Thursday, 2 April 2015

The Follow-Up Scan

Often when I see patients in their third trimester, I am asked, "So, am I going to get another ultrasound?" Some are more presumptive and will enquire "when is my next ultrasound?" My colleagues and I recently recently admitted to each other that we dread hearing this question, because in most circumstances, we have to explain why the answer is no.  For a healthy woman with a normal singleton pregnancy, there are only three occasions for an obstetrical ultrasound. Early pregnancy assessment to confirm location, viability, number and dating. An optional Nuchal Translucency measurement for genetic screening, and the anatomy survey at 18-20 weeks, which evaluates the major organ structures and fetal growth. Other indications are determined by an individal basis. Follow up will be performed if there is an abnormality on the anatomy scan. Monitoring for cervical length may be needed for patients with a history of cervical surgery or prior preterm birth. Women with underlying chronic medical conditions or gestational acquired diabetes or hypertension will require more frequent scanning to follow baby's growth and development. Multiple gestation also means multiple ultrasounds. There is no data to support routine use of ultrasound in the third trimester during an uncomplicated singleton pregnancy. There needs to be a medical indication for another ultrasound. I have often tried to explain that if we're ordering an ultrasound in the third trimester, it's because of a concerning reason. The fundal height is measuring too small or too big, there may be a malpresentation. Scarier circumstances include a patient who is bleeding or reports decreased fetal movement. It's not about the novelty of seeing the baby again, and unfortunately, in some situations, it's not a happy ultrasound.

As the days grew closer to my follow up scan, I kept hearing the echos of my own counselling. I wished that I didn't need another ultrasound. I would love to have been told that all looked well with the baby, my placenta was normal and that I could enjoy the rest of my pregnancy until delivery without needing any further assessment. Of course, I know that my chronic hypertension buys me 1-2 more scans in the third trimester, but I would happily wait four more weeks for my next survey if it meant that I could have a normal placenta. Actually, Husband and I sort of forgot that this ultrasound would allow us to see the baby again, as we've been so focused on the placenta. On the morning of our scan, our friends in LA sent a text wishing us well and they added, "Say Hi to Baby Jate for us!" We just looked at each other as it dawned on us that we've only been focusing on the placenta... oh yeah...and we hope all is well with baby too! As Jate has been moving around quite a bit and I seem to be getting appropriately bigger, it just felt like less of a concern. Meanwhile, the Pregnant Phlebotomist kept hounding me for her Pan.orama results. Not that she was worried about a potential chromosomal abnormality. She just wanted to know if the presence of a Y chromosome had been detected, as she announced how upset she would be if she were having a boy. Oh, it must be nice to have such an issue as your primary concern.

Once again, I didn't watch most of my scan, as I feared accidentally determining gender and quite honestly, the cuteness fades as the pregnancy progresses. It's harder to get a nice profile and as baby gets bigger and space gets smaller, sometimes you're looking at a ball of arms and legs.  I had tried to study ultrasound findings of a placenta acreta in order to prepare myself, but after reading about some tragic cases and poor statistics, I decided to cut myself off from the internet. We had the same tech who did our anatomy scan, and once again, she deferred to the perinatologist to deliver the news about my placenta. However, she reported the good news that Jate's growth is still right on track and he/she is in the 69th growth percentile. (Cue the Sixty-nine, Dude! high five.)

My placenta is still covering the cervical opening. The distance from the os to the edge of the placenta is 1.75 cm, so it moved about one centimeter. I am encouraged by this, even though it's not going to influence the management and the perinatologist doubts the previa will resolve. I feel that any migration can reduce my risk for bleeding, so I'll take what I can get, along with some reassurance from my cervical length, which is still holding strong at 4.3 cm. The perinatologist then turned on the doppler colour flow to take a better look at the vessels. After spending a lot of time focusing on one section, I saw him write the words "possible placenta acreta".

I can't say I'm surprised at all. I knew going into the ultrasound that we were not going to find that my placenta moved and no longer showed any signs of an acreta, as I live in the real world and not a fairly tale. I can't find any evidence to support this, but as I appreciate all of Jate's movements high in my uterus, I just knew that my placenta was still low. Ideally, I would have been satisfied with a placenta previa but no signs of an acreta, but it would make me wonder about a misdiagnosed acreta. The perinatologist had stated that if findings were equivocal for an acreta, he would recommend approaching for a presumed acreta. My next stop is to have an MRI to help determine if an acreta is present. I'm already starting to see the writing on the wall. At 19 weeks there were findings to suggest I was at risk for an acreta. Now at 25 weeks, there is a possible acreta, which I'm sure will become an inevitable acreta. The good news is that the invasion (if there is invasion) in only limited to a few centimeters of space. An acreta-lite.

A few weeks ago, we made the decision not to go to Florida. We wanted to give my parents enough time to ask is anyone else could join them, and fortunately my mother's middle sister and her husband were available. I'm disappointed as I was looking forward to a Spring Break and it would be nice to see my parents before the baby's arrival. I just can't take the risk. If I started bleeding, I would be at the mercy of a random on-call Obstetrician who hopefully would be able to coordinate the care that I needed. Not to mention, that my HMO might not cover any out of network services and a large hospital bill could ruin us financially. My mother reminded us that there will be other basketball tournament, and is improbable as it may seem, we will see another UCONN women's team as good as this year's crew. Maybe we would go and everything would be fine, but no one wants to live with the guilt if it wasn't. So we're back to another four week wait for my next ultrasound and interim MRI results. Having already prepared for the worse case scenario, our next steps are to put the details of my five-page birth plan in place.

Oh, guess what?  Pregnant Phlebotomist learned she's having a girl (although I am a little suspect of her results). I want to genuinely be happy for her but I'm a bit bitter. I am annoyed that someone with such skewed priorities is getting what exactly she wants. What a relief, she didn't have to return all the pink shit she already purchased. Crisis averted.


  1. I'm sorry you had to cancel your spring break trip and that you have this added stress during your pregnancy. Shouldn't we just get a pass after all the trouble we go through to get pregnant in the first place? Yeah, I know that's not how it works, but it should. Hopefully spring break will come and go without any bleeding or further complications. I'm glad Baby Jate is doing well though!

  2. Aw, I hate that you continue to have to deal with stress and real and potential complications in the pregnancy, and more testing and more testing. You attitude is amazing though; you come across as so calm and resolute. (Reading this I feel like I was a complete wimp.) I hope that you can take it day by day and enjoy Jate's growing presence!

  3. Argh, I'm sorry that you're still at considerable risk for accreta. That's scary.
    I can totally understand not traveling - we went to Hawaii at the end of my first trimester, and then I basically didn't leave the city until SB was born. Because, as you said, I couldn't live with the guilt.
    But yay for Jate growing as s/he should!

  4. People like the phlebotomist are hard to deal with face-to-face, where you can't just roll your eyes and close that tab. I know, I always partly hope they'll get what they think they don't want, so that they learn to be a little flexible, and partly hope that they get what they want, so that the poor kid doesn't have to face any possible thoughts of not being as loved.

    I'm definitely sorry to hear about the possible accreta, but the way you described it before, I doubt any of us would be surprised. I guess I'm glad it's small? I mean, yes, definitely, if the size of it makes a difference to your possible outcomes. I don't know, but you sound relatively optimistic about it, so I will be, too. :.) In your last post, you mentioned dealing with an accreta with a nearly mandatory hysterectomy--is that true even if it's a small one? You'd also talked about feeling mixed on the possibility of losing your uterus, even though you didn't plan on more kids, which I definitely understand. We can't bring ourselves to use permanent birth control, almost because it's just so galling to have spent the money and gotten the surgery to correct existing problems and then have surgery and spend money to basically have them put back again. (We're definitely taking very reliable measures, though. Not chancing it.) Well, I know if you did decide to try with your other embryos and a surrogate, you could find one in, like, a day, just posting here!

  5. I'm sorry that you are seemingly not going to have the miracle happen of no acreta but acreta-lite is at least better right?

    If I were you (in my mind at least) I would have been totally hoping for a boy for phelobotomist! But that is just because I am mean.

  6. I'm sorry you don't get to go on your vacation :( Still keeping my fingers crossed that everything goes ok for this delivery.

    1. Oh, PS: Per your comment on my blog about being sorry for a generic test: Lol it's all good. Really, to get my first positive on a generic is awesome! And who doesn't like free tests in the mail? ;)

  7. It definitely would be nice for you to have things go smoother after all that you have been through. While an ultrasound always feels like it will be comforting I think it then just adds more stress to some degree. This is a great reminder to just be thankful if you don't need more.

  8. Sounds like it's not the worst possible scenario, for which I'm glad. I hope that things continue to improve over the next few months. The phlebotomist is just so obnoxious.

  9. ugh i feel the same - when people are obsessed with getting one sex I hope they get the other one, just so they can learn how much it does not matter. I am sorry the issue is not resolved but you seem to be handling it well - as i knew you would! and great cervical legnth! I've been thinking of you and Jate often!

  10. Still praying for you, my friend.

    I'm bummed you couldn't go to FL. How amazing are the UConn women by the way?! Truly- they amaze me every year! Go huskies!

  11. wow. This all blows. Sorry you are dealing with this and had to cancel your trip, but sounds like staying home is definitely your best bet. I took a huge risk traveling/working out of state during my pregnancy and am glad the girls didn't decide to show up earlier than they did. Looking back, it probably wasn't the best idea to be away from home until 29 weeks with twins.
    Also, I'm secretly hoping the phlebotomist has a boy. Because I'm mean like that.

  12. I knew the chances were long, but this blows!

    But hooray for viability… you're what 26-27 weeks? I know it's obviously not what anyone hopes for, but it's still an achievement. And it's good to hear that Jate is still doing well. I'm thoroughly impressed with your ability to wait on the gender still. Designing a gender neutral nursery was actually a lot more fun than I thought, so maybe I could do it, but the stress of needing two names would probably make me cave!

    Sending hugs!