The first time was a charm for Tomball residents Marisa and Dylan Christie.
The couple had been trying for two years to add to their family and give their son Grayson, now 4, a sibling.
Marisa, 30, tried a "trigger shot," meant to stimulate her ovaries, and it worked right away. She learned that she was pregnant at two weeks.
"I knew pretty much from the beginning," she said. "And while I knew that with fertility treatment, you can have multiples, it never once entered my mind."
That is, until her first ultrasound, when the nurse said, "I'm 95 percent sure there are triplets."
"You could have heard a pin drop in that room," Marisa said. "I was shocked. We prayed for so long for one baby, and we got three."
Having triplets moves a pregnancy into the high-risk category. Dr. Christopher McGuirk, who had delivered her son, recommended she see Dr. Amber Samuel, medical director of Obstetrix Maternal-Fetal Medicine Specialists of Houston.
Complications are always a concern both during pregnancy and after delivery when multiple births are concerned, Samuel said.
There's a higher possibility of gestational diabetes, preeclampsia and anemia for the mother, as well as various complications for the fetuses. After birth, there is an increased likelihood of hemorrhaging.
Carrying triplets to full term is also risky. Almost always, early delivery is recommended. Samuel usually sets a goal of 34 to 36 weeks.
One of Marisa's triplets had a condition concerning an extra tissue that could have lead to fetal anemia. "She was the one we were really worried about," Samuel said.
Mother and doctor set a date a little after 33 weeks for a C-section.
"We had a plan," Marisa said. "But nothing went to plan."
She had been feeling a lingering sense of dread, and had even mentioned a few worst case scenarios to her husband, like what to do in case of a hemorrhage or if she ended up in a coma.
"That's not going to happen," he reassured her. With Grayson, the delivery had gone by the book.
"When we thought about the risk of triplets, it was all about them being early," Marisa said. "I don't think it was ever in any of our minds that I was the one who would be the risk."
Marisa packed and headed to Memorial Hermann The Woodlands Medical Center on Aug. 21. By then, her anxiety had dissipated.
"My husband said he was the one freaking out and that I was totally calm," she recalled.
The doctors brought her into the operating room around 8:30 a.m., set up the drapes and then called Dylan into the room.
"It was all pretty routine," Marisa said. "They got all three girls out."
Samuel's surgical assistant was Monica Ellingston, also a mother of triplets.
"The beginning of the surgery went great," Samuel said.
Since the babies were born prematurely, there were benefits of delayed cord clamping, preventing them from iron deficiency.
The girls -- Charlotte, Kendall and Collins -- were swaddled and laid on Marisa's abdomen, while the clamping began. At that point, Dylan stood up to take a photo of his wife with their newborns.
Samuel and Marisa chatted about how happy she was to safely deliver Collins, the triplet at risk of developing fetal anemia.
Suddenly, Marisa's arms lifted in the air and she let out a groan.
Anesthesiologist Dr. Ricardo Mora noted that Marisa's blood pressure had bottomed out.
"He was explaining that we no longer had vital signs," Samuel said. "Marisa didn't have a heartbeat."
Dylan and the babies were ushered out of the room and sent to NICU, while the medical team sprung into action.
"Everything happened at once," Samuel said.
She quickly sewed up the incision for the C-section, while nurses Amy Walker and Juanita Salmon started chest compressions and CPR.
Samuel also called in the Memorial Hermann's OB/Gyn, Dr. Tiffany Morgan.
In addition to Scott Oldebeken, who was already assisting, Mora brought in another anesthesiologist, Dr. Luke Carroll. Together, the team decided that Marisa should be placed on extracorporeal membrane oxygenation, or ECMO, an advanced form of life-support.
On a break from chest compressions, Samuel realized Marisa was suffering from uterine atony, when the uterus does not contract properly during or after childbirth, which results in vaginal bleeding.
The team administered medicine and a device to help her uterus clamp down.
Cardiothoracic and vascular surgeon Dr. Stephen Maniscalco arrived and placed Marisa on ECMO. Then she was moved to the ICU.
"I just couldn't make the bleeding stop in her uterus," Samuel said.
Marisa had developed disseminated intravascular coagulation, a leading cause of maternal mortality, which can cause uncontrollable bleeding from several areas of the body.
After 15 minutes, the medical team called for an emergency hysterectomy, performed by Samuel and gynecologic oncologist Dr. Christine Lee.
Next, the top layer of her abdomen was covered and packed so it could heal on its own, which decreases the need for future surgery.
Almost immediately, Samuel knew the cause: Amniotic Fluid Embolism, a rare and life-threatening complication of pregnancy.
"There are very few things that right at the time of delivery would cause the heart to stop," she said.
And considering Marisa's age and general good health, stroke and heart attack were unlikely. "Almost never would it be anything else," Samuel said.
Amniotic Fluid Embolism was first described in the 1920s, Samuel said. At the time, doctors thought that an embolism caused heart and lung failure in mothers.
"More recently, we realized that it's not an actual embolism, but more like an allergic reaction," she said.
The mother has a response to the amniotic fluid and fetal material entering her bloodstream, which normally would not cause a reaction. She experiences constriction of the pulmonary vessels and the heart is no longer able to pump.
"So the heart fails," Samuel said.
DIC is also a common complication. According to the Cleveland Clinic, AFE is rare, occuring once in 40,000 pregnancies in the U.S.
Samuel has witnessed the condition before. "But this was the worst I've ever seen," she said.
She found Dylan in the NICU and explained the situation, that mortality for AFE has been reported as high as 80 %.
"I don't know if she's going to survive," Samuel told him. "I don't know that even if she survives, what the long-term outcomes will be."
"The first conversation we had was probably the hardest he had ever had, and one of the worst I have had," Samuel recalled. "All the conversations that day were hard."
Still, she held onto hope for her patient.
Marisa was placed in a coma for six days, and Samuel was unsure if there would be any neurological damage if and when she woke.
After a couple of days, Marisa was breathing on her own and was taken off ECMO, while still in a coma.
When she did regain consciousness, in the middle of the night with nurses rushing all around, her first thought was, "Am I dreaming?"
"My whole pregnancy, I had really vivid dreams," she said. "I thought, 'I'm going to wake up and everything will be fine, because this is terrifying."
Then, Marisa was hit with an excruciating pain, and she knew she was awake.
She had no recollection of coming to a hospital. She thought perhaps she had been in a car wreck. Her last memory was going to the movies with a friend to see "It Ends With Us," the weekend before her C-section.
Dylan told her, "We had the babies, and everything went fine."
"There's no way," she responded.
It would take a while before Dylan and Marisa understood that she had lost all memory of the past few days.
Marisa ended up staying in the hospital for two weeks. She had to relearn to eat, to breathe, to walk. Her wound also still had to heal.
The first day that she was able to walk, the nurses told her that if she could go a certain distance in the hallway, the reward would be to a wheelchair ride downstairs to NICU to see her babies
"I was like, 'Sold!'" she recalled.
Dylan had already been visiting them multiple times a day. From then on, Marisa made an extra effort to see her daughters as often as possible.
"The NICU nurses were always willing to wheel me downstairs to see the girls," she said.
She was also eager to get home to Grayson. She worked hard to reach each required milestone. Finally, she was discharged.
Her oldest triplet, Charlotte, came home about a week after Marisa, on Sept. 14, followed by Kendall and Collins on Sept. 26.
The details of her story remained fuzzy for a while, Marrisa said. She had a few details from her husband and multiple doctors.
"I knew I had almost died because everyone kept saying, 'It's a miracle you're alive,'" she said.
"It's still very surreal," she said. "There are quiet moments right before I sleep, I sometimes go back and look at the photographs from the hospital. In those moments, it's very raw. There are many, many moms who were not as lucky as I was to live."
For Samuel, one of her most difficult days in clinic has turned into an amazing story of survival. "It's the reason you go into medicine," she said. "It's what you want for your patients -- not to have to go through this -- but to make it to the other side and be healthy."
Samuel keeps a photo of Marisa, Dylan and the triplets on the reel of pictures rotating on a digital frame in her office.
"I think of it as a modern miracle," Samuel said. "The surgery is the miracle, that this team came together, that they were the best team on their best day and made this happen for her."
As the only Level II Trauma Center in South Montgomery County, Memorial Hermann The Woodlands was able to readily assemble a team and the resources needed to save Marisa's life, just in the nick of time.
"Those doctors did the hard work," Marisa said. "I just woke up and reaped the benefits."