? isn't this a good thing if they're big and I have no other symptoms? etc? -- but I ultimately acquiesed. It did buy me some brownie points (which I intend to cash in later )

Also, my "big" twin has flip-flopped from peri visit to peri visit. At one pt A was 13% bigger, then B was 7% bigger. My MW & I laughed about it -- talking about how inaccurate some of these "medical certainities" can be.

I personally would weigh how much say in your care the peri has (including whether you can seek another opinion) and decide from there. If he/she can make things difficult for you, I might do it. I took the 3 hr b/c it helped my MWs "prove" that my twin PG was still a-OK and normal. It's an admittedly crappy way to have to go about things, but twins (I've found) can make providers so crazy sometimes it is worth it.

Have they started on you can't have a vaginal birth b/c B is so much bigger than A? That's what I'd expect next (unfortunately).

Good luck (and hoping your DH is doing ok).
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#10 of 29 Old 06-05-2008, 08:52 AM - Thread Starter
 
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Have they started on you can't have a vaginal birth b/c B is so much bigger than A? That's what I'd expect next (unfortunately).
OMG, I hadn't even remembered to connect that in. This most recent peri did mention that in a kind of aside, I think. It was the whole "Soon we're going to be talking about 'when these babies should be born'" line. Greeeeaaaat. My doc already said she has no set protocol for mono/di twins, and that at 38 weeks she goes on an individualized, case-by-case basis consulting with the team of peris who've been involved in my care all along. The problem with that is, I'm pretty dang sure their recommendations won't include "waiting" until 38 weeks is completed. I've heard rumblings of 36 weeks, as well as the usual 37 week deadline. (My doc has said she wouldn't push induction/elective delivery until 38 weeks, when it would become a matter of evaluating "my" situation day to day & assessing the peri rec's. I don't know where she'd stand on that if they were pushing for earlier elective delivery, though.)

This last dude mentioned the potential for problems "especially" with baby B being "so big." Like an ominous "get your (probable) diabetes under control or you might not get a vaginal birth." I was thinking what the heck? It's baby B. And the womb will be empty (of his co-twin) by then. What is the specter, here?

It's two vaginal deliveries, right? Successive. Even if he were "huge" for a twin and near/at 9 lbs or something (and frankly, I think I'd go spontaneously a little earlier, like by 37/38 weeks if they really were getting big & ready, anyway), it is completely possible to birth a 9 pound baby vaginally. To my way of thinking, what's hardest about twins is carrying them, because you have to do it together. Vaginal birth is, at least, successive and you do it one baby at a time.

It's quite possible I'm missing something, and a big baby B might impede baby A's progress or birth in some way? I dunno. But I really felt annoyed at the "especially since it's twin B that is the larger" comment, in my novice/uneducated knee-jerk reaction state.
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#11 of 29 Old 06-05-2008, 09:02 AM - Thread Starter
 
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TTTS - do you know what they share in terms of amnion/ chorion? If they were early split monos it might be they wouldn't be able to be affected iyswim. Maybe more clarification on that point from the OB would help....
They share the chorionic membrane/placenta and they have their own amniotic sacs. I'm not sure what early split monos are....is that splitting early on in the 4 (or so) day window for becoming mono/di? I haven't really read about any distinctions in that, beyond the initial split ranges being determined by what has/hasn't formed at that time.

i.e., if the egg splits within (guessing at an old memory, here, for the day ranges) the first 4 days after fertilization, the chorionic membrane hasn't begun forming and they will have their own placentas & everything. If it splits in the 4-8 day range, the chorion is already on the way so they have to share that (and obviously, share the resulting single placenta) but the amnion hasn't begun to form so they will get their own amniotic sacs. Are you saying that the earlier the egg splits in that range of (guessing) day 4-8, the "less" they might share while still being monochorionic? I've never heard of that, but something like that might influence the type of vessel structure of the cords or just how intimately linked their vascular connections are...

I dunno.

We had an u/s at (estimated) 14 weeks. I had no idea of my dates at the time. When they saw the twins, they couldn't detect a membrane. So they sent me to a MFM center for a higher level U/S and the membrane was detected. They made the mono/di diagnosis based on the thin membrane, the very apparently single placenta, and the clean T of the membranes joining the placenta. But it wasn't an early enough u/s to have the "best look," as far as optimum certainty. I never heard any estimate of early or late split monochorionicity.
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#12 of 29 Old 06-05-2008, 09:31 AM
 
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Maybe I'm more prepared for this exchange with my OB tomorrow than I thought I'd be when I started writing this message. Thank you so much for the feedback here. When I finished the message (I'd left it sitting on my computer unfinished for hours), I figured I was posting too late to get any responses tonight....
I think multiple mamas stay up late trying to get that "free" time after their little crazies go to bed! ;-)

I hope your conversation with your doctor goes well and gives you some peace of mind. And I hope your husband is doing well and will continue to do so.

Betsy, mama to beautiful, strong MZ twins Lillian and Kate, born 11 weeks early on January 10, 2006.
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This last dude mentioned the potential for problems "especially" with baby B being "so big." Like an ominous "get your (probable) diabetes under control or you might not get a vaginal birth." I was thinking what the heck? It's baby B. And the womb will be empty (of his co-twin) by then. What is the specter, here?

It's two vaginal deliveries, right? Successive. Even if he were "huge" for a twin and near/at 9 lbs or something (and frankly, I think I'd go spontaneously a little earlier, like by 37/38 weeks if they really were getting big & ready, anyway), it is completely possible to birth a 9 pound baby vaginally. To my way of thinking, what's hardest about twins is carrying them, because you have to do it together. Vaginal birth is, at least, successive and you do it one baby at a time.

It's quite possible I'm missing something, and a big baby B might impede baby A's progress or birth in some way? I dunno. But I really felt annoyed at the "especially since it's twin B that is the larger" comment, in my novice/uneducated knee-jerk reaction state.

I *thought* the docs started getting crazy if B was bigger than A. That certainly seems to be the norm on another twin board I pop in on...Some of them have been told that if Baby B is bigger at all (even minimally) they can't have a vaginal birth @@.

The theory (as well as I understand it, which is not much) is that a big A is ok but a big B is not. I was told greater than a 20% weight discordance was "problematic" for a vaginal birth...And I have di/di twins.

I haven't found much but I did find this article describing a higher incidence of c/s with a bigger baby B:

http://www.greenjournal.org/cgi/content/full/103/3/413

Anyway, maybe someone else knows more about this aspect but just wanted to alert you to be on guard for that conversation

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Maybe baby B being bigger is an issue to them because of worries, ( like with anti-breech birth stuff) that he/ she who comes behind A might get stuck - whereas if baby A is bigger they feel they can relax that baby B will make it too.
So just in case we'll section.

BUT as you say, ultimately, if a singleton can deliver at 9lbs, why would a twin not be able to also.

Thing is, we can all get totally paranoid about what can go wrong, locked twins, shoulder dystocia etcetcetc....but what about what might go right.

If it goes wrong we can choose to section, so why not wait and see?

There are very few problems that can be definitively predicted before birth - tens of things that can go wrong within labour and birth, we watch and wait and see how everything is fitting together.....otherwise all multiple and singleton mothers must have c sections from this point onwards 'just in case'....and what devastation to babies and mothers that attitude is creating.
Bleurgh bleurgh bleurgh.

No wonder we end up dreaming of and going ahead with unassisted births.

'monochorionic' - sorry I was reading monozygotic, so when monozygotic but with an early split they could have seperate placentas which would mean no TTTS as far as I understand.

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#15 of 29 Old 06-05-2008, 02:27 PM
 
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Are they worried that if you push out Baby A and then Baby B is bigger, you'll be too tired to push that baby out, too? I'm not saying that's a valid worry (I'm certain I could've done it, had that been my case), just brainstorming to see if that's their line of thinking.

Betsy, mama to beautiful, strong MZ twins Lillian and Kate, born 11 weeks early on January 10, 2006.
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Just here briefly...I think one worry with the second twin being bigger is the breech presentation. At both hospitals (my local & the tertiary center with the MFM department & NICU where I'd go if I went into preterm labor or some kind of complication came up later in the pregnancy), the second twin being breech does not rule out vaginal delivery. However, I think they really like to see that the larger of the two is your vertex presenting twin, Baby A. The idea is that if the second twin is breech, they're happier if it's also the smaller of the twins. I don't think the larger 2nd twin (also being breech presentation) automatically contraindicates vaginal attempt, but maybe it puts more flags on your file? Makes them antsy to induce?

It will blow my mind if, as time goes along, I start hearing their reasons for recommending elective delivery at 36/37 weeks involve things like size of the second twin, and how "big" they are in general, and "twins are ready earlier than singletons" rather than concern about acute TTTS. The prospect of them developing acute TTTS near or during labor probably would be the most compelling argument (to me) for an induction, barring some other kind of complication. Otherwise, it would feel too precipitous to me. But if that's not even their big concern, that would be very telling to me.

I am hoping that Hypnobabies will help my babies and me be in synch, and that they will come at an optimal time for them and before I am needing to fend off the induction talk too aggressively.... I'm also glad we picked the latest of all the available due dates (they were all within a week of each other, I think, but at least we got the latest one on record.... My husband does think it's pretty accurate as to our best guess at date of conception, though, so it's not like it's really a sneaky or fake due date! But still, every bit helps.)

And my weeks always are up/starting on a Friday, (I'm 33 weeks tomorrow, for example), so I always figure I can argue at least for waiting out another weekend, right?
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#17 of 29 Old 06-06-2008, 08:04 AM
 
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I'll have to ask about the weight difference thing. AmyC's idea re: breech makes sense. When I googled weight discordance there are many articles but only that 1 I posted seperates it out from the TTTS-size difference (more along the lines of issues that arise when "a" twin is more than 25% bigger).

Personally, it seems like one more way to get you into the oh-so-easy for them c/s. Scare-dy cats In my MW practice, there's one back-up doc that won't do anything but a c/s if twin B is breech -- so you just have to roll the dice and hope she's not on call.

At least I haven't gotten too much induction pressure.
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#18 of 29 Old 06-09-2008, 07:47 PM
 
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This actually sounds a bit like what went on with my friend, except that she knew she had GD (and it was under control). Her boys were fraternal, two placentas, etc, and had also always measured with one bigger than the other. And like you, one didnt appear to grow as much one week (actually they didnt see any growth at all and she was having bi weekly US-so itd only been a few days since her last one). In her case, the doctor freaked out and did a cesarean the next day. It turned out both boys were bigger than the US showed, the smaller one was markedly larger, and the weight difference between the two was much smaller than they thought (although, as someone else said, weight difference isnt a huge deal in itself). So-they freaked, took them at 30 weeks, had to spend 10 weeks in the NICU, all because of an ultrasound that wasnt right.

Ultrasounds are notorious for being off. Now, if I saw your little one wasnt growing at all for a couple of weeks, I'd be worried. But he DID grow. Babies are like any other person, they can go through growth spurts. Its entirely possible one has slowed down a bit and the other went through a little spurt. I know with my pregnancies I've sat at the same fundal height for weeks and then all of a sudden will gain like 4cms in a week!

Admittidly I havent been one to trust ultrasounds since my first-they told me the day before he was born he was measuring at 7lbs even. The NEXT DAY he was born weighing 8lbs 6oz. Bit of a difference! I think it can be a combo of factors...tech experience is one, the whole measuring inside/outside the bone line thing is another, some just dont get the measuring done well at all, and I really think the amount of fat/muscle the particular baby has can make a decent difference in itself. My kids have measured smaller probably because they are shorter at birth. Their bone structure is just...shorter. But they come out all rolley polley.

If I were you, I'd stay away from the 3hr test and just keep taking it a week at a time. As long as the smaller guy keeps growing too, I'd let him stay in there and try not to worry.

PS my friend was told after her babies were born they had TTTS-FRATERNAL TWINS with TWO placentas. Just goes to show that some docs really have no problem lying huh? :P

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Add my chiming to the "GO MAMA!" camp! Your perseverance and care toward baking those little sweeties big will give them a great start (and give you a great start as a mama of twins)! Hit the ground running! You'll need to

On the matter of suspected GD because one twin is growing more quickly than the other: your thinking is on-track. This makes no sense. If GD is a "culprit" in their weight gain, it should affect both (unless there is another problem limiting the growth of the smaller twin). Listen to you gut instincts. You know you're hearing a line from this doctor who says with such authority that twins just don't get that big.

RE: risk of acute TTTS being a cue for induction: I don't really see why. This was something we worried about (a bit) with our mono-di boys. Yes, I realize the risk is extremely tiny at that point, but it was more of a "Murphy's Law" sort of a fear. . . the idea that you could get so close to the finish line. . . Anyway, have you read anything that leads you to believe an induced vaginal delivery is at less risk of acute TTTS during labour than a non-induced delivery? I never did. The stage is set for acute TTTS during labour in how the blood vessels grow during the pregnancy. If anything, I could only suspect that the abnormal stresses of an induced delivery might make acute TTTS more likely if those "pathways" are already existing across the placenta.

I know there's a lot of controversy about whether GD is even real and I won't wade into that debate. But I'll just add another example to the fray, in illustration of how intervention-happy a lot of obstetricians get. The OB who reviewed my ultrasound when I found out I was having twins told me that I should expect I would develop GD in my twin pregnancy. I had three previous babies all 9-11lb at birth. This was a multiples pregnancy. I had NO other risk factors at all. Nice!

I know you are under a lot of stresses right now - physical, mental, emotional. It just concerns me to know that there is such focus already on planning about getting the babies out. 33 weeks is a great, but you're just heading into the home stretch. Hang in there! (Unless your instincts or resounding/unequivocal medical evidence compels you to do otherwise).

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#20 of 29 Old 06-10-2008, 11:50 AM
 
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I am having fraternal twins, so my situation is a little different. But, there is about a 15-20% difference in the size of my 2, and the peri isnt' at all concerned. He said sometimes they just grow at different rates (even sometimes identical twins) and that anything up to 20% wasn't "concerning" and anything over 20% would require extra monitoring. The only time he'd be really worried is if one twin consistently fell further and further behind appointment after appointment. but, if they both seemed to be growing well, there wasn't much to be done.

I also don't put a whole lot of stock into the u/s being accurate. My ds was supposedly "huge" at 36 weeks, weighing approx 7.5 pounds. He was born one week later at 6lbs 9oz. Hmmmm......

Denise, mama to ds1 (03/26/05) and boy/girl twins born 08/12/08
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#21 of 29 Old 06-10-2008, 01:53 PM
 
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Exactly. Its just like a mama having 2 babies of the same gestation being different sizes...like, my 2nd was 8lbs 12oz and my 4th was only 7lbs 11oz at the same gestation (give or take a day). My overdue babe was only 8lbs 6oz. They vary a lot in weight-I'm mean, itd be odd for one woman to have a 5 pounder and then a 10 pounder at the same gestation, unless something was going on with one or the other, but all babies vary in size. And as I said, it isnt uncommon for them to slow down for a bit, then go through a growth spurt, or even just start back up again at the previous rate.

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#22 of 29 Old 06-10-2008, 02:14 PM - Thread Starter
 
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Updating to say that I did meet with my OB and she said nothing about the GD concern being because of the growth disparity. (The nurse or receptionist who called me with the info represented it incorrectly or had it mixed up, I think. "Everything looks great but there IS a difference in twin size, in that one twin is much bigger than the other, and the perinatologist wants you to be tested for gestational diabetes.") According to my OB, the issue was not the 25% difference. It is the fact that twin B has tracked consistently in the 97th percentile. She said big healthy twins are good, and that my babies show every sign of being healthy & happy (she had me in for a NST and took me off after ten minutes, I think, because their strip was "perfect") but that it IS unusual to see 97th percentile.

She also remarked that I'd passed the one hour test with no problems, but that it can be "false" for a twin pregnancy. She said if we ruled out GD as an issue, it might make invasive testing further down the road less likely to be recommended (i.e., amnio to test lung maturity at 37 weeks, since GD babies can have respiratory issues--but that all was predicated on the possibility of the recommendation to induce at 37 weeks, which I wouldn't be comfortable with, anyway....particularly because of the likelihood of respiratory distress!!! I think she thinks 37 week MZ twins withOUT GD are likely to have mature lungs because of the whole "twins are term earlier" rap.)

I neglected to ask her how the one-hour results would be false for a twin pregnancy....didn't ponder it until later. But, I already know that the 3-hour test is more accurate than the one-hour screen, and that the one-hour screen is supposedly just a simpler thing to rule out the majority of people who don't need further testing. Isn't the inaccuracy of the one-hour more in the realm of producing false positives? (i.e., people who fail it, but go on to pass the more accurate 3 hour test?) What is the likelihood that passing results would be FALSE for a twin pregnancy?

I should have asked.

Anyway, my whole approach in questioning her was sort of from the angle of "why suspect GD because one twin appeared to grow less?" And she put that one to rest right away.

The issue with the undiagnosed GD possibility was not the disparity, but the consistent size trend. (The fact remains that both twins have tracked above average, so we're supposedly dealing with two "big babies" even though one is consistently bigger than the other.)

I also started thinking what if the one-hour results were false and these babies ARE growing big because of GD, what would the impact be? (I do compare my "instinctive" diet with its natural aversions/tastes to the probable management diet for GDM, but I don't really know much specifically about that. And it's true that I eat a dish of ice cream with a banana almost every night before bed.... And in the last week before that ultrasound, I had eaten cookies in the middle of the day and a bunch of fruit leathers, when I was out and about and lunch plus an extra apple wasn't holding me.)

re: ice cream. It keeps me through the night and lets me get up feeling "normal" instead of shaky or nauseated, so I've stuck to the ice cream at night diet. I think it helped some with my weight gain (though it's only one dish a day, not like everything hinged on that ) since through the 2nd trimester I was eating mostly broccoli, bok choy, graprefruit, miso, brown rice, carrots/onions/peppers, eggs, apples, avocado and chicken. Closer to the 3rd trimester I added in pork. Not that all of those foods were "lean", but I'd say there weren't tons of calories in most of the things I was able to eat. So I think the ice cream helped.

Only once I was into the 3rd trimester could I seem to tolerate beef, and I started eating fish 2 or 3 times a week (haddock, cod, or salmon) then, too. That ice cream pretty much is the only time I have any dairy at this point, save a dollop of sour cream if I have a quesadilla (which also has cheese in it), or the very occasional grilled cheese (bread doesn't appeal to me very much.)

So, those have been my dietary instincts. No pancakes or French toast (wholegrain or not), I don't tolerate things like oatmeal or other cereal grains, bread, pasta (again, not even wholegrain), and I've been off milk/yogurt/most cheese since the 1st trimester. (For awhile, I ate lots of cheddar slices with apples, but now I just eat apples alone and cheese gives me an "off" feeling. No more nausea, just a bad aftertaste and an icky feeling overall.)


So the upshot is I consented to the three hour test. Which I took yesterday. And found out today that I passed.

I also had an NST, and twin A (the smaller one) wasn't as reactive on the strip as they'd like. Which nags at me a bit, but then, this was after the horrid GD test experience and I went to get some eggs when I finished (4+ hours after arriving at the lab) only to find out that they stopped serving breakfast at 10:15 and they only had things like bagels and breakfast pastries out. Ugh.

So instead of having my usual good protein meal and showing up for the NST, I was feeling icky from the test and from eating "off" for me. Hopefully that's all the NST results were about...

Well, another ramble.

Hopefully these test results put "Doctor Clouseau" and his comments to REST! Twins DO "grow big," and ultrasounds estimate size and can be wrong either way (my first child's late-term u/s measurements were off the other way, indicating a "nice small baby" even though my instincts told me she was 8 lbs + and I disbelieved the results but was relieved that they went "that way" because it was less likely I'd be pressured to induce, or pressured into a c-section for "failure to progress" even though my labor was long because of her positioning.... She was 8 lbs 12.5 oz when she was born, and I still remember my medwife's shock. She actually remarked quietly to the apprentice midwife, "Lucky I didn't know that baby was so big." Irked me so much, just the obvious implication.)
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#23 of 29 Old 06-10-2008, 02:19 PM - Thread Starter
 
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Also, I was prepared to defend against "suspicions" of TTTS if they came up to explain the growing disparity (mentioning the plus/minus factor of u/s measurements, plus the very normal doppler cord flow, the good fluid amounts, observable bladders with contents, and the usual signs of fetal well-being) but my doc was quick to acknowledge (before I started in) that all signs pointed to no distress or issues accompanying the widened gap in size. There was no playing on my fears with that angle, or trying to say that the larger twin was "growing bigger" or anything like that.

The only issue she voiced was if the overall size indicated that we'd missed a diagnosis of GD. Which, assuming the 3 hour test can be trusted , is not an issue.

I've been feeling like breech/transverse twin B has turned vertex. It's also possible that he jockeyed into twin A status (presenting closest to the cervix.) Wouldn't that be a convenient thing, if the "bigger" twin were suddenly in line to be born first? I don't know how accurate my hunches are, and I can't tell if twin A is still vertex (as he's been pretty consistently) or if he's turned breech....I do feel something hard high up on that side (that always has been twin B's head lying across the top, before now.) Maybe I'm completely baked on the whole positioning thing, but this is what it's been feeling like...a big shift on B's side.
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#24 of 29 Old 06-10-2008, 03:42 PM
 
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Thats good news about the test. Yeah, I had always understood it that they got false POSITIVES with the 1 hour test, not negatives. I know I had a false positive with my first, then passed the 3 hour with flying colors. The tests made me so sick though, I never did them again, lol. I'd do it if I had a good reason to, but I have no history of diabetes in my family, also eat a fairly diabetic type diet to begin with, and I'm only a lil bit overweight. Basically my midwives said I have no risk factors-unless baby was measuring big or they started seeing glucose in my p, they arnt worried about it.

Anywho, its good to see your OB isnt freaking out You go girl! (and wow, an 8lber being *huge*? HAHA-I mean, that isnt exactly tiny, but seriously, I know women who have had 11.5 lbers :P)

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#25 of 29 Old 06-10-2008, 04:39 PM
 
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The ultrasound I had the day before I went into labor estimated Claire at 7.3 and she was only 6.6. We couldn't even get a good read on Ben because at 38 weeks they were so squished together and Claire was laying her head on his stomach and throwing the measurement way off. He ended up being 7.6. AND he was my twin B. And posterior. And he had a nuchal cord. I still pushed him out. It was rather hard at that point because laboring a footling breech and not pushing for 2 hours had exhausted me but I still did it just fine.

Anyway, I obviously don't have mono twins but I wanted to comment to those two things since they related to my situation. Ultrasounds can be way off or a little bit off and you have to wonder if your tech is different each time are they measuring consistently off or bouncing all over the map? Claire was teeny but had a big head (13 3/4 inches) and really long legs so I'm sure that accounted for the size discrepancy.
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#26 of 29 Old 06-11-2008, 04:09 AM - Thread Starter
 
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Originally Posted by DocsNemesis View Post

Anywho, its good to see your OB isnt freaking out You go girl! (and wow, an 8lber being *huge*? HAHA-I mean, that isnt exactly tiny, but seriously, I know women who have had 11.5 lbers :P)
That midwife kept pushing us to transfer upstairs (from the alternative birthing center) to have an epidural and "rest" (It's true we'd been laboring at home from 0% effaced & 0cm dilated for 32 hours, then came in to the birthing center and spent 12 hours there. I was pretty tired and I know my husband was wrecked--he is 6 feet tall and only 132 lbs, very slender frame, and he needs his sleep and his food! I am more of a tank in terms of being able to cut corners where sleep and regular nourishment are concerned, without suffering overmuch. Poor guy. )

Late in the day at the birth center, my labor finally was getting "good" after I left everybody and spent all this time alone in the shower. I got out and dried off and stayed alone (with my husband) walking in the back bedroom, leaning against the wall during contractions. And I was in the zone, relaxing more with the contractions instead of fighting them, vocalizing less, but feeling productive. My midwife said that my being "quieter" during contractions was a bad sign, that things don't get easier with labor, and that this was called failure to progress. She kept recommending the epidural "to rest," and pitocin to "help things along," and kept mentioning my small baby and my excellent chance for a vaginal delivery if I did those things....rather than sticking with our plan and getting more and more tired, and stalling completely. (And ending up with a c-section.) I kept thinking, "I don't have a small baby," but of course I didn't say anything like that!

I know that an 8lb 12oz girl is not huge or off the charts in any kind of unbelievable way. That is part of why hearing my midwife say that ("Lucky I didn't know") just felt so undermining and confirmed how adversarial and pre-conceived her notions and opinions were....hearing from her own mouth that if she'd even suspected that size--which obviously I was able to birth vaginally--she'd have been pushing c-section and calling for surgical backup just based on THAT! I don't know what that late-term u/s actually said in terms of size, but I know she had her nose in my file and she kept saying "you've got a baby between 6 and 7 lbs, most likely under 7 lbs, with excellent chances for a vaginal birth if you just rest and get some help...", so I'm assuming she was relying on the u/s and that the estimate was pretty far off. But also, I think that u/s was a couple of weeks before I actually had the baby.

Even so, I think 8/12 is in the upper percentiles for girls, and most of the perinatologists we've seen have seemed to relax about Twin B's measurements after they find out the size of my first child, (referring to her as a "big baby" or 90-something percentile in a kind of "that explains it" way.) In fact, the first peri we met of the team we're seeing walked into the room after reviewing the scan results with the tech and the first thing he said to me was, "How big was she when she was born?" as he pointed at my four-year-old. When I told him her stats, he gave the tech a pointed look and said, "There you go, there's the reason for the big babies right there."

I was fully expecting my first to be between 8 & 9 lbs. As far as "big" or not, I figure it's a nice "baby-sized" baby! And sort of has bought me insurance, a bit, with the twins. Except for with the one GD-happy perinatologist....
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#27 of 29 Old 06-11-2008, 12:22 PM
 
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Honestly, I think the average baby is around 8-9 lbs-of course it depends on the woman and the baby-but so many OBs push for induction or cesarean before they are even due or get the dates off or freak out over a *big* baby on US, that it majorly skews the numbers to the 7lb range.

Ironically my biggest baby (at 8lbs 12oz) was by FAR the easiest to push out and the smallest (6lbs 14oz-she was 3 weeks early) was the hardest. That seems so backwards...but for whatever reason, the small one hurt so bad the entire time, and the big one is the only one I've had that urge to push really kick in and it really felt good to push.

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#28 of 29 Old 06-13-2008, 02:46 AM - Thread Starter
 
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Just updating about the size thing.....

I went in for a scan at my OB's office. It was supposed to be a biophysical profile with no measurements (since we did measurements at the perinatologist consult just over a week ago on June 3), but the tech started right in with head & abdominal measurements. I let it go without comment because I was tweaked by twin A's sudden drop on his curve, and wondering if it was a matter of the (different) tech mis-measuring something last week.

(The twins do share a placenta and the gap between them widening to 25% is not really comfy given the possibility of TTTS, but there were no signs indicating any kind of transfer problem so nobody jumped to that conclusion.)

Well, the result of the most recent u/s measurements is that either twin A gained 17 ounces in a little over one week (while twin B gained 6 oz), or last week's measurements indeed were off.

The estimates:

twin A: 5 lb, 13 oz
twin B: 6 lb, 12 oz

This puts them back to their usual size difference, minus the extra gap that suddenly was reported a week ago. And still pretty big boys for 33+ weeks. Though I guess I'm 34 weeks as of today (Friday.)
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#29 of 29 Old 06-17-2008, 09:09 PM
 
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I have not been able to read the other responses so sorry if I reapeat anything that was said.
I had my original GD test and then had to have another because of ecess fluid (which can be caused by GD) And tested slightly pos. the second time. I adjusted my diet and the fluids eturned to normal. WIth that said I don't think size would be reasonable reason to test, but with all the stress with your dh and all it might be easiest/less stressful you to just do the test. Its a pain and all they would do is adjust your diet. Though if you refuse the testing maybe you could appease them by saying you will eat like you have GD?
Its not the most invasive but it is a PITA. Sorry you are dealing with this, try to take the road with the less stress for you, you are goin through alot right now.
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