The Things No One Tells You

People are somewhat entranced with a twin pregnancy.  The thought that someone is carrying TWO babies in their belly is understandably fascinating to folks (and I’m told by twin moms the fascination does not end with pregnancy – but continues on for quite some time after they’re born.)   For the most part – people are excited (of course there are some folks – parade rainers – who have nothing nice to say but they likely have nothing nice to say in general so you have to discount them for the most part.)

But there are some things .. that no one tells you.  Until, well, it’s too late.  For example, “oh – after 25 weeks it gets really hard to breathe.”  Wait, what?  Hard to BREATHE?  But I need to breathe! I like to breathe.  It relaxes me – and also keeps me, well, alive.  And, “oh – the acid reflux?  It’s unbearable.”  And even. “you’ll probably need to get Poise pads at some point.”  Poise pads?  The ones you pee on?  Oh my.

Thing is - a twin pregnancy is tricky.  The human body is really only designed to carry one baby.  Throw an extra one (or more!) in there – and things get complicated.  Not impossible … as evidenced by the recent quintuplet birth at a Pittsburgh hospital … just, more complicated.  There is more pain, there is more pressure, there is more weight gain, and there are more tears.

As I continue gestating my little boy and my little girl — at a weight I’ve never even come close to in my previous life, with protesting knee joints, aching hips (especially overnight), pelvic bones that zig when they’re supposed to zag, and sciatica to spare … there are times when I think “I can’t do it anymore.  I just can’t do it.”  Then I realize I have no choice – grit my teeth – and put one foot in front of the other.  But boy do I have a new found respect for the multiple moms who have walked this path before me.  Especially the TINY ones … oh my word.  I’m TALL – nearly 5 feet 8 inches – I have some extra room in which to stash these two babies.  Those moms who are shorter than me – HOW did they do it?  Yet somehow, they did.  And I am doing it too.  And — I haven’t purchased Poise pads.  Yet.

A Personal Decision

When you’re 41 and pregnant – you face some important questions during your first trimester.  Actually – they’re the same questions you face if you’re 35 and pregnant.  At 35 – you officially enter the ranks of “AMA” – Advanced Maternal Age.  By 41 – you unofficially become “an old pregnant lady.”  Or at least that’s how I characterize it.

The questions you face revolve around first trimester screenings, and genetic testing.  You don’t HAVE to do either.  No one will make you.  But many moms want to do at least some type of screening to try and get a picture of their baby’s (or in my case, babies’) health.  You can opt to do only do screening – and find out what your risk factor for having a baby with Down’s Syndrome and other trisomies is – or you can opt to go further and undergo diagnostic testing – after which you’ll get clear cut answers about whether or not your baby has a genetic or chromosomal defect.

Initially – my husband and I decided we would go forward with diagnostic testing.  During the first trimester – the test that is available is called a CVS test – CVS stands for chorionic villus sampling – and you can find out more about the test here:

http://www.babycenter.com/0_chorionic-villus-sampling-cvs_328.bc

At the time I scheduled the test – I felt strongly that I wanted to KNOW if anything was wrong.  I wanted to know if one or both of the babies had a chromosomal issue.  I wanted to know if they were healthy and I could breathe a sigh of relief.  I wanted to know their genders!  And so, I scheduled the test .. and tried to ignore the little sliver of fear I had that something would go wrong.  Because unfortunately – the test does carry with it a slight risk of miscarriage.  That risk is made even more slight by seeking out a very experienced practitioner, and I did, but still. The risk was there.  According to some the risk is 1 in 500 – others say it’s as small as 1 in 1000.  But couldn’t help but wonder … what if I was “number 1000?”  (Hypothetically speaking, of course!)

Still, I kept the appointment.  Up until the day before the test when I called to say “I’m chickening out.  I don’t want to go through with the CVS test.”

The person on the other end of the phone understood – but she encouraged me to keep the appointment – so that I could have an intelligent conversation with a genetic counselor and thoroughly understand my risks, based on age and a comprehensive health history, and also so that I could undergo less invasive (and less accurate) first trimester screening.  The screening would involve something called a nuchal translucency or NT scan of both babies – and blood work for me.

I went to the appointment.  I had done loads of my own research – and was able to have an intelligent and forthright conversation with the genetic counselor.  She was supportive and non-judgmental as far as my decision to skip the CVS.  BUT.. since I was going to have the NT scan right then and there – my husband and I decided that we WOULD go ahead with the CVS test IF the NT scan looked wonky.

During an NT scan – the ultrasound technician measures a pocket of clear fluid found on the back of the developing baby’s neck.  The test can only be performed during a certain window of opportunity during the pregnancy.  You can find out more about the test here:

http://www.babycenter.com/0_nuchal-translucency-screening_118.bc

We knew we were looking for a measurement of under 3.  We decided if the measurement for either baby came back at 3 or more – we would go ahead with the CVS test right then and there.   When I got into the room, the ultrasound tech asked “so, are you having the CVS test?”

“Well, we’re not sure,” I replied.  “We want to see what the NT measurement is first.”

The tech looked like she smelled a rotten lemon.  Clearly, she thought the 41 year old patient on her table was foolish for not opting to have the test.

“Well, doctor so and so is the BEST,” she told us.  “In fact I’ve told him he CAN’T retire until I get pregnant and he can do MY CVS test!”

Hey, terrific for you lady.  You do whatever you want once you’re pregnant and faced with these types of decisions.  But all I can do is what feels right for ME… and so that’s how we proceeded.

The babies were scanned.  Both came back with NT measurements of 1.1.  That’s excellent.  “We’re happy with those measurements,” we told the u/s tech.  “We are not going to do CVS test today.”  And with that – I hopped off the table, and we went on our way.

I still needed to get first trimester blood work – so headed to the lab – and had a blood draw.  The lab would then go on to measure HCG levels – and something called PAPP-A.  These two values – coupled with NT measurements and one more value – my age – ultimately are all calculated together to form a picture of overall risk of Down’s Syndrome or another chromosomal anomaly.

When my blood work came back – my overall risk was calculated to be 1 in 315.  That may not sound great when compared to a younger woman – but going by my age alone – my risk was 1 in 82 for Down’s Syndrome and 1 in 53 for other trisomies.  Based on NT scan and blood work results – my risk had lessened considerably.  I was satisfied with those results – and comfortable with what had been a very personal decision — that only my husband and I could make, together.  Which is what I would tell any other “AMA” couple – you have to do what YOU are comfortable with; do your research, and make the decision that feels right for YOU.

 

Where oh where can I get prenatal care?

When I got pregnant with my first son, Jack (now age 4.5) … I knew exactly where I wanted to go for prenatal care.  I wasn’t sure if they’d have me – they were known for only taking on low risk, healthy pregnancies and I was worried a minor issue I was dealing with might put the kibosh on my receiving care there – but my concerns were unfounded.  The Midwife Center for Birth and Women’s Health – www.midwifecenter.org – welcomed me with open arms – and I began my first prenatal journey some 5 plus years ago.  I loved every minute of it.  Excellent clinical care coupled with a warmth and mutual respect that was very important to me as a pregnant client of the center.  I don’t do well with medical professionals who add a dose of condescension to the healthcare they provide – and have found that all too often, pregnant moms – especially first time moms, find themselves the recipient of a proverbial patronizing pat on the head as they make their way their way toward the birth of their child.  That was never the case at the Midwife Center – I always felt like a partner in my own care, I felt heard, I felt valued.

This time around, however, I wasn’t going to be able to skate through their doors with only a minor health complication to contend with.  This time around – I was 41 years old, pregnant with twins, on a preventative dose of blood thinners and I’d had a previous C-section (my first born didn’t cooperate with my desire for a med-free, natural birth – he parked himself in an upright, frank breech position during the last three months of my pregnancy and stayed there until Dr. Ronald Thomas, then head of perinatology at Allegheny General Hospital (and currently delivering babies at West Penn Hospital) – pulled him out via cesarean section.  It turned out he was literally lassoed in place by his umbilical cord as well – he never could have flipped into a vertex, head down birthing position.)

My beloved midwives kindly referred me to another practice.  They don’t take on twin pregnancies – much less twin pregnancies coupled with all the other baggage I was bringing to the table.  They specialize in the care of low risk pregnancies – and have some of the best stats in town (if not THE best stats in town) in terms of the very low numbers of their patients who ever require a C-section (sorry for being one of those stats, midwife center!  ;-) )

Luckily for me — as a huge fan of midwifery care — the Midwife Center is not the only such practice in town.  They ARE the only practice with an independent, freestanding birth center – but there is another group of midwives in town who practice in a hospital setting.  They are the Midwives at Magee – and in consultation with the Maternal Fetal Medicine group there – they were able to take on my care.

Sometimes I think folks are confused when I tell them I’m a) pregnant with twins and b) seeing a group of midwives.  Actually, I know they’re confused because I see the look of puzzlement on their faces.  People assume that a twin pregnancy is scary … high risk … results in bedrest and premature babies!  But while all of that is sometimes the case – it is certainly not ALWAYS the case.  Many twin pregnancies proceed beautifully – with healthy mamas producing healthy, full-term babies.  In fact while a twin pregnancy is higher risk than a singleton pregnancy – it’s not until you get into more multiples: triplets or quads or more also known as “super twins” – that you see those significant increases in risk for mom and her babies.

And so, I was off to the races – beginning a new journey with a new group of care providers that included a highly qualified group of midwives plus the as-needed care of the perinatologists who make up the Maternal Fetal Medicine practice at Magee.   In fact at my very first appointment – I met with MFM first – went over all of my various and sundry issues – and a final determination was made that it was indeed appropriate and safe not only for me to receive prenatal care from the midwives – but also to aim for a twin VBAC (vaginal birth after cesearean.)  With that goal in mind – I had my first intake appointment with the midwife group – but instead of seeing a midwife saw a nurse practitioner instead.  We talked about my overall health .. my goals .. and also what type of screening, if any, I was interested in during the first trimester.  I left the appointment excited about what was to come – but with some trepidation about what being pregnant with twins at age 41 would mean in the weeks and months to come.   My next hurdle –  would be making a decision about which screenings and/or early diagnostic procedures I wanted to include in my care.

 

Two Little Heartbeats

16 and pregnant?  Please.  Try 41 and pregnant.  With twins.  Now THAT’S a show.  But apparently a show that puts me in good company … as older MoM’s (Mothers of Multiples) are becoming increasingly common in ob/gyn and midwifery offices across the country.  I didn’t set out to become pregnant with twins (who says to their partner one day, “Let’s have twins?!”) – but it’s where I’ve ended up – and I’m not alone.  According to this January 4, 2012 article from cbsnews.com:

More U.S. women are having twins these days. The reason? Older moms and fertility treatments.

One in every 30 babies born in the U.S. is a twin – an astounding increase over the last three decades, according to a government report issued Wednesday. In 1980, only 1 in every 53 babies was a twin.

http://www.cbsnews.com/8301-204_162-57352309/cdc-more-u.s-women-having-twins/

A baby boom, indeed.

My husband and I greeted the news as you might expect: with a healthy amount of trepidation.

We found out about our twins as the result of an early ultrasound.  Initially, I was alone with the ultrasound tech.  I’m not sure why that’s the rule at that particular office – but they like to take a look-see and find out what’s going on before Dad is allowed back as well.  I’d had some somewhat high blood level readings of HCG (pregnancy hormone) when initially tested for the pregnancy – so was already a little concerned about what kind of party might be taking place in my uterus.  But I had been assured that my high-ish hormone levels were still well within the range for a singleton pregnancy – so that’s what I had decided this was.

The tech started looking around.  She was quiet – businesslike – and then announced, “well, I see one heartbeat.”

“Just one, right?” I asked her.

“Wellll…..” she replied.  “No.  There’s another one.”

“Oh my God,” I said, as the tears started to spill down my face.  I felt a lot of different emotions, but the most prominent among them – was fear.   How would we handle this?  How would I handle this – physically, emotionally…  and what would this mean for my older child, my sweet 4 year old, Jack?  I felt pregnant with too many babies.  I felt overwhelmed.  I felt like maybe pursuing this pregnancy – had been a mistake.

The tech left me alone with my emotional maelstrom – and went out to the waiting room to get John, my husband.  As he walked into the darkened ultrasound room he immediately noticed my tear-streaked cheeks.

“What’s wrong?” he asked quickly,  “Bad news?”

“Noooo,” I wailed.  “TOO MUCH GOOD NEWS!”  Commence more tears…

My husband’s response was to burst out laughing.  (His freak out would come later…)

We left the office somewhat shell shocked, and not sure what would come next.  But first on my list – was figuring out who was going to provide the rest of my prenatal care.  I’d have my answer the following week.

preg with twins

(photo: 3.5 months pregnant with twins, December 2012)