potential complications of multiple births webcast march 8...

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Potential Complications of Multiple Births Webcast March 8, 2010 David Schrimmer, M.D. Ted and Monica Fogliani Please remember the opinions expressed on Patient Power are not necessarily the views of UC San Diego Medical Center, its staff, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you. Introduction Andrew Schorr: Believe me, starting a family can be an exciting time in your life, but finding out you're pregnant with multiples is life changing. Believe me, from my friends it is a big change. Learn about both common and rare risks associated with multiple births, particularly for older parents, on this edition of Patient Power. Andrew Schorr: Hello and welcome to Patient Power. I'm Andrew Schorr. In this program, like so many we do sponsored by Diego Medical Center where we connect you with leading experts and discuss important health issues. Well, if you think of happy times, if you're trying to have a baby, having a baby and having a healthy one, that is something certainly to celebrate for mom, dad and the whole family. What about if you get the news that you've been trying to get pregnant, maybe increasingly you're one of those folks who've made use of fertility treatments, and it's worked. And guess what, what if you get the news that not only has it worked but you're having triplets? And maybe the news can even be, rare as it could be, that among those three babies two of them identical twins? Well, that's what happened to Ted and Monica Fogliani of Carmel Valley north of San Diego. Want you to meet them now. So, Monica, you get the news. That must have been just a mind blower. Monica: It was a little shocking at the beginning, just we were not expecting that news. But it was definitely very exciting for us just because we were just thrilled to have a baby and we were not only having one but three. It was just a great surprise for us. Andrew Schorr: Right. Now, you already had your son, Teddy. Monica: Yes.


Andrew Schorr: And he was about five or so, not quite five when the new babies were born, so I guess he's about four when you get the news or so. So you get that news, and now you're going to have triplets. So what about husband Ted? That must have been a shocker for you too. Monica and Ted’s Big Surprise Ted: Yeah, I was probably a little more shocked than Monica was. I thought we would instantly need new car, new house, new life, you know, but you get over the shock and you just get back to your priorities, which is get the mom through healthy, get the kids out healthy. But it was something we never expected. I thought there might be twins, put two eggs in during the process and thought that maybe they would both take, but no one ever prepared us for one of them splitting, so it was a big shock. Andrew Schorr: Right. So you ended up with two girls, and that is Natalia and Camilla, and then a boy, Christian. And we'll tell the end of the story first because we have a lot more to talk about with your doctor. The end of the story is that in December of 2008 the babies were born healthy, the girls six pounds and five and a half and the boy five pounds at 34 weeks, right? But healthy, didn't stay in the hospital long at all. You were the one who needed to say a little longer, right, Monica? Monica: That is correct, yes. Andrew Schorr: And things are going well. Monica: Things are going great. We've been very lucky and very blessed because never had an issue with them. They're healthy, normal babies and they're already walking and it's been a lot of fun. Andrew Schorr: Wow. Now, of course it's been an adventure, a journey with a pregnancy, and certainly a multiple birth pregnancy is a high-risk pregnancy and there's a lot to be monitored. I understand you had something like 14 ultrasounds, Monica? Monica: That about right, yes. Once they know, especially with the case that we had the girls being identical they were monitoring them very closely. So sometimes I was there once a week or sometimes towards the end twice a week.


Andrew Schorr: And of course measurements and, as you said, frequent visits. And so it's got to get your heart pumping a little more each time you go in for that exam knowing that it's a high-risk pregnancy and hoping things are okay. Monica: Exactly. Yes, every time we were there I was just like hoping that everything will be okay with them, but they surprised us, all of us. They were very good since the beginning, so they did great. Andrew Schorr: Well, good for you. Now, let's face it, you really want to have top-notch care with any pregnancy and certainly with a high-risk pregnancy, and that brings us to your doctor who is our guest today on Patient Power. That's Dr. David Schrimmer. Dr. Schrimmer is a professor in the division of perinatal medicine at UC San Diego Medical Center. He's a perinatologist, so he specializes in high-risk pregnancies. Dr. Schrimmer, I know you love hearing this story when it seems like a mom and the babies can sail through and that makes you sort of breathe easier, but it's not always that way and there are things to be watching out for. It certainly is a high-risk pregnancy, right? Complications with Multiple Births Dr. Schrimmer: Yes, it definitely is, and we're always very grateful when patients such as Monica and Ted do sail through the pregnancy, but unfortunately patients who carry twins and triplets are definitely at risk for a whole host of complications. Andrew Schorr: We're going to go through that. Now, first of all, the frequency of multiple births now, is it going up in the United States? I know a lot of couples are delaying pregnancy so we have some older moms and also like Ted and Monica turn to fertility treatments, and I know that science has gotten better. Dr. Schrimmer: There's no question, Andrew. As the infertility treatments have improved over the years the success rates have gone up dramatically, and with that we do see an increase risk of twins and triplets. There is also a small increase due to the delay in childbearing that we're often seeing today. So older moms are at higher risk for multiples. Andrew Schorr: Okay. So we talked about there's a risk, and there certainly are more things you've got to watch out for. Let's talk about some of the things that can happen. Now, our first child, and we have not had any multiple births in our family but have three kids, I have had some of this experience because my wife had preterm labor just


with one baby, and she was on bed rest for like a month, and the baby was born at 34 weeks, like Ted and Monica's children. Is bed rest common for moms with multiple births? Dr. Schrimmer: It is common. The average age of delivery for triplets is about 32 weeks, or eight weeks early, and I would estimate that at least half of our patients end up at bed rest at some point during the pregnancy. Now, what's changed over the years is that we used to just put everyone at bed rest automatically at 20 or 22 weeks gestation, but now we're a little better and we can measure cervical length as indicator of risk of preterm delivery, so at least for some patients we can be quite reassuring and they can go on with their normal life. Andrew Schorr: Doctor, one of the things that any woman, any couple worries about is any kind of bleeding or spotting during a pregnancy. Tell us about what you look for and what is just alarming and what is maybe just things sort of settling in. Dr. Schrimmer: Well, small amounts of blood early in the pregnancy are really extremely common, especially with in vitro fertilization. And in talking to my infertility colleagues, many of them actually tell their patients that they can except some mild spotting. And by spotting I mean just that, spots of blood, dime-size or so, but not overt bleeding. If someone calls and says they're bleeding on the order of a menses, then that's a different story. Andrew Schorr: All right. So there are these three babies developing. You want them to all thrive, so there's measurements going on all the time. What are you looking for? And let's say in the rare case that there are identical twins as part of the triplets or somebody might be having identical twins alone, what are you looking for as far as their equal development, if you will? Dr. Schrimmer: Well, with multiples we are constantly tracking their growth, and we are looking for what we call concordant growth, which means that the babies are within about 20 percent of their estimated weight of each other. And in this case with triplets we want them to be roughly equal in size. So we're measuring them about every four weeks to make sure that they're staying on track and that one or more is not beginning to lag behind. At the same time we're looking at how they develop, and we're looking at their different organs especially the heart to make sure that it's able to function normally, and we look at the amniotic fluid within each sac. And those are indicators of whether, in this case with a shared placenta with the identical twins, whether there's any shunting of blood which is going on from one twin to the other.


Andrew Schorr: Okay. And that of course deals with identicals. If, let's say, each baby has its own supply, if you will, maybe that's not an issue but you're looking at how they're each being formed. So all these ultrasounds and measurements, what are you looking for there. Let's say if the blood supply is separate for each one what are other things you're looking for with the babies? Dr. Schrimmer: Unfortunately, depending on where that placenta implants, not each baby gets an equal placenta, so we run into the problem where the babies are programmed to grow, one of them gets a nice normal placenta and is growing perfectly, and the other one gets a very small placenta, and it literally tries to outgrow its placental supply of oxygen. So you can be in the unfortunate situation of needing to deliver both of the babies because one of them is actually outgrowing its source of food and oxygen because it's just simply got a small placenta or there's something wrong with that placenta. So even when they're completely separate it doesn't mean that they're going to be equal in their size or their function. Andrew Schorr: Doctor, as a woman goes through pregnancy of course you're concerned about her health and the baby's health, conditions the mom may develop. For instance one that I think of is gestational diabetes. Does that happen more often with multiple birth pregnancy? Gestational Diabetes and Multiple Births Dr. Schrimmer: There is absolutely no question that that increases. When I teach here at the university about multiples, I often tell our house staff that having twins or triplets is basically like having a pregnancy on steroids. So everything that can happen to you in terms of gestational diabetes, hypertensive disorders, bleeding, all of these things can happen sooner, and they can happen in a much more severe manner. So we constantly worry about those other entities, and, as you said, gestational diabetes is a leader. Preeclampsia is another one, maternal anemia and then complications of course of the delivery. Andrew Schorr: That preeclampsia, that refers to the blood pressure. Is that right? Dr. Schrimmer: Yes. Preeclampsia is a syndrome of hypertension and swelling, but it also can affect the fetus in a very severe manner because its placenta tends to not be working as well. Andrew Schorr: So you're looking for all this. Now, we mentioned ultrasound, and I know a lot of measurement is done with ultrasound, but it used to be with tape measures and a lot of wisdom of the doctor and the nurses. Are there blood tests as well, and what are they looking for?


Dr. Schrimmer: The blood tests work the best in terms of looking for maternal conditions, so they are excellent at looking for maternal anemia as well as preeclampsia, gestational diabetes and some of the more rarer disorders such as gallbladder problems or liver problems that can occur in pregnancy. So really the emphasis of the blood tests is on the maternal side. I think in the future that that will change as we begin to detect more and more fetal substances that leak across into mom's bloodstream, but currently it's best for looking at the mom. Andrew Schorr: Well, this will all bring up a question which we'll discuss in our next segment, and that is when you find something what do you do about it. We talked about bed rest, and of course that could be one approach, but lots of others, and medical science has come a long way. And then we'll also get some advice from Ted and Monica for families who have gotten the same news and are in the midst of it just as far as coping as parents. That's all coming up as we continue our discussion on multiple birth pregnancies and we hear more from our expert guest, Dr. David Schrimmer. Andrew Schorr: Welcome back to Patient Power. Andrew Schorr here. This program is sponsored by US San Diego Medical Center. We're visiting with a leading perinatologist, a specialist in high-risk pregnancy, that's Dr. David Schrimmer, who is a professor in the division of perinatology at UCSD. And we have also with us a family he helped, Ted and Monica Fogliani, who had triplets in December of 2008 after fertility treatments and ended up with identical twin girls and then a little boy, Christian, as well, and all has gone well, thank goodness. Dr. Schrimmer, so when you find something, now, of course the something could be many, many different things, but let's talk about some of the things you find and where we are with medical science at UCSD and how you are able to intervene and help. Dr. Schrimmer: Well, it's a great question, and if I think about that I have been really lucky in that I have been able to witness I think one of the greatest advances in obstetric care during the course of my career. So when I first started in medicine, which is now 19 years ago, there was this new invention called ultrasound, and for the next five years or so people lived with ultrasound and tried to figure out exactly what it was they were seeing and what it meant. From there as the quality of the machines got better we began to identify growth patterns, now confident that we understood at least what we were looking at, and we started to look at things as they were going wrong. So are babies growing appropriately? Do they have abnormalities? Is this going to be a normal child or is this an abnormal child? And then finally over the last few years we're beginning to actually begin to treat the fetus in utero. So we've sort of come through an evolution of finally being able to look inside of the uterus to see how the baby is developing, to recognizing


patterns of abnormalities, and now we sit on the edge of the science in terms of beginning to actually treat babies before they're born such that they can survive or that we can alter their life before they are out into the world. Andrew Schorr: That's really incredible. Now, I know one of the interventions can be with a laser. Tell us where that comes in. Laser Surgery in Fetal Development Dr. Schrimmer: Laser surgery, it's commonly called fetoscopy today, is used in the situation of identical twins, so Ted and Monica were at risk for this with their identical twins even though they were having triplets. And in about 10 percent of identical twins they have a shared placenta with blood vessels that connect to each side of that placenta and over time one baby shunts blood to the other baby, and you end up in the situation where one baby has basically too much blood and it doesn't know what to do with all of it and it puts a tremendous strain on its heart trying to pump all of it, and the other baby becomes progressively more anemic. And this can progress literally to the point where that baby has not enough blood to survive. And with laser surgery we can now put a small three millimeter scope into the uterus, just through the abdominal wall with a very tiny incision, and we can actually trace those blood vessels on the placental surface, and we can find the ones that connect and we can laser them and we can interrupt them, therefore providing each baby effectively with a placenta. Andrew Schorr: Wow. That's incredible. Now, that's in the case where there's identical twins and you need to make sure they're getting equal supply. Well, in triplets for example I know it's not common at all to have identical twins, and identical twins aren't common anyway. So what are other interventions that would apply more broadly if there is a concern in a multiple birth pregnancy? Dr. Schrimmer: Well, unfortunately with twins even though they may or not be identical certainly their abnormalities are not identical, and there is fetal surgery today which is working on fixing a diaphragmatic hernia, for example. There is a study that's looking at fixing spina bifida before babies are born. And there are problems with the fetal lungs which are also being treated before birth. Andrew Schorr: And these are the kind of advanced treatments that happen at an academic medical center such as UCSD. Doesn't happen everywhere. Dr. Schrimmer: No. Unfortunately the teams of individuals that need to be trained and the specialized equipment limits that to academic centers, and there is approximately 12 centers in the United States.


Andrew Schorr: Right. And your center of course has been consistently recognized as one of the best. Let's talk about mom for a minute. So we talked about gestational diabetes. We talked about this hypertension during pregnancies, other issues. What about interventions for mom? Interventions and Breakthroughs for Pregnant Mothers Dr. Schrimmer: Well, these are certainly improving as well. We are on the edge of having diagnostic tests for preeclampsia. Where we used to just sit back and wait for this to develop and then we would really try to play catch-up in effect, trying to keep mom healthy or to prolong the pregnancy, we are now developing blood tests which will help us predict who is at risk. In addition a very large problem with multiples has been that at the time of delivery with hemorrhage and operative risks, and our ability to deal with that has just improved dramatically over the last decade. So we are anticipating the hemorrhage problems that now occur, and we try to be always one step ahead of them, and in fact it's quite rare now that you hear of a hemorrhage problem. So that's been really a major advance. When I was in training I saw at least a half dozen cases or so where mom simply did not survive the hemorrhages that occurred at the time of delivery of multiples. So that's been a dramatic improvement. Andrew Schorr: So you said staying a step ahead. It sounds like that's sort of the name of the game related to pregnancy, but certainly, as you said, pregnancy on steroids with multiples. Dr. Schrimmer: Absolutely correct. Again, when I teach I always try to teach our house staff that we try to be one step ahead of the next problem. We try to anticipate what that problem is, and we try to interrupt the cycle that's going to make that problem come to fruition. So if you're measuring the cervical length and you see the cervix shortening, we now understand that to be a predictor of preterm labor, and we can start altering lifestyle early in the pregnancy, putting mom to bed rest, and we can greatly prolong the pregnancy because we saw something coming, and that's really the key to success with multiple gestation. Andrew Schorr: Ted and Monica, so you listen to all this and you notice they were doing all this measurement. So, Monica, all that attention, while it could raise your blood pressure a little just going through all this and knowing what they were looking for, you must have felt comforted that they were monitoring this so closely.


Monica: Absolutely. As a woman trying to figure it out, like how is all this going to work out for you, so you just trust your doctor and they're doing all these tests and all this measurement and all that, you just feel great to know that they're taking care of you and they know what they're doing and everything for us worked out great. Andrew Schorr: Now, you remained a pretty active lady. You were telling me earlier you were still going up and down the steps like at 28 weeks. Monica: Yes. Andrew Schorr: Wow. And ended up with no bed rest. You ended up though as most do with cesarean section, and you knew that was coming, that that was likely, right? Monica: Yeah. Yeah, we discussed that before it got to the time the babies were born. But, yes, I think I knew that, that we were going to do that. Andrew Schorr: Doctor, let's talk about that. So that's typical, right? Why is that, you know, so many women want to have natural childbirth and this and that, but things kind of change the picture a little with multiples. Tell us why that's necessary. Dr. Schrimmer: The biggest issue with that is really the presentation of the babies. And with one baby it's pretty easy for it to line up, hopefully head down or head first, but when you get more than one they start going in all different positions. So we have delivered actually quadruplets normally or vaginally, and it can certainly be done, but if they're all going in different directions and one or two of them is sideways in the uterus, then it's really the safest for the babies to go straight to cesarean. Andrew Schorr: And as you said safest for the babies, and as you were looking back at your career what's safe for mom, too. Dr. Schrimmer: Well, I think that's a matter of preparation. You can have a normal delivery, but you need to be prepared for the fact that you could have hemorrhage at the time of the delivery, so either way it's really, it comes down to preparation and being ready, having blood available, having the appropriate drugs available to help you deal with the hemorrhage, having surgeons available to help you. In either case I think again it's just being one step ahead, hopefully not needing any of it, but if it comes up you're ready to go.


Andrew Schorr: So, Doctor, you look back over your career and you've seen tremendous changes. How do you feel about your team that you have there at UCSD? Dr. Schrimmer: Well, that's been exceptional, and I feel really very, very fortunate to have landed at UCSD. I have worked with a sonographer, Gina James, who is just extraordinary. She can see things on ultrasound that the rest of us would never see, and she helps me see exactly what's going on in there. The rest of the labor and delivery staff is also superb. They're well trained in how we deal with multiples, so fortunately we have the volume that they're not a surprise, the volume of patients that they're not a surprise to us, and they're always ready to go. And then the rest of my colleagues, my partners in the perinatal division, they are a superb group of physicians. We each have our own area of expertise, and when I have for example a hypertensive problem in a patient I have a hypertensive expert that I can go to and we can combine that with all the different complications and complexities that come up. So the support overall is really incredible, and it makes it a pleasure to work at UCSD. Andrew Schorr: Right, a pleasure for you, and, Ted, I understand you sometimes have a little more anxiety about some of the things that could have happened than Monica. Seems like she's a low key lady, at least she sounds that way today. So were you comforted and felt that things about being handled and if something needed to happen they were well equipped to do that? Ted: Yeah, there was no doubt on that. They made great decisions, and we were smart enough to trust what they were doing, and it took us, you know, after our first meeting to realize that we ended up at the right spot to get through this as well as we could. Andrew Schorr: All right. So there are couples listening who have not gone very far down this road is all. Maybe they found this program because they just found out. I'll start with you, Ted. Ted, what would you say to them that you learned looking back that maybe would be helpful to them, knowing it's a high-risk pregnancy and not knowing exactly how it's going to go? Advice From Ted and Monica Ted: I think you need to get to a multiple specialist as soon as you can. We're fortunate to be at close to UCSD as we are that it was a relatively simple decision for us because the facilities are great, the doctors are great, and we found a practice that we just trusted a hundred percent. You've got to trust your doctor because you're going to have to listen to them because it's something that you probably haven't gone through before and you probably aren't going to go through again. So meet


the doctors, go to the practice, and if you're not near UCSD you need to get to a facility that has the same facilities that they have and the same equipment that they have to get through this. Andrew Schorr: Monica, what about you? So there are moms out there. I have a friend who had triplets, and I can imagine when she just found out. What would you say to that woman, whether she's 24 or 34 or older, who has found out she's having multiples so that she can go on this journey with sort of her head in the right place? Monica: Absolutely. Just like Ted said, just go to a specialist because, like he said, they know what they're doing. Light Dr. Schrimmer told me in the beginning when we first met, he's like, I've done this a lot of times so you can call me with a problem and I can tell you exactly what's going on. And, you know, since that moment I just felt confident that he was going to take care of me and the babies and that everything was going to be okay so long as I followed their direction. And fortunately for us everything went amazingly great. So definitely have to have someone that you trust and everything just will work out good. Andrew Schorr: I sure hope so. Well, all the best to the two of you. And you've got your big brother there, Ted didn't, and then you got the girls, let's see if I get it right, Natalia and Camilla. And then Christian, who is the light-weight guy compared to the girls. They're probably going to be all over him for years, but I'm sure it's all the best to you. And, Dr. Schrimmer, just one last thing. She just mentioned something, Monica did, about you encourage calls so if somebody is worried about something or something is changed you as a specialist want to hear about it, right? Dr. Schrimmer: Yes. We definitely want to know about it, and we like to know about it sooner rather than later. Andrew Schorr: Okay. Staying ahead of the game. Dr. David Schrimmer from UCSD Medical Center and in the division of perinatology, thanks for being with us and thanks for helping couples like this and babies who, you know, years from now those triplets are going to walk in, they're going to pat you on the back, and they're going to say thank you, okay? Dr. Schrimmer: I look forward to that. Andrew Schorr: Okay. Thank you so much, everybody, for being with us. This is what we do on Patient Power, and I'm so grateful to UC San Diego Medical Center for having the


teams they do, and I get to interview them and learn a lot, and we hope it was helpful for you. Remember, knowledge can be the best medicine of all. I'm Andrew Schorr. Thanks for joining us. Please remember the opinions expressed on Patient Power are not necessarily the views of UC San Diego Medical Center, its staff, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you’re your own doctor, that’s how you’ll get care that’s most appropriate for you.

potential complications of multiple births webcast march 8...

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