Saving Twin Babies

Dr. Robyn Horsager
Chief of Obstetrics and Gynecology, UT Southwestern Medical Center University Hospital-Saint Paul

ToughestCase3_RobynHorsager Dr. Robyn Horsager photography by Adam Fish

A woman and her husband had come to me for a third opinion. She was in her late 30s, and, after working with an infertility specialist, she was finally pregnant for the first time with twins, a boy and a girl. Unfortunately, when she was three and a half months pregnant, the amniotic sac around the little girl had ruptured. She had come to me seeking advice on how the pregnancy could be managed.

When somebody’s sac breaks, we have to look at two issues. The first is that the sac protects the uterus from getting infected, and when that membrane ruptures, the chance for infection increases. When infection sets in, you can lose the entire pregnancy. That was a concern in this case, although it had already been a few days, and she didn’t show any signs of infection.

But the more critical issue, at least for the baby, is that a fetus needs fluid around it in order for its lungs to develop. Without the fluid, babies can survive in utero but they won’t have enough lung tissue to breathe after they’re born. It’s called pulmonary hypoplasia, and we don’t have a good way to figure out if that’s going to be the case or not.

One solution that had been proposed to her is something called selective reduction, in which you convert this twin pregnancy, where both babies would be at risk if infection set in, to a single pregnancy with the one baby. And that would have been the boy in this case. People had recommended this as maybe the best option.

But that’s a devastating thing to face when you’ve worked very hard to become pregnant. I have a set of twins myself, and I understand how she could feel about having to make a decision to lose one baby to save the other. That being said, if it were truly something that I felt was dangerous to the mother, or if I could have told her that there is a 100 percent chance that one baby is not going to survive, then I would have done that as well.

We did an ultrasound, and clearly the girl didn’t have fluid around her, but the boy’s sac was completely normal. We talked about the possibility of losing both babies and the possibility of both babies being born alive but the girl not surviving because of the pulmonary hypoplasia.
At the end of that visit, she decided to continue with the pregnancy as it was and asked if I was willing to co-manage her pregnancy with her obstetrician. And I said certainly.

I get a lot of people referred to me, and the first thing out of their mouths is “Well, my doctor told me to do this.” My goal is to get people to the point where they are comfortable with their decision. I don’t have to live with the consequences necessarily, but they do, and they need to be given as much information as possible to balance the pros and cons.

She came in weekly, because we didn’t know if the girl was alive unless we looked at her on ultrasound. Then we decided to use a magnetic resonance imaging (MRI) study. We had used them for other conditions, but we thought maybe we’d have a sense of how much lung was present when the baby reached viability, and that would help us make a decision as to how to manage the patient. We had to walk a fine line between doing the right thing for both babies and not jeopardizing the little boy.

The MRI suggested that the girl’s lungs weren’t as developed as we had hoped, and it was a teary day. Still, we continued the course. Ultimately, after about 28 weeks of gestation, my patient had some vaginal bleeding. She was having some premature separation—and not with the girl, but with the boy.

She had a cesarean section, and the end result was that the girl spent only days on a ventilator, while the boy spent a longer period of time in the NICU, which was normal given his sex and gestational age.

Both babies did remarkably well, and a year later, the patient, her husband, and both children showed up in my waiting room—on the twins’ first birthday. They brought me a lovely framed portrait of the babies, and it still hangs in my office. I look at it every day and am reminded that the practice of medicine isn’t always easy, but it’s incredibly rewarding.

—As told to K.L.