One OB Doc's Quest to Save High-Risk Multiples

There aren't many women who can understand what the mother of the octuplets, born in California this week, might be thinking right now. Cintya Diaz is one. In early 2008, after a series of fertility treatments, she went in for a 10-week ultrasound, thinking—based on four previous scans—that she was carrying a single fetus. The ultrasound technician said "the baby looked small," Diaz recalls. Then, the tech turned from the screen, surprised. "Cintya," she said, "I didn't know you were expecting four!" (Article continued below...)

Diaz, 29, hadn't known either—and suddenly, she was "scared to death." She had good reason to be. Her first pregnancy had been successful; she had a healthy 12-year-old daughter, Daisy. But her second ended in tragedy; she lost twins at 26 weeks. I wasn't able to carry two babies, she thought. What would make me think I should try to carry four? Diaz's obstetrician agreed. He said she would need to "selectively reduce" the fetuses, aborting some of them to give the others a better chance.

The risks were clear, yet the idea of abortion made Diaz uneasy. She had the name and number of a reduction specialist in hand when a friend, the mother of triplets, told her there was an alternative: Dr. John Elliott, the director of maternal-fetal medicine at Banner Good Samaritan Medical Center in nearby Phoenix, who specialized in large multiple pregnancies. She went in for a consultation and, four hours later, came out determined to carry all four fetuses to birth. "I don't trust a lot of doctors," she says. "But Dr. Elliott empowered me. I came out of that appointment like"—she raises her fist —"yes! I can do this."

Carrying multiples—or, as they're called when there are more than two babies, "supertwins"—is a risky proposition, healthwise, for both mother and children. It's also an increasingly common one. Fertility therapies such as IVF and treatment with Follistim, a drug that prods eggs to mature, have become more advanced, successful and widespread in the past two decades. As viewers of TLC's "Jon and Kate Plus 8" know, occasionally—particularly if infertility docs are not careful—the treatments cause many embryos to take hold in the womb instead of one. And that's where the wrenching decisions come in. (Follow the history of multiple births in our photo gallery.)

Although there are no comprehensive statistics that show how many women are accidentally impregnated with multiple viable embryos—no one collects data on women who abort in those circumstances—it's clear the number of women carrying multiples has been on the rise. The California octuplets are only the most extreme example (no set of eight has ever been conceived naturally).

Twenty years ago, there were 90,118 sets of twins born in the United States, 2,529 triplets, 229 quadruplets, and 40 sets of five or more babies. By 2005, according to CDC data, those figures had risen to 133,122 twins; 6,208 triplets; 418 quadruplets; and 68 sets of five or more. The numbers peaked in the late 1990s and early 2000s, but did not subside to anywhere near previous levels.

The increase in multiple births doesn't just reflect a jump in babies being conceived with the help of medical technology; it is also the result of efforts by some obstetricians to help women bring those high-risk multiple pregnancies to term despite the odds. Elliott is one of the most radical practitioners of what might be called "extreme obstetrics." Medically, Elliott's strategies seem to work: his patients carry their triplets, quads and quintuplets for longer than the national average. But some doctors criticize his methods as unproven or even dangerous, and they worry that docs like Elliott are inadvertently encouraging more women to try to carry supertwins—and to risk serious medical complications—simply by offering hope. On the other hand, pro-life advocates, among others, would certainly say that controversial doctors like John Elliott are saving lives.

Elliott can come off as a cowboy—he occasionally wears a gold chain under his scrubs, and he says there's something to the idea of Phoenix as the academic "Wild West," where doctors take risks and "think out of the box." Still, with patients, he is gentle, thorough and not in the least intimidating. He uses very few technical terms; he refers to a "baby" instead of a "fetus." "A lot of OBs are very busy, and they don't spend much time explaining things," he says. "It's amazing how a patient responds to that."

Few of Elliott's out-of-state patients are referred by other OBs. He does not advertise, either. Instead, nearly half the patients find him through enthusiastic postings from other moms on Web sites such as Mothers of Supertwins and The Triplet Connection. At least one patient saw him on a Discovery Channel show and came all the way from St. Maarten. 

Despite his high profile, Elliott did not set out in medicine with a plan to become the go-to OB for the highly multiparous. During his fellowship in Phoenix, from 1978 to '80, he says, "there was only an occasional triplet. You never saw quads." But as numbers of multiple pregnancies started increasing in the '80s, Elliott began to experiment with magnesium sulfate, a drug that was used to treat pre-eclampsia. The drug had extremely unpleasant side effects, including severe fatigue, muscle weakness, low blood pressure, and difficulty breathing; while on it, Elliott's patients told him, only half-jokingly, that for his own safety he'd better hide his surgical knives. But Elliott thought "mag" might be useful in extremely high doses for prolonging large pregnancies. In 1992, he published data showing that 10 local women on his protocol had carried quadruplets on average for 32 weeks and a day—a paper he describes as "saying to the world, 'it's not as bad as you think it is'."

For quadruplets, 32 weeks and a day is indeed impressive. Most quads, if they're lucky, are born at 31. (As a rule of thumb, every extra baby in a pregnancy subtracts three weeks off the standard 40. Twins are born at 37 weeks, triplets at 34 and so on.) Each extra day in the womb is precious, allowing the babies to develop their lungs and pack on the ounces, potentially avoiding long-term neurological problems such as cerebral palsy, which are linked to low birth weight. For women carrying multiples, then, every day that they manage to stay pregnant is a good one—no matter how painful and weak that day may make them feel.

With multiples, there's also a higher risk of going into labor before the babies are viable at all. In 1996, Elliott got a call from a woman's husband in Peoria, Ill. She was pregnant with quads and had started having contractions at 23 weeks—so early that all four babies would surely die if they were born immediately. "Her doctors basically told her and her husband that she would be delivering and that there was nothing that they could do," says Elliott. "They weren't giving her enough [magnesium sulfate], and they were afraid to go any higher than they had." Elliott wasn't so reluctant. After trying, and failing, to convince the Illinois doctors to up the woman's dosage of magnesium sulfate, he said he'd take over her care himself. She managed to get to Phoenix, where he put her on bed rest and a high dose of "mag," and the babies stayed put until an astonishing 34 weeks. Word spread and suddenly, other women from outside Arizona started flocking to Banner Good Samaritan.

Delivering triplets, quads and quintuplets is a regular part of Elliott's practice now. His quints, he says, generally stay in utero even longer than his quads, for 32 weeks and four days. (He is writing up the data for publication.) In 2007, Elliott delivered a set of quints that broke the world record for total weight. He also delivered the Masche sextuplets, that entered the world relatively healthy in the same week that another set of six, under the care of doctors in Minnesota, was born too early to survive. But of course other examples of large sets of surviving multiples abound—just watch the Discovery Health Channel or TLC for a few hours and you'll hear their stories.

Elliott is puzzled as to why other doctors do not use very high doses of mag, as he does, to prolong pregnancy. They prefer lower doses of mag, bed rest or other drugs, including antibiotics, beta-mimetics, calcium channel blockers and nonsteroidal anti-inflammatory drugs (NSAIDs)—none of which is guaranteed to stop early labor. "Many places today don't think you can be successful [with large multiple births]," Elliott says. "We're just more willing to do the best we can."

If using magnesium sulfate in extremely large doses makes Elliott "radical"—and he himself says that it does—he is doing so in a fairly radical country. Magnesium sulfate is widely used in the U.S. and Canada to forestall labor, albeit at much lower doses than Elliott's. No other country in the world uses it so widely for that purpose. A Cochrane Review—a scholarly survey that many doctors look to for guidance—recently found that mag doesn't actually work as a tocolytic (a type of drug that prevents labor). "There was never any scientific foundation for using it to stop labor in the first place. It was based on theory, and on several flawed, uncontrolled studies," says Dr. David Grimes, an obstetrician-gynecologist with the Durham, N.C. nonprofit Family Health International, who wrote an opinion piece in "Obstetrics and Gynecology" based on the Cochrane data. "Anyone who's using it to prevent labor at this point is out on a limb."

This is where the medical controversy around Elliott comes in. It is not so much a matter of pro-choice versus pro-life values as one of data interpretation. Elliott and Grimes essentially look at the same literature and come to vastly different conclusions: one says he can use mag to prolong pregnancy, the other says no one can. Each says the other has cherry-picked data to support his point of view. Grimes says Elliott makes "dogmatic statements based on no data" and has published the results of his work in Phoenix-only substandard formats or "minor league journals." Other detractors knock Elliott for not publishing all of his work.

Meanwhile, Elliott has been fuming for two years over Grimes's article and recently finished a response, which he has submitted for publication in a major journal. "Anybody who has used the drug knows that it works,"  says Elliott. "When it doesn't, that's because people use it for only 48 hours and then they stop. I mean, come on: Well-meaning people have basically underdosed mag and then found that, gee, it doesn't seem to work as well as we hoped."

Dr. Mark Evans, an obstetrician and geneticist and a specialist in "selective reduction," is another of Elliott's critics. Evans more or less invented selective reduction in the late 1980s and continues to be its most vocal, and most radical, practitioner. He is even willing to reduce twin embryos to a singleton if he thinks the procedure is medically warranted. The point of reduction, he says, is "maximize the chance of having a healthy family" by avoiding the complications of large multiple births, which can include brain damage and death for babies.

And for the mother, the health risks can be life-threatening too. One of Elliott's patients, —Jenny Masche, who gave birth to sextuplets on July 11, 2007, had pre-eclampsia (common in high-risk pregnancies) and went into heart failure in the delivery room. With her children in the neonatal intensive care, Masche found herself fighting for her own life in the ICU. She remembers praying to survive so she could be with the six babies that she had miraculously carried for 30 weeks. (You can find our video of the Masche sextuplets at their home in Arizona and footage of the babies' delivery here.)

Evans worries that doctors like Elliott are "putting patients at huge risk" and "leading them down a path of over-optimism." Even when a full set of supertwins is carried to birth with no fatalities, he notes, the babies have higher risks than singletons of "lifelong calamities" such as cerebral palsy, and the mothers may suffer long-term health consequences as well. He questions how many of Elliott's babies end up with cerebral palsy and suspects that the number is high.

Elliott counters that he believes the number to be low. He can name many sets of supertwins he has delivered who have grown up completely healthy. But the disease is usually diagnosed long after delivery and Elliott says he's "too busy taking care of patients" to track down and write up the data. Besides, he adds, he is a clinician first—i.e., he is not in the business of running large, randomized clinical trials. "If I publish it," he says, "it'll just be, 'where's your control group?' "

In any case, Elliott is adamant that he does not want to encourage women to carry many babies at once. He's all too aware of the risks. But, he adds, if women are set on a big multiple pregnancy, someone has to get them through it. He is willing to be that person. So he's sticking to his protocols. "I think we're right. Everybody else thinks we're wrong,"he says. "I'm OK with that. But it gets a little frustrating fighting uphill."

Elliott may never win the support of much of the medical establishment, but he does have advocates—particularly in the heartland, where fertility treatment is now fairly common and pro-choice attitudes are not. "There is," explains Mark Evans, "a big blue-state, red-state divide in how patients and doctors look at this." And of course Elliott can always point to happy patients—including Cintya Diaz. On June 25 of last year, "five feet around" after several months of bed rest and so heavy a normal hospital bed would no longer support her, she delivered David, Diesel, Damien and Dayami. They were small but apparently healthy, and only David required oxygen after birth. Less than three weeks after they were delivered, the babies were out of the hospital and sleeping at home, all four of them sideways in a single crib. Afraid of losing them, Diaz had refused to prepare the nursery, buy onesies, or even pick names in advance. Now, she acquiesced to a baby shower. Elliott, she said, had given her a miracle. Elliott himself didn't see it that way. "It's your job to save those babies' lives," he says. "You've gotta do what you gotta do."

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