Fetal Health and Development

Mamas on Bedrest: I’m Pro-Action!

August 27th, 2012

I “shared” the image at the right on our  Facebook Page last week because I thought that it was an interesting statement and one that we all need to consider. Needless to say, it created quite a bit of controversy.  At first, I was dismayed by the negative comments. Not because they pertained directly to the image, but because the insinuation is that we here at Mamas on Bedrest & Beyond don’t care about women and babies and how best to help mamas have healthy babies. I thought for awhile about the comments and then replied directly on the post. But the more I thought about it, the more I had to say.

When it comes to reproduction, the issues are much more than pro-life or pro-choice. At the heart is the fact that a woman has become pregnant and she may or may not want to be, and she may or may not have the resources to adequately care for herself and her unborn child. I think that rather than having a philosophical debate about whether or not she should be made to keep the child, I think that our first obligation is to mama herself because after all, if mama is well cared for, her baby will be well cared for.

Many people think that women who have abortions do so because they don’t care about their babies or that they are somehow loose and just want their freedom. In my experience, nothing is further from the truth. Women that I have spoken with who are either contemplating an abortion, having an abortion or have had abortions, at the time felt that they had no other recourse. Often at the ends of the age spectrum, many were young, under educated women without money or resources to care for themselves-let alone a child. Others were older women for whom another pregnancy would place undue hardship on them financially, emotionally and physically. And of course there were all the ages in between. But the one thing that I can say across the board is that not one woman that I ever spoke to ever had an abortion without great thought and consideration. Most women agonized over the decision.

I think that the image brought up such emotion because it asked, “Will you still be Pro-Life after she’s born?” It’s a really great question. We have to ask ourselves, if we save a baby girl’s life (or any baby’s life), are we as committed to her once she is here? Are we committed to making sure that her mama has a safe and secure place to live free from harm and/or danger (the questions of homelessness/poverty/violence)? Are we committed to making sure that her mama has adequate food to feed her at all stages of her life (starvation/malnutrition and poverty)? Are we committed to making sure that she has access to quality health care so that she will be properly immunized and have proper health, dental and vision care throughout her life (the questions of poverty and access to health care)? Are we committed to her education, and making sure that she will be a functioning and contributing member of society (poverty/economics)? Will we commit to keeping her safe (out of the ravages of war, rape and pillage)? Are we committed to making sure that she doesn’t end up in growing up and living in some of our country’s most impoverished and contaminated areas (Planetary Degradation) that are waste infested (and not just sewage. We’re also talking about chemical and industrial wastes as well as electrical and nuclear wastes emitted from industrial complexes residing beside some of the nation’s poorest communities)?  And are we committed to teaching her right from wrong so that she doesn’t end up in prison and, the worst case, on death row (capital punishment)?

When considering these questions, I realized that I am not pro-life or pro-choice. I am pro-action. Quite frankly, I don’t believe that either of the political parties in the United States are aware of the scope of the problems affecting women nor are they equipped to deal with them. I think that it is going to take a concerted effort on all of our parts to make sure that mamas and babies are provided with all the resources that they need not only to survive but to thrive. What good does it do if we save a baby from abortion yet can’t ensure its survival beyond its first year?

So to those who were offended by the post, I say this. Bring your offense. But also bring your ideas. If you believe that all babies, all people,  have the right to life (as I do) then come to the table and offer suggestions on how we are going to ensure that these babies have all that they need to survive. Better than that, come to the table and share what you are prepared to do-right here, right now-to save babies and mamas. (I say babies and mamas because bottom line is that an unborn baby is only as “viable” as its mama. If mama is malnourished, ill or ill equipped, that poor little baby really doesn’t stand a chance at a healthy life!). Are you willing to take a teen mama under your wing and nurture her not only through her pregnancy but also through motherhood? Are you willing to help mamas and their babies get the prenatal, intrapartum, post partum and childhood healthcare that they need? Are you willing to be a doula or birth coach to a mama without resources? Are you willing to house a pregnant, homeless mama? What are you willing to do?

Your moral indignation is not enough. We need action! Quite frankly it doesn’t matter if you are pro-choice or pro-life. What matters is what you do with your convictions. If you are pro-life, get out there a help provide the resources necessary for women to have a healthy pregnancy, and to raise a healthy and contributing member of our society. Provide baby clothes or diapers, offer to volunteer at a shelter. If you feel strongly that women should not have abortions, work hard to help them have access to birth control. Help them, if they are pregnant, to access prenatal care. Take them to office visits. Help them get vitamins. Get in there and do!

Likewise, if you are pro-choice, then be willing to sit with a woman as she mulls over her choices. Be able to share with her the pros and the cons (all of them, not just the moral ones!) of each of her options and be an unbiased support for her. Be willing to go with her to a clinic, cross the lines and sit by her side. Be willing to listen to her after if she is sad or depressed. Step in and help if she is struggling. Be willing to DO, not just speak!

I’m pretty sure that I may lose a few readers with this post. No matter. I don’t have time to get bogged down worrying about what some people may think of me. My focus has always been and will continue to be trying to help mamas on bed rest get the medical care, home care and personal care that they need to have healthy pregnancies and healthy babies. And if that offends people, so be it.

Mamas on Bedrest: Running While Pregnant

June 4th, 2012

Jenny Wright jogged throughout her pregnancy. As a blogger for the British online newspaper The Daily Mail, Wright shares her experience, even being called “a Selfish Cow”, of jogging while pregnant. Following the flurry of comments, Wright wrote a follow up blog post addressing the naysayers entitled, My Perfect Baby Proves that Jogging is Safe.

I am a huge proponent of exercise during pregnancy. I am even a proponent of women running in the early stages of pregnancy. However, as pregnancy progresses, I am less of a fan. The increased levels of the hormone Relaxin, softening the ligaments and tendons, puts a pregnant mama at increased risk of injury. Additionally, pregnancy completely changes a woman’s center of gravity putting her again at increased risk of falls and injury. But my friend and colleague Kaisa Tuominen, a world class fitness instructor with extensive expertise in exercise science, public health and perinatal fitness provided an even more detailed explanation of the potential “cost” of Wright’s jogging while pregnant. Her entire blog post can be read here, and below is a summary.

Pelvic floor stress

As a general rule I (Kaisa Tuominen) discourage running during pregnancy. Not because pregnant women are fragile or because running is detrimental for the baby. The main reason for this rule is the pelvic floor. The hormonal status of a pregnant woman changes how her joints and tissues react to exertion. The pelvic floor is 80% connective tissue which becomes lax during pregnancy due to these hormones. Pregnancy ALONE is tough on the pelvic floor, weakening it little by little as the baby grows and exerts constant pressure on the perineal structures. When you add the impact and pressure caused by running the damage to the perineum is greater….In Jenny’s birth story I couldn’t help but notice that her baby did not rotate properly and she needed ventose to be turned manually. This is a typical situation of a pelvic floor that is weak.

Risk vs. Benefit

Physical activity and exercise are very beneficial, and truly essential, for pregnant women and unborn babies. There are numerous studies that show how fit women have healthier pregnancies, easier births, and recover faster. Babies are also positively effected by growing inside active women. Jenny is right when she says that being fit helped her get through hours of labor and birth without anesthesia. These benefits can be found by doing other types of exercise that are not detrimental to the pelvic floor. This is why I discourage running.

Ease Back into Exercise

 I would suggest that all moms take it easy in the beginning and only do postural and corrective exercises for the first month or so. It’s essential not to go too fast! I really hope Jenny does not return to jogging without rehabbing her pelvic floor first. In general women’s bodies are not ready for the intense impact from jogging for a few months postpartum. Generally it takes quite a bit longer. Again, risk vs. benefit. (See our posts on pre and post partum exercise here)

Thanks so much to Kaisa for providing these very salient points about jogging perinatally. Kaisa is an expert in perinatal fitness and has developed a program called The Postnatal Body Fix for mamas wanting a safe, effective post natal program that will help them regain their prenatal strength and fitness.

 

 

Mamas on Bedrest: When Twins Share Too Much-TTTS

January 18th, 2012

About a week ago one of my mamas on bed rest called to give me an update on her condition. She’s carrying twins and after several weeks of grizzly hyperemsis gravidarum, things have finally settled down-or so she thought. Now at 25 weeks, she is having a Level II Ultrasound to evaluate whether or not her twins have Twin To Twin Transfusion Syndrome or TTTS.

What is Twin to Twin Transfusion Syndrome (TTTS)?

TTTS is a very specific condition that occurs in twins under very specific conditions. According to the Texas Children’s Hospital,

In two-thirds of identical twins, each twin has its own amniotic sac but shares a common placenta. This type of monozygotic (identical) twinning is called monochorionic, diamniotic since there is an inner layer surrounding the amniotic sac of each twin, but there is only one common outer layer (chorion) surrounding both of the sacs.

TTTS occurs in monochorionic, diamniotic twins. In almost all of these pregnancies, the single placenta contains blood vessel connections between the twins. For reasons that are not clear, in 15 percent to 20 percent of monochorionic, diamniotic twins, the blood flow through these blood vessel connections becomes unbalanced, resulting in a condition known as twin-twin transfusion syndrome (TTTS).

In TTTS, the smaller twin (often called the donor twin) does not get enough blood while the larger twin (often called the recipient twin) becomes overloaded with too much blood. In an attempt to reduce its blood volume, the recipient twin will increase the urine it makes. This will eventually result in the twin having a very large bladder on ultrasound, as well as too much amniotic fluid around this twin. At the same time, the donor twin will produce less than the usual amount of urine. The amniotic fluid around the donor twin will become very low or absent.

In some severe cases of TTTS, Twin Reversed Arterial Perfusion (TRAP) sequence occurs.  TRAP sequence or acardiac twinning is a very rare problem, occurring in approximately 1% of twins sharing one placenta. One twin is usually structurally completely normal. The other is an abnormal mass of tissue, consisting usually of legs and a lower body, but no upper body, head or heart. Because of the absent heart, the term “acardiac twin” is used to describe this mass. The normal fetus is referred to as the “pump twin” because its heart is used to pump blood to the abnormal mass. The “acardiac twin” has no chance of survival.

When I realized what my mama would be facing, I had to share it here. While the vast majority of twin pregnancies proceed with few complications, i.e. each twin has its own placenta and sac, its a staunch reminder that multiple pregnancies carry their own inherent risks. While Mother Nature in her marvelous wisdom allows for these wondrous births, sometimes things don’t proceed as planned.

Diagnosis and Evaluation of TTTS

So how would a mama know if her babies were having TTTS? Many times mama has no idea at all. Then when she has an ultrasound, the imbalance in amniotic sacs is noted, there is growth retardation in one baby or develpmental abnormalities in one twin. On occasion, mama may notice that she is increasing in girth quickly. This often happens when the “recipient” twin in TTTS is putting out too much urine in an attempt to normalize its fluid volume, so mama’s belly is getting larger more quickly. The Diagnosis of TTTS is made via ultrasound and the severity is determined by the timing in the pregnancy (the earlier it is detected, the more severe it tends to be), the development of the fetuses and the status of the amniotic sacs and placentas. To better determine the severity of TTTS in the twins, doctors at the UCSF Fetal Treatment Center also evaluate the babies hearts via echocardiogram, their kidneys, bladders and arterial blood flow via the umbilical cords.

Treatments for TTTS

Amnioreduction. Amnioreduction is a minimally invasive treatment in which some of the excess amniotic fluid produced by the recipient twin is removed via amniocentesis. While this was at one time the standard treatment for TTTS, it has been replaced by laser treatments that have superior results and birth outcomes for both twins. It is still effective in some lower risk, very specific cases.

Septostomy

In some cases, the imbalance in amniotic fluid levels is balanced by making a small hole in the membrane separating the two fetuses, called a septosomy. With a septosomy, excess fluid from the recipient twin can flow back into the sac of the donor twin who has low amniotic fluid levels. Complications include all the complications associated with amniocentesis (infection, preterm labor and/or premature rupture of membranes), widening or complete rupture of the septosomy in which case both twins would share one sac, subsequent tangling of the fetal umbilical cords, fetal death (s).

Laser Ablation of Placental Blood Vessels

In more advanced stages of TTTS, laser ablation of the blood vessels on the placenta found to communicate between the twins are closed using laser light energy. If done at the appropriate time and on the appropriate blood vessels, Laser ablation can be a curative procedure. According to the Texas Children’s Hospital,

Laser ablation has been shown to result in the survival of at least one twin in 70 percent to  80 percent of cases and both twins in one-third of cases.Should one fetus die after the procedure, the likelihood that the surviving fetus will develop complications is reduced from 35 percent to approximately 7 percent, because the babies are no longer sharing blood vessels between them. In one-third of cases, neither twin will survive.

Selective Cord Coagulation. Unfortunately, some parents are faced with the heartbreaking decision of whether or not to end the life of one twin to save the life of the other. This decision often has to be made in cases where laser ablation is not an option and/or the survival of one twin is questionable at best. By stopping the flow in the cord of the dying twin, the other twin can is protected from any adverse events as a result of the iminent demise of its twin and be given the best chance of survival. Survival of the one remaining fetus can be expected in 85 percent of cases.

Radiofrequency Ablation.

This procedure is usually reserved for TRAP sequence. In this procedure, a specialized needle is passed into the amniotic fluid and then into the body of the acardiac fetus. A special current is then applied to the needle to burn the area around the major blood vessel in the abnormal fetus. This will stop the blood flow and allow the pump twin (normal twin) to no longer have to send blood to the acardiac twin. Complications of infection, premature contractions and premature rupture of the membranes can occur as in any needle procedure. In one series, the risk for premature rupture of the membranes was 8 percent.  In this same series, the chance for a successful live birth for the pump twin was 90 percent.

Truly this is overwhelming information and parents faced with TTTS face some unheard of decisions. However, in today’s technological world, there are more treatment options and more opportunities for successful live births. Hopefully, this brief and very simplistic overview of TTTS will help some parents cope with a very difficult situation and make very difficult choices.

Do you have experience with TTTS? Please share your experience with our Mamas on Bedrest in the comments section below or by sending an e-mail to info@mamasonbedrest.com.

More information can be found at The Twin to Twin Transfusion Syndrome Foundation, The UCSF Fetal Treatment Center, The Texas Children’s Hospital Website.

Note: A huge thanks to Ms. Jenya Cassidy for sharing her story about TTTS. Jenya shared an invaluable resource, Dr. Julian De Lia. Dr. De Lia is pioneer in laser surgery treatment for TTTS and has also done extensive research into the nutritional needs of women with high risk pregnancy. Here is his contact information:

INTERNATIONAL INSTITUTE FOR THE TREATMENT OF
TWIN-TO-TWIN TRANSFUSION SYNDROME
“…so that babies and families who are suffering today will live and be happy”

 

ST. JOSEPH REGIONAL MEDICAL CENTER
5000 WEST CHAMBERS STREET
MILWAUKEE, WI 53210-1688
414-447-3535
www.tttsmd.org