Best Doctors 2011: Dr. Jane Corteville

A case I'll never forget: Monitoring the difficult pregnancy of a mother due with twins

Christine Miller's twins had been diagnosed with twin-to-twin transfusion.

It happens when identical twins share a placenta, and their circulation systems are connected. In Christine's case, the placenta — which is the fetus's lifeline — contained abnormal blood vessels, which connected the umbilical cords and circulations of the twins. One twin, the donor, was pumping the majority of his blood to the other twin, the recipient, through these connecting blood vessels. As a result, the donor twin was becoming weak and anemic from lack of blood while the recipient twin was taking in more blood than his heart could handle.

It was around 24 weeks that we first examined the twins. The donor twin was having a hard time getting blood to flow through the placenta, which supplies oxygen and nutrients to the fetus, from the mother. He was very weak.

At this point, there wasn't a lot we could do except watch very carefully and get the fetuses as far as we could to the point of being able to live outside the mother. Babies have a much better chance of surviving without complications if you deliver after 28 weeks. But we were really walking a tightrope. The donor twin was sick. If he died, the blood pressure on the recipient twin would go to zero, and there was a 50 percent chance he would die too within 24 hours.

It's a scary place to be.

We did Doppler tests two to three times a week to make sure that the donor twin's heart was continuing to pump at least some blood to the placenta and that oxygen was still circulating to his brain. Doppler tests work by sending directed sound waves into the abdomen of an expectant mother, sort of the way one tests the depth of a well by yelling into it.

We kept Christine on bed rest to increase the blood flow to her uterus. All the while, we were monitoring her for signs of preeclampsia, which occurs when the mother starts getting sick because the placenta is not getting the nourishment and oxygen it needs.

A few weeks in, Christine's blood pressure started becoming abnormal, and she did develop preeclampsia. This was three weeks before I wanted to deliver the babies.

We monitored Christine and gave her medication, but at the 30th week, there was a lot of protein in her urine — a sign that blood vessels in the kidney tissue are starting to become leaky. At the same time, the recipient twin was getting sicker as the placenta was failing to deliver healthy blood flow.

It was time to deliver. Christine needed to have a C-section because the donor twin was not going to tolerate labor. The main danger is that with two sick babies, you're never really clear how well they're going to do until right after they're born.

We delivered the recipient twin first, who arrived at 2 pounds and 12 ounces. Then we delivered the donor twin. He weighed 1 pound, 13 ounces.

I was excited to see that both babies were actually doing very well. They were crying and had good tone. It was a good start.

I looked at the placenta afterward. In twin-to-twin transfusion, we know there's an uneven sharing of the placenta, but we never know by how much until the babies are born. In this case, the donor twin had only a 10 percent share of the placenta, the recipient 90 percent.

The two boys, Jeffery and Braydon, are doing excellently. They're eating and growing. Right now, I'm just sighing a big sigh of relief.

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