Very sad update on the twins

[RaeT,RN]

She went for her ultrasound today with the perinatologist. Baby A, a girl, is perfectly normal. She was a previa 4 weeks ago, but the placenta seems to have moved. Baby B also had perfect anatomy and placenta; if you remember, B was the one with oligo. Well, he decided that Baby B is ruptured. At 15 weeks. Here are her options:

1) Selective reduction of Baby B, even though there is nothing grossly wrong, s/he is just ruptured, in the interest of preventing infection and giving A a better chance of going term.

2) Sit and wait and hope Baby B does not get an infection before they can get her far enough to get Betamethasone. She will be on Amoxicillin and Zithromax PO and on bedrest until Mon when she sees her OB again (though he said most likely after that she would be as well). I guess they are wondering if maybe it will re-seal? She is to see him weekly from now on.

She said she got the feeling that the perinatologist felt that reduction was the best bet, though he did not come out and say that. He said that the only time he had ever seen Baby B rupture in the 2nd trimester (the one furthest away from the cervix, you probably know) the couple opted for the reduction and had a very good outcome for Baby A. She later spoke with her OB and did not feel that he agreed with the perinatologist about the reduction being the way to go. Of course, she may just have been hearing what she wanted to hear.

This is definately one of those decisions that no one wants to make. She said it is not so much the idea of the reduction that bothers her, but just that:

A) there is no guarantee that B will completely dissolve and get reabsorbed if reduced. If there is still tissue from Baby B in the uterus, does that not carry the same risk of infection and other problems as having the living ruptured fetus?

B) what is the guarantee that A will be completely healthy if B is reduced?

How long could she typically remain ruptured before she developed chorio? And does Baby A being on the bottom kind of create a pseudo barrier for Baby B?

Any insight at all ?????????

[fergus51]

Unfortunately even if she continues the pregnancy and is able to carry babyB to term, there is still the problem of oligohydramnios. Severe oligo at an early gestation usually results in very poor lung development. She would have to last at least 9 weeks without an infection to deliver babyB and even then, delivering at 24 weeks should be avoided at all costs and would risk both babies lives. It's possible it will reseal, but most people wouldn't bank on it.

I don't know a perinatologist who wouldn't recommend selective reduction in this case. Sure, even doing the reduction it's possible she could still get an infection and it's possible that baby A will still have problems, but it's less likely. Unfortunately no one can give her a firm prediction. If she feels the OB and the perinatologist are in disagreement, it's best she talks to both of them and asks them straight out what they recommend and why.

[sirI, MSN, APRN, NP]

This mom and her unborn twins are in my thoughts and prayers, RaeT,RN:icon_hug:

[Jolie, BSN]

I will keep your friend and her family in my prayers.

One thing bothers me. Other than the oligohydramnios, has there been any evidence of ruptured membranes? Did your friend ever experience a gush or trickle of fluid? Has a speculum exam revealed ferning? Has she experienced any s/s of PTL or cervical changes?

I can't imagine the heartbreak of having to make such as decision, and would not feel comfortable making it myself without indisputable evidence that the baby's membranes are actually ruptured. Would they consider serial U/S to monitor fluid levels over a week or two? Is there a possibility of obtaining another perinatologist's opinion?

Thank you for supporting her in such a terrible time.

[RosesrReder, BSN, MSN, RN]

I pray for the mom and the babies.

[BabyRN2Be]

Just wanted to let you know that I'm also praying for this mom and her unborn babies.

I know that this is a hard decision to make. Please keep us posted on her progress.

Kat

[SmilingBluEyes]

I am sorry to read this update. My thoughts are with that family.

[babyktchr, BSN, RN]

Oddly enough, I had a patient with the same scenario at the beginning of the month. She had twin gestation with rupture of twin A at 13-14 weeks. The only thing she felt was trickling for a while and it would stop and then start again. Serial US revealed severe oligo with that twin, but twin B was fine. She did fern positive (I made the midwife do one, cause I just didn't believe the whole scenario) and it was positive. She remained pregnant until 24+weeks. The affected twin had shrouding membranes (seen on US). This mom was subsequently transferred to tertiary center and did deliver, unfortunately with a bad outcome for both babies.

I can't imagine the anguish in making a decision like this. There are no guarantees in any situation. I too join the others with prayers of hope and of guidance in this. And a huge hug to you for all of your support to your dear friend.

[RaeT,RN]

Thank you all so much for your responses. Here's what's happening:

She said she has had increased discharge, but just thought it was because she had twins. Never really noticed a gush or trickle.

She is to see both the perinatologist and her OB on Mon for ultrasound. They will check the fluid again and determine if it was a gross rupture. The feeling is that it most likely will not reseal, but they will check and make sure.

I spoke with our Clinical Nurse Specialist yesterday to get her thoughts. She said that it is dicey either way (no kidding.) She also gave me some info that I was not aware of: the literature has shown that often in early ruptures like this, there is usually some kind of infection already present. Also worth noting is that this mom has TMJ and had to have a cracked wisdom tooth cut out two or three weeks ago. If I am not mistaken, there has been a link found between dental work/problems and PTL (not sure about PROM, though.) She also developed a temp last week and had what she thought was the same stomach bug her two year old had. Another thing our CNS said was that babies that suffer from infections in utero have shown an increased incidence of CP.

I spent a couple hours with the mom last night. She said that she has good and bad moments, and has been looking online for case studies and any kind of info she can find. She said that she and her husband had basically made the decision before they left the perinatologist's office. She said that she could not handle losing both, and did not want her body to take over via mother nature and lose the whole pregnancy. Although there is no guarantee for A, she said she was not willing to lose both because they chose to gamble.

My heart just hurts for her:bluecry1: . She found support groups in her research online yesterday. She found a couple instances where there was a loss in the second trimester, and apparently at that stage, the fetus will "fossilize" or "mummify." She is pretty freaked out over carrying and delivering B in this form whenever A delivers. I am afraid too, because I promised her I would be her nurse ten weeks ago when she found out she was pregnant, and I am just worried that I won't be able to handle it. I would not dream of backing out on her - I think that is when she will need me the most.

I thank you all again for your thoughts and prayers. I'll keep you updated.

[madwife2002, BSN, RN]

That is such a sad situation for the poor parents, my thoughts are with them.

[CrunchRN, ADN, RN]

I have said a prayer to give these parents and you strength to deal with this situation and whatever may come. Very sad, but hopefully a happy outcome may be achieved in some manner. The mother sounds like a strong woman and with your support she can get through it.