Managing Monoamniotic Twin Pregnancies
What Is The Standard Of Care?
This site pops up when you do a Google search for "monoamniotic." I doubt many people would do such a search unless they had a personal interest in the subject of monoamniotic/monochorionic twins. And so I assume, dear Reader, that you already know something about this subject. (If not, you can learn more at Monoamniotic.org.) I further assume that your interest is great enough that you will read these pages to the bitter end. In exchange for the time you will be dedicating to this material, I promise to make it as readable as possible. You are invited to email me with any suggestions for improvement.
I became interested in this rare condition when a Detroit mother contacted me who had carried monoamniotic twins. Her primary care OB diagnosed twins, and he properly referred her to a maternal-fetal medicine (MFM) specialist. The clinic was at a smaller, suburban hospital, and I think this explains why the MFM doctor put her on the "standard" twin track with twice weekly testing. On Friday the monitor showed both twins were normal. By the next Tuesday, one twin was dead. A cesarean section to rescue the other twin was "successful" in that the twin lived, but she is severely brain-damaged from being left in the womb over the weekend. This tragedy was completely avoidable if the MFM had recognized the following.
1. Monoamniotic twins are at high risk because the umbilical cords become entangled and knotted. The twins then die from strangulation of the cord.
2. Doctors call this a "cord accident," but it is a predictable cord accident, and it is an accident waiting to happen.
3. It has been recognized since the 1980's that these twins can be successfully delivered by following a "game plan" (a) to intensively monitor the twins as soon as they are viable [around 24-26 weeks], (b) to deliver the twins by cesarean section at the first sign that either twin is threatened by cord entanglement, and (c) to routinely deliver the twins as soon as the risk of a cord accident outweighs the risk of prematurity.
4. "Intensive" surveillance means fetal monitoring at least every day to look for signs of cord compression. Steroids are given to the mother (as necessary) to promote fetal lung maturity. There is now a high success rate for preemies born at 32 weeks. When monoamniotic twins get to that week, it is safe to deliver them, and they should be delivered at that time.
5. If there is any "controversy" over how monoamniotic twins should be managed, it is whether the intensive surveillance should be in-hospital versus outpatient, and whether it is acceptable to let the pregnancy go to 34 weeks (assuming the fetal monitor looks good).
A doctor is required to do what is "reasonable" under the circumstances. Once you are familiar with the research articles (and in what follows I will analyze these articles in detail), you will agree that the doctor committed malpractice because it would be crazy not to manage a monoamniotic pregnancy as I've outlined.
The mother called me after a local lawyer turned her case down. He was apparently unfamiliar with this rare situation. She runs a small business, and while I sat at her kitchen table to discuss this case, the cell phone rang constantly. "FedEx will be there tomorrow ... I'll take delivery on Friday ... We have that size in stock.'' Then the cell chirped with a call from the school district. "You told me you'd call last week to set up that appointment ... She needs to start her therapies now ... O.K., I'll bring her there on Thursday for the intake interview, but I expect you to get started right away." After she got off the phone, she said, "You have to be an advocate or you don't get anywhere."
She told me that since the delivery she's now an authority on monoamniotic twins through the internet. But she regrets that she didn't ask more questions back when she was carrying her twins. I pray your story isn't similar, and I hope you learn something on these pages that will make it unnecessary for you to contact me.
