Yesterday, we hit 31 weeks, and today is my 47th day inpatient.

This pregnancy has required us to make some very difficult decisions. The first big decision was when to come inpatient, since you don’t want to come in before you would want the babies delivered. We didn’t think through that decision super carefully, so we just picked a date, and I came in at 24w4d. In retrospect, I would probably come in a week or two later.

Now we have the harder decision of deciding when to deliver the babies. The target range is 32-34 weeks. We had ourselves scheduled at 33w on the dot, but as we’ve gotten closer to the 32w mark, I’ve had more and more doubts about pushing it an extra week.

I think I mentioned this before that many hospitals don’t let you go past 32w. I’m on a Facebook group for mono mono twins, and there are stories of people who lost a baby or two in the time after 32w. There could be some short-term benefit of less NICU time by letting them stay in an extra week, but the long-term outcomes between 32, 33, and 34 weekers are very similar. Meanwhile, the risk of a cord accident grows as time goes by (but it’s unclear by exactly how much and when since there aren’t enough of us to really study that). There are ways to make the final week more safe, like adding more monitoring or going onto continuous monitoring, but my babies continue to be difficult to monitor. I don’t think continuous monitoring for a whole week is in the cards for us. This past week, I added a fourth NST, so now I’m doing them at 8a, 2p, 8p, and 2a. Even adding just one extra session is exhausting, especially since many of them extend well beyond the 1 hour minimum.

There aren’t many studies on this topic, but one says this:

The prospective risk of a nonrespiratory neonatal complication was lower than the prospective risk of fetal death after 32 4/7 weeks of gestation (95% confidence interval 32 0/7-33 4/7)…

CONCLUSIONS: The in utero risk of a monoamniotic twin fetus exceeds the risk of a postnatal nonrespiratory complication at 32 4/7 weeks of gestation. If close fetal surveillance is instituted after 26-28 weeks of gestation and delivery takes place at approximately 33 weeks of gestation, the risk of fetal or neonatal death is low

That’s a wide margin of error, and I don’t really want us to be a statistic. We’ve been asking ourselves the question: “could we live with ourselves if we lost a twin (or two) by going an extra week?” The answer is a strong no.

It’s kind of like trying to decide when to cash out at a casino when you’re up, knowing that the odds are against you, and in this case, the odds get worse as time goes by…probably. Maybe I could make a few more bucks, or maybe I could lose it all. I did just cash out a bunch of stocks in anticipation of a recession, so I guess I tend to fall in the “quit while you are ahead” bucket.

Other factors go into this decision, like how well the babies are doing and what we are seeing in the monitoring. I’ll do another ultrasound on Tuesday, but so far, the babies have been on the small side with lagging femur lengths, and Baby B is quite a bit smaller. That doesn’t give us a ton of confidence to push on, but we will see on Tuesday if my protein consumption via daily eggs and bacon has helped at all. In the monitoring, we have seen a few strange things here and there that indicate some placental issues, but we aren’t seeing regular patterns of strange things. My doctor said that it’s like the babies are knocking on a door to come out. Sometimes Baby B will go “Knock!” but then back away. Then sometimes Baby A will go “Knock!” and then back away. The doctors are looking for a pattern of knocks — “Knock, knock, knock! Let me out!” which we haven’t seen yet. But the random knocks and erratic behavior are not super reassuring. It’s hard to tell what it means. Even my doctors admitted that.

All these factors have led us to reconsider the delivery date. We’re currently scheduled for 32w AND 33w, but we are leaning towards 32. Better out and safe. I think. Ugh.

We have one last ultrasound that may help us decide, however I’ve learned from my day job as a product manager to ask myself “if I had that data, how would it change my decision?” In this case, I don’t know that it would. Outcome 1: baby B is still small. In this case, we should deliver sooner than later to help her get the nutrients she needs on the outside. Once they are out, baby A won’t be able to steal her food anymore. Outcome 2: the babies have grown and are doing well. In this case, my doctor said we could keep going to help them grow a little more. But my take is that if their birth weights would be good at 32w, why push it?

So the answer is probably 32w. I think. Ugh.