...The following day, I had a long discussion with Joy and Andres about what to expect over the next 3-4 weeks, the discomforts, the psychological drain, the ever-present concerns for outcomes and the risks. The uterus is now the size of a term one. She had gotten to the point where she developed a rapid heart rate (tachycardia) and low blood pressure (hypotension) in almost any position. I explained that the placentas are like having 5 large arteriovenous (A-V) malformations (direct connections between the arterial and venous sides of the circulatory system) and that this was stressing her already stressed heart.
We talked about my concerns of uterine rupture, discussed plans for the delivery itself, hopefully under very controlled circumstances rather than as an emergency, and discussed the immediate peripartum concerns related to rapid fluid shifts that might increase her risk for congestive heart failure and pulmonary edema at the time of delivery. We revisited the concern that a hysterectomy might be necessary at the time of delivery as the result of uterine rupture, placenta accreta, or uterine atony with hemorrhage. I distinctly recall that she was not at all enthralled with that possibility if there was anything that could be done to prevent it. I informed them that earlier in the day, planning with Dr. Ohning from the NICU (Neonatal Intensive Care Unit) and his staff had begun in earnest now.
Over the next three weeks, she did very well. She flirted with preterm labor and continued to have the expected discomforts associated with hypotension, tachycardia, and general discomfort. At that point, I sent the following letter to my colleagues…
Joy Gonzalez is 27 weeks today. I have seen her just about every day she has been here, but I will be on vacation next week (but mostly in town) and wanted to apprise you all of where she stands.
Currently, she is on a running dose of indomethacin 25mg q6h. We are scanning the babies twice weekly to confirm well-being, assess amniotic fluid, and to do Doppler flow studies, including evaluation of patency of the ductuses when we can. At this point, unless the amniotic fluid begins to drop, I would stay the course with the indomethacin. That and the combination of vistaril and stadol in the early evening have helped control her uterine activity and anxiety. If the amniotic fluid drops, and everything else looks good, consider stopping the indomethcin for 48-72h. If the indomethcin has been the contributing factor to the decline in fluid, it will correct in that period of time. If it does not, or if there is differential correction, then we are probably dealing with placental insufficiency problems.
I took her off metronidazole earlier this week because of nausea and light-headedness and that seemed to help a lot. That can be restarted if her vaginal discharge returns and is bothersome to her. She was complaining of more “pressure” today (and over the past several days). The presenting baby is sitting right on the cervix but is still ballotable. The cervix remains long, but is extremely soft. There is no cervical dilation or tearing because of the cerclage at this point.
She continues to gain weight and her laboratory parameters have been stable. Albumin remains in the 2.3-2.4 range. She has made a major effort with regard to caloric intake. Her platelet count has drifted down, but was back in the 170,000 range yesterday. She has no abnormalities of her LFTs (liver function tests), LDH, etc. We have not done a formal glucola screen on her because all of her labs have always had glucose in the 70-80 range until yesterday’s random sugar (within an hour or so of breakfast) returned at 124. I still don’t know if a screen is worthwhile, but we might consider a fasting and 2hr pc evaluation to see if she has developed some carbohydrate intolerance along the way.
Her blood pressure is good, there is no edema, but her reflexes have become brisk within the past week. She has no specific complaints and is in the best spirits I have seen since she was admitted.
I have not yet given her steroids (to accelerate fetal lung maturity). My feeling there has been that if she gets to the point where we use magnesium to stop contractions or perhaps at 28 weeks, if not needed sooner, we could give them to her then. As the next step in tocolysis, if that becomes necessary, I would avoid nifedipine, consider a single dose or two of terbutaline (very carefully) to assess her response and tolerance to this, but probably go with the magnesium. If she needs magnesium, the plan is to transfer her to L&D. It is possible to get FHR(fetal heart rate) tracings on ALL of the babies and I suggest we start doing this every other day from this point forward.
We have worked closely with the nursery, L&D, and anesthesia to prepare for the delivery and everyone appears to have their roles well-defined. The plan will be to deliver her in O.R. C, nursery staff will take the first 3 babies to the ‘NICU annex’ we have set up in the recovery room directly handed off by us from the operating table, and the last 2 babies will be placed by us in the two warmers set up in O.R. C. The goal will be to make EVERY effort to deliver her on L&D. If she has complications and needs to be recovered in the SICU, that can be done afterwards. Anesthesia was pushing us to deliver her downstairs in the main O.R., but that creates almost an untenable situation for the nursery (and believe me, we have looked into that option). So unless we are in an extraordinary situation, please insist on delivering her upstairs.
Joy has a special request that we attempt to deliver the babies in the ‘order’ in which they have been evaluated antepartum. We have periodically drawn the orientation of the babies on her abdomen AND THEIR POSITIONS HAVE NOT CHANGED. This is not an unusual request under these circumstances and if it can be honored, that would be much appreciated. She would also like us to do “everything possible” to preserve her uterus.
The last is a special request on my part. I will tell her today that I may not be readily available over the next 11-12 days. After my vacation this week, I am then scheduled to go to that CDC meeting on the 10th and 11th. However, over the next week or so, I will try to get in to see her periodically. I will have my beeper and cell phone on and would truly appreciate a call if there is any significant change in her status. I would also like to be able to come in to assist with her delivery if at all possible. She is a very special patient to me and I know she would appreciate it too if I could be there to help out.