The Starting Line-Up

Quints

As many of you may have heard, our starting line is four girls and one boy!

The boy is currently guarding the gate and is located at the very bottom with the four little ladies piled on top.

On Tuesday, I had another ultrasound to assess heart rates and fluid. It also was another opportunity for a photo shoot. It appears that we have some shy gals and guy because each time they went to take a close up on their faces they drew there hands in front of their face. Either that or there was an epic game of peek-a-boo that we were witnessing!

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Sir Clahj

Sir ClajSir Clahj, is not a character from Medieval times, but it is rather how you pronounce the surgical procedure, cerclage, which is the “knight in shining armor” who has saved our pregnancy.

It is my understanding that pre-term labor can be caused by a shortening and dilating cervix, as well as, an increase in prostaglandins.

Treatment of pre-term labor varies, but typically includes a cerclage, tocolytic drug therapy and adjunctive bed rest. Some of the drug choices include:

I had my emergent cerclage and Friday and the procedure went very well. They keep you awake during the surgery and use a spinal block, which is quite similar to an epidural. Being paralyzed from the ribs down is one of the weirdest sensations I have ever experienced. You see your legs, can touch them, but you sure can’t use them or feel them. The paralysis typically lasts 2-5h, whereas the procedure is just under 30minutes.

Cerclage

Upon admit my cervical length was 1.2-1.4 centimeters long with no dilation. Today at my post-op follow-up, I found out that the miracle-making surgeon has secured it at 3.0-3.1cm with no dilation. The doctor thought immediately following that the length was just over 2cm and was surprised to also hear that it was at 3cm- high fives were in order.

He also monitored my contractions during the post-op visit to assess if the motrin and bed rest were helping. He likes to keep his patients at less than 4 contractions per hour if they are out of the hospital and I was right at 4. This is much improved from the 6 to 8 contractions per hour that I was having over the weekend. The hard part is I can’t feel the contractions, so I’m of little help in monitoring them on my own.

All in all, I think we are back on track after that detour. Thank you to all for your prayers and support- you are a blessing!

Hope in the Valley of the Sun

4

This past Monday afternoon, Frank and I had our first 2nd trimester cervical screen where they measure the length of your cervix. I approached the appointment with minimal apprehension, assuming all would be well.

Our ultrasound technician surprised us with another peek at our little ones, and all was well. Everyone continues to have strong heart beats and are growing appropriately. They also have nestled into their locations, which makes identifying babies much easier for the trained eye. To me, it just looks like a big slumber party.

After we got to check-in on our little miracles they performed a trans-vaginal ultrasound to examine my cervix. The tech’s tone at this point completely changed. She measured it at least ten times and would not relay any information. Frank and I had no idea what was ahead, but we got a sense when we were walked down the hall to what was clearly a “bad news room” that that is what awaited us.

We just looked at each other as we waited for the doctor to come and see us, trying to figure out what was so wrong. When the doctor arrived he relayed that my cervix was 1.2 to 1.6cm in length, where ideally it would be greater than 3cm at 19 weeks into pregnancy, or at least 2.5cm. He then informed us that pre-term labor was inevitable within the next 3-4 weeks and there was nothing we could do about it.  I inquired about bed rest, medications, inversion and cerclage (the stitching of the cervix); he said there was nothing we could do to help, nothing. Then, the tears started to flow, and flow, and flow for the next 2 days… Until!

Until, I was praying on Wednesday morning asking for clarity and that my mind would quiet so, I could hear His still small voice granting me direction. The thought of simply being a ticking time bomb awaiting an ugly delivery was angering and fearful. Then, I remembered that His perfect love casts out all fear and that I needed to rely on His love which has been with us since day one of this journey. I calmed down and realized that we were not helpless, we definitely still had several choices.

I then hopped on Facebook and extended a question to my other momma’s of multiples and the answer was clear: We needed to switch doctors, get a cerclage and consider moving to Arizona. As scary as all of that may sound to someone who does not enjoy being away from her husband and family, traveling, or being awake during surgical procedures (aka me), I was at complete peace. I picked up the phone and called the best high order perinatalogist in the country.

He continued to build upon this renewed optimism, but also made it clear that time was our enemy and if we were going to save our pregnancy it needed to happen by Friday, or in 2 days. So, one door opened after another and I am now writing this post from a hospital bed in Mesa, Arizona awaiting my cerclage in 3 hours.

My devotional this morning read:

By faith Abrahsunriseam, when called to go to a place he would later receive as his inheritance, obeyed and went, even though he did not know where he was going. By faith he made his home in the promised land like a stranger in a foreign country…11 And by faith even Sarah, who was past childbearing age, was enabled to bear children because she[a] considered him faithful who had made the promise.” (Hebrews 11:8-9, 11)

I am certainly in a place that recognize as an inheritance from God. It is a promised land filled with proactive, compassionate physicians and kind, optimistic nurses. Though I am of childbearing age, I was enabled to bear children only by his grace. This assurance of faith and God’s love has certainly restored our hope here in the Valley of the Sun.

17 weeks and counting

We are now at 17 weeks and counting, which is halfway to 34 weeks!

I thought I would show the fruit of all those supplements that I referenced in my previous post. I’m growing, the babies are growing and apparently it’s a bit contagious!

Cassie, Frank & JD at 17 weeks

Cassie, Frank & JD at 17 weeks

We also thought we would share our bumps with my mom and Grandma-to-be!

Mommy in the Middle

Mommy in the Middle

This picture is very special to me!

Mother's Day 2013

Mother’s Day 2013

The Elite Eight Plus One

food and supplementsRegistered dietitians stand behind the mantra of “food first;” which means skip the supplements, as long as, you can obtain what you need from what you eat or drink. I have also always practiced and preached this stand point, but now I can no longer obtain enough of certain vitamins and minerals to reach the recommended daily values.

The Institute of Medicine (IOM) publishes dietary reference intakes, or DRI’s, for most vitamins and minerals. This administration individualizes the values based on gender, age, pregnancy and lactation. For example, it is recommended that a 30 year old woman strive for 18 mg of Iron everyday, however if that woman is pregnant she now needs 27 mg. As one can imagine the needs for moms-to-be of multiples are even greater, and while the IOM does not have current recommendations for these individuals, such as myself, the research literature does. I have obtained most of my micronutrient goals from Dr. Barbara Luke‘s and Dr. John Elliott‘s publications, which give specific recommendations for the following vital amines (vitamins) and minerals.

Vitamin B6This water soluble vitamin, like the other B-Vitamins, is critical for the metabolism, or breakdown and use, of protein, fat and carbohydrates. It also helps to form the developing brains and nervous systems of all the growing babies, while also playing a role in the formation of new red blood cells, antibodies to support the immune system, and neurotransmitters, which are those happy hormones such as serotonin, dopamine, and DHEA.

It can be found naturally in chicken, fish, pork, chickpeas, and baked potatoes. The DRI is 1.9 mg, but people can tolerate up to 600 mg without side effects. The literature also supports the use of vitamin B6 to help control morning sickness/nausea with recommendations of 25mg, three times per day along with Vitamin B12. Although, the mechanism of how this works remains unknown, my hypothesis is that it alters pathways in the vomiting center of the brain by increasing serotonin.

Folic Acid (Vitamin B9): This B-vitamin is one of the most popular pregnancy vitamins, partially due to the movement to fortified all refined grains in the United States to insure adequate folate to prevent neural tube defects during pregnancy. Most prenatal vitamins have 400-800 mcg of this vitamin, which is the DRI for a singleton and multiple pregnancy, respectively. Thus, it is evident that folate plays a critical role in the neural development of the babies, but also is required for DNA synthesis and aids in cell division. Also, like vitamin B6 it helps in the formation and maintenance of red blood cells to prevent anemia. Good sources of folate include dark leafy green vegetables, beans and legumes, egg yolk, sunflower seeds and liver.

Vitamin B12: B-12 is another powerhouse for neural and blood development and maintenance. It also helps to regulate DNA synthesis and can be found in every cell of the body. It can be found naturally in animal-based foods (meat, chicken, fish), dairy and eggs, as well as, from fermented teas such as kombucha. The DRI for B12 is 2.6 micrograms. As mentioned previously, Vitamin B12 can also be taken in conjunction with vitamin B6 for morning sickness. The recommended doses vary from 4 mcg per day up to 25 mcg, two times per day.

Vitamin DThis fat-soluble vitamin is unique in that in can be synthesized in our skin with the help of the sun. Unfortunately, for folks in the Midwest there is only adequate sunlight in a small window of the year. Therefore, most are commonly deficient in this vital amine. The DRI for vitamin D is 200 IU, however the human body can make 10,000 IU in about 20 minutes in the sun, which tells us our bodies can handle much more. Some research literature suggests that some women need up to 4,000 IU to obtain adequate serum levels during pregnancy. Vitamin D is not found in very many foods, but can be found in mushrooms, eggs, and fatty fish. It is also added to some foods such as in the case of milk.

Most people know that vitamin D helps to support bone development and maintenance by increasing the absorption of calcium and magnesium from the gut. It also plays a role in preventing cardiovascular disease, multiple sclerosis, and some forms of cancer.

IronIron is commonly supplemented during pregnancy and is the cause of several unwanted side-effects, such as nausea and constipation, but it is important in providing oxygen-rich blood to both mom and babies. Most moms-to-be need more than the DRI (27mg) for iron to maintain adequate amounts. The research that I have reviewed recommends 325 mg of iron daily for moms of multiples.

Iron can be found in red meat, liver, chicken, fish, beans, leafy vegetables and molasses. But, typically a supplement containing Iron sulfate is recommended. I encourage, and take myself, a slow releasing version of iron. SlowFe is a common name brand for this type. I also always take iron with vitamin C to improve absorption, and avoid taking it with calcium-rich foods which tend to inhibit absorption and utilization.

Calcium and MagnesiumThese minerals are the super heroes for building and maintaining mom’s bones while constructing baby’s skeletal structure. The DRI for calcium is 1,000 mg, however the research literature recommends closer to 2,000 mg and the DRI for magnesium is 36o mg but again the literature suggests 1,200 mg per day. In addition to calcium’s bone building role, it also acts as a signaling messenger for some hormones and a co-enzyme, or “right-hand man” in blood clotting. Magnesium also has significant roles in over 300 bodily reactions, including muscle and nerve function, maintaining a steady heart rhythm and regulating blood sugar and blood pressure. There is also a growing body of research on the use of magnesium sulfate to prevent pre-term labor. It is usually administered intravenously (via IV) in boluses of 4 to 6 g over 30 minutes and then maintained at 1 to 3g per hour to achieve serum levels of 5 to 8 mg/dL. This level is considered therapeutic at inhibiting, or stopping, myometrial (middle layer of the uterus) activity a.k.a. contractions. Needless to say, food sources of calcium and magnesium, as well as, supplements are very important for moms of multiples. Calcium is found in high amounts in tofu/soy, green vegetables, sardines, molasses and of course dairy products. Magnesium is found in wheat bran, dark leafy green vegetables, nuts and seeds and beans and legumes.

ZincThis mineral is required for an assortment of processes in the body. It is necessary for the activation of over 100 enzymes, and plays a large role in immune function, protein and DNA synthesis, cell division and wound healing. Therefore, one can see how it helps to support normal growth of the fetus during pregnancy. The DRI for zinc is 11 mg and daily intake is very important because it is not stored in the body. This mineral is another one that researchers believe is required in larger amounts. It is recommended to strive for 45 mg per day when preparing for a multiple birth.

So, those are the elite eight! Or, the eight micronutrients that are touted for playing very crucial roles in the maintenance of mom and growth and development of babies during a multiples pregnancy.

There is one more nutrient, a macronutrient, that recent research has pin-pointed as another key to neural development during pregnancy- DHA. Omega 3 fatty acids have exploded in popularity due to their powerful role in reducing inflammation, or putting out the fire, in the body. This decrease in inflammation can be attributed to two of the omega-3’s found in fatty fish, Docosahexaenoic acid (DHA) and Eicosapentaenoic acid (EPA).  DHA, specifically, is now being added to some prenatal vitamins due to studies noting that DHA can help reduce risks of poor retinal (eye) development and poor cognitive development. The International Society for the Study of Fatty Acids and Lipids currently recommends 300 mg per day of DHA for pregnant and lactating moms.  A new article published in the American Journal of Clinical Nutrition stated that mom’s who took 600 to 900 mg of DHA per day had longer gestations, bigger babies and longitudinal data points to better cognition for the children in their preschool years.

Despite obtaining 150-200% of the DRI for the nutrients listed above, supplements are still a critical part of my daily dietary regimen. If you’re a mom-to-be and have questions, or recommendations, about the information above, please contact me.

Written by: Cassie Vanderwall, MS RD CD CDE CPT