What Happened? The Medical Version

I need to take some time to write down my thoughts and memories of this last week. I know it will be essential to my healing, but it's going to take some time to go through the many events that have happened recently.

Up first, what happened?

Some of this is speculation pieced together by the neonatologists, my obstetrician, and the placental pathologist. Almost 3 weeks ago I had one of my regular ultrasounds. At that time both of the babies were doing extremely well. There was always some question about whether they shared a placenta or if it was two placentas that had merged to look like one. Since they were growing so well, we didn't worry very much at the answer. They were exactly the same size and they were swimming safely in their own amniotic sacs. At some point shortly after that appointment many things began to systematically go wrong, one right after the other.

Twin to Twin Transfusion Sydrome
My babies developed what is called "Twin to Twin Transfusion Syndrome". This is a condition that can occur with identical twins in utero, where one twin begins to have access to most, if not all, of the nutrients through the shared placenta. (Our twins have been confirmed identical twins with one shared placenta, by the way.) This syndrome is caused by various abnormalities in the placenta that will redirect arteries and veins from where they should be going. Normally this is something that happens very gradually and can be monitored over time to determine severity and possible intervention. In our case, it came on very suddenly and was an extremely acute case that progressed very quickly. There is evidence of a lot of activity that took place in the placenta recently and in the past, many mini-strokes throughout the placenta that disrupted proper function. By the time the twins were born, Dex (the recipient twin in this situation) was quite a bit larger than Crew. TTTS is very dangerous for both twins because one is deprived of nutrients and the other is overloaded with fluids, blood, and other things that are damaging in unbalanced quantities.

Updated: I have since learned that my OB had noticed at the last ultrasound that Dex was starting to become a little larger, but didn't want to alarm us. He was going to evaluate at the next ultrasound and see if it was a trend that needed a perinatal evaluation. Unfortunately, as such a dramatic and acute case of TTTS, it was all over two and a half weeks later. Do I wish he had told us? Absolutely. Would we have had a different outcome? I'm not sure, especially with how unbelievably quickly everything happened. These are some of the "what ifs" that we find to be unhelpful since we can't turn back time.

Membrane Rupture and Tangled Cords
TTTS was only the first of a few problems. While they had previously been swimming safely in their own separate sacs, sometime recently there was enough erosion near the placenta where both of the umbilical cords were located that the umbilical cords were able to start moving back and forth between the sacs. Earlier in the week we believed that the twins had been swimming together for some time, but that no longer looks like the case. It appears now that there was just enough erosion between the sacs to allow access for the umbilical cords to travel back and forth between the sacs, at times tangling on each other, sometimes tangling on themselves. The delivery staff said that they were more tangled than anything they had seen in some time, mostly on each other.

Placental Abruption
Many of you have probably heard of "placental abruption", when the placenta begins to tear away from the uterus. This is believed to be the official cause of all the drama. Incidentally, this also has nothing to do with either of the previously described problems. The placental pathologist found evidence of many "infarctions", which can be compared to "strokes" within the placenta, that caused it to start breaking down and tearing away. Some serious, some mild, some very recent, some within the last few weeks. We'll never know exactly when or why these happened and we try not to speculate very specifically about this question since it drives down the unhelpful "what could we have done" avenue. There is sometimes severe abdominal pain associated with placental abruption, but in my case there was not anything out of the ordinary beyond what has been described in previous posts. It was occuring relatively gradually, not the result of a car accident or other sudden bodily trauma.

Water Breaking
At 2:30 in the morning last Sunday night my water broke, very obviously. At the time, we thought that was the main problem. When we arrived at the hospital, we assumed that the worst of our concerns was a massive rupture in the water sacs. Again, it had nothing to do with any of the previously described events. But had my water not broken, we never would have gone to the hospital and we would have lost Crew within hours. Our greatest nightmare, waking up with my water broken at 28 weeks, turned out to be the best thing that could have happened under the circumstances.

Under Age
Because of the TTTS and other problems, the babies are delayed in our expectation of their development. Based upon the fact that their eyes were still fused shut at the time of their birth and a few other physical indications, they measured closer to 26 weeks, not 28. This is not surprising, considering what they have been through in the womb.

As you can see, there were many factors that led to the drama surrounding the arrival of our sons, and none of them had anything to do with one another. We feel there was nothing that could have made the outcome any better and are grateful that my water broke when it did, to give Crew a fighting chance in this world.