Details and Followup

Okay, so my last entry was rather abrupt and seriously lacking in detail. It was a rather visceral reaction to a not-very-good appointment which frankly captured my mood, but not so much of the specifics. So let me esplain! No! There is too much. Lemme sum up... wait. This is my blog, I can take all the time I want. So here it all is... or at least as much of it as has remained in my brain since then:

Sunday
Sunday evening, as you'll recall, I was having about 4 contractions per hour and I paged the doctor on call. Dr. M called me back pretty quickly and she told me that if it continued, I should definitely come in to L&D to be monitored, but agreed that if I could sleep through them that coming in to my already-scheduled appointment at 10am was probably fine. She said that if I could sleep through them, the contractions were probably not so worrisome, but that if they were keeping me awake, I should definitely come in, get monitored, get IV fluids and probably terbutaline. She told me that I'd be seeing Dr. R in the office if I was able to hold off until morning. I wasn't thrilled to hear that. I'd never met Dr. R and I love the other three doctors and I just didn't want to meet another doctor. I couldn't, after all, possibly like a fourth doctor, could I? I don't deal well with change. At all. I get very set in my ways, so adding a new variable was definitely not something I was loving. Still, I definitely didn't want to spend all night in L&D and laying down for a few hours did slow my contractions back down to about 2-3 per hour, even if I didn't really sleep through them (Seriously... who was I kidding? I don't sleep through the best of nights!)

Monday
Monday morning I got up, took J to camp, hung out in my recliner for a bit and then headed over to my 10am appointment. I was of two minds about this appointment. On the one hand, I was a bit worried about the fact that my cervix had started to act a little wonky last Wednesday, but on the other hand, I really didn't expect that there would be any significant change, either. Other than taking J to school, I'd been pretty much continually sitting/laying down on my tush since Thursday afternoon. I hadn't done any moving around to speak of, everything had been going really well. I expected, really, to hear from the doctor "gosh, I don't know what Dr. G. was so worried about, everything's looking great." Or at least to hear, "Well, I see why he was concerned about the change, but there's not been any additional progress since Wednesday, so you're still doing fine."

Instead, one look at the ultrasound, before a single measurement was taken, and even I could tell that it wasn't good. Wednesday's measurement had been around 3cm. There was no way that it was still that long. Worse, as we were watching, we saw it start to funnel and shorten even more. The doctor froze the image and measured. 1.5cm. A few more measurements revealed that it shifted between 1.5 and 2.3 cm. This is called a "dynamic cervix". I never google this stuff, but if you DO happen to google the term "dynamic cervix" you'll see it referred to often as a precursor to an incompetent cervix. However, the doctor said that she sees a dynamic cerix a lot with high order multiples in general.

I told her that I'd been having 4+ contractions per hour the night before but they had slowed to 2-3 per hour through the night. I asked what my guideline ought to be...how long I should put up with them occurring 4 per hour before I call, etc. She said that if I'm getting 3-4 per hour for 2 hours or more after laying down, drinking water, etc. I should absolutely call. She said also that in light of my noticeably shortened cervix, I needed to "limit my activity" as much as possible. It wasn't until later that I realized I didn't know what the hell that meant. I did ask whether I could still drive J to and from day care and she said she would get someone else to do it.

She said that we could consider doing a Fetal Fibronectin test which might be one indicator of my risk of going into labor due to a cervical issue in the next two weeks. But, we couldn't do it then, because you can't do the test if you've had any sort of vaginal exam in the last 24 hours, including vaginal ultrasound. She also wanted to research whether the test was valid with triplets. She knew it was with twins, but wanted to check with triplets.

So we left things at: 1. Limit activity as much as possible; 2. No driving J. to and from day care; 3. Call if contractions increase to 3-4 per hour persistently; 4. Return for a re-check in a week - and we could consider doing the fetal fibronectin test then before the ultrasound. I waddled off to get my weight and blood pressure checked (down a pound, but didn't hear what my BP was). The doctor wandered back in to let me know that she found an article written by John Elliot about fetal fibronectin tests with triplets and quadruplets, which seemed to indicate that test results are valid even with HOMs, so she was comfortable recommending that we go ahead and do the test before my next ultrasound. Fair enough. She made a bit of friendly chatter and as I was leaving asked if the triplets were the result of IVF or IUI. Interesting that it didn't occur to her that they could have been spontaneous, but regardless. I told her that they were from a last-ditch IUI and that in fact, I'd been pushing for IVF for some time specifically to avoid the triplet scenario if possible, but here we are. I mean, I am now very excited about my triplets, don't get me wrong. But I'll tell you what, all the excitement this week was excitement I could have lived without. So she said, "Yeah, if I had needed fertility treatment, which I didn't, I'm quite fertile with three children and no need for more, thankfully, I would have done IVF because I wouldn't have wanted to risk it with IUI."

What. The. Heck? Did she seriously just say that? Yeah. She really did.

Basically I left the appointment in a haze. I made a couple calls to make sure I could arrange to have J picked up from camp that afternoon. I let my husband know what was going on. And I IM'd Jess and FREAKED THE HECK OUT. And she, good calm friend that she is, listened. And told me I really needed clarification on what "limit my activity" really means, which was true. I'm a girl who follows directions very well, if they're very specific. You tell me I may never get out of my chair ever again and I won't do it. You tell me to "use my judgment" and that's where we've got a problem. I'm not objective enough. I fully admit this character flaw. So I called my nurse to clarify. She gave me more specifics, which didn't sound terribly restrictive to me, considering that I'd already been pretty restricted in the first place. Outside of going to and from work, up until this point, my activity level has boiled mostly down to sitting my tush in my recliner and staying there, with only occasional trips into the kitchen and whatnot. So the only real difference seemed to be that I shouldn't take J to and from daycare/camp and that I shouldn't go to work anymore. I was told I needed to use my judgment about working from home, but I decided I didn't want to risk the stress of it. I was given permission to go into my office for an hour on Thursday because my coworkers were planning a "surprise" party for me (I've since cancelled that). But otherwise, trips out should be pretty much restricted to doctor's appointments.

"What we really need," the nurse said, "is to keep these babies in at least a few more weeks."
"I'm rather hoping for another 8 or 10 weeks!" I said.
"Well, I don't know about 10 weeks. Right now, we need to get you to at least 28 weeks, and we'll take every week after that as a bonus."

I. Freaked. Out. This was the first time I'd ever heard anyone from the practice ever say anything about 28 weeks being even remotely in the picture. They get most of their triplet patients to 34 weeks. It never occurred to me that I could or would be the exception to that rule. I didn't know whether she was speaking from her own experience with the practice. Or if she was speaking from specific knowledge of my case and details. Or if she was speaking based on her discussion with another doctor (she'd had another doctor review the notes from the visit before calling me back). I didn't know where it was coming from, all I knew was that I'd never, ever, ever wanted to hear those words. The whole reason I never wanted triplets was because I never wanted to hear the words, "We're hoping to get you to at least 28 weeks" or anything of the kind. I spent the rest of the day completely freaked out. How was I supposed to go an entire week without knowing what was going on? Why was waiting a week prudent? What was I waiting for? To lose another cm? I couldn't afford to lose another cm on my cervix! Ack, the stress!

I exchanged several emails with several triplet mamas who gave me some good advice, recommended I look for more agressive advice from the doctors in the practice that I know better (I did NOT come out of that appointment liking the new-to-me doctor one bit). I worried a lot. I spent a LOT of time thinking about that 28 week remark. I could not get that out of my head. That's only 4 weeks away. It can't be. There's no way that could be real. She couldn't have meant it. Could she? Eventually, I wrote my blog entry here, spent some time with S and J, and then went to bed. I was exhausted, anxious, and frankly, tired of thinking about this anymore. I would just see how I was feeling in the morning and take it one day at a time.

Tuesday
Things were going less well in the morning. I was in a blind panic most of the morning, not made any easier by the fact that the contractions had increased a lot, both in intensity and frequency. I kept thinking about that 28 week remark. I kept wondering what would happen if I waited a week. I continued to wonder when I should call the office about the contractions. I didn't want to be alarmist, but I didn't want to miss anything either. I have a tendency to second-guess myself when it comes to calling doctors because I spent a number of years getting called a hypochondriac as a kid (when all along, it turned out that, in fact, I really was sick all the time). The contractions did me the courtesy, though, of striking on the hour, every hour. Which made it easier to notice that they were every fifteen minutes. At first I thought that was crazy; it seemed a bit too coincidental. The next hour, I realized that they were closer together; almost exactly 10 minutes apart. And so I called and left a message for my nurse. And waited. And I emailed Jess and apparently freaked her out, because she immediately jumped on IM and told me that I shouldn't wait too long, I should just go straight to L&D if I didn't hear back soon. At 11:58, I called back, figuring I'd better try to catch them before they closed for lunch. My nurse said she'd talk to the doctor and call me back. Tick tock. Tick tock. Jess IM'd a list of items I should pack in a bag to take with me in case they sent me to L&D. She reminded me to call my husband (I had remembered to call him, but admittedly, it wasn't that long before Jess told me to call him that I'd realized that it hadn't occurred to me up until that point!).

My nurse called back and told me to go in to the office where they were waiting for me, so they could reevaluate me. This meant I had to see Dr. R. again, which wasn't really what I wanted given how uneasy I'd been with her the day before. But, in I went. I am nothing if not compliant. And I'm really glad I did, and very glad I saw Dr. R. in particular, because it gave me a chance to revise my first impression of her completely. She was thorough. She took a lot of time with me. She clarified a number of things. She talked me through what was going on, what the plan was, why they were going to do what they were going to do that, and this was all during her lunch break.

She went ahead and did the fetal fibronectin test before she did anything else, since it had been more than 24 hours since my last ultrasound. Then she did an ultrasound to check my cervix, and miraculously, it had lengthened since Monday! It was, at its shortest 1.7cm and at its longest it was 2.5, but it spent MOST of its time in the 2.x range, whereas on Monday it spent most of its time in the 1.x range, so this was quite the improvement. You could SEE the relief cross over the doctor's face immediately. This obviously still means that it's significantly shorter than it was last week, and even moreso than two weeks ago, so I'm not saying that I'm out of the woods or anything, but it is AWESOME. Unfortunately, this didn't get around the problem of the contractions which were coming one on top of another. "Contractions by themselves are not the enemy necessarily," she said. But when you put it all together you have to start thinking about the impact they have. So the first goal is to calm down the bulk of the contractions with a tocolytic. So I'm now on Procardia (Nifedipine) extended release tablets. That should calm most of the "background contractions" which will allow them to concentrate on the breakthrough contractions which are more likely the ones that they need to worry about. And for those, I've got immediate-release Procardia.

I will also be using a Home Uterine Activity Monitoring Service (HUAM). There are mixed reviews on whether HUAM does any good. The possible benefit that comes from HUAM is debated... some researchers believe the benefit actually comes from the close contact that patients have with a medical professional on a daily basis. Some researchers, in fact, believe that there may be a possible negative effect on patients because it could cause additional anxiety. Dr. R. said that this practice does frequently use HUAM, but that she came from a background of practices in which they did not frequently use HUAM. She wanted to make sure that I understood that I should not allow the monitoring to cause any additional anxiety. I told her that as far as I'm concerned it's nothing more than a datapoint to help piece the puzzle together. She agreed that this is precisely how it should be viewed.

She then took some time to really talk about what I can and cannot do. She said that whenever possible, I should do nothing, but recognized that I have a four year old in the house and sometimes that's not 100% possible. However, I should avoid anything that involves prolonged standing, excess stairs, I should do no lifting, no reaching, no cooking. I can get up to go to the bathroom, I can get up to get a sandwich. Combining trips would be good. I can stay in the recliner instead of bed if I am sufficiently reclined. Sitting upright is bad. Doing nothing is good. "You need to understand, however, that if you get up for a sandwich and your membranes rupture, you did not cause it to happen. It did not happen because you stood up, it did not happen because you wanted a sandwich. It will not be your fault." She said the truth is they don't know how much, if at all, bed rest helps, but that that it certainly seems that bed rest does a lot more to prolong pregnancy with higher order multiples than it does with singletons. (I realize as I'm writing this that I failed to ask about showers...)

She said that the next ten weeks were going to be a very long and tedious ten weeks for me and I said, "do I have another 10 weeks in me?" I told her about the 28 week remark that had so freaked me out the day before and she explained that a bit to me. First of all, on Monday they really had been worried. But more significantly, the nurse who said it comes from a NICU background and with preemies, the 28 week mark is a SIGNIFICANT milestone. The difference between a 24 weeker and a 28 weeker is astounding, she said. (A pediatrician friend of mine explained even more explicitly... she said with a 24 weeker, you spent the first week in electrolyte hell, and the next 6 months worrying about whether electrolyte hell caused brain issues, but when you get to or at least closer to 28 weeks, more of the prematurity issues you're dealing with are growth and development issues, rather than brain issues) She emphasized that it is absolutely still the goal to get me to 34 weeks, but that definitely the first milestone they want to get me to between now and then is 28 weeks. Then they'll be looking to 30 weeks, 32, and if I get to 34, she'll bring me a cupcake (which actually, she won't because she's moving back to Boston before I get to 34 weeks, but the thought is there). I felt a LOT better about the 28 week remark after that.

She also talked a little bit about the possibility of bringing me in-house for hospital bed rest. This isn't something they normally like to do for triplet patients if they can help it, but it's definitely under consideration for me. I bought myself some time, though, since my cervix lengthened a bit. They're going to keep a pretty close watch on me, but will continue to keep the idea under consideration and we'll just have to see how it goes. I continue to be astounded at just how quickly things change in this pregnancy. I am very grateful to have a team of truly excellent doctors. Yesterday it became clear that a lot had gone on behind the scenes within the practice that I didn't know about. Clearly my case had been discussed more than once among the practice members between my two visits (which were only about 26 hours apart). It's good to know I'm more than just a name and Patient ID number.

More good news... she called me at 6:30pm to let me know she'd gotten the fetal fibronectin result and it was negative, which is great. It means I've got a low likelihood of going into labor in the next two weeks due to a cervical issue. We can repeat the test in two weeks and continue to do so. They'll try to use the test as one way to help determine when to give me steroids to mature the babies' lungs. They don't want to give them too early, because they don't want to have to repeat treatments too many times before the babies are born. They'll give the steroids to me at 30 and 32 weeks regardless, but they'll give them to me sooner, if they need to.

Anyway, all in all, I feel a lot calmer. It was a much better visit. Although I don't love that I was having that many contractions, I feel like a lot of good came of having to go into the office, so I'm not sorry about the result. And in our next episode, I'll describe Wednesday's antics of getting the home monitoring set up. All I have to say is that this bed rest thing is seriously harder work and more stress than just going to the office!

Sorry for the novel, but a lot has happened in a short period!