Sunday, August 28, 2011

OCPs today!

Today I start my oral contraceptive pills (OCPs) - ortho cyclen.  I have never been more excited to start OCPs in my life!  I have been off of them for 10+ years now, but with my current 5 day long periods, heavy bleeding and 3 days of intense cramping, I am ready for continuous OCPs for 2 months!

It will be especially nice not to have to have a period while I am in Ghana.  T-5 days until I leave!

OCPs may seem counterintuitive to IVF, but the RE uses them to suppress your own hormones in order to manipulate them externally to induce the greatest chance of high egg count retrieval and implantation with transfer.

Spoke with IVF coordinator at my RE office.  She said she would get a calendar to me out this week via email of what I need to do for the next 2 months in preparation for our first round of IVF.  More to follow!

Saturday, August 20, 2011

Case Study

I thought I'd post an interesting case here and see what you midwives, midwives-to-be and medical detective/mystery junkies think.

S:  A 28 year old G3P2002 presents to the community care clinic stating that she is 22 weeks pregnant with a certain last menstrual period (LMP) of 3/17/2011.  Patient states her abdomen has grown larger as it did with previous pregnancies and that she can feel her baby move.  The problem lies in that she has taken numerous HPTs (home pregnancy tests), and they have all been negative.  She has presented to the ER at 8 weeks with spotting where a urine pregnancy and a B-hCG were completed and both were negative.  The ER physician told her she was not pregnant and did not exam her further (no ultrasound or other assays).  The patient is uninsured and so she does not have a primary care provider.  The patient has no other complaints.  Denies problems with bowel or bladder, no nausea or vomiting, no pain and spotting has ceased since ER visit.  Patient is stressed because she says she is sure she is pregnant, but no one believes her.

O:  T 36.4, BP 128/76, P 100, R 40, weight 138 - up 8# since LMP
Head & Neck - mild exophthalmia, no thyromegaly
Heart - tachycardic, regular rhythm
Lungs - clear to auscultation bilaterally, tachypneic
Abd - appears gravid, soft, nontender, no masses noted
Uterus - consistent with 8 weeks, no fetal parts palpated, no movement noted
FHT - none found by doppler in all 4 quadrants
Urine pregnancy test - negative
No US machine at community clinic

What is your plan of care?

Our plan was to order laboratory assays - CBC, CMP, thyroid panel, LH, FSH and prolactin, quant B-hCG, CA 125, and an ultrasound.  However patient is self-pay and would not be able to afford all of the tests.  The quant B-hCG alone was $127.

We referred her to the high risk resident Women's Clinic and she has an appointment on next Wednesday a.m.

So let's take a poll and see what your differential diagnosis would be.  I will report back next week with lab assays and definitive diagnosis.

Friday, August 12, 2011

Latest Update

We have decided not to do a 4th round of IUI.  I would have had the scan this past Monday with intrauterine insemination on Wednesday, but we have weighed the pros and cons and decided against it.  Our RE said that she has seen many successful pregnancies happen with the 4th round, but there were just too many cons to consider.  My thought process was that I did not want to be pregnant in Ghana in case I -
  • have severe nausea
  • have an ectopic
  • have a SAB (spontaneous abortion/miscarriage)
  • need a D&C
I also was concerned because I will have to take anti-malarial tablets and of the 3 kinds that are recommended for Ghana - Malarone, Mefloquine or Doxycycline - none are safe during the 1st trimester.  I definitely do not want to contract malaria whilst I am there, but I also do not want to cause undue harm to my unborn child.  Which, I guess in theory, could happen with not taking anti-malarials and contracting malaria AND with taking anti-malarials.  According to the WHO, pregnant women are more vulnerable to malaria as pregnancy reduces the immunity to malaria (an immunity of which I have none of) and increases ones attractiveness to mosquitos due to hormones and pheromones.  Contracting malaria in pregnancy increases risk of illness, severe anaemia and death.  Maternal malaria also increases the risk of a SAB, stillbirth, premature delivery and low birth weight, which is the leading cause of infant mortality in Ghana.

All these thoughts culminated in us skipping our last round of IUI.  

We met with our RE this past week, and told her our decision.  We discussed doing a 4th round when I return from Ghana, but we are already booked for an IVF start date of 27 October, so there was not a way to squeeze in both the IUI and IVF start in October, especially with having to take anti-malarials for 2 weeks post-return.

So, we now are set for the following schedule, some of which has been completed:
  1. Husband do pre-IVF infectious disease blood work 
  2. Re-apply for Springstone IVF financing at end of August
  3. Leave for Ghana beginning of September
  4. Husband donate sperm for freezing on 2-3 separate occasions during September
  5. Return from Ghana early October
  6. IVF counseling 3 October
  7. Husband leave for 6 months
  8. Begin IVF cycle 27 October
I know there are many more steps between 3 October and 27 October, but I do not know what they are yet.  We will find out on the 3rd!  I know I do need to let Attain know that we are beginning our treatment on the 27th.  They are providing us four rounds - 2 fresh and 2 frozen - for $16,000 USD.  I also need to work out our financing.  Our clinic wants the money up front, so we are going to go through an IVF financing company called Springstone.  We applied earlier with them and were approved for the IVF amount with monthly payments of $300 for 60 months, $335.97 for 48 months, $412.44 for 36 months or $573.50 for 24 months.  It IS quite expensive, like a monthly car payment (which thank goodness, we do not have), but we are going to have to use the financing route as we do not have $16,000 in cash to pay up front by October.  Unfortunately, our application was only good for only 60 days, so we will now have to re-apply.  I hope we are able to secure as good of a rate and financing for the whole amount when we reapply at the end of this month.  

It's nerve-wracking thinking about all that needs to be done and the possibility of not having a successful outcome whilst being out $16,000.  I am trying to be positive, of course, but the fear is still there.  I had a dear friend who just went through her 4th failed IVF attempt.  It is heart breaking.  I am truly hoping and praying for success on the first go-round.  I'd like to get our money's worth, but really, I'd much prefer early success.

Wednesday, August 3, 2011

A Disappointing Day

I had a hard day at my hospital clinicals yesterday.

We had a patient that wanted a natural, unmedicated birth.  With her previous birth, she was induced with pitocin, had a very difficult labor, and subsequently has a very negative image ingrained in her memory about her birth experience.  This time she wanted to have a simple, serene birth - the one we all dream of.  She presented to the hospital already dilated to a 7 as a G2P1.  My midwife and I thought that this would be perfect for her, and that she'd easily give birth in the next few hours.

After 5 hours of hands and knees, walking, birth ball, rocking, squatting, in and out of the bath tub, lighting candles, and listening to soothing music there was relatively little change in her cervical dilation, and yet she was experiencing increasingly worse contraction pain.  She was beginning to give up; thinking she would not be able to carry on with her plan.  We were not checking her, so I was encouraging her to continue - telling her soothingly that she was almost there, that she could surely make it.  At the 6 hour point, we finally checked her to see if she was close.


She was the same.

Upon further inspection, her baby's posterior fontanel was extremely posterior, which is not typical, and we could not 100% decipher what the presenting part was.  It felt like a face.  We had the attending come and confirm for us, and she said it was definitely a face presentation with mentum transverse (MT).

MA or mentum anterior is the only one able to delivered vaginally.  It is done by placing a finger in the woman's rectum and flexing (or tucking) the head forward so the baby can still go through the cardinal movements of delivery.  Unfortunately, this is not possible for MT or MP (mentum posterior) presentation.

Oh sigh.  It was a such a heart wrenching moment to tell her she was not going to be able to physically birth from below.

When I came to get her husband to bring him back for the cesarean section, I asked him if he wanted to bring his camera and he said quietly, "No, I think we'd rather not remember this part."  My eyes welled up with tears and I had to look away.  How absolutely crushing.

Thankfully the baby was born easily and did not need any resuscitation efforts.  Both of the baby's eyes were swollen shut, but there was only minimal bruising over the right brow.  The mom, dad and baby spent the rest of the surgery time trying to bond with their new baby in the OR.  The mother was shaking uncontrollably (due to the spinal anesthesia) and despondent.  The father was quite sad.  It was a bittersweet moment for them.

The attending ensured a triple layer closure so that should they decide to have another baby they could attempt again to have the birth they so desperately desired.  She made sure they knew this, but I am not sure how much comfort it provided in the moment.

I am sure the healing both physically and emotionally will take some time, but my hope for today is that they are enjoying their baby much more and are able to let go of their negative perception of this birth bit by bit over time.