Reduction of 1 identical twin

[coley144]

Hi

I'm 11 weeks pregnant with triplets and have just got back from a scan. We have 1 baby in its own sac and 1 set of monozygotic diamniotic twins. One of the twins has severe structural issues (lots of excess fluid and big nuchal fold measurement) and the consultant has told us our options are:
1) Wait and see but if that baby dies it might affect the other twin
2) Reduce both twins
3) Reduce 1 twin but this is a specialist procedure with more risk

Has anyone had a selective reduction of 1 diamniotic twin? I understand its very rare (and only done 1 place in England) and done with a lazer but that's all I know for now. I'm due back in 2 weeks but anything I can find out before then would help. Thanks

[momto3angels]

I reduced my identical twins and kept my singleton. My perinatologist told me that reducing only one could affect the surviving twin bcs the medication can cross the placenta and cause severe disabilities, developmental issues, etc and/or death in surviving twin. Of course, if the procedure is done by lazer, that would probably take that risk out, since there woudl be no medication. I'm unfamilar with that technique so don't know anything about it.

I wish you the best of luck with whatever you decide to do.

[lmapreg]

I asked if we could do the same thing. I have one set of identical monochorionic twins and one singleton. I was told we had two options: reduce the singleton and be left with a still high risk pregnancy of mono twins; or reduce the mono twins and be left with the singleton greatly reducing the risks of the entire pregnancy. I was disapointed hearing this as I had it in my head we could just reduce one and have twins - somthing our RE said was possible. However, our peri would not give us that option due to the risks. I am also unfamiliar with laser as I don't think it is offered in the northeast. We have decided to go with a singleton pregnancy for many reasons. Our reduction is Friday. Good luck to you.

[Shoshie]

I was also pregnant with triplets - one single and one set of monochorionic diamniotic twins. I live in Los Angeles and the laser cord coagulation was offered to me, but the doctor who performs it only does it at 18 weeks, at the earliest. It is normally reserved for cases of extreme twin to twin transfusion where one fetus will demise, and the other would die as a result. If the cord of one fetus is coagulated via laser, then the other twin will not suffer the ill effects of the first fetus's demise since their is no longer a linkage via the placenta. Obviously, the cord coagulation will also cause a fetal death of the intended fetus due to it no longer getting any nutrients from the placenta. It is actually only done three places in the US.

Here is an abstract for a study that looked at outcomes using laser cord coagulation in 80 monochorionic multiple pregnancies: Pregnancy and infant outcome of 80 conse... [Am J Obstet Gynecol. 2006] - PubMed - NCBI

In the end, we thought it would be agonizing to wait until 18-20 weeks to do this surgery, and seeing the babies on ultrasound when they are more and more developed. We opted to do a reduction of the monochorionic twins instead.

Good luck with whatever you decide.

[coley144]

Thank you so much for your replies - and Shoshie for the link - I have been trying to find any info on the internet and that really helps. I think the procedure is carried out about 16 weeks here so not quite as late.

I'm nearly 12 weeks now so have time to find out the risks for us. I need to get all info I can before deciding. Thanks SO much to everyone who has responded. How awful though that we are all facing (or have faced) such terrible decisions. x

[coley144]

Just to update this. At the next scan nucal fold was fine and they couldn't find any sign of structural problems. Doc suggested amnio on the twins to see if there was some genetic issue with them both. Intial results are fine so it looks like we will not need reduction. They are keeping an eye on me for Twin to Twin transfusion syndrome (another potential cause of high nucal fold) but otherwise it looks like I'm going to have triplets! I'n nearly 17 weeks now.

[Akst]

I just wanted to give some info on this difficult situation from our own personal experience....We were pregnant with triplets--one fraternal and set of mono/di identicals. Everything looked great with all 3 babies (even had amnios done and all results came back normal). Then, at about 18 weeks, when they were doing the Level II detailed ultrasound, the doctor noticed that one of the identical twins appeared to have some developmental brain issues (brain did not look like it was developing properly). We then had MRI done and confirmed that one of the identicals was suffering major brain developmental issues (possible fetal stroke or hemmorage) that blocked the blood flow to developing brain. Needless to say, we were devestated by the shocking news. After seeing numerous specialists, they all confirmed that one of the identicals either 1) would not make it for duration of pregnancy & could jeopardize the life of other identical or 2) probably would not make it outside of the womb without major medical intervention, etc....and would be severly impared.
We were left with the options of 1) reducing the both identical twins & leave the one fraternal or 2) going forward with a higher risk procedure to reduce the severly sick and brain damaged identical by "cord occlusion" - similar to laser coagulation. In this procedure they "tie off" the umbillical cord of the twin and the other healthy identical can continue on.
In the end, we went with the higher risk procedure to try to save the fraternal & one identical. Luckily, all looks good with the 2 surviving babies and we are at 28 weeks now.
There is not alot of information about this type of procedure, we were only made aware after being in such a dire situation. I think these types of procedures are really set aside for real medical need for intervention and not just to "reduce one identical". Not that I am implying that anyone here is interested in that.....it was just one of our first questions when we learned of having triplets....and we were told "No, you cannot reduce one identical twin." But, in the end, we learned the hard way and with many tears and sleepless nights that it is possible to reduce one identical twin (but not without risk and dire necessity). We live in Los Angeles, but had to go to Miami to have the procedure perfomed. Good luck to you all with whatever decision you make and hopefully you will have a successful pregnancy.

[lianyla]

Just remember, a LOT of tests done on singletons cannot have proper results when there are multiple fetuses present. You can get FALSE results! I have read a TON on the subject and the risks of reducing ONE identical and not both is very highly linked to both eventually passing on. They share such a strong blood supply that it often ends badly for both. It's terrible that you have to make this decision. Good luck!!

[Grace919]

Hi. I am new to posting here, but I was using this site by reading blogs for info when I was trying to make the heart-wrenching decision to reduce or not. I came back to update some info for people like me trying to figure out what is the right decision for their pregnancy.
After transferring 2 embryos with fresh IVF cycle, I became pregnant with triplets, one fraternal & one set of identical monochorionic, diamniotic twins. I was sent to a high risk OB by my RE at 10 weeks. This doctor,Dr. Chavez, is one of the only doctors on Long Island, NY who does laser fetoscopic surgery (at Winthrop University Hospital in Mineola, NY). Initially there were no problems, but the doctors let us know that the pregnancy was very high risk & that we had the option of reduction of one or both twins. We felt like the right choice for us was to get a CVS on both placentas & wait to see if there were any abnormalities, I didn't want to reduce unless there was something seriously wrong with the babies. I had them do the Chromosomal microarray with the trisomy testing with CVS ( it tests for almost everything). Came back negative for all babies. As time passed the doctors kept letting us know that the babies were not yet in any Stage for TTTS but there was some discordance in the size & fluid of Babies B&C. Our anatomy scans & fetal echos were normal but on the day of the fetal echo we were informed that baby C was stage 1 for TTTS (polyhydramnios-too much amniotic fluid) & baby B was in stage 3 (oligohydramnios- too little fluid, no visible bladder- dehydration/renal failure, and absent Doppler signal in the umbilical cord). Keep in mind I had been going once a week to keep an eye on this but once it started it progressed very quickly. Also Baby B was now MUCH smaller than A & C, where before he was only about an ounce to 2 ounces less. We were told that if Baby B survived (big IF) he would probably have severe problems, but more likely without intervention, it would continue to get worse and he would probably die. If it got worse, it would also probably result in the loss of Baby C as well from cardiac failure because his heart would not be able to continue to pump all of the extra blood he was receiving. They said we needed to think about our options because we were at the end of 22 weeks at this point. In NY state, Selective Reduction cannot be done after 24 wks. I wanted to give Baby B a little more time, but it wasn't realistic. If I did I would be risking both the lives of B & C. The next day I went to the hospital because my tummy was very tight & I was afraid it was getting worse. Baby B was about the same, but Baby C had about 5 cm more fluid than the day before. I was admitted. We decided on selective reduction of only baby B but if needed also baby C. The doctor said it was possible he wouldnt be able to get to B's cord to do the fetoscopic laser coagulation without harming C, but he wouldn't know until he was in my uterus. The other option was to try the fetoscopic laser coagulation of the abnormal blood vessels on the placenta to fix the problem of TTTS, but baby B already suffered the damages and we felt the selective reduction was the right choice. The hardest one I've ever had to make but, I know we needed to do it. Another factor in this decision was that baby A in his own little world was just fine & all of this was risking his life too.
I had the surgery, I was awake (spinal anesthesia) and could hear the little one's heart Doppler, slow down and become irregular. That was the hardest part. (I highly recommend bringing an iPod! I had mine but on low so I could phase out the noise if needed but at times I wanted to hear.) I think hearing that and a few days later seeing the baby on sono, as hard as it was, helped me with closure. It's different I think when you have a loss of pregnancy but there are no survivors, it's completely devastating, I would imagine. But I was lucky, my doctor is a rock star & saved the other twin. So I am pregnant with twins now. They are healthy so far and the loss is sad & my baby will never be forgotten, but I have to be happy about what I still have.
I hope this helps the next person trying to make this impossible decision & know that it can be done now in the Northeast ( at least in NY- Long Island & Manhattan) and also you can reduce just one of the identicals, just depends on the situation, in my case severe TTTS. But my doctors offered it even before they were sick. I think (don't quote me!) early in pregnancy they can reduce with potassium chloride injection into the heart, but in identicals who share a blood supply you can't do this without harming both. So the laser surgery is reserved for later in pregnancy when the vascular supply is established, and at that time one identical can be reduced. You may want to research that if you are in the early stages and want to reduce.
To all those who have posted in the past on the topic of selective reduction, thank you from the bottom of my heart. The wisdom, experiences & knowledge you posted helped through the hardest thing I have ever had to deal with.