Parenting Stress and Psychosocial Health in Mothers with Twin–Twin Transfusion Syndrome Managed with Laser Surgery: A Preliminary Study

Insecure attachment and internalizing behavior problems in growth discordant identical twins

BACKGROUND

Psychosocial development in monochorionic (MC) twins born after selective fetal growth restriction (sFGR) has been unreported to date, despite its importance for daily functioning and future relationships.

AIMS

To investigate psychosocial development, attachment and school functioning in MC twins with sFGR and compare outcomes with the general population and between smaller and larger twins.

STUDY DESIGN

Observational cohort study.

SUBJECTS

MC twins with sFGR (defined as a birth weight discordance ≥20 %) born between 2002 and 2017 and aged 3-17 years.

OUTCOME MEASURES

Multiple parent report questionnaires: the Child Behavior Checklist (social-emotional development and behavior), the (Early) Childhood Behavior Questionnaire Very Short Form (temperament), the Attachment Insecurity Screening Inventory (attachment) and a school functioning questionnaire.

RESULTS

Median age for the 48 twin pairs was 11 (interquartile range (IQR) 8-13) years. Attachment insecurity for both twins was higher than in the general population for ambivalence/resistance (34 % (21/62) vs. 16 %, p = 0.024) and total attachment insecurity (35 % (22/62) vs. 16 %, p = 0.016). Smaller twins had more internalizing behavioral problems, i.e. negative emotions and behaviors turned inwards (22 % (10/46) vs. 11 % (5/46), p = 0.021) and a higher negative affect, i.e. more likely to experience negative emotions (3.2 (2.9-3.7) vs. 2.9 (2.2-3.2), p = 0.009) than larger twins, as well as a lower secondary school level (p = 0.031).

CONCLUSION

MC twins with sFGR have more ambivalent/resistant attachment insecurity following the complicated pregnancy course. Smaller twins have a tendency towards negative emotions and internalizing behaviors compared to larger twins, indicating an increased sensitivity for depression and anxiety.

Pregnancy and parenting experiences of women with twin-to-twin transfusion syndrome: a qualitative study

Background

Qualitative research can reflect the actual thoughts and experience of research subjects and can be used to explore the experiences of women presenting with twin-to-twin transfusion syndrome (TTTS) to facilitate the provision of targeted psychological support.

Methods

A semi-structured interview method was used to assess the pregnancy and parenting experiences of women with TTTS. Colaizzi method was used for data analysis.

Results

Eighteen women participated in the study. We found that women with TTTS during pregnancy experienced persistent worry about their children’s health from the disease diagnosis to the subsequent parenting processes, even in case of minor changes in their children’s health. The lack of an efficient referral process and health information increased their uncertainty about their children’s health.

Conclusion

In addition to the children’s health, other difficulties encountered during pregnancy and parenting may aggravate the pressure. Clinicians in the first-visit hospital and foetal medicine centre should improve the referral process and establish a follow-up system to provide women with health information and psychological support.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04057-0.

Risk Factors for Parenting Stress in Parents of Children Treated with Laser Surgery for Twin-Twin Transfusion Syndrome 2 Years Postpartum

OBJECTIVE

Twin-twin transfusion syndrome (TTTS) is a rare but serious condition that can occur in monochorionic and diamniotic twin pregnancies. Research indicates almost half of postpartum mothers with TTTS may have clinically significant levels of stress. However, no studies have measured the levels of parenting stress at 2 years postpartum, and little research has been conducted on sources of stress.

STUDY DESIGN

A prospective cohort study was conducted. Data were collected from parents whose children were treated with laser ablation in utero and were 2 years old at the time of screening. The Parenting Stress Index - Short Form (PSI-SF) and its three subscales were used to collect data. Descriptive, bivariate, and multivariate analyses were conducted to determine significant predictors associated with each outcome.

RESULTS

A total of 99 children from 56 families were enrolled. Unmarried status (B = -22.8; p = 0.039) and lower maternal educational level (B = -7.8; p = 0.01) were both significantly associated with higher PSI-SF total score.

CONCLUSION

Subgroups of parents whose pregnancy required laser surgery for TTTS may continue to have clinically significant levels of stress at 2 years postpartum. It is important the health care team is aware of this and the sociodemographic risk factors to provide appropriate support for families.

Maternal Satisfaction with Healthcare after Perinatal Loss in Monochorionic Twin Pregnancy

INTRODUCTION

The analysis of patients' satisfaction with healthcare is recognised as being useful in the evaluation of health outcomes and perceived quality of care. Little is known, however, about how the psychological status of women who experience perinatal complications may affect their perceived satisfaction with care.

METHODS

We assessed healthcare satisfaction in 52 women who had undergone intrauterine surgery during a complicated monochorionic twin pregnancy and examined the influence that fetal loss and sociodemographic, clinical, and psychological factors had on the degree of satisfaction. Data were gathered in an individual interview and through the administration of the Medical Patient Satisfaction Questionnaire, Beck Depression Inventory, and State-Trait Anxiety Inventory. Relationships between variables were analysed using a chi-square test, Spearman's rho, Student's t test, and the Mann-Whitney U test, in accordance with the metric nature of the variables and the assumptions fulfilled.

RESULTS

Age and level of education were not associated with the degree of healthcare satisfaction. Negative but non-significant correlations were observed between the level of satisfaction and symptoms of anxiety and depression. Satisfaction with healthcare was high in the sample as a whole, although it was significantly higher among women who had not experienced fetal loss. There were no differences in satisfaction with services involving direct contact with medical staff, whereas satisfaction with indirect services was lower among women who had experienced perinatal loss.

CONCLUSIONS

Due to the unique characteristics of this population, specialised care teams of both professional healthcare and indirect services are needed. Although administrative aspects of healthcare are regarded as being of secondary importance, this may not be the case with more vulnerable populations.

Health-Related Quality of Life and Depression in Women following Intrauterine Interventions in Complicated Monochorionic Twin Pregnancies

INTRODUCTION

The aim of this study was to explore maternal health-related quality of life (HRQoL) and depression following intrauterine interventions in complicated monochorionic twin pregnancies at the Medical University Graz.

MATERIAL AND METHODS

In a cross-sectional questionnaire survey, women with at least one liveborn infant following intrauterine intervention during 2011 and 2015 were matched with uncomplicated monochorionic and dichorionic pregnancies. All completed the 12-Item Short Form Health Survey to measure HRQoL and the Patient Health Questionnaire-9 to measure depression. Results were compared with local normative values.

RESULTS

There were no differences in physical and mental HRQoL as compared to those with uncomplicated pregnancy. However, the whole study population had significantly lower HRQoL scores (p < 0.001) than the normative sample. Additionally, 11% of the whole study population experienced moderate (6.2%) or moderately severe (4.6%) depression. Women following uncomplicated dichorionic pregnancy revealed more depressive symptoms compared to women with intervention.

DISCUSSION

Women with at least one surviving infant following intervention in complicated monochorionic twin pregnancy do not seem to have an impaired HRQoL as compared to women following uncomplicated monochorionic or dichorionic pregnancies. However, twin pregnancy itself appears to impair HRQoL, at least in the first 4 postnatal years.

Identifying families' shared disease experiences through a qualitative analysis of online twin-to-twin transfusion syndrome stories

Background

Twin-to-twin transfusion syndrome (TTTS) affects 10–20 % of monochorionic diamniotic (MCDA) births and accounts for 50 % of fetal loss in MCDA pregnancies. This exploratory qualitative study identified shared experiences, including potential emotional and psychosocial impacts, of this serious disease.

Methods

Forty-five publicly accessible, online stories posted by families who experienced TTTS were analyzed using grounded theory.

Results

Shared TTTS experiences included a common trajectory: early pregnancy experiences, diagnostic experiences, making decisions, interventions and variable outcomes. Families vacillated between emotional highs such as joy, excitement and relief, and lows including depression, anxiety, anger and grief.

Conclusions

TTTS disease experience can be considered an “emotional roller coaster” exacerbated by TTTS’s unpredictable and quickly changing nature with the potential for emotional and psychosocial effects. Increased TTTS awareness and research about its corresponding impacts can ensure appropriate patient and family support at all phases of the TTTS experience.

The pediatric surgeons' contribution to in utero treatment of twin-to-twin transfusion syndrome

OBJECTIVE

To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination of endoscopic fetal surgery-specific techniques and surgical restraint.

SUMMARY BACKGROUND DATA

TTTS is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of placental vessels (LASER) causes premature rupture of membranes (PROM) in 10% to 20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of >=1 twin of 75% to 80%.

METHODS

We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe TTTS. Pregnancies with TTTS (stages I-IV) managed in the last 8 years were reviewed. LASER was offered in stage III/IV only.

RESULTS

Ninety-eight cases of TTTS were managed in a pediatric surgery/maternal-fetal medicine collaborative Fetal Treatment Program-39 were observed (40%) and 59 underwent LASER (60%). Survival of >= twin was seen in 82.7%, and overall survival was 69.4%. These survival rates are similar to, or better than, other comparable series with similar stage distribution (low:high stage ratio 1:1) in which all patients underwent LASER. PROM rate was 4%.

CONCLUSIONS

Reserving LASER treatment for severe TTTS results in outcomes similar to, or better than, LASER for all stages. Applying fetal surgery-specific endoscopic techniques, including port-site sealing, reduces postoperative complications.