Quick action saves twins in high-risk pregnancy at UK King’s Daughters

ASHLAND, Ky. (July 1, 2024) – In her first trimester of pregnancy, Allison Brown joked that because she was so sick, she must be having twins.

At her eight-week ultrasound, she and her husband Andrew discovered they were right.

“My husband’s dad is an identical twin, and I have three sets of twins in my extended family, so we knew it was possible,” Allison said. “But nothing prepares you for two heartbeats.”

Allison, a speech therapist for Johnson County Schools and her husband Andrew, a sports medicine physician at UK King’s Daughters in Paintsville, were thrilled by the sight of two pink lines on the pregnancy test. This pregnancy came on the heels of a miscarriage, so while they were excited and hopeful, they were understandably cautious.

Allison’s pregnancy continued relatively uneventful until about 24 weeks, when a routine ultrasound showed twin “A,” Noah, was measuring smaller than his wombmate, twin “B,” Jordan.

The twins are monochorionic/diamniotic, or mono/di, twins. Occurring in about every three or four births per 1,000, mono/di twins are genetically identical twins who develop in separate amniotic sacs but share a placenta. Because they share a blood supply, there is an increased chance of complications, and mono/di pregnancies are considered high risk.

"As I performed that initial ultrasound and identified the viable twin gestation, Allison and I celebrated the identification of seeing the two heartbeats,” said Tony Dotson, D.O., Allison’s primary obstetrician. “There were tears of joy and excitement initially. It was obvious that this twin gestation was going to be definitely high risk due to the fact that it was a monochorionic diamniotic twin gestation. I did not want to deflate the joy of the visit, but by the end of the appointment, I think they understood the reality of the potential for complications including gestational diabetes, pregnancy induced hypertension, growth disorders of the pregnancy, prematurity, cesarean delivery, prolonged neonatal intensive care stay, and the one that I worried the most about which could be a twin-twin transfusion syndrome.”

Twin-twin transfusion syndrome occurs when the blood passes unequally between the placenta and the twin fetuses, leading to one receiving too much blood while the other receives too little. While Jordan was thriving in utero and meeting his growth milestones, Noah was diagnosed with intermittent absent-end diastolic flow in his umbilical artery. The poor placental function, demonstrated by the abnormal blood flow studies seen on ultrasound, was inhibiting his growth. Fetal growth restriction occurs in about 10% of pregnancies and can lead to infant mortality.

Allison was closely monitored by UK HealthCare’s Maternal-Fetal Medicine Telehealth providers. Also known as “Kentucky Angels,” specially trained ultrasound technicians travel throughout the Commonwealth performing diagnostic imaging to patients experiencing high-risk pregnancies. The patients then consult with maternal-fetal specialists via video conference who review the ultrasounds and discuss the results and any necessary next steps.

“The Kentucky Angels Telehealth Program is an innovative model of providing sub-specialty high-risk obstetric care to areas of the state that previously had limited access to these highly specialized services,” said Emily DeFranco, D.O., chair of the Department of Obstetrics and Gynecology at UK HealthCare. “Through the Angels Program, UK perinatal sonographers travel to nearly a dozen locations throughout Kentucky and perform ultrasounds for women with pregnancy complications. This improves access to subspecialty care to women in Ashland and other areas of the state where these services are otherwise limited.”

“I reassured Alison and her husband that her care would be coordinated with my office, as well as the maternal fetal medicine team at the University of Kentucky which was present on our campus here at Kings Daughters Ashland,” said Dotson. “I reassured her that for over a decade, we had the luxury of having the maternal fetal medicine team here to provide the highest level of care possible for our high-risk patients. I also reassured them that our Level III NICU, and our neonatologists were top notch and would be able to provide the care that premature babies potentially would need."

To ensure continuity of care, patients monitored in the telehealth program typically see the same ultrasound technician throughout their pregnancy. Allison became close to her technician, Dee Howard.

“Imaging Allison on a weekly basis, she quickly became one of my favorite patients,” Howard said. “Noah and Jordan sure kept us on our toes!  Each week was a blessing as her boys would get closer to 32 weeks. I appreciated the opportunity to participate in Allison’s care as one of the ‘Kentucky Angels.’”

As Allison’s pregnancy progressed, the size discrepancy between Noah and Jordan grew. Weekly appointments became biweekly. Allison was admitted to the hospital twice, once to administer steroid injections to speed up the babies’ lung development, and a second time just before delivery to monitor the pregnancy. These frequent trips to King’s Daughters made her something of a celebrity.

“Most of the nurses knew me by name, or at least as ‘Twin Mom,’” she said. “I was only at 32 weeks, but trust me, I was hard to miss. I was huge.”

At 32 weeks, the blood flow studies worsened, suggesting that Noah’s placenta function was declining. This led to Noah showing signs of distress in the womb. Allison received another course of steroid injections to help prevent prematurity complications after birth.

The obstetricians on call, Ashley Wright, D.O., and Thomas Mahoney, M.D.,  advised Allison to undergo an emergency cesarean section right away.

“The delivery was a whirlwind, and a lot of it I don’t recall because it all happened so fast,” Allison said. “The C-section itself wasn’t horrible, but nothing could prepare me for hearing my babies cry for the very first time.”

Nervous and unsure what the next steps were for her family, Allison watched as Noah and Jordan were rushed to the neonatal intensive care unit (NICU). Under the care of neonatologist Ramon Ymalay, M.D., Noah and Jordan would fare better with specialized medical intervention in the NICU rather than risk being stillborn if Allison had carried the pregnancy further.

“All efforts were made to buy as much time as possible, but the decision to deliver was made when Noah was showing distress on the monitor,” Allison said. “I’m extremely grateful for Dr. Wright’s quick decision as I truly believe it saved Noah’s life.”

Born on July 28, 2023, Jordan weighed 4 pounds, 2 ounces, while Noah weighed 2 pounds, 12 ounces. Allison and Andrew first found the NICU intimidating, but quickly found themselves at ease with the expert care of the providers and staff. Despite his smaller size and in-utero complications, Noah was discharged first after 35 days. A few days later, Jordan was discharged. After 32 harrowing weeks, another month of intense medical monitoring, the new family of four were finally home – safe, healthy and together.

As the twins approach their first birthday, Allison and Andrew can’t help but marvel at their little personalities. Even though Noah and Jordan are genetically identical, they couldn’t be more different in temperament.

“Noah doesn’t care if it snows oats,” Allison said. “He’s incredibly laid back and more reserved. Jordan has a big personality. He’s more vocal and has all kinds of feelings and he’ll let you know about them. Overall, we couldn’t ask for better tempered boys. Every day they are growing, thriving and learning new things.”

Despite measuring behind his brother in the womb, Noah is catching up to Jordan and they are both meeting their growth and development milestones. Their stay in the NICU turned out to have an unexpected benefit; early exposure to noise and activity means the boys can sleep through just about anything.

Looking back a year later, Allison still feels overwhelming gratitude for the care she and her family received, both at UK King’s Daughters and through the UK HealthCare Maternal-Fetal Medicine Kentucky Angels Telehealth program.

“My twin team – their ultrasound techs, Ashland Center for Women’s Health, my King’s Daughters OB, the UK high-risk OBs – kept me informed and included in all decisions. With twins, there were risks I knew of from the beginning, and I truly feel I was prepared as possible for all the complications that ended up arising in my pregnancy. I recommend delivery at UK King’s Daughters to everyone I speak to. I can’t thank them enough for getting the boys healthy.”