Shortly after Co-worker and I started working together, we decided we need a covert way to communicate if a new OB patient had a non-viable pregnancy. I think she coined the phrase, 'the lights are on, but no one's home' and it seemed to stick. Thus we had a more subtle way to alert other staff members to the situation and could avert any awkward interactions with the patient. The medical assistant would know not to issue any due date confirmations, the phlebotomist understood the message and would not draw the full prenatal panel. The front desk receptionist would know to book her follow up as a GYN return visit and not a return OB. Most importantly, this discreet phrase would help prevent any staff members from unknowingly offering words of congratulations, or require the patient to provide an explanation.
I often think about that phrase when I am breaking the bad news, as one of the questions patients often ask is, "am I actually pregnant?" The answer is technically yes; it's just not a pregnancy that will produce a baby. I started to warn some patients that they will still have a positive pregnancy test, as I once had a young girl who called our office the day after I diagnosed her miscarriage, claiming that I was wrong as her digital test told her she was still pregnant. "Why do I have symptoms of pregnancy?" is the other question that usually follows. Well, HCG is just a cruel bastard that will mislead and mess with you. I often think that is adding insult to injury; to endure the misery of pregnancy symptoms without anything to show for it. "But, I'm not bleeding..." I explain that before early first trimester ultrasound was adopted into practice, this is how patients presented and how practitioners would make the diagnosis. We're now recognising non-viable pregnancies earlier, prior to the inevitable bleeding. Yet, bleeding during pregnancy is so strongly associated with a miscarriage, that it becomes hard to accept one with out the other.
It somewhat becomes much easier to inform a patient of an impending miscarriage when she has bleeding, cramping or some type of warning sign. Yet, most patients who present to me with bleeding turn out to be fine, and the majority of my non-viable pregnancy diagnoses are in asymptomatic and unsuspecting women. That is the aspect that makes the situation even more difficult; the fact that they are completely blindsided by the news. The patients who make me nervous are the ones who come into the office with complete confidence of a good outcome. The Dad who has the camera ready to start recording the ultrasound images. The ones who bring their kids to introduce them to their new brother or sister. Some times it is a little easier with couples who are familiar with this process, as they know what to expect to see in their ultrasound. It's always heartbreaking when I hear couples coo 'look at our baby!' as I'm recognising a non-viable pregnancy. However, the diagnosis seems to be a bit harder to accept when couples have had two or three normal pregnancies. This is not consistent with their prior experience. Everything worked out for them in the past, why shouldn't it now?
Thus, I felt prepared for bad news as we approached our first ultrasound. Not only did I have professional experience acknowledging the commonplace nature of miscarriage, but I have doubts about our embryo quality as well as a general dose of skepticism. I had a surprising sense of calm on the night before our scan; but once morning dawned on the moment of truth day, I became a bundle of nerves. After counting down the hours, I was finally back in my RE's office. I shared my photos at the start, and as anticipated, he just responded with "well, let's take a look." I saw him calculate measurement of the single gestational sac, which was now 11.5 mm -appropriate progression from prior measurements. There was a clearly identifiable yolk sac, and something that my RE called a questionable fetal pole. He measured it at 3 mm, which along with the gestational sac corresponded to 5 weeks and 6 days -align with my prior calculations. However, there was no evidence of cardiac activity.
Although cardiac activity should be seen with a measurement of 5 mm, (some say 3 mm) the threshold for diagnosing an early pregnancy failure is absence of a heart beat in a fetal pole measuring 7 mm. While he admitted that he would prefer to see cardiac activity, my RE reported that he was satisfied with these findings. He added that he is still a bit guarded with our prognosis. Once again, I was laughing inside my head. As if it were possible that anyone could have less confidence about this pregnancy than I already do. New Girl somewhat scolded me for my preview scanning. "You're just making yourself more anxious!" she perceived. Quite the contrary. If I went into this scan believing that I should have been 6 weeks and 3 days and discovered that I was measuring behind with no cardiac activity, I would be suspecting that the growth arrested. Rather, it is reassuring to know that I have been consistently four days behind, but progressing appropriately. As Husband pointed out, our progeny seems to be taking after me already; takes forever to get ready and shows up late. We are scheduled for a follow up in a week. I promised New Girl I would keep the probe away from my vagina. I've broken enough hearts and crushed too many dreams already; I can't deliver such news to myself.
Yet, we're still in the game. I'm still at the plate and I've evened the count. We think there is somebody home. We're just waiting to see a flicker of light.