7 Common Complications of a Multiple Pregnancy

 

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On Episode Five, we discuss the seven most common complications that can arise in a multiple pregnancy.

Maternal-Fetal Medicine Specialist Professor Craig Pennell explains certain conditions to be aware of, what to look out for, and what do when you receive a diagnosis you’re not expecting.

Author Alexa Bigwarfe talks about twin-to-twin transfusion syndrome, and I share my story of intrauterine growth restriction.

By the end of this episode, you’ll have an in-depth understanding of the many possibilities that could affect your pregnancy, but hopefully, you’ll be reassured that if you’re in the right hands those obstacles can be surmounted and you’ll be able to enjoy your pregnancy.

The risks of having a multiple pregnancy

Once you’ve been diagnosed with a multiple pregnancy, there is so much to learn that falls outside what you might already know about pregnancy. When you’re carrying twins, triplets, or quadruplet babies the risk for complications rises and depending on what type of multiples you have on board will determine the level of that risk, and what treatment options are available to you.

Maternal-Fetal Medicine Specialist Professor Craig Pennell says even though there are increased risks involved with multiple pregnancies that doesn’t mean you can’t enjoy your pregnancy.

“The things that can go wrong in multiple pregnancies are divided into those that can happen to all multiples and those that are specific to particular multiples,”

“For example, Monochorionic Monoamniotic twins, also known as MoMos, account for just one-percent of identical twins and they’re the type of twins where cord entanglement can cause problems, which is associated with a loss rate in the pregnancy of up to 50 percent,”

“In all the other types of twins where there is a membrane between them so those conditions can’t occur,” explains Professor Pennell.

If we look at twins, in general, some of the things that can occur are:

Hyperemesis

Severe nausea and vomiting are very common in a multiple pregnancy, according to Professor Pennell.

Professor Pennell reassures us that the condition usually goes away at the end of the first trimester, so around 13-or-14 weeks, however, in about 10 percent of women it continues throughout the pregnancy.

Miscarriage

According to Professor Pennell, the other thing that is more common in the first trimester of a multiple pregnancy is a miscarriage. He says the rate of miscarriage in twins is at least double, if not higher, than the rate in singletons. And, it’s often not noticed or simply missed depending on when you have your first ultrasound.

“If you’re having scans from five-weeks, you may see what starts as a twin pregnancy that then ends as a singleton somewhere between six-and-12 weeks, whereas if your first scan is at nine-weeks, you may not realise that it started as a twin,”

Not surprisingly, the rate of miscarriage in Higher Order Multiples is again higher. This is somewhere in the order of 30-50 percent where you would lose at least one of the embryos in the first trimester, according to Professor Pennell.

Structural Anomalies

All babies have the chance of having a structural problem (about five-percent), which includes such things as a clubbed foot, an extra finger, cleft-lip-and-palette, a hole in the heart, or an issue with the kidneys.

“With Dichorionic twins, the rate is double that of a singleton,”

“With Monochorionic twins, the rate is even higher than that because Monochorionic twins in itself is an anomaly,” says Professor Pennell.

He goes on to explain that if you have an early blastocyst splitting into two embryos there’s an increased risk of issues in structural development.  The more severe anomalies can be picked up at the 11-13-week scan, however, most of them are detected during the 18-20-week anatomy scan.

“When you have a multiple pregnancy, you want to go to a specialist centre who at a minimum specialises in pregnancy ultrasound, and preferably someone who specialises in ultrasound in high-risk pregnancies, because you need to have a lot of experience to do these types of scans well,” says Professor Pennell.

Alexa’s story

Alexa Bigwarfe agrees with Professor Pennell and admits that if she had been with a team that specialises in multiple pregnancies when she was diagnosed with an identical twin pregnancy, her life would be vastly different to what it is today. You see, Alexa has Systemic Lupus and Hashimoto's Disease, so when she discovered she was pregnant with her third baby, her doctor called her in straight away, despite being just 6-weeks’ pregnant, due to her classification of being High-Risk.

“The doctor came in and confirmed, she said yep it’s definitely two,”

“She said to come back in two weeks and we’ll just check and make sure there’s still two,” says Alexa.

When they went back for the next ultrasound the doctor told them that the babies were identical and sharing a placenta.

“I’ll never forget that day, it’s like burned into my mind because I remember the doctor very nonchalantly, very nonchalantly saying to me ‘sometimes with twins sharing a placenta like this, one of them will get too much of the placenta and one of them won’t get enough, and they’re not sharing the fluids and everything equally,”

“And, then she was like but if that happens there’s stuff we can do and she said it like it’s no big deal,”

“I constantly wonder how different my life would be today if she had said the words twin-to-twin transfusion syndrome if she had said anything to indicate that it would be something that we should follow closely.” Alexa Bigwarfe.

Alexa says that over the next ten-weeks many mistakes were made, including not being scheduled for a 16-week ultrasound, and that was simply because she was with an obstetrician service where patients were rotated through doctors in the event that if you went into labour you’d be tended to by someone you knew.

“I never had twins before, I wasn’t looking up twin-to-twin transfusion syndrome because she didn’t say anything about it,”

“When we went in for the 20-week ultrasound they diagnosed us officially with twin-to-twin transfusion syndrome and we were already stage-3,”

“This meant we were well on our way to one baby dying, if not both babies dying,” says Alexa.

Alexa was then transferred to a Maternal Fetal Manager, which she says should have happened much earlier in her pregnancy. She had an amnioreduction, where the fluid is drained from the recipient baby’s amniotic sac. However, according to Alexa, her MFM wasn’t as up to speed on TTTS as he should have been.

“There were some missteps taken along the way, some bad information, some procedures that probably could have happened that didn’t happen because of his lack of awareness and knowledge on the subject,” says Alexa.

Several more amnioreduction procedures were carried out over the following weeks, and as a result, Alexa went into labour at 30-weeks-and-five-days gestation. She explains that Kathryn wouldn’t have survived a vaginal delivery so she underwent an emergency caesarean section.

“Kathryn had to be resuscitated, she was the larger baby with hydrops, and when she was born she had so much fluid in her abdomen that it was swollen to the maximum extent,”

“The little one we had just cleared viability with her, even though they were 30-weeks, she was about the size of a 24-25 weeker, one-pound-10-ounces,”

“But she squeaked when she was born, it sounded like a little bird, and that was the most exciting sound,” says Alexa.

Kathryn survived for two-days.

Charis spent 84-days in NICU.

What is TTTS?

Twin-to-twin transfusion syndrome (TTTS) is a prenatal condition in which Monochorionic twins (identical) share an unequal amount of the placenta’s blood supply. This results in the fetuses growing at different rates. Around 70 percent of identical twins share a placenta and 20 percent of these pregnancies will be impacted by TTTS.

“This condition typically occurs between 16-26 weeks and is due to an imbalance in the blood vessels that connect the twins across the surface of the placenta,”

“This is usually a rapidly progressive condition and untreated can be associated with a loss rate of up to ninety percent. If it’s picked up and diagnosed, there are good treatments available now that give good outcomes in 80 percent of women,” says Professor Pennell.

“If you are being managed by an experienced team and modern treatment, you can expect better outcomes now than were possible ten or twenty years ago.” Professor Craig Pennell.

As Professor Pennell explains the baby with more of the blood supply is called the recipient and the one with less is called the donor. Because the donor has less blood flow, it will grow much slower and will be significantly smaller than the other twin. In contrast, the recipient twin has too much blood flow and grows fast and is much bigger.

Stages of TTTS Stage 1: There is an imbalance of amniotic fluid, with a small amount (<2cm) around the donor twin and a large amount around the recipient twin (>8cm). The twins often have a 20% size discordance. Stage 2: The bladder of the donor twin is not visible, or it does not fill with urine, during an ultrasound exam. Stage 3: The imbalance of blood flow starts to affect the heart function in one or both babies. This is observed as abnormal blood flow in the umbilical cords or hearts of the twins. Stage 4: The imbalance of blood flow causes signs of heart failure in one of the twins. Stage 5: One or both of the twins has passed away from severe TTTS.

For Stage 1 cases, observation may be all that is necessary, but for Stage 2 or higher cases, fetal surgery may be the best option.

Symptoms of TTTS in the mother

• Sudden weight gain.
• Fundus appears large for dates (often will appear like a term pregnancy).
• Abdominal pain and tightness.
• Premature onset of contractions.

Treatment options

• Observation – weekly ultrasound assessment
• Fetopic Laser Photocoagulation – in cases of stage 2 or higher, between 16-and-26 weeks surgeons insert a small laser fibre into the mothers’ uterus and laser energy is used to stop the blood flow between the twins. As a result, the placentas are separated, allowing each twin to develop independently.
• Amnioreduction - this procedure removes the excess fluid from around the larger twin, reducing amniotic pressure and reducing the risk of preterm labour. This is usually performed with fetoscopic laser photocoagulation.

“TTTS is a moving feast and it needs to be reviewed regularly as our ability to prognosticate beyond a week or so is very limited.” Professor Craig Pennell.

Professor Pennell explains that twins with untreated advanced stages of TTTS during pregnancy usually don’t do well after delivery with a 90 percent fatality risk, and for those who do survive there’s a 15-50 percent risk of neurologic handicap.

The good news is, according to Professor Pennell is that if TTTS has been successfully managed by an experienced team and treated during pregnancy, there is a much better chance that the babies will be healthy.

Sally’s story

There’s a common theme when I talk with people who have experienced a multiple pregnancy. There’s the initial shock when hearing the diagnosis and then there’s the steep learning curve while attempting to understand the type of multiple they’re carrying. And, then there are the complications.

Looking back, I think I was in a state of shock for months because it seemed as though there were only a handful of weeks where I wasn’t faced with the prospect of losing one or both of my babies.

Most people would shrug off my concerns about the discordance in size of the girls with comments like – ‘one twin is always bigger than the other’, even my private obstetrician dismissed my concerns before I decided he wasn’t the right person to guide me through my pregnancy.

What these people didn’t realise was with my diagnosis of Intrauterine Growth Restriction or IUGR I was carrying a ticking time bomb. You see, IUGR in a twin pregnancy is a condition where one or both babies don’t grow in the manner that’s expected, due to an uneven share of the placenta, what that means is that these babies are much smaller than other babies of the same gestational age.

“What these people didn’t realise was with my diagnosis of Intrauterine Growth Restriction, I was carrying a ticking time bomb.” Sally Barker.

Fortunately, following the recommendation of the Sonographer at the specialised imaging centre I went to for my 12-week scan, I went to the local tertiary hospital in Perth Western Australia two-weeks later to have a follow-up assessment. It was then that I was placed in the care of the GOLD team, which is a group of highly skilled specialists who have extensive experience with multiple births.

The management of my pregnancy was such that I was seen twice a week, and sometimes three times. I knew that the girls would be pre-term, there was no doubt about that. But just how early was a waiting game. During the scans, close attention was placed on the blood flow to my smaller baby, Aasha, who it turned out had a cord insertion at the lower edge of the placenta, which meant she was only getting about 25 percent of the nutrients she needed.

At 24-weeks the blood flow to Aasha had slowed and showed signs of reversing. It was explained that the girls would need to be delivered and their chance of survival was slim, however, there had been cases where following a corticosteroid injection the condition could stabilise.  Thankfully, for us, that’s exactly what happened.

We were hoping to get to at least 30-weeks’ gestation, and I was so certain we would get there, but when that blood flow stopped again at just 28 weeks’ gestation, this time there would be no intervention.

The girls were so tiny, just 825 grams or 1.8 pounds and 1075 grams or 2.3 pounds. They came home together 64 days after they were born.

Intrauterine Growth Restriction (IUGR)

Professor Craig Pennell explains that IUGR can occur in both Dichorionic and Monochorionic twins, but it’s more common in Monochorionic twins, with an 80 percent chance the twins will share a placenta.