On the whole, the pregnancy progressed well. At about 13 weeks, we placed a high cerclage in her cervix. This stitch around the cervix was intended to help prevent subclinical cervical changes leading to early labor as well as a means of providing us a ‘safety net’ and perhaps some opportunity to interrupt premature labor should that ensue. Between 15 and 17 weeks, she gave me my first real scare of the pregnancy. Her nemesis of nausea and vomiting which she had managed to keep under reasonable control as an outpatient returned with a vengeance. She required two hospitalizations in mid-January 2007 and during those stays her electrolytes were abnormal and blood protein levels dropped precipitously to dangerously low levels. Her hemoglobin had also dropped dramatically in only 6 weeks. From past experiences with high order multiples, I knew this deterioration in her nutritional status could be the first sign that we might have difficulty getting the babies to a point of good viability. Electrolytes can be readily replaced, but if protein is not maintained in the blood, then sooner or later, she would begin to leak fluid into her soft tissues and lungs. Fortunately, with medications, dietary adjustments, and a great effort on Joy’s part, the blood chemistries stabilized and then improved and the pregnancy went on.
From that point forward, she was seen weekly in our office. At her 20 week check, the babies’ growth and anatomy appeared normal and the cervix had maintained its length with the cerclage in good position. At 21 weeks, she complained that she was having increased uterine contractions, especially when she was on her feet, and was again “having more trouble eating, but I am working on that.” By this point she had gained more than 30 lbs since her first prenatal visit and more than 40 lbs since she had conceived. On February 23 at 22 weeks, her laboratory studies were rechecked and the results were very encouraging – her blood protein levels had climbed to a level comparable to that at the beginning of the pregnancy and her hemoglobin levels had stabilized since her January admissions.
Over the next week, however, she developed a low-grade fever and upper respiratory infection and, as a consequence, had a hard time keeping up with her fluid and food intake. When she was seen in the office on March 3 with these complaints at 23 weeks she was having uterine irritability, her cervix had shortened to just above the level of the cerclage (still providing 25-30 mm of cervical length), she now had protein in her urine, and her blood protein levels had again dropped to the point they were at during her January admissions. In addition her white blood count was elevated in a way that suggested an infection, presumably, upper respiratory in view of her symptoms but with the concern on my part that this could also be intrauterine because of the frequent, mild uterine contractions she was having. She had developed mild swelling in her lower extremities but, fortunately, her blood pressure was normal. On that day, we admitted her to the hospital and she understood that this would probably be for the duration of the pregnancy.
She was begun on bed rest and antibiotics at the time of the admission. Fortunately, with intravenous fluids and improved dietary intake, her uterine contractions resolved and her condition again stabilized. Her laboratory studies did show that she had a significant amount of protein in her urine and we knew that this would make it even more difficult to maintain her blood protein levels if she was losing protein by this route as well as across the placentas supporting the growth of the babies. We also knew this could be the first sign that she was developing preeclampsia.
A week after admission, the babies were found to be growing well by ultrasound and their total estimated weight was in the range of 7 lbs. We were now at 24 weeks and the general feeling was “so near yet so far.” Survival of babies at this gestational age in our neonatal intensive care unit (NICU) is in the range of 50%, but we also knew there were very high risks for long-term complications for survivors born at this early time. I remember this day well, because I gave Joy a hanging ornament with five dangling ornaments that was inscribed “Hang in there.”...