Tuesday 10 December 2013

Lights are on, but no one's home

Shortly after Co-worker and I started working together, we decided we need a covert way to communicate if a new OB patient had a non-viable pregnancy. I think she coined the phrase, 'the lights are on, but no one's home' and it seemed to stick. Thus we had a more subtle way to alert other staff members to the situation and could avert any awkward interactions with the patient. The medical assistant would know not to issue any due date confirmations, the phlebotomist understood the message and would not draw the full prenatal panel. The front desk receptionist would know to book her follow up as a GYN return visit and not a return OB. Most importantly, this discreet phrase would help prevent any staff members from unknowingly offering words of congratulations, or require the patient to provide an explanation.

I often think about that phrase when I am breaking the bad news, as one of the questions patients often ask is, "am I actually pregnant?" The answer is technically yes; it's just not a pregnancy that will produce a baby. I started to warn some patients that they will still have a positive pregnancy test, as I once had a young girl who called our office the day after I diagnosed her miscarriage, claiming that I was wrong as her digital test told her she was still pregnant. "Why do I have symptoms of pregnancy?" is the other question that usually follows. Well, HCG is just a cruel bastard that will mislead and mess with you. I often think that is adding insult to injury; to endure the misery of pregnancy symptoms without anything to show for it. "But, I'm not bleeding..." I explain that before early first trimester ultrasound was adopted into practice, this is how patients presented and how practitioners would make the diagnosis. We're now recognising non-viable pregnancies earlier, prior to the inevitable bleeding. Yet, bleeding during pregnancy is so strongly associated with a miscarriage, that it becomes hard to accept one with out the other.

It somewhat becomes much easier to inform a patient of an impending miscarriage when she has bleeding, cramping or some type of warning sign. Yet, most patients who present to me with bleeding turn out to be fine, and the majority of my non-viable pregnancy diagnoses are in asymptomatic and unsuspecting women. That is the aspect that makes the situation even more difficult; the fact that they are completely blindsided by the news. The patients who make me nervous are the ones who come into the office with complete confidence of a good outcome. The Dad who has the camera ready to start recording the ultrasound images. The ones who bring their kids to introduce them to their new brother or sister. Some times it is a little easier with couples who are familiar with this process, as they know what to expect to see in their ultrasound. It's always heartbreaking when I hear couples coo 'look at our baby!' as I'm recognising a non-viable pregnancy. However, the diagnosis seems to be a bit harder to accept when couples have had two or three normal pregnancies. This is not consistent with their prior experience. Everything worked out for them in the past, why shouldn't it now?

Thus, I felt prepared for bad news as we approached our first ultrasound. Not only did I have professional experience acknowledging the commonplace nature of miscarriage, but I have doubts about our embryo quality as well as a general dose of skepticism. I had a surprising sense of calm on the night before our scan; but once morning dawned on the moment of truth day, I became a bundle of nerves. After counting down the hours, I was finally back in my RE's office. I shared my photos at the start, and as anticipated, he just responded with "well, let's take a look." I saw him calculate measurement of the single gestational sac, which was now 11.5 mm -appropriate progression from prior measurements. There was a clearly identifiable yolk sac, and something that my RE called a questionable fetal pole. He measured it at 3 mm, which along with the gestational sac corresponded to 5 weeks and 6 days -align with my prior calculations. However, there was no evidence of cardiac activity.

Although cardiac activity should be seen with a measurement of 5 mm, (some say 3 mm) the threshold for diagnosing an early pregnancy failure is absence of a heart beat in a fetal pole measuring 7 mm. While he admitted that he would prefer to see cardiac activity, my RE reported that he was satisfied with these findings. He added that he is still a bit guarded with our prognosis. Once again, I was laughing inside my head. As if it were possible that anyone could have less confidence about this pregnancy than I already do. New Girl somewhat scolded me for my preview scanning. "You're just making yourself more anxious!" she perceived. Quite the contrary. If I went into this scan believing that I should have been 6 weeks and 3 days and discovered that I was measuring behind with no cardiac activity, I would be suspecting that the growth arrested. Rather, it is reassuring to know that I have been consistently four days behind, but progressing appropriately. As Husband pointed out, our progeny seems to be taking after me already; takes forever to get ready and shows up late. We are scheduled for a follow up in a week. I promised New Girl I would keep the probe away from my vagina. I've broken enough hearts and crushed too many dreams already; I can't deliver such news to myself.

Yet, we're still in the game. I'm still at the plate and I've evened the count. We think there is somebody home. We're just waiting to see a flicker of light.

15 comments:

  1. You are still in the game indeed. I will continue to think of you a lot this week and hope for the best for your follow up scan!

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  2. I have been checking for this post all day! And as I read it my own heart dropped! YOU ARE STILL IN THE GAME!!! I can understand your concern but I am still hoping for the best! Just take one day at a time.... (I know..it's so freaking hard!)

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  3. I've been stalking your blog all day for this. I just keep thinking back to all the blogs I've read with wonky betas or slow/behind embryos, and more often than not things work out just fine. I guess it's good for you to be guarded at this point but I'm really hoping the next scan is going to give you what you need to be satisfied that all is progressing as it should. Turn on the lights, fetus!! Light 'em up!

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  4. Oh Jane, I was so anxious as I was reading this. I'm glad there's still some hope here. I know anecdotal evidence isn't really helpful, but one of my closest friends who finally got pregnant after 2 years of trying did not see a heartbeat at her first ultrasound around 6 weeks. But the next week, the heartbeat showed up, and she is now 19 weeks and doing well. I'm hoping that will be the outcome for you. Your attitude, as always, is so admirable. Thinking of you and hoping for good news at your next appointment.

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  5. My heart was in my throat the entire time reading this! I was so afraid to get to the end. But there's still hope! I'm so glad to learn that the growth is still consistent and you are still in the game. I don't know how you'd be able to help scanning yourself throughout this next week, but then again, like you said, it would be really hard to deliver bad news to yourself.

    Also, New Girl needs to mind her own business, I think.

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  6. Oh this is good news....cautiously good news! I will be sending you good vibes this next week! At 6 week, 3 day US we could see a "fetal flicker" but my Dr. couldn't measure it. I was measuring exactly 6 weeks, 3 days too. A week later the fetal pole grew by 2/3rds and there was a good measurable, normal heart beat. I am hoping a week makes all the difference!

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  7. I admit it, I scrolled down to the end of the post before reading the rest. Glad that it's still growing adequately! I'm cautiously hopeful for you.

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  8. I'm so happy there's still hope- hang on to that!! :)

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  9. You are still in the game! Hoping that your game last for years and years to come. I think this is why our fertility clinic won't do u/s prior to 7w. Glad you did the early scans to know that things are growing in there and that your light is on next week.

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  10. That was some suspenseful build up there! I almost quit reading to scan to the end, I was so nervous. So glad to hear there is hope. I will be sending you good thoughts this week while you wait.

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  11. I was holding my breath the entire time I was reading this. I was so relieved to find (cautiously) good news at the end. Like others have said, I feel like I have read so much anecdotal evidence of situations like this where everything turns out fine. I will be anxiously waiting for your next scan.

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  12. It was almost torturous to read this post without skipping to the end! I am so glad that things are progressing. I think with IVF we often expect to see too much too soon. Everyone grows at their own pace. I am so relieved!

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  13. I was holding my breath while reading this debating what the end was going to say! I'm glad things seem to be ok, I really, really hope they're ok next week. I can't wait to see your next post about the scan! It's a good thing you did do the early scans on yourself, or else - like you said - there would be a lot less hope. Here's praying for a heart beat at your next appointment!

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  14. The title of this post scared me a little. Glad that progression is on target. Hoping for a heartbeat next week!

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  15. You really dragged out the suspense with this one, but so delighted to read the happy ending. I will be thinking of you and really hoping your little one is just a late bloomer.

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