The Allure of Multiples

I don't get it. Right now in the NICU we have 18 babies. Of these, only 4 are singleton births. And one probably shouldn't count as a singleton because she started off as a twin but her sister died at 23 weeks gestation.

We have two sets of triplets, and all the rest are twins. I can't tell you the number of times I've heard women express the desire for twins. I'm not sure where the romanticized idea originated from, but I guess the idea of getting two children with one pregnancy or the attention that moms get when they walk down the street with a double stroller plays a part. Honestly, though... I just don't get it.

A normal pregnancy is one baby. That's what the human body was built for. A multiple pregnancy is a complication. Call it what you want... a miracle, a double blessing, whatever. I just feel that people don't understand the risks of what they're wishing for.

For starters, the most immediate risk involved with multiple births is pre-term labour. A typical, single pregnancy lasts about 40 weeks, but a twin pregnancy often lasts between 35 to 37 weeks-- and that's if they're lucky and stay put. Nearly half of all twins are born prematurely (before 37 weeks), and the risk of having a premature delivery increases with higher-order multiples. Prematurity carries an enormous amount of risks unto itself, the most common complications being feeding difficulties, sepsis and apnea (episodes where the amount of oxygen in the baby's blood falls to dangerous levels, usually due to immature respiratory drive). Then there is the risk of various twin-to-twin transfusion syndromes, where one baby essentially 'steals' blood and nutrients from the other, putting the smaller twin in danger of intrauterine demise. Now I'm no neonatologist (clearly) but why would anyone wish for a condition that would put their baby's health at risk?

And the risks aren't just to the babies. Women are not built to breed large numbers of offspring at once. Imagine all of the ways that pregnancy is hard on a woman's body. Now imagine them doubled. Preeclampsia, gestational diabetes, and placental problems are all more likely to happen in the case of a multiple pregnancy, and can be much more serious as well. The labour is also riskier, as regardless of the initial presentation of the multiples (even if they're vertex-vertex as opposed to one or more babies being breech) as soon as one baby is born the other frequently changes position. This often requires an emergency c-section, which is significantly riskier for both mother and baby than vaginal delivery.

I know... not my most lighthearted post. But it drives me crazy to hear another misguided mom express how much she's always wanted a multiple birth. Particularly when I've spent the last month caring for the complications of just this kind of 'miracle'.

An interesting article was published in the journal 'Fertility and Sterility' in 2004, examining the desire of infertile couples for multiple births.* They reported that 20% of infertile couples expressed a strong desire for a multiple pregnancy. In one way, it makes sense-- if these couples have had significant difficulties in conceiving, they probably figure that having more than one baby with a single pregnancy gives them more 'bang for their buck' so to speak. They end up with more children without having to go through the stress and financial strain of additional fertility treatments. Also not surprisingly, this desire was correlated with a lack of knowledge regarding the risks of twin gestations. The study concluded that patients need to be educated about these risks before attempting fertility treatments that put them at higher risk of conceiving multiple fetuses. No kidding.

I need to get out of the NICU. I have babies on the brain. Thank God I start full-time family medicine next week.

And before you ask, yes... all of the babies but one set of triplets and one set of twins were conceived on Clomid. So these are man-made multiples, not naturally occurring multiples. But I'm not getting into fertility treatments and their repercussions. That's a post for another day.

* Ryan, G.L., Zhang, S.H., Dokras, A., Syrop, C.H., Van Voorhis, B.J. The Desire of Infertile Patients for Multiple Births. Fertility and Sterility: 81(3), 500-504.

A Dying Breed

This is what happens when I have too much time to think. In recent days, it's likely due to the amount of time I've spent travelling in planes, trains and automobiles (honest! all three!) to get to various emergency medicine fellowship interviews. Which are done now, thank God.

So I've been more than a little pre-occupied with thoughts of procreation lately. Partly because now that I'm married apparently everyone thinks it's the next logical step. And partly because I'm 32 years old and am starting to picture my ovaries shrivelling up like a pair of raisins from both age and neglect. And I do want kidlets... I just don't feel ready. But if I DO wait until I'm ready, we may be pulling the goalie shortly before I start getting pension cheques from the government. Which is not promising for fertility.

So here's my first observation. Medicine begats medicine. I remember reading a statistic somewhere that nearly a quarter of medical students in Canada today identify at least one parent as a physician. It's hard to say why. Maybe simply from being exposed to medicine as a career earlier than other kids? Maybe from parental pressure? Maybe it's a reflection of socio-economic status? Maybe from some weird genetic mutation that confers on them the desire to pick at scabs? Who knows? But the point is that the children of physicians are more likely to pursue a career in medicine than other children.

Here's my second observation. Residents have trouble making babies. This isn't based on anything other than my own observations of the people around me. I don't know any female resident who has managed to get pregnant easily, stay pregnant to term and have an uncomplicated labour and delivery. Scary, isn't it? Male residents don't seem to suffer from the same curse, getting their wives and girlfriends knocked up at a dizzying rate. But female residents struggle. There are plenty of reasons why the cards are stacked against us. We delay childbearing later than the norm since we tend to spend our peak childbearing years studying. We work crazy hours that stress our body to the point that achieving a regular menstrual cycle is nothing short of a miracle. We work through pregnancy in conditions that expose us to a number of bacteria and viruses. We work though pregnancy in conditions that are often stressful. We eat erratically, often from vending machines. We spend one night out of four sleepless, and often compensate with higher-than-average caffiene intake.

It's scary. As a medical student, three of my female classmates had babies before graduation. There were miscarriages, early rupture of membranes (and I'm talking before 30 weeks gestation), preterm labour, multiples (although this one was through word-of-mouth since the mom in question left med school during pregnancy and didn't come back before the class graduated)... nothing simple or straightforward. Most recently, the resident that I did surgery with last year gave birth at 33 weeks. Her baby is still in the nursery, plagued with many of the problems common in premature infants. So it seems that women who get pregnant during residency not only have problems getting pregnant, but don't have much luck carrying their babies to term without problems or complications.

Add observation #1 and observation #2 together, and I'm forseeing a major physician shortage in the next 30 years or so. It's pure Darwin. Or IMpure Darwin, at least.

It's trains of thought like this one that are the reason why I need to be kept busy at all times.

Life Isn't Fair

Still in pediatrics, I am now part of the team that attends deliveries if there is any reason to think that there might be a problem with baby. I was half-hoping that this experience would help calm my fears regarding pregnancy and childbirth as the centre I'm at now handles much more low-risk and uncomplicated stuff than the centre where I actually did my baby-catching rotation.

Just before midnight last night we were called to a delivery because there was some meconium in the amniotic fluid. This means that the baby passed its first bowel movement in utero, which can be a sign of fetal distress. On top of that, if the baby manages to inhale meconium with its first breath, it can cause a very serious pneumonia and breathing complications. So that's why we were there.

Baby came out pink and wailing. These are good things. The nurse put the baby under the warmer, and I went to work. Rubbing the baby dry, suctioning his mouth and nose... soon the gurgles quieted and he seemed to be the perfect newborn boy. But as I was doing the quick head-to-toe exam required in all newborn assessments, it quickly became obvious that the baby lacked tone. Instead of holding his elbows and knees bent, arms and legs curled against him, his limbs were splayed out limply to his sides. I pointed this out to the attending after the rest of the exam proved normal. The attending spun the baby around an looked carefully into it's face.

"Did you have prenatal testing?" He called out to the new mom having her fun parts stitched up behind us.

"Yes, the integrated prenatal screen" she replied.

"And it was all negative?"

"It was. Why?" asked the new mom, understandably growing concerned.

"We need to look at your chart for a minute. We'll be back to talk to you soon."

And with that, we left the room.

Once we were safely out of the family's earshot, the staff pediatrician swore under his breath.

"That kid has Down's Syndrome."

"What? Why? But she had a negative IPS!" I didn't understand how such a thing could have been missed by such a sensitive test.

"Micrognathia, macroglossia, slanted eyes, low-set ears, nuchal fold, transverse palmar crease and hypotonia. I couldn't be any more certain without having the chromosomes laid out in front of me."

I was stunned. I always thought that the IPS protected people against surprises like that. The biggest risk of IPS is that it is sometimes TOO sensitive, identifying risk where there is none and exposing women to unnecessary tests as a result. And now this perfectly healthy 28-year-old woman has to be told that the similarly perfect child she was expecting will suffer from one of the exact syndromes that she thought she was safe from.

The reason that this scares me so much is that I, personally, don't think I would be able to handle the challenges of raising a child with severe developmental delay. I don't want my children to be physically dependent on me for the rest of my life. And as shallow as it might sound to many, my husband and I have agreed that we would likely terminate a pregnancy if something serious were found to be wrong. We will get IPS, and if a positive result occurs we will have an amniocentesis. How am I supposed to work up the nerve to get pregnant if even IPS can't predict outcomes?

Before you all comment that I'm deluded and juvenile and that nothing in life comes with a foolproof guarantee, I know. But I guess I just figured that when it comes to pregnancy and childbirth, there is SO MUCH that is still out of our control that it's nice to have some control when you can.

Now, back to worrying. This may have pushed back the babymaking schedule another 6 months, easy. Sorry, mother-in-law.

Last Round of Apologies...

A whole 3 weeks have elapsed since my last post. There has been good reason. Dr. Couz became Mrs. Dr. Couz two weeks ago, and then spent a hard-earned week in Mexico celebrating the fact that someone was brave enough to marry me.

Now I'm in the midst of CaRMS... the sequel. I am interviewing at four different schools for spots in their emergency medicine fellowship programs, an extra year of specialized training tacked on to the end of my residency (fast approaching in just 8 months). More forgiving than my first CaRMS tour, I am hitting 4 cities in a week. Totally doable.

After this week, life will settle again. I hope that I'll soon be back to my weekly posting pattern. Don't give up on me yet!

In the meantime, I'll share some photos.



A photo of the Mayan ruins at Tulum in the Yucatan Peninsula











The beach at Tulum.












Not a screen saver... a real place. Can I live here?












An iguana piggyback.












Flying Mexicans! Apparently, this is some kind of tradition.









A friendly gator... right by the beach where were snorkled the reef. Nice.









Storm rolling in...












This is what happens when you go to Mexico during hurricane season.









Sigh. Is it too late to transfer my residency training to the University of Hawaii? I could get used to this kind of view.





Real medically-related posts to follow. Once I'm ready to face reality again.