Before I became distracted by a plethora of administrative responsibilities, I was in the middle of writing a series about multiple gestations. Although I did not want to spend a lot of time discussing 'high order multiples' (three or more babies) in this series, I did want to highlight some of the medical and ethical dilemmas of such pregnancies (which have again been raised with the recent delivery of octoplets in California) and thought that this might best be done by reviewing the course of a patient from our own practice. As some of you may recall, about a year ago, I posted a note with my thoughts regarding the first birthday of the Gonzalez quintuplets. Fortuitously, over the past month, the family asked that I compose a 'forward' to a book they are writing about their experiences during the pregnancy and following delivery. Over the next several days, I would like to include the draft of that 'forward' so that our readers can gain a better appreciation for the issues involved in such cases...
I first met Joy Gonzalez on November 7, 2006. I remember the date well because it was my birthday and little did I realize at the time what I wonderful birthday gift she would turn out to be. Joy was sent to me for consultation from our specialists in Reproductive Endocrinology and Infertility (REI). She had conceived quintuplets, was now 6 weeks pregnant, and all five babies were alive by ultrasound evaluation. She was well aware of the potential for having a ‘high order’ multiple pregnancy resulting from her infertility treatment, but no preconceptional counseling could have prepared her for the reality of having conceived five babies. My task and responsibility that day was to put that reality into an honest and realistic perspective, a perspective that frequently runs contrary to the popular press portrayal of such pregnancies.
It had actually been many years since I cared for a patient carrying more than three babies. Earlier in my career, such pregnancies, usually the result of infertility treatment, seemed more common, but as the specialists in REI have honed their craft over the years, the occurrence of more than three babies has diminished. There were good reasons to support this approach. The maternal and fetal complications related to such high order multiple pregnancies are well-documented and, even with the remarkable advances in neonatal intensive care, the pregnancy risks are too high to justify intentional efforts that result in more than twins. But, despite the usual precautions to prevent this from happening, here we were with five.
During this first conversation with Joy, I remember being very cautious and candid about the prospects for the pregnancy. She was not a good candidate for a successful outcome under these circumstances with great risks for both her and the babies. Her starting weight was in the range of 108 lbs, she was no more than 5’ 4” tall, she was already having difficulties with nausea, vomiting, and dehydration (problems that had plagued her previous singleton pregnancy until delivery), and she had delivered just a year earlier by cesarean section at 36 weeks for fetal complications during labor. Despite being physically in ‘good shape’ she had had a past history of “bone pain” and had been found to have low bone density (osteopenia). There are risks associated with each of these factors and we proceeded to review these and others with her during that visit.
Without going into detail herein, our discussion focused on a variety of issues. As is always the case in such pregnancies, there are the obvious concerns related to the ‘hormonal load’ of five separate placentas (often contributing to a ‘hyperthyroid-like” state, particularly in early pregnancy), premature labor and delivery, severe hypertensive disorders of pregnancy, gestational diabetes, profound maternal nutritional deficiencies secondary to nausea, vomiting, and the fetal demands (over which she would have no control) and the simple difficulties of maintaining an adequate dietary intake, increasing the risks for fluid and electrolyte imbalances and, later in pregnancy, relative ‘fluid overload’ and even heart failure or pulmonary edema associated with the extraordinary demands on the maternal cardiovascular system. Because she had previously had a cesarean section, she also was at increased risk for uterine rupture, even prior to the onset of labor, with the possible loss of her uterus, the babies, and even her own life. Beyond these medical concerns, we reviewed the additional demands such a pregnancy will place on her family life, both during and after the pregnancy, and interpersonal relationships, financial resources, and those that will be imposed by public scrutiny which may impinge on personal privacy and at times may be less than supportive.
Once these concerns were reviewed with Joy, my professional responsibility was to be quite frank. Joy was told that the medical complications of the pregnancy might threaten both her life and the lives of her babies, that her husband could come out of this pregnancy with no wife or mother to their young daughter, no babies, and that even if the pregnancy got to the point where the babies might survive, the survival might not be without long-term complications. She knew that she would have a difficult course ahead of her and as is always the case in these circumstances, she also knew that she would have some very difficult decisions to make along the way, not the least of which was the pressing decision as to whether or not she would even try to continue the pregnancy with all five babies. I told her that I could not make these decisions for her but I did promise her that whatever decisions she made, we would be there to support her and that we would do everything we could to optimize the pregnancy outcome for her and her family.
Joy left that day to discuss this with her husband, Andres, and returned firm in her resolve. She would continue the pregnancy as is and would put her faith in us to help her and the babies get through the difficult times. At that point I remember looking her in the eye and touching her hand saying, “You have to promise me only one thing and that is when I look you in the eye again and tell you it is time to have the babies, I need you to trust me, regardless of how far along we get in the pregnancy.” She agreed. I also remember thinking to myself at the time that she will need all our tricks and all our prayers to see her through. At that point, we outlined a “plan” for her care during the pregnancy. Part of the “plan” was that we keep the details of the pregnancy out of the public eye until she and Andres felt comfortable enough to face that challenge. Shortly after that visit, I reviewed my concerns about the pregnancy and the “plan” with the other members of our Maternal-Fetal Medicine group and emphasized the importance of respecting her privacy both during and after the pregnancy. Staff members were also informed of this strict responsibility....