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Twin Pregnancy Complications
What You Need To Know
Another suberb article written by our friend Geodhe, M.D. and mother of twins. A personal experience with twin pregnancy complications offered with a twist of science and
broken down by trimesters.
Twins. Twice the Babies,
Twice the Pregnancy Complications.
I've previously had the pleasure of writing an article on this site detailing just what it's really like to conceive twins with the aid of IVF, a.k.a the ever-detested euphemistic "unnatural" way.
In a small aside, I dub my babies pure finest Astroturf when people get a little too nosey in the supermarket in combination with the word "natural" these days.
I shall now go on to relate something of the risks and management of twin pregnancy, partially from a medical perspective, and partially from my own experience.
Twin pregnancies aren't easy, most of the time.
Forgive me for sounding surprisingly gloomy for such a determinedly irreverent soul, because the vast majority of twins are born at or near term with no long term complications, but it bears remembering that some are sadly not so lucky. Additionally, even relatively minor prematurity has a much bigger emotional impact that I ever though it could, until it was me tube feeding my tiny baby and crying my eyes out for three days straight because neither twin has the strength to even attempt breastfeeding and my milk failed to come in.
My breasts may have LOOKED the E-cup business, but sadly, they should have been labeled "For recreational use only".
But, I'm getting ahead of the story, again.
Simply put, growing two babies at once in a space designed for only one is very, very hard work. If nothing else, it's often incredibly uncomfortable. The uterus gets much bigger than usual (for obvious reasons) measuring around term size by the early third trimester. Blood volume expands even more than in a singleton pregnancy to supply the extra baby/placenta, with uterine blood flow at only 25 weeks gestation already being equivalent to full term with a single baby and therefore your poor heart has to pump this enormous load. It's like running a race, at rest. Things are simply physically harder than singleton pregnancies, and therefore it is unsurprising that there are increased risks of complications.
The medical risks were something which I was quite aware before even becoming pregnant, but gleefully disregarded as "Not THAT high". As many people in am infertility/loss situation are wont to do, I glossed over unpleasant words like "pre-term labor", "pre-eclampsia", "intrauterine growth retardation", "steroids" and "NICU", "septic work-up", "gavage feeding", "lumbar puncture" and the like when serenaded by the emotive aspect of getting ANY baby at all, let alone the miracle two at once. I’m an utter eSET (elective single embryo transfer) hypocrite. I can see why it would have been the safest thing for me to do, but I didn't do it. Not by my third IVF, anyway.
Unfortunately, however, I personally experienced each of the not-so-nice words in quotation marks above first hand during my pregnancy. So, to recap slightly, in case I have rambled excessively in this introduction, previous to this article I had the pleasure of sharing my IVF experiences that GOT me pregnant with twins in the first place. I now plan to pick my story up from the 'got pregnant and looking like I'll stay that way' point.
(see my IVF Twins article)
The First Trimester
Please don't hit me, or to be more accurate, risk bodily harm to yourself by thumping your computer screen repeatedly if I say that I found the first trimester easy.
Anxiety was the only symptom I appeared to have of pregnancy, albeit unusually rabid in intensity. As soon as I knew I could see a fetal heart beat (or two!) on transabdominal ultrasound scan, I was skulking into my own radiology department and borrowing the machines for a quick self-scanned fix of "Yep Still Alive!" on at least a once a week basis. Sometimes more often.
If you've just found out you're having twins and you're reading this with your head firmly resting over an emesis basin
(or your toilet bowl, should you actually take a PC in the loo), please don't send me emails of hate for lacking the Spew Gene. Read on.
I thought multiple pregnancy was going to be an utter doddle. I'd be in heels still working at 38 weeks when I gently started contracting. My skin would be blemish-free. My hair would be lush. I would wear make-up every day. I wouldn't put on weight ANYWHERE apart from my beautifully un-stretch-marked belly.
Yes, I was delusional.
The Science:
General stuff to be thinking about in the first trimester.
Ideally you should have an early ultrasound if you suspect multiples because you're either usually sick, big for dates, your beta hCG is very high, or (like me) you’re an ART graduate who knows that two embryos were left in there in the first place
The main reason for this advice is that the easiest time to tell chorionicity is when you are still in the first trimester. By the second trimester, it can be harder to tell if your twins are identical or not (unless the genders are different), and this can alter the monitoring and risk management later on.
Chorionicity?
Twins come in several flavors:
DCDA or di/di (diamniotic / dichorionic) - These twins are usually fraternal (absolutely fraternal if different genders), but some will actually prove to be identical twins where the embryo has split very early in development (about 1/3 of identicals may be DCDA). First trimester scans will show two embryos in two separate sacs. The dividing membrane between the twins is thick, being made up of two layers of chorion and two layers of amnion (one from each twin). This thick separation gives rise to the so-called ‘lambda’ sign, where there is a wedge shaped piece of tissue between the edges of sacs of the twins on ultrasound. The circulations and placentas of the babies are separate, even though the placentas may push up next to each other later in pregnancy. DCDA twins generally carry the lowest risks of all the subtypes of twin pregnancy.
MCDA or mo/di (monochorionic / diamniotic) - These twins are always identical. They are within a shared chorion, but have separate amniotic sacs. This means that there is a dividing membrane between the twins, but it is thinner as it is made up of two layers of amnion only. A special risk to this type of multiple pregnancy is where the placentas share vessels, which can be unbalanced in flow so that one twin receives excessive blood supply, and one too little. This is a condition called TTTS (twin to twin transfusion syndrome) and it can occur in up to 15% of MCDA twins. MCDA twins will be monitored via regular ultrasounds for signs that TTTS is developing. MCDA are intermediate risk twin pregnancies.
MCMA or mo/mo (monochorionic / monoamniotic) - These twins are identical twins that divided relatively late, and thus both babies share the one amniotic sac. These are the highest risk form of twin pregnancy due to the risk of cord entanglement with two babies in one sac, as well as the rarest.
Your obstetrician may discuss the need for extra vitamin supplementation, especially of folate, iron and calcium due to the increased demands of carrying multiples and that you can expect to gain more weight than with carrying a single baby.
You may also be given advice regarding work depending on the nature of your job, especially considering finishing earlier than with a singleton pregnancy.
Additionally, your obstetrician may discuss the need for increased frequency of visits, as well as general education regarding the increased risks of multiples (most commonly pre term labor and delivery, gestational diabetes, pregnancy induced hypertension and pre-eclampsia in the mother, and intrauterine growth retardation and the complications of prematurity in the babies).
No, I didn't even stay pregnant that long. My problem was that pregnancy with multiples is easy in the first trimester while they're still less than 2 inches long each (if you don't get morning sickness). It's a different kettle of fish entirely when they're over five pounds each and YOU weigh over sixty more than you started out.
The Second Trimester
It's fairly obvious that if you're carrying multiples, you're likely to look pregnant (and not just several donuts too many) sooner. Unfortunately for those of us that like to keep such things under our hats until safely well into the second trimester, this makes a daily wardrobe of baggy jumpers a must.
I don't think I even GOT to the second trimester before a nosey-parker at work cornered me in an office, late on a Friday (in case she was wrong and therefore I'd have the weekend to get over the insult) and asked the dreaded "Are you pregnant?". I briefly considered stammering a bad lie, or an even more bold-faced "No, why?" in the hope that the shame of calling me fat, even indirectly, would forestall further questioning along this line but the thought of being proven a rather obvious liar in the coming months dictated honesty.
Being pregnant after IVF and a loss is nerve-wracking. That "yes" was scarier that the thought of parachuting from a jumbo-jet mid-flight. I was outed. I think the moral of the story is that if somebody hasn't told you that they're pregnant, unless they're actually giving birth at the time, you should probably wait for them to offer that information!
Regardless of knocked-up etiquette, I looked silly.
Courtesy of my more customary scrawny beanpole-ness, I looked quite ridiculously like a snake that swallowed a watermelon. My "baby bump" was going to turn into more of a mountain range.
To be more scientific about it, I measured 20 weeks in fundal height at a mere 13. I continued to measure exceedingly ahead, such that I measured term size at 28 weeks (the start of the third trimester). My final measurement was 50cm. My "waist" was an eye-wateringly uncomfortable 52 inches. That's not uncommon for twins.
The Science:
Fundal height is a measurement usually taken at each obstetric visit that runs from the top of the pubic bone (symphysis pubis) to the top of the uterus. It gives a rough idea as to how the pregnancy is going, running on the assumption that if the size of the uterus is growing, the baby is probably growing too.
It is normally measured in centimeters, because of a bit of biological luck that means the normal height of the fundus in cm equals the weeks of gestation (plus or minus a couple of cm) from about 20 weeks onwards.
Of course, in a multiple pregnancy where there is more than one baby in the uterus this measurement is less helpful for two reasons:
Firstly, you will inevitably measure ahead- there’s twice as much baby in there!
Secondly, one baby can be growing well and one not so well, and the tape measure will still show growth. It can’t differentiate.
This is the reason that multiple pregnancies often have monthly (sometimes more often depending on the type of twin pregnancy) growth scans to check on each baby individually, especially in the third trimester even if all is going well.
Other things that may happen in the second trimester, depending on your pregnancy and your caregiver:
More frequent visits.
Checks of your cervical length. This can be either manual (by vaginal examination) or with ultrasound (a more accurate method, especially if with a transvaginal approach). Since approximately half of twins will be premature, and it is hard to predict who will deliver prematurely and who is more likely to go to term, much effort has gone into finding ways to identify those at greater risk. Cervical length is one method, but it is not absolute. Having a shorter cervix to start with, early or rapid shortening of the cervix is a known risk factor for preterm delivery, but doesn’t mean it is inevitable. However, checking this can help identify women who are at increased risk of having their twins prematurely and allow closer monitoring.
Ultrasounds. Apart from the scans related to looking for abnormalities in your babies, commonly performed at 12 and 18-20 weeks of pregnancy (if you choose to screen for Down syndrome and other conditions), you may have additional growth scans in the second trimester, especially if you have mono-chorionic twins as there are special risks with mo/di and mo/mo twins. Whatever type of twin pregnancy you have, by the third trimester you are likely to be having at least monthly growth scans. You will likely be lucky enough to see your babies on ultrasound many times before they’re born, often down to the shape of the nose, hair and thumb sucking.
If you have monoamniotic twins (mo/mo, or MCMA), you may be admitted to hospital later in the second trimester for closer monitoring of the babies.
Then I began noticing that the relatively-painless Braxton-Hicks contractions that had plagued me since the end of the first trimester on and off (usually annoying me by interrupting my sleep) were happening kind of often and were getting increasingly uncomfortable.
Hmm.
It turns out that I was now the owner of a uterus that liked contracting every ten minutes in runs of several hours long, often more than once a day. My uterus, like the rest of me, was officially dubbed rather irritable.
(a brief digression- there is natural variation in the inherent tendency of our uteruses to contract in pregnancy. Some women have very ‘quiet’ uteruses, and don’t have many Braxton Hicks, or only late. Some, like me, contract early and often. Women with more ‘active’ uteruses do tend to deliver earlier, on the whole, but again it is not inevitable. It’s just another risk factor when it comes to premature delivery.)
Fixing the traditional provokers of uterine irritability like dehydration and excessive activity didn't help. I drank until I had to pee non-stop. No dice.
I wasn't quite twenty weeks pregnant, but my uterus was not unreasonably protesting about the additional load.
I had to leave work. I was benched for the duration.
The Science:
Treating early contractions.
Premature labor comes in two major varieties, threatened and actual. The difference between the two is that actual premature labor is defined as uterine contractions causing cervical effacement and dilation. Threatened premature labor implies contractions without cervical change.
Medications can be given to help halt early contractions, and are especially useful in that they may allow a woman who is at risk of delivering very prematurely to be transported to a hospital with a high-level NICU and allow sufficient time for steroids to be given to help mature the babies’ lungs.
There are several options, and several medications may be trialed to find the most effective for a given situation:
Nifedipine (also known as Procardia). This medication has the advantages of being available as a tablet and not requiring injections or a IV. It is a newer medication in the treatment of early contractions, and there is some evidence it may be better tolerated by the mother and associated with slightly better outcomes for the baby. The more common side effects are low blood pressure (it is more commonly used as a treatment for high blood pressure) and swelling of the ankles.
Terbutaline. This drug requires injection. It may make you feel a bit shaky and your heart may feel as if it is racing (palpitations).
Indomethacin. This is a type of drug known as a non steroidal anti inflammatory (NSAID). It is usually only used in the short term because of side effects on the babies if used for longer periods.
GTN. An angina medication in its more common use, GTN will occasionally be trialled. The major side effects are low blood pressure and headaches.
Magnesium Sulphate. This medication requires an IV infusion, and is used in hospital, often when other drugs are not effective.
Progesterone. There is research showing that in women with singleton pregnancies who have had a premature birth previously, progesterone will reduce the risk of this happening again (recurrence). Evidence is now coming out that progesterone may be useful in multiple pregnancies, too.
Over time, stability was achieved with increased nifedipine and the addition of progesterone. Together they held my misbehaving uterus at bay, although I was till contracting, my cervix stopped shortening and I could at least get some sleep at night, apart from the legion of trips to wee, anyway.
Simply put, weeks 20-28 weeks were scary. I had several risk factors for premature delivery (a contracting uterus, a shortening cervix and multiple babies) and the realities of extreme prematurity are terrifying.
I was lucky. We did prophylactic steroids twice, but I didn't deliver.
The Science:
Prematurity and twins. A bit more.
Term is normally considered to be 40 weeks of completed pregnancy with a range of 37-42 weeks allowed as normal, so by definition less than 37 weeks is premature, and over 42 is postmature. The reason that attention is paid to these dates is that mortality (death) and morbidity (illness) are higher the further on departs from the normal gestation length .
In twins, 38 weeks is considered full term.
Even if term, twins are often smaller than single babies born at the same gestation as the uterus may not be able to supply two growing babies completely. This tendency to lower birth weight may also compound the effect of prematurity, as larger babies at a given gestation tend to do better than those of smaller birth weight.
Premature birth is taken quite seriously, because despite significant technological advances in the care of premature infants, there is still a significant rate of complications in babies born very premature both in the short and longer terms. Prematurity is also often a significant health expenditure in many countries.
The major trigger of prematurity in multiples is uterine ovredistension. The more babies, the more likely they are to be premature, and the earlier they will be born on average.
Around half of all twins will be premature, the average birth being at 36 weeks gestation. Around ten percent of twins will be born sooner than 32 weeks, some of which will be born very premature (before 28 weeks).
Prematurity is commonly divided up into mildly premature (less than 36 but more than 32 weeks), moderately premature (32-28 weeks) and very premature (less than 28 weeks). Extremely premature infants born in the weeks of viability (24-26 weeks) do have a high mortality rate, very sadly.
The earlier a baby is born, the greater risk of complications and the longer they are likely to need to spend in hospital. Broadly speaking, minorly premature infants may have some difficulty regulating their body temperature and blood sugars initially due to small size and are likely to need tube feeding for some of their nutrition until they grow bigger and stronger. They may occasionally have some trouble with breathing, but usually will only require CPAP (a non-invasive breathing support).
More moderately premature infants are likely to spend time in a humidi-crib, require tube feeding for longer and may need to spend some time on a ventilator to help their breathing, especially if there has not been time for steroids to be given to help mature the lungs before birth.
Very premature infants will need extensive help to keep warm, hydrated, fed and breathe and are likely to spend a long period of time in hospital.
Although most twins are born at or near term, and I personally find it hard to talk about the scary things that can happen when babies are born very early, I think it is also important to be honest and not gloss over it excessively. Babies that do come very early have risks of serious health complications including bleeding into the brain, severe infection and difficulty with their breathing, even with the aid of breathing machines. Some do pass away because of these and other complications. If they survive, they are at increased risk of long term disability. If you are in the situation where your twins are born very early, it is likely to be a very scary and emotionally intense time. Please seek support.
The Third Trimester
As mentioned at length already, and not to belabor the point, I got ridiculously large.
I couldn't sit, without spreading my legs to gynecological proportions apart in order to make room for the ever-expanding Fetus Module. I needed assistance lifting my abdomen to roll over in bed. I certainly wasn't shaving my legs. I couldn't see them.
Walking was an act that had me huffing and puffing like the big, bad wolf with a particularly resistant house to demolish. Understandably, I stopped brushing my hair.
Additionally, the contractions were an all-day every-day phenomenon and I was sick of them. I was sick of counting down to the next dose of medication, which was working less and less well as time wore on.
Then my blood pressure, high for weeks, got higher. My swollen cankles got cankles of their own and my wedding rings no longer fit.
I developed, as is more common in multiple pregnancy, pre-eclampsia.
It was probably a good thing in retrospect that my waters broke all over the bathroom floor at a very antisocial 3am at 36 weeks, 0 days and I went into labor For Real after practicing it for sixteen weeks, although by this point a c-section had already been scheduled for the next day.
Life After
The inconvenient timing of my labor set off an amusingly keystone-cops series of events that fortunately culminated in the healthy birth of my twins an hour later by c-section.
Stoned on morphine, thrilled that neither baby had any trouble breathing and had beautifully normal apgars, and (pathetically) hungry again, it took me several hours to wonder just why I hadn't seen either child since their birth.
Here I was, thinking I looked fabulous swanning around ward, jabbering away at high speed on mobile phone, only two hours post major surgery. It couldn't last and it didn't.
I was in for a rude shock when I did track down my newborns.
They were in the NICU...What? Why?
One twin, had a seizure-threshold low blood sugar. The other wasn't warm enough. Neither could eat and so had nasogastric tubes. They were in humidi-cribs.
All of this is such small potatoes in the world of prematurity but it is a big shock when it's YOUR babies and you think you're so near term that you'll swan out of hospital, impossibly thin and with two babies in your arms. Sometimes people do, I just wasn't so lucky.
I ended up going home with neither.
Even now, recounting that makes me teary. The emotions were heightened at the time by massive sleep deprivation. Nobody tells you the birth high is at jumbo jet cruising altitude.
I couldn't sleep at all for three days, despite sleeping tablets.
The crash that followed was as inevitable as it was impressive. Morphine -aided failed breastfeeding attempts of babies who were too tired to suck in all sorts of not-quite-private locations followed. My milk didn't come in, I couldn't let down at all for the pump. Sobbing, I left the nurses to feed babies as I was clearly useless.
Begging the staff to talk to me like I was actually a rational human being, I bawled my eyes out about the fact that my diastasis recti (splitting of the abdominal muscles, another common event when pregnant with multiples) was so big you could fit both hands in it.
But it did get better.
Despite some bumps in the road involving a readmission of one twin followed by a god-awful full septic workup (including lumbar puncture, bladder aspirate and a dozen IV sticks followed by a heavily provoked breath-holding attack and fitting), I'm now out the other side with two healthy, crawling infants.
In summary, despite all the scary talk, you are likely to take home two healthy babies.
Good luck!
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