Wednesday, 29 April 2015

Pregnancy is not an off season

I debated back and forth over whether I would enter our league's championship swim meet, although I knew I would probably sign up just before the deadline, just so it wouldn't be too late if I changed my mind. Although I know I have the pregnancy excuse, I had to acknowledge that I probably wouldn't have been as prepared for this meet, even if I weren't pregnant.  Last year, I found myself needing to take breaks from swimming, fearing that I would lose my enthusiasm and resent my training. However, each comeback was interrupted by something else, and I never really regained momentum. I occupy an unusual spot within my swim team. I'm not as fast as the former high school and collegiate swimmers, but I'm faster than the others who took up swimming later in life. I have some physical features that are conducive to swimming fast, but I know that in order to become faster, I have to perfect my technique, which is much more tedious of a task.

As the weather turned colder, I started swimming in the evening than in the morning. Why wake up at 0530 to jump in an outdoor pool when it's 45 degrees outside, when you can sleep in and swim after work in 60 degree temperatures? The only trouble is that I can't make it to class on Monday nights due to my work schedule and there isn't a class on Wednesday. So I've only been swimming once or twice a week for the past three months. As there are nights when I don't sleep that well, I still can't bring myself to get up in the morning, even as it's become slightly warmer. Yet, admittedly, I had been avoiding the morning practise sessions so that I wouldn't have to confront Lena in the locker room. At the end of last year, Lena announced her pregnancy by describing how they weren't even really trying and she was so grateful as she could never go to the extremes of those infertile people. You know, people like me and you.

I decided I would sign up for the distance events. I'm not a natural distance swimmer, but as not too many people like the distances, it's an easy way to score some points for our team. Mostly, I didn't want to have a permanent record of some really slow times for my regular events in the USMS database. I knew my coach would ask me to swim on a relay team. Relays count for double points, so it doesn't matter how slow you swim, anyone with a pulse gets placed in a relay. Yet, I didn't expect that I'd get selected for four relay events over the three day championship. While I was happy to see there was a high demand for an out-of-shape pregnant swimmer, it was hard to see my name listed for the 'B' relay teams. Last year , not only was I selected for the 'A' (fastest) teams, but two of those teams made it into the USMS National Top Ten times. Again, I had to admit that I probably wasn't 'A' team material even without my pregnancy. I decided it would serve as an excuse for now and I found the motivation to return to training after the little one is born.

Other than the bump, the other challenge to relay swimming while pregnant, is that I couldn't dive. I had to start from the wall, which costs valuable seconds. Once again, our coach will take whatever she can get, plus she factors that at least 1 or 2 teams will DQ. I swam the freestyle leg on our 35+ 200 yard Mixed Medley Repay and I had the fastest split. Okay, freestyle is the fastest of the four strokes, and should be the fastest leg. Yet, while pregnant and from a wall push, I still beat two male swimmers! I feel a  smug sense of pride. The next day, I had to swim on a relay with Lena. My coach thought it was adorable to have  two pregnant women on a relay. I hadn't seen Lena since that day in the locker room. I thought about what I would say to her. I tried to work on some slight jab to let her know I heard her comment about not being one of those infertile people. I couldn't come up with anything. We exchanged pleasantries and a few pregnancy details. We're both keeping the gender a surprise and high-fived for being old school. I was proud to swim with her on our team's first (technically) six person 35+ 200 Freestyle relay. I had the fastest split in a time one second faster that my medley relay swim.

My not-so shining moment was my 1000 yard freestyle swim. A nice long slow distance at the end of the meet felt great, but I finished two and a half minutes slower than last year's time and 40 seconds behind my seeded time. The lead swimmer in my heat received the bell while I still had 100 yards to go, which means she lapped me twice. Nonetheless, I picked up 7 points for our team with my third place finish.

The fact that there were only 3 people entered in the event is completely irrelevant.

I started swimming a few months before my 35th birthday, as I wanted to compete in a triathlon. Training for this event represented my childfree life, as I didn't have any responsibilities or obligations to hold me back. Then I discovered that a Facebook friend was also signed up for the competition, also her first triathlon. Six months after the birth of her baby. On race day, I spotted several children holding handmade signs as they cheered for their mom or dad. As I started running in other races, I took notice of families running together. Mothers and daughters with matching outfits. A young boy with a shirt that read "My mom can run faster than your mom..." At a Halloween themed half marathon, one woman won her age group while pushing two toddlers in a baby jogger and wearing a costume. It was more than inspirational, it was transformational. Everything that I embraced in my childless life, career success, sports, travel... became something that I wanted to share with a new person. The world is too much amazing. There is so much beauty and so many good things in life, that I no longer wanted to contain it for myself.

Our primary hope is that Jate is healthy enough to participate in any sport that he or she chooses (although there will be many suggestions toward hockey, tennis, running, swimming...). Sports have been such an important part of our lives. Tennis helped me gain self confidence. Gymnastics taught me determination and discipline. Husband and I met through hockey. I hope to tell Jate that he or she ran four 10 Ks, a 10 mile race, a half marathon, swam in two swim meets and continued to Cross-Fit all before birth. Maybe that will inspire him or her                                                

Tuesday, 21 April 2015

Left alone to figure out my leave

Husband had been pestering me for a few weeks to gather information about my maternity leave. It was one of those chores I had been postponing until we reached viability, but when the perinatologist thought I may have an acreta, he mentioned in passing that I could be taken out of work at 28 weeks in that scenario. I tried to make the argument that since I work right next to a hospital, I would be safer at work than at home, but it was the push I needed to start this research. I started by digging up my employee handbook and turned to the Leave of Absence Policy Summary and found the section on Pregnancy Disability Leave (PDL).

If an employee is disabled by pregnancy, childbirth or a pregnancy-related medical condition, they are entitled to time off due to pregnancy of up to four (4) months. If the employee meets the eligibility requirements for a Family Care Leave (Family Medical Leave Act and/or California Family Rights Act) before the date leave is requested, their FMLA entitlement will be designated to run concurrently with the Pregnancy Disability Leave (PDL). 

An Employee may request a Family Care Leave (leave covered under the Family Medical Leave Act and/or California Family Rights Act) if they meet specific reasons. Family Care Leave provides up to 12 weeks of unpaid leave in a 12 month period.

Family Care Leave for Baby Bonding: If the employee has met the eligibility requirements for Family Care Leave, they may request up to 12 weeks of leave under the California Family Rights Act (CFRA) to bond with a newborn child. This leave will run concurrently with all other applicable leaves. XYZ will apply FMLA-qualified leave and/or CFRA qualified leave against the employee's leave entitlement under XYZ's leave policies. 

I have read this section over and over again and still don't feel that I have any grasp. I understand the words that are used, but they don't seem to hold any meaning. Is this what I sound like when I use medical jargon?

I needed to speak with someone knowledgeable, I went to our company's intranet to look up my Human Resources contact, only there weren't any names listed. "They've been dissolving the HR  department" Co-worker informed me. Um, how does a large affiliation dissolve their HR department? Apparently by outsourcing. I sent an inquiry to an administrative staffer and she gave me an address of some private company in Sacramento. "So there is no one at XYZ who can help me understand the policies at XYZ?" I asked. The staffer directed me to speak with the Bean Counter. The Bean Counter, aka the Director of Operations , is an administrator who no one really understands what her job is or what she does all day. I sent her an email informing her of my pregnancy and possible need to start leave early due to complications and I asked who can I speak with regarding my leave. I never heard back from her. At press time, almost four weeks have passed and I still haven't received a response to my inquiry, nor any acknowledgement of impending leave due to pregnancy. I don't expect her to exhibit any response on a human or compassionate level; she's a bean counter. However, as I am one of the most productive clinicians in our group, I would imagine she would be concerned about the loss of my productivity. She hasn't mentioned anything to our clinic director nor my Lead Physician. I have fears that she'll deny any request for a leave, as I didn't indicate on my 2015 Expense Request that I anticipated taking any FMLA time.

I decided to contact the Primary Care doctor who had a baby last year, to ask her if she had any contacts she could share with me. Apparently there is someone at the outsourced management company in Sacramento who is assigned to assist XYZ employees. I set up a time to call this person. "So what type of disability is this for?" she asked. I informed her it was for pregnancy and added that I might need to leave early due to complications. No words of 'Congratulations!' or 'I'm sorry to hear that you may be delivered early...' They made sure they dismantled the human aspect of Human Resources. She explained that I would need to submit a request for leave thirty days before my intended date, they need to verify my eligibility through my benefits, then they will submit a certificate for my doctor to sign. Once that is complete, I receive my leave packet which will explain how to apply for disability through the state of California and through my Short Term Disability. If I need to go out suddenly, I just submit the request as soon as I can. She seemed really annoyed to be answering my questions and I could tell she was desperate to end the phone call as soon as she could.

So, I really had no answers to the burning questions, which are how much leave can I take and how much will be paid? They say when you work for yourself, you have the toughest boss. The second toughest boss is your husband when you earn more than him. Husband has expressed concerns about how we will manage our finances without my salary. While not saying anything outright, I think he would like me to work as long as possible and return when my paid leave runs out. Myrtle asked how much time I would be taking for my leave. "Don't you get 6 weeks for a vaginal delivery and 8 weeks for a C/section?" I wanted to reply, oh yeah, I've only waited three years, went through two miscarriages and multiple failed transfers to finally have a baby and I'm only going to spend 6-8 weeks at home with him or her... Yet I know for many new mothers that time frame is their reality. A measly 6-8 weeks is inadequate for anyone.

Actually, I was reluctant to discuss my leave with Myrtle because even thought I don't know the exact details, I know mine will be better than hers. I'm very fortunate that California is one of four states that offers some paid family leave. Myrtle made an arrangement with her boss to work until the day before her due date as long as she could work from home during the last month of her pregnancy. She cashed in her unused sick days and vacation time, but a few weeks into her leave, the pay cheques stopped. At the same time, her husband who had been unhappy with his job for a long time, decided to quit without lining up any other prospects. Talk about feeling pressure to go back to work. I wouldn't have been as forgiving if he were my spouse. Myrtle took three months off, only because three months was the minimum entrance age for little Myrtle's day care; otherwise, she would have gone back sooner.

Fortunately, my cousin works in human resources and was finally able to answer my questions. Admittedly, she did have to draw me a diagram. According to her, I'm eligible for 8-10 weeks as paid disability post delivery and 6 weeks paid family leave. However, paid leave is 60% of my salary up to a defined maximum. I know I shouldn't complain at all, especially as I just wrote about Myrtle's unpaid leave. Still, the reality is that families are being financially penalised for having a baby. Yet, I know what it's like to be on the other side. I had to go to work the day after severing my finger as Co-worker was treating herself to a spa day while on Baby Bonding leave. (Yes, I am still bitter about that). Why should I be taking home the same amount of pay as my colleagues who have their work load increased due to my absence? I don't have any solutions.

According to my cousin, I could receive 14 -16 weeks partially paid leave. I also have four weeks of PTO that I can use. On my most recent scan, my placenta is still covering the cervix. It would need to move at least 4 cm to allow for a vaginal delivery. The good news is that the perinatologist did not see anything that looked concerning for an acreta. So, at this point in time, my C/section would be scheduled between 36 and 37 weeks. We are planning to go back east in October as Husband is scheduled to umpire several hockey matches and his parents will travel from England to meet their grandchild during that time. I will go back to work upon our return, as Jate starts day care in November. I can stretch this duration of time with my paid leave if I work until the day before my C/section.

Once again, I know I shouldn't be complaining at all, but I was hoping to be able to take a little time off before the birth. For so many years, I've listened to patients beg me to start their leave early. One of my favourites was a 28 week pregnant woman who wanted to go out on disability for 'baby brain'. Sorry, that's not an actual diagnosis. More recently, I saw a patient for her first visit and she asked to be taken out of work as she described how her boss is a jerk and her co-workers are mean. Unfortunately, you have to deal with jerk bosses and mean co-workers when you're not pregnant. Pregnancy is not an escape clause. To my dismay, she played Mommy against Daddy and got her primary care provider to grant her disability.  So, it makes me a little resentful that I have to work right up until my delivery date, but I'd rather be able to work than to be on restrictions due to bleeding, preterm labour, or pre-eclampsia. I just have to make the most out of my remaining weekends.

Tuesday, 14 April 2015

Out of the Closet

I formally announced my pregnancy and our story with this Facebook post:

Expecting in June, thanks to Science.

Although joyful, our hearts are heavy as we know there are many others who are wanting and waiting  to make such an announcement. Our experiences with infertility, repeat pregnancy loss, and a high risk pregnancy will always be will us and always affect how we feel.

We may become survivors, but we're forever scarred. 

Wednesday, 8 April 2015

A New Perspective

Husband and I soon learned that there is a difference between acknowledging the worse case scenario, and actually preparing for it. Although the perinatologist couldn't definitively determine if an acreta was present on the ultrasound and was recommending an MRI, we both knew it most likely was there, or if not present now, it would become an eventual acreta. Cue the launch into research mode. We kept reminded ourselves that everything would be planned with my delivery with all the necessary professional and equipment in place. Yet I read one chilling statistic in an ACOG bulletin; Be mindful that even with a planned delivery, the mortality rate with a placenta acreta is still 7%. Husband found the original research article that produced that statistic and discovered that it was published in 1996, which was offered us some comfort, but not quite enough. Husband recommended that I contact my parents to invite them out before the delivery date. 'If for some reason you didn't make it, they wouldn't get over it if they didn't see you beforehand." I spoke with my parents and filled them in on all the potential complications with a placenta acreta. My mother started crying. It was the lowest moment of my pregnancy, if not of my life. I couldn't help going back to some of the deepest and darkest places during my infertility days. Why did we not pay any attention to all the obstacles the Universe kept throwing at us? Maybe we really weren't supposed to procreate and now we're being punished for defying natural law.

I wasn't in a particular hurry to have the MRI performed. Yet, in one business day, my insurance issued authorisation for the procedure and I received a call from the imaging department with a next day appointment. It makes you wonder how serious a condition is when bureaucracy moves this quickly. The MRI itself wasn't too bad, although,  I admit I had an emergency dose of Ativan to use if needed. I also wasn't too anxious to receive the results. I figured the MRI would either confirm the presence of the acreta, but even if it didn't show anything now, it wouldn't mean that is still couldn't become an acreta.

We met with my OB on the day after my MRI. She viewed the films with a radiologist as did the perinatologist and they all compared notes. They all agreed that there is no evidence of an acreta. No abnormal lacunae were detected. The location of my placenta noted that the edge of the placenta is right at the internal os of the cervix, with a lip of placenta tissue overlying the os. Although it was described as a likely persistent previa, it seems to be much closer to resolving than previously noted on the ultrasound. Both my OB and the radiologist feel that an MRI is more precise for determining placenta location, as an  ultrasound is more operator dependent. The perinatologist doubts that the previa will resolve, but he admits he's been wrong before.

This was by far the most encouraging news we've heard. At this point in time, we're looking at a C/section at 36 weeks if the previa persists. If by some miracle it resolves, we can proceed with an induction between 37 and 38 weeks to try for a vaginal birth. Although I know that my cervix would probably be unfavourable at that gestational age and I could be tortured for a few days just to lead into a C/section for a failed induction, but for someone who was preparing for a hysterectomy, it was unbelievable just to have a conversation where a vaginal delivery was on the table. Of course, things could change by the time we have our next ultrasound and we could be revisiting the acreta scenario again, but for now and the next few weeks, we're going to celebrate this news as a victory!

So, remember how I feared my fertile friends would be too keen to share their know-it-all expert advice? Well, sometimes it turns out they can be pretty helpful. Myrtle sent me a text suggesting that we should start looking into day care centres as we would probably need to secure a place months in advance. We had discussed looking into doing a Nanny share with our friends Amy and Sheldon, as they had one with their first child. Every other week, the Nanny and the other child come to your house. While it would be incredibly convenient on the weeks where everyone descends upon our place, they live in the next town over. It's in the opposite direction from my work and the commute would involve some of the most mind-numbing, infuriating traffic ever. The transport could easily consume two hours each day. Location was upgraded to a priority feature for our day care search. Lo and behold, we found a reputable centre within three-quarters of a mile from our house. We could walk there if we felt so inclined. I made an inquiry and learned they had four spots available in the time we need. We attended an open house and were impressed with the cleanliness and organisation. I put my obstetrical skills to work and sized up the gestational ages of the other expecting couples and estimated that there were five couples including us looking at the same time frame. Husband slipped out to get our cheque book, as it is only a two minute drive to our house. We put down a deposit and our child, who is not even born yet, is enrolled in day care. Did I mention how convenient the location is?

We received some more good news, as the HOA finally approved our requests related to our garage project. After a month on hold, work can continue! Additionally, I passed my glucose test with flying colours and I'm trying to avoid needing a transfusion with a solid haemoglobin at 12.8. Wow. We're racking up almost as many wins as the UCONN Women's Basketball team.

Thursday, 2 April 2015

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.