When a 37-year-old woman conceived after years of infertility treatment, she and her doctors knew the pregnancy would require close monitoring. But what unfolded at Rainbow Hospital, HRBR, was an exceptionally high-risk twin pregnancy involving two babies sharing not just a placenta, but the same amniotic sac.
The woman was carrying monochorionic monoamniotic (MCMA) twins, one of the rarest forms of twin pregnancy. In this type of identical twin pregnancy, both foetuses share a single placenta and a single amniotic sac, leaving them vulnerable to complications such as umbilical cord entanglement, foetal growth restriction, twin-to-twin transfusion syndrome and sudden foetal compromise.
The pregnancy followed fertility treatment under Dr Manju B Nair, Clinical Director – Fertility Services. Once the MCMA pregnancy was identified, the obstetric and foetal medicine teams adopted an intensive surveillance strategy.
“Managing a monochorionic monoamniotic twin pregnancy requires constant vigilance, specialised foetal surveillance and timely decision-making,” said Dr Manjula Deepak, lead consultant, Obstetrics and Gynecology, Rainbow Hospital, HRBR.
From 16 weeks, the woman underwent detailed ultrasound examinations every two weeks. The team monitored the twins’ growth, amniotic fluid, Doppler parameters and, crucially, the condition of their umbilical cords.
The pregnancy progressed to 32 weeks, when the woman developed premature rupture of membranes (PROM). Given the risks associated with MCMA pregnancies and the membrane rupture, doctors decided to proceed with an emergency caesarean section.
It was during the surgery that the extent of the danger became apparent.
The two umbilical cords were found to be extensively entangled, with approximately eight knots. Such entanglement is one of the major concerns in MCMA pregnancies because the babies share the same confined amniotic space, allowing their cords to become intertwined and potentially compromising blood flow. Despite the complexity, the team delivered two premature baby girls weighing 1.52 kg and 1.437 kg.
The twins were transferred to the neonatal intensive care unit.
Born at 32 weeks, the babies required specialised care for prematurity, including respiratory support, nutritional management, establishment of feeds, infection prevention and close monitoring of their growth. They also faced acute issues including respiratory distress and cardiac concerns.
Gradually, however, both babies stabilised. They established full feeds, began gaining weight consistently and were eventually discharged home in stable condition. The hospital said the girls are now healthy, growing appropriately and achieving age-appropriate developmental milestones.
MCMA pregnancies account for approximately 1 per cent of all twin pregnancies and are considered among the most challenging twin gestations to manage. Historically, reported perinatal mortality in such pregnancies was extremely high, although outcomes have improved substantially with better foetal surveillance, planned delivery and advances in neonatal intensive care.
“This outcome reflects the importance of specialised expertise, teamwork and compassionate care in managing complex high-risk pregnancies,” Dr Deepak said.
The pregnancy involved a multidisciplinary team spanning fertility medicine, obstetrics, foetal medicine, anaesthesiology and neonatology.
For the family, what began after years of unsuccessful attempts to conceive ultimately ended with the arrival of two daughters born prematurely, despite an extraordinary complication, and now growing up healthy.
