Dichorionic twin moms had more depressive symptoms

Women, who had at least one baby born alive following intrauterine intervention during 2011 and 2015, were included in the study. They were compared to women who had uncomplicated monochorionic and dichorionic pregnancies. The researchers found that there were no differences in how the complicated monochorionic pregnancy group perceived their mental health compared to women with uncomplicated monochorionic or dichorionic pregnancies. Women with uncomplicated dichorionic pregnancies actually had more depressive symptoms compared to the women who had an intrauterine intervention.

Postpartum depression with twins is a risk

The twin moms in the study scored significantly lower on quality of life than singleton moms. The study concluded that postpartum depression with twins is a risk factor at least in the first four years after birth. About 11 percent of all the twin moms experienced moderate (6.2%) or moderately severe (4.6%) depression.

• It’s important that you consult your GP, midwife or health visitor if you suspect that you might have a postpartum depression.

• Please e-mail us or leave a reply to this article if you’ve had a postpartum depression with twins and is interested in sharing your journey. 

* Archives of Women’s Mental Health is the official journal of the Marce Society and the North American Society for Psychosocial Obstetrics and Gynecology (NASPOG).

Elevated symptoms regardless of outcome

The women experienced significantly elevated symptoms of depression and anxiety during and after pregnancy, regardless of the outcome of their pregnancy. Some women had double survivors, other single survivors, or double loss. The women reported feeling devastated by their experiences and indicated they would have accepted mental health care had it been offered and had barriers to care been addressed.
The researchers recommend that prospective studies of women with TTTS pregnancies are done. They are needed to learn more about TTTS effects on mental health and to determine how to best address emotional care needs of the mothers.

The surgeons use a fetoscope – a long tube – with a camera at the end of it. They insert the fetoscope and a laser device into the uterus. The surgeons look for the vessels that are providing the blood flow between the two babies and blazer those vessels, so blood flow can no longer happen between them. This should enable the babies to each have their own blood supply.

Look at this video from the Fetal Care Center in the U.S showing how TTTS laser surgery is done. Many doctors believe that this type of TTTS surgery will lead to the best outcome in severe TTTS cases. Research backs this up, showing that TTTS surgery by laser is associated with a 75-80 percent survival rate of at least one twin.

Some babies develop Twin Anemia Polycythemia Sequence (TAPS) after having had laser surgery for TTTS. Studies show that the post-laser form of TAPS might affect up to 16 percent of TTTS cases. Occurrence of TAPS after laser treatment is often due to very small residual anastomoses –  and is often regarded as a treatment failure.

Interview with chief physician Karin Sundberg

Karin Sundberg specializes in Obstetrics and Gynecology. She is employed at Rigshospitalet, Denmark’s largest hospital. It’s the only hospital in Denmark that treats TTTS and she is overall responsible.

How do you detect TTTS?

“The women, who are referred to us, have all been diagnosed with TTTS. Any well trained sonographer can spot TTTS during an ultrasound. Midwives can also help in order to ensure that women pregnant with twins are sent to a specialized doctor in time. If a woman’s uterus grows too fast due to an overload of amniotic fluid in the recipient twin, her stomach will usually hurt or feel very uncomfortable. It’s important not to write that off as common pregnancy discomforts. We often experience that a mother feels instantly physically relieved after we’ve done an amnioreduction,” says Karin Sundberg.

How do you classify at what stage the disease has progressed to?

“To a great extent we use Dr. Ruben Quinteros staging system. The staging system isn’t perfect, but it’s the best we’ve got. We also look at the length of the cervix. If the TTTS is at stage 1 we’re presented with a dilemma. The babies who stay at stage 1 survive, but half of the cases progress to a higher stage, where intervention is crucial. Intervention, however, has it’s own risks. Together with the parents we discuss whether we perform laser surgery or we do amnioreduction instead. Amnioreduction is not a treatment for TTTS, but helps prevent the spontaneous breaking of water and premature labor from the enlarged uterus. The cases we treat at our hospital have typically progressed to TTTS stage 2 and 3,” says Karin Sundberg.

How do you treat stage 2 and 3 TTTS?

“About half of our patients get laser surgery and half choose selective termination of one baby. This is often the case if we can determine that one of the children is brain damaged, has a neural tube defect, other malformations or a large size discrepancy. In Denmark there’s generally a very liberal attitude towards abortion and that also influences the risks a family are willing to take during a pregnancy,” says Karin Sundberg.

Are all TTTS cases eligible for laser surgery?

“No, not all severe TTTS cases can be successfully treated with laser surgery. The outcome is usually better if TTTS is detected early in a pregnancy. After 25-26 weeks we usually don’t perform laser surgery and more often have to rely on amnioreduction or premature delivery. We do experience cases, where laser surgery is a last option and where the outlook even after surgery isn’t great. This is for instance cases involving triplets or if the placenta is filled with liquid. There can also be an accumulation of blood in the uterus. Most often we perform laser surgery, even if the odds aren’t great, because if we don’t, the children die or are born extremely preterm,” says Karin Sundberg.

If you have experience or knowledge about TTTS surgery and would like to share, please feel free to leave a comment below this article or e-mail us at kate@about-twins.com

TTTS treatment

Aggressive monitoring:

If the TTTS is mild, you may require no treatment. It’s possible that the condition will remain stable or improve. You’ll be monitored aggressively and your doctors will intervene if the condition becomes more severe.

Laser surgery:

This type of surgery is the only TTTS treatment that can destroy the connections in the placenta and stop the transfusion of blood from the donor to the recipient twin. The surgeons use a fetoscope – a long tube – with a camera at the end of it. They insert the fetoscope and a laser device into the uterus. The surgeons look for the vessels that are providing the blood flow between the two babies. They blazer those vessels, so blood flow can no longer happen between them. This should enable the babies to each have their own blood supply. Read more about laser surgery for TTTS.

Amnioreduction:

Amnioreduction is not a treatment as such, but a procedure to treat some of the risks associated with TTTS. Amnioreduction helps prevent the spontaneous breaking of water and premature labor from the enlarged uterus. The amniotic fluid from around the recipient twin is drained. It’s done by inserting a needle into the amniotic sac of the recipient twin. It may need to be performed multiple times during your pregnancy. Since the babies remain connected, there is the continuing transfusion process between them.

Delivery by C-section:

If your babies are mature enough to survive outside the womb, doctors might consider immediate delivery. They’ll weigh the risks of your babies being extremely or very premature up against the stage and severity of TTTS.

Selective termination of one twin:

When doctors recommend the selective termination of one twin, it’s because they believe that the twin has a poor outlook and may endanger the life of the second twin, who’s more healthy. It’s also recommended if you’re diagnosed with a parasitic twin. Here one twin is severely malformed. The heart is missing or deformed, as are the upper structures of the body.

Termination of the entire pregnancy:

If TTTS is discovered early in your pregnancy – usually earlier than 20 to 24 weeks – doctors might raise the possibility of terminating your pregnancy. Some will also recommend termination if they assess that there’s a very low chance of your babies surviving or a high risk that they’ll be born severely handicapped.

If you have experience or knowledge about TTTS treatment and would like to share, please feel free to leave a comment below this article or e-mail us at kate@about-twins.com

Follow recomendations

Ditte Toft Heskjær points to the fact that it generally puts great strain on the body to be pregnant, and with a twin pregnancy even more so. When you’re pregnant with twins it’s important to listen to your body. You need to react if you experience signs that worry you. According to her, the best thing you can do to remedy twin pregnancy complications is to follow official recommendations about twin pregnancy and maternity leave. You need to go on maternity leave earlier than you would need to with a singleton. Also, visit your midwife for regular check-ups. She’ll among other things check for signs of early effacement. This shortening of the cervix is important to discover, because it’s a sign of early labour. There are actions the medical staff can take to prevent early labour, if prevented in time. Also get some rest.
“You need to rest during the day, but this doesn’t mean that it’s a good idea to rest on the couch all day. You need to keep your body active, so it can handle carrying the extra pounds.”

Twin pregnancy complications

Premature labour 

You will often experience quite a lot of braxton hicks contractions in a twin pregnancy. This is normal. However, if the contractions become increasingly severe, painful, you’ve got bloody discharge or a heavy sensation in your pelvis area, your need to contact the hospital. If anything deviates from the norm,  call the hospital or your midwife. You need to be sure that you can feel both babies move around. You need to react if one twin has markedly changed his or her pattern. It’s okay that one child is more active than the other, as long as their patterns are consistent. Also, be aware that your babies might move a little less than a singleton baby would. This is because your placenta area is larger. This might happen if your placenta(s) is positioned in front of your uterus.

Twin to Twin Transfusion Syndrome (TTTS)

Twins, who share a placenta, can develop Twin to Twin Transfusion Syndrome. It’s rare and only happens to identical twins. This is because babies need to share a placenta in order to be at risk of TTTS. All fraternal twins have their own placenta. Read about how twins are formed. As a result of sharing a single placenta, the blood supplies can become connected, so that the twins share blood circulation. The blood can be transferred disproportionately from one twin (the donor) to the other (the recipient). The donor, as a result, has decreased blood volume which leads to a slower than normal growth. The donor produces less urine than normal leading to a lower than normal level of amniotic fluid.  In turn, the recipient twin becomes overloaded with blood. This excess blood puts a strain on this twins heart to the point that he or she may develop heart failure. It also makes the recipient twin produce more urine than normal, leading to a higher than normal level of amniotic fluid. This can cause premature labour due to extra pressure on the cervix. The mortality rate for severe TTTS is high if left untreated. Read about TTTS and the possibilities of treatment. Mothers with TTTS may experience rapid growth of the womb, a uterus that measures large for dates, abdominal pain, tightness, contractions, sudden increase in body weight as well as swellings in hands and legs.

Twin Anemia Polycythemia Sequence (TAPS)

TAPS can be viewed as a passive form of Twin to Twin Transfusion Syndrome.  Research indicates that TAPS probably results mainly from slow inter-twin blood transfusion without hormonal imbalance, while TTTS results from imbalanced inter-twin blood transfusion in combination with imbalanced hormonal regulation. In TAPS a few small artery-to-vein connections on the placenta allow a slow transfusion of blood from a donor twin to a recipient twin. This creates an imbalance of red blood cells between the babies, that gradually becomes highly discordant. This makes the donor baby anemic, whereas the recipient baby produces thick blood (polycythemia). There are no amniotic fluid discordances in TAPS.

Intrauterine growth restriction (IUGR)

Intrauterine growth restriction is a condition in which one or both twins don’t grow well. A baby with IUGR is too small compared to other twin babies of the same gestational age.

Selective Intrauterine Growth Restriction (SIUGR)

Selective intrauterine growth restriction (SIUGR) can only happen to monochorionic twins – identical twins who share a placenta. It’s characterized by unequal placental sharing which leads to one twin being growth-restricted.

Monochorionic monoamniotic (mo-mo) twins

The risk of complications is very high if you’re carrying monochorionic monoamniotic (mo-mo) twins. Mo-mo twins are extremely rare. They only account for about one percent of all identical twins and can never be fraternal. Mo-mo twins share a placenta and both the outer and inner membrane. They lie in the same sac and this make them at risk for umbilical cord entanglement and compression during pregnancy and birth. If you’ve been diagnosed with mo-mo twins, you should see a Maternal-Fetal Medicine (MFM) physician regularly as you’ll need aggressive monitoring and expert care.