Twin Articles
Adopting Twins a Special Blessing
NUTRITIONAL IMPLICATIONS IN TWIN-TO-TWIN TRANSFUSION SYNDROME
Identical twins with shared (monochorionic) placentas develop twin-to-twin
transfusion syndrome (TTTS) from movement of blood through vascular connections
in the placenta. Everything else about TTTS seems to be considered poorly
understood or enigmatic, or controversial such as which treatment option is
best. TTTS investigators have had difficulty: a) showing significant differences
in blood counts between the twins by fetal sampling or at birth; b) trying to
demonstrate transfusions from one twin to the other by injecting substances Into
the donor and sampling the recipient; or c) trying to link clinical outcome to
placental findings at delivery. Clearly, there are factors that remain to be
identified in the pathophysiological process of TTTS.
We recently published a study reporting nutritional abnormalities in women with
TTTS pregnancies (Twin Research 2000;3:113-7). In almost 100% of our patients
seen for placental laser surgery, we observed below normal blood counts (anemia)
and blood proteins (hypoproteinemia). These findings in the mothers, who have
typically been ignored in TTTS research and fetal therapy in general, may
explain, in part, amnionic fluid production rates in the twins. In addition,
these findings may explain why some women with twin or higher multiple pregnancy
experience serious complications when treated for premature labor and the like.
Individuals with nutritional deficiencies have low levels of an important blood
protein called albumin. Albumin has many functions in our blood streams, but it
is mainly responsible for maintaining our colloid osmotic pressure (COP). This
means keeping water in our blood streams, as water is strongly attracted to the
albumin molecules. When low COP exists, water leaks into our tissues and we can
develop swelling (edema) and abnormal weight gain.
As a consequence of transfusion between TTTS mates, the donor develops lower
albumin than normal, and the recipient a higher level. The high COP in the
recipient eventually leads to excess amniotic fluid (polyhydramnios), as this
twin absorbs water from the mother through the placenta. Polyhydramnios is the
most problematic finding in TTTS, and without treatment the main cause of
pregnancy loss. If the protein levels go down in the face of nutritional
abnormalities, the recipient twin, who may then have a level higher than the
mother, absorbs greater amounts of water from the mother. The degree of
polyhydramnios and classification of TTTS as mild or severe based on the volumes
of amniotic fluid observed at ultrasound and/or removed by amniocentesis may,
therefore depend on worsening (or improving) maternal nutritional factors.
Returning to potential problems in the mother, the swelling could be localized
to her ankles, or she may gradually develop water in the lungs (pulmonary
edema). There are many reports of such serious complications in mothers of twins
when they are treated for pre-term labor or undergo fetal surgery, but no one
has identified the specific reason for these. We believe the abnormal metabolic
parameters seen in our study population, the low protein levels (low COP) in
particular, may be partially to blame. At our institution, we administer
intravenous fluids cautiously and monitor weight closely when treating
complications of multiple pregnancy. The swaying from maternal water retention
and polyhydramnios in tie recipient twin will both contribute to significant
increases in weight, which renders maternal weight gain an inaccurate
determinant of actual nutritional status. Ironically, significant weight gain by
mid pregnancy is desirable, but our findings dictate that caution be use in
interpreting maternal weight.
The nutritional deficiencies of women with TTTS IikeIy develop from the demands
of carrying more than one fetus. a greater tendency for morning sickness and a
larger uterus that normal for the gestational age factors which are beyond one's
control. Is there something that can be done to potentially counteract the
nutritional component of TTTS and serious maternal complications? The 'why' of
supplemental nutritional therapy is outlined in table 1. For the last 9 years,
we have advocated that TTTS mothers, empirically regardless of the severity of
the findings, augment their three daily meals by drinking slowly, throughout tie
day, 2 to 3 cans of Boost High Protein (or Carnation Instant Breakfast, NuBasics,
etc.). These products are convenient to use, and provide additional protein,
calories, minerals, and vitamins efficiently. The should be consumed until the
birth of the twins.
Women with TTTS may now have a means to participate in their own treatment, and
do something in behalf of their babies and themselves.
Julian E. De Lia. M.D., F.A.C.O.G.
Judy Zunk, M.S., R.D., C.D.
International Institute for the Treatment of Twin-to-Twin Transfusion Syndrome
St. Joseph's Hospital
Milwaukee, WI
USA
Table 1. Proposed Benefits of Supplemental Nutritional
Therapy in TTTS.
• Correct maternal deficiencies
• Reduce the risk of maternal complications
• Reduced mother/recipient albumin difference
• Reduced amniotic fluid production in recipient
• Maximize growth and development of the twins
• Maximize twin's weight for likely early delivery
Adopting Twins a Special Blessing
Wendy Lucht, Palmyra WI
As parents of multiples, I’m sure you know the routine all too well. A person approaches you and your twins and proceeds to ask questions about them or upon finding out that they are twins, says to you that old stand-by phrase “Double trouble!”, and you quickly reply, “Not double trouble, but a double blessing!” We, too, have had that conversation more times than we wish to count, but if only those people could know how special our double blessing is, as our twins are adopted.
Every adoption story is unique. It took us thirteen years on-and-off of various medical tests, procedures, and then IVF to become pregnant finally with twins. The pregnancy lasted about ten weeks and then a routine ultrasound showed that our precious babies were gone. Our dreams were shattered. We tried IVF one more time but with no success. The years of infertility procedures had taken an emotional toll on us and after much soul-searching, we decided to build our family through adoption.
We were somewhat familiar with adoption as some of our friends had adopted children. We began on our adoption journey by choosing an agency that one of our friends had adopted through, Special Beginnings Adoption Services, which is located in Waukesha but also has offices in Madison and Appleton. Special Beginnings is a division of the national organization Volunteers of America. We met with the agency director and filled out many forms, including our choice for an open or closed adoption, and specifics for what we preferred in a child, such as age, race, medical conditions we would accept, single child or more, and the birthparents’ medical and social history.
The next step was our homestudy, which is a process required by the State of Wisconsin. A homestudy does not involve checking to see how neat and clean your home is, but includes a search and clearance procedure of prospective adoptive parents. They check police and driver’s records, employment and insurance verification, protective service reports from County Human Services and request personal references. A social worker interviewed each of us individually and also together and asked us questions about many topics such as our understanding of adoption, motivation to adopt, family history, marital relationship, religion, lifestyle, personality, what we desired in a child, etc. We each also had to have a medical check-up. After we successfully completed our homestudy, we received our foster care license from the State of Wisconsin and were accepted into the agency’s pool of waiting families.
Our agency required us to write a profile to be shown to prospective birthparents; some agencies have adoptive parents make a video about themselves. Our profile included a handwritten letter to the birthparents about why we were looking to adopt, a written narrative about ourselves and photos. Special Beginnings’ philosophy is to have the birthparent(s) select the adoptive parents they feel would be the right choice as parents for their child and they could look at the profiles of waiting families and then meet with the one(s) they chose. You often hear people say that a birthparent “gave up their child for adoption”. A better way of saying this is that the birthparent “made a parenting choice” or “placed their child for adoption” and with the current increased involvement of birthparents in the adoption process, these positive phrases are certainly more appropriate.
We began attending the “Waiting Families” group provided by our agency, where we received various handouts on adoption and could share any feelings, frustrations or hopes about adoption with other couples. Little by little, our group would change as couples became parents after being chosen by birthparents and then having their adoption finalized. Some couples were chosen after only a few months and others had a longer wait. You may wonder if it is rare to adopt twins, but two other couples in our group adopted twins. We waited…and waited…and waited – two years of waiting. It seemed like an eternity! We wondered if we would ever become parents! Then came the day we will always remember as I received a phone call at work that changed our lives forever.
Our social worker asked if we would be interested in adopting twins who were two and a half months old, were preemies, both had severe acid reflux and were both on apnea monitors. Wow! Not one baby, but two?? We were thrilled, nervous, and excited! A week later we went to meet Hunter and Hailey at their foster mother’s home and for the next two months we made weekly trips to see them. We had many meetings with our agency social worker, a social worker in the county where the twins lived and met Hunter and Hailey’s birthmother. We also met another special set of fraternal twin boys, Austin and Taylor, who are Hunter and Hailey’s full siblings. They, too, are adopted and we quickly became friends with their parents and continue to get together with them regularly so the children will grow up knowing each other. We both also visit once a year with our childrens’ birthmother and send her pictures.
The two months before we brought Hunter and Hailey home seemed to go slow at times when we were waiting for paperwork to be completed and yet time also went by too fast. We had recently begun a complete renovation of the upstairs of our house and in those two months we went from open walls to finished rooms, feverishly working every night after our day jobs with the help of my parents to get the work done. I have to say between the worry about finishing our upstairs and the ups and downs of the last part of the adoption process, I ate a ton of antacids! The support from family and friends helped us get through the last nerve-wracking weeks. In preparation for the arrival of our babies, I quit my job of the past sixteen years and John took paternal leave from his teaching job.
Finally the day arrived when we drove to our foster mother’s house to bring home our babies. It was an emotional day for us as well as the foster mom and the county social worker, who had grown close to these little babies. We did not tell any of our family or friends what we were doing for fear that a last minute delay would change the plan. All went well though and we arrived home and called everyone to tell them of our good news! The babies were home!!
The next several months were a blur as any new parents of multiples knows! Making a lot of bottles, having many visitors including weekly visits from our social worker, plus dealing with the acid reflux and apnea monitors kept us busy. We had three wonderful baby showers and friends and family loaned us baby furniture and other baby items so we had enough for two babies. After six months time, we celebrated the official of our adoption of our children. The courthouse finalization brought us peace of mind that we were now truly parents, and I think our Christmas letter that year summed up our feelings as it began “Miracles happen, prayers are answered, dreams do come true!”