33 weeks, 6 days: Close calls, interdoctor discord, and THE PLAN
February 13, 2014 § 34 Comments
Still pregnant! But holy, cow.
Crazy days, my friends.
Last Wednesday, I got my rankings submitted for the next phase in my clinical training. In 9 short days, on Match Day, we’ll know where our little (all of the sudden not so little) family is going to be living next year.
And then on Friday, we very nearly met the new members of that not so little family.
Friday was one of the most stressful days of my life. It was the first day I have had to make a serious decision for these children. My children. It was the first time I felt the weight of that – of being someone’s mother. The mother to two particular someones. Two small humans who have only me and The Artsy Engineer and who need us to make the right choices. It was so heavy. My throat closes up a bit thinking of it.
Since the last time I updated, things have fluctuated considerably. A few days after I wrote that post, they sent me home to continue bed rest there, because baby boy’s cord blood flow was consistently showing continuous (but still reduced) end diastolic flow. That lasted for under 36 hours. I got home on Monday evening and was readmitted a week ago today on a Wednesday morning after they saw intermittently absent flow again on the Doppler ultrasound. We were disappointed, but I knew the respite from the hospital would be temporary. I was just really really hoping for another couple of nights of dog snuggles and home cooked meals that my husband doesn’t have to unpack from a cooler. The good news about that Wednesday (32+5 weeks) was that we had the growth measurements taken again (as they only do it every two weeks to minimize error), and both babies had pretty solid growth estimates. Baby girl had gained a full pound and was estimated to be 4lbs 4oz and baby boy had gained 3/4 of a pound and was estimated to be 3lbs 6oz.
Then on Friday, my friends, it got real. The flow went back to absent end diastolic flow and the proverbial shit hit the proverbial fan. If you peek back at that last update, absent end diastolic flow is what was going on when I was admitted in the first place. The exact same issue. I was only 31 weeks then, but the data was the same. I had a particular protocol that the perinatologist (MFM doc) recommended and that my OB implemented. It involved 3x/day NSTs and 3x/week ultrasounds, bed rest, and steroid injections. However, I am situated at a major academic medical center, which has a lot of really excellent benefits but which also means that there are LOTS of people involved on my team. It’s a big freaking hospital with the highest ranked NICU and perinatology program in the state. But on Friday, the perinatologist who I had been seeing all along was out for medical treatments and that meant that I would be passed along to the others, depending on who could squeeze an inpatient into their schedule. There are 7 of them. This is apparently how it typically goes for people, but my OB had arranged it so that this particular perinatologist would see me whenever he could. With him out of commission for 2 weeks, I saw this new guy. This new guy was described as “excitable” by several people before I met him, and I wasn’t sure what they meant. It could be demonstrative excitable, which is not a bad thing at all and was frankly what I was picturing, but it turned out that they meant more of the high-strung, impulsive, temperamental flavor of excitable. Bummer for me, apparently. Because he walks in, and with no further ado, he says, your baby has absent flow and you’re past 32 weeks and so there is no sense of waiting around until reversed flow because of risk of stillbirth so I am recommending that we deliver your babies today. BAM. Just like that. I’m all alone, sitting in his outpatient clinic office on the exam table, and I can’t walk anywhere or escape (which is strangely what I wanted to do) because if I look like I’m going to pass on the wheelchair, people get all concerned like.
By the time I got back to my room, my OB was there waiting for me, and he was not pleased. Pacing, fired up. He had to lecture to medical students, so he said that he was going to leave but that he’d be back 2 hours later to have a conversation about what we wanted to do. He had me call Bryan in and stop eating and drinking in case we decided that we wanted to proceed with the c-section that afternoon. Apparently, he had asked the perinatologists to speak with him before speaking with me and especially before making any specific recommendations to me, because he knew how different their opinions regarding what to do with absent end diastolic flow at 32, 33, 34, etc weeks.
When he came back, the three of us talked it out and decided to wait and try to squeeze out a little more time. We just felt as though this was the SAME DATA we’d had when I was initially admitted. Babies continued to look great on monitoring, BPPs were excellent, and there was absent flow. The only difference was that I was now past 32 weeks, so this doctor decided he thought the risk of leaving him in was now greater than the risk of taking them out. To appease this doctor, we’d increase monitoring to daily ultrasounds to look for reversed flow and do continuous fetal monitoring except when sleeping and eating (although I was woken up between 1-2 in the morning for a briefer monitoring session). The trickiest part was that my OB was leaving town for the weekend and was unreachable until Monday night and thus could not act as an advocate. He left saying that he’d tried to tie down all of the loose ends he could, but that he couldn’t control it once away. If whatever perinatologist did my scan on Saturday or Sunday or Monday suggested delivery and the OB on call agreed, we’d be delivering. He spoke with all of the OBs who were on call over the weekend to try to tell them the situation, but he wasn’t sure it would be enough.
I won’t go into all of the details of the weekend, because this is getting long enough (and confusing enough) as it is. But I was essentially told that my plan of care was being changed by every single doctor who came in the room, which amounted to about twice a day. One said that using a different set of norms our boy was actually not growth restricted at all (that he was at the 20th percentile rather than below the 3rd) and put me back to 3x/day monitoring. The next told me that babies were doing great and they’d deliver me at 34 weeks unless something changes before then (this is the first I’d heard of a 34 week cutoff). The next said that she wanted me back on continuous monitoring (even though nothing has changed) and that there was talk again about delivering that day. The next said that there was no way continuous monitoring made sense and that I would also be changed from full bed rest to modified bed rest but that our boy is, in fact, IUGR based on the set of tables that they just switched over to using and that is used in much of the recent research. I did my best to let it go in one ear and out the other and to just hold down the mental fort, so to speak, but it was tough. Without my OB here to be the ringleader (and he is, in fact, the ringleader), I was left to the devices of a group of practitioners who practice as individuals. We didn’t know how to gauge our fear and anxiety. Should we be as concerned as doctor number 1? Did I want continuous monitoring because any minute my baby could die? Or should I be as concerned as doctor number 3, who was clearly confident that there would be indicators of fetal distress leading up to something catastrophic that we could catch using less frequent monitoring. Etc etc. It was a nightmare, my friends, and I think I am just coming down from it.
Nobody signs up for randomized clinical trials and signs on to put their babies at risk, so there isn’t a lot of research for these doctors to go off of. There is no standard of practice for absent end diastolic flow in the umbilical arteries, here at this hospital or anywhere else. My OB pushed the 7 perinatologists to meet and come up with some guidelines that they all agreed on, and yesterday, finally, they did.
So. The plan.
Before 34 weeks: Either absent or intermittent end diastolic flow mean closer monitoring but not delivery. Reverse flow, less that 200g growth in 2 weeks, or indicators of fetal distress on the monitors or on the BPPs mean delivery.
After 34 weeks: Intermittent or forward mean I get to stay pregnant (provided that indicators and growth are okay). Reverse flow OR absent flow mean delivery.
Regardless, delivery no later than 36 weeks. Which means that my OB scheduled our c-section for Friday, 2/28. Two weeks from tomorrow (and one week after Match Day).
So, essentially, if they see absent flow after 34 weeks (which, ahem, is tomorrow), they will choose to deliver me that day. My ultrasounds have gone like this intermittent, absent, intermittent, forward, forward, forward, intermittent, absent, absent, absent, intermittent, intermittent.
Tomorrow I am at 34 weeks. From here on out, every Monday, Wednesday, and Friday are scan days and are going to be the decision points. If you look at the list above, I received a round of betamethasone (the steroids to help with fetal lung development) on the first day there was absent flow. Flow then improved and did not go back to absent for 10 days. If you ask the perinatologists, they’ll tell you that there is no research in support of betamethasone improving flow but that they see it in practice often enough to notice it. They would never give it for that reason alone, but because I was due for a booster (it had been two weeks since the last injection and I was still before 34 weeks), they would be interested to see if it might buy me an extra week or so before I would go back to absent and need to deliver. I got my booster on Tuesday and Wednesday, and baby’s flow was improved to intermittent on Wednesday’s scan. If the steroids are part of what helped the last time and it follows a similar trajectory, perhaps I can make it to the 21st (Match Day and the day I turn 35 weeks) before it turns absent again. I’d love to make it through the weekend and buy just a few more days.
But I could also go in tomorrow and see absent flow and deliver two tiny babies, one estimated to be just under 4 pounds and the other estimated to be just under 5 pounds, within a couple of hours.
I’m on the scan schedule for 7:10 AM. Wish us luck, friends.
* That was going to be an earlier post, because it was a very, VERY upsetting development for me. Apparently our baby girl, who is closest to the cervix, is footling breech, and because of the way our boy’s bag of waters has settled in around her, we have known for about a month that it is highly unlikely that she’ll be able to turn. My doctor will deliver vaginally so long as Baby A is vertex, regardless of the position of Baby B. He will happily do a breech extraction for Baby B. Baby B is moving all around still, flipping vertex to breech to transverse to breech to transverse to vertex daily (I know because I get ultrasounds ALL THE TIME). But it’s Baby A who makes the decisions here, and she’s not turning for us. I cared A LOT about this a month ago. I could care less now. I’d be thrilled if she shocked us and turned after 6 weeks of being in one position, but it ain’t gonna happen. And now, with all of this, I just want some healthy babies to come out of me – through vagina or uterine incision or nostril. I don’t love it. But I have bigger things to fret about.