Category: fetus

Sir Clahj

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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!

Double Time

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It’s double time!  For those bandies and musicians or Tae-bo pros out there, you know this means it’s time to pick up the pace.

During the 2nd trimester, from weeks 15 to 20, babies double in size. So, you can imagine that the nutrient needs of both mom and babies alsoescalate. There are a variety of methods to determine how many calories are ideal during pregnancy. There are estimated energy requirement equations, some just say 300 extra calories and 30 extra grams of protein per day, and others encourage moms to add 500 calories per fetus and 25g protein. I, personally, think it is best to consume the amount of calories that promotes the ideal weight gain per week. For a mom of high order multiples it is 2.0-2.5 lbs. per week.

I was able to gain this at 3,000 Calories per day during the first trimester. This was a true blessing because with the nausea there was no way I was going to get to the original 5,000-calorie estimation. During weeks 13 to present, I have watched this weight gain slow-down, so I know it’s time to bump up the kCals. I really was quite surprised that there were not any meal plan examples- that I could find anyway- on the Internet. My best resource was in Dr. Barbara Luke’s book, “When you’re expecting twins, triplets, or quads.” This is where I derived the information regarding calorie and food group goals. Since there seems to be a gaping whole on the World Wide Web, I thought I’d go ahead and fill it.

Below you will find recommendations for calories, macronutrients (carbs, protein and fat) and suggested food group goals during pregnancy. While this information is targeted at high order multiple pregnancies, it is of course applicable to any pregnancy.

Calories goals may vary from 3,000-5,000 Calories per day, and I recommend watching your average weight gain from week-to-week to be sure you are getting enough. The composition of these Calories is important and different than the recommendations for the average American. Typically, it is recommended to consume a daily diet composed of 50-55% calories from carbohydrate, 15-20% calories from protein and 25-30% calories from fat. However, during pregnancy with super twins it is recommended to consume 40% of calories from carbohydrate, 40% calories from fat and 20% calories from protein. The reduction in calories from carbohydrate, I presume is to decrease one’s risk of gestational diabetes, which is much higher in pregnancies with 3 or more. Per Dr. Luke, this breaks down to the following:

Nutrients

3,000

3,500

4,000

4,500
Protein

 150g

176g

200g

225g
Fat

 133g

155g

178g

200g
Carbohydrate

 300g

350g

400g

450g
Food Groups

Servings per day
Lean Protein

4

5

5

6
Dairy

4

8

10

12
Grains

8

10

12

12
Fat

5

6

7

8
Fruit

7

7

8

8
Vegetables

4

4

5

6

This type of meal plan is quite different than my pre-pregnancy diet, so my typical pattern is a bit different. For example, prior to pregnancy I ate very little dairy and meat/poultry and the majority of my protein came from beans, peas, lentils, whole grains, and fish. It has been easiest for me, and my mild lactose intolerance, to add the lean meats versus 8-10 servings of dairy per day.  Also, before pregnancy I ate a lot of veggies and not so many fruits, so I continue to consume only 2-3 fruits per day and 8-plus servings of vegetables.

As mentioned previously, I have been consuming 3,000-3,500 Calories per day so I decided to share a few meal plans, or as RD’s call them “Typical days” to help make these recommendations real.  There are a few original high calorie, high protein recipes in the meal plans that I will add later. If you’re interested check back because I will be adding a recipe section to my blog. Also, I did not comment on the variety of supplements that I believe are a crucial safety net, so look out for that content coming soon!

Day 1

(3,065 Calories: 316g Carb, 92g Fat, 175g Protein)

Breakfast

  • Breakfast Taco Dip
    • ½ tsp Olive Oil
    • 1 Organic Egg
    • ½ Avocado
    • 4oz 0% Plain Greek Yogurt
    • Lentil Loaf (Recipe coming soon)
    • 2 Hard Shell Tacos, broken into chips
    • Up Your Mass™ Banana Smoothie (Recipe coming soon)

AM Snack

  • Fruit and Yogurt Parfait with Granola
    • ½ cup Fresh berries
    • 1 cup Low-fat Vanilla yogurt
    • ¼ cup Nutty Granola

Lunch

  • Turkey and Avocado Sandwich
    • 2 slices Homemade Whole Wheat Bread
    • 3 oz Oven-roasted Turkey Breast*
    • ½ Avocado
    • 1 cup Fresh Spinach
    • 2 Clementines
    • ½ Cup Baby Carrots

PM Snack

  • Oat and Nuts Cereal
    • 1 ¼ C Oat Cereal
    • 1 C Unsweetened, Organic Soy Milk
    • ¼ C Roasted Pepitas
    • ¼ C Slivered Almonds

Dinner

  • Basil Mac & Cheese (Recipe coming soon)
  • 12 medium shrimp, cooked
  • 1 C Asparagus Spears
  • Skinny Cow™ Ice Cream Sandwich

Evening snack

  • PowerBar™ Harvest Peanut Butter Chocolate

Day 2

(2,993 Calories: 319g Carb, 94g Fat, 171g Protein)

Breakfast

  • 4 Up Your Mass™ Banana Nut Pancakes (Recipe coming soon)
  • 1 C Unsweetened, Organic Soy Milk

AM Snack

  • Cinnamon Raisin Bagel with 1oz Cream Cheese
  • 1 C 2% Milk

Lunch

  • 1 Large Baked Potato with Lentil Loaf, melted Cheese stick and 2 Tbsp Salsa
  • 1 C Asparagus spears
  • 1 C Fresh Pineapple

Dinner

  • ¾ C Cooked Quinoa with 1 tsp Olive oil
  • 4oz Organic, Skinless Chicken Breast
  • 1 C Steamed Zucchini Squash
  • Skinny Cow™ Ice Cream Sandwich

 

Day 3

(3,710 Calories: 367g Carb, 154g Fat, 176g Protein)

Breakfast

  • Stuffed Baked Potato
    • 1 Large Baked Potato
    • ½ tsp Olive Oil
    • 1 organic Egg and 1 Egg white
    • 1 Melted Cheese stick
    • ¾ C Kidney Beans
    • ¼ C Salsa

AM Snack

  • ¼ C Dried Fruit
  • ½ C Almonds and Pumpkin seeds, mixed
  • 1 C Organic Skim Milk

Lunch

  • ¾ C Pasta with ½ C Meat Tomato Sauce and ¼ C Melted Mozzarella Cheese
  • 1 C Steamed Spinach
  • 1 Banana
  • 2 Tbsp Peanut Butter

PM snack

  • 1 Whole Wheat Pita
  • ½ C Original Hummus

Dinner

  • 5 oz Salmon with ¼ C Avocado Salsa
  • 1 C Wild and Brown Rice
  • 1 C Steamed Broccoli

Evening Snack

  • 1 ½ C Neapolitan Ice Cream**

* I try not to consume deli meat, so this was a baked turkey breast. I do reheat any lunch meat/protein that I bring as a food safety precaution.

** When you want to promote glycemic (blood sugar) control, eating sweets and desserts alone is a no-no. However, if the dessert is consumed within 1 hour of a meal or healthier snack, typically the blood sugar response is more favorable.

Written by: Cassie Vanderwall, MS RD CD CDE CPT

2nd Trimester here we come!

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We are all happy, healthy and going strong at 12 weeks and counting! Today we had our 2nd consultation with our perinatologists and this meeting was much more uplifting than the previous. It was a balanced discussion of impending risks, as well as, strategies to promote a healthy gestation. It appears that there is little medical intervention prior to 20-24 weeks. I, however, recognize that there is a lot I can do to help us all get to that 6 month milestone- the viability period.

My personal mission in the next 2-3 months is three-fold:

12 week bump
12 week bump

1) Gain weight. Researchers have published that women who have gained 75% of their total weight by 24-weeks have longer gestation periods. This means I have 40lbs to gain in the next 3 months, so I’m all stocked up on high calorie, high protein recipes and don’t forget my Up Your Mass Powder. I’ll most likely share my meal plan in the next few weeks for other mom’s of high order multiples.

2) Stay active as safely as possible. All that I have read encourages 30-minutes of aerobic exercise daily. I have been practicing this on “good” days  and I have to admit, it definitely is energizing and I even think it helps to combat the nausea a bit. I have also read that hydrotherapy is especially beneficial later on in pregnancy, so I plan on incorporating that as soon as I’m brave enough to buy a maternity bathing suit. I believe the more difficult achievement will be to practice bed rest when it comes time. I have to say I have been better at “taking it easy” than anticipated…I think it helps that I have 5 very important reasons to chill-out.

3) Continue to be a student of my body and our babies. I believe it will be important for me in the later months to be able to monitor and measure contractions, and currently I am not quite sure I know what those feel like. The doctors assure me that I will know them when I feel them. Some literature that I have read said that it is important to keep background contractions at less than 3.5 minutes apart. We’ll see how this all plays out.

Enough about me…on to those babies!

V-5 Family Photo
V-5 Family Photo

The second part of our visit today was focused on completing the 1st trimester screening which included anatomical assessments, heart rate assessments, nuchal scans, and numerical assignments. Overall, everyone is right on track. They are all just shy of 2.5 inches long, have all 4 limbs and strong heart beats between 150-155bpm. Also, the nuchal scan is an assessment of the thickness of the skin on the back of the baby’s neck. Greater thickness (> 2-3mm) is correlated with an increased incidence of congenital heart defects and Down syndrome. All of our little ones’ nuchal scans were <2 mm! They were also able to number each placenta for good, or so they are hoping. Based on the photo above, number 1 is on the bottom right, number 2 is in the center row on the right, baby 3 is to the left of baby 2, baby 4 is just below baby 3 and to the left of baby 1, and baby five is the cherry on top! All 5 have a distinct location, but have shifted a bit since the last ultrasound to provide themselves more room for growth. The ultrasound technician said that the placement of all of the placentas look great!

Cue “Eye in the Sky” by the Alan Parsons Project (a.k.a. the Chicago Bulls Intro Song)

And now all the way from Madison, Wisconsin, 12-weeks and 2.5 inches long the Vanderwall quintuplets!

When we were introduced to baby 1 at this visit, their little hand was right up to its ear, just like it was chatting on the phone. Our technician said it was probably calling the others to let them know Mom and Dad were watching :O) We deemed this one both our chatterbox and tattletale!

Baby 1
Baby 1

The next stop was to the three arranged in the middle. Starting from right to left: baby 2. It’s difficult to tell from the photo, but this one we think is going to be the tough cookie of the bunch. They had their fists raised just like a boxer and were kicking their legs like crazy. Little did we know, but those little legs were right up against baby 3’s placenta. We think we got to witness an epic battle of footsie!

Baby 2
Baby 2

Moving to the left, the monkey in the middle, baby number 3. This little one couldn’t sit still for a moment. They looked like they were break-dancing with an impressive worm.

Baby 3
Baby 3

On the far left, is baby number 4. Who appeared to be the most mild mannered of the bunch. They were chillaxin’ with their little legs propped up and ankles crossed. They moved a little, but looked quite content watching the others.

Baby 4
Baby 4

Baby number 5 was previously the baby they were most concerned about because they had nestled in near to the opening of the fallopian tube. They also were lagging a bit in growth last time we checked in. But, this time they scooted over a bit and have plenty of room to grow and they are tracking beautifully on growth. They are still the shortest of the bunch, but what they currently lack in length they make up for upstairs. The technician said this one had a beautiful brain! So, we’ve got a shorty with some smarty pants.

Baby 5
Baby 5

And those, folks, are the V-5! The next time we will get to see them is at 20 weeks! That is also when we will be able to assess their genders. So, please keep the prayers and positive thoughts flowing because these kiddo’s and their Mommy and Daddy have their eyes set on 34 weeks!

Eating for…Six

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“Let food be thy medicine and medicine be thy food.”  -Hippocrates

Food-Is-Medicine

This is a statement I passionately believe in. Medicine is defined as “the science or practice of the diagnosis, treatment and prevention of disease,” and thus nutrition is also the science of the diagnosis, treatment and prevention of disease.

This is especially true when educating and counseling persons with chronic diseases, such as diabetes, high cholesterol, high blood pressure, kidney disease and the list goes on and on. Tweaks in what these persons eat on a daily basis can dramatically improve their disease state.

Many of you are probably waiting for the link to pregnancy, well here it comes. While I continue to believe in the power of nutrition, my view of food has shifted during pregnancy. I believe food during pregnancy is very similar to food for the elite athlete; it is its most basic form- fuel.

While dietary quality is of the utmost importance during both pregnancy and athletics, but quantity often is slightly more important. I have been intrigued by the amount of energy (Calories) required to grow and sustain life, let alone 2, 3, or 6 at one time.  The average adult woman needs approximately 1600 Calories per day and the average adult male needs nearly 2000 Calories per day. These amounts of course vary depending on an individual’s metabolism, body composition and daily physical activity. But, the average woman pregnant with one child needs approximately 300 additional Calories per day beginning in their 2nd trimester. However, this is not the case with multiples. This additional energy requirement starts in the 1st trimester and quickly escalates with each fetus:

  • Twins: 3,500 Calories
  • Triplets: 4,000 Calories
  • Quads: 4,500 Calories
  • Quintuplets: 5,000 Calories

One may be jumping for joy at this amount, because it’s like Thanksgiving everyday! Unfortunately, when you add in morning sickness, indigestion and limited belly capacity, this feat requires a bit of creativity.  Again, it is important to remember that quality is a close second to quantity and thus the type of Calories consumed is also very important.

The average dietary composition is 50-55% Carbohydrate, 25-30% Fat and 15-20% Protein. During pregnancy, this also shifts to approximately 40% Carbohydrate, 40% Fat and 20% Protein. Fat, primarily from unsaturated sources high in omega 3’s, like DHA, is critical for neurological development. Protein is known as the building block for life and food sources that maintain a complete amino acid profile, animal-based proteins, are ideal. The percentage of carbohydrates decreases during pregnancy, and my assumption for this decrease is two-fold: 1) To account for the increases in necessary fat and protein and 2) To limit edema, or swelling and bloating. Carbohydrates tend to pack on water has they are stored and extra L.B.’s from fluid tend to be unappreciated, especially later in pregnancy.

Overall, we know that nutrition is an individualized science and all of the energy goals have to be adapted to the individual. I believe the best outcome for measuring a person’s nutrition during pregnancy is maternal weight gain. Future mom’s of multiples are to gain an average of 2-2.5lbs per week beginning with week one, so that by 30 weeks mama has gained nearly 80lbs. Maternal weight gain is highly associated with fetal growth and gestational age, which we know are the two variables that often influence fetal complications.

So, for you “bump” lovers out there I will be sure to post a pic or two in the coming weeks along with some updated ultrasounds. Until then, hang tight…patience is a virtue (lol). And, for you nutrition geeks and foodies out there, much like myself, there will certainly be future posts on nutrition tips and meal planning for mom’s of multiples.

Five Buns in my oven

Written by: Cassie Vanderwall, MS RD CD CDE CPT

Visit to the High Risk Clinic

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Keep Calm and Choose Life

It has taken me over a week to process our first visit to the perinatal high-risk clinic. Frank and I went into the visit excited and prepared to askour long list of questions about how we can make this pregnancy the most successful it can be. We anticipated a thorough discussion on treatments, tests and procedures as well as detailed instructions for each trimester. Much to our dismay, this is not what occurred.

The visit started off wonderfully. We had our second ultrasound and had the opportunity to see all five of our blessings at appropriate lengths and with strong heartbeats. The ultrasound tech was amazing! She walked us through everything we were looking at for each of the fetuses. It was breath taking!

Frank and I were so encouraged after the ultrasound that we decided to launch our announcement and once again we were overwhelmed by the love and support from everyone! We don’t have words to describe how thankful we are!

We then headed over to the consultation room to meet our maternal and fetal medicine specialist and his fellow. Even within the first few minutes I sensed tension that you could have cut with a knife. The doctor also did not congratulate us, but hopped right into reviewing my medical history and highlighted each condition that put this pregnancy at risk. Then, he decided to transition to the stat list and read the probabilities for each of the chronic and acute disabilities and conditions. I made it halfway through the list and burst into tears. The fellow kindly stopped and was very apologetic. He just kept saying, “Oh no, Oh no… I’m so sorry.” I sensed his compassion at this point, but unfortunately the floodgates had already opened. The specialist quickly took over and the fellow excused himself; I’m fairly certain he went out into the hallway to cry because he came back with tear-stained cheeks.

I knew where this conversation was going. Our perinatologist then walked us through additional studies on the risks of quintuplets and the benefits of multi-fetal reduction. I must admit his approach was much softer than our first doc, but it was clear he was on a mission. He told us that there was a chance that all five of our children could be born with cerebral palsy. This really hit home; would I be able to mother 5 children with several disabilities? My immediate answer was yes, if that’s what I was called to do.

He also shared several studies that highlighted the importance of gestational age and birth weight. There is no doubt that I comprehend the risks we are facing of CP, compromised lung function, IVH, blindness, deafness and the list goes on and on. But, as a mother-to-be I cannot help but be optimistic and fight for these little ones. I have catalogued the research articles that were shared by the docs below, and would love others’ opinions. But, I have also found countless studies that demonstrate that medical technology today provides strategies to prolong gestation and decrease the risk of neurological abnormalities and respiratory complications.  If any others have additional research studies that have been pivotal to their care, please do not hesitate to share.  My hope now hinges on the fact that I could make it past 32 weeks. For quints, this would resemble a birth at 28 weeks, which continues to pose a risk, but according to the articles the risks tremendously decrease for (Condition, probability):

If we can make it to 34 weeks, the probabilities of RDS decreases to 55%, IVH to 2%, Sepsis to 11% and NEC to 15%.  So, our Doom and Gloom conversation, part II, finished up on a very sad note. Frank and I drove home in a haze of what if’s, statistics, and desperately sought some good news. Our next visit back to this clinic is not until our 2nd trimester, or one month. Until then, we continue to take one day at a time doing all that we can to prepare mentally, physically, emotionally, spiritually and of course financially to parent five beautiful babies.

Research Articles:

Multiple Gestation associated with infertility therapy: an American Society for reproductive medicine practice committee opinion

Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR)

Estimation of neonatal outcome and perinatal therapy use

Long-term Medical and Social Consequences of Preterm Birth

Long-term family outcomes for children with very low birth weights

Multi-fetal Pregnancy Reduction, Committee on Ethics

Management of High-Order Multiple Gestation

High-Order Multiple Gestations

The Case Against Multi-Fetal Reduction

Determinants of Gestational Weight Gain

Outcomes in Young Adulthood for Very-Low-Birth-Weight Infants

Written by: Cassie Vanderwall