My wife and I counted ourselves lucky
when we found out we were pregnant.
Better yet we found out we were
expecting twins. We were cautious in
our hopes for the first 14 weeks and
didn't mention the news to anyone. We
were waiting for an ultrasound which
was done at 14 weeks to ensure all was
ok prior to our sharing the news.
The ultrasound showed twin a was very
small but had normal amniotic volume,
and twin b was normal size and normal
amniotic fluid.
2 days after the ultrasound, my wife's
water broke while she was at work. She
went into the hospital where the
diagnosis was confirmed. Twin a had
virtually no amniotic fluid left. We
were told that the likely outcome was
the onset of labor within 1-2 weeks.
We were stunned and went home to
collect our thoughts/feelings.
We decide to get a second opinion of
our options and saw a perinatologist
who said our options included:
termination of the entire pregnancy or
expectant management with a very
uncertain outcome for both babies. We
didn't come to any conclusions and
decided to research the problem of
PPROM in Twin A with regards to the
outcome for the whole pregnancy and the
outcome for twin B if Twin A should not
make it. I was able to find lots of
literature which almost universally
predicted a dire outcome for the entire
pregnancy and the likely outcome was
delivery of both babies within 1-2
weeks as we were told. There was the
odd case where delivery was delayed for
a longer time especially if the PPROM
occurred very early in pregnancy.
However these cases were few and far
between.
In my research I did come across a few
papers that discussed the use of
selective fetal reduction in 2nd
trimester PPROM (our situation). This
means that a perinatologist selectively
terminates the twin whose membranes
have ruptured, The rationale is that
that baby is at high risk of lack of
lung growth and limb contractures and
more importantly to Twin B to have Twin
A stop producing urine which becomes
the amniotic fluid in its sac. If you
stop the fluid, you minimize the risk
of infection because amniotic fluid is
a good growth medium for bacteria and
if you stop the fluid you minimize the
risk of preterm labor as it is usually
infection which causes the preterm
labor. The evidence in these papers
was not strong as the numbers were so
few, but it seemed to indicate that
this procedure affords twin b a good
chance to progress for a much longer
time.
It was a hard decision, but we weren’t
willing to chance having 2 extremely
premature babies, especially since
TwinA was at much increased risk of
pulmonary hypoplasia and severe limb
contractures because it was just in the
early 2nd trimester. There was also
the very real concern that twin A was
abnormal, given that it was so small (<
10th percentile). So we discussed with
a perinatologist and decided to have
the procedure to terminate twinA, which
we did at 16wks 3 days. My wife was
started on antibiotics when the PPROM
first happened and she was put on again
after the procedure, because the likely
cause of the rupture was infection in
the first place.
We went home and prayed that she didn’t
go into labor, while she was kept on
bedrest. She had a few tightenings
but nothing else, thankfully. The
pregnancy then proceeded pretty much
uneventfully until 29 weeks when an
ultrasound picked up some umbilical
artery flow problems. She was
hospitalized until 32 weeks when things
seemed to improve. She was on
antepartum home care until 34w4d when
she started contracting nonstop. We
went into hospital and later that day a
c-section was performed for non-
reassuring heart tracings and a poor
biophysical profile exam. At section a
placental abruption was diagnosed,
which accounted for the irritable
uterus contractions and the unhappy
baby. Our son was born at 35w5d and
weighed 4lb 4ounces. He had a rocky
first 48 hours, as he needed to be on a
ventilator for a day and a half, and
was on blood pressure support for 2.5
days. He has improved dramatically
over the past 4 days and is now
breathing on his own and has started
feeds and seems to be doing ok on all
fronts. I just got home from the
hospital and wanted to share our
experiences on this website so others
in our situation can look up the
information themselves if they want.
The journal articles that I found are
listed below. Good luck to anyone who
is unfortunate enough to experience
PPROM and has found this site.
Papers:
Obstetric outcome after fetal reduction
to singleton pregnancies. L. De Catte
and W. Foulon. Prenat Diagn 2002: 22:
206-210
Selective Feticide in Twin Pregnancies
with Very Early Preterm Premature
Rupture of Membranes. Luc De Catte et
al. American Journal of Perinatology.
Volume 15, No. 3, March 1998. 149-
152
Second Trimester Selective Termination
of a Twin with Ruptured Membranes:
Elimination of Fluid Leakage and
Preservation of Pregnancy. Dorfman et
al. Fetal Diagn Ther 1995: 10: 186-
188
Selective Termination versus Expectant
Management of PPROM of One Sac in
Multifetal Gestations. Debbs et al. Am
J Obstet Gynecol 180:S96
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