Lemme Esplain. Wait. There is Too Much. Lemme Sum Up...

We are working on Information Overload here in the Perky Household, as I'm sure you can all imagine. I wish I'd gotten a chance to write up my doctor's appointment yesterday while it was still fresh in my mind, but I'm going to have to wing it (and I'm currently EXHAUSTED, so who knows how coherent this will be). This is a really, really, really long post. Sorry!

Genetic Counseling
Okay, so you all remember the fun on Thursday, of course. I was only moderately satisfied with the answer I got from the OB's office, but I wasn't too terribly stressed about it, since I figured the perinatology practice would be able to fill me in on any other details if there was anything to be found. I was right of course. Anyway, I'm getting ahead of myself. Let me back up. My husband and I met first with the genetic counselor, and found out lots of good things (like we don't have serious risk factors in our family history that are huge deals). She gave us more information on what to expect from the nuchal fold and CVS. She talked a lot about percentages. She reassured me that my coke addiction isn't killing my babies (seriously, people, I have about 50mg of caffeine per day, I'm DOING FINE). She was very nice and was surprised at how much working knowledge we already had (I can talk the talk pretty well at this point and my husband is a pharmacist, so you know...). We'd already been screened for CF, Tay-Sachs, etc, so we were good on those fronts. Among other things, she asked if I'd had any problems with the pregnancy and I mentioned the bleeding/cramping. She asked a lot of questions about that and took very detailed notes that got passed on to both the sonographer and the doctor, which was great.

Sonogram
Then back to the waiting room while waiting for an ultrasound room to be free. And I thought I was going to float away. I swear, they tell you to come in with a "comfortably full" bladder. Yeah, right. YOU try finding that happy medium of "comfortably full" when you're pregnant with freaking triplets! Eventually, when I really thought I couldn't take another single solitary second without peeing in the waiting room, we were called back for the ultrasound. The first thing the sonographer asked was what was going on with the bleeding. She wanted to make sure that in addition to looking at the babies we looked around for a cause of the bleeding. She also said she'd be looking at all three and she wanted to know if I wanted to see them also. I suspect there are folks who DON'T want to see if they're considering a reduction, but that wasn't the case for me, even when reduction was on the table.

First she went looking at the babies with a transabdominal scan. They were all in fine form, but a tad bit too small for useful NT measurements. The NT data starts being useful when the babies are 4.5 cm, but the biggest one of my trio is 4.45 cm (or was as of yesterday... who knows how big it is now!). She took detailed measurements on each of them, plus a heartbeat. We saw them doing somersaults and waiving at us and flipping around, curling up, stretching out, all in all, pretty darned cool. She showed me where my cervix was and where the placentas were. She showed me where my uterus was... the top of my uterus was all the way up at my belly button which freaked me out, because that seems awfully quick on the growth, but she explained it was because my bladder was pushing it upward. The babies measured at 11 weeks 2 days, 11 weeks 1 day and 11 weeks 0 days (I was at 11w, 2d on Friday, so perfect). The heartrates were 163, 163 and 158 (so they're slowing down a little bit, which is what I was told would happen). When she was done with all the measurements, she left to talk to the doctor to find out whether she should do the NT measurements, since it was a bit too early (the answer was no, we need to wait). Then she came back and told me (bless her heart) that I could empty my bladder and then they wanted to do a transvaginal scan to check on the cervix and one of the placentas. Okey dokey.

Placenta Previa and Meeting Dr. P.
When she came back after I had appropriately disrobed, she brought the doctor with her and he chatted for just a second or two before I "assumed the position" and got wanded. It was IMMEDIATELY apparent that there was a complete placenta previa and you could even clearly see where the blood flow was coming from. The doctor seemed almost surprised I wasn't having even more bleeding than I was based on that picture. He took a lot of time to point things out on the monitor to explain what they were looking at and what the significance was. he said my cervix is nice and long, which is great. Done with the wanding, the sonographer withdrew the wand (but the condom stayed in me! EW!... I mean, she pulled it right out, but it was seriously embarrassing!) and left the room. I sat up with a drape covering my lower half and then we started seriously talking to the doctor.

The doctor we met with, Dr. P, is the head of the practice and we were very impressed with him. He was clear, articulate, empathetic, forthcoming and candid. He preemptively answered a lot of the questions on my list and had no problem spending a lot of time with us. I think he talked with us for a good half hour or more once the ultrasound was finished with. He did not put the pressure on the reduction option, though it's obviously there as an option if we want it. He was clear about what I can expect, but didn't terrify me so things were good. In light of the relatively heavy bleeding I'd had on Thursday (particularly combined with the cramping) and the discovered placenta previa he told me I should be on severely restricted activity for 48-72 hours starting immediately. I said I was just glad it wasn't all in my head, and he didn't miss a beat before he said, "So... what? You think you imagined vaginal bleeding? That's a neat trick." Yeah, we liked him a lot. Oh, and no lifting anything over 10 pounds, not just for 48-72 hours, but for the duration. Okay.

Short Stature as a Factor?
We asked about the height factor and he said it is definitely a factor to consider, but not a deal-breaker. He said that generally with shorter women he finds that they are put on bedrest sooner (and in light of that plus my other medical issues, no I will NOT be the exceptional woman who never ends up on bedrest with a triplet pregnancy... he'll automatically put me on bedrest at some point). He said that the problem is that because I've got a smaller abdomen, there's less room for growth so the uterus will eventually push up against the diaphragm. This is what another doctor had said, but she suggested that the real implication of that would be discomfort on my part. In fact, having the diaphragm pushing down on the uterus can cause a greater number of uterine contractions, which can equal preterm labor. This is one of the reasons for bedrest, though, because it should shift some of the pressure away. No matter what, they won't let me go past 34 weeks, because at that point, the babies tend to do better on the outside than the inside. He said that mostly their triplets deliver at 33 or 34 weeks. Except for one case (an 18 year old who was completely noncompliant), all their triplets have gone to at least 30 or 31 weeks (the 18 year old non compliant patient went at 26 weeks, but that was their only case, and I think he said the babies ended up doing just fine in the end).

Concerns about risks of Reduction
I expressed that one of my concerns with reduction was that it seems like it can increase the risk of total fetal loss, or at least that's what the studies are suggesting. He said the problem with just looking at studies is that they show averages over a long period of time (it's true... most of the studies I saw pooled 25 years worth of data and medicine has changed a lot over that time) and don't differentiate a lot of factors (like whether the care after reduction is managed by an OB, family doctor, hospital center, perinatologist, etc.). Fair enough. This preinatology practice delivers between 12 and 15 sets of triplets per year. He said that for every set of triplets he delivers, he has about 2 triplet pregnancies that he reduces. Most women, he said, are still opting for reduction for a variety of reasons. He was NOT advocating that reduction was our only option, however. I thought those numbers were fairly astounding, though. So my husband, smart man that he is, asked what his practices rate of total fetal loss after reduction is and he said they have not had a total fetal loss after reduction. Then he corrected himself and said that he had one woman who came in for a reduction of sextuplets to twins at 16 weeks (very late for a reduction... they prefer to do them before 15 weeks), and she was not followed by their practice after the reduction. She went to her OB at 23 weeks and complained of cramping, the OB told her not to worry, and she delivered her 23 weekers and they didn't survive. I appreciated that Dr. P gave us full disclosure on that loss, but it sounds like that was somewhat unrelated to the reduction itself (not to mention reduction from sextuplets is riskier than reduction from triplets in terms of total fetal loss).

He acknowledged that for sure triplet pregnancies carry more risk than twin pregnancies, so I asked whether it is signficant that in fact I'm not comparing a triplet to twin pregnancy, I'm looking at comparing a triplet to triplet-reduced-to-twin pregnancy. He said that it is true that it's an intermediate step, but that the risks after reduction far more closely approach the twin pregnancy than the triplet pregnancy and he provided very specific statistics to support that statement. I don't remember enough to type them out now, but I was certainly satisfied with his answer at the time.

Size of Babies
Dr. P was not concerned that one of the babies has been lagging behind a little bit in size. He said the important thing is that it's following a predictable growth curve (which it is), because just like normal humans, fetuses have a range of normal. He said it's possible it's just genetically predisposed to being smaller. Or, yes, it could have been a slightly later implantation, and I asked if that was troublesome but he said at this stage it is not. Overall, he was pleased with the growth and the heartrates etc. He said the biggest hurdle right now is to get me through the next week and half or so to get me to the second trimester. Shortly after that, we'll start having weekly checks for fetal growth and cervical changes and to see if the placenta previa resolves itself (this often happens over the long term, but with triplets, it's sort of 50/50 over whether it will resolve since there's limited uterine real estate available).

More on Placenta Previa
I asked if the placenta previa was a big deal, because I mean, with singletons, sure it's rotten because it's an automatic ticket to a C-section, but since I have a guaranteed C-section anyway, who cares, right? Well, to a point that's true, but the problem with it remaining a complete placenta previa is that if too much pressure is put on the cervix or if the bleeding becomes too heavy, it can trigger a miscarriage or preterm labor. However, we'll manage this risk with the monitoring I'll be having done as a matter of course anyway. And with any luck, it will migrate away from the cervix as the uterus expands. He also noted that I should not allow my bladder to get too full (easy for him to say) because the bladder putting too much pressure on the uterus can cause a greater likelihood of uterine contractions. This put me in a weird conundrum today because I wasn't supposed to be getting up from the couch much, but I had to PEE about every 15 minutes. Oh well.

Weight Gain or Lack Thereof
My husband asked me if I'd stopped losing weight and I said yes, but I hadn't gained anything yet. Dr. P was unconcerned. He said they aren't worried about the pounds specifically, but the volume. My metabolism is obviously working in overdrive. But he wants me to push fluids, drink soup if I can, keep hydrated, eat enough calories to whatever degree the Zofran allows. (He did note that the nausea should abate soonish) He said that eventually they'll want me to take my prenatal vitamin twice a day, but wouldn't recommend trying that until the nausea really does abate. He noted that the extra vitamin is for MY benefit, not for the babies. He said they are voracious little parasites who will suck the life out of me, so they're not worried about the babies having enough vitamins, they're worried about my reserves being diminished. This seemed fair enough.

Bilateral or Unilateral Care?
Lastly, we talked about long term care. He asked whether I would be seeing my OB's practice bilaterally with their practice (which is their usual way of working with patients... but that's because most patients referred to perinatologists just need a bit of higher-level monitoring for a specific risk factor... triplets apparently get me into my own special class of patients). I told Dr. P I wasn't certain what would happen because originally, I'd understood that it would be bilateral care but that the evil doctor (also, ironically, Dr. P) who I saw on Thursday had said maybe my care should be transferred entirely. I explained that I love, love, love my OB, but that I wasn't entirely certain what the better route is. Dr. P said that with the OB practice that I'm at, he's not so concerned about things slipping through the cracks, because it's a very good practice (good to know!). However, he said, if he's to be totally candid, his gut reaction is that it's easier that if the perinatology practice is going to care for me, to just have them do all my care. He did say that it was entirely up to me and my current OB practice and that they were willing to work either way. I'm inclined to agree with him that the best thing is to transfer my care directly over to the perinatology practice (much as I hate to lose my beloved OB). I'm going to be seeing the perinatologist more often than I'll be seeing my OB as it is, and the perinatologist will be likely doing the delivery, and my OB made quite clear that he would defer to the perinatologist on all critical care decisions, so I'm not sure there's a real advantage to keeping my OB in the loop, and it might actually make things more complicated. In the meantime, however, I should continue to use my OB as my first-line of help if I have complications, but they will likely have me contact the perinatology practice anyway. I should continue to get my scripts from the OB (e.g. for Zofran) until such time as my care is transferred over entirely. I didn't think that the perinatology practice ever did full-blown prenatal coverage, but apparently they do for the special people (like me!).

Final Thoughts (for now)
So no kidding on the whole Information Overload bit, right? And honestly, there was a LOT more information in that appointment than I even detailed here. I thought it was a really positive appointment. We will go back in two weeks to try again with the nuchal fold, but don't anticipate finding any problems. He said if I felt anxious to come back sooner, I could, but this way I can minimize the number of appointments I need right now, since I'll be having so many soon enough. So nuchal fold on May 3rd and on May 4th I already had an appointment scheduled with my OB, so I'll go to that and talk about transferring my care alltogether to Dr. P's practice (it makes me sniffle just thinking about it, but I think it's the right thing).

Dr. P told me to please not hesitate to call this weekend if I had any problems, he said he was the doctor on call for the weekend, but that he genuinely hopes I don't need to. I liked him so much and I felt very much reassurred after meeting with him that my care would be well managed and that I would be in the best of hands. I asked my husband if he still wanted me to try to reschedule the Georgetown consult appointment but he said he was satisfied. He felt much more confident coming out of yesterday's appointment than he had been feeling.

One thing that I really like about the practice is that it's obvious they communicate well. Dr. P had clearly read my chart very thoroughly before wallking in the room (the same had been true with Dr. M). It was clear that Dr. M's notes from my last appointment were thorough and accurate. The genetic counselor had obviously passed on the concerns about my bleeding to both the sonographer and the doctor. Everyone seemed thoroughly familiar with the notes from Shady Hell as well. It saves a lot of stress if I don't have to repeat things or remember what I've told whom, and it's very nice that they obviously take great care to educate themselves before stepping foot into the room with the patient. It's hard to describe, but it just inspires a whole different level of confidence.

Finally (and I mean it this time), I have to say, I've gotten a quick taste of what my life will be come June-ish, because I've been on the couch for all of ONE day, and I have to say, I am bored stiff, and cannot believe how absolutely limited I felt being housebound. (And I even went out and sat in a chair on the lawn for a bit while my husband and foster son played together... even that didn't help the trapped feeling for very long!) I am obviously going to have to change my entire mindset to get through months of bedrest. I was really struck with the reality of it last night when I looked at my gigantic fat cat (15 pounds) and realized I could not pick her up again until the fall at least. Even the slightly smaller cat is over 10 pounds. It really made me realize that I cannot "cheat" and pick up our 40 pound preschooler even occasionally. Seriously? Bedrest is not going to be so easy!