Looks like I will be seeing the MD more often - My 25 week ultrasound

Today I was scheduled for just an ultrasound. The babies were on their best behavior - moving and kicking up a storm! The tech tried to lay me back, and we quickly learned that I cannot spend much time in that position! The girls are now both head down - I guess for the late night chats they need to be face to face! It was really cute seeing all four feet in one frame! The girls are both 1 pound 10 ounces!!!! They are measuring right on for their due dates. This also means that have be doing a lot of growing in the last 6 weeks - which would explain my ever expanding belly (I will try to post an updated belly pic tonight).
Just as I thought everything was peachy, the tech left to see if one of the doctors would like to take a look. This is code for there is something concerning. The doctor came in and explained that she wanted to look at the amniotic fluid levels. Baby A's fluid is lower than Baby B's. Baby A still has enough fluid, but they are concerned about Twin-Twin Transfusion Syndrome (TTTS). Back in the beginning, it was Baby B who was smaller and had less amniotic fluid... TTTS occurs in identical twins sharing a placenta. They have some abnormal blood vessels that connect the circulation of one Baby to the other. They end up not sharing the placenta evenly, leading to one twin receiving more nutrtion that the other, placing both the baby with lower nutrition as well as the baby with more access to the placenta (due to overload) at risk. I have placed some questions regarding how TTTS is determined, with how our girls measured on the key issues.

What is the largest vertical pocket of amniotic fluid in each baby’s sac?
In normal twins, the deepest pocket of amniotic fluid should be around 3-8cm. When the fluid is greater than 8cm (polyhydramnious) and less then 2cm (oligohydramnios), the babies have Stage I TTTS. The fluid level differences are distressing to see, but are the findings most likely to change with treatments such as horizontal rest and nutritional supplements. You can determine the severity of TTTS to some degree, by watching what these numbers are, and how much they vary from the normal range. This information can help you to know when treatment may be needed and why, and gives you a tool to help make these decisions.

Baby A (Madelynn) was 5 cm and Baby B (Matilda) was 6.5 cm

Can you see the urinary bladder of the donor baby?

The baby’s bladder is visible on ultrasound when it contains urine. Urine is the main source of amniotic fluid. If it cannot be visualized within 30 minutes, or if the donor baby has no or little amniotic fluid, its blood volume may be too low (from transfusion into the recipient) to perfuse the kidneys enough to urinate. Recipients always have larger than normal bladders in TTTS. If the ultrasound finds a visible bladder and a 2cm or more pocket, this much better news for the donor. These findings will help give you some perspective on the donor’s status and the seriousness of TTTS.

Yes! The doctor even noted that the bladders were visible.

What are the weights of the babies in grams? (every 2-3 weeks)

The relative size differences between monochorionic twins with TTTS (or in general) are best calculated with grams (typically 3 digits) rather than ounces (3 digits rounded to 1 or 2). The percent difference is calculated by taking weight difference in grams, and dividing that number by the weight of the larger baby. If the weight discordance is 20% or more, it is considered significant. The most likely cause of the discordance in monochorionic twins is unequal sharing of their single placenta. The smaller a placenta portion, the less nutrients are delivered to that baby. Small placentas are often associated with two vessel or velamentous umbilical cords, and Doppler flow abnormalities. Since the twins’ shares of the placenta are fixed from the beginning of the pregnancy, and cannot be improved upon, nutritional supplementation and horizontal rest may help maximize the supply of nutrients to the smaller twin and help it thrive.

Madelynn: 747 grams; Matilda 724 grams - 3% difference

I am sure everyone is wondering about treatments for TTTS. A lot of information (on the web...) talks about nutrition modification and horizontal rest (bed rest - BLAH!!!) One option is always taking the twins early. The twins are in the viability stage. Other options include fetal laser surgery to cut the blood vessels that connect the two circulations. Another option is amniocentesis to remove the excess fluid for the baby who is gaining more nutrients. All options have risks...

So what is the plan for our girls? Well, I have my monthly MD apt on Jan 12th. They had added an ultrasound to check the fluid levels again. It sounds as if there will be weekly ultrasounds to continue to monitor the girls. Here's praying that everything will look okay at the next ultrasound and I can go back to having an uncomplicated pregnancy!!!!