A 35-year-old with several children discovers she is having a twin pregnancy. This is happy news, until a potential abnormality in twin B is found.
Twin B is measuring much smaller than twin A — almost a full 10 to 14 days behind — and there is fluid around the fetus. While it is too early to diagnose, it appears there is a brain abnormality.
The patient, with a lot of apprehension and many questions, sees high-risk obstetrician Dr. Maeve Hopkins. Genetic testing is needed for decision-making — to help determine if twin B can survive or if the patient’s life and twin A are at risk, meaning a pregnancy reduction will need to be considered. Dr. Hopkins orders a biopsy of twin B’s placenta.
The results from genetic testing reveal that twin B has three sets of chromosomes, instead of two. This results in a rare genetic condition that causes severe birth defects. Most pregnancies in this situation end in either miscarriage or stillbirth. While there are very rare cases of live births, survival is generally limited to an average of five to seven days.
Carrying the fetus poses significant risk to both the patient and twin A. There could be a build up of amniotic fluid and difficulty swallowing for twin B, which could lead to preterm labor symptoms and birth, as well as stillbirth. Losing twin B in utero may increase the risk of losing twin A and put the patient at risk, too.
In this case, there are two options.
One is expectant management, which is essentially to wait and see. The other is a multi-fetal pregnancy reduction, where the cardiac activity of twin B is stopped, and the patient continues with a single twin pregnancy. While pregnancy reduction is considered a fairly safe procedure, there is a small risk that the patient could still lose twin A.
“I think she was somewhat in shock,” Dr. Hopkins shared. “And I think she wanted some guidance, which is always difficult when patients want to know what to do … it’s a very personal, very familial decision for the patient … I generally say these are the risks to you, these are the possible outcomes, and these are the risks of a procedure. And a procedure likely carries less risk than continuing a twin pregnancy. And ultimately, she was able to make the decision.”
The patient decides to move forward with the reduction procedure.
Reflecting back, Dr. Hopkins shared, “What I’ve learned practicing high-risk OB is when you face a situation like this with a patient, it is impossible to know what decision that you would make if you were in that clinical situation … So just taking a step back and not necessarily trying to put yourself in the patient’s shoes, but just stepping back and giving the information and just listening to the patient. I think as high-risk obstetricians, we’re often the ones who have these stories and who see these patients, whether we’re political or not, that’s a life-saving procedure for us many times.”
Maeve Hopkins, MD
Maeve Hopkins, MD is a maternal-fetal medicine specialist at Cleveland Clinic’s Ob/Gyn & Women’s Health Institute. She completed her residency training in obstetrics and gynecology at Duke University in Durham, NC, followed by a fellowship in maternal-fetal medicine at the University of Pennsylvania in Philadelphia, PA.
Dr. Hopkins is passionate about caring for complex pregnancies particularly affected by fetal anomalies (genetic or structural).
She is from Northeast Ohio, and loves Cleveland sports, and spending time with her family.
DDx SEASON 7, EPISODE 2
Pregnancy Reduction in a Twin Pregnancy
RAJ: This season of DDx is sponsored by Cleveland Clinic. The case studies you’re about to hear are real patient stories. Some details may be changed to preserve confidentiality.
Dr. Hopkins: When the idea of abortion as healthcare is posited to me, I think of the mom who was diagnosed with cancer in her first trimester, who really wants to spend time with her children who are at home and knows that she might pass away during a pregnancy. A mom with severe maternal pulmonary hypertension who had eight kids at home who had decided to terminate so she could spend time with her kids, knowing that she might pass away from actively carrying a pregnancy into the third trimester. These are the patients that come into my mind and my heart, these are all personal cases that I’ve been through.
RAJ: This is DDx, a podcast from Figure 1 about how doctors think.
I’m Dr. Raj Bhardwaj.
This season, we’re doing something different. We’re taking you inside the minds of doctors who perform an essential – and often lifesaving – service in healthcare: abortion.
Throughout this series, you’ll hear from obstetricians inside Cleveland Clinic.
They’ll tell you about their patients.
Patients whose lives have been saved and emotional health safeguarded by this essential service.
We’ll talk about abortion as it affects physical and mental health.
Today, a case from Dr. Maeve Hopkins, a maternal fetal medicine specialist at Cleveland Clinic in Cleveland, Ohio.
CHAPTER 1 – CASE STUDY
Dr. Hopkins: She was a mother of several children and she was in very good health, and slightly older. You know, we consider anything “advanced” maternal age above age 35, but in very, very good health and had had several uncomplicated pregnancies prior to coming in.
RAJ: But what brought this patient to Dr. Hopkins was an abnormal ultrasound.
Dr. Hopkins: She presented for a routine screening ultrasound in the first trimester and was diagnosed with twins and initially excited about the twin pregnancy. However, there was a suspected abnormality of one of the twins.
RAJ: There was twin A, the twin closest to the cervix and twin B, the twin furthest from the cervix.
Dr. Hopkins: Even early in pregnancy and at her very early ultrasound, there appeared to be abnormalities relating both to the size and the brain structure of baby B in her twin pregnancy. When my partner first saw her and identified that baby B was measuring much smaller than baby A, almost a full 10 to 14 days behind, and baby B also contained fluid around the fetus.
RAJ: This fluid around the fetus was a strong indication of a genetic abnormality.
Dr. Hopkins: It appeared that there was some sort of brain abnormality. It was a little bit too early to characterize at the very early ultrasound in her 10th, 11th week.
RAJ: Genetic testing would provide more answers.
But in the meantime, the patient was processing this information.
Dr. Hopkins: I think initially she was excited about the diagnosis of the twins, but when she learned that there was potentially abnormalities of her second twin, she came to me with a lot of apprehension and some worry and really I think wanting some guidance in terms of what are the next steps.
The primary question was, how bad is this? Will my baby be able to survive? And what are the risks? Do you think the other baby is healthy? And are there any risks to the healthy baby? Those were the primary questions and they are difficult to answer without the genetic information.
RAJ: A biopsy of the placenta of twin B was taken.
Dr. Hopkins: Each baby has its own placenta, the placenta of twin B, the abnormal twin was able to be biopsied. It would’ve been technically challenging to biopsy twin A’s placenta. Traditionally, we would normally do both, but we were able to get a placental biopsy for twin B and send that off to the genetics lab to try to confirm the genetics for the abnormal twin.
RAJ: The results came back and confirmed that twin B had three sets of chromosomes, instead of the normal two, resulting in a rare genetic condition which causes severe birth defects.
Dr. Hopkins: So we were able to confirm the genetic diagnosis, which we know is a lethal condition. There are very, very rare case reports of live births from this condition. Most pregnancies end in either miscarriage or still birth. The rare cases of live births have survival that’s generally limited to an average of five to seven days if they’re live born.
RAJ: Continuing to carry this fetus would pose significant risk.
Dr. Hopkins: The suspected brain abnormality and birth defects might include buildup of amniotic fluid around the abnormal baby, difficulty swallowing, which could lead to preterm labor symptoms and preterm birth, as well as, stillbirth. So losing baby B on the inside may increase the risk of losing baby A, the healthy twin.
RAJ: In this case, there were two options.
Dr. Hopkins: Basic options are either expectant management or doing nothing essentially. And then another option is to do what’s called a multi fetal pregnancy reduction. That’s a procedure where we can stop the cardiac activity for one of the twins in a twin pregnancy and continue with a single twin pregnancy. The risk for expected management is significant. In terms of the reduction procedure, while that’s a fairly safe procedure, there is a small risk of loss of the healthy co-twin with the reduction procedure.
RAJ: The patient listened as Dr. Hopkins presented these options.
Dr. Hopkins: I think she was somewhat in shock and I think she wanted some guidance, which is always difficult when patients want to know what to do. But I think that she really just wanted me to tell her what to do or to say what the right decision was, which I am unable to do particularly with a difficult decision like a pregnancy reduction because it’s a very personal, very familial decision for the patient and while weighing risks and benefits that certainly seems to be clear, which is the least risky path, both for her health and the health of the her co-twin, which was healthy twin A.
It’s a decision that needs to be made by the patient. So while she said, What should I do, or, you know, what would you do? Those are always too difficult to answer. You know, I generally say these are the risks to you, these are the possible outcomes, and these are the risks of a procedure. And a procedure likely carries less risk than continuing a twin pregnancy. And ultimately, she was able to make the decision.
RAJ: She chose to move ahead with the reduction procedure.
Dr. Hopkins: She came to see me twice within 24 hours, which is standard for a reduction procedure. A patient needs to come in and sign consent forms and listen to the heartbeat, or be offered to listen to the heartbeat or heartbeats, and then return 24 hours later if they would like the procedure.
RAJ: After 24 hours had passed, the patient met with Dr. Hopkins again to review the procedure, the risks and confirm that she wanted to move forward. She did.
Dr. Hopkins: So under ultrasound guidance, in sterile conditions, the cardiac chamber of the abnormal twin is injected with just one milliliter of potassium chloride. And under ultrasound guidance, we can visualize the cardiac activity ceasing for the abnormal twin.
RAJ: Although the healthy-twin tolerated the procedure very well, Dr. Hopkins was uneasy.
Dr. Hopkins: The other twin is a constant source of anxiety for me. I can’t speak for other reduction providers, but knowing that you have a healthy, precious pregnancy that is ongoing during an invasive procedure makes this procedure for me very high stakes.
RAJ: Although complications following this procedure are rare, Dr. Hopkins was concerned that the healthy twin may have an adverse reaction.
Dr. Hopkins: So we monitor under ultrasound guidance after the procedure and confirm the cardiac activity for the surviving co-twin. And then I monitor this patient weekly up until the third trimester to check for any membrane separation, which is when the amniotic cavity might separate from the uterus. Which can be a complication of an invasive procedure.
RAJ: There were other concerns too.
Dr. Hopkins: We did this procedure late enough that I felt fairly certain that the co-twin was anatomically normal, but you never truly know until the second trimester, about 20 to 22 weeks, with certainty, the anatomy of the fetus is normal. So you know, the early anatomy looked normal on the healthy co-twin, but there’s always this anxiety that, oh, what if the healthy co-twin had the same genetics, but the phenotype looks normal? This early in pregnancy, since we didn’t ever do genetic studies on the healthy co-twin, she didn’t want another invasive procedure. I offered her an amniocentesis later in the pregnancy for the healthy co-twin, but she didn’t want it, so we were working on faith that this was a normal baby.
RAJ: As it turned out, it was.
Dr. Hopkins: I monitored this pregnancy weekly up until the third trimester, and the healthy co twin continued to grow very normally, and the amniotic fluid remained normal. And she ultimately went on to have a healthy third trimester and a full term delivery.
CHAPTER 2 – LESSONS
Dr. Hopkins: What I’ve learned practicing high risk OB is when you face a situation like this with a patient, it is impossible to know what decision that you would make if you were in that clinical situation. And sometimes patients ask me, What would you do? And I’ve been through enough of these cases and I have children of my own that I don’t know what I would do. I can’t say what I would do unless I were the person in that situation and that were my body because these decisions that we’re asking patients to make are impossible. There’s no right or wrong decision in this case.
There’s no good option. There are only bad options. To me, the most important thing that I’ve learned, and I try to instill this in my trainees, is that you don’t know what you would do if you were in this situation. So just taking a step back and not necessarily trying to put yourself in the patient’s shoes, but just stepping back and giving the information and just listening to the patient. I think as high risk obstetricians, we’re often the ones who have these stories and who see these patients, whether we’re political or not, that’s a life saving procedure for us many times.
RAJ: Thanks to Dr. Hopkins for speaking with us.
This is DDx, a podcast by Figure 1.
Figure 1 is an app that lets doctors share clinical images and knowledge about difficult to diagnose cases.
I’m Dr. Raj Bhardwaj, host and story editor of DDx.
Head over to figure one dot com slash ddx, where you can find full show notes, photos and speaker bios.
This season of DDx is sponsored by Cleveland Clinic.
Cleveland Clinic is consistently ranked as one of the nation’s top hospitals for gynecologic care, by U.S. News & World Report. Learn more from Cleveland Clinic Women’s Health experts at consult qd dot cleveland clinic dot org.
Thanks for listening!