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.