Cords

As we know, most, if not all, momo twins have some knots and twists in their cords. It is these knots that is the cause for great concern. If the knots tighten too much or their cords get compressed it could be fatal.

Here are pictures of our little ones cords. Their was one very distinguishable knot and a twist beneath it. Later I was able to touch and examine the knot. It was very tight. I'm not sure how blood and nutrients traveled through it, but it did. It is truly a miracle that my babies not only survived, but thrived with their cords like this.

A View "In the Womb"

Here is a clip from National Geographic's In the Womb Series on multiples.  This small clip of the 90 minute video shows interaction between multiple babies in the womb.  Beginning at 3:23 they give you an idea of what momo twins are like in the womb.  You can see them actually touching and grabbing each other. Our first experience with this was in our 1st ultrasound.  It looked like our boys were cuddled up next to each other.  If the video does not show below, please click here.

Met My New Specialist

Yesterday I had the pleasure of meeting the head perinatologist in the practice that is now taking care of me.  He has a great reputation and is very familiar with monamniotic twins.  He was apart of an 8 year study advocating for intensive hospital monitoring. 

I had to switch peri's because the one I was originally seeing did not have privileges at the hospital close to my home.  I loved my former peri.  He and I were on the same page and had a similar outlook about pregnancy.  Not only was he a fabulous physician, but he was also compassionate, thoughtful and engaging.

The peri did a full ultrasound screen on me and the twins are weighing 3.3 lbs and 3.5 lbs.  So excited!  Grow babies! Grow!  The peri was very impressed with their growth and how the monitoring as been going.  He made a comment about some singletons tracings (heart rates over an extended period of time) do not even looking that good.

But it was clear it the realm of doctors that are taking care of me that his role is the "enforcer".  My OB who is wonderful knows my wishes listens and as long as things continue to look good has expressed support for them.  The other peri in the practice expressed a desire to proceed with caution, but was also supportive of my desires.  The head peri was much more stringent.  He believes there is a way things should go and that's that.  He wants me to come off Sulindac, have an amnio and to deliver at 34/35 weeks.  Now don't get me wrong, he listened to what I had to say and even comprised on a few things, but overall he wants things the way he wants them.

I should explain that my desire for this pregnancy is outside of the norm of how monoamniotic pregnancies typically go.  Typically, patients are admitted into the hospital at 24 weeks for monitoring and deliver between 32-34 weeks.  Admission into the hospital is about viability; what do you consider viability.  While some doctors will require their patients to be admitted at 24 weeks, this decision is a very personal choice for the mother and the family.  Survival rate, quality of life, all of these things are very difficult matters to discuss and should be by no means made by the health care provider.  We haven't even gotten into the nuts and bolts of how often to monitor or how difficult it is to keep 24 week old babies on the monitor.  These are all things my husband and I considered before my admission into the hospital which we decided to do at 27.5 weeks.  I did begin home monitoring at 24 weeks and was comfortable with that level of "intervention."

Once admitted to the hospital families have to be prepared to deliver.  So assuming everything is going great, the next question is when to deliver.  As I stated, most momo twins are delivered between 32-34 weeks.  The studies show this is the safest time to deliver.  However, there is a gap in the studies.  There is a not a study that addresses continuous monitoring and a later delivery.  Since, I am on 24/7 monitoring and any signs of the babies distress can immediately be detected I see no reason to not let the babies stay inside longer.  Honestly, ideally I would wait until I actually go into labor, but I also realize that babies gain a lot of weight in the last month which could very easily cause cord compression.  Due to this, I am willing to deliver at 36 weeks.  Again, I understand this is not the norm, but I do not feel as though I am comprising myself or the twins because I am on continuous monitoring.  As I told the doctor, if they look as good as they do now, I will be hard pressed to deliver any earlier than 36 weeks.  

The peri is most comfortable with deliver no later than 34 weeks and may be willing to push it to 35 if everything is going great.  I left the conversation there because we are still 4-6 weeks off from any of this conversation mattering and anything could happen between now and then.

I do not believe the twins need to be routinely delivered by c-section, that moms routinely need to be put on bedrest, or that they need to be routinely delivered at a certain week.  I DO understand that twin pregnancies are considered high risk and therefore must closely be followed and their care adjusted to how mom and the babies are developing, but all things being equal....let nature take its course.

With all this said, I am taking each step day-by-day.  My wants do not matter to the little ones growing inside of me.  They have their own desires and needs and they may decide to come much sooner than I would like, but I will do what is best for them.  I will also continue to listen to my perinatologist, my OB, and the neonatologist.  I will not blindly follow their directions, but I will ask questions when I don't understand and encourage discussion when I disagree. This is my body and these babies are mine and my husbands.  Sometimes doctors need to be reminded that you are apart of making healthcare decisions.

The Shock & Reality

Now that you know the nuts and bolts, how are I am feeling?  Initially, I was in a 100% state of shock.  Shock that I have been blessed with twins and shocked that learning the difficulties I face in this pregnancy.  The pregnancy of my 1st born was very smooth.  Minor problem here and there, but nothing that prevented me from carrying to term or enjoying my pregnancy.

I cried for several days straight.  Crying for the a loss of innocence and enjoyment of my pregnancy, crying for what might happen, crying for cryings sake.  I was pretty devastated and scared.

I spent hours online learning all I could.  Reading as many studies as I could, learning from others experiences they shared on online forums, and soaking every piece of information I could

I had a follow-up appointment with the perinatologist two weeks later and was in a much better place about the twins and my pregnancy.  I had a whole host of questions for him.  It was the first time I didn't feel fatalistic about the pregnancy and really felt like everything would be ok.  That the twins would be ok.  That I and my family would be ok.

Monoamniotic Monochorionic - Nuts & Bolts of MoMo Twins

At our first visit with the perinatologist we learned that as my OB suspected, our twins did not have a separating membrane. They are monoamniotic monochorionic (MoMo Twins).  MoMo Twins are pretty rare counting for 1 in 25,000 to 1 in 60,000 births.  If there was no doubt before, they are special!

What are MoMo Twins?

MoMo twins are by definition identical.  Identical twins are formed when a single fertilized egg splits in the womb.  If the egg splits prior to the placenta being formed each embryo has its own placenta, chorionic sac, and amniotic sac.  If the split occurs after the placenta has begun to form (typically 7-9 after conception) the twins begins to form in the same placenta and sacs. 

Identical Twins

 Monoamniotic Monochorionic Twins

Why are MoMos special?

Besides being a rare occurrence (less than 5% of identical twins pregnancies), momo twins are at risk for health complications due to the close proximity of their umbilical cords in the amniotic sac.  

What are the concerns for the twins?

Momo twins are at risk for cord entanglement, cord compression, and twin to twin transfusion.  

Cord Entanglement - Because the twins have no membrane separating them their umbilical cords can be easily tangled.  Actually, most MoMo twins cords are tangled at some point in during the pregnancy, but severe entanglement can cause fatal complications

Cord Compression - Without a membrane separating them as the twins move around in their sacs, one can compress the other's cords cutting off nutrients and blood flow.

Twin to Twin Transfusion - This occurs when one twin receives the majority of the nourishment in the womb causing the other undernourished and sickly.  

What can be done to help ensure a healthy babies and mom?

First recognizing that carrying multiples is different from carrying a singleton.  May seem obvious, but the needs are different and not always proportional.  Secondly, very little until viability (24 - 26 weeks).  Intensive monitoring of fetal movement, blood flow between the cords and development prior to viability and then increasing post viability.

How does this affect your pregnancy?

My pregnancy is officially considered high risk.  I see my doctor's on average of every 2-3 weeks during the 1st part of pregnancy increasing to 2-3 times a week as my pregnancy progresses.  I get to see the twins often with ultrasounds at every appointment.  Once the twins reach viability I will start with home monitoring 2-3 times a day and multiple weekly ultrasounds to monitor blood flow and development.  At some point yet to be determined, I will enter the hospital for 24/7 monitoring.

What about delivery?

MoMo twins are typically born between 32-34 weeks barring any complications.  Due to cord entanglement they are born via c-section.  Due to their premature arrival, most spend  period time in the Neonatal Intensive Care Unit (NICU).