I found out that I was pregnant on March 19, 2011 and we gradually got used to the idea that we would be welcoming another little Schwendy into our family sometime around November 23rd. Life always seemed to be busy with a very active toddler, both parents working full time and also in graduate school, but these things have a way of working themselves out and we set out to enjoy what freedom we felt we had in the next coming months before the new addition.
My ambitions of lightly exercising to stave off the morning sickness, which I had very mildly with Audra between 7 and 11 weeks pregnant, were quickly abandoned as I began to feel sick pretty much at 5 weeks along. We told my immediate family about the pregnancy at my father's very belated and my early birthday dinner the next weekend on March 26th. The drive up to the restaurant was pretty rough and I felt VERY sick - I chalked it up to nerves or car sickness, but since the sickness never went away I now realize that the morning sickness was just kicking in.
The news was shared by giving my dad "his gift", which was a tiny, little boys madras print sun hat. Nobody knew quite what to make of it until my younger sister exclaimed, "You're not pregnant..." and I sheepishly admitted that yes, I was. It may have been the only time my mother has been speechless! At that point Steve and I already had it in our heads that we would be having a little boy, which was odd because when I was pregnant with Audra we only ever considered having a girl and the thought of a baby boy was totally foreign, hence the purchase of the little hat. During that dinner my mom and sister were also fascinated by the bump/extreme bloating and necessary maternity top that I was already sporting. That was the beginning of the twin musings. Fraternal twinning does have a hereditary link through the maternal side due to hyperovulation (releasing 2 eggs instead of one) and my maternal grandmother was a fraternal twin herself. The next few weeks were spent chalking up the heightened pregnancy symptoms to being a second pregnancy, busy at work, Steve in class two nights a week, and having a very active almost 3 year old to wrangle at home.
About a week before my first appt, I finally called my OB practice to ask if it was normal to be throwing up bits of blood (ewwww) when vomiting and they kindly said that sometimes this happens from tears in the esophagus and to try some TUMS to reduce the acid content. The Dr. also mentioned that they could pull me in for a sonogram to see if it was a multiple pregnancy, but that normally those moms are sick 8 times a day so that I shouldn't worry and they'd see me at my regularly scheduled appointment in one week's time.
April 14 finally came around. When I was pregnant with Audra, my first appointment was very early - we had our "viability" ultrasound when I was only 6 weeks 4 days along. The wait to our 8 week appointment seemed much, much longer. Steve and I were very nervous that morning as we took Audra to school and headed to our appointment. When we were called in the sonographer barely touched down on my abdomen before asking me to go to the bathroom and come back for an internal ultrasound so they could have more detail. During these few minutes I was preparing myself and Steve for them to tell me that they did not see a heartbeat since I knew they could see Audra right away even though that she was 2 weeks earlier in gestation at my first ultrasound with her. When I was settled back the sonographer very quickly said, "Well - you know how you've been so sick? That's because there's two in there!" Steve and I just laughed. When she finally turned the screen towards me so that I could see I commented on the fact that there was still only one black oval - are they identical?? She confirmed that they appeared to be. I also made sure to ask that there were only two in there, you can never be too sure!
The two weeks following that included our trip to San Francisco to visit Steve's sister and her husband and to share our news. They were also very stressful because of the fact that they had not seen a separating membrane between the twins at the initial visit, and though that condition (Monochoronic-Monoamniotic) is very rare, it was tough to wait until our next perinatal appointment to make sure that there was a membrane and the two cords becoming knotted was not likely. Thankfully, we saw the membrane on our May 2nd appointment and it was once again confirmed that the twins were identical and shared a placenta. This is called Monochorionic - Diamniotic (MoDi) twinning. This was a time for celebration and praise (or as much was possible with my moderate to severe all-day-sickness).
We continued to have positive appointments at 11w6d and 15w5d, seeing them on the ultrasound and hearing their heartbeats without any further instructions other than to eat whatever I can whenever it stays down. Through researching MoMo twins I also became aware of the other risks involved with identical twins beyond the risks of a multiple pregnancy. I tried to keep my reading to a limit since there are always horror stories on the internet and to stick with the recent research. Going into our appointment this past Tuesday I was aware of the fact that identical twins run a higher risk of some congenital defects, and of Twin to Twin Transfusion Syndrome (TTTS) which only occurs in monochorionic pregnancies.
I woke up early on Tuesday anxious to get Audra ready for "school" and to go find out if we were having boys or girls. Like I mentioned before, they were always boy(s) to me. We hadn't discussed any girl names, I picked out boy crib bedding, and referred to them as the crazy boys who needed to give me a break with this sickness already. I was also anxious to "see" them on the screen since it had been 6 weeks since my last ultrasound and to check on their development. To this point both babies had been measuring right on track with their gestational age, measuring only 1 day apart.
Steve and went into the exam room and the ultrasound began. It wasn't too long before we saw boy parts (phew! mother's intuition was spot on) but it was pretty anticlimactic as I was glued to the screen, trying to discover any potential issues. We were happy to have the sonographer point out a perfect 4-chamber heart on one of the babies, but I was also very aware of the fact that while Baby A was measuring spot on at 19 weeks, Baby B was measuring quite a bit smaller. While size difference isn't uncommon, a 20% difference is fairly significant and points towards possible TTTS. The initial ultrasound was scheduled for an hour and we were pretty far beyond that with, what seemed to be, a lot of checks on the umbilical blood flow, another important factor in the growth and development of any child. They also checked to make sure that my cervical length was good and that I wasn't showing signs of preterm labor, thankfully these measurements were fine.
While we waited for the doctor to come in, I mentioned to Steve that the sizes of the babies seemed off and I thought it would be mentioned once the doctor came in to review everything. When our perinatologist came in, she immediately asked if we had ever discussed the risks of identical pregnancy with my OB or was aware of the potential complications. I confirmed that I had read up on some, mainly TTTS. She then set to work reviewing the findings and occasionally asking the sonographer questions. After about 5 minutes she started us off by stating that both twins' anatomy looks great. This is something to be HUGELY thankful for! At this point Dr. R began to discuss her concerns that the twins were developing TTTS.
There are basically 4 things doctors look at when diagnosing TTTS:
**this is literally my own words and not clearly not taken from a medical text, I reserve the right to be mistaken**
1 - The deepest vertical pocket of amniotic fluid surrounding the babies. Fluid levels should not be >8cm or <2cm. Right now our little guy is right above the low mark and our bigger guy is on the higher end of normal. Though the disparity is very concerning, I am relieved to know that right now each twin has enough fluid around them for now as I wait for my next appointment. This brings us to number two...
2 - The presence/size of bladders in both twins. Often, the smaller twin, referred to as the donor, has a much smaller bladder, or one that is not visible/functional. This is because of the lack of resources he is getting, and the amount of work he is doing to pump blood for himself and the larger twin, the recipient. Basically, the donor twin dehydrates and is creating no urine, which is the reason for the lack of amniotic fluid. Yes, the baby pee = the amniotic fluid. Our wonderful news is that both bladders are looking good so far. They are both well sized and not overfilled (as in the recipient) or underfilled/empty (as in the donor).
3 - The cause of all of these imbalances is too tricky for me to paraphrase so here you go: "...there is unequal exchange of blood between twins - placental sharing of nutrients, fluid and oxygen is not balanced. For one twin, the amount of blood that leaves through the vascular anastomoses is not replaced by an equal amount coming back. For the other, the amount received in the veins coming back from the placenta is more than was sent in the arteries to the placenta. This imbalance occurs mainly because of blood vessel problems deep in the placenta. Each twin has part of the placenta where his arteries put the blood in, and his veins drain the blood out. Between the fetuses, there is an area where the blood is brought in by one fetus' artery, but drained away by the other's vein. This artery-vein mismatch produces the imbalance between circulations. This imbalance affects each fetus, but in different ways." (taken from: http://www.obgyn.umm.edu/ttts/what.html) The extra time in our exam did show that Baby B's blood flow is restricted which then causes the growth delay that we see.
4 - Size difference: The 20% size difference isn't actually diagnostically sound since it could be the result of another condition (selective interuterine growth restriction), and that acute TTTS can occur so quickly that growth is not affected before it is caught. However, this is certainly a symptom of the condition. Baby B is definitely 20% smaller at this point.
The above link is from the University of Maryland school of Medicine and does a very good job of explaining this condition, and a few others, in a succinct manner so please refer to that and not blogging if you want more information.
At our appt. Dr. R. let us know that she was very concerned, this is a very dangerous condition - seriously threatening our children's lives, but that it was in the very beginning stages of developing. On the proposed staging chart of TTTS - we don't even fit into Stage 1 because the twins are still skirting the normal levels of amniotic fluid. I certainly hope and pray that flow of blood between the twins balances out and that we can move back from even "Stage 0" as Dr. R. called it. Technically, this could happen. And with a miracle, it could definitely happen!
From this point in our appointment we learned that there is an actual procedure, selective fetoscopic laser photocoagulation (SFLP), that can be done and that one of the best specialists in TTTS treatment/surgery works out of University of Maryland Medical Center! Dr. R. said she used to send patients to Florida for this surgery, but now UMMC has gotten so good at it she can refer them there! I am really feeling the blessing of being in Baltimore at this time with such great medical care at our fingertips, or at least within 10 miles.
I think this initial post has turned into quite the monster, so I will leave you here, asking for your continued prayers for our baby boys (!!!still super excited!!!), for Audra as she adjusts to a progressively encumbered Mom who is not always able to meet her carrying/cuddling needs, and for Steve and I as we continue to seek guidance from the doctors and from God. Even if things work out perfectly and without further risk, we still have a huge change ahead of us with adjusting to 3 kids, 3 and under!
Much Love,
Bethany
