If you’ve found your way to this article, it’s likely that either you or someone close to you has been diagnosed with a monochorionic monoamniotic twins pregnancy, also known as MoMo or Mono-Mono by obstetricians.
A Google search for MoMo twins pregnancy throws up mostly scary stuff that often leaves the expectant parents confused and overwhelmed. That is why I decided to share my MoMo pregnancy story. The prime intent for sharing my story is to offer hope to parents-to-be who are faced with this type of pregnancy.
The good news
When I discovered I was pregnant, I was over the moon. The very next day, the nausea hit me hard with the morning sickness lasting all day. During my first appointment, my Obstetrician (OBGYN) got me to do a blood test called the beta-HCG to confirm the pregnancy. When the test results came back as a 4 digit figure [high!], she immediately suggested an ultrasound to rule out twins, because sky high beta-HCG levels too early in the pregnancy usually suggests multiples. However, the ultrasound confirmed a single baby.
The first trimester went by smoothly and the subsequent two follow-up ultrasounds showed a healthy, single baby and a single loud heartbeat each time.
And then there were two
At 12 weeks, I went for an NT scan. This is an ultrasound scan done to check for any chromosomal abnormalities in the baby. As the radiologist progressed with the scanning, he shared with me and my husband his observations—he said everything seemed fine with our baby. Then, as he was about to finish, he said he needs a few more minutes and looked intently at the screen as he moved the probe over my belly. In a few minutes, he uttered those words, after which life would never be the same: “Congratulations, you have twins”. My husband and I let out a gasp as we looked at each other wide-eyed.
Even before the news of twins sank in, the radiologist revealed that he can’t find a separating membrane between the two babies, which meant that both babies were in a single amniotic sac and shared a single placenta. [In lay terms, the amniotic sac is like a bag in which the baby grows and the placenta is likened to a kitchen from where the baby gets food.]
The radiologist didn’t seem pleased with this discovery and went on to inform us that this type of pregnancy is called a MoMo pregnancy and it is extremely rare and is considered very high risk. He said one of the commonest issues with MoMo pregnancy was the risk of the babies being conjoined, but thankfully that was not so with our babies. However, because a pregnancy of this type comes with several risks, he believed my OBGYN will most likely ask me to terminate the pregnancy.
Dealing with the shock
Both my husband and I were dumbfounded. My head was spinning with all this information. The doctor asked us to wait outside till he prepared my reports and we stepped out in silence.
When my husband and I found our voices, the first thing we uttered in unison was, “Are you OK?” Yes, we were heartbroken at the prospect of having to let go of a cherished dream (and now they were two!) but we were more concerned about how the other is going to deal with this emotional blow.
As we left the radiology office, we reluctantly accepted that this was a joy short-lived while a part of us was holding on to that faint glimmer of hope—especially since ours was a natural conception and not assisted. We decided to visit our OBGYN right away.
Thankfully, our OBGYN didn’t suggest termination. She said that I could go ahead with the pregnancy if I wished to, but that I could no longer be under her care as my case needed an OBGYN with fetal medicine expertise. She wished me good luck and, on a parting note, advised that we should go ahead only if we could afford the expenses of a MoMo pregnancy and the sky high Neonatal Intensive Care Unit (NICU) costs, which the babies will most likely require as they would have to be delivered very pre-term.
What makes a MoMo pregnancy so high risk
We were at a crossroad and had to arm ourselves with all the information available before we took our next step. I began calling up my physician friends and sought their advice, while my husband stayed up through the nights researching everything he could on MoMo pregnancies. I also joined support groups on Facebook for moms of MoMo twins.
What we learned was that in a MoMo pregnancy, since both babies grow in the same sac and share a placenta, there are many things that could potentially go wrong:
- Without a separating membrane, the umbilical cords could get entangled or compressed, cutting off blood flow to and demise of one or both babies. Fetal death, usually of both babies, occurs in 70% cases
- Twin to twin transfusion syndrome [TTTS] is also common. In this condition, one twin receives more blood flow and the other receives less
- The risk of congenital anomalies is much higher in MoMo pregancies than in other types of multiple or single pregnancies
- Extremely premature delivery, which is a given in case of a MoMo pregnancy, brings its share of complications and risks.
In most developed countries, if you are expecting MoMo twins, you are hospitalised between 24-28 weeks and remain in-patient until the babies are delivered. This is required as the mother and babies are continuously monitored. Now, this is not easy—for the mother or for her immediate family, especially her older kids, if any.
What causes MoMo twins
A MoMo pregnancy occurs when a single fertilised egg splits into two. There is no known reason why this happens.
Unlike other types of multiples, the incidence of MoMo twins pregnancy does not increase with the age of the expecting mother. Indeed, MoMo twins are often diagnosed in young women.
Also, MoMo twins are not just seen in pregnancies resulting from IVF but also in natural (also called spontaneous) conceptions like mine. MoMo twins are always identical.
Seeking a second opinion
All this overload of information seemed too much and we decided to seek a second opinion from a trusted expert. That’s when my husband suggested that we meet Dr C, an OBGYN whom I had consulted once in the past.
The next morning, I made a call to a gynaec friend in Mumbai, who encouraged me to go ahead with the pregnancy, warning me that it was going to be a bumpy road and I should immediately get myself under the care of a fetal medical expert. As luck would have it, she too suggested Dr C, the same OBGYN my husband had said we should meet.
Meeting our OBGYN and planning the way forward
Dr C, who was a fetal medicine expert, first decided to repeat the NT scan to confirm whether this was indeed a MoMo pregnancy. The scan confirmed two healthy babies and no separating membrane. He also identified cord entanglement on a color doppler, which crushed any doubts of this being a Mo/Di [monochorionic diamniotic] pregnancy.
Dr C said I could deliver in his maternity hospital, and the babies could be managed in their NBSU [Newborn Stabilisation Unit]. However, in case they need ventilator support, they will have to be moved to a hospital with level-III NICU. To my absolute relief, he informed that there was no need for me to go inpatient at 28 weeks, provided we follow the plan he outlined.
Plan to manage my MoMo pregnancy
Here’s what my OBGYN recommended to me:
- I would have to undergo ultrasound scans every two weeks until delivery
- I would be on a low dose aspirin daily to manage the risk of pregnancy induced hypertension [high blood pressure] and preeclempsia
- My delivery would be at about 32 weeks, via C-section
- I would be required to take dexa injections before delivery — because my babies were going to be delivered several weeks before their full term, their lungs would be underdeveloped. These injections would provide a boost to the development of their lungs
- I would be administered magnesium sulphate [MgS04] before delivery, to protect our babies’ brains
While our doctor kept reassuring us that he knew what he was doing, my husband and I were well aware of our situation and the fact that the consequences of our decision would have to be borne by us, not our OBGYN.
Staying calm during your MoMo pregnancy
Here’s how my husband and I managed to stay calm clear-headed during our MoMo pregnancy:
- We made sure that we both fully understood and accepted the risks associated with this pregnancy
- Despite the COVID-19 pandemic and the stringent lockdown, we agreed to undergo scans every two weeks, or even more frequently when the doctors recommended, so that the pregnancy could be monitored closely
- We decided to take it one scan at a time. Since there was a high chance of things going wrong at anytime during the term, we were prepared to take some tough decisions if it came to that
- We stayed positive and, with every passing day, fell more in love with our babies—but we also gave ourselves and each other a reality check frequently
- This was difficult, but we agreed to not go ahead with the pregnancy if the scans revealed that the babies had any serious abnormalities. We agreed that it would be unfair to bring babies into the world only for them to suffer—this was our personal conviction. We knew that as per the Indian law we could only terminate until 20 weeks (it’s now changed to 24 weeks.) Of course, this would have been a very painful decision for us, but in such situations, time is of essence. We wanted to be clear about what each other wanted, right from the start so that there is no conflict later
- We kept the news of the twin pregnancy hidden even from immediate family, because we wanted to be able to take our decisions rationally and independently, without any additional emotional baggage or pressures
- Early on, we sought an estimate on expected costs and calculated whether this fit in our financial plans. Unlike many developed countries, pregnancy expenses in India are not covered by insurance. Multiple expensive scans, longer post-delivery hospital stay and NICU costs can make a MoMo pregnancy an exorbitant affair and we didn’t want surprises for which we were unprepared.
Monitoring and delivery
MoMo babies are typically delivered between 32 – 34 weeks. This often implies that the babies might spend some time in an NICU. Depending on which part of the world you live in,
- you may be required to check into to a maternity hospital after around 28 weeks for continuous monitoring till delivery or
- you may be asked to get a scan done every two weeks, and more frequently as the term progresses.
Either way, this is absolutely crucial in a MoMo pregnancy and should be adhered to, without any reluctance. I met Dr C every two weeks for a detailed scan and follow up. From 28 weeks onward, the scans were done every week and sometimes twice a week. During the last eight days, a scan was repeated almost every alternate day.
Delivery and neonatal care
A few studies have determined that the best time to deliver MoMO twins is 32 weeks + 4 days—this is when the risk of underdevelopment of babies’ organs is lowest while the risks of cord entanglement and TTTS are not yet severe. So, quite appropriately, my C-section was scheduled at 32 weeks and 4 days, under spinal anaesthesia.
A team of neonatologists and paediatricians were present in the operation theatre. Since the hospital I was delivering at was equipped with an NBSU, if my babies had any breathing difficulty and needed a ventilator, they would have to be moved to a hospital with NICU right away. Dr C ensured that the logistical arrangements for this had been made, with an ambulance on stand by and a team of neonatal experts waiting at the other hospital. My surgery was strategically scheduled for a Sunday morning, since traffic would be minimal and we would save on travel time between hospitals.
A happy ending and a new beginning
Our miracle culminated in loud cries of both my babies as soon as they were delivered—and in that moment I knew that they are fine and will not need a ventilator or an NICU.
My twin girls were born at 1500g [3.3lbs] and 1700g [3.7lbs] respectively. They were absolutely healthy and spent only 12 days in the NBSU, mainly for establishing feeding and for general observation. For the first two days they were exclusively fed formula. Once I was able to express breast milk [third day onwards], the nurses would feed it to my babies using a spoon. While in the hospital, though my babies were not with me in my room, I was encouraged to spend as much time with them as I could manage, even though it was physically draining, considering that I was still recovering from a complicated C-section and preeclampsia.
My babies turned one a couple of months back and have brought us indescribable joy, notwithstanding the stress associated with MoMo pregnancy and delivery as well as caring for two pre-term infants.
In the end, I am grateful that everything worked out wonderfully for us, but I also understand from first-hand experience that a MoMo pregnancy and delivery can be terrifying for the expecting parents and their families. Despite encountering discouragement from well-meaning others, my husband and I relied on our conviction that life often defies the odds. I do hope my story offers hope (and much needed information) to help you stay calm and deal with it one day at a time.
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