Doctor Update

Had my (last?) consult with maternal-fetal medicine on Friday (32 weeks). There are at least 5 doctors there, 3 of whom I have met on 3 different visits. Today, we got a repeat, of Dr. F, who is thankfully the one that I loved.

We started with another ultrasound. Got technician #3 out of 3 ultrasounds at this office. She was clearly the most in a hurry of any of them (she was running almost 45 minutes behind schedule by our 10 AM appt) which may be why the photos are not as clear. But, perhaps the poorer quality is just because the baby is getting more crowded in there. Still, nice to see more shots of the beautiful little girl.

Jeremy likes the "face-palm" view. There is a certain expression on her face of "Oh, good grief, are we doing this again? Can't a girl get any peace?"

Jeremy is getting pretty good with the ultrasounds - he can pick out much of the anatomy now. As he said at the previous ultrasound, "I could look at these all day. This is so amazing."

Other than the photos, we got a few updates. Weight: 3.5 pounds (27th percentile, down from 35th % at previous ultrasound). Position is currently breech. Organs and internals all looking good. Funniest thing was the technician pointing out hair! There was a spray of short, spiky hair off the back of her head, splayed out like hair tends to do when underwater. Of course, can't tell color or thickness from an ultrasound, but there is no way that Maggie had enough hair in utero for it to splay out like that. Guess I had better adjust my mental picture for a newborn girl with some hair!

Next, we went in for the consult with Dr. F. The main point of this visit was to answer any remaining questions we had and discuss delivery options. Unfortunately, we have already established that there are no answers to our remaining questions. As for delivery options, I had been hoping that today's ultrasound and discussion with the doctor would make this decision clearer. Instead, it seemed to make it all more murky.

The official "recommendation" from both Dr. B in NYC and Dr. C (pediatric hematologist here in GR) is to either (1) schedule a planned C-section, to be on the safe side in case the baby has low platelets, or (2) do a cordocentesis at 36-37 weeks, to check the baby's platelet levels, after which we would decide whether to schedule a C-section or proceed with a normal vaginal birth.

I had been leaning towards option 2. This had the advantage of giving me some concrete information, earlier in the pregnancy. If anything was wrong with this baby's platelet, we would know sooner, and could take care of it. If nothing is wrong, then I can (maybe?) quit worrying for the last month of pregnancy, let things take their natural course, and avoid a C-section (a big bonus). But, obviously, to pursue this option (2) I needed to better understand the risks associated with the cordocentesis procedure.

Dr. F began by explaining the process. I am prepped as for a C-section and taken to an operating room. A needle is inserted into my abdomen, aiming for the vein in the umbilical cord. A small sample of blood is withdrawn. This procedure is most often done for younger babies (20-30 weeks gestation) who are getting not just a blood sample but a platelet transfusion. That would be a more lengthy process, obviously. In my case, if all goes well, maybe 15 minutes or less. Most serious risk is that the cord will rupture, leading to the baby bleeding to death. It is for that reason that it is recommended that I wait until good viability (36+ weeks). Then, if a rupture would happen, they see it immediately on the ultrasound and do an emergency C-section.

This procedure involves mild sedation for me, and sometimes requires sedation for the baby. If the cord is attached on the backside of the uterus, for example, then the doctor needs to catch a piece of it, floating freely. To keep the baby from moving or kicking it away, the baby is fairly heavily sedated (another possible risk factor, particularly if the baby is then emergency delivered while sedated - breathing assistance is required).

The only statistic that Dr. F could give us for the risks of this procedure is a very global average: 1% fatality over all the procedures done. But, she stressed that we are very different from the typical case where this is done, so our risk factor is much, much lower. She couldn't put a number on it, and of course reminded us that any procedure has risks. But she said she wouldn't hesitate to have this done for herself under these circumstances.

She explained what was in our favor, as far as risk and outcome:

1) We are a textbook perfect case for a good outcome on the cordocentesis. The cord in our case is attached to the placenta top and front, making the whole process much easier. The cord sample can come right through the placenta, without ever even entering the amniotic fluid. This means little to no sedation for the baby, and no fishing around for a floating cord.

2) We would be at 36+ weeks, much further than most babies who have this procedure, so if an emergency C-section were needed, it would likely have a good outcome.

3) We don't need the transfusion, so the procedure itself will be much shorter and less complicated.

On the other hand, the procedure is expensive. Dr. F didn't really know the details, but was certain it is more costly than a C-section itself. She assured us that insurance should cover it since we have letters from two doctors recommending the procedure. But of course, someone still pays for this.

Dr. F then confirmed my concerns, that a C-section has risks as well. "Yes," she said. "We treat them as routine, but it is a major surgery and that can always come with complications."

Jeremy, ever the optimist, then introduced option (3) to the list. Since all seems to be going well, why not skip the cordocentesis and the c-section, and just do a normal delivery, hoping for the best? Dr. F agreed that this would not be an unreasonable approach, in her opinion. However, for legal self-protection, a doctor (such as the two who have written recommendations so far) won't give a written recommendation for that path, simply because no one knows the risks involved with that (because the baby's platelet count is unknown and the progress of a vaginal birth in terms of trauma can never be fully predicted). 

SO, here we are. Dr. F cheerfully agreed that

• option (1) - planned C-section - would be a reasonable choice, but does involve risks and certainly a difficult recovery
• option (2) - cordocentesis followed by selection of vaginal or C-section delivery - would be a very reasonable choice with very low (but non-zero, unquantifiable) risk but considerable expense (to the insurance, at least)
• option (3) - scrap it all and go with a normal vaginal birth like the first three kids - would be a medically justifiable decision as well, given the available information (and lack thereof). However, the risks of this approach are completely unknowable because the baby's platelet count is probably okay but might be dangerously low, and the birth trauma would probably be negligible but might be significant.

Argh. I found myself quietly cursing my good luck at having such perfect cord placement. If this would be a challenging cordocentesis, it would be a no-brainer for me. I would bite the bullet and schedule a C-section (skipping the cordo). But it is not. So, can I morally/medically/financially justify the cordo simply to give me peace of mind for the last month of pregnancy, and to possibly avoid a C-section?

I also have to figure out how to deal with Jeremy's infernal optimism. I am in no way ready to embrace his option (3). As appealing as it seems, it feels like the ostrich approach to me (sticking my head in the sand and hoping the problems will disappear). But as long as that is the solution that he is most comfortable with, I don't feel like we can really come to a mutual decision about the other two options. So again, I am feeling desperate for someone to advise me in this, and offer wisdom. Seems like a recurring theme in this pregnancy.

Praying now for discernment, and peace.  We have about 4 weeks to figure it out.

Braxton-Hicks going like crazy

Last week, I saw Dr. R for my regular check-up. Nothing too interesting there beyond the disappointing bloodwork (see earlier post). I did ask her about my disturbing inability to exercise, which often includes even moderately paced walking.

Walking in to work, which used to take 10 minutes, has taken closer to 20 over the past few months, as I have increasingly more contractions while walking. I have had to stop and breathe through them on occasion. Even walking to class from my office can bring this on. Dr. R seemed more amused than alarmed, as is to be expected from her. So, do what feels okay and live with it, apparently.

Yesterday (Saturday) was a real test, though. I was tired anyway. I made a few trips up and down the stairs with laundry. Then I gave up on the loads and asked James and Jeremy to carry the laundry.  Still, just the steps led to contractions so painful that I had to sit down. Momentarily, I felt panic. If I could be this miserable now, how would I survive labor? But, I must allow reason and not fear to rule. I have done this 3 times before. It will be fine.

I remember lots of these Braxton-Hicks contractions with John, too. Just not so early, and not so painful. Perhaps being 3 years older makes a difference.

32 weeks

I reached this milestone 3 days ago. Overall, feeling pretty good. Still have days when I feel enormously huge and uncomfortable; other days when I feel fairly small and peppy. This weekend has been a loss. Exams finished up this week. We still have a big stack of grading ahead of us, but the scheduled stuff is done until Jan. 5. My body seemed to just say "Ahhh..." and let down in response.

Saturday, I slept in until 8:30 (woken up by John needing to be wiped in the bathroom!). Found that all the kids had been up and playing quietly for over an hour. After breakfast, managed to fall back asleep for a leisurely nap. Then, still feeling sluggish, had a second nap in the afternoon.

Unfortunately, today (Sunday) wasn't much better. Up at 7:30 for church today, but napped over 2 hours this afternoon. I will have to get back on a schedule eventually (like, tomorrow) so that I can get work and Christmas stuff done. But for now, it is nice to have a breather.

Test results

Sigh. Nothing seems to be the same this time around in pregnancy. For the previous two, I had to have my tegretol levels monitored, but it was nothing much. Both times, I increased medication by 15% in month 6, responded well, then came right back down after delivery. So, I expected pretty much the same thing this time.

Sure enough, in month 6 my levels dropped enough to earn an extra pill a day. But the recheck in month 7 showed no response - my levels haven't come up at all. That is new. So now, I go up by another pill. Which would all be just a minor nuisance, except for the complicating factors.

I have also had a low platelet count throughout the entire pregnancy. Not dangerous, just borderline. Every month, my OB orders another CBC. Then after each one, I get a call from the nurse. "Your platelet count is low, so Dr. R just wants to recheck it next month." Okay. Makes sense to me. I wonder if she finds all the info, with which she apparently plans to do nothing, just randomly interesting? At least I am well used to blood tests, so I don't really mind all the extra pokes - but it is an annoying expense.

Well, the last few times, "low" platelets have gotten lower. Again, not dangerous, but definitely dropping, and now out of the range of "low normal" and into "low." And the bummer is, based on all my investigations for this pregnancy about low platelets, I now know that low platelet count can be a side effect of tegretol. So I feel a bit "damned if do, damned if don't."

I can't very well drop the tegretol and risk a seizure. Bad for me; very bad for the baby. But if it really is the culprit in my low platelet count, then it might very well be exacerbating a low platelet count for the baby that could already exist due to immune factors. Maybe this would push her over the edge into the "dangerous" levels. And now I find that I need to start taking a higher dose of tegretol than I have ever had before.

I reached 32 weeks today - 8 weeks to go. With these competing bad options before me, it starts to feel like a race to the finish line. At what point is this baby better off on the outside, early or not?

Ironically, in all other respects, this pregnancy feels like it is going really well now. I feel pretty good, overall. I have energy. I haven't gained too much weight. I don't have major aches or pains (almost no heartburn this time; no sciatica or lower back pain). As long as I don't have to smell Dawn dishsoap, the nausea seems under control. (I don't know why...it just is. We gave the Dawn away and I am much happier.) The baby moves lots every day, reassuring me of her continued vitality.

Well, tomorrow is our (probably?) last visit to the specialist OB (maternal fetal medicine). It is another ultrasound, and a consult to discuss cordocentesis, c-sections, and other delivery-related options. Maybe after tomorrow we will at least have the plan in place, and the timetable. That should help me to stop fretting over these other things that I really can't do anything about anyway.

Hang in there baby! See you at the finish line.

Mixed feedback

At my last prenatal checkup (3 weeks ago), Dr. R. asked me if I felt small or large.

"HUGE!" I replied. Of course, she caught me on a "bloaty" feeling day, but in general I have felt big.

"Well, what do your friends say about how you look?"

Fortunately, they are mostly too polite (or wise) to say anything.

"Well," she continued, "You are measuring a bit small, but if you feel big, then you are probably just about right." Hmm. That sounds like classic Dr. R. speak for "I will be watching this but I refuse to alarm you about it."

I am not very alarmed, really. The ultrasound at 22 weeks measured a baby in the 35th percentile, so it would not be too surprising if I measure small. Maybe she is just a small kid. After all, none of my babies have started out very big. Maggie was the biggest at 7lbs 7oz, and James was only 6 lbs 6 oz.  (John was in between at 6lb15 oz.)

On the other hand, these things do fester in a hormonally soft mind. I have noticed that I feel this baby's kicks much more strongly than any of the other three. They are right near the surface and feel like they will burst through. So now, I find myself wondering if she doesn't have enough amniotic fluid. That would lead to a smaller uterine measurement for me, and possibly less cushioning for her kicks and pushes. It is something I can't quite dismiss now that I have thought of it. But, not much I can do about it now, either. I have a check up on Friday (5 days) and an ultrasound next week. I can ask about it then.

I did get my first feedback on size from an observer, though. I think maybe I was better off without it. I went to church this morning in my one maternity "business suit" because I was serving as Liturgist. Then, I changed into slacks and a tartan plaid turtleneck for the evening's Children's Christmas program. A kindly(?) woman chatting with me after the evening service mentioned, "Wow, you looked so slim this morning, but that plaid shirt really brings out your belly! When are you due?) Um, yeah, thanks.

Making progress...

I am 30 weeks now. 75% done. Kind of hard to believe.

A couple of weeks ago, when I hit 28 weeks, I found myself thinking as I walked to class, "This really isn't so bad. I could maybe do this again." Now, that kind of insane self-talk is a clear sign of passing a milestone. As I have entered the third trimester, already the first is fading from my brain. You know, the one where I couldn't get up off the couch for two months. Where I vomited regularly. THAT trimester. But, it is nice to (re)discover that all misery truly is transient, no matter how insurmountable it feels on that particular day, or week, or month.

Of course, James caught me off guard recently, too. We were sitting at the dinner table and he made some comment along the lines of, "When we have our NEXT baby..." I confess, as good as I now feel about things, I was not excited about him planning for baby 5 before I have even finished with number 4. I really don't see that happening, realistically. :)

Now, I am settling in for the long wait. This is the part where it always seems to me that the birth should be "any day now." I realize this is way too soon, but mentally, I am ready to be done. Gotta get to the finish line, still.