Twin Pregnancy

This is a collection of Frequently Asked Questions from the Twins List. Topics covered here deal specifically with pregnancy, though there's some overlap with the multiple childbirth FAQ. Please keep in mind that the contributors are not medical professionals. These suggestions are not meant to replace your doctor's advice!

For questions and comments, please contact Lisa

Pregnancy Belts

Hi Folks,
Has anyone used that support belt they sell in the baby catalogs (ie. Right Start, Next Step Ahead)? I had pretty bad lower back pain with my twin pregnancy and am thinking about trying that belt for the later months of this pregnancy if I start getting back pain again. Even though it's a singleton this time, my back is always the first thing to go when I get fatigued.

I used a support belt starting in my 30th week and it definitely did help. I was carrying twins also and you could feel the difference in your lower back after you took the belt off. I strongly recommend getting one especially if your back pains are anything the way mine were.

I used a very simple one from J.C. Penney's, after my doctor practically *ordered* me to get one! I didn't have any trouble with back pain etc. but it did help me stay more comfortable in terms of holding my stomach up. Maybe that's *why* I didn't have back pain?? Anyway, the one I got was pretty simple, maybe $20.00, through Penney's catalog.

I have a GREAT suggestion for the maternity belts. I found out earlier on that a maternity brace is considered DME equipment on insurance, and if you have DME (durable medical equipment) coverage it will cover it.

What I had to do was simply ask my doctor about it, and he wrote me a prescription for a "Mother to Be Brace". I was sent to a prosthetics clinic, and the great part about this brace (besides insurance FULLY covering the $190 for it) was that it's molded to your back, so it gives more support than your normal over the counter type braces. I'm only at 23 weeks now, but it has been a godsend to me. I haven't had any more back pain, and the round ligament pain is rare now. I usually don't notice the difference until I take it off, and then the round ligament pain starts back up again, and then I can definitely tell how much it helps!

Oh, and one more tip. I had the problem at first of having to take it ALL off before using the bathroom (which of course we twin moms do a LOT of), and finally realized an easy solution. I just put the brace on first, and then my underwear on over it. I usually wear the maternity undies, so they fit completely over it, but even the bikinis fit over the bottom part of it so I don't have to worry about taking the brace off at all during the day.

Hope this helps someone out!!!

I bought my first belt for about $28 at a maternity outlet. Instant relief. All it is is two elastic wide bands with some velcro, but what support. I find I don't use it much unless I am walking a lot or standing. And no one can tell you are wearing it.

However, I have now graduated to needing one with more support. The one I am about to try is called Loving Comfort Maternity support. It has a huge support piece in the back, comes around in a smaller more cushioned strap underneath the belly, with one strap across the belly. Quite frankly it felt like wearing a big bra around the middle, but provided much more support while standing, and didn't cut in while sitting which the other one did. Anyone carrying twins should try them on and buy whichever kind they want.

I have back problems although they haven't been bad for several years. One of my biggest worries with a twin pregnancy was that my back was going to go out on me.

I used the elastic belt (about 2-3 inches wide, I think this is what you are refering to) for the beginning of my pregnancy and then switched to a wide belt by about 5 months. Someone that I work with who is a physical therapist gave me a belt that had about a 10 inch wide elastic for the front panel, kind of like those back support belts that people who do lots of lifting at work wear. The sides and most of the back were heavy leather for great support. It also had a lumbar support piece that went on my lower back. My dr. had never seen anything like it and immediately wanted to know were they were available from. She spoke directly to the PT but I have no idea where you can get them, but they were advertised some kind of physical therapy journal. I wonder if the back support belts that workers use would work similarly.

Anyway, the support belts worked great! Except for two days early on in my pregnancy, when I overdid it at work, I had little to no back pain. I wish I could say that now. With all of the bending and lifting of the boys and picking up their stuff, my back is killing me. To make matters worse, my DH threw his back out this week and is out of commission for at least several more days. A little advice: take good care of your back and always bend and lift from the knees-- I'm learning the hard way to remember good bending and lifting habits.

I used a Prenatal Cradle with my firstborn, and found it to be great for support and relieving back pain. It's elastic straps that criss-cross between your breasts and go around your back and tummy. I think this is sold in The Right Start catalog.

With my twins, the Prenatal Cradle helped from 3-5 months, until I felt like I needed more support. From 6 months until I delivered (at 38 1/2 weeks) I wore a Belly Bra. I highly recommend this. It's stretchy lacy fabric that's a bra and support for your entire abdomen. It has a wide band at the bottom. Both the fabric and the band support your belly. Their advertising says it's for the third trimester, but of course with two you need the support long before that. I also used it after my c-section. I didn't like wearing the binder they gave me in the hospital. I found the Belly Bra to be much more comfortable. I have seen the Belly Bra in one of the baby catalogs. I bought mine at a Baby Superstore.

Hope this helps!

I ordered the one from The Right Start that goes over your sholders too. I loved mine. I could really tell a difference. It helped to keep my stomach from pulling me into a hunched position. Also the stomach muscles themselves had less strain on them, at least for me it did.

Please remember that while back pain is a common complaint in multiple pregnancy, it can also be a sign of preterm labor. Make sure your doctor knows about it, and let him/her know if it changes in type or intensity.

Signs of Preterm Labor:

  • Diarrhea
  • Low back pain
  • Abdominal cramps
  • Pelvic pressure
  • An 'intuitive' feeling that something's not right.


Maternity Clothes

This is a topic that comes up fairly often, so I'll add more suggestions soon.

One common suggestion for finding something, anything, that will fit past 30 weeks is to skip the maternity stores and go to the large sizes. You'll be able to find comfortable shirts and leggings at more reasonable prices. (If you can still put up with hose/tights, you may find the fit better if you wear them backwards....)

Any other suggestions? Let me know.... Lisa

I'm 33 weeks along, no problems or complications so far...getting close...and big!! As far as maternity clothes I had wonderful experience with "Belly Basics". They are available on-line ( ) or at Bloomingdale's. I was a large size pre-pregnancy and am still wearing the pants, tops and skirts comfortably! Just thought I'd pass the info along!


Sleep Problems

I am currently 30 1/2 weeks along with b/g twins. They're doing just fine (which is great!), but I have been having a lot of problems getting comfortable at night. I know that part of this is a result from some chronic upper back pain/spasms that I have been dealing with throughout most of my pregnancy (has anyone else experienced such back pain?) but now it is also compounded by the fact that I have babies poking out on all sides!!! I'm at the point now where the only comfortable position is on my left side, but the problem with that is within a couple of hours, my left shoulder is killing me.

Does anyone have any suggestions about positions/how I might prop myself so I can be more comfortable sleeping?

Oh, I hear you!!!!!!! I didn't have the back pain that you describe, but I sure didn't get more than a few hours of sleep a night during my entire pregnancy. The DAY I conceived my allergies went into hyper drive, and I had horrible heart burn (not to mention a zillion other wonderful pregnancy symptoms). I could not lay down, or my sinuses would be plugged in a matter of minutes, and I felt like I had a bonfire in my stomach. My solution was to sleep semi-sitting on the couch every night.

I couldn't begin to describe my sleeping position to you, only that it took 5-6 pillows every night to get me situated to where I could be comfortable enough while propped up to sleep for a while. Of course every time I had to get up to use the bathroom, it would take me another 10 minutes to get all re-positioned again! I know how frustrating it is, and how important it is to rest up before the babies are born. Maybe you could try sleeping sitting up on a couch, or in a recliner chair? Hope this helps out some, hang in there and you'll get through it. Just keep thinking of those beautiful babies that will make their appearance soon!!!

I had the *exact* same experience, with very sore (almost numb and achy) shoulders and hips resulting from lying on my left side. What worked for me was sleeping on our king size waterbed (I unplugged the heater everynight just in case there's any truth to that low level radiation thing), with a body pillow on either side of me and between my knees. I had to have almost pressure against my back and would make my hubby push the pillow up against my back and then sleep like that. : ) I still woke up sore/numb every few hours, but that was okay because I had to go to the bathroom every few hours anyway! ; ) When I came back to bed, I would just switch to my other side. My doctor told me that while the left side was good, it really didn't matter as long as I was sleeping on my side and not my back.

The answer for me was pillows and more pillows. Between my knees, under my belly, you name it. This was tough because I was in the hospital and they were so stingy with pillows. A body pillow would have been great! I had a terrible time rolling over because my hips hurt so bad and getting up to pee was pure torture.

I used two body pillows, one on each side. By the time I managed to roll over, I didn't have the energy to move a pillow from one side to the other.

Besides using a body pillow to get comfortable sleeping, I put a small, wedge pillow under my tummy at night and also added one of those egg crate foam mattress pads under our mattress cover. It made it more difficult to get the fitted bedsheets to stay on but it did wonders in relieving the hip and shoulder pain that was waking me up after a few hours of being on the same side. And by the end of my pregnancy, turning over at night was nearly impossible.


Breathlessness and Sleeping Difficulties

My wife, now at 28 weeks, is having trouble sleeping. When she sleeps on either side, the babies kick so much they keep her awake. On her back, she gets breathless. Any suggestions?

My wife has been having difficulties also. She has found that it helps to be propped up slightly with a pillow between her legs, a pillow against her back, a pillow against her stomach, and a pillow to lay her arm over. Needless to say, there is very little room for me. It's been very hard on her because she likes to sleep on her back but is unable to right now. I don't know if there is a good answer to this. But I sure would like to hear some suggestions also!

I have a similiar problem. I am 26 weeks-- each side has a kicking kid when I want to sleep--not too comfortable. I gather a whole bunch of pillows and fall asleep in a semi-reclined, slanted to the left position. After I am sleep--I have learned (am learning) to ignore the side kickers. I believe they are just trying to adjust themselves and get comfortable.

The breathlessness is caused by her cutting the blood supply off to her Vena Cava. They say never to sleep on your back when you are far along. The doctors told me that this is a sign of it. And sure enough, I can be lying on one side and slide into being almost flat for awhile, then all of a sudden I can't breathe, but then shifting sideways immediately brings relief.

The way to get around this is to elevate one butt cheek (so to speak), so that there is no direct pressure on this artery. I start out with one big pillow on each side and one between my knees. Then if my lower back starts being painful, I sort of lean back into one of the two, so that I am half on my back half on my side. The babies seem to kick less this way too because they have more room.

Hope this helps.

I'm trying to remember what I did to alleviate these problems--it's been a while! I often found myself with my arms above my head--during my waking and sleeping hours. Lifting my arms felt like opening up space for my lungs, stretching them north of the growing babies and allowing for some of those air sacs in the lower lobes to get some oxygen!

I was on bedrest for 15 weeks (weeks 23-38) and on terbutaline, which tends to increase your heart rate above and beyond what pregnancy does to it anyway. I remember having a 'stuffy' feeling in my sinuses and head which is evidently from the membranes swelling in response to pregnancy hormones. I had occassional bloody noses. These didn't help the breathlessness. My ob recommended a dilute nose spray or saline spray which really helped to let me breathe long enough to fall asleep at night!

I used a myriad of pillows to prop me this way and that, also. I was sleeping in a nearly upright position toward the end of the pregnancy--it was the only way I could get comfortable. (Weeks 30-34 were spent in the hospital in an adjustable bed which was *very* nice! If insurance covers it and you think it might be worth it--rent one of these beds for your wife. They are great for pregnant moms-o-multiples!)

Another thing provided at the hospital was an egg-crate foam pad just over the mattress and under the sheets. It really seemed to help distribute the pressure points so that hips and shoulders didn't tire as easily from lying on one side. My insurance covered the cost but they are relatively inexpensive in any case.

Someone mentioned how they sleep semi-prone by putting a pillow under one cheek and/or lower back. This works as it prevents the weight of the babies from compressing the vena cava (it's the primary vein, bringing blood from the lower extremeties back to the heart), and usually provides relief to shoulders, neck, hips, back, etc. from just lying on one side or the other.

I've seen recommendations for body pillows, especially for propping up bellies, used with other pillows where needed. I didn't use one myself but it makes sense that it would provide support and comfort!

This thread sure brings back memories. I will definitely second the suggestion of raising arms over your head. I really found that this gave me more lung capacity. The only disadvantange was that when I got back out of bed the twins had stretched out to the point that I had to walk with my back arched for a few minutes until they settled back down into position. My rib cage would just be sitting on a couple of "rocks".

I also found that turning from side to side only brought me more grief as the twins would begin wrestling for position (nobody wanted to be on the bottom!) If I could adjust position, pillows, etc. without actually turning over I was MUCH better off.

Wishing your wives as much comfort as possible during these last weeks....

P.S. As difficult as it may be to believe. I, for one, actually miss carrying them inside of me. Those last couple of weeks I could have done without, but it was such a miracle!


Gestational Diabetes

I have just been diagnosed with GD. I am almost 27 weeks with twins. Does anyone else have experience with this issue? I am waiting to hear back from the NP, but I know that I will be on a modified diet now. What else does this mean?

First of all, try to relax, I among many others on this list also had Gestational Diabetes while pregnant with our twins.

I am not a doctor, but know something about it. I was diagnosed with GD at 28 weeks with my twins. Every person is unique & different. I saw a nutrionist who really gave me tons of info on the subject & I saw her every 2 weeks until delivery. I ate 3 snacks & 3 meals a day, at specific times, and wrote down everything I ate, plus I monitored my blood sugar level 4 times a day. (That was the tough part but I wanted healthy babies & was willing to prick my finger for blood 4 times a day.) I never felt hungry at all, had plenty of energy & worked until my 34 1/2 week. A modified diet worked for me, but some people need to watch their diet & take injections of insulin also.

Remember the key here is that your body isn't processing the sugar in your foods as well as it used to do. By eating very regularly a good combination of foods you will be able to help keep your blood sugar level at a level that is healthy for you as well as your babies.

Write down all the questions you have & be sure to ask your Doctor about them.



Hi, all.

I'm 24 wks this Friday with b/g twins and wanted to ask a question. I'm having a lot of contractions which I believe are BH. I do recall having them quite frequently with my first preg (singleton/'89), but naturally I worry more about them this time around after all we have been through and that I believe they are even more frequent (sometimes six or more in one hour). I went to the OB on 12/1 for the contractions and the cervix is closed. They seem to come and go but are present even when I'm resting. I've heard that they are more frequent with a second pregnancy but wanted to see if anyone had any advice as I'm naturally worrying about them constantly. Thanks for the help.

Yikes!! You are right behind me with your pregnancy -- congrats! I would mention the contractions to your doctor, and see if you can be monitored for a few hours at the hospital. Do it at the time you are experiencing them (even if its late at night). I posted my story last week, but I started having BH contractions around 20 weeks. When I went to the hospital for monitoring, nothing happened and my cervix was great. I continued to have them, but figured all was OK -- especially because I asked my doc to check my cervix at my 23 week appt. and everything was still fine. I had an ultrasound at 24 weeks, where they measured my cervix. Within a week, I had already started to efface! I was admitted to the hospital, and this time, the contractions showed up right away. I'm now taking brethine, on bedrest, and am using a home monitoring device twice a day to measure contractions (the info. gets sent to a nurse, who calls me when she receives the info.) I'll be 26 weeks as of tomorrow, but constantly worry about any more changes to my cervix. I hope I can make it to the 36 weeks my doctor wants me to.

Please don't ignore these contractions!! Have them checked out! They may be nothing (not causing any cervical changes), but its worth it to check it out. You certainly don't want two premature babies!

I have been lurking on this list for some time, not responding too much, because of my situation, but I feel compelled to post at this time due to the nature of the discussion on contractions at 24 weeks. I started having contractions at 24 weeks and 3 days gestation. Having never had a baby before, I was not quite sure what was going on so when I did call my doctor, about 12 hours later, I was 90% effaced and dialated 1. Needless to say, 12 hours later, after having had all of the drugs available in medical history to stop contractions, I delivered my identical twin girls at 24 weeks and 4 days gestation. Baby A weighed 1 lb. 2 oz. 11 1/4in and Baby B weighed 1 lb. 4 oz. 11 1/2in long. The nightmare that we experienced following this premature birth is too lengthy to go into here. But just let me end this post with my beautiful Baby B is now in heaven after fighting and suffering for 6 months and 1 day. We buried her on September 27, 1997, one day after my 38th birthday. Baby A is doing beautifully after a 2 1/2 month struggle. She is perfect in every way, and "healthy as a horse". Oh yes, and let me add that my little Baby B never made it home from the hospital. What ultimately took her life was a complication of prematurity, called Necrotizing Enterocolitis. So, if anyone out there feels intimated not to call their doctors and insist something be done, monitored, etc., please, please, please think twice about that decision, because, this is the most horrible, tragic, devastating experience I have ever had in my life. Please call your doctors, now.

I'd like to echo what others have said - better safe than sorry! I had a lot of contractions that I thought were BH, but when I went in for a routine NST, I found out they were real contractions! Guess what - I was put immediately on bed rest and terbutaline. I stopped the Terb at 34 weeks, and by 37 weeks I had to be INDUCED (how ironic) because my BP had gone up slightly and I was totally miserable. Ha! Anyway, my twins weren't considered preemies and they were fine at birth - 5 1/2 lbs. each and apgars of 8/9 and 6/9. I'm glad I had things checked out and I'm convinced the bed rest allowed me to have such healthy babies. Best of luck, I have b/g twins too and they are so much fun! I love having a boy and a girl and seeing them develop at the same time. Next year at this time yours will be sitting up and crawling and laughing at each other!

I'm a mother of ID twin girls who are now 8mo. old. When I was pregnant with them, I started having contractions at my 24th week which was the first day of February. I was in the hospital for 1 week and they decided that the contractions were false, and I didn't dilate. I was then bed ridden, same as you. Then on March 1st I got up at 3am to go to the bathroom and noticed blood in my urine. The doctor had me go to the hospital to get checked, he thought it might be a bladder infection. When he examined me it turned out that I went into labor, I was 3cm dilated and 100% effaced!!! I never even felt that I was in labor until after he examined me. They rushed me to a hospital that specialized in premature babies. By the time I got there and they finally were able to stop my contractions I was 4cm dilated 100% effaced. They were able to hold me off for 3 weeks before I ended up dilating to 5cm and then my water broke. I delivered at 31 1/2 weeks. Both of my girls were 3lbs. 11oz. and very healthly. The doctors were so surprised that I didn't go earlier. I just did a lot of praying and so did a lot of people I knew and didn't know. Just hang in there and say some prayers, your babies will be fine. There are some babies that were delivered earlier and they did just fine. Good luck and God bless!



I'm 9 weeks, 2 days (but who's counting) pregnant with twins. Last week I interviewed a perinatologist who seems ideal. Everything he said made me feel that even though this is a high risk pregnancy (I'm 40, this is my first, it's twins, etc.) he had no hard and fast rules that applied to all pregnancies -- he tailored his recommendations to my specific needs.

The only thing he said that I was not expecting was that it might be a good idea to do a preventative cerclage at 13 weeks. He said that he would give me a spinal and stitch the cervix so that I was less likely to have problems later in the pregnancy.

I have my first "official" check-up with him next week, and I'm certain we'll talk about this again, but I don't even know what to ask! He mentioned that a spinal headache was a possible side-effect. I HATE the sound of that (how bad can a headache be? Somehow putting the word "spinal" in front of it fills me with dread!). How can stitching my cervix stop pre-term labor? And if I went into pre-term labor, couldn't I pull the stitches out? And if I don't have a problem, when do they pull the stitches out? I figure they have to come out sometime or how can I deliver the babies? Where do they do this procedure? It sounds fairly simple, but how quickly can I get up after a spinal? And couldn't they just knock me out??!!

OK. I'll acknowledge that I'm panicking a little about this. Does anyone have experience with a preventative cerclage?

I too had a cerclage done at 19 weeks. When I went in for my 31 week appointment (fat dumb and happy) I was working full time and feeling great.... I was also, although I didn't know it, in labor and fully effaced. Those blessed little stitches were all that was keeping my cervix closed. Although I got stuck on drugs and bedrest, the stitches did hold util the doctor took them out at 36 weeks (took me off the drugs the day before) and I had the babies the same day! Although I didn't ENJOY getting the cerclage done, it was well worth it, and I had it done again with my current pregnancy. For what it is worth, I had an epidural the first time, no headache although I did get the shakes and throw up for a few hours. The second time I had a spinal block. No shakes but I did get the dreaded headache! Had to go back to the hospital for a blood patch (Basically they take blood from your arm and put it in your spine to replace the leaking fluid). Which again was not pleasant, but cleared the headache up instantaneously. They do a spinal or epidural because that anesthesia does not go to the baby and a general (putting you to sleep) does.

Here's my experience... Cerclage was put in at 17 weeks. Had the spinal and other than the actual injection site pain and pelvic discomfort for a couple of days. It wasn't really all that bad. I never had a headache from it.

As for the stitches and pre-term labor, there are a few things that will happen should this occur. First, of course, they will try to stop the labor with medication. There are all sorts of meds that can help. some oral, some by IV. Many docs, after a cerclage, require that you stay on bedrest. But....that depends on why exactly you have the cerclage in the first place. I was on complete bedrest for the duration of my pregnancy until I delivered at 30+ weeks. If you have a bag rupture, they will immediately remove the stitches because they don't want to run the risk of your cervix tearing if it is trying to dialate. ...and if you do rupture a bag... they will also (in most cases) stop the meds if you are taking any. I went for almost a whole week with a "slow leak" from one of my son's bags. When they removed the stitches I was sure (as was the doctor) that my sons would just come shooting out, but... they were able to stay put for almost a whole week. I never felt any of the stitches being removed. Only a little pressure.

If you don't have any problems and hopefully you won't.... they will probably remove the stitches somewhere between 34-35 weeks.

I had a bad first pregnancy - lost triplets at 17 and 24 weeks (1, then the other two), and the only thing they could decide was that I must have had a cervix that couldn't handle it. So then we adopted three kids and THEN God decided we needed two more - by sheer miracle - and I found myself pregnant with twins. The VERY first thing my OB said was - gotta put a stitch in!

I had mine at 11 weeks, had a spinal, which was no big deal. The "poke" is not pleasant, but no shot is, you know?!?! So I was awake and he talked to me while he did it and I was in and out in 30 minutes. Spent about two hours in recovery eating and drinking, then went home and had to basically take it easy for a week given my last problems. But from then on it was smooth sailing. I know about the worries - I was 40 minutes in good weather from the hospital, and the babies were due mid-winter, which could make the drive an hour and a half. So at 24 weeks I started home monitoring (twice a day I strapped a monitor to my belly for an hour and then transmitted it to an office where nurses read it). That way if I WAS going into labor they would know right away and I could go to the hospital. But, unlike the last time with its frequent trips, I never had to go. If baby A had been head down and we had been planning a vaginal birth, then they would have removed the stitch at 35 weeks and the weight on my cervix would have caused labor fairly soon. But since he was breech and I was thrilled at the thought of being able to plan their birthdate (as we have no family in the area to care for my other three), I chose to have a C-section and they took out the stitch before they delivered the twins. Had a spinal for that, too, no big deal. Yes, I had a small headache, but only had to stay flat for about two hours, then took tylenol and nursed my healthy babies! I was told that the cerclage is what keeps the cervix from changing, and the changing cervix is a lot of what signals the body to go into labor, so if your dr. feels it is prudent, go for it. What's a headache companred to two beautiful bundles of joy?!?!?!

I also was advised by my dr. to have a cerclage, mine was done at 20 weeks. Mine was done with a full anesthesia, just because a spinal was not an option at that specific hospital, but I'm sure a spinal is less stressful on your body.

With a cerclage, the babies just can't come out and when the pregnancy goes full term or when there is reason to induce labour or have a C-section, the stitches are pulled. From what I understood from my drs, a cerclage is necessary for some pregnancies, especially multiples, because there is so much more strain on the cervix, or if you have a weak cervix to begin with. The procedure itself is very simple, and it won't hurt the babies. In my case, my twins would have been born if I did not have a cerclage, because I did not feel the preterm labour. My twins still came early, but it probably would have been a lot earlier without the stitches. Don't hestitate to ask your dr. many questions until you feel comfortable with the decision.

For additional posts on epidurals and spinals, see the Multiple Childbirth FAQ.


Pregnancy Rash (PUPP)

I'm at 36 weeks. Recently, I've noticed this horrible rash spreading all over my body. My hands are the worst. The doctor says it's related to pregnancy, and that I can try calamine lotion, but it doesn't help. Is there anything else I can try to relieve the itching? It's driving me crazy!!

While your doctor might be able to prescribe something which will be safe to use at this stage of pregnancy, the most commonly recommended remedy was Aveeno oatmeal baths (they also have a special soap).

While this rash usually develops in the last trimester of pregnancy, it can even start after the birth of the baby(ies), and, unfortunately, can last several weeks. But it will go away eventually....

Pregnancy Belts | Maternity Clothes | Sleep Problems | Gestational Diabetes | Contractions | Cerclage

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Please send comments and questions to Lisa