In the name of not re-inventing the wheel or some other time-sucking and energy-draining analogy, below I'm posting the e-mail that went out to our parents after my initial conversation with my OB. It outlines the basics of my plan of care, and I'll update/fill in more another day. But now I've got to put the first plus sign to bed. :)
Sent 12/28/11 (or so):
So - I talked to Dr. Sizemore, who has been my OB/GYN for the past year and a half or so. He also delivered Becca when he was a resident at Vanderbilt. So you could say that he knows my case inside and out. Literally. Because of my history (namely, severe pre-eclampsia and HELLP syndrome before 28 weeks), I've got significant risks. (Duh.) The most significant change we've made in my care is to, oh not be in the job I was in when I was pregnant with Becca. No overnight on-calls, no rushing to the bedside of dying pregnant women, no skipping meals because I'm the only chaplain in the hospital. The most stressful thing I have to deal with is my 5th and 6th graders...and working with the likes of Paul Bonner and Mark Price. While the effect of stress on a pregnancy can't be measured, I think it's obvious that my work situation definitely did not play in our favor with Becca's pregnancy. So I think that might go a long way towards a healthier pregnancy.
We're also handling my medicines very carefully. Here's the run-down on those, starting with changes to my regular meds:
- Zoloft - which I've been on for over a decade now for anxiety/depression - we're dropping my dose, leaving it for a few weeks, and then POSSIBLY dropping it again to see how low I can go and still feel okay. Since my last pregnancy (when they were handing Zoloft out like candy), they have determined that there is some risk to taking Zoloft in the 1st and 3rd trimesters, so they want me as low as possible - but there's also a great deal of risk with a depressed and/or anxious mother, so we're looking for the balance.
- Prilosec - thankfully, I get to keep it! That is very exciting because, even though I am only, oh a couple of hours pregnant, the pregnancy heartburn has already begun. Yuck.
- Zytec - I get to keep it! Breathing is a good thing.
- Symbicort and albuterol - Speaking of breathing, my inhalers are good to go. Very few inhalers are considered risky, I think because they don't act systemically.
- Trazadone - my beloved sleep medicine - it's gotta go. It's also an antidepressant and in the same category as the Zoloft, so it's out. So far, I've tried to replace it with Ambien, which makes me totally panicked and worthless the next day, and Tylenol PM, which was like taking a sugar pill. Or a caffeine pill. Next up is Unisom...so we'll see how that goes tonight. I really, really love to sleep, and my body really, really needs it right now, but I really, really can't sleep without help...so cross your fingers that the Unisom or something else does the trick.
- Baby aspirin (81mg) - I've been taking this for over a year so that I would be on it when/if I ever did get pregnant. Some studies have shown that this can help prevent pre-eclampsia in subsequent pregnancies. The science isn't clear on it, but there's plenty of anecdotal evidence that it works, and it's certainly not going to hurt.
- Vitamins - I've been taking over-the-counter prenatal vitamins since before I was pregnant with Becca (as should every woman of childbearing age), but now I've switched to Rx ones, specifically one called PreQ10. It claims that it can also be effective in preventing pre-e, but, again, the science is kind of soft on it. But it's certainly not going to hurt, either, so as long as I can get those, I'll stay on them. (Unfortunately -- and very stupidly -- our insurance doesn't cover prenatal vitamins, so staying on these depends chiefly on my ability to get samples of them - and they don't sample these a lot.)
We're also adding some new ones:
- Metformin - I had actually just started taking 500 mg of this, prescribed by my PCP for a number of reasons. This is the drug that helped me get pregnant with Becca (but I JUST started it, so it's not to blame for this adorable blastocyst in my belly). Women with PCOS have a higher risk of miscarriage (even apart from my crazy history), and there is some evidence that Metformin can help sustain a pregnancy through the first trimester. So what the heck. I'll take it.
- Prometrium - which is just progesterone - the brilliant Lauren McCormick, APN, suggested that I take this through the first trimester, also to help sustain a pregnancy by giving it bonus progesterone. During the 1st trimester, it's up to my body to produce progesterone, so if I'm low, these little pills should help compensate. After the 1st trimester, it's up to the placenta to produce progesterone, but it's not making it then, there's not much we can do (and we have SUCH good luck with placentas...). Anyway, Lauren started me on it, and Dr. Sizemore thought it was a very wise call. (Good job, Lauren!)
- Lovenox shots - yep, I get to give myself a shot everyday now. Becca and I can do them together, I guess. Last time, I tested borderline positive for a clotting disorder in pregnancy, so I eventually started the shots then. We're going to be proactive and go ahead and start them now. Anything we can do to help the placenta (again, our best friend/worst enemy in Becca's pregnancy) is a good thing, and while we're not sure it will help, again, it won't hurt, so I'll certainly do it!
Dr. Sizemore will see me soon after I get back in town, right around 6 weeks, and they'll do an ultrasound (hopefully visualize a heartbeat) and run a BUNCH of baseline tests. There are lots of levels that we will have to keep checking throughout the pregnancy (liver enzymes, protein in my pree, blood counts, platelets, etc), so they will want some baseline readings to compare then to. I've still got my blood pressure meter, so I'll be checking that regularly at home. We'll formally decide which specialists I want to see at my appointment - I know Dr. Sizemore likes the guy just above his office at Williamson Med, but they only deliver at Centennial for Level III NICU care, and, while I've got friends who have had positive experiences there, it's not Vandy. And I know enough about the NICU's around here to know that the absolute best care a preemie can get in Nashville is from being IN-BORN at Vandy - not getting transferred there later. So I think we'll co-manage with Dr. Sizemore and the Maternal-Fetal group at Vandy (the only high-risk folks who can deliver there). Like John said yesterday, I'm just not going to be comfortable going anywhere else. And my being comfortable is half the battle here.
Emotionally, I am doing okay. Of course, I am OVER THE MOON excited, but I'm also anxious. It would be impossible not to be, given our experiences. I had a moment today when I was at the pharmacy to pick up my Lovenox shots when they told me that I'd have to come back tomorrow because they had to order them. I started to freak out about waiting a day to start them and was trying to think of a way to demand that they get them to me (crazy preemie mama coming out)...but then I realized that one day is probably not going to make a difference, and besides, the doctor wasn't 100% sure we needed to do them anyway. But of course I'm going to freak out a little bit. Not only am I facing trigger after trigger for the former trauma, I have very real risks that I have to take seriously. So I'm trying to give myself some grace and let myself freak out when I need to...but then come back around to the really good plan we have in place. It sounds cliche, but I am finding it easy to really and truly experience every day that I am pregnant as a blessing. It was damn hard to get here and there's not telling how long it will last, but at the moment, today, I am pregnant, and I am loving it - the pregnancy and the little bitty poppy seed itself.
Physically, I am (predictably) exhausted. And really hot. And somewhat heartburn-y. And really hungry. And when I get too hungry, I start to feel faint and just a touch nauseous, so I'm afraid that the nausea may be on its way. Cross your fingers on that one, too. (I was very sick the entire pregnancy with Becca. I could give you a tour of most of Louisville, just showing you all the restaurants and roads I throw up in and on. It was a rough 7 months.) There's a chance that the extended nausea I had with Becca was linked to the placental issues, so maybe if we avoid the big stuff, we will also avoid the puking. Of course, I will take puking for 9 months if that's what it takes, but it would be nice not to feel awful the entire time.
So that's what I know. I'll keep you posted. (Yes, Mom, I will. See? I am.) I'm hoping there won't be much to talk about. And like I said, I'll probably switch to the blog format soon to keep our adoring public happy. :) But for now (and then), we'd appreciate all the kind and healthy thoughts and prayers you can conjure up!