In part two of this episode, Dr. Rebarber continues the discussion on prenatal care for twins. He covers common complications including preterm birth and fetal growth restriction and how OB/GYNs can prevent or treat these issues.
“Prenatal Care of Twins Part 2: Preterm Birth & Fetal Growth Restriction” – with Dr. Andrei Rebarber
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics of women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
All right, we’re back with Andrei Rebarber. We’re talking about prenatal care twins. Last week, we talked about general prenatal care twins, sort of early pregnancy and how we counsel women about nutrition and exercise and what to take and visits. And we’re gonna focus today on a really interesting topic, which is the prediction and prevention of preterm birth and also fetal growth restriction. And we know, as we talk about this all the time, the two sort of big risks that twins have, women with twins have, is, number one, preterm birth, delivering early, which is extremely common. And number two, fetal growth restriction, which is where one or both babies is not growing as expected, which is also very common. How do you talk to women about this? Let’s start with preterm birth. How common is it? What should they expect? And what types of things might we do?
Andrei: Let’s take preterm birth. The average length of pregnancy for a singleton gestation is 40 weeks. And that’s what we give as the due date, 40 weeks from the last menstrual period. The average length of pregnancy in twins is about 36.5 weeks, which is 3.5 weeks earlier. That’s average, that means that 50% of twins deliver preterm, which is defined as less than 37 weeks. And, if you take triplets, for example, the average length of pregnancy is about 33.5 weeks.
And, so, looking at per fetus, you lose about 3 weeks in length of gestation per fetus. It’s kind of just a nice rule of thumb. And that, no matter where you go and who’s taking care of you, the national literature suggests there are just limited interventions to stop this. Primarily why we think preterm birth occurs in this population has a lot to do with the uterus kind of just stretching and uterus stretch, what they call, receptors and, at some point, that just stretch becomes too great. And, depending on the biology, and again, we know that there’s just genetic variation among all of us, about what will each individual uterus accommodate, it starts to get activated and says, “I’ve had enough, I’m not gonna stretch anymore,” and it basically goes into preterm labor.
There are other causes of preterm labor, this is mainly, what we call, spontaneous preterm birth. About 70% of preterm birth is due to spontaneous preterm birth but about 30%-40% of it is due to, what we call, “medically-indicated.” Medically-indicated preterm birth occurs when either the fetus is in danger inside and needs to come out or the mother’s in danger of continuing the pregnancy and we need to stop the pregnancy. And, so, medically-indicated preterm birth’s about 30% and can be due to either early onset severe preeclampsia or growth restriction in the fetuses.
And, so, particularly for twins, the growth restriction and timing of delivery becomes complex in the preterm period because you would sacrifice one who’s growing fine at the expense of the other who may be in jeopardy. And, depending on the gestational age, these sort of ethical management decisions and discussions with patients can become quite complex when you’re dealing around the time of, what we call, “periviability” or very remote preterm birth. And that’s a little more complicated, we can talk about that when we talk about the growth issues.
Dr. Fox: Yeah, I think that a lot of people are surprised to learn that, you know, here, in 2021, we don’t have good treatments for preterm labor, prevention of preterm birth in twins. I mean we’ve tried medications that stop contractions and they either don’t work at all or they work minimally. We’ve tried giving progesterone to all women who have twins, which has been effective in some sub-populations of women but doesn’t seem to help, you know, if [inaudible 00:04:11] twins. There have been studies looking at putting up a pessary, which is sort of a cervical stabilizer, in all women with twins. That doesn’t seem to help. Bed rest doesn’t seem to help. There’s really so little we have that’ll prevent preterm birth in all twins or in women who start contracting. And people are surprised by that, but why is it? How come nothing works? Is it just because the uterus stretches too much and that’s it, there’s nothing we can do, or do you think that it’s just we haven’t mapped out, you know, sort of the biochemical pathways well enough?
Andrei: I just wanna add also [inaudible 00:04:42] stitches, surgery does not work routinely, as does routinely doing pessary or progesterone for all twins. I think subsets of twins that may show certain signs, you might consider these various treatments, depending on the gestational age. And there’s data to suggest that, while we don’t stop preterm birth with some of these interventions in unique high-risk scenarios, we may prolong gestation. And I think that we may be looking at the wrong endpoint sometimes where we have these endpoints of preterm birth before 34, preterm birth before 37, but the reality is that individual cases can prolong gestation to even a week or 2 buying time with some of these interventions can be quite dramatic in the improvement of outcome. And I think that I’m not as nihilistic as some of my other peers in that nothing works because I actually disagree with that. I think nothing works to actually stop preterm birth, maybe that’s a correct statement, but I do think that we have various tools and treatments that we may be able to prolong gestation in situations where just buying time allows us to have simple interventions such as steroids to help the lungs mature, magnesium sulfate, so you’re buying time to get those on board to improve outcome to weeks of delay, for example, in some situations, that allow for prolongation of gestation. Which would improve outcome theoretically.
So, I think we just don’t have good ways to measure on individual basis if a particular intervention prolonged gestation versus not. And, you know, we do have randomized controlled trials on some of these, but again they do fall short in the numbers that are recruited for unique situations where these treatments may actually work.
Dr. Fox: Right. And just to clarify what you’re saying is I absolutely agree with you. We haven’t found anything that works in all twins, meaning we can’t say, “All right, you’re twin pregnancy, you’re 8 weeks or 10 weeks or 12 weeks, start doing this and it’s gonna help you across the board.” But we do screen twins for a lot of different things and there are unique circumstances in individual situations where, like you said, there are treatments that might prolong pregnancy enough time to make a difference in the outcomes, even if it doesn’t prevent delivery before 37 weeks, let’s say. I would say the only intervention, and we spoke about this in the last podcast, that probably does work across the board is good nutrition, amazingly, that simple thing. But in terms of like high-tech stuff, no, nothing seems to work. And, so, that is an important thing. And, so, one of the things that comes up a lot…
Andrei: Good nutrition and baby aspirin probably.
Dr. Fox: Yeah, baby…probably, no agree…
Andrei: Because, believe it or not, that might actually help to prolong gestation because preeclampsia doesn’t develop or develops later. So, that may actually in and of itself avoid medically-indicated preterm birth. But I mean I think those are the two basic things that there’s actually pretty good evidence to support. And what’s interesting with nutrition is that a lot of times it’s, having twin gestation, insurance companies do not cover a nutrition consult. They assume physicians would just be able to do this, of which most doctors have a nutrition class that’s about, you know, somewhere between 2 to 4 weeks in their medical school class, and that’s about it. And, so, I don’t think that most physicians are equipped to properly guide on nutrition, unless they have an interest in it and take extra time with it.
Dr. Fox: Yeah. No, I totally agree. And, so, when we have women with twin pregnancies, one of the things that we do in our practice and a lot of people don’t do, and there’s a lot of controversy over this, is doing cervical length screening. So, can you explain first what that is and, second of all, why do we do it?
Andrei: The cervix is sort of like the gateway to the uterus, and think of it sort of like the doorway. And, if the door’s shut, then nothing comes out, that’s the simplistic approach. And we had seen, back in the 90s, at least in singleton gestations, and then, by the early 2000s, they wrote these papers in twins as well that a short cervix in the mid-trimester is associated with an increased risk of subsequent preterm births, at some point, prior to 37 weeks. And the mid-trimesters often refer to somewhere between 18 to 22 weeks. And, so, cervical length, the longer the cervix, the lower the risk, the shorter the cervix, the greater the risk. But, unfortunate, like everything else in medicine, it’s not an exact science. You can have a very short cervix and go to full term and you can have a long cervix and, ultimately, deliver preterm. So, it’s really just a risk assessment for physicians to use and as a tool and, so, it doesn’t tell you what will be, it just tells you what might be.
And I think, again, why this might be helpful is in managing expectations, determining interventions that may help. So, for example, a short cervix after 16 weeks, particularly between 16 to 24 weeks, those are scenarios where people have recommended interventions like vaginal progesterone. And that has been shown in observational trials it may be beneficial to prolonged gestation and improved outcome in twins. And I’m a believer in that, and there are meta-analyses or, what we call, pooled studies. So, people took 20 studies, put them together to look at what the effect was because you got larger number of patients treated versus untreated and it does show a benefit in that.
More recently, you know, people were pretty negative about cerclage, for example or stitching the cervix in twins. In fact, we were quoted once on the labor floor, you know, about 10 years ago, that it was illegal to put a cerclage in, which it’s not. But the data has caught up to our viewpoint, which is a small subset, maybe 1% to 2% of patients with twins may benefit from cerclage in extremely short cervixes, or dilated cervixes, and that is reasonable. And that seems, on an individual basis, to prolong gestation or improve outcome. So, I wouldn’t do it routinely, and we don’t do it very often, but a cerclage, or a stitch, around the cervix in a twin gestation may be helpful in some unique situations.
So, there are some treatments that you can do, which is why looking is valuable. And, in addition, I think looking is valuable in that, for a lot of people, you know, they may not wanna leave the country if they know that they have a short cervix or go far away from their physicians. They’d be more keyed into the symptoms that we’d be concerned about for actual preterm labor itself. So, those are the reasons why we think cervical length screening is valuable.
And then for the other patients, those that actually have a long cervix, it’s still valuable because, again, they do have pelvic pressure, they do have cramps, they are concerned about preterm labor and delivery. And, so, the majority of twins have a lot of symptoms and the negative predictive value or something what we call when you have a normal study, that the likelihood of a bad thing happening was very very low is very useful for patients to go on in their normal lives, like go about their exercise, go about to work, go continue normal activities in the sense of sexual activity. So, there’s really no reason to change your lifestyle in any way if you have a normal cervix. And, so, I think those are important for screening and reassurance along the way, particularly in this usually symptomatic population of pregnancy.
Dr. Fox: Yeah. I mean I have a lot of thoughts about cervical length screening. And listen, we practice together, so…and I do it and I’m a fan of it also. I think that, when people recommend against it, they say, “Don’t have it done,” I think there’s a couple of reasons why. One reason might just be pure laziness. They’re like, “I just can’t deal with this information because we don’t know exactly what to do every time,” and they have a very difficult time taking care of patients in these uncertain situations where it’s not 100% clear what the right thing to do. And, so, like I’d rather not know than know and not know exactly what to do.
And other times people are saying it because, let’s say, on a population level, if we had everybody checking every twin, we’re gonna have all these people getting information and not knowing what to do and then something complicated and some people are gonna be scared when they shouldn’t be and some people are gonna be reassured when they shouldn’t be…and, so, it’s just not, you know, valuable on a population level. But in our practice, you know, we take care of a lot of twins, it’s so important for us to know this information, like you said. Number one, it could be something that we can use to actually intervene. Right? So, if the cervix is short at a certain time, there is data about vaginal progesterone, there’s some data about pessaries, a little bit weaker than the progesterone. And like you said, for some people, we find, “Oh, we think she needs a cerclage,” or, “oh, we need to bring you back in a week and then decide if you need a cerclage.” Right? Because, also, it’s, “Do you check once? Do you check every week? Do you check every 2 weeks?” And, you know, we have to make those decisions. And that’s, so, purely like in a prevention type of model. Like we’re gonna look and we’re gonna try to get some data and do something to prevent.
But even if you take prevention out of the equation, just knowing what’s gonna happen potentially, having a prediction, right, saying, “You are in the,” you know, “20% that’s very high risk to deliver in the next month,” versus, “you’re in the 80% that’s a very low risk to deliver the next month,” there’s a lot of value in that. Again, like you said, people practically, “Am I gonna go on that vacation? Am I gonna,” you know, “travel? Am I gonna,” you know, “train for that half marathon?” those things. “I’m not gonna take these…what do I do with these symptoms?” Or what if you’re in a more rural area and you live 3 hours from the hospital? Well, maybe it’s time to get closer to the hospital and start living there, you might do this. And also there’s interventions that we have that don’t prevent preterm birth but improve outcomes in babies, like you said, giving steroids, giving magnesium. And, if you don’t know someone’s about to deliver, you don’t know when to give them.
And we’ve looked at this in our own studies, and the concept is, if I have, let’s say, two women who are carrying twins and they’re both gonna show up and deliver at 32 weeks, right, 2 months early, that’s gonna happen no matter what. But for one of them, someone taps you or me on the shoulder and says, “Hey, she’s gonna deliver in a week,” like a week before someone tells us, “she’s gonna deliver in a week,” those babies are gonna do better. Because there’s things we’re gonna give to the mother in that week before delivery that’ll improve outcomes for the babies. And none of this gets taken into account when people make that recommendation, “Oh, don’t do it,” and that I find that to be very frustrating, personally.
Andrei: Yeah. And I also would say some of the criticism we’ve had is that, again, you can get proper counseling or increase maternal anxiety by doing these tests, I find the opposite…first of all, I think proper counseling is based on proper medical care and I think that people should get proper medical care. And it’s up to the physicians to train themselves to understand the implications of what a short cervix would mean in the context of a twin pregnancy, and there’s ample data now, over 20 years, to suggest that. But, additionally, as far as maternal anxiety, and we know maternal anxiety, particularly untreated maternal anxiety or heightened anxiety, may actually be associated with increased risk for preterm birth in singleton gestations.
And, so, the reality is that our patients have access to a lot of information. And, so, when they google or they go online, they know that they’re high-risk of preterm birth and they know that, you know, anything can happen and complications arise with twins, and so they’re already nervous and anxious and they’ve read all the complications potentially. And, so, the reality is that it’s not that people aren’t aware of these concerns…and, in fact, we lower anxiety the majority of the time because most people have a normal cervical length. And, in fact, because of that they really, you know, are less anxious about their pregnancy because, even though they have cramps and they have pressure and they might have backache, as long as their cervical length is normal, they actually have, less anxiety less stress throughout the pregnancy, which is, you know, again, hard to measure but the data does suggest it’s independently associated with increased risk of preterm birth. So, lowering maternal anxiety, providing information that is accurate and appropriate can be very helpful for people and, potentially, may actually improve outcomes. So, I question sort of the argument that doing cervical length serially overdoes it or increases anxiety, if anything, it actually lowers it, in my experience, with particularly our patient population.
Dr. Fox: Yeah, I’m sure there are people who we do a cervical length and it’s short and we worry them and we do this and we increase their anxiety [inaudible 00:17:13]. Yeah, that definitely happens but, like you said, that’s the minority of people. The majority of people were lowering the anxiety because they say, “No-no-no, don’t worry, your cervix is fine. Go back to work, enjoy,” like, “you’re fine. Come back in a couple of weeks.” And that’s what happens for most people. So, yeah, there are people for whom we increase anxiety. Again, maybe appropriately, maybe that’s like healthy anxiety because they are at increased risk for things, and maybe not. But for the overwhelming majority of the women of twins who come in, it’s the opposite. They get good news and there is, “Oh, I’m not at such high risk. I can,” you know, “sort of,” you know, “not worry about that for the next couple weeks until my next visit and repeat the process.”
Andrei: With doing cervical length screening, we often can more accurately diagnose placenta previa and something unique called vasa previa, which really often gets missed in transabdominal scanning, the latter. And, so, twins are uniquely at a higher risk for both of these placental abnormalities that can be associated with a pretty significant adverse outcome if not diagnosed appropriately and managed appropriately. So, cervical length and transvaginal imaging can identify location of the placenta, location of the vessels that go into the placenta, so, things like velamentous cord insertion, as well as vasa previa. So, there’s a lot of data to suggest that a good transvaginal scanning and assessment can be very helpful in determining these things.
Dr. Fox: Yeah. It’s so remarkable how passionate people are about it. It’s like crazy, like, “Oh my god, I can’t believe you do cervical length. What’s wrong with you, people?” I have a slide, I’m gonna give this lecture where it’s like controversial topics and, you know, first is like abortion, the second is like universal health care, the third is like taxes, the fourth is like Middle East peace and policy, and the fifth is cervical length screening in twins. Everyone goes nuts about this, nobody cares that we send 14 blood tests on every pregnant patient at the beginning of pregnancy. Like nobody cares about any of that, like, “Ah, fine, yeah. Who cares, we never need these tests.” But a cervical length, it’s just unbelievable. And I think that it’s, again, in the wrong hands, I can see how it could be misinterpreted or people could be counseled too much in the reassurance direction or too much in the opposite direction and, potentially, you know, do harm with cervical length screening if they don’t know what they’re doing. Again, it’s like we do this every day, you know, on twins and we sort of know, you know, what to do with it. And I think that overall it’s been really helpful in our practice, taking care of twins. I think we’re all very comfortable with that.
Andrei: Yeah, I agree with that.
Dr. Fox: Let’s talk about fetal growth. So, growth restriction is very common in twins as well where one or both is not growing well. How do we screen for that?
Andrei: So, doing ultrasound of course because we’re maternal-fetal medicine specialists, so, really our right arm is hooked to an ultrasound beam. And while it has limitations, and I’ll be the first to suggest that growth ultrasounds and biometric measurements, which was first established in the 1970s, which we’re still using those formulas, 1980s, there are potentially better tools slightly but they don’t really impact on outcomes, so, we kind of stick with the old tried and true measurements where we measure the femur length, the leg length. Leg bone length I mean, the abdominal circumference, so, the belly size, and the head circumference, and something called a bipartite diameter, which is going from one side of the head to the other and measuring it. And then it goes into a magic formula developed by various people to give us an estimate of the growth across gestation.
And, so, all of these are important because, again, a growth restriction is a real and significant cause for preterm birth and a higher morbidity and mortality, which means complications and death rate of twins exclusively higher even than singleton, so, and twins are at higher risk. Some of the theories why that happens, the slower growth, you know, is thought to be due to whether it’s where the umbilical cord is inserting, we touched on that earlier, something called the velamentous cord insertion where it inserts lateral to where the main placenta is and then the vessels have to course along the membranes to get to the main placenta instead of inserting right in the center. Or because of what they call placental crowding, which means that just the placentas are close to each other and they just can’t expand and grow at their own pace and migrate where they want. There’s several theories behind that. It may be as high as 30% to 40% of growth restriction can occur if you take twins to term. So, it’s not unusual to find growth issues or growth lag in twins. The average birth weight of twins is about 5 pounds or so at term, so, it’s not that unusual to see that.
Dr. Fox: Yeah, and I think that one of the things that comes up is, since it’s so common for twins to be smaller…and, again, not smaller because they’re born earlier, which is also true, but smaller than, you know, by gestational age, you know, sort of standardization, that people have developed different curves for twins, meaning saying, “Okay, if most singleton pregnancies…let’s say this gestational age are 7 pounds, we’ll say that’s the average, and twins are 6 pounds, we’ll just say that 6 pounds is the average for twins.” And there’s a lot of debate, is that a good thing? So, we’re gonna sort of say, “Okay, this is normal and, therefore, we’re not gonna freak off everybody out with twins saying, ‘your babies are too small.’” Or, in fact, is that a problem? Because we’re, you know, we’re now normalizing something that’s actually abnormal.
And there’s a lot of debate about what to do. We personally, if twins are measuring small, we call them small, we say that that’s not, quote-unquote, “normal,” even though it’s common. People disagree with us. And no one’s really quite sure what the best thing to do is with the situation. The twins are typically small, whether to view that as something that’s abnormal and concerning versus something that’s sort of normal and healthy. And it can lead to a lot of issues, you deliver early, do not deliver early. And, so, one of the things that we do to try to avoid delivering earlier than necessary is we rarely will deliver early just because of the wait. Or not a lot early just because of the weight. We need to see other findings that there’s a problem, like the fluid is low or the blood flow is abnormal. But that’s important because sometimes you see a small baby, like, “Oh, it’s time to deliver,” but maybe you’re causing harm by delivering too early. And, so, you have to sort of use a lot more data than just the weight to figure out what to do.
Andrei: Yeah. Just to back up a little bit, one thing to remind everybody is that doing fundal height assessments are not accurate in twins. So, just doing a tape measure, it’s not worth it. I think that’s really important. Also, growth is measured because we’ve had early first trimester ultrasound that documents the current accurate gestational age. So, I think that’s really important that coming for prenatal care early, in the first trimester, one of the single best things we can do to assess later on growth in the third trimester is have first trimester measurements of something called a crown-rump length that accurately identifies the actual gestational age of the fetus. And I think that’s really important because last menstrual period dating may be accurate but we’d like to have it corroborated with an early first trimester scan.
And then, finally, the actual growth itself is as important as sometimes something called the growth discordancy where you actually have differences between the sizes of them. So, sometimes you may have…so, they may, quote-unquote, be both above the 10th percentile but one of them…so, 10th percentile is often the number we use as sort of a criteria where we suspect growth restriction might be starting where the baby’s growing small but there also could be where you have discordancy of about 25% or more where there’s such a wide difference between growth between the two of them that that can suggest us that something might be going on. So, in twins we use growth discordancy in addition to the actual growth itself as a sign that something might be happening. And then, ultimately, to decide, “Is the baby better in than out or out than in?” we basically will do more information, which is looking at fluid, at fetal movements, we’re gonna look at blood flow studies and the umbilical cord as a reflection of how the placenta’s functioning, something called dopplers of the uterine arteries. And you can doppler or look at blood flow in every vessel of the fetus. So, some people use looking at fetal brain doppler, some people use dopplers of something called the ductus venosus. So, there’s a lot of analysis.
And, also, the other thing early on, if we see growth restriction, often that can be associated with congenital anomalies which twins are at higher risk for that having structural abnormalities or syndromic issues, so, particularly the earlier the growth restriction starts. So, that becomes quite relevant and screening for those things, it becomes important and you have to be quite diligent to know which fetus you’re scanning, which one has the problem or not, and so on.
Dr. Fox: Yeah. And I think that this is an important topic because one of the things that go with women is that…with twins is that this is very common. I mean it’s very common that, if someone’s carrying twins, we are concerned about one or both babies and how they’re growing. So, number one, like you said, for expectations, I said that in the last podcast, you know, sort of setting up expectations that that doesn’t mean that there’s necessarily a problem but it’s something that we’re gonna be investigating. And it happens pretty much as common as preterm birth is gonna happen, that one or both babies are gonna be small. And number two, that this is actually a situation where it matters because our interventions can actually change the outcomes. Because, if you have a baby that’s not growing well and it’s because the placenta is not functioning well, that can deteriorate over time and hurt the baby or even lead to a stillbirth if you don’t intervene and deliver before that happens.
So, when we’re doing all these screenings to check the babies, it’s not just because we’re curious what the weights are gonna be at birth, it’s we’re worried that, if there’s a placenta or multiple placentas not working well, if we don’t know when to intervene and we don’t, right, then we could potentially have a stillbirth. And, on the other side, we don’t wanna deliver everybody too early and cause preterm birth. So, it’s a fine balance between not delivering too early but not delivering too late before there’s a disaster. And, so, it’s really important to know how these babies are growing and whether there’s other parameters going on that are concerning because it can affect the outcomes.
Andrei: And then the only other thing to add routinely, since we’re just talking about twins, is what, we call, antepartum fetal testing or non-stress tests and biophysicals. We routinely, starting in 32 weeks, we see our patients weekly and we perform weekly antenatal testing to look for risks of complications. And, so, it’s still controversial whether there’s proven benefit but we wrote a paper, now years back, it’s almost 6 years ago, we’re looking at the biophysical profile and its role in twins and being a better tool to assess fetal movement, fetal tone, fetal breathing…which they’re not breathing but diaphragmatic movements, up and down, as a reflection of fetal well-being, in addition to the amniotic fluid assessment. And we found that to be quite accurate and effective in identifying at-risk fetuses that may need to get delivered.
And, so, from 32 weeks until delivery, we do weekly antenatal testing in our practice. Which some doctors may not do. Though, you know, when I think the SMFM actually did a questionnaire on routine twin [inaudible 00:28:55] testing, they suggested it’s pretty widely practiced but everybody does it routinely starting at 32 weeks. But most people are using something called the non-stress test where they’re just putting people on a monitor for 40 minutes instead of the ultrasound. So, the biophysical has lower false positive rate and maybe more fetus-specific in its accuracy. So, we tend to like that better.
Dr. Fox: Yeah. And the principles that, anyone carrying twins, there’s an increased risk of stillbirth. And, so, these tests are designed to identify fetuses at increased risk of stillbirth so you can either do further testing or do [inaudible 00:29:33] usually treatments potentially but delivery potentially before that happens. And, so, that’s why it’s designed and it’s hard to prove whether it works or not because the studies you’d have to design, you’d have to like do the test on half the women and not do the tests on the other half of women and count the number of stillbirths and see who…
Andrei: In large numbers because the incidence low because we do other monitoring like growth. And, so, it [inaudible 00:29:55].
Dr. Fox: So, it’s not really done…like patients don’t wanna sign up or doctors don’t wanna do [inaudible 00:29:58] around that study so you have to sort of sort out the data that’s there. Wow, Andrei, we covered a lot. Thank you so much for coming on the podcast and coming again.
Andrei: It’s interesting, it’s a miracle that I survived my twin gestation with no ultrasound and no monitoring and no nutrition counseling and I went to term. Because we were undiagnosed until we delivered. So…
Dr. Fox: Yeah, you were the surprise, Andrei, they just thought it was Ted.
Andrei: No, my brother was, I was twin-A.
Dr. Fox: Oh…Ted, if you’re listening, we love you but we didn’t know you were coming.
Andrei: Right, that’s…
Dr. Fox: Excellent. Well, thank you for coming on the podcast. Obviously, there’s a lot of twins…this is part of a long series of twin podcasts, but they’re fascinating and we love seeing twins, it’s just so interesting and exciting. And, you know, we’re gonna I think finish this series with re-dropping the podcast on “Delivery of Twins,” which is just a whole, you know, pile of fun for everybody.
Andrei: Beyond the fun I think it’s really important to…doing this now 30 years I think that the reality is that twins are a unique set of complications and a unique set of management skills are required for them. And I think that, if we could centralize the care like in other countries, you probably might get more optimal outcomes, whether it’s the delivery itself and the skill sets for that, as much as the antenatal testing and the monitoring and skilled ultrasound units. Just because somebody has an ultrasound machine or, you know, can scan a singleton doesn’t mean they know how to scan twins, they know to manage twin complications. And, so, I think it is a unique aspect of prenatal care that occurs about 1% to 2% of all pregnancies. And it’s rare enough that, in a routine OB practice, this may not be that common. And, ideally, maternal-fetal medicine specialists should be involved in their care.
Dr. Fox: Thanks for coming on, Andrei. Have a wonderful day, and I’m sure I’ll see you many times.
Andrei: Thank you.
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