The "Triary"

December 14, 2007

15 Weeks (Second Trimester)

The Babies:
Triplet A 15.2(15 weeks 2 days in size)
Triplet B 15.3
Triplet C 15.3
These readings indicate the three to be growing at approximately the same rate --no discordancy.

The Mother:
Blood Pressure 134/74 (Repeated, 128/76)
Negative proteinurea (protein spilling in the urine, a sign of Pregnancy Induced Hypertension, formerly called "Toxemia")
Negative glucosurea (sugar spilling in the urine, a sign of gestational diabetes)
Fundal Height (Size of the uterus as felt through the abdomen) = to that of an early third trimester single pregnancy.
All labs are normal, except for anemia and the fibinogen.

Anemia:
The blood value is a fraction--a comparison between the red blood cells and the plasma.  This fraction is called an hematocrit (HCT)

HCT is 33.5% (Normal is 35 - 46).  This slight anemia doesn't frighten me, as I've treated women with HCTs in the 20s often at Charity Hospital where I trained.  However, since we're heading for a C-section with the triplets, it would be prudent to make sure the HCT doesn't fall below 32 or so.  This is because over-distension of the uterus (womb), as with twins or triplets, can stretch the muscle to the point where the uterus won't contract down after delivery.  A large, boggy uterus that doesn't contract down can't cinch closed the gaping veinous (vein) sinuses (openings), and the blood loss can be brisk.  Forewarned is forearmed.  Since this mother is at a high risk for this phenomenon, what is called "atony" (from "atonus," or a- + -tonus, or, "without tone"), we know that we may come out behind on the delivery.  Therefore we need to increase her HCT as much as we can.  At this point, simple Iron supplements are indicated.  If the anemia were to get severe enough, pre-operative transfusion would be indicated.  This, thankfully, is very unlikely.

All pregnant women tend toward anemia to some degree.  Of course, with triplets this tendency is increased exponentially.

Fibrinogen:
Fibrinogen is one of the elements in the clotting of blood.  This patient's fibrinogen was elevated.

There is an entire sequence of events that result in clotting of the blood, and if it didn't exist, we'd all bleed to death.  Hemophiliacs experience defects in this sequence, and some are lucky enough to be able to replace that one item missing.  This sequence is called the Blood Clotting Cascade and is a series of many steps, each dependent on the other.  In this way clotting doesn't happen accidentally within the vascular system, a goof-up that would result in stroke or pulmonary embolism (blood clots to the lung).

Pregnancy alters the Cascade.  In this case there is elevation of the Fibrinogen.  So I repeated the value one week later and it fell a bit, indicating that the rise was not a trend.  So it appears to be stable.  This will be checked periodically.

Discussion:
Strangely enough, too much clotting potential in the body can result in LACK OF CLOTTING and serious bleeding.  At first this seems like a contradiction until the phenomenon is thought out.  If clotting factors rise because of some problem--infection, for instance--they can all be consumed at the microscopic level--a "miniclotting" phenomenon that doesn't result in clots you can see, but a microscopic using up of the clotting factors.  In pregnancy, the placenta is a very vascular organ, and any slight separation at the attachment to the uterus can initiate this consumption of factors.  First we'd see a rise, then the values would all fall--the dreaded "Consumptive Coagulopathy"--(disease of consuming all of the clotting factors, leading to hemorrhage).

In this case, the stability of the value indicates this to be a normal variation of the Fibrinogen levels, especially since her other values were normal.

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