Monday, April 14, 2014

Update

Sorry, this post is from my phone as well, so no pix. It kept telling me to download google plus, and I did, and it is still not working. Blaargh.

About my little miracle:At first, everbody thought that the respiratory issues stemmed from the c-section. However, soon after birth, it became increasingly apparent that Gauri had a infection, which, from the timeline, looks more like it was acquired in utero (the pediatrician says he sees this sometimes in babies born of surrogates--that is why he started antibiotics so very soon, which turned out to be the right call to make). It responded to antibiotics, and her respiration stabilized within 36 hours, letting them start feeding her.

She is now up to full feeds (she seems to be a good eater, knock on wood) and will be discharged to my hospital room tomorrow, where her antibiotics will have to be continued. Poor baby has been stuck with an iv in three different spots already, and I'm so sorry for that, and for the fact that she had this infection to start with.

Can't wait to get out of the hospital and go home! They are taking good care of us though, and NICU staff are awesome...I'm pretty impressed.

Thursday, April 10, 2014

It is a girl!

Gauri was born yesterday evening: 5.5 pounds and a miracle all in all. Great apgars. J came through the c-section fine.

Will post about how things went down soon: she is doing well, but there are mild respiratory issues (mild to moderate transient tachapnea and maybe the beginnings of a lung infection) that are keeping her in the NICU.

The poor little thing has only saline so far: they will start feeds only when the respiratory rate stabilizes, and I'm praying that happens by tomorrow: she was started on antibiotics by the neonatologist within 12 hours of birth. The mildly high respiratory rate has not worsened, but it has not improved significantly either.

But she is beautiful, fiesty, alert, and fairly stoic about all the indignities we are subjecting her to.

Pics, more details, updates coming soon: this is posted from my phone.

To all my readers who have helped me cope and survive though this winding road to this beautiful destination, from the bottom of my heart, thank you.

Monday, April 7, 2014

No date set

I know some of you are checking back in for updates regularly, and I just wanted to keep you all in the loop: there is no date set for delivery. There was one (it was supposed to be the 9th), but it got scrapped. Long story, but I had little to do with this decision. J will come in for a checkup on the 9th, which is 37 weeks exactly, and the OB will decide what to do then.

I am trying be zen about things, but I will be slightly on tenterhooks till she gets checked.

It is really too bad I stopped working on the 1st of April, but the problem about that job was that it was all consuming, and I did need time off to prepare for various things.

With all this time on my hands, I really need distractions. I am reworking my way though the seasons of The Office (maybe my all-time favorite show, though I do have a lot of those). Fun ART-related piece of trivia: California Cryobank gives you the celebrity lookalike for a particular donor, and the celebrity with the most look-alikes in the CCB donor pool is apparently is John Krasinski. Sigh. That man would probably make very cute babies.

Wish me luck with the staying distracted!

Sunday, April 6, 2014

The homemade goat milk formula revisited

This is a super technical post, and will be useful only for those who want to come up with a homemade goat milk formula.

First, here is an important point to take note of: Babies allergic to cow milk can ALSO be allergic to goat milk. The incidence of goat milk allergy and its severity relative to cow milk allergy appears to be a subject of some controversy. As previously noted, goat's milk has really low levels of the main culprit implicated in cow milk allergy, A1 casein, although it does have an another allerginic substance, beta-casein. I kind of got cross eyed when I tried to figure out what percentage of children with cow's milk allergy are also allergic to goats milk. One study puts this at 26%. There are also studies that show that infants that are not allergic to cow's milk may be allergic to goat's milk.

However, overall, studies as well as anecdotal evidence suggest that goat milk allergy/intolerance is far less of a problem than cow milk allergy/intolerance. It comes down to how your child responds to it: many children who are miserable with cow's milk fare very well when they go to goat's milk. Also, food allergies are insanely complex: I was struck by one story I read a long time ago on Amazon. This child was having issues when on a cow milk formula, and they switched him/her to goat's milk and  found a huge improvement.  At the same time, they were having him tested for allergies, and testing revealed that he WAS allergic to goat's milk (based on IgE, I think). They then took him off it, but what was surprising to me was that they noted a real improvement in symptoms when he was switched to goat's milk.

I tried to find where I had read this, but was unable to. The point of this is it may be better to see what your child tolerates best, rather than just looking at what the clinical testing reveals. Sometimes, only one clinical parameter (like IgE levels) may not provide the full picture. This point is made by Dr. Sears, who states that clinical studies about goat milk allergenicity really do not appear to correlate with parental observations as to how well it is tolerated.

However, keep your pediatrician in the loop and always proceed with caution when introducing something new: anphylactic shock has been observed in very rare instances in response to a milk allergy, and there has been one documented case of it occurring in response to goat milk. However, I would emphasize that such a situation may be exceedingly rare.

Also, while we spend so much time talking about allergy, keep in mind that true cow milk allergy is low in frequency: maybe only 2% of the population. Even if you suppose this quoted study under-represents this issue and you double this figure, this is still not a very widespread problem.

The majority of the population should do okay with either goat or cow's milk. However, goat milk has some advantages, and moreover, most formula makers have made some really poor choices when coming up with baby formulas (even the organic ones), and hence I would want to go with a homemade formula.

Most of this goat milk formula recipe comes from the one recommended by Joe Stout from Mount Capra. The first thing I did when I was analyzing his formula was to make sure the protein level was okay, because goat milk has about 3 times the amount of protein as human milk, which can mess with a newborn's kidneys.

The biggest issue in coming up with a formula to replicate human milk is that the levels of the various components of human milk can vary, apparently (I have not verified this statement myself). I found one study which stated that human milk contained about 1.1 g protein/100 mL.  Based on my calculations, the amount of protein suggested for use on the Mt. Capra site (1 tbsp Myenberg's powder/8 oz) would deliver a little more protein (1.7 g/100 mL).

I communicated this to Joe Stout, who very kindly explained that trying to come up with the "correct" amount to mimic that in human milk is a crapshoot, because the composition of human milk can vary.

Moreover, formula manufacturers have to follow an extremely unclear system (or so I think):
Based off of the regulations in the 1980 Infant Formula Act, the infant formula must contain at least 1.8 grams of protein and no more than 4.5 grams of protein per 100 kcal formula.

The fact that they did not specify this per volume, and did it per 100 kcal of formula,  is rather insane, I think. This system is immensely difficult to follow and allows wide variation, and I decided to go with a slightly different approach.

I tailored everything to mimic what little we know about human milk composition, on a per volume basis, and I used most of the calculations specified in the Mt. Capra formula. The end result may not resemble everybody's milk, but atleast it resembles somebody's milk. The thing to remember is, no matter what minor variations there may be in the protein composition between formulas and even in different human milk sources, babies do just fine generally on all of them, unless you really overshoot or undershoot.

It would be a smart idea to take a formula recipe (either the one below, or the Mt. Capra one), as a starting source and modify it slightly if required, based on your baby's response, growth, and general well being. 

Here is a formula, if one is making it with Myenberg's goat's milk powder


Notes:
  • The amount of goat milk powder added is not set in stone:  I'm planning to start with a low amount of protein by adding 2.1 tbsp of the goat milk powder/24 oz; this works out to 1.1 g protein/100 mL, same as that specified in that one report on human milk. I'm being conservative because I'm feeding a newborn, and I really do not want to overwhelm the kidneys in any way. Because this is generally lower than that in most formulas, I may consider increasing  gradually based on the baby's growth.
  • Alternatives to lactose include turbinado sugar, maple syrup, or organic brown rice syrup. I prefer lactose as it is what is present in human milk. The reason that formula companies use other things (corn solids, etc) is because they are cheaper. When making your own formula, unless your baby shows signs of intolerence, lactose is a good choice.
  • The blackstrap molasses supplies minerals and B complex vitamins
  • The Vitamin D dosage can be tailored to meet your baby's needs (you just need to ensure that the levels are above 30 ng/mL for optimal health)
  • The multivitamin is highly redundant: almost everything provided by this multivitamin also comes from another sources in this formula, with the exception of Vitamin B-12. This multivitamin supplies it as cyanocobalamin, not methylcobalamin. If you want to leave out this multivitamin, you could go with ghee (rich source of B-12), or go with a methylcobalamin formulation like the Douglas labs methycobalamin. Note that the RDA for B-12 in newborns is 0.5 mcg (approximately). 
  • I'll be writing a blogpost on the probiotic (Biogaia Protectis) soon.

Wednesday, April 2, 2014

Update

My mom went and had a really long conversation with the OB, and got the true picture of what happened in the last few days. The situation (and getting the details we did not have) was reassuring: her bp was down, and she has been sent home with beta-blocker pills.

The reason I was stressed out yesterday was I had NO idea what was going on: I did not know if her BP had stabilized, I did not know if her infection had cleared, or even what sort of infection she had. Even if she has no access to decent care where she is now, she is atleast stable, and has promised to come back in time for her weekly appointment next week.

We now have to set a date for induction. Unfortunately, we cannot wait for long because her home environment is not the sort of place you want to be in, in the event of any emergency; I've driven there; getting vehicles in and out is a nightmare, it is far away from the hospital, and the local medical care is definitely un-vetted  and far from ideal (it is the local clinic in a seriously poor neighborhood). So we will have to pick a date for stuff to happen at or close after 37 weeks, which is the 9th.

I'll be so very glad when this is over, hopefully, with a healthy baby in my arms. This is when knowing the gender would have been a little useful in making a decision. Have you guys heard about the "wimpy white boy syndrome?" This is a term that may be somewhat hurtful if bandied about in the NICU; don't know who is the insensitive genius who came up with it. Basically, it has arisen from the fact that, in general, girls mature faster than boys, and the maturation in utero also depends on race. White male babies are the slowest to develop and hit all the landmarks (lung maturation and various reflexes, including the suck-swallow-breathe one). My baby is half-white, and if it is a boy, the odds of him needing those last 2-3 weeks more is higher, give the race-specific data. I have NO idea what the influence of his Indian genes would be: Asian, black, and white babies have been studied, but not south-east Asian. Irrespective of race, it is a girl, we could, in theory, breathe a little easier about inducing close after the 37-week-point. But bleh, this is India, so I can't bloody find out.

Sigh. But still, overall, I can breathe again. Yesterday was rough.

Tuesday, April 1, 2014

In need of sedation

I found out, mostly because I had an intuition that something was off, that J discharged herself against medical advice, and has gone home. Nobody even bothered informing me of this: I found out because I asked.

I don't know her medical condition and what was done in the past 4 days when she was in the hospital. Right now, I have to wonder if the baby would be safer out of her than in her, but we have to wait to talk to the OB to figure that out.

I have to take really deep breaths and pray that everything will be okay.

Sunday, March 30, 2014

More on the realities of surrogacy in India

Part of this post is prompted by the the commenter in the previous post; her first comment was rather judgmental, but allowable. The second one was fairly rabid in tone, and talking about how a blood pressure value of 150/90 is not preeclampsia (no, of course it is not), and how the situation could have been managed while not uprooting J from her home environment, and finally ending with a rant on the utter uselessness of vitamin D, and how I was inflicting this utterly pointless thing on her.

Now, since I am slowly starting to attract the trolls, here are some ground rules for this blog: comments of that tone, with such a content will just be deleted, and you will never be allowed to comment again. You can say whatever you want anywhere else on the internet, and if you can find somebody to listen to you, good for you, but here, you get no talktime. You are, of course, welcome to spend a long, long time composing a new vitriolic comment. I will then delete it as soon as I spot it, and you would have wasted all that time. If the situation ever gets truly annoying, I will turn on comment moderation to save myself a headache, and then nobody can ever see your words of wisdom  for even a short while.

But overall, this annoying episode, and Katrina's very thoughtful comment highlighted that it would be useful to talk a little bit more about this situation.

I can't even begin to sum up what a minefield surrogacy in India is. All the doctors involved have expressed upon me a 1000 times that these surrogates are not like surrogates in the west, and how they should be handled differently. How they should be handled is the billion dollar question, and trying to come up with the most optimal way to do it is a very complex topic. I think I'll spend a good part of my book trying to thrash it all out, and atleast outline how some of the current practices should change, and how that change is sometimes stifled by various issues.

First, about medication compliance: from the start, her bloodwork has not tallied with the doses she said she was taking. I didn't want to not believe her, but if two sachets of 60,000 IU have not increased your blood levels at all, then something is off. She could be absorbing it very poorly, or she could be lying, or she could have been throwing up what she took. None of these possibilities could be dismissed, and to this day, I do not know what to believe. After I kicked up a fuss after the first few months, the Vitamin D she was taking started to be reflected in her blood levels. I have not checked in several months, and this drop has shocked the crap out of me. Again, cannot tell what the issue is, whether it is lying, poor absorption, vomiting after the dose, or very much increased needs.

Also, surrogates in India would have a very different take on say, prenatal vitamins and nutrition than a surrogate in the west. Such a person would be self-informed, and would understand what was going on. Because surrogates in India are mostly uneducated, they may not also take these things seriously. Also, nobody bothers explaining anything to them. They just say "here, take this pill or this injection." I've spent a lot of time just talking to J explaining what each thing does, and it is my duty to convey that information, even if she pays me no attention or does not understand. I've also tried to give her similar health advice about her own kids. Completely goes over her head, and if she ever takes my advice, I'd be shocked. Still, I cannot help myself. 

Here is some background on the housing situation. J lives in a sort of housing called a chawl. Her bathroom is outside her apartment, which means she has to get up in the middle of night and leave her house to go use the facilities, which is insanely difficult when your pregnancy progresses to this point. It is also getting hot here, and sometimes, without air conditioning in the noonday sun, you feel like you would get heatstroke. Imagine dealing with this when you are nearly 9 months along. Keeping all this in mind and how exhausted she is, I offered her the only comfortable option I could offer: hospitalization. She wanted to get admitted to the hospital after April 2nd, because she was also feeling run down/exhausted. When she showed up with a steadily increasing BP on March 26th, it was the OB's decision to hospitalize her, and I was definitely on board with that because I am really afraid about the medical facilities she has access to right next to her house (an extremely poor neighborhood), where her care would be coordinated by the handler. 

If you went with other agencies, you could have more options. Many surrogate agencies/doctors offer housing/more hands-on care. People can move in in the start, or in the last few weeks in case of a special situation (such as this one). My RE offers nothing other than the handler to manage the whole shebang. Dr Patel at the Akansha Clinic in Gujarat offers a home of sorts, where surrogates live for 9 months. The Mumbai-based agency Surrogacy India (SI)  has a few apartments where surrogates can be housed, and there is a nursing home in the same building, with an ambulance on the premises. While these options offer many benefits, what I do not like about these situations is that the surrogate is separated from her family. While there many be some advantages in separating her from her husband in some (e.g., if the husband becomes positive for an STD, or is deadbeat spouse (very much common in this socio-economic group), I would definitely feel a great deal of guilt if I separated her from her children for this really long period.  If I ever do this again, I'd want a situation where the surrogate could move in with her kids, and I'd be more than willing to spend the extra money to make this happen.

An alternate, viable option is to have your surrogate live at home with the family  (close to the agency's housing), and, if there is any sort of emergency that requires separation from her husband (SI told me the story of a husband who became positive for syphilis during the pregnancy) or for greater medical supervision, move into the agency's housing for maybe the last few weeks.In that way, she would be much closer to her family and see them on a daily basis, etc.  However, in my unique situation, I have no options other than the hospital.

Anyway, I just spoke to J. Apparently, she received IV antibiotics for an infection last night. I have no idea what is going on; going to go to the hospital to try to figure things out.

Friday, March 28, 2014

Admitted!!

Two days ago was J's 35-week appointment. The handler, who was supposed to ensure that J's appointment was kept, was herself unable to come there this week, and J wanted to cancel. I put my foot down and and badgered her into showing up. Had I not been on the scene playing policewoman,  J would have skipped this week, and that knowledge frightens me a little.

It frightens me because when she showed up, her blood pressure was 150/90 and she was admitted on the spot. I'm SO glad she is in the hospital now, where she will be monitored regularly for blood pressure and proteinurea. She is also on medication (alpha dopa) to bring the BP down. It turns out this was the story in the last pregnancy too: things were fine until around this point, and then her BP started rising, and she spent the last two weeks in the hospital.

Thank you Pam and Josey for your inputs. Yes, absolutely, waiting till 39 weeks and beyond will ensure that your baby's first few weeks are more comfortable/easy. I don't think I'll have that choice now. As of now, J cannot wait to get this done. She asked me if she could deliver at 36 weeks. The answer was a firm hell no.I told her that if things are fine medically, there is no way anything is happening before the 37-week point. I also told her that the OB would decide when things would happen.

To make matters a bit more strained, J wants to attend a wedding on April 15th: her sisters. I was flabbergasted: Even if she gives birth on, say, the 12th, I fail to see how she could be up to speed three days later. I'm not going to say, wheee....lets induce on the 9th, which is the 37-week point. All in all, I'm butting out of this and leaving it to the doctor. It is going to be a rather uneasy balance to strike, I think.

I had another jolt when we redid her Vitamin D test...I've been giving her a sachet of 60,000 IU every 2-3 weeks, and around like 6-month time point, her levels were a rather comfortable 23 ng/ml. This week, it was 11 ng/ml!! (just as a note, if you get below 10 ng/ml, you fall into very unhealthy territory).

If she has indeed been taking her sachets as she told me she was, it clearly shows that babies are little vitamin D leeches/vacuums, apparently. I know the mother's vitamin D requirements go up strongly in pregnancy, and it is logical it would go up even more in the third trimester when the growth really picks up, but to this extent?!?

The baby apparently has been growing well. There was an ultrasound done yesterday, and I got the information secondhand through J, and it hence may be inaccurate:  it seems rather high for 35 weeks, especially given that this has been a smallish baby all this while: 2.8 kgs (over 6 pounds!). This was a different operator/machine though.

All in all....getting into the final stretch. Gotta pack that bag now. Monday is my last day of work. Hoping to spend whatever little time I have working on that proposal for the book on Surrogacy in India.. It is also time to launch my new blog. And write a few pending blogposts for this one. And prepare for a baby!!!! So very unbelievable.

Saturday, March 15, 2014

Driving myself batty

I'm having a teeny tiny freak out. FOR NO GOOD REASON.

Everything is okay. J's blood pressure was 130/75 yesterday, so in the normal range. She is getting it checked out every two days.

The baby, as mentioned in the last post, is fine. After I put up the last post, another mom who used my donor told me that her baby was in the 95th percentile for height too. Awwww. As one of my friends puts it, the most random things are turning me into mush. The thought of my baby being similar to one of its (many) half siblings in any way makes me just melt. And I don't even have pregnancy hormones to blame!

Going a little off topic on a rant here, but India's decision to ban sex determination is one of most useless of its many useless decisions. I recently found out PGD is banned too, unless you have a genetic disorder, and can prove you have a "valid reason." Since I have only recurrent miscarriage, I would not qualify.

I wanted to talk about the futility of outlawing sex determination and the unbelievably ugly realities surrounding this situation in this country. I had it all typed out, and then I deleted it. I can't have that in the same post as this (see below!).

Moving to better, happier topics: my doctor switched the 4D mode on for a little bit at the last ultrasound, and I saw his/her little face!!  What is driving me batty is I want to discover my child. For example: This is going to be a biracial child: I spent a looong time wondering (googling) what colored eyes he or she would have. It is going to be utterly up in the air. Most likely, it would be brown, but then I may be surprised because I have people with hazel eyes and green eyes in my extended family. After brown, hazel probably comes in second, with respect to probability. All the rest should be way lower.

And some days, like today, I feel like I have no patience left. Recent studies have shown that babies born at 39 weeks onwards do best, and do slightly better than the ones born at 37 week in many aspects. These findings are prompting people to change the definition of "term" to 39 weeks.

Nonetheless, in India, the average point of delivery for surrogates with singletons is 37 weeks. If you are a surrogate carrying twins, it is before 35 weeks, I think.

I feel like I am hanging on by my fingernails till the 37-week point, and honestly, I should be pushing them all (J who is anxious to deliver, and my docs who will probably give the green light at around 37 weeks) to wait 2 weeks longer. And yet, I absolutely do not want to do that. I need to be disciplined enough to try to do the right thing when the time comes.

Wednesday, March 12, 2014

Checking in: 33 weeks

We had the weekly ultrasound a few days ago, and things looked good: this is one seriously long baby, the femur length is at the 95th percentile! Weight-wise, this baby is sort of small (20th percentile) when compared to the US growth charts, but he/she is bang in the middle in the Indian population charts. So yep, everything looked good there.

Went to Hiranandani Hospital. Chatting with a bunch of surrogates made me realize one thing: Indian surrogates (in Mumbai anyway) don't seem to get epidurals, even if their labor is long and painful. I asked the handler like 4 times...nobody gets epidurals? She was like, nope. Just FYI, if I were going through a delivery at the same hospital, I would definitely get the choice of an epidural. They are common here for all the "regular"  upper middle class moms. When I told my mother about the surrogates not getting an epidural for the pregnancy in which the cost of an epidural is a mere drop in the bucket compared to the other expenses, she just sadly shook her head.

If J goes through labor, I'm going to make sure she gets one if the labor is protracted. However, around 75% of all surrogate deliveries are C-sections. J asked me wistfully if she could get a C-section because the last time had been so rough. I was like...but you suffer AFTER the procedure, instead of during. And she was like, well, yes, that is true.

From my end, I definitely don't want a C-section; what I want is for J's water to break naturally after she is safely ensconced in the hospital, so she does not have to go through the more painful induced labor process. I highly doubt that fate would cooperate like that.

After a 2-hour wait for me (a 4-hour wait for the various surrogates gathered), the doctor saw us.  Her BP was on the high end: 130/84. Gotta start monitoring that.

Slightly nervous now.

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