Friday, 27 February 2015

We Beat a Fertile Couple! (just barely)

About a month before our final transfer, we got together with our good friends Amy and Sheldon. After bringing them up to speed with all the plans and preparations for our transfer, Amy announced that she had her IUD removed and they were officially trying for baby #2. "So, you know they are totally going to become pregnant before us." I told Husband as we drove home. "Of course!" he replied. "Do you think this is my first time playing this game?" Once we made it through our betas and had at least two scans, I couldn't resist taking a victory lap. As Amy hadn't announced a pregnancy yet, I felt free to declare, "We beat a fertile couple!" as Husband and I high-fived in a truly immature fashion.

I felt a bit guilty being so gleeful, especially as she called me on Thanksgiving morning to ask how I was feeling and to see  if I had any food requests. We had them for dinner around the Christmas holiday while my parents were still visiting. As she and my mother spoke about my pregnancy, I felt badly for her. Even when it is relatively easy for you and you have no major obstacles, it's still hard to be present while others are talking about something that you want. I started to wish that she would become pregnant soon in the way that I wish I had magic fairy dust that could make all deserving couples pregnant.

So, I was a little alarmed when she send me a text message to ask if she could call me later in the evening. I mean who talks on the phone any more? What did she have to say that couldn't be told over text? After engaging in small talk, she made her announcement, "I'm pregnant!" I issued my congratulations and she followed with, "I'm really pregnant." "Twins?" I guessed. "No, I'm 18 weeks." she informed.

No My God! She was only one week behind me. As she started talking about how we'd be on maternity leave at the same time, and could take our babies on walks together, my mind started tracing back over the past few months. When I told her my final beta result, she was probably just getting her BFP. She was just as queasy on Thanksgiving when she called to ask about my needs. I noted that she wasn't drinking when she came over for dinner, which we all know is universally equivocal with being pregnant, so I suspected she may be in the very early weeks, not nearly at the end of her first trimester. I asked her when she started showing with her pregnancy and she probably giggled to herself and thought, 'which time?' I was one of the first to know with her last pregnancy, although it was because she had a positive home test the morning they left for Hawaii and she wanted to know which fish she could eat. Why did she wait so long to share this news? I didn't dare ask, especially as I still haven't told everyone at my work yet, I can't really question anyone else who keeps her pregnancy a secret. Husband suspects that she wanted to let me have the spotlight for a while. Knowing Amy as well as I do, I think he's right.

It was my turn to focus on her pregnancy. She was pretty sick in the beginning, but not as bad as her last pregnancy when she also picked up food poisoning in Hawaii. Genetic screening was negative and the sonographer seemed to think it might be a boy from their NT scan. Already feeling lots of movement. She feels much bigger this time around. Her doctor thinks she is a good candidate for a Vaginal Birth After Caesarean (VBAC) and suggested that they could schedule a repeat C/section between 41 and 42 weeks to allow her time to go into spontaneous labour. Alas. Two roads diverged in a yellow wood. My pregnancy may be cut short due to life threatening complications, while she was being encouraged to go into overtime just to have the experience of pushing a baby out her hoo-ha. One of these things is still not like the others.

When I first came to terms with the fact that I have chronic hypertension, I found a silver lining with the knowledge that I would not be delivered past my due date. After all the uncertainty during years of infertility treatments, it felt good to be able to say, 'by this date, our baby will be here.' An earlier delivery between 38 and 39 weeks is recommended for women with chronic illnesses such as hypertension, diabetes, lupus due to concerns about placenta insufficiency. My Lead Physician, who is now officially my obstetrician, indicated that she would want to deliver me at 38 weeks for the fact that although currently controlled, when my blood pressure does get high, it sky rockets. That sounded really good to me. Baby would be full term and I could skip out on those final days of being very uncomfortable. If the placenta previa persists or becomes an accreta, the delivery date could be even earlier. I've been finding benefits with less weight gain, less potential for stretch marks or varicose veins, but it doesn't seem right to view those as favourable against the risks of prematurity. At the same time, extending a pregnancy nearly two weeks just sounds insane.

We beat a fertile couple, just barely. Although there is only one week difference between our official due dates, the difference in the actual birthdates could be a month or more. Makes me wonder what I really thought I was winning.

Sunday, 22 February 2015

There Always Seems to be Something

I didn't sleep very well during the night before our anatomy scan. Perhaps it was because the cats were chasing each other about, or perhaps it was because it dawned on me that this pregnancy was progressing too easily. After all the challenges to become and stay pregnant, I seem to be managing it well. I made it through the first trimester without any bleeding scares or vomiting episodes. "Are you tired?" I often get asked by my colleagues who are in the know. No, my energy level is great. My appetite is normal, I'm eating healthily, and my weight gain is right where I want to be. I credit much of this to the fact that I've still been exercising. I placed my hands over my bump as I tried to fall asleep. Savour this. I reminded myself. It can still be all taken away from you...

The ultrasound technician began our scan by measuring my cervix. Hmm, my placenta looks awfully close to it...I observed. Once she completed the anatomy scan and offered the reassuring words that baby Jate was growing appropriately and no major structural issues were noted, I started mentally composing the text update to my colleagues: baby looks great, but placenta is low-lying. A low lying placenta isn't a big deal. It indicates that the placental edge is close, but not covering the cervical opening. The protocol is to repeat a scan in about 8 weeks to ensure that the os is still unobstructed. Then the tech took another look at my placenta. "Actually, I think it may be covering the cervix." she announced. "So is this a marginal placenta or partial previa?" I asked. "We'll see what the doctor says when he takes a look." she replied, which I know is code for 'yes, it is, but I'm going to let him be the one to tell you...'

The perinatologist arrived a few minutes later, which was just long enough for Husband and I to exhale a sigh of relief and bask in the triumph of Jate's normal anatomy survey. He shook my hand as we acknowledged the long time mutual name recognition, but this was our first time meeting in person. He started scanning my placenta and turned on the colour flow doppler to get a better appreciation of the vessels. "It's a complete placenta previa isn't it" I asked while simultaneously learning the answer. "Yes, it is." he replied. In the situation of a complete previa, the entire placenta is covering the cervical opening. It's a common finding at this gestational age, and in 90% of cases, the placenta will migrate away from the cervix as the lower uterine segment develops. However, for the 10% of patients whose previas persist, it puts her at a bleeding risk and necessitates an earlier Caesarean delivery. In fortunately rare situations, the placenta can invade the myometrium, creating the obstetrical nightmare known as a placenta accreta.

We'll repeat a scan in six weeks to re-assess the placenta location. As we made our follow up appointment and left the office, I think some mothering instincts started to develop. I wasn't phased at all by the issue with my placenta. I was just so delighted that all was well with Jate. We weren't coming back for a follow up scan because they saw fluid around the kidneys, or something questionable in the brain. We weren't being referred for a fetal echocardiogram due to a hypoplastic left ventricle. The rest was just details. Prior to infertility and pregnancy loss, I would have been devastated by the prospect of needing a Caesarean. Now I really don't care. Actually, avoiding the pain and anguish of labour, getting to have my stomach muscles re-approximated, and as I recently had my first leak with a sneeze, a C/section is sounding better and better by the day! I've long abandoned the dream of having the fucking textbook perfect vaginal delivery that Myrtle had. That is just not my reality. I've accepted that I have no control over my delivery process, and besides, pregnancy is not a competitive sport. However, I can control the fact that I've gained much less weight than Myrtle.

"Wow. Nothing seems to be easy for you." Two friends made this comment to us, but I wasn't quite comfortable with it. Things could be much worse. Yet, as Husband went home to google 'placenta previa' and I reluctantly acknowledged the risks involved, we came together to address the fact that things can become much worse. The details surrounding my placenta location are not insignificant. Best case scenario: the placenta migrates far enough from my cervix and I am able to proceed with an induction at 38 weeks. Worse case scenario: the placenta previa persists and I'll have a scheduled Caesarean at 36 weeks. Worser case scenario: the previa becomes an accreta, and I'll have to be delivered at 34 weeks with a hysterectomy. Worst case scenario: a major bleeding episode occurs and an emergent delivery will hopefully be performed in time.

What makes this situation so difficult to process is that there is such a wide range of possible outcomes, from everything will be fine to complete catastrophe. We both have been acknowledging that we're not usually on the favourable side of statistics. This six week wait is harder than any previous two week wait. I was proud of myself as I didn't inspect the TP during my first trimester. I figured that if I were to start bleeding, I would wait until it was obvious. Now, I'm meticulously examining every time. Just as when we were going through infertility treatments, our lives feel on hold again. My parents keep asking when we want them to come out after Jate's arrival, as they are keen to book their flights, but we really have no answer for them. We have a trip to Florida in April that may need to be cancelled. Our approach is to take things day by day. Pre-eclampsia now feels like it could be the least of our worries. After waiting so long to become pregnant, and knowing that this will be my only pregnancy, it makes me sad to think that it may be cut short.

Cue a bit of whining from my inner petulant child. Seriously, Universe. Was it too much to ask for a normal anatomy survey and no other complicating factors? Apparently. There always seems to be something.

Wednesday, 18 February 2015

Just as long as it's healthy...

It was taking my usually efficient medical assistant a long time to room my patient. Not a good sign. The patient was a transfer from Kai.ser at 12 weeks and 4 days. This was her fifth pregnancy and will be her fifth baby. Finally, she emerged from the room. "The patient doesn't speak English, so I had to use the translator phones. The husband was annoyed as he offered to translate." [we're not allowed to have family or friends serve as translators] "I explained that we don't need to do an ultrasound today, as she's had two with Kai.ser and he is also annoyed as he thought they would get an ultrasound today and learn the gender. He was particularly focused on the gender." my medical assistant explained. It's always good to know what I'll be facing when I enter the room. The patient had a pretty complicated medical history and the translator was having a tough time keeping up. The husband started answering a lot of my questions, which I let pass, as he was pretty detailed. I could sense the frustration in his voice. Finally when I concluded with her intake, he brought up the fact that the call centre agent told them they would have an ultrasound today [as he or she probably didn't know they were a transfer] and he took the day off from work so he could find out the gender.

Perhaps I was a bit sympathetic, as I took an afternoon off for my most recent OB appointment which involved a 5 minute interaction with a doctor who hadn't looked at my chart and a lab tech who had to stick me twice as he didn't draw for my second trimester genetic screening in spite of the fact that the order was in my hand... How incompetent was this office? Let me count the ways... Anyway, I offered to the couple that I would do an ultrasound as courtesy, but I explained that 12 weeks is too early to accurately determine the gender. The baby was cooperative and I was able to get a good measurement and some nice photos. As I was finishing, the patient asked (in perfectly spoken English) "So, is it a boy or girl?" I reviewed again that it's too early to tell. "TRY." she commanded in a very demeaning tone. I was struck by the audacity of her request and the fact that she understood and spoke English after we spent her entire visit using the translator service. She then added, "My children will be very disappointed as they thought they would be finding out today." "Well." I replied as I prepared to leave the room "You can tell them that you're having a boy or a girl."

I figured she would go home and tell her kids that about the mean lady who wouldn't try to determine the baby's gender and was making them wait six more weeks. Maybe she'll look for another provider. I couldn't believe that after four prior pregnancies she expected to learn this early. I offered that they could do a gender scan at 14 weeks, but they weren't interested when they were informed that it wasn't covered by insurance and would be an out-of-pocket expense. This patient stuck in my head for the rest of the day, as I started to question if my own decision not to know our baby's gender makes me less sensitive. (Although two of my medical assistants who have children couldn't understand why they were so obsessed as she already had two boys and two girls.) I defend my bias by noting that I've seen enough tragic cases to understand that there is more at stake than determining if you'll be painting the nursery pink of blue. Noting the genitalia on an ultrasound is really an incidental finding (with the exception if a parent is a carrier of an X chromosome linked disorder) as the purpose of an anatomy scan is to assess the growth and development of the baby's vital organs. Determining gender doesn't affect the obstretical management. I recently discovered a blog where a woman left her anatomy scan disappointed that they didn't uncover the gender during their scan, only to find out how trivial such a disappointment was when her obstetrician called later that night with the horrible news that multiple deformities were found on her scan. Since we've started using the Pan.orama Non-Invasive Prenatal Test, we have been correcting patients who refer to it as 'The Gender Test'. Co-worker is not so subtle. "It's a genetic screening test, not a gender test. How would you feel if we called you with the news, 'Guess what! You're having a Boy! Snails, Pails and Puppy Dog Tails! Go Team Blue! Oh, by the way... he may have Trisomy 18...'"

Oh, we don't care... Just as long as it's healthy... Despite the fact that this statement embodies what I preach, I find this cliche rather annoying. 'Healthy' just seems like such a vague and generic term in this context. It's more than just a normal set of chromosomes. There is physical health, developmental health, emotional health, psychiatric health... we all want our babies to be perfect in every way. Maybe I still hold a little distain as I hear echos of Myrtle's smug words during her pregnancy, "I'm older than you and my baby is healthy..." as I expressed my intention to do an amniocentesis [this was prior to any fertility treatments and eventual CCS testing on our embryos]. No Myrtle, my proximity to you and your perfectly healthy baby does not offer me any reassurance. Speaking of Pregnant Women [who] Are Smug, I have to give props to Garfunkel and Oats who call attention to the fact that gender and health are not mutually exclusive. "I mean, it's not like you have to chose one or the other." It's okay to have a preference for a girl or a boy and to wish for him or her to be healthy. Although they challenge anyone to admit that she "doesn't care if it's brain dead, or limbless, just as long as it has a penis." (If you're confused, click on the link)

There is one more case that stays with me. When I was working in an inner city clinic in Connecticut, I saw a young patient in her third trimester. She was a bit immature and rather bratty. She requested to have another ultrasound to make sure the baby was actually a ________ (I can't remember what the gender was). I explained that our clinic doesn't perform scans just to determine gender and she didn't have any other indication for an ultrasound. "Well, if it's not a [whatever the gender was], then I'm going to be really MAD!" she threatened. I sighed. Earlier that week, I had helped deliver a full term stillborn baby girl. The patient was 41 years old and this was a surprise, but desired spontaneous conception. "No." I told her "You'd be mad if something horrible happened to your baby and you went home to an empty nursery." Although I had no basis of experience, I added, "As long as your baby is fed, warm and comfortable, he or she won't care what colour the walls are painted. Trust me, when you're getting up at three in the morning for a feeding, you won't care either."

"So we're still not going to find out the gender?" Husband asked as we drove to the anatomy scan. "I could go either way at this point." he quipped. I thought about how quickly we exclaimed 'NO' in unison when the French embryologist asked just after our transfer. How we double checked that the 'gender of baby' box wasn't ticked on the Pan.orama form, and I had Co-worker look at my results first just to be sure our request was honoured. "We've come this far without knowing, we might as well go all the way." I replied. Perhaps it's an obstetrical obligation; that if I talk the talk, I'd better walk the walk. Least, I come across as sounding noble, I do have to confess that once upon a time I viewed unveiling the gender at birth as a novelty. I thought people might be impressed with my restraint, given how easy it would be for me to determine. I was bitter when both Myrtle and Co-worker also held out until the end, as I feared I wouldn't be perceived as being original, or could be accused of copying. I've finally learned the lessons that I've preached over the years. It doesn't matter, just as long as he or she is healthy. Whatever that means.

I actually didn't watch most of my ultrasound, for fear of accidentally discovering the gender, but also so I could focus on the technician's face. She was very serious, but I didn't see a wrinkled brow or look of fear in her eyes. Jate's measurements are on target and no abnormalities were found. "Based on the American Institute of Ultrasound Medicine (AIUM) guidelines, this is a normal obstetrical study." my report will read. Of course, it will be followed by the legally mandated statement, "the presence of a normal anatomy survey does not rule out a genetic, structural or chromosomal abnormality," but I'll take it.  I can't smugly proclaim that my baby is healthy. I can only hope.

Sunday, 8 February 2015

2015 Challenge Update #1

Unknowingly, we actually started this project before my parents' arrival. While we were cleaning and trying to make it looks as if no one actually lives in our house, we had a good cull. We got rid of all things that we don't actually use, including the stuff that we'll claim we'll use, but really won't. Anticipating that our home will be dominated by all things baby related, if this pregnancy goes the distance, I want to pare down as much as possible. We threw all the discarded items into the garage, as we didn't think my parents would have any reason to go into the garage. One of the best things about our neighbourhood is that various charities will come around to collect old clothing and household items. They'll send a flyer in the mail announcing the next date, you leave your crap by the curb and they'll put your donation receipt for the tax return in your mailbox. Usually, the flyers are like buses; if you miss one, just wait five minutes and another one comes along. Sometimes there will be multiple pick-up opportunities within a week. Yet, over a month went by and nary a flyer was seen. So one obstacle was that we had to work around the clutter. The other challenge was that we had to take down the ceiling lights, so all work was done when natural light was available.

While my dad was still here, he and Husband installed a set of pull down stairs in order to gain access to the new storage space.
Stairs and Materials: $300

Husband's friend Susie came over one day to let us have access to her truck. They brought a truckful of unused construction materials to a recycling centre, where they will be repurposed. While, he had access to a truck, Husband picked up the insullation, framing and flooring materials from Home Dep.ot. Susie stayed to help Husband complete the framing in preparation for the dry wall. 

Insullation and Lumber: $600
Recycling Fees: $50

In order to be able to dry wall the ceiling and create a storage space, we realised that we would have to move some of the wiring in the garage. Husband is pretty adapt at simple electrics, but this was a little out of his reach. Plus, my dad noticed there were a few things with the current wiring that weren't done according to code. The professional electricians moved the wires, corrected the faults, and added several new outlets, including a few outside, so that we no longer have to drag extension cords through the garage when we want to use the leaf blower. They accomplished quite a lot in a single day's work. (During which, Husband failed to offer them a cold beverage...) We also had to purchase some new lights for the ceiling (we had been repurposing the flourescent lights that had been in our kitchen) as well as a new outside flood light (it was broke during my father's visit, but I never heard the story on how it happened...) We also needed to call our Alarm company, as our service was disrupted after the electrians' visit.

Electrician: $825
Lights: $200
Alarm Service Call: $175

Total to Date: $2,150

We started installing the floor in the storage space, but all construction came to a screeching halt as Husband went back to the East Coast and then to England for two and a half weeks. I kept things going by re-organising all our tools and researching storage solutions (don't worry, I'll spare the pictures). In all honesty, I appreciate the distraction from my pregnancy and I somewhat hope it keeps us occupied until we have to start planning and preparing for the baby's arrival. One thing is certain; there is no way we could have started this project with a newborn in the house. It does make me wonder when we'll ever be able to tackle other renovations. Husband went into the crawl space under the house (I'm not quite sure why...) and I was in charge of keeping Tyler away from the opening. I thought I had shut the door completely, but Tyler is clever enough to open any door that is ajar. Just as I went to make sure the door was shut, I saw his fluffy ginger tail disappear into the crawl space. Husband spent almost half an hour crawling around trying to find him and to coax him out. It was one of those moments that made me realise how great a father he will be, and I felt that I was doomed to be a horrible mother if I couldn't even keep my cat out of a dangerous place. I left some food out for Tyler and sure enough within twenty minutes, he was either hungry or bored and made his way to the opening and within my reach. He was fine with the exception of being a little dirty. Crisis was adverted. Still, if it is this difficult to work having a cat around, how will we get anything done with a small child? 

Monday, 2 February 2015

The Invisible Fence

Recently, I ran into one of my patients at Starbucks. I recognised her right away, but I couldn't think of her name. She had a spontaneous conception at the age of 41, who was now the adorable 18 month old boy on her hip. "I'm going to be seeing you soon!" she announced. "I'm pregnant!" She went on to explain that she had recently messaged my colleague about trying for a pregnancy at the age of 43, and lo and behold, she was peeing on a stick a month later. I know cases like this are more of the exception rather than the norm, but why does it seem that I see so many of them? I decided I could be jealous of her ability to get pregnant so quickly, but I also know the risks of miscarriage that are present for her, so I can't be too envious. As I walked back to my car, I had to remind myself, you're pregnant too!  I made a conscious effort not to acknowledge my pregnancy in the early weeks when I was still going through scans with my RE, but even at sixteen weeks, it still is so easy to forget.

Actually, I should clarify that thoughts about my pregnancy only escape my mind during my working day. When I get home each night, Husband's first question is to inquire how Jate and I are doing. Both my parents send me a text message every Thursday, as I reach a new week, and I've been sharing my weekly bumpdate photos with them. The bump has become more apparent at the gym, and more people are taking notice. Myrtle recently described how when she announced her pregnancy and her bump became more prominent, it seemed to invite her co-workers to over share about their experience. She learned about everyone else's hemorrhoids, incontinence episodes, varicose veins, swollen ankles and delivery horror stories. I realised at that moment that I'm especially not ready for my patients to learn of my pregnancy as I don't want it to take any focus away from their visit.

So far, I've still managed to conceal myself at work. It's a great advantage to having a closet full of little black dresses, and best of all, no one really notices that you're repeating the same outfits each week. My clothes still fit, but some reveal the bump more than others. I wish someone would create a line of transitional clothing. 'Transitional Pregnancy Clothes: When you're not big enough for maternity clothes, but you don't want to stretch and ruin your regular clothes...' Sometimes, it's not as easy as just selecting a larger size. I'm reluctant to purchase maternity clothes for a few reasons. Firstly, anticipating that this will be my only pregnancy, I don't want to spend much money on things I will only wear for a few months, possibly less if I need to be delivered pre-term. Secondly, although I'm sure they're super comfortable, jeans with the large expandable panel have to be the unsexiest item ever. I am very grateful for a local blogger who offered some exercise clothes to me.

Nonetheless, I decided to do some research and started looking through a local parenting website to check out recommendations on where to shop. Husband was watching some strange movie on the Sy-Fy channel and I was bored. I typed my search into the google and clicked on the first interesting link. Then Safari suddenly crashed. I felt as if I had been zapped by an invisible fence. Icarus had flown too close to the sun. What are you doing Jane? You haven't even had your anatomy scan yet! You can look at this yet. 

I know it was merely a coincidence. It seems that whenever I install the updates on my iPad, programmes crash more frequently. Yet, I felt it was a reminder that I can't get ahead of myself. I decided to start searching something safer and began looking into garage storage units. "What do you think of this one?" I asked Husband, who could barely turn away from some alien attack. "We don't need to think about the storage unit until the dry wall is done." he replied. Apparently, there is also an order to planning for the garage as well. "This unit is 30% off now." I informed him. "The savings is over four hundred dollars. That's a pram or a car seat."

I smiled to myself. When I first met Husband, he compared the price of anything to how many pints of beer he could by for the same amount of money. When we first renovated our house, we calculated fees according to building materials. Most recently, we measured costs in terms of fertility medications and treatment procedures. This was the first time I was acknowledging a monetary value as it related to items for our baby. My actions may need to be contained within the invisible fence, but my imagination is free to wander.