“It's not easy to find out that you can lose both children at once.” The lesson of a mother of twins: how much the specialist who monitors the pregnancy matters

Marinela Tudor was pregnant with identical twins and hoped, like any mother, that the possible complications she had heard about would remain just a list of risks on paper. She was reassured because she was monitoring her pregnancy every two weeks at a doctor in her town and everything seemed to be going normally. Maybe that's why, the dangers he pointed out Dr. Răzvan Rădulescu-Botica since the first fetal morphology they did not alarm her. When the risks became apparent and she learned there was only a 50-50 chance that both girls would survive, “the whole sky fell in,” she says. The story has a happy ending: the mother was able to take them both home, and now Marinela Tudor insists on how important it is that high-risk pregnancies are monitored correctly, on time and by the right specialists.

“I was hoping it wouldn't happen to me”

For Marinela Tudor, the news that she will have twins came with joy, but also with an anxiety that, at first, she managed to keep at bay. The pregnancy was with identical twins, and the girls shared the same placenta. In medical terms, such a pregnancy is called monochorionic and should follow a different follow-up protocol than a regular pregnancy.

Dr. Răzvan Rădulescu-Botică, obstetrician-gynecology primary physician at the MedLife Medical Park Hyperclinic, explained to her since the morphology of the first trimester (12-14 weeks) that it is a high-risk pregnancy and that it must be monitored carefully, every two weeks. Not because every twin pregnancy leads to severe complications, but because when they do occur, they can progress quickly.

“Mr. Dr. Botică, whom I came to through a recommendation for morphologists, even warned me from the first meeting that it is a pregnancy that can have complications. I had also read something, but I think that, deep in my soul, I hoped that all those complications would not happen to me,” says Marinela.

Meanwhile, the pregnancy was monitored by another doctor, from her locality – Târgoviște, and the atmosphere was more relaxed there. When she relayed the concerns raised by Dr. Botica, she received a reassuring message: to stay calm, because it is unlikely that she will develop transfusion-transfused syndrome – one of the most feared complications of monochorionic twin pregnancies. This type of response is easy to understand for a pregnant woman who needs reassurance. But in the case of a high-risk pregnancy, silence should not replace monitoring, the mother of twins now believes.

Why do monochorionic twin pregnancies track differently

In a typical pregnancy, important ultrasounds are scheduled at certain intervals, depending on the trimester and the objectives of each evaluation: risk calculation, fetal morphology, growth. In monochorionic twin pregnancies, however, the rhythm must be different.

“In the first trimester, when we see that it is a twin pregnancy that shares the same placenta, the follow-up of the pregnancy changes and becomes more frequent. The protocols require evaluations once every two weeks, precisely to catch severe complications”, explains Dr. Răzvan-Florin Rădulescu-Botica.

The reason is that the two boys share the same placenta, and the blood vessels can communicate with each other. In certain situations, the blood gets unbalanced from one fetus to another. This is how transfusion-transfused syndrome occurs: one of the children receives too much blood, the other too little. The former may develop excess amniotic fluid, cardiac overload, and fluid accumulation in the body, while the latter may be left with too little fluid and insufficient resources.

The problem itself cannot be prevented. But it can be detected at earlier stages if the pregnancy is followed according to protocol and if the ultrasound is done by a doctor who knows what signs to look for. “We cannot prevent the complication, but we can find the optimal moment for an intervention that can be life-saving,” says the doctor.

The signs my mother felt but didn't immediately understand

Marinela continued to go to the doctor every two weeks, but to the local doctor, who continued to reassure her by telling her that the little girls were developing normally, according to the charts.

“When she came to me the second time, at the morphology of the second trimester, at 22 weeks of pregnancy, the signs that make up this diagnosis of transfusion-transfused syndrome began to be seen. I told the mother to return for a new monitoring in 3-4 days, to see if all the criteria for this diagnosis are met and to determine the next steps”, recalls Dr. Rădulescu-Botica.

Through a series of circumstances, Marinela arrived at Dr. Botica after 3 weeks, when already “those criteria were not only met, but the situation was so severe that we were on the verge of losing both children. For this transfusion-transfused complication there is a 5-step staging and, in this case, we were already at stage 4,” says the doctor.

One of the girls had very little amniotic fluid and was much smaller, the other had a lot. The one receiving too much blood had developed heart failure.

“My biggest regret is that I felt that something was wrong – my belly had grown suddenly, my abdomen was very tense, the skin was “shining”, I had pain and burning under my ribs – and I didn't call Dr. Botica to go straight to him. I went to my local doctor again, who noticed that I had accumulated a bit of fluid, but he told me, again, that the symptoms were normal for a twin pregnancy. So I waited the appointment and I reached a very advanced stage of the complication – I could lose one or both of the girls. The whole sky fell then”, says Marinela Tudor.

“I did the next steps mechanically”

From that moment on, things unfolded very quickly. In order to try to save the girls, Dr. Botica explained to the mother that there was a possibility, in another clinic, to carry out a laser coagulation intervention of the placental vessels that produced the imbalance between the two children. “In such situations, the priority is only one: the children must be saved, and the chances were 50-50”, the doctor emphasizes.

For Marinela, the night before the intervention was a shock. “I did everything mechanically. I didn't sleep all night. When I realized how serious the situation was, I was overwhelmed by everything that was happening. Without intervention, the risk was the loss of both girls. Another option was to try to save just one of the children. The third was to try to save both, with the risks of an intrauterine intervention at such an advanced stage. Even if there was a small chance, I wanted to try the option that could save them both”, she says.

After the intervention, monitoring became even more important

The intervention was successful. Within about a week, the signs of distress began to subside. After two weeks, the fluid build-up in one of the girls had receded and the flows had improved. But that didn't mean the danger was over. After such a procedure, the pregnancy remains fragile. Rupture of membranes, premature birth, facial imbalances or other complications may occur. Marinela started going for check-ups very often, even twice a week.

Ultrasounds took a long time. Sometimes two hours or even two and a half hours. For the patient, this monitoring has become a form of safety. She felt that the doctor was looking at every detail, that he was not treating the pregnancy as routine. The goal was to manage to delay the birth as much as possible.

At almost 31 weeks, the girls were born prematurely. One weighed about 1,100 grams, the other 1,400 grams. Six weeks of hospitalization, close neonatal monitoring, investigations, treatments and emotions followed. The evolution was even better than the doctors expected, but the difficult road did not end with the discharge, because some sequelae of the complication during pregnancy need time and patience to recover.

The lesson of a mother of twins: “When you feel something is wrong, insist”

Marinela took her little girls home with great joy, but remains rational: prematurity still means check-ups, physical therapy, ophthalmological, cardiological and neurological evaluations. One of the girls has changes that need to be followed over time. But they're both alive and that's the most important thing.

When asked what she would tell other women pregnant with twins, her message is straightforward: seek out doctors experienced in such pregnancies, don't settle for general reassurances, and trust your own body. “When they feel that something is wrong, don't wait, call, insist, go to the doctor”, says Marinela.

For Dr. Botica, the case shows once again how important it is that twin pregnancies are followed according to protocol and, when complications arise, the patient is quickly sent to where there is a solution. “Twin pregnancies can be followed anywhere, if they are followed correctly. Complications are visible to an experienced eye, that is why it is necessary for pregnant women to go for monitoring to doctors who also have a competence in maternal-fetal medicine. A protocol must be followed, and when a complication occurs, the patient must be sent further, to the doctors and centers that can intervene”, says the doctor.

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