Friday, March 2, 2012

Week 25: The Waiting Game

I've half a mind not to go in for the 20-week ultrasound next time around.

As many of you know, our third baby (in utero) was diagnosed with bilateral hydronephrosis at his 20-week ultrasound. Two weeks later, the situation remained unchanged. As far as I know, it remains unchanged still, and I go in for another ultrasound today.

What I can't figure out is how having this information has helped anyone, and I'm trying to process what we've really gained from this exercise. I'll do some pro and con on the 20-week ultrasound, and maybe you can tell me what you think. If anyone has had an early delivery recommended (and I mean, REALLY early - like 28 weeks?!), I'd be particularly keen to hear your opinion.

Some people criticize early diagnostic ultrasound as putting women and babies at risk for abortion. This may be true, and I certainly wouldn't want to put myself at risk for an abortion. But no one even dared mention the "a" word at my appointment. Perhaps they would have if I'd brought it up first, but we had all just seen a cute little baby boy swimming around in my uterus on the ultrasound, no one was really in the mood to talk about ending that little one's life. Besides that, abortion requires some pretty significant forethought, planning, and consent, and wouldn't just randomly happen to me because I had an ultrasound at 20 weeks. I wouldn't ever do it, and as far as abortion is concerned, I just don't really care what my health care providers think. So I'm not worried that abortion will somehow just happen to me if I have an ultrasound conducted at 20 weeks.

The maternal-fetal specialist said they were particularly concerned to see whether the amniotic fluid level drops, and from what I've read, if this problem develops in the second trimester, it is somewhere between 80% and 100% fatal to the baby. But when I asked her at what point they would consider an early delivery (ostensibly to keep the baby from dying), she only said that they would "want to keep the baby in as long as possible." So even in the event of this worst-case scenario, say I go in today and the amniotic fluid has dropped and baby Statesman is not growing well, aren't we just a little bit helpless, watching the Titanic sink? If this baby dies because of a problem with his kidneys, I am going to spend the rest of my life grieving his life...but I don't feel like I need to make a nail-biter out of it if there's nothing that we would have done differently.

Another point that my sister and my OB made is that so much diagnosis on ultrasound is based on trends, which gives some value to multiple data points (for example, having ultrasound readings from 19 weeks, 21 weeks, 25 weeks, and so on). That may justify ultrasound prior to a point in the pregnancy when intervention is recommended. This is the one I've been mulling over.

I guess the question really boils down to how many data points you need, and how early you are willing to actually go in to intervene to assist the baby?

Regarding the number of data points you need, I do have some experience with abnormal ultrasounds. When I was pregnant with our eldest, the Pious One, a growth ultrasound at 28 weeks showed he was in the third percentile. The concern was that he might not be growing due to IUGR, and that he might need to be delivered right away so he could be nourished on the outside better than I was nourishing him on the inside. A second ultrasound at a different clinic the next day showed that the first ultrasound was wrong, and a third ultrasound two weeks later showed that he was, in fact, fine.

This tells me a few things. First of all, if the situation is serious enough, they might do something at 28 weeks, and on the basis of only one or two ultrasounds. Second of all, apparently two data points two weeks apart were sufficient to allay concerns about his growth and send me on my way.

In my current situation, the doctor has told me they want to keep the Statesman in "as long as possible." I assume this may have something to do with the fact that a baby with kidney problems may actually have underdeveloped lungs (owing to the impact of amniotic fluid on lung development), and therefore what might be healthy for a baby with adequately developed lungs (say, delivery at 34 weeks) may not even be advisable for a baby with kidney problems.

In addition, it seems like if the situation is serious enough, you could tell in one or two ultrasounds (for example, a baby not growing well, as we suspected the Pious One might not be). Would there be any placental abnormalities you could detect on ultrasound? Wouldn't extremely low amniotic fluid be obvious? These, in combination with a kidney problem and a baby with low growth percentiles seem like they would pop out in just one viewing.

So here's what I'm proposing: next time I'm pregnant, I just go in for my 28-week growth ultrasound and we go from there. They will certainly be able to see all the same, and probably more, abnormalities than they would have at 19 weeks. In fact, some of these problems (like choroid plexus cysts, and maybe even small amounts of kidney dilation) may have disappeared. And even at 28 weeks, wouldn't most doctors be loathe to deliver early? If the situation is so obviously desperate - just go in and get that baby out! But if there's a risk to early delivery and it's more likely to be in the baby's best interests to stay in, couldn't we wait just a week or two, take another measurement, and then decide?

These are all open questions for me, but I am heavily leaning the direction of waiting next time. Experiences, anyone?

No comments:

Post a Comment