On Episode Five, we discuss the seven most common complications that can arise in a multiple pregnancy.
Maternal-Fetal Medicine Specialist Associate Professor Craig Pennell explains certain conditions to be aware of, what to look out for, and what do when you receive a diagnosis you’re not expecting.
Author Alexa Bigwarfe talks about twin-to-twin transfusion syndrome, and I share my story of intrauterine growth restriction.
By the end of this episode, you’ll have an in-depth understanding of the many possibilities that could affect your pregnancy, but hopefully, you’ll be reassured that if you’re in the right hands those obstacles can be surmounted and you’ll be able to enjoy your pregnancy.
The risks of having a multiple pregnancy
Once you’ve been diagnosed with a multiple pregnancy, there is so much to learn that falls outside what you might already know about pregnancy. When you’re carrying twins, triplets, or quadruplet babies the risk for complications rises and depending on what type of multiples you have on board will determine the level of that risk, and what treatment options are available to you.
Maternal-Fetal Medicine Specialist Professor Craig Pennell says even though there are increased risks involved with multiple pregnancies that doesn’t mean you can’t enjoy your pregnancy.
“The things that can go wrong in multiple pregnancies are divided into those that can happen to all multiples and those that are specific to particular multiples,”
“For example, Monochorionic Monoamniotic twins, also known as MoMos, account for just one-percent of identical twins and they’re the type of twins where cord entanglement can cause problems, which is associated with a loss rate in the pregnancy of up to 50 percent,”
“In all the other types of twins where there is a membrane between them so those conditions can’t occur,” explains Associate Professor Pennell.
If we look at twins, in general, some of the things that can occur are:
Severe nausea and vomiting are very common in a multiple pregnancy, according to Associate Professor Pennell.
Associate Professor Pennell reassures us that the condition usually goes away at the end of the first trimester, so around 13-or-14 weeks, however, in about 10 percent of women it continues throughout the pregnancy.
According to Associate Professor Pennell, the other thing that is more common in the first trimester of a multiple pregnancy is a miscarriage. He says the rate of miscarriage in twins is at least double, if not higher, than the rate in singletons. And, it’s often not noticed or simply missed depending on when you have your first ultrasound.
“If you’re having scans from five-weeks, you may see what starts as a twin pregnancy that then ends as a singleton somewhere between six-and-12 weeks, whereas if your first scan is at nine-weeks, you may not realise that it started as a twin,”
Not surprisingly, the rate of miscarriage in Higher Order Multiples is again higher. This is somewhere in the order of 30-50 percent where you would lose at least one of the embryos in the first trimester, according to Associate Professor Pennell.
All babies have the chance of having a structural problem (about five-percent), which includes such things as a clubbed foot, an extra finger, cleft-lip-and-palette, a hole in the heart, or an issue with the kidneys.
“With Dichorionic twins, the rate is double that of a singleton,”
“With Monochorionic twins, the rate is even higher than that because Monochorionic twins in itself is an anomaly,” says Associate Professor Pennell.
He goes on to explain that if you have an early blastocyst splitting into two embryos there’s an increased risk of issues in structural development. The more severe anomalies can be picked up at the 11-13-week scan, however, most of them are detected during the 18-20-week anatomy scan.
“When you have a multiple pregnancy, you want to go to a specialist centre who at a minimum specialises in pregnancy ultrasound, and preferably someone who specialises in ultrasound in high-risk pregnancies, because you need to have a lot of experience to do these types of scans well,” says Associate Professor Pennell.
Alexa Bigwarfe agrees with Associate Professor Pennell and admits that if she had been with a team that specialises in multiple pregnancies when she was diagnosed with an identical twin pregnancy, her life would be vastly different to what it is today. You see, Alexa has Systemic Lupus and Hashimoto’s Disease, so when she discovered she was pregnant with her third baby, her doctor called her in straight away, despite being just 6-weeks’ pregnant, due to her classification of being High-Risk.
“The doctor came in and confirmed, she said yep it’s definitely two,”
“She said to come back in two weeks and we’ll just check and make sure there’s still two,” says Alexa.
When they went back for the next ultrasound the doctor told them that the babies were identical and sharing a placenta.
“I’ll never forget that day, it’s like burned into my mind because I remember the doctor very nonchalantly, very nonchalantly saying to me ‘sometimes with twins sharing a placenta like this, one of them will get too much of the placenta and one of them won’t get enough, and they’re not sharing the fluids and everything equally,”
“And, then she was like but if that happens there’s stuff we can do and she said it like it’s no big deal,”
“I constantly wonder how different my life would be today if she had said the words twin-to-twin transfusion syndrome if she had said anything to indicate that it would be something that we should follow closely.” Alexa Bigwarfe.
Alexa says that over the next ten-weeks many mistakes were made, including not being scheduled for a 16-week ultrasound, and that was simply because she was with an obstetrician service where patients were rotated through doctors in the event that if you went into labour you’d be tended to by someone you knew.
“I never had twins before, I wasn’t looking up twin-to-twin transfusion syndrome because she didn’t say anything about it,”
“When we went in for the 20-week ultrasound they diagnosed us officially with twin-to-twin transfusion syndrome and we were already stage-3,”
“This meant we were well on our way to one baby dying, if not both babies dying,” says Alexa.
Alexa was then transferred to a Maternal Fetal Manager, which she says should have happened much earlier in her pregnancy. She had an amnioreduction, where the fluid is drained from the recipient baby’s amniotic sac. However, according to Alexa, her MFM wasn’t as up to speed on TTTS as he should have been.
“There were some missteps taken along the way, some bad information, some procedures that probably could have happened that didn’t happen because of his lack of awareness and knowledge on the subject,” says Alexa.
Several more amnioreduction procedures were carried out over the following weeks, and as a result, Alexa went into labour at 30-weeks-and-five-days gestation. She explains that Kathryn wouldn’t have survived a vaginal delivery so she underwent an emergency caesarean section.
“Kathryn had to be resuscitated, she was the larger baby with hydrops, and when she was born she had so much fluid in her abdomen that it was swollen to the maximum extent,”
“The little one we had just cleared viability with her, even though they were 30-weeks, she was about the size of a 24-25 weeker, one-pound-10-ounces,”
“But she squeaked when she was born, it sounded like a little bird, and that was the most exciting sound,” says Alexa.
Kathryn survived for two-days.
Charis spent 84-days in NICU.
What is TTTS?
Twin-to-twin transfusion syndrome (TTTS) is a prenatal condition in which Monochorionic twins (identical) share an unequal amount of the placenta’s blood supply. This results in the fetuses growing at different rates. Around 70 percent of identical twins share a placenta and 20 percent of these pregnancies will be impacted by TTTS.
“This condition typically occurs between 16-26 weeks and is due to an imbalance in the blood vessels that connect the twins across the surface of the placenta,”
“This is usually a rapidly progressive condition and untreated can be associated with a loss rate of up to ninety percent. If it’s picked up and diagnosed, there are good treatments available now that give good outcomes in 80 percent of women,” says Associate Professor Pennell.
“If you are being managed by an experienced team and modern treatment, you can expect better outcomes now than were possible ten or twenty years ago.” Associate Professor Craig Pennell.
As Associate Professor Pennell explains the baby with more of the blood supply is called the recipient and the one with less is called the donor. Because the donor has less blood flow, it will grow much slower and will be significantly smaller than the other twin. In contrast, the recipient twin has too much blood flow and grows fast and is much bigger.
Stages of TTTS
Stage 1: There is an imbalance of amniotic fluid, with a small amount (<2cm) around the donor twin and a large amount around the recipient twin (>8cm). The twins often have a 20% size discordance.
Stage 2: The bladder of the donor twin is not visible, or it does not fill with urine, during an ultrasound exam.
Stage 3: The imbalance of blood flow starts to affect the heart function in one or both babies. This is observed as abnormal blood flow in the umbilical cords or hearts of the twins.
Stage 4: The imbalance of blood flow causes signs of heart failure in one of the twins.
Stage 5: One or both of the twins has passed away from severe TTTS.
For Stage 1 cases, observation may be all that is necessary, but for Stage 2 or higher cases, fetal surgery may be the best option.
Symptoms of TTTS in the mother
Sudden weight gain.
Fundus appears large for dates (often will appear like a term pregnancy).
Abdominal pain and tightness.
Premature onset of contractions.
Observation – weekly ultrasound assessment
Fetopic Laser Photocoagulation – in cases of stage 2 or higher, between 16-and-26 weeks surgeons insert a small laser fibre into the mothers’ uterus and laser energy is used to stop the blood flow between the twins. As a result, the placentas are separated, allowing each twin to develop independently.
Amnioreduction – this procedure removes the excess fluid from around the larger twin, reducing amniotic pressure and reducing the risk of preterm labour. This is usually performed with fetoscopic laser photocoagulation.
“TTTS is a moving feast and it needs to be reviewed regularly as our ability to prognosticate beyond a week or so is very limited.” Associate Professor Craig Pennell.
Associate Professor Pennell explains that twins with untreated advanced stages of TTTS during pregnancy usually don’t do well after delivery with a 90 percent fatality risk, and for those who do survive there’s a 15-50 percent risk of neurologic handicap.
The good news is, according to Associate Professor Pennell is that if TTTS has been successfully managed by an experienced team and treated during pregnancy, there is a much better chance that the babies will be healthy.
There’s a common theme when I talk with people who have experienced a multiple pregnancy. There’s the initial shock when hearing the diagnosis and then there’s the steep learning curve while attempting to understand the type of multiple they’re carrying. And, then there are the complications.
Looking back, I think I was in a state of shock for months because it seemed as though there were only a handful of weeks where I wasn’t faced with the prospect of losing one or both of my babies.
Most people would shrug off my concerns about the discordance in size of the girls with comments like – ‘one twin is always bigger than the other’, even my private obstetrician dismissed my concerns before I decided he wasn’t the right person to guide me through my pregnancy.
What these people didn’t realise was with my diagnosis of Intrauterine Growth Restriction or IUGR I was carrying a ticking time bomb. You see, IUGR in a twin pregnancy is a condition where one or both babies don’t grow in the manner that’s expected, due to an uneven share of the placenta, what that means is that these babies are much smaller than other babies of the same gestational age.
“What these people didn’t realise was with my diagnosis of Intrauterine Growth Restriction, I was carrying a ticking time bomb.” Sally Barker.
Fortunately, following the recommendation of the Sonographer at the specialised imaging centre I went to for my 12-week scan, I went to the local tertiary hospital in Perth Western Australia two-weeks later to have a follow-up assessment. It was then that I was placed in the care of the GOLD team, which is a group of highly skilled specialists who have extensive experience with multiple births.
The management of my pregnancy was such that I was seen twice a week, and sometimes three times. I knew that the girls would be pre-term, there was no doubt about that. But just how early was a waiting game. During the scans, close attention was placed on the blood flow to my smaller baby, Aasha, who it turned out had a cord insertion at the lower edge of the placenta, which meant she was only getting about 25 percent of the nutrients she needed.
At 24-weeks the blood flow to Aasha had slowed and showed signs of reversing. It was explained that the girls would need to be delivered and their chance of survival was slim, however, there had been cases where following a corticosteroid injection the condition could stabilise. Thankfully, for us, that’s exactly what happened.
We were hoping to get to at least 30-weeks’ gestation, and I was so certain we would get there, but when that blood flow stopped again at just 28 weeks’ gestation, this time there would be no intervention.
The girls were so tiny, just 825 grams or 1.8 pounds and 1075 grams or 2.3 pounds. They came home together 64 days after they were born.
Intrauterine Growth Restriction (IUGR)
Associate Professor Craig Pennell explains that IUGR can occur in both Dichorionic and Monochorionic twins, but it’s more common in Monochorionic twins, with an 80 percent chance the twins will share a placenta.
“With that, the vessels on the surface of the placenta connect the babies’ circulation and when they have IUGR one twin has a smaller portion of the placenta, and has a harder time getting enough oxygen and nutrients,”
“It is important to note that twins don’t grow the same as singletons, so it’s important to have the twins assessed on twin growth charts if possible because it’s well known that the rate of growth in twins is much slower,” says Associate Professor Craig Pennell.
How is IUGR Diagnosed?
Once you have a diagnosis of a Monochorionic twin pregnancy, whether that’s part of a twin, triplet, or quadruplet pregnancy, and that they are sharing a placenta, frequent ultrasounds are performed to monitor the growth and condition of the twins.
According to Associate Professor Pennell, it’s widely recommended for ultrasounds to be performed every two weeks between 16-and-24 weeks of the pregnancy for Monochorionic twins, to pick up any differences in amniotic fluid levels or growth discordance.
“If this is the case more frequent ultrasounds will be performed to monitor the progression of the condition,”
“During these scans, the sonographer will pay close attention to the heart function and anatomy, also the blood flow to the babies’ brains, umbilical cords, and other vital organs will be assessed,”
Babies with IUGR will almost always be delivered preterm and always via Caesarean section.
Preeclampsia is a blood vessel disease and is a common complication of pregnancy. It involves the diagnosis of hypertension or high blood pressure along with a series of systemic complications, generally associated with having large amounts of protein in the urine (proteinuria). Preeclampsia is generally diagnosed after 20-weeks’ gestation and resolves after delivery.
“The disease can happen in any pregnancy, however, it’s much more common in multiple pregnancies, where it occurs in up to 30 percent of pregnancies,”
“Severe preeclampsia is the most serious form of the condition, which is HELLP syndrome, and occurs in about one-in-ten cases,” explains Associate Professor Pennell.
HELLP (H – Haemolysis, EL – elevated liver enzymes, LP – low platelets) syndrome is one type of severe preeclampsia
Types of Preeclampsia
For most women, preeclampsia is a slowly evolving process that develops over a number of weeks and gradually gets worse towards the end of pregnancy. In this instance, delivery solves the problem.
“In contrast, there are some women with severe preeclampsia where things can evolve over a matter of hours,”
“It’s this group who frequently present symptomatic and will most likely have both maternal and fetal disease,”
“These women will require urgent inpatient care and careful treatment by a team who are experienced in the management of severe forms of preeclampsia,” says Associate Professor Pennell.
For many women diagnosed with preeclampsia, they’ll have no symptoms. However, the effects of the disease are quite variable and some women will present with headaches, swollen legs, hands, and face (oedema).
In the more severe cases, the symptoms can be quite prominent, where the mother has extremely high blood pressure and abnormalities in any of the organ systems.
“The most common scenario for the vast majority of women with preeclampsia is high blood pressure and proteinuria, with some abnormal blood tests reflecting changes in renal function towards the end of pregnancy,”
“For those women, the treatment is simply delivery,” explains Associate Professor Pennell.
Other women present with neurologic symptoms where you can get:
and hyperreflexia (very brisk reflexes).
These women will often be treated with preventative drugs (magnesium sulphate drip) aimed at avoiding seizures.
Preterm birth is a major concern in multiple pregnancies. Fifty percent of twin pregnancies are preterm, while in triplet, quadruplet, or quintuplet gestations 90-100 percent will be born early.
A Preterm or premmie baby is defined as being born alive before 37 weeks of pregnancy are completed. There are sub-categories of preterm birth, however, based on gestational age:
Extremely preterm, or micro premmies, are born at less than 28-weeks’ gestation,
Very preterm are those babies born between 28 and 32-weeks’ gestation,
And, moderate to late preterm, which are babies born after 32-weeks and before 37-weeks’ gestation.
According to the World Health Organisation, worldwide an estimated 15 million babies are born too early every year. That’s more than one in every 10 babies. Sadly, of these babies, approximately one-million will die due to complications of their preterm birth.
Why does preterm birth happen?
Well, there are many reasons preterm births occur, the most common causes include multiple pregnancies, infections, and chronic conditions such as diabetes and high blood pressure. However, oftentimes no cause is identified but may be due to genetic influences.
As Associate Professor Pennell explains, although there are many complications that can occur in a multiple pregnancy that are different to that of a singleton pregnancy, being informed and educated on those conditions will greatly help you during this time.
“It is, however, extremely important to be under the care of a Maternal-Fetal Medicine Specialist team with experience in multiple pregnancies,”
“With that, you can be confident that your pregnancy will run smoothly and if complications do arise you will be in the best hands to manage it,”
“If you start having contractions, tightening, fluid leaking, or bleeding then it’s important to go and see your doctor to make sure if you are having signs of going into labour early that steps can be taken to try and stop it or at least make sure that the twins will be born in the best condition possible.”
~Associate Professor Craig Pennell~
Twin-to-Twin Transfusion Syndrome (TTTS) affects approximately 15 percent of identical twins that share a placenta.
TTTS will normally develop between about 16 and 28 weeks’ gestation.
Preeclampsia is a blood vessel disease and is a common complication of pregnancy. It involves the diagnosis of hypertension or high blood pressure along with a series of systemic complications, generally associated with having large amounts of protein in the urine (proteinuria). Preeclampsia is generally diagnosed after 20- weeks’ gestation and resolves after delivery.
Preeclampsia can happen in any pregnancy, however, it’s much more common in multiple pregnancies, where it occurs in up to 30 percent of pregnancies.
Babies with IUGR will almost always be delivered preterm and always via Caesarean section.
Fifty percent of all twins are delivered prematurely.
Worldwide an estimated 15 million babies are born too early every year.
On Episode Six, we’re discussing your couple relationship and why it’s important to nurture it before, during, and after your multiple pregnancy.
We’ll hear from Psychologist Dr Gretta Little, who offers some practical tips to help keep you on track.
Rebecca Perrie and Jannelle Snaddon share their stories of the struggles they had in their relationships while carrying their multiples.
And, I talk about the pressure the complications in my twin pregnancy put on my couple relationship.
Until next time,
I wish you Double Happiness … Multiplied.
Double Happiness Multiplied – The Complete Guide to Enjoying Your Multiple Pregnancy and Building a Happy, Healthy Family Life.
Never the Same: Families Forever Changed by Twin to Twin Transfusion Syndrome
By Alexa Bigwarfe
The goal of this book is to spread more awareness and provide an outlet for families to share their stories, celebrate their babies, and remember the many who did not survive.
Sunshine After the Storm
-A Survival Guide for The Grieving Mother-
Miscarriage, stillbirth, and newborn death support
Helping Little Hands
Australian Multiple Birth Association
Pregnancy, Birth, and Baby
Podcast music was written and performed by:
Catherine Ashley Harpist