Wednesday, June 10, 2009

Pre-conception visit

Hold on, now, don't get your panties in a wad...we're not talking ANY time soon.  Becca's not even crawling yet, for Pete's sake!

But, John and I (mostly I, as the designated worrier in the relationship) wanted to meet with the maternal-fetal specialist to talk about what a future pregnancy might look like BEFORE deciding whether we'd like to try again or not.  I need as much information as possible, and I feel like we got it!  It was such a good appointment.  We spent nearly 1.5 hours with Dr. Carpenter at Vandy (in the new 100 Oaks location...interesting)  From Dr. Carpenter's bio:

Dr. Carpenter's clinical and research interests include fetal ultrasound and prenatal diagnosis, fetal growth restriction, immunology in pregnancy, and placental function. She received her undergraduate degree from Vanderbilt University and her medical degree from the University of Tennessee. She completed her residency and a Maternal-Fetal Medicine fellowship at the University of Cincinnati College of Medicine where she also was a Women's Reproductive Health Research Scholar.

Hello, exactly who we needed to talk to!  (Remember, pre-eclampsia is a form of placental dysfunction.)  Here's the recap I posted on a discussion board for preemie parents.  I'm including the background paragraph just to give you a refresher and hit some points that may have gotten lost in the drama - some of which I have just now come to understand, as I was too overwhelmed by what was going on to really understand the medical part of it.  So, if you want to cut to the chase, just skip the next paragraph. 

The background: Becca was born at 27.6 with severe IUGR (370 grams, 9.5 inches). It all seems to have come back to the placental issues. At first it was really big, but by the time she was delivered, it was normal size and extremely "mature" (read: dying). It literally fell apart after they took her. There was also a velamentous (sp?) cord insertion, basically meaning that the umbilical cord was just barely hanging on to the placenta.  That's a problem.  I had a borderline result for an clotting disorder in pg, but was cleared of any issue outside of pregnancy. In the last few weeks of pregnancy, we saw reverse-end diastolic flow (super bad problems with blood flow through the placenta, keeping her from getting the oxygen she needed - an indication for immediate delivery), severe decelerations (of her heart rate - also an indication for immediate delivery, had she been big enough to be "viable"), high bp, protein in my urine, some facial swelling that we thought was normal pregnancy weight gain (b/c I had just started gaining weight b/c of prolonged morning sickness), and shortness of breath.  I was admitted on 6.16, finally diagnosed with pre-e (I have moved out of state 2 days before and thus changed doctors, thank goodness), put on hospital bedrest for the duration of the pregnancy, set up camp (brought in the dvd player and everything!) but developed HELLP syndrome by 6.21. Becca was born by emergency c-section soon after. I was put on magnesium sulfate (to prevent seizures and stroke) and stayed on it for 24 hours after her birth, so I didn't get to see her until she was 26 hours old. My body fairly quickly returned to normal, and I was discharged when Becca was 3 days old. (Apparently, I was really sick, and many moms with HELLP have to stay longer, and some have permanent damage - from stroke or seizure or liver and kidney damage.  Scary.  Glad I didn't know that at the time.)

So, the doctor's conclusions: trying again is certainly not unreasonable, though the risk of another pre-term birth is higher than average. Her partner put my risk of developing pre-e again at 55%, though it's perfectly possible that I'll have a normal pregnancy or if the pre-e develops again it will be less severe and/or later - like full-term later. I'll be watched closely, and b/c I live an hour from the hospital (Vandy - closer to community hospitals, but with my risks, baby and I will both need to be at Vandy), if I start showing signs (protein, spike in bp, etc), there's a very good likelihood that I would be put on hospital bedrest, possibly for weeks. She's confident that I would be monitored closely enough that the chance of causing permanent or severe damage to my own body is very low, since they would deliver when my health was at risk and be equipped to stabilize me. (Of course, there is still a risk to me.) She told us that placental problems lead to pre-e (I had never heard that before!), so it may just be that this particular placenta would have caused the same cascade of events in any woman, and the next time around would be fine. Or, I could have a genetic predisposition to developing pre-e (of which HELLP is actually just a variant), even though there is no actual family history. Also, since I have PCOS, I am slightly more predisposed to develop pre-e, as would be someone with pre-existing diabetes or cardiovascular issues.

While she insists that there is nothing I could have done to prevent the problems from forming, there are some things I can do to try to tip the scales in our favor next time. The biggest thing, she said, is to get into the best shape possible. I'm carrying some extra weight (had lost 15-20 pounds pumping, but gained it back during the RSV lock-down of winter), so the closer I am to my ideal body weight when I get pregnant, the better my chances are. I'm hoping to lose 20 pounds in the next 6 months. Related to the weight is exercise - obviously, exercise will help me lose the weight, but she said that exercise can make a difference on its own - as in regardless of how much you weigh, your chances are better if you exercise regularly before pregnancy - something about oxidation. Yay for the Wii Fit!  Not sure how they would recommend exercising in a high-risk pregnancy - last time it was kind of out of the question b/c I would throw up just walking, but she emphasized that before pregnancy, it's really important. Also, since having had pre-e and HELLP puts you in a higher risk category for later non-pregnancy-related cardiovascular issues, it's a good idea to get a handle on a good diet and exercise program now anyway, while I have the added motivation.  Also, if you remember, my stress level during my pregnancy was ridiculously, off the charts high: preparing to move, working as a chaplain (on the perinatal loss team, even), doing a residency, working evenings as the ONLY chaplain in the hospital, 2-3 overnight on-calls each week, being pregnant for the first time, being told we were going to lose the baby...kind of insane, really.  My life may not be easy now, and I definitely stay busy, but it's much more regular-life stress now, which is manageable.  As far as how they would medically manage the pregnancy differently, she talked about baby aspirin (probably beginning at 8 weeks gestation) and calcium supplements. There is a theory that suggests that some other vitamins and minerals (A, D, and anti-oxidants, I think??) could make a difference, but, unfortunately, the latest studies haven't found benefits to them. I would, of course, be seen more regularly and at least co-managed by a regular OB and a maternal-fetal specialist (or I could go straight to the MFM folks - good thing about Vandy is that they are all in the same group, so communication is better than in some settings - like my last set of doctors!). I'm sure I'd be taking my BP at home, but she said that blood pressure meds don't stop the progression of pre-e; they just protect you from the effects of high blood pressure (stroke, etc.) - which is definitely important! - but wouldn't have solved my issues before.

Phew. I think that's about it. It was really, really, really helpful to talk through everything with her and see how she - the pre-eclampsia specialist - thought all the general information that I've read applies to my case specifically. I feel like I finally have some answers, even though she didn't tell us all that much new about what happened with Becca.  It seems to make more sense now, though.  Maybe I'm just now ready to make sense of it all in my mind.  She was very patient with us, and I feel a lot better informed - both about what did happen and what may happen in the future.  Again, we're not talking near future here.  At the VERY least, we'll wait until after our trip to Malaysia...pretty sure I don't need to travel internationally pregnant now!  In the meantime, I've got plenty on my hands with our crazy adorable Becca, about whom I'm hoping to post soon.  Oh - Dr. Carpenter also gave me a Rx for Zithromax, so hopefully I'll be able to breathe again soon.  Turns out my sinuses really don't agree with living in the country. 

Gotta run - my little miracle is waking up!  Will post pictures of her soon!


  1. Jennifer Cannon NicholsJune 10, 2009 at 1:10 PM

    Nancy, I know you don't know me but I grew up with John at SAUMC. I really enjoy reading your posts about Becca. This one was particularly interesting because I am 25 weeks pregnant with my second child (my baby is 13 1/2 years old). Anyway, I had pre-e with my daughter who miraculously I carried to term, but not without a lot of bed rest and a few hospital stays. I have been seeing a high risk specialist with this pregnancy along with a regular OB. So far, no problems other than SVT's which make my heart jump out of rhythm every so often, more scary than dangerous. I too worry about my blood pressure and getting pre-e again. I did not know it had anything to do with the placenta either. I learn a lot from reading your blogs. You guys are so blessed to have such a precious little fighter. Thanks for all the info and I hope one day I will be in Ashland the same time as you all to meet you both.

  2. Jennifer, So glad to hear your story! I hope that this pregnancy keeps going smoothly, and you keep that little one cookin'! I had some heart-skipping as well...not related to the major issues, but more doctor's appointments to get to. I swear, by the end of this, we ought to be medical degrees! :) Peace, Nancy

  3. Just wanted you to know I read this entire post... and now I have no time for anything else :)

  4. Good for you for going in for a pre-conception check. Not everyone thinks to do that but it's so important, especially if you have had medical issues in the past. Sounds like you got some excelent advice which you're planning on following. Great!