ChezPerky

This was the scan done at my last Shady Hell Appointment. Three sacs, three heartbeats, three of everything. Dr. Amazing was positively adamant that I must schedule a reduction. I understand to him triplets and high risk pregnancy equal failure. For that matter, I’m not so thrilled about having a triplet pregnancy. I wish I could have nothing but happiness over it, but I can’t. I’m still worried about it. I’m happy that I’m pregnant, but I’m worried about the risks and hardships associated with triplet pregnancies. That being said, I don’t know that I agree with Dr. Amazing’s assessment that a reduction is the only logical option. I’m not even terribly convinced that it’s the best option. It seems that no one wants to talk about the risks associated with multifetal reduction, but they really shouldn’t be discounted. From what I’ve seen, the risks aren’t insignificant and the studies I’ve found haven’t suggested that the benefits of triplet reduction are significant enough to overcome the risks. (The benefits of quadruplet reduction to twins or less are stacked significantly in favor of reduction, but it is less clear with triplets)

What I didn’t realize was how quickly I could get attached to the little parasites growing inside me. Nor did I realize how quickly they grow! In six days the growth was tremendous.

See how squished up against each other they are now? This isn’t as clear a picture because it was transabdominal, so you can’t see the little fetbryos inside in this picture, but you can see that the sacs were spaced out before and now they’re all squished together. This scan was taken at the perinatologist’s office on Monday. It was a very long, detailed scan made more difficult by the fact that I absolutely could not manage to empty my bladder enough to see Baby C with a transvaginal ultrasound (but all other views were much clearer). We could very clearly see the hearts beating, whereas before I had to squint and pretend like I saw that random blinking on the screen. Now it’s very obvious and impossible to miss. Like I said in my last post, the heart rates were 171, 171 and 168. Baby C is measuring three days behind, which I understand isn’t a terrific sign at this stage, but I didn’t get a really straight answer about what the ramifications of that size differential really are. At the NT scan, I’ll be seeing the head of the practice, so I’m hoping for more clear-cut answers.

The more I think about it, though, the more annoyed I am about my visit to the perinatologist. I didn’t get to think about it much after the appointment, because we had a houseguest for the first days of Pesach, and I had other things on my mind. Now that I’ve had some time to think, I’m seriously annoyed. On the one hand, the doctor took a lot of time with us and answered a lot of questions. She even told me that there are some neuroleptics that I can take for migraine prevention. I’d previously been told that all neuroleptics are out because of risks of neural tube defects. I’m not sure I’m willing to take that tiny risk, but it was nice that she suggested some options. She calmed my fears about the bleeding and cramping and suggested that both are normal, particularly with higher order multiples. She said that the triplets they follow do very well.

That being said, she was most definitely in favor of reduction. Now I could be all about that position if she’d given me some specifics that I could really work with to get on board with her, but she really didn’t. She gave me some generic statements about how uncomfortable I’ll be with a triplet pregnancy. She talked about how twins deliver later than triplets, which is of course a good thing. She talked about the fact that there’s a lower incidence of IVH with twins than with triplets (though the statistics I’ve found haven’t been terribly compelling). She mentioned that the generic risks of pregnancy are lower with twin pregnancies than with triplet pregnancies. What she did not talk about at all was the risks of multifetal reduction. In fact, I have a hard time finding much literature on the risks, but there are associated risks. The risk of total fetal loss, for example, seems to be at best 3-5%. Not high, no, but it IS a risk. Some studies, in fact, put the rate of total fetal loss (miscarriage) at closer to 25 to 30%. That’s nothing to ignore.

Then there’s the question of real benefit. Average triplet pregnancies go to 32 or 33 weeks gestation in the US, depending on whose figures you use. Average twin pregnancies go to 36 weeks in the US. Triplet pregnancies reduced to twins still carry a higher risk of preterm labor than do natural twin pregnancies. Average gestation for triplets-reduced-to-twins pregnancies is 34 weeks. This is a significant and critical week, but the difference isn’t as drastic as the shift from quadruplet vs. reduced quadruplet (to twins) pregnancies. Not even close. If I had quadruplets, this wouldn’t even be a discussion.

As for my specific medical concerns, yes they are factors. In particular, the hole I have in my heart is something that should be monitored. But it doesn’t appear to be a deal-breaker. Turns out my OB isn’t crazy with regards to the whole short factor either… I found one study in which the conclusion stated: “The taller patient (>165 cm) may be at a significantly lower risk of very low birth weight neonates and very premature delivery as compared to the shorter patient (< 165 cm). Therefore, the factor of maternal height may be taken into consideration in multiple gestation pregnancy consultations.” (I’m about 152 cm short) My husband is going to pull the full article from the medical library at work tomorrow. And yes, if you pile everything up together, there’s a decent argument for reduction given my specific medical factors.

But I also think there’s a rather significant argument against reduction and that’s a discussion no one seems willing to have with me. I’m almost to the point of finding another perinatologist, except that when asking ANYONE for perinatologist recommendations, this practice is the name that ALWAYS gets brought up. The head of the practice is also the head of maternal fetal medicine at both of the hospitals that I would want to deliver at. They are arguably the best maternal fetal medicine practice in the area. But I’m still squeamish about them for some reason. I feel like my care there would be excellent no matter what decision I make, so it’s not a question of my care, really. It’s a question of why no one will have a discussion with me about the other side of this argument. That being said, my husband is checking with one of the nurses in the NICU at his hospital to see who she would recommend as a maternal-fetal medicine specialist, so I can get a second opinion. I intend to receive my care from the office I’ve already been to, but I’d like to have a consultation with at least one more doctor to see if I can get some straight answers.

The problem, of course, is that I’m running out of time.

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This was the scan done at my last Shady Hell Appointment. Three sacs, three heartbeats, three of everything. Dr. Amazing was positively adamant that I must schedule a reduction. I understand to him triplets and high risk pregnancy equal failure. For that matter, I'm not so thrilled about having a triplet pregnancy. I wish I could have nothing but happiness over it, but I can't. I'm still worried about it. I'm happy that I'm pregnant, but I'm worried about the risks and hardships associated with triplet pregnancies. That being said, I don't know that I agree with Dr. Amazing's assessment that a reduction is the only logical option. I'm not even terribly convinced that it's the best option. It seems that no one wants to talk about the risks associated with multifetal reduction, but they really shouldn't be discounted. From what I've seen, the risks aren't insignificant and the studies I've found haven't suggested that the benefits of triplet reduction are significant enough to overcome the risks. (The benefits of quadruplet reduction to twins or less are stacked significantly in favor of reduction, but it is less clear with triplets)

What I didn't realize was how quickly I could get attached to the little parasites growing inside me. Nor did I realize how quickly they grow! In six days the growth was tremendous.

See how squished up against each other they are now? This isn't as clear a picture because it was transabdominal, so you can't see the little fetbryos inside in this picture, but you can see that the sacs were spaced out before and now they're all squished together. This scan was taken at the perinatologist's office on Monday. It was a very long, detailed scan made more difficult by the fact that I absolutely could not manage to empty my bladder enough to see Baby C with a transvaginal ultrasound (but all other views were much clearer). We could very clearly see the hearts beating, whereas before I had to squint and pretend like I saw that random blinking on the screen. Now it's very obvious and impossible to miss. Like I said in my last post, the heart rates were 171, 171 and 168. Baby C is measuring three days behind, which I understand isn't a terrific sign at this stage, but I didn't get a really straight answer about what the ramifications of that size differential really are. At the NT scan, I'll be seeing the head of the practice, so I'm hoping for more clear-cut answers.

The more I think about it, though, the more annoyed I am about my visit to the perinatologist. I didn't get to think about it much after the appointment, because we had a houseguest for the first days of Pesach, and I had other things on my mind. Now that I've had some time to think, I'm seriously annoyed. On the one hand, the doctor took a lot of time with us and answered a lot of questions. She even told me that there are some neuroleptics that I can take for migraine prevention. I'd previously been told that all neuroleptics are out because of risks of neural tube defects. I'm not sure I'm willing to take that tiny risk, but it was nice that she suggested some options. She calmed my fears about the bleeding and cramping and suggested that both are normal, particularly with higher order multiples. She said that the triplets they follow do very well.

That being said, she was most definitely in favor of reduction. Now I could be all about that position if she'd given me some specifics that I could really work with to get on board with her, but she really didn't. She gave me some generic statements about how uncomfortable I'll be with a triplet pregnancy. She talked about how twins deliver later than triplets, which is of course a good thing. She talked about the fact that there's a lower incidence of IVH with twins than with triplets (though the statistics I've found haven't been terribly compelling). She mentioned that the generic risks of pregnancy are lower with twin pregnancies than with triplet pregnancies. What she did not talk about at all was the risks of multifetal reduction. In fact, I have a hard time finding much literature on the risks, but there are associated risks. The risk of total fetal loss, for example, seems to be at best 3-5%. Not high, no, but it IS a risk. Some studies, in fact, put the rate of total fetal loss (miscarriage) at closer to 25 to 30%. That's nothing to ignore.

Then there's the question of real benefit. Average triplet pregnancies go to 32 or 33 weeks gestation in the US, depending on whose figures you use. Average twin pregnancies go to 36 weeks in the US. Triplet pregnancies reduced to twins still carry a higher risk of preterm labor than do natural twin pregnancies. Average gestation for triplets-reduced-to-twins pregnancies is 34 weeks. This is a significant and critical week, but the difference isn't as drastic as the shift from quadruplet vs. reduced quadruplet (to twins) pregnancies. Not even close. If I had quadruplets, this wouldn't even be a discussion.

As for my specific medical concerns, yes they are factors. In particular, the hole I have in my heart is something that should be monitored. But it doesn't appear to be a deal-breaker. Turns out my OB isn't crazy with regards to the whole short factor either… I found one study in which the conclusion stated: "The taller patient (>165 cm) may be at a significantly lower risk of very low birth weight neonates and very premature delivery as compared to the shorter patient (< 165 cm). Therefore, the factor of maternal height may be taken into consideration in multiple gestation pregnancy consultations." (I'm about 152 cm short) My husband is going to pull the full article from the medical library at work tomorrow. And yes, if you pile everything up together, there's a decent argument for reduction given my specific medical factors.

But I also think there's a rather significant argument against reduction and that's a discussion no one seems willing to have with me. I'm almost to the point of finding another perinatologist, except that when asking ANYONE for perinatologist recommendations, this practice is the name that ALWAYS gets brought up. The head of the practice is also the head of maternal fetal medicine at both of the hospitals that I would want to deliver at. They are arguably the best maternal fetal medicine practice in the area. But I'm still squeamish about them for some reason. I feel like my care there would be excellent no matter what decision I make, so it's not a question of my care, really. It's a question of why no one will have a discussion with me about the other side of this argument. That being said, my husband is checking with one of the nurses in the NICU at his hospital to see who she would recommend as a maternal-fetal medicine specialist, so I can get a second opinion. I intend to receive my care from the office I've already been to, but I'd like to have a consultation with at least one more doctor to see if I can get some straight answers.

The problem, of course, is that I'm running out of time.

Read Full Post »