by: Dr. Pinky Imperial [1]
My family and I came back in May 2010, and we had barely settled down when I began to have hyperacidity, nausea and eventually vomiting, which in my experience signified only one thing – that I was pregnant again! After 3 sons, my husband and I were not really planning on adding to the family, but the 2 pregnancy tests that I took proved my suspicions to be all too true. I knew that I was already a high-risk patient since I was now an elderly multigravid. Not wanting to leave anything to chance, I immediately consulted a perinatologist in the hospital nearest our home. In the week following our return, the ultrasound done showed that I was pregnant with twins! And thus began the steady uphill climb that would characterize the course of my pregnancy.
I usually had excessive vomiting bouts during the first trimester of all my pregnancies, but this time around, the very high hCG levels in a twin pregnancy amplified my vomiting even more. When I reached my fifth month and the vomiting had just started to abate, I had my second ultrasound which showed that we were expecting girls. My husband and I were ecstatic at the thought of having girls this time around, but the joy dimmed considerably when my doctor told me that there was a “double bubble” sign in the first twin, accompanied by polyhydramnios, which were both signs that she had some form of gastrointestinal obstruction. I knew that her condition could only be remedied by surgery, and I started to become fearful of the possible outcome when the twins were delivered. Another few weeks went by and my blood pressure, which hovered in the higher limits of normal, became persistently elevated and I had to be maintained on anti-hypertensive medications. By the sixth month, I had already developed edema in my legs, which was quite early compared to my previous pregnancies. Laboratory tests done also showed mild hypothyroidism. Subsequent ultrasound tests showed persistence of the double bubble sign, progression of the polyhydramnios and beginning discordance in the weights of the twins. My perinatologist maintained a calm demeanor but by this time she was asking me to return more frequently for check-ups and by my 32nd week she already advised me to have a course of betamethasone injected in the event that a combination of all the existing conditions would trigger premature labor. It slowly began to sink in that the babies would, in all probability, be born early, so I informed my doctor that I had planned for EINC to be done when I gave birth. It was still the pre-EINC period in the hospital and she acknowledged my request but replied that it would really depend on the twins’ condition upon delivery.
A few days after I had my betamethasone injections, I came in for check-up and while my non-stress test showed that at 33 weeks age of gestation the babies were fine, I had to be confined for blood pressure control. Soon I was being treated for pre-eclampsia, and after 3 more days my OB made the decision to do emergency cesarean section due to non-reassuring fetal heart rate patterns. Having previously delivered all my sons by NSD, I was terrified at the thought of undergoing surgery this time around, and I was crying as they wheeled me into the operating room. My anesthesiologist gently reminded me that crying would hinder my breathing and advised me to calm down. I composed myself and asked her not to sedate me because I wanted to be awake when the girls were delivered and placed on skin-to-skin contact with me. When my OB came in, I again asked her if we could do properly timed cord clamping and she assured me that she would discuss this with the neonatologists attending the delivery. She started the procedure, and a little while later the first twin came out, and after drying and cord clamping, she was placed on my chest. I knew she was the one with the problem but was relieved to see that she looked stable and was comfortable. Then soon enough the second twin came out and she joined her sister on my chest. After a short while my OB gently asked me if the twins could be taken to the NICU already and I nodded, knowing that they had to be worked up and referred ASAP. They were 35 weeks by pediatric aging, and weighed 1.49 kg and 1.62 kg. Neither of them had any breathing difficulty.
 |
| Mika and Ella together again |
After spending some time in the Recovery Room, I was finally wheeled back into my room. It was a good thing that the NICU nurse started to bring Ella, the second twin, to my room to breastfeed, and I would do this every 3 hours or when the baby would demand to be fed. After the first 24 hours, they could no longer bring her to the room as a matter of hospital policy, and I had to go to the NICU for the breastfeeding. So despite still having an IV line and a urinary catheter I continued to go to the NICU regularly for feeding. It was the following evening that the pediatric surgeon finally made rounds on Mika, the first twin. The x-ray done showed massive pneumoperitoneum, certainly one of the worst ones I have ever seen in all my years of practice. I instantly knew the risks my baby faced, and I burst into tears as the surgeon explained to my husband and my siblings that immediate surgery was indicated. We requested for a priest to come and the baby was baptized prior to the contemplated procedure. Mika was stable and did not look distressed, which was totally incompatible with the ominous x-ray picture. She was prepared for surgery, and our family and dear friends started storming the heavens for a miracle.
After the surgery, the doctor came back into my room with good news – he repaired the gastric perforation, and did not find any obstruction. We thanked God for the strength He gave Mighty Mika, and the miracle of a second chance for her. She remained stable and seemed fine every time I would sit with her when I would go into the NICU for Ella’s feeding. On the 2nd hospital day, Mika developed a heart murmur, labored breathing and poor perfusion, and was referred to a pediatric cardiologist. Because of her small size, he suggested transferring Mika to another institution which had a better 2-D echocardiography machine that would yield better diagnostic results. We then prepared for the transfer, which was facilitated by midnight. Early the next morning, the pediatric surgeon at the second hospital saw Mika and the repeat x-ray again showed a significant re-accumulation of free air in the abdominal cavity. He offered us two options – he could insert an abdominal drain at bedside to relieve the pneumoperitoneum (air leak) or do another exploratory laparotomy to look for the obstruction which he believed was the cause of the perforations. We immediately agreed to the surgery, and true enough the exploration revealed an annular pancreas as the root cause of all the complications. The surgery went well and Mika finally seemed on her way to recovery.
Back at the first hospital, 3-day old Ella was still maintained in an incubator and had an IV line for calcium supplementation. She settled into a regular feeding schedule of every 2-3 hours and I would immediately go to the NICU as soon as she showed signs of being hungry. After one particular feeding, however, the nurse called me back because the baby was crying again. It was just an hour after the feeding and I was wondering why she was agitated. I went to the NICU and as soon as I held her in my arms she stopped crying and promptly went to sleep. The nurse remarked that maybe she just wanted to be held. This made me resolve to have her roomed-in right away despite all the contraindications that traditionally dictated that low birth weight premature babies should remain in the Nursery/NICU. I requested the neonatologist to already remove the IV fluids of Ella because since birth she was able to breastfeed well, and I also asked that they start weaning her from the incubator. I kept pestering the nurses on duty to remind the neonatologist about the IV and weaning, and after another day, Ella’s IV line was finally removed and she was transferred to a bassinet. That night I asked that she be roomed-in because I planned to take her home the next day when I was due to be discharged. So she was brought to me and we spent the night on skin-to-skin contact to ensure that she would not become hypothermic. The next morning, the neonatologist made rounds and I assured her that I would monitor my baby very closely at home and make sure that she is always thermoregulated. She looked at me with some uncertainty because Ella was only a few days old, was still losing weight (she was now down to 1.44 kg) and had been out of the incubator for only half a day. She reluctantly agreed despite the baby’s weight because she was reassured by the fact that I was also a neonatologist. I heaved a sigh of relief because I couldn’t bear to leave her alone in the hospital after all the time we spent together breastfeeding.
When we got home, I was delighted to have Ella with me but then the realization that I brought home a tiny baby who was 1.4 kg and not quite 4 days old hit me and I began to have doubts if I made the right decision. It was one thing to absolutely refuse to leave her with strangers but caring for her at home was an entirely different thing altogether. Our first few days together revealed what a truly complicated situation I had gotten myself into. As a neonatologist, I had gotten used to just taking for granted the orders I wrote on the charts of my "growers:" strict thermoregulation, feeding with increments every 3 hours, supplementation of feeding and daily weighing. With Ella, I was now doing all these things myself and I developed a renewed appreciation for the NICU nurses who did these things routinely, day in and day out. Everything that was being given to Mika in the NICU, Ella was also getting at home. Aside from breastfeeding Ella I would also be pumping out my milk several times each day, then would measure out the multivitamin drops, virgin coconut oil or be adding human milk fortifier to the expressed breast milk and would feed this to her by cup or by syringe. We struggled with the supplemented feeding at first, but after some time, she got the hang of it and was able to do syringe feeding effortlessly. There was one time that the NICU nurse texted us that Mika’s milk supply was running low, and then she also asked how Ella was being fed at home. I said that aside from breastfeeding she preferred being fed by syringe and the nurse replied that Mika, too, preferred the same method of feeding. I smiled at the thought of the invisible bond between the twins being evident even that early.
In the NICU, Mika was tolerating her feedings already and the volume was gradually increased. I had to pump out more milk for the two of them and when it was not enough, we had to get from the milk banks of 2 large tertiary hospitals, and were lucky if it was available. Mika’s doctor also referred me to her previous patient who had established a milk bank of sorts in her home and was giving breast milk for free to those who needed it. Another pediatrician-friend referred me to the mother of her patient who was regularly storing her excess breast milk and on several occasions she gladly shared her milk with our twins.
Mika continued to recover steadily, and was already tolerating full feeds for 2 weeks when she developed fecaloid vomiting due to post-operative adhesions. I slumped in my seat after hearing the news, and was worried that she might need to undergo surgery once more. Thankfully the obstruction resolved with medical management and after 2 days she was able to resume feeding again. She had a second bout of infection, and had to complete another course of antibiotics. She was also given a blood transfusion to correct anemia. Her hearing screening, cranial ultrasound and ophthalmologic evaluations were all normal, and she was gaining weight again. Ella at home was not gaining weight as rapidly, but remained in stable condition. At this time she seemed to be quite pale, but did not become symptomatic and did not require a blood transfusion. We continued with our prayers of thanksgiving that both girls were doing very well and asked that God grant us the continued strength to overcome all obstacles until such time that the twins were together once more.
Finally, after 50 long days in the NICU, Mika was cleared by all her 6 doctors, and exactly a week before Christmas, she was discharged from the hospital. It was the best Christmas gift we could ever hope for, and once again we thanked the Lord for the blessing of having both girls safely home and into our warm Unang Yakap embrace.
No comments:
Post a Comment