Category: Pregnancy

Vanishing Twin Syndrome (VTS), Part 2

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This article is for information and overview purposes only and does not represent every possibility or situation.  If you are concerned about any aspect of your pregnancy, please consult your doctor as affects your particular situation.

The use of diagnostic ultrasound imaging has made it possible to determine as early as five or six weeks that Mom is pregnant. Ultrasound (US) picks up the fetal heartbeat(s) allowing the medical team to also determine how many fetuses are present. In some cases, two or more fetal heartbeats can be found leading to excitement and some trepidation for the expecting parents. The use of US to determine pregnancy at such an early stage, however, has also identified another issue which might occur known as Vanishing Twin Syndrome (VTS).1  For women experiencing VTS, during a subsequent US (up to about 12 weeks gestation), one or more fetal heartbeats may no longer be found. The empty sac may, or may not, be visible on the screen.

In years past, women had their first US after the 12th week of gestation therefore eliminating the possibility of knowing that they were initially carrying more than one fetus. The availability of US as early as the 5th week of pregnancy has allowed researchers to conclude that the rate of multiple-birth conception is much higher than previously thought. It is estimated that one in eight people may have started as a twin, but only one in seventy pregnancies actually resulted in a twin birth.2  VTS usually has no symptoms, but sometimes a pregnant woman might have unexplained bleeding, cramping or passage of tissue in the week(s) in her first 12 weeks of pregnancy. Such symptoms could indicate the loss of a multiple pregnancy, a blighted ovum, or in some cases nothing at all. Not all cases of VTS are associated with any outward signs and many women continue with an uncomplicated pregnancy and the birth of a healthy child(ren).

VTS does not just occur with twin pregnancies, but can occur within higher order multiple sets as well. The loss of one, or more, embryo in the first trimester can be emotionally devastating for expecting parents. For example a couple was 8-1/2 weeks pregnant with triplets when they registered for a multiple-birth prenatal class.  When they arrived for the class at just over 13 weeks pregnant, they advised that a subsequent ultrasound had shown that they were now carrying two babies, and an empty sac had been visible on their latest ultrasound.  The couple had a difficult time because two other couples in the group were carrying triplets and they realized they were no longer part of that special group.  In such cases, referral to counseling may assist expecting parents in dealing with their early fetal loss and allowing them to celebrate in their continuing pregnancy.

Risk factors for experiencing VTS are generally unknown but seem to include a maternal age over 30. If the vanishing fetus occurs in the first trimester, as it does in most cases, no medical intervention is usually necessary. The mother, the placenta or the surviving co-multiple may absorb any miscarried fetal tissue within a few days.

VTS does not generally affect the ability of a woman to conceive again, although there could be underlying genetic or health issues that should be explored with a physician.

While VTS usually poses no problem physically for the mother or the surviving child(ren), it is not uncommon for mothers to have feelings of disappointment, grief and loss as they had anticipated and looked forward to a multiple-birth.3  As the pregnancy continues with at least one healthy child, these mothers may be told that the loss isn’t important or to focus on their healthy baby. It can be difficult for mothers to find acceptance or a safe place to grieve this loss as family and friends fail to understand that a unique parenting experience has also been lost as well as a much-wanted child. Women and their partners experiencing VTS are encouraged to seek counseling if feelings of depression, sadness, or anxiety continue.  Local and national parenting support groups may offer networking opportunities for parents who have suffered from VTS.

Vanishing Twin Syndrome (VTS), Part 1

See Part 1 of this article, Vanishing Twin Syndrome (VTS)

References

1) De la Fuente, G., Puente, J., Garcia-Velasco, J., & Pellicer, A. (2011). Multiple pregnancy vanishing twin syndrome. In Biennial Review of Infertility (pp. 103-113). Retrieved from http://link.springer.com/chapter/10.1007%2F978-14419-8456-2_9?LI=true

2) Heim, S. (2007) It’s Twins! Charlottesville, VA: Hampton Roads Publishing.

3) American Pregnancy Association. (2007). Vanishing Twin Syndrome. Retrieved from http://americanpregnancy.org/multiples/vanishingtwin.html

Additional Resources

Mothering Multiples, by Karen Kerkhoff Gromada, La Leche League International

The Art of Parenting Twins, by Patricia Maxwell Malmstrom and Janet Poland, Ballantine Books

Twins! Pregnancy, Birth and the First Year of Life, by Connie L. Agnew, Alan H. Klein and Jill Alison Ganon, Harper Perennial

Differences Between Multiple and Singleton Pregnancies

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How is a Twin Pregnancy Different from a Singleton Pregnancy?

What a great question.  There are distinct differences between the two, and taking a multiple-birth specific class, either in your community, on-line or by DVD will answer many of your questions.

As each pregnancy is different, even for the same woman, there may be differences woman-to-woman and/or situation-to-situation.  IF YOU ARE NOT SURE ABOUT ANY ASPECT OF YOUR PREGNACY, PLEASE CONSULT YOUR PHYSICIAN IMMEDIATELY.

Woman 22 weeks pregnant with twins
22 weeks pregnant with twins

Here are some expected differences.

  • A multiple birth pregnancy is nearly always considered “high risk,” meaning that doctors will be more vigilant to ensure Mom and babies are doing well.  “High risk” is a normal label for parents expecting multiples and not necessarily anything to worry about;
  • As a “high risk” pregnancy, Mom can expect a greater number of doctor’s visits, fetal monitoring and blood tests.  As the pregnancy progresses, doctor’s visits will increase from once a month to every other week during the second trimester and once a week until birth in the third trimester;
  • Moms will be checked for excessive nausea, appropriate weight gain, edema (swelling), gestational diabetes, twin-to-twin transfusion (including in sets of triplets and more) if the babies are monozygotic (identical), preeclampsia, and the babies will each be monitored to make sure they are growing and developing properly;
  • Morning sickness can be more severe and begin earlier with multiples and like a singleton pregnancy, it may last only the first few months or continue through the complete pregnancy.  Each woman is different;
  • Mothers expecting multiples will get bigger faster and be in maternity clothes much earlier than with a singleton;
  • Mothers expecting multiples report feeling tired more often and earlier.  If you think about it, Mom is creating and growing several fetuses at once, plus maintaining her own system with its many body changes to accommodate these babies.  It is tiring work;
  • Nutritional requirements are different for a multiple-birth pregnancy and your doctor or nutritionist will be able to explain how much weight gain is ideal for you in each trimester.  Your particular weight gain expectation will be influenced by how many fetuses you are carrying.
  • Most multiples are born preterm, i.e. before 38 weeks, and will be smaller at birth than a singleton.  The more infants Mom is carrying, the earlier they are likely to arrive;
  • It is not unusual for multiples to be delivered by c-section.  The more babies carried, the more likely there will be a c-section.  For twins, a vaginal delivery usually depends on the position of the lower baby.  If the baby’s head is down, there may be a chance for a vaginal delivery.  In a small percentage of cases, one baby may be delivered vaginally and the other may be breech and need a c-section for delivery;
  • Moms, especially in the latter stages of their pregnancy, may find their balance compromised due to the position of the babies, the number of placentas and fluid retained.  Take very good care when walking or using stairs; and
  • Mothers may need to spend some time on bed rest either at home or in the hospital.  Your doctor will let you know should you fall into this category.

To find out more about pregnancy differences, check out my Suggested Reading List at https://jumelle.ca/prenatal-education/suggested-reading-list-for-parents-expecting-twins-triplets-and-more-2/

 

 

Multiples Illuminated: Book Review

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I really enjoyed this book and categorize it as a must-have on the bookshelf for parents expecting multiples.  Laid out into the natural flow categories of conception, pregnancy, labor and delivery, Neonatal Intensive Care Unit and the first years, submissions by parents of twins, triplets and more honestly explore their journeys with insight, hints, tips, fears, expectations, realities, humour and ultimately, the joy of having two, three or more babies at a time.  Each author has managed to include the reader on their unique journey in a most delightful and personal way.

Multiples Illuminated, by Megan Woolsey and Alison Lee

Window measurements copyIn addition, the editors offer concrete ideas throughout for handling trying times, e.g. coping with infertility issues, and include a “must-have” list of accessories for having multiples and thoughtfully provide places to journal your own thoughts and feelings about your particular journey.

This book would be the perfect gift for anyone you know who is expecting multiples!

Anyone with an interest in multiples needs to pour her/himself a coffee, find a quiet moment to sit back and savor the experiences of families who have already begun a unique, exciting, challenging and rewarding parent experience.

A Doctor’s Guide to a Healthy and Happy Multiple Pregnancy

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Expecting two or more? Dr. Franklin has a light-hearted, easy to understand writing style, generously laced with humour. Her book takes you through each stage of the pregnancy. She includes chapters on learning the news that you’re having multiples, “…and What To Do About It”, she addresses issues you might expect to face in each trimester of your pregnancy, focusing on nutrition, exercise, and preparing for the babies.

Expecting Twins, Triplets, and More: A Doctor’s Guide to a Healthy and Happy Multiple Pregnancy, Rachel Franklin, M.D., M.O.M.* (*Mother of Multiples), 2005, St. Martin’s Griffin, N.Y., 221 pages

Expecting Twins, Triplets, and More is like having a friend, who also happens to be a doctor, share her experience and expertise to help you best take care of yourself and your babies at this very special time. Dr. Rachel Franklin’s practical wisdom helps you understand the unique circumstances of multiple pregnancy and birth. Throughout and after your pregnancy,  Expecting Twins, Triplets, and More will act as an invaluable resource on what to expect, how to cope, and how to enjoy the journey.

Here are some of the topics Dr. Franklin covers in her book:

  • Telling family, friends, and coworkers the news
  • Choosing a doctor
  • Exercising and eating well
  • Coping strategies trimester by trimester
  • Preparing for labor and delivery
  • Understanding potential complications and their solutions
  • Navigating the NICU (Neonatal Intensive Care Unit)
  • Celebrating the births and bringing home the babies

Forever Linked: A Mother’s Journey Through Twin to Twin Transfusion

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Two cords tangled
Click to enlarge

Twin-to-twin transfusion syndrome (TTTS) is a disease of the placenta and can affect monozygotic (identical) babies, including within triplets or more when there are monozygotics.

It has a spectrum from mild to severe and if left untreated, can result in death for one or both babies, or put in jeopardy the complete pregnancy for triplets or more.

Forever Linked: A Mother’s Journey Through Twin to Twin Transfusion Syndrome, Erin Bruch, Philatory Ink, 299 pages

Twin to Twin TransfusionErin Bruch explains what TTTS is, how it can happen, the need to have the diagnosis as early as possible in a multiple-birth pregnancy, about managing it and what it feels like for the parents and families to go through, sometimes with the loss of one or both babies.

In addition, 21 mothers’ stories of their twin pregnancies are followed from finding out their babies had TTTS, the worry that knowledge carried, through their births and outcomes.

Bruch has included a drawing of what a TTTS placenta might look like. It is a helpful visual in understanding what is happening with the babies and why their struggle with TTTS can be a life and death matter. I also find both the cover pictures to be important visuals of what the babies go through with their unequal sharing within the womb.

If your babies have or had TTTS and if you like first hand accounts, this is definitely a must-read book.

Multifetal Pregnancy Reduction

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Note: The term used by the International Society of Twins Studies (ISTS) is “Multifetal Pregnancy Reduction” and is the one used here. For the Reader’s information, this procedure may also be referred to as “Selective Reduction”.

Couples who are expecting three or more babies may wish, or be advised, to consider reducing the number of viable fetuses to two. The reduction procedure is usually performed between the 10th and 12th weeks of pregnancy by injecting one or more of the fetuses. Fetal reduction increases the chance of a mother having one or two healthy babies instead of a miscarriage or very premature delivery of three or more babies who are much more likely to die or to suffer from long-term disability.

The balance of risk and advantage will be different for each couple but nevertheless for all there will be a sense of responsibility and much anxiety. For couples considering multifetal pregnancy reduction, there are additional issues that compound their anxieties.

Firstly, many couples have struggled with becoming pregnant, sometimes for years. Here they are pregnant, with some type of fertility assistance, but they are carrying triplets, quadruplets, quintuplets, sextuplets or more. To now have to consider reduction (killing?) of some (or even one) of the babies that they have strived so hard to conceive, goes against all of the time, energy, disappointment, heartbreak and money that was invested in getting pregnant in the first place.

Secondly, when it is determined that there are three or more fetuses, the timeframe for the multifetal reduction choice is often very narrow, sometimes as short as only 3 or 4 days. In that small window, the parents have to learn all they can about the procedure, perhaps connect with others who have had the procedure, learn about the risks to mother and the remaining fetuses and come to grips with losing (aborting? killing?) one or more of their unborn children. This is enormous pressure to endure, to come to terms with and to decide upon in a few, short days.

Thirdly, and as yet perhaps one of the most unstudied and unrecognized issue, are the possible long term psychological effects on the parents and by extension, the children as well of choosing a multifetal pregnancy reduction procedure. Some of the questions that have been bandied about my parents having had the procedure are: “Did we kill our son?” (this from parents who had two beautiful daughters from a triplet pregnancy); “Am I a murderer?” “How and when do we tell the others (surviving children)?” Some parents have reported fantasizing about the baby(ies) that was reduced and wondering about the sex of that child(ren), if they would have looked like their co-multiples and even if they should tell the siblings about the reduction. Some parents have named the reduced child(ren) in an attempt to come to terms with their decision and to find some peace regarding this socially unrecognized loss.

Regarding telling the other children about the procedure and what it could entail, once again the answer will be individual and personal. If you have shared with other family members that you are carrying many fetuses and are considering multifetal reduction, then have the procedure and wish to keep hush regarding your decision, it may already be too late. If parents choose not to tell their surviving children but have conferred with other family members regarding the procedure, then there is always a risk that someone will tell, even inadvertently, your surviving children. Secrets in a family are extremely hard to keep and usually fester and erupt at a most inopportune time and sometimes awkward moment. It stands to reason that parents considering the multifetal reduction procedure would want to confer with other family members who love and care for them, as they struggle with emotions, guilt, worry and anxiety over their babies. To share personal information and then to expect silence may be too much. A child who discovers, from someone other than his parents, an important piece of his history can become confused and angry regarding this important piece of his life which has been kept from him.

With families being more open these days and encouraged to speak of their dead baby, this could be helpful all around. It is usually better for children to know from the start that they were once a part of a set. The reaction of each child will be unique and personal and parents will need to provide age appropriate feedback and information to their children’s questions. The beauty of this approach is that, a child asks at his or her own rate and in a manner that meets his or her needs at that time. Expect questions at all stages of their lives.

When considering multifetal pregnancy reduction, there are many questions and the answers will need to be considered individually and as will affect each family’s personal situation. Here are a few common questions:

I am expecting quadruplets and am being asked to consider reducing to twins. I know it is possible to carry healthy triplets, what do we do?

You are correct, many families have carried triplets to a healthy outcome. There are many considerations and only you, your partner, informed healthcare professionals, perhaps other multiple births parents, genetic counselling can help you reach a decision.

Some things you might consider:

Ascertain the health risk vis-à-vis the mother and all of the babies. If one (or more) fetuses have anomalies, you may feel that reduction is the decision to make, thereby giving the healthy fetuses a better chance at a healthy gestation and life.

Learn the survival statistics

  • 70% of quadruplets survive. Of that figure, 50% of them have disabilities ranging through a series of impairments such as blindness, to cerebral palsy. The average gestation for quadruplets is 28 weeks.
  • 85% of triplets survive and 10% impairment rate can be expected, with an average gestation of 30-33 weeks.
  • 98% of twins survive with a 5% impairment rate and the average gestation is 35-38 weeks (NOTE: a singleton gestation rate is based on 40 weeks).*

*Statistics quoted from research paper by V.M, quadruplet Mom who reduced to triplets and gave birth at 34+ weeks to three beautiful, healthy babies. Their weights ranged from 3.12 lbs. to 4.9 lbs. and the family brought them home from the hospital within 15 days.

Did we do the right thing?

This is such a difficult question and there are no easy answers. Even though the timeframe for decision whether to have the procedure or not is so short, be sure and do your homework. Below are some Internet Sites to visit, talk to other families who have considered the procedure, learn as much as you can about the procedure and the possible ramifications. Knowledge is Power and permits you to make the best possible decision for your personal situation.

I must go back to V.M. thoughts and wisdom. As V puts it:

Someone once said to me “make the decision from your head, not your heart”. I agree with the intent of that comment. An informed decision is the best decision. However, you can never really feel good about such a decision, and you will never be 100% certain of your choice. You can survive this and one day you will be at peace with it. Recently I was able to answer a question that had tormented me from the beginning. “How do I ask forgiveness or understanding from that lost child – the one I never gave a change at life?” The answer – there is no need to ask for forgiveness for a child loves unconditionally. The love we have for that child was and is equally returned. It was through love that my husband and I conceived and it was with love that we reduced. It is the love not the loss that I chose to hold onto. Somewhere between your head and your heart, what you know and what you feel, you will find the answer. Allow yourself to listen to both.

We have lost a child(ren). We hurt so much and we cannot share nor openly talk about our pain.

Multifetal pregnancy reduction is one type of loss that is nearly impossible to ‘share’ with others let alone have them fully understand the anxiety and dilemma that has been faced. We conceived many babies and chose to reduce one (or two, or three). While our dream has been drastically altered, we may choose to keep our personal feelings to ourselves and if not, our loss(es) may not be acknowledged, recognized or even fully understood by others in a manner that we might feel fitting or helpful. A sense of isolation coupled with the grief of the new reality can combine to make the pain greater.

It may not be unusual, like a miscarriage, for others to have difficulty in relating to your loss. “Well it wasn’t a baby yet” or “you have others” may be expressed to you. Try and find a caring and understanding person to share your pain and grief with. It might be a special friend, grief counsellor, religious leader, family doctor or bereavement support gorup. Grief is personal and knows no timetable. Grief is a journey not a destination and may require some support at different stages of your life. It is important to recognize the pain, possible feelings of guilt and grief and to work with them, address and acknowledge them. Only then can we move on, forever changed and with a new reality. Don’t be afraid to cry or seek appropriate professional support, if need be.

Sources

Bereavement: Guidelines for Professionals, These guidelines focus on the particular issues raised by the loss of a twin, triplet or more by Elizabeth Bryan, MD, FRCP, FRCPCH and Faith Hallett, The Multiple Births Foundation
Selective Reduction: Research Tools for an Informed Decision, by V.M.
Twins! Pregnancy, Birth and The First Year of Life by Connie L. Agnew, M.D., Alan H. Kein, M.D., and Jill Alison Ganon, 1997, Harper Perennial

Vanishing Twin Syndrome (VTS), Part 1

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Vanishing Twin (VT): Frequently Asked Questions (FAQs)

To my surprise, the Vanishing Twin article is the most hit-on article on my Site. Due to very early ultrasounds (5 or 6 weeks) we learn early if we are pregnant and with how many. By about week 12, things can drastically change. Following are some FAQs on Vanishing Twin:

LYNDA IS NOT ABLE TO ANSWER MEDICAL QUESTIONS. ANSWERS PROVIDED ARE GENERAL IN NATURE AND MAY NOT APPLY TO YOUR PARTICULAR SITUATION. IF YOU HAVE ANY CONCERNS AT ALL ABOUT YOUR HEALTH OR YOUR PREGNANCY,PLEASE CONSULT YOUR DOCTOR!!

Q – How long will I continue to bleed?

Ans: Each woman is unique as is each pregnancy, even for the same woman.  Duration of bleeding can depend upon when VT occurred. For example if it occurred at 7 weeks, a woman may not bleed as long as if it occurred at 10 weeks. Some women don’t bleed at all and their body reabsorbs the VT tissue with no outward indication of the loss.

Q – Will the VT hurt the other baby (ies)?

Ans:  In the majority of cases, if the other baby(ies) is healthy, it(they) will be fine. Your doctor can confirm, through ultrasound and fetal monitoring, the health of your remaining baby(ies). Generally there will have be no difficulty as the pregnancy progresses through to a healthy birth.

Q – Will there be any evidence left at the birth of the survivor?

Ans: Usually at birth, there is little if anything left of the VT. There might be a “thickening” of a portion of the placenta.  It depends upon when the VT and the birth of the surviving baby occurred as to whether or not the VT is visible. For example: if say the VT occurred at 8 weeks and the birth of the survivor occurred at 39 weeks, there is little chance of any remaining physical evidence of a VT. If the VT occurred at 12 weeks and the survivor is born prematurely, say at 32 weeks, then there may be some evidence of VT or there may not.

Q – What caused the VT? What did I do wrong?

Ans: It isn’t fully understood why VT occurs but it can be surmised that an embryos did not properly attach to the uterine wall and therefore failed to receive adequate nutrition to grow and develop. As can be appreciated from the scenarios mentioned in Ques. No. 3, there can be little to study after birth in order to ascertain why a particular pregnancy failed to produce healthy multiples. Early ultrasounds (at 5 to 6 weeks), can indicate a woman is pregnant and with how many. Two decades or more ago, the first ultrasound occurred much later in a pregnancy, about 16 to 20 weeks, well past when a woman would have known that she was initially carrying two or more. As a result she would have no knowledge that she had been carrying more than one.  It is generally felt nowadays that many more of us begin life as twins than was previously thought. What can be assured is that VT isn’t anyone’s fault and neither parent did any thing wrong.

Q – How long will it take for the empty sac to be reabsorbed by the mother’s body?

Ans: Each case is unique and needs to be evaluated on an individual basis. Your doctor is the best person to advise you for your particular case.

With ultrasound, it is now possible to know as early as five or six weeks that you are pregnant. However, with these first trimester, early ultrasounds an interesting side effect has occurred. The early ultrasound confirms two or more fetuses and a subsequent ultrasound reveals the ‘disappearance’ of at least one of the fetuses and an empty sac may be visible. This ‘disappearance’ is called Vanishing Twin.Researchers now suspect that many more multiples are conceived than previously thought and unexplained bleeding early in the pregnancy may be the miscarriage of a multiple. In the past, women usually had their first ultrasound later in their pregnancy (after 12 weeks pregnant) and therefore would never have known that they were carrying multiples. Nowadays the use of early ultrasound (in some cases as early as five weeks pregnant) can confirm a multiple birth pregnancy, while a later ultrasound confirms the loss of one or more of the babies. While not all cases of vanishing twin are associated with bleeding, this may explain why some women experience some cramping, bleeding or passage of tissue early in their pregnancy, but nevertheless the pregnancy continues, is uncomplicated and culminates with the birth of a healthy child(ren).

Vanishing twin can also occur within higher order multiple sets. I made an initial contact for registration for multiple birth prenatal classes with a family 8-1/2 weeks pregnant with triplets. When they arrived for the first class at just over 13 weeks pregnant, they advised that a subsequent ultrasound had shown that they were now carrying two babies and an empty sac was visible on the ultrasound. This family had very sad feelings because two other families in the class were carrying triplets and they should have been part of that group.

It is not uncommon for families with vanishing twin to experience feelings of sadness, grief and loss as they had anticipated and looked forward to a multiple birth.

It is not clear why one (or more) fetus fails to develop and is either miscarried or reabsorbed into the mother’s system.

For additional information, please see Vanishing Twin Syndrome, Part 2

Some Resources on Vanishing Twin

Twins! Pregnancy, Birth and the First Year of Life, by Connie. L. Agnew, Alan H. Klein and Jill Alison Ganon, Harper Perennial
Multiple Blessings, by Betty Rothbart, Hearst Books
Double Duty, by Christina Baglivi Tinglof, Contemporary Books
Mothering Multiples, by Karen Kerkhoff Gromada, La Leche League International
The Art of Parenting Twins, Patricia Maxwell Malmstrom and Janet Poland, Ballantine Books

Website: www.vanishingtwin.com

Please Note: I am unable to answer any medical questions. If you have any concerns regarding your medical situation, please check with your healthcare professional.

Additional information about ultrasounds and sonograms – particularly relating to diagnostics, exposure principles, and the role of an ultrasound technician – can be found through a variety of medical resources.

Miscarriage

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Miscarriage is the unplanned ending of a pregnancy before the 20th week of the pregnancy. 15 to 20% of all pregnancies end with a miscarriage. 75% of miscarriages occur within the first trimester (12 weeks) for several possible reasons: improper attachment to the uterine wall, imperfect fetus either genetically or more usually, by a chance mutation of cells at the time of conception. 25% of miscarriages occur during the 13th to 20th week. Usually the fetus is normal but there may be other problems: improper attachment of the placenta, uterine difficulties or an incompetent cervix.

There may be several reasons for a miscarriage as discussed above or a mild virus, more serious disease or infection may be the cause. Environmental facts and malnutrition of the mother are two more possible causes.

Many times there are no definite reasons for a miscarriage and we, who prefer answers, may have some difficulty in coming to terms with that fact.

If you lost one more or all of your babies through miscarriage, you may feel empty, angry or let down by your body. Even worse, you may find that family and friends don’t properly acknowledge the pregnancy or the depth of grief. In fact, society tends not to think of miscarriage as a real loss. People tend to think that because you didn’t know the baby, you shouldn’t feel too sad. The loss is downplayed and the parents are often advised to “try again.” If parents are to have any hope of healing, many of those whom have dealt professionally with pregnancy loss or studied it, agree that parents need to grieve their baby’s loss if they are to heal.

If it is possible to see your child, ask the hospital staff in this regard. They are best suited to advise you. Even if the baby can’t be viewed, it might be wrapped in a blanket and brought to you to hold. The physical sensation of holding your child gives you tangible memories of the baby’s real existence as a part of your family. Other mementos, such as copies of early ultrasound photographs of the multiple pregnancy with all fetuses intact, are cherished by many families.

If it is not possible to see the baby due to the miscarriage at too early a stage, it still may be possible to arrange formal burial or cremation with the cooperation of the hospital and a funeral home. If this is not an option for you, it is helpful for many families to hold a memorial ceremony, either officially with religious involvement or personally with only family and friends. You might decide to plant a tree(s) in a special location in memory of your child(ren).

It is important to find a safe place to grieve your loss. You may join a bereavement support group, see a therapist who specializes in pregnancy loss issues, find a caring friend or relative to share your feelings and emotions. Research has shown that parents who do not talk about a tragedy pregnancy take much longer to resolve their grief.

Women usually will grieve longer than men and want to speak of the miscarriage for weeks or months afterwards. Mothers may be receiving adequate care and attention afterwards, but bereaved fathers are sometimes overburdened and overlooked. Not only must they console the mother who just suffered a loss and who may be seriously ill herself, but they must also deal with their child(ren)’s death and memorial arrangements while also juggling household duties and possibly a job as well.

This article was written with grateful input and assistance from:
Dr. Elizabeth Pector, Illinois, U.S.A.

Sources

Bereavement in Multiple Birth, Part 1: General Considerations, Elizabeth Pector, MD; Michelle Smith-Levitin, MD, The Female Patient, Vol. 27, November, 2001
Miscarriage, pamphlet prepared by Canadian Mental Health Association, Windsor, Ontario, Canada
At a loss, article by Kimberly Pfaff, printed in The Walking Magazine, September/October, 2001

Reading Resources

Twins, Triplets and More, Elizabeth M. Bryan, M.D., St. Martin’s Press
Guidelines for Professionals: Bereavement, Bryan, EM; Hallett F, Multiple Births Foundation, London England www.multiplebirths.org.uk
Living Without Your Twin, Betty Jean Case, Tibbutt Publishing
Bereavement in Multiple Birth, Part 2: Dual Dilemmas, Elizabeth Pector, MD; Michelle Smith-Levitin, MD, The Female Patient, Vol. 27, May, 2002
The Worst Loss: How Families Heal from the Death of a Child, by Barbara D. Rosof, Henry Holt
Empty Cradle, Broken Heart: Surviving the Death of Your Baby, Deborah L. Davis, Fulcrum Publishing
Men & Grief, Carol Staudacher, New Harbinger Publications
Trying Again: Guide to Pregnancy After Miscarriage, Stillbirth and Infant Loss, Ann Douglas and John R. Sussman, M.D., Taylor Trade Publishing
Empty Arms: Coping with miscarriage, stillbirth and infant death, Sherokee Ilse, Wintergreen Press

Other Organizations

Nutritional Guide for Multiple Birth Pregnancy

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Food Group
Milk and milk products
Breads and cereals
Fruits and vegetables
Meat, fish, poultry and alternatives		 Number of Daily Servings
4-6
8-12
6-10
2-3

Please refer to Canada’s Food Guide for information on portion sizes.

Use in moderation: Fats and oils (example: butter, margarine, salad oils)

This nutritional guide will provide you with about 2000-2600 calories. It meets the nutrient needs for the second and third trimesters of the average, healthy woman expecting twins or triplets. The foods listed here are to guide you only, as the needs of each individual will vary. If this is not enough food for you, more servings can be selected from the food groups. Small, frequent meals, with snacks, may help you eat the larger volume of food and aid with the control of heartburn.

Following are some sample Menus which incorporate foods from the Canada Food Guide for a Multiple Pregnancy.

Breakfast
1/2 grapefruit
Shreddies and Milk
Whole wheat toast with margarine		 Supper
Pasta
Tomato meat sauce
Grated cheese
Steamed zucchini or broccoli
Milk pudding
Lunch
Baked beans or chicken leg & bread, margarine
Spinach and Tomato Salad with salad dressing
Banana
Milk		 Snacks
Yogurt
Bran muffin
Cheese and crackers
Hard boiled egg
Fresh fruit

Adequate fluids are important and 6-8 glasses of fluids per day are recommended. Alcohol should be avoided and caffeine consumed in moderation (e.g. coffee, tea, chocolate, soft drinks)

You will need an iron and folic acid supplement for your multiple pregnancy and these are prescribed by your doctor. Your doctor, dietician or nutritionist can advise if there is a need for further vitamin supplementation and if so, which ones.

Salt (sodium) should not be restricted. Moderate amounts may be used at the table or in cooking.

WEIGHT GAIN FOR MULTIPLE PREGNANCIES

Studies have shown that women who gain 26-35 pounds (16-21 kg) with their twin pregnancies, have healthier babies. The weight gain pattern for twins and a singleton in the first trimester is the same. You can expect to gain 1-4 pounds (0.05-2kg). In the second and third trimesters, you can expect to gain about 1.5 lbs. Per week (0.75kg). By 24 weeks gestation, you will likely have gained 24 pounds and by 32-36 weeks, 32-40 pounds.

REMINDER: All weights noted are suggested amounts recommended for the average, healthy woman.

Triplets and Quadruplets: A suggested weight gain for a triplet or quadruplet pregnancy has not been documented. However, one could deduce that a triplet suggested weight gain should slightly exceed that of a twin pregnancy, while a quadruplet weight gain be slightly more than the triplet pregnancy.

NOTE: When weight gain is too low, it could negatively affect the outcome of a pregnancy. Low weight gain affects the hormonal response to the pregnancy and therefore limits intrauterine growth. It is recommended that if any point in your multiple pregnancy you should feel that you are unable to eat one of the good groups, or are not sure whether you are eating properly, whether you have sufficient vitamin supplements or are unable to gain the recommended weight, ask your doctor for a referral to a dietitian.

Adapted and Compiled From:
Canada Food Guide

Nutritional Guidelines for a Multiple Pregnancy, by Pauline Brazeau-Gravelle and Julia Watson-Blasioli, printed by the Ottawa General Hospital; May, 1997

Calgary Foothills Hospital, Clinical Nutrition Services.

Twin to Twin Transfusion Syndrome

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Two cords tangledTwin to twin transfusion syndrome (TTTS) is a random abnormality of a monochorionic placenta that causes one identical twin to receive less than normal amounts of blood supply during pregnancy while the other receives too much. The babies share blood vessels in their placenta that cause an imbalance of blood flow and nutrients between them.

There are degrees to the severity of the syndrome, but it is always life-threatening due to the fact that it can worsen at anytime during pregnancy. Below is a summary of the difference between dizygotic (fraternal) and monozygotic (identical) twin pregnancies. TTTS can only happen with monozygotic twins, or as a pair in a higher multiple pregnancy, that share a single monochorionic placenta.

NOTE: The following information is provided for your information only and does not necessarily reflect each person’s individual situation. If you have any concerns whatsoever about your pregnancy, please consult your physician immediately.

There are two types of twins:

TwinsDIZYGOTIC (DZ)
two eggs meet up with two sperm. These babies are technically siblings who happen to have been born at the same time. They are commonly known as “fraternal”. They always have one placenta each and are called dichorionic (DC).

MONOZYGOTIC (MZ)
one egg meets up with one sperm. These babies are always the same gender and are commonly known as “identical”. MZ pregnancies can experience high complication rates, particularly if the twinning process occurs more than 4 days from fertilization resulting in a single monochorionic placenta share by two or more babies.

There are two types of monochorionic pregnancies that can be affected by twin to twin transfusion syndrome:

MONOCHORIONIC-DIAMNIONIC

When the embryo randomly splits between 4-8 days after conception, the pregnancy results with two babies each in their own amniotic sac (diamnionic) as well as sharing a placenta (monochorionic). The majority of these pregnancies proceed without complications. However, approximately 15% of the time, the babies will share blood between them disproportionately and warning signs of the syndrome will appear on ultrasound (see warning signs below). The syndrome can occur with two or more babies in a higher multiple birth pregnancy as long as the babies share a single monochorionic placenta.

MONOCHORIONIC-MONOAMNIOTIC

When the embryo randomly splits between 8-12 days after conception, the pregnancy results with both babies sharing a single placenta (monochorionic) but the babies are in the same amniotic sac (monoamniotic). This type of pregnancy can still result in TTTS but it is more difficult to diagnose with the babies in the same sac. Also, there is a greater concern that the babies’ cords will become entangled. It is estimated that approximately 50% of the babies will pass away from cord entanglement. It is recommended that mothers be hospitalized at 24 weeks for 24 hour monitoring of the babies until they are born.

One of the warning signs of TTTS shown on ultrasound is a size difference in the babies. One baby, the donor, becomes restricted in growth receiving less then normal blood flow. The donor baby does not urinate very much and has little to no fluid in his or her amniotic sac. Sometimes the baby is referred to as a ‘stuck twin’ or having oligohydramnios. Subsequently, a much larger blood flow goes to the co-multiple, referred to as the recipient twin. Due to the shared, interconnecting veins and arteries in the single placenta, the blood disproportionately flows through the donor twin and collects in the recipient twin, who is unable to efficiently rid his or herself of the extra blood. The recipient baby urinates frequently causing too much amniotic fluid or polyhydramnios. Because of this abnormality in the placenta, both babies’ well-being can be severely compromised.

PLACENTAL SHARE

It is important to understand that one reason babies can become growth restricted is that the babies may share the placenta itself unequally. The donor baby could have less then half of the placenta to nourish it. This is one reason why The Twin to Twin Transfusion Syndrome Foundation advocates weekly ultrasounds from 16 weeks through delivery of the babies. If a baby has a small placental share, and you cannot know prior to birth for sure what the placental share is, the baby will get to a certain gestational week and it will stop growing. The baby will not get enough blood and oxygen from it s share of the placenta to ‘get bigger’ than the size that it is. The rate of growth for the babies is extremely important and is often overlooked. The sharing of the blood from the syndrome also adds to size differences of the babies. TTTS is often combined with an unequal placental sharing.

Some treatment options are available

AGGRESSIVE SERIAL AMNIOCENTECES removal of the excess fluid around the recipient which may need to occur several times;

LASER SURGERY which identifies the connecting blood vessels in the shared monochorionic placenta and cauterizes them with a laser beam. The babies are being separated in the placenta so each will then get their blood supply independently from the other. The scope used is inserted through amniotic cavity of the recipient baby. There are specific criteria that must be met based on ultrasound findings.

BEDREST AND NUTRITION which is explained below and combined with the therapies listed above.

What Can We, as Parents, Do?

  1. Make sure your obstetrician has plenty of high-risk pregnancy experience.
  2. Make sure that your obstetrician uses intensive ultrasound to determine the chorionicity (DC or MC) of the babies as early as possible in the pregnancy. If the babies are like-sexed, you need to know if they share a placenta or each have their own. If they share a placenta, weekly ultrasounds are crucial in the care of your babies and you may have to really fight to have them. Don’t take no for an answer. If the babies are unlike-gender, they must be fraternal twins and cannot have TTTS. Keep asking questions until you are satisfied and understand the answers.
  3. If your babies are monochorionic, take really good care of yourself. One way is to follow advice from Dr. Julian De Lia who pioneered laser surgery almost 20 years ago. He is now recommending adding protein drinks to your diet, such as 3 cans of Boost drinks a day. He feels that TTTS can make mothers malnourished adding to the fluid problem around the recipient babies. Drinking the protein can help get the protein in your blood back to normal. Many women have seen improvements from this. Nutrition is completely overlooked by most doctors. Bedrest is also strongly encouraged along with adding liquid protein. Bedrest is defined as laying horizontally on your left side and getting up to eat, shower, use the bathroom, and go to appointments. Laying on your left side takes pressure off of your cervix and helps increase blood and oxygen to the placenta to help your babies.
  4. Make sure that your cervix is checked weekly. This is also overlooked by many doctors. If your cervix length shortens to 2cm or less, a cerclage or stitching of the cervix can be done up through 25 weeks. This has saved many pregnancies. Laser surgery can still be done after a cerclage only through the 26th week.
  5. If early signs of TTTS appear, or there is a sudden increase in your size, ask for a perinatology appointment immediately. Your feto-maternal medicine specialist will know about the options for treatment. Ask what they think about possible laser treatment and whether this is a possibility for you. Once again, don’t take no for an answer. It is also encouraged by The TTTS Foundation to contact the laser doctors on your own so you get the correct and up-to-date information directly from the doctors who perform the procedure.
  6. Understand a monochorionic placenta and what TTTS is. Understand specifically what is happening to your babies with measurements of their size difference, your fundal height, the biggest pocket of fluid around each baby, where your placenta is located in the uterus, their doppler readings and your cervix. Create a medical plan of action with back-up plans so you can be as prepared as you can for each appointment.

Warning Signs of TTTS

  •  a large-for-dates uterus
  • water in baby(ies) body (heart failure called hydrops)
  • a single placenta
  • same sex babies
  • growth discordance, babies are growing at different rates
  • too much amniotic fluid in one sac and too little in the other
  • being 16-26 weeks pregnant with fundal height of 30 cm or more
  • a doppler reading for the babies which is absent diastolic or reverse flow
  • a cervix which is thinning and shortening to 2cm or less
  • sudden weight gain and/or swelling in the mother’s body

The TTTS Foundation says that without treatment, the death rate for twins who develop TTTS at mid-pregnancy (16 to 26 weeks gestation) may be as high as 80-100, mostly as a result of premature delivery. The later the condition develops in the pregnancy, the better chance the babies have since they could be delivered if signs of distress are present. Your health care professional is the best source of information regarding your personal situation and can discuss fully with you how your situation can be managed. However, remember that the ultimate decisions for your children are yours.

Please also note that TTTS can occur with monozygotic (identical) sets of babies in triplets, quads or quints and not just twins.  If you are pregnant with multiples, you need to know if you are carrying any monozygotic babies and if they have TTTS.

Definitions

Diamniotic twins: twins who have developed in separate amniotic sacs. They may be either dizygotic or monozygotic.
Dichorionic twins: twins who have developed in separate chorionic sacs. They may be either dizygotic or monozygotic.
Dizygotic twins: twins formed from two separate zygotes.
Fraternal twins: see dizygotic twins
Higher order multiples: triplets, quadruplets, quintuplets or more
Hydropic (hydrops): a condition due to the abnormal accumulation of serous fluid in the tissues or in a body cavity
Identical twins: see monozygotic twins
Monoamniotic twins: twins who have developed in a single amniotic sac. These twins are always monozygotic.
Monochorionic twins: twins who have developed in a single chorionic sac. These twins are always monozygotic.
Monozygotic (monozygous) twins: twins formed from a single zygote.
Oligohydramnios: the presence of too little amniotic fluid around a baby.
Polyhydramnios: the presence of too much amniotic fluid around a baby.
Serous fluid: a thin and watery fluid
Zygote: a fertilized ovum.

Twin to twin transfusion syndrome (TTTS): results from abnormalities of the placenta in monozygous twin pregnancies. TTTS results from blood passing disproportionately (transfusing) from one twin baby to the other through connecting blood vessels within the shared (monochorionic) placenta. (TTTS Foundation)

Written by Lynda P. Haddon, Multiple Birth Educator, www.jumelle.ca

Consultation Sources for this article

  • Elizabeth Bryan, M.D., FRCP, FRCPCH, Founder, Multiple Births Foundation, London, England
  • Mariana Herskovitz, M.D., General Practice, Ottawa, Canada
  • Dr. Geoff Machin, Department of Pathology, Kaiser Medical Center, Oakland, California, USA
  • Mary Slaman-Forsythe, BS. MNO, Founder and President, The Twin to Twin Transfusion Syndrome Foundation, Bay Village, Ohio, USA
  • Julia Watson-Blasioli, R.N., B.Sc.N., Ottawa Hospital, General Campus

Sources

  • Multiple Blessings, by Betty Rothbart, 1994
  • Double Duty by Christina Baglivi Tinglof, 1998
  • Twins! Pregnancy, birth and the first year of life, by Connie L. Agnew, Alan H. Kein and Jill Alison Ganon, 1997
  • Twin to Twin Transfusion Syndrome Foundation, literature
  • Dr. Julian E. Delia, Founder and Director of the International Institute for the Treatment of Twin to Twin Transfusion Syndrome, St. Joseph’s Woman’s Hospital, Milwaukee, WI WS: tttsmd.com

Other Resources