Arya and Kinsley Schwartz were born to a grateful mom and dad via cesarean section at the Childbirth Center at Missouri Baptist Medical Center, but it was a long and at times uncertain road to their successful delivery
Last year, St. Louis mom Sara Schwartz discovered she was pregnant with not one but two babies––identical twin girls. Sara, who was already a mother of three to children ages 12, 11, and 9, felt excited about her “bonus babies” on the way, despite it being a high-risk pregnancy.
The good news wasn’t without a complication. Early in her pregnancy, Sara and her husband, Stephen Schwartz, learned that the babies were sharing a placenta and had to be monitored to ensure they were growing and developing at the same pace.
“The doctors told me about the risks of both babies sharing a placenta and that there was the possibility of me developing twin-to-twin transfusion syndrome,” Sara said. TTTS is a potentially life-threatening condition for the fetuses in which one twin receives more blood and nutrients via the blood vessels in the placenta.
Steve Liao, MD, the Chief of Pediatrics at Missouri Baptist Medical Center, explains that 1 in 7 pairs of twins who share a placenta will develop TTTS.
Sara started to receive co-managed care by a team of providers. Her primary obstetrician, Jennifer Smith, MD, a Washington University OB-GYN at Consultants in Women's Healthcare, and BJC Medical Group maternal-fetal medicine specialist Michael Paul, MD, who consults on high-risk pregnancies at Missouri Baptist, watched her closely.
“At Missouri Baptist, we have an excellent team and a strong relationship with the Barnes-Jewish Hospital Fetal Care Center to help treat TTTS,” Dr. Liao said. “One of the things that tends to happen with TTTS is prematurity. TTTS babies tend to be delivered early and may have premature lungs, premature kidneys, and premature intestinal tracts. We are very good at providing care for these premature babies.”
“I was being seen by one of the doctors every two weeks, and everything had been going smoothly,” Sara said.
However, right after the winter holidays, one appointment changed everything.
Racing against time
“I could tell right away there was something wrong,” Sara remembers. At her 17-week appointment at Missouri Baptist, she recalls how the sonographer was interested in the area around the babies’ bladders during her ultrasound. Once she was back with Dr. Smith, the doctor told Sara that the ultrasound had revealed a difference in fluid levels in the amniotic sacs. “Baby B seemed to have a whole lot of fluid, like a swimming pool,” Sara remembers. “Baby A hardly had any fluid. Baby A kind of looked like she was shrink-wrapped, and they couldn't see her bladder. And that is often times indicative of twin-to-twin transfusion.”
Katherine Bligard, MD, a WashU Medicine maternal-fetal medicine specialist at Barnes-Jewish Hospital and St. Louis Children’s Hospital, explains that because of the difference in the placenta’s blood vessel connections, Baby A was dehydrated and Baby B was overly hydrated. “Amniotic fluid is baby's pee,” Dr. Bligard says. “So if a baby's dehydrated, they're going to pee less, and so they make less amniotic fluid. Both dehydration and overhydration can make babies very sick in the uterus.”
Risks for fetuses with TTTS include organ failure and heart complications, and it can be fatal for one or both babies if there’s no medical intervention. With TTTS, quick intervention is critical following detection.
The next day Sara was sent to the Fetal Care Center for another, more in-depth scan, which confirmed her twins had TTTS. Luckily, there was a procedure that could help: a minimally invasive laser ablation surgery done while the babies were still in utero. The Fetal Care Center is the only provider in the St. Louis region that offers laser intervention for babies with TTTS. This early intervention can make a significant impact and be lifesaving, especially because the condition can progress quickly—two weeks earlier, Sara’s amniotic fluid had looked normal. Sara and Stephen knew that time was of the essence.
The couple weighed their options and decided that their goal was two healthy babies. Sara would move forward with the laser ablation surgery the morning after her diagnosis.
Whispered promises
Sara’s surgery was scheduled for 17 weeks and five days gestation at Barnes-Jewish Hospital. Dr. Bligard explained that during the procedure, she would make an incision in Sara’s abdomen and insert a camera into the bag of fluid that surrounded Baby B, the twin who had more amniotic fluid.
“We look with a camera at the placenta to see those blood vessels, and we use a laser to seal off the ones that communicate between the two babies so that the sharing of blood is no longer possible,” says Dr. Bligard.
Within 24 hours after the surgery, the doctors would know if the surgery was successful based on the fluid collecting around the babies. In the days and weeks following the surgery, doctors should be able to see both babies growing, signaling the procedure’s continued success.
On the morning of her surgery, Sara appreciated how her medical team made her feel well cared for. “We arrived, and a whole team of people was ready for us,” Sara says. “They were so thorough in explaining everything that was going to happen and what was going on. They did it all so quickly, too.”
Before Sara was taken to the fetal care operating room, Stephen whispered to Baby A: “If you survive this surgery, I call dibs on naming you.”
Signs of life
Twenty-six. That’s the number of shared blood vessel connections between Sara’s twins that the Fetal Care Center team was able to ablate. After the procedure, Dr. Bligard assured Sara and Stephen that the surgery had gone as well as possible, but as welcome as that news was, the couple still had a difficult day ahead of them. Sara and Stephen still had to wait 24 hours after the surgery to ensure both of their babies still had heartbeats. The agonizing wait was practically unbearable, so the parents requested updates before the 24-hour mark.
“It was a 7 a.m. surgery, and the medical care team came in that evening—12 hours later—and said there were still two heartbeats, but that they didn’t want to give any false hope,” Sara remembers.
Finally, after 24 hours, Sara and Stephen were told that both babies still had heartbeats. The couple was overjoyed.
After she was discharged from Barnes-Jewish Hospital, Sara was co-monitored by Drs. Smith and Paul every week until 32 weeks and five days gestation, when Sara and Stephen’s identical twin daughters, Arya and Kinsley, were born at the Childbirth Center at Missouri Baptist. The twins stayed in Missouri Baptist’s level 3 neonatal intensive care unit for three weeks, and today they are thriving.
Similar to the high level of care offered at the Fetal Care Center, Missouri Baptist is known for its excellence in maternity care, particularly with multiples. Dr. Liao attributes this in part to the nursing staff. “Our nurses are great,” he says. “We have a very stable core group of nurses that are NICU-trained. The average years of experience of our nurses is 10–15 years, and that absolutely makes a difference.”
Dr. Liao emphasizes the emotional care families receive in the NICU as well. “The nurses here know the emotional journeys that these families go through. Our nurses are not just here to do a job, but they’re here to care for the family as a whole,” he says.
As promised, it was Stephen who named Baby A, the twin who Sara and Stephen worried wouldn’t survive the surgery.
“Her name is Arya,” Sara says. “It’s after a Game of Thrones character. Arya…a little warrior name.”
Learn more the level 3 newborn intensive care unit at Missouri Baptist Medical Center.