when to del mono/di twins? (pastes from this qu from another site)

www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1160580

hi, i found a recommendation to read this article from the ttts site after reading the following posts..bear with the cut and pastes...

When to deliver a mono-di pregnancy?
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What are your thoughts? I was planning / hoping to del vaginally when the time came and if circumstances allowed..otherwise i would just go with a c sect,
ha anyone heard of mono di twins being lost late in the uterus? it sounds very scary to me, and if there is any guts to the study i will def opt to go under the dreaded knife and forgo a vd.

 

I think it's a personal decision. You'll find people that are adamant either way. Yes, I have heard of all types of twins being lost late in the pregnancy and I have heard the same for singletons. It's not incredibly common though and I know of some twins (here at Twinstuff) that had acute ttts at delivery but none that died of it. If you go to a TTTS-specific site you will get a different sampling.

Pretty much all the late loses of twins that I know of personally had an unknown cause. There is a real risk of Acute TTTS with mono/di twins that should not be overlooked but many, many mono/di twins have been delivered safely vaginally. You decide which is a safer bet for your babies: a natural delivery with all the positive aspects that come from it along with the slightly increased risk for acute ttts or a c-section and it's possibly positive and negative aspects. Whatever you decide will be the best choice so don't second guess yourself.

BTW, my girls did have TTTS (discovered at our 1st u/s at 19 weeks) and we went with the induction for vaginal delivery with no problems resulting in the babies. I did end up having a c-section but that was due to problems with me. Good luck!

 

natasha: I contacted Mary from the TTTS.org website and she said no later than 36 weeks. This is with weekly scans for fluid checks and a perinatologist who is monitoring their blood flows, etc.

I think that because of IVF (although this can affect them too) too many doctors have become lax in treating twins and they treat those who share placentas as if they don't. Also, there are issues with the placenta in vaginal deliveries. If you are pregnant with 1 baby and that's it, after the baby is born, the placenta is detaching. I don't think it changes when there are 2, and so it puts the 2nd baby at risk in that way as well.

My dr. wants to push me to get as close to 40 weeks. No plans for c-section prior to then unless I go into labor and babies are breach. I secretly hope I do go early, but I also don't want to take risks with my babies lives by waiting it out. Oh and instead of at least 2x a month u/s, she's lowered it to 1. I went to UCSF after my first OB disaster with another dr. and the OB there had sent my new OB with these orders and so she's following them and saying "well, he's the expert." and just last night I found out that there are quite a lot of bad issues with MFM OB's from UCSF who aren't doing all they can to care for mono/di twins, even when TTTS is found.

So I'm working with Mary on this personally and i'm hoping to find an OB who will work with me and treat me like a colleague in this and not like some dumb patient who is hormonal and finds some sadistic joy in looking into ways my babies can die.

 

I guess I am a bit confused about this post. Do you have a question you are wanting to know about?

 

Well, I don't know - I saw this on the forum too. I am goinig to be 36 weeks on Thurs with mo/di twins that have at least mild TTTS. However, my peri, who is very conservative, is monitoring closely and will deliver the minute we become unstable. We have a c-section scheduled for 38w4d in case nothing happens before then. I think something will.

I plan to ask her about the placenta aging and stuff at our appt this week, but I really do trust her. She sees no reason to see how far we can get. I also have no doubt that she will deliver at the very first sign of a problem. They are both breech, so we're not doing vaginal delivery anyway.

Jenny

ETA: We've been monitored with weekly u/s since 18 weeks due to the TTTS.

 

I have mono di twins and was told that i could go to full term with no problems... and even so I want to keep them bakin as long as possible the longer they are in the better unless there is an issue...

 

QUOTE(summerfun @ Nov 6 2007, 08:47 PM) [snapback]484639[/snapback]
I guess I am a bit confused about this post. Do you have a question you are wanting to know about?


yes, in my post i asked for peoples opinions on this study and when to deliver mono di twins. This was the first time i had heard of any risk to the babies so late in pregnancy. I was wondering what other peoples thoughts were on this.

had you heard of this?

sorry if my post is confusing. :blush:

 

QUOTE(natasha163 @ Nov 6 2007, 09:11 PM) [snapback]484688[/snapback]
yes, in my post i asked for peoples opinions on this study and when to deliver mono di twins. This was the first time i had heard of any risk to the babies so late in pregnancy. I was wondering what other peoples thoughts were on this.

had you heard of this?

sorry if my post is confusing. :blush:

Sorry, I don't know anything about it, but I check out all posts.

It was hard to see where the question was with the links and the other posters info., I was just confused by it. :wacko: Thanks for clarifying.

 

My girls were mono/di and even though I did deliver at 35 weeks nothing was ever mentioned about needing to have them out by a certain point and I had VERY conservative peri's.

 

I think the study is pretty clear. It is certainly conducted by reputable academics.

One can't argue with them about the percentage of inter-uterine deaths they found.

The only thing that one argue about is how to best try and prevent it

Another response is to this data is

http://www.pubmedcentral.nih.gov/articlere...i?artid=1160585

They advocate letting patients decide on whether they want elective c-section at 34 weeks, and weekly monitoring beforehand.

Currently they are conducting a randomized trial in Europe to test whether c-sections or vaginal delivery are preferable for uncomplicated mono-chorionic pregnancies. Until then this is the best evidence there is.

 

I demanded to go no longer without a perinatologist. And my dr. got "offended" of all things. I'm beginning to really dislike her. She's so full of herself. But anyways. yeah I'm looking for another one and I have a recommendation from a trusted source for one in particular.

I told her that I was concerned about the placenta, possible undiagnosed Acute TTTS that can present during labor/birth and will cause problems to the babies. She poo poo'd them away.

So yesterday I brought it up again and brought 3 printed things from what Pettums has posted, about the importance of delivering (they say actually 34 weeks) at the latest at 36 weeks. I took them out for her and she refused to take them or look at them and just went on and on about her own thoughts, feelings, and studies on them.

I asked how many mono/di twins has she delivered and she said "10% of hundreds." I'm not sure about that one, as she did what I asked and later on contacted a perinatologist (although I'm wary of how she presented the case) who actually backed me up but only with the not trying to reach 40 weeks, and said 37 weeks at the latest.

The reason why I'm wary about how she presented it was that she quoted him saying "We may not even need to see her." So I'm frustrated because of my fears and the risks and I just don't feel those risks should be taken with my babies lives.

 

Bernice - Sounds like you definitely need a new doctor, mainly because your doctor is clearly not doing a good job of addressing your concerns.

In my practice, I personally don't deliver normal mono/di twins before 36-37 weeks because I think the risks from prematurity are still fairly significant that early. I start weekly BPPs at 32 weeks (that study first mentioned only did them every 2 weeks which is too infrequent). As long as the fluid is normal and the babies are moving well, there is no need to worry about the placenta "aging".

Also that second study from Columbia which discusses offering an elective preterm delivery at 34-35 weeks does not actually state that it must be a c-section. In fact, it's very safe to induce labor preterm as long as the babies are positioned right. And yes, there is a chance that the placenta can start to detach after the first baby is born, but usually the second baby is born quickly enough that there is no risk. Besides, that second baby is still being monitored and if there are any signs of fetal distress, a c-section can always be done at that time. That's the reason most twin deliveries take place in the OR.

 

QUOTE(allboys @ Nov 9 2007, 10:14 PM) [snapback]489431[/snapback]
Bernice - Sounds like you definitely need a new doctor, mainly because your doctor is clearly not doing a good job of addressing your concerns.

In my practice, I personally don't deliver normal mono/di twins before 36-37 weeks because I think the risks from prematurity are still fairly significant that early. I start weekly BPPs at 32 weeks (that study first mentioned only did them every 2 weeks which is too infrequent). As long as the fluid is normal and the babies are moving well, there is no need to worry about the placenta "aging".

Also that second study from Columbia which discusses offering an elective preterm delivery at 34-35 weeks does not actually state that it must be a c-section. In fact, it's very safe to induce labor preterm as long as the babies are positioned right. And yes, there is a chance that the placenta can start to detach after the first baby is born, but usually the second baby is born quickly enough that there is no risk. Besides, that second baby is still being monitored and if there are any signs of fetal distress, a c-section can always be done at that time. That's the reason most twin deliveries take place in the OR.


allboys: thank you for your reply. I was feeling shakey about the 37 weeks thing and not 36, but as long as they keep on monitoring them and making sure there is no TTTS developement, I'm fine with that. I'd be fine with a vaginal delivery as well, as long as that's ruled out a week or so before. I heard that it may be hard to induce, but I hope the babies will be in position (they are both breech and hurtin' mamma right now) and everything will be fine. My OB is only going to do NSTs and said she'll do a BPP only if an NST doesn't turn out good.

Their fluids look good, they are both growing at the same pace, measuring same for growth (although different individually by 4 days) Hearts look good and they really actually look very happy and almost chubby (we got a face shot). I just want to be sure everything is taken care of. I'm glad to hear about the weeks coincide with what you are familiar with.

I had an OB appointment yesterday and here's how it went: My dr. actually begged me to keep her on, but her attitude is sooooo irksome that prior to this visit I wrote a very respectful but assertive letter about my wants and fears and told her that if she didn't agree with me or make sure I got the attention I needed, I would change doctors. I actually doubted giving it to her, until towards the end of the visit I couldn't take her ego any more that I whipped it out and gave it to her. She said she'd read it that night. Can you belive she got offended at me for demanding a perinatologist (which is ROUTINE for monochorionic/diamniotic twins). My mom was with me and saw the whole thing. So she said "What's the harm in reassuring her by having this?" and she cooled down and later on called me and told me she talked with one (and hopefully will help me set up an appointment) and they said I shouldn't go longer than 37 weeks. This was one of the issues and I have 3 different studies and documents from medical journals stating twin interuterine demise raises after 34 weeks and to deliver prior to 36. I tried to show them to her which she absolutely refused and ignored. So when she admitted she learned something new, it was nice to hear but gave me a reason to continue to be irked that she refused to listen to me. I mean, what about the 10% mono/di she claims to have delivered... what risks has she put them through and in? I'm not sure how she presented my case to the Peri as well because she made it seem like he didn't even think I needed to see him. How can I get it into her head that I just want to make sure everything is OK, up to the time I deliver! I even asked about steroids (which is what I believe it is called) to mature their lungs and she said "Absolutely NO WAY." Maybe I didn't put it right, but I thought that if you had to be induced early or to have a c-section for any emergency reason - but it could be put off by a day or two - that's what they do as well.. check their fluid to see if the lungs are mature and if not, do something if you have a day or two to do it in.

I'm not trying to be "glass is half empty" but my daughter had a rare thing happen to her in june and I just don't feel like because something is rare, you can act like it won't happen to you or the babies. ID twins are rare as well, but here they are. I'm glad it's not siamese or monoamniotic....
I'm trying to be polite and respectful but assertive. I just need reassurance and to be sure that I'm not only working with 1 person who thinks the world of themselves and absolutely refuses to have others involved to concur with.... I don't see how she can say she's following the OB's notes that I got from UCSF with an OB and a perinatologist - when he also wanted me to be continued to be seen by an perinatologist - and she hasn't followed that advice. I trusted several doctors and only ended up hurt because they cared more for their egoes than about someone's life and choices. I swore that I wouldn't deal with a dr. like that again...

 

dear bernice, i am in total agreeance with you, some ob's just think that twins are like any other delivery, and they are so wrong...and like you said, just because something is rare dosn't mean that you won't be the one that it happens to.

good luck with you on, (and yes, she sounds like a real....piece of work) Keep on honing it in to her want you want and expect from her services. You are paying her do do her job, and so she should do it. Well done for sticking up for your babies, and keep us poseted.

 

I'm still not sure I'd stick with your OB, bernice. It's not very difficult to at least send you for a consultation with a peri just to make you feel better.

As for the steroids, most doctors only give them when they anticipate a delivery before 34 weeks. They do have some side effects like increasing risk of infection for both you and the baby, so they are typically avoided later in pregnancy when the lungs are already well developed.

Also (and this is just my opinion), but I think you should be having BPPs (not just NSTs) after 32 weeks. Or at least an NST and a measurement of the fluid.

Good luck getting all this sorted out.

 

My girls were mono/di twins and I delivered them 39 weeks via c-section. I had a very good OB and never once felt like I needed a perinatologist. I did see one at about 22 weeks, to make sure everything was looking good. I was having NST done every week as well as a U/S, it was nice to see my girls every week.

The most important thing is to have confidence and mutual respect for your OB and if your not getting that, then maybe its time to move on. Good luck.

QUOTE(allboys @ Nov 10 2007, 12:00 PM) [snapback]489767[/snapback]
As for the steroids, most doctors only give them when they anticipate a delivery before 34 weeks. They do have some side effects like increasing risk of infection for both you and the baby, so they are typically avoided later in pregnancy when the lungs are already well developed.

I was going to say this but you already did.