Friday, March 30, 2012

Week 29: Hello, Third Trimester! Goodbye, Earthly Comfort!

I have entered the third trimester. It seems like it took forever to get here, probably because of how medical imaging technology and the uncertainty issuing from it ruined my second trimester.

I find the third trimester to be a much greater pain in my rear than any other. The first trimester nausea is a pain, but for me tends to go quickly. But I know there are women who are sick for their entire pregnancies, and I don't think my discomfort even holds a candle to theirs. In fact, my sister, who is also pregnant, told me just the other day that she was feeling sooooo much better. The kicker was her reason: she hadn't thrown up in 2 or 3 days. Oh, my!

But as I was saying, for me, the third trimester is the worst. In fact, actually delivering the baby is just a dramatic way to begin a new stage of discomfort in the childbearing continuum that continues from conception through...well, I guess it goes on for a long time.

In fact, when people joke that I should "get my sleep now, since you won't after the baby comes!", I feel like inviting them to get up for me in the middle of the night to roll over, re-arrange my pillows, check my blood sugar, get a drink of water or juice, use the toilet, let my unborn child use the inside of their stomach as a springboard, and worry about the future for me. At least after the baby is born my husband can occasionally take on a middle-of-the-night diaper change!

So, in one sense for me, the real difficulty of childbearing for me has just begun, which I can expect because of the special curse granted to it since the days of our first earthly mother. But just as Christ gave up his life for ours, ushering in a new era of heavenly comfort, so, too, do I offer mine up for the life of this little one.

I'll try not to gripe too much about it...

Tuesday, March 27, 2012

Chapter 4, in Which A Nice Man Opines About Our Situation and I Sigh Deeply

I went for a consultation with a pediatric urologist today, to discuss the Statesman's problem. This is something I have felt would be helpful from the very beginning, even after our first ultrasound, which showed an abnormal prenatal kidney finding.

The pediatric urologist was a very pleasant middle-aged man. I was seen promptly, and aside from the overtly sexual images of Wonder Woman in the waiting room (seriously? I guess I didn't actually know what she looked like), I would highly recommend the whole outfit.

First of all, a little history on this problem, beginning with our 20-week ultrasound.

Diagnosis #1: Possibly Down's Syndrome, more likely Trisomy-18, or it could be an isolated problem with the kidneys. It might resolve before birth, or the baby might die before birth, or your child may be seriously disabled forever.
Treatment Options: Nothing, except freak out.
My Brain On Diagnosis #1: Sweaty brow, shallow breathing, hands wringing. Or was that just my low blood sugar?

Diagnosis #2: This is probably not a chromosomal defect, and more likely just a kidney problem. The baby's growth looks great, but we still need you to come in all the friggin' time just in case we decide not to do anything about it.
Treatment Options: Nothing, except freak out.
My Brain On Diagnosis #2: Phew. I knew this was probably all overblown. Now to get on with life...

Diagnosis #3: We were confident all along that you would never be able to have three healthy pregnancies as a Type I diabetic woman and it turns out that you have, indeed, transmitted a serious problem to your child. Even though your A1Cs were very good, you still weren't controlling your blood sugars well enough to keep those nasty birth defects away.
Treatment Options: Nothing, except freak out AND wallow in guilt about some of the high blood sugars I had early in pregnancy.
My Brain On Diagnosis #3: Shooooooot. Now my endocrinologist will have even more reason to psychologically sucker punch me every time I come into the office. And, even though my little man will almost certainly be fine, wouldn't life be better with two kidneys?

Well, besides getting an excellent lesson in kidney anatomy and physiology today, we also got a new diagnosis. Based on the same images that the maternal-fetal specialist looked at, the pediatric urologist thinks it's something very different! He led the consultation by describing how this may be a variation of normal development (a large, relaxed renal pelvis) or a result of the hormonal milieu of my body (hormones causing the tissues to relax or constrict). Lastly, he mentioned that the dilation may be from an anatomical blockage of the ureteropelvic junction. This kind of blockage is more common in little boys, and it frequently resolve as the child grows older. They only infrequently require surgery to correct.

He thought MCDK was extremely unlikely, because he did not see cysts within the renal cortex. In fact, he saw an apparently anatomically typical renal cortex on the "affected side," which made him think it was probably a functional kidney. He was especially reassured by the good amniotic fluid measurements. He ruled out some other problems based on the normal size of the bladder and the ureter.

I think I have good reason to trust the pediatric urologist's judgment over that of the maternal-fetal specialist, and not just because it makes me feel like a better mother. Most notably, pediatric urologists have probably seen dozens (or even hundreds) of ultrasounds of kidneys affected by a variety of abnormalities. On the other hand, given how uncommon they are in the general population (MCDK is only found in 1 out of every 4000 or 5000), a maternal-fetal specialist might only have seen one, or none at all.

So, we have a new chapter in this little baby's history.

Diagnosis #4: Most likely a variation of normal, possibly a small anatomical defect that may not even require surgery to correct.
Treatment Options: Nothing, except feel good about what a healthy baby you've grown and look forward to your son's future as a potential kidney donor.
My Brain On Diagnosis #4: Aaaaaah.

After he's born, the Statesman will have his own kidney and bladder ultrasound, and will probably be on prophylactic antibiotics to prevent urinary tract infection (I don't know how long). From the ultrasound we'll be able to see if there are any problems significant enough to warrant an intervention like surgery, but that sounds increasingly unlikely.

I have another ultrasound on Friday, but I doubt we'll receive any more earth-shattering news. I also doubt that I'm going to let them freak me out about that kidney one more time! I'll keep you posted.

What a life he's had so far! The Statesman, thanks to his patron saint and all our friends and family who have been interceding for us, has bolstered our faith and confidence in God's providence. In the uncertainty of the diagnosis, we prepared for a crown of thorns and a cup of bitter gall, but instead we have been anointed with oil and fed with milk and honey. Thank you!

Wednesday, March 21, 2012

One Good Reason for the 20-Week Ultrasound

I have mentioned a couple times that I'm not sure if I want to do the 20 week ultrasound next time I'm pregnant. Unfortunately for this lovely family, I've found at least one reason this ultrasound might be a good idea after all.

As far as I can tell, the mother of this family was having what most would have considered a low-risk pregnancy. However, at her 20-week ultrasound, her unborn daughter was diagnosed with spina bifida. Then, within a matter of weeks, the mother underwent surgery so that her unborn daughter could also undergo surgery to close the opening in her back. At 24ish weeks gestation! Apparently the long-term prognosis for children with spina bifida who receive the in utero surgery is much better. The monumental task before them now is to keep the mother from delivering her daughter prematurely.

Say a few prayers for this growing family!

Monday, March 19, 2012

Tips for Managing Blood Sugars During Pregnancy

When Lauren sent us her birth story, Jenn and I were both amazed at how low her A1Cs were, and how small her baby was when he was born! Since both my boys were on the large-ish side, and knowing that doctors get squeamish about big babies from Type I diabetics, and also knowing that good A1Cs have all sorts of good outcomes for pregnant mothers and their babies, we asked Lauren to share with us a little bit about how she did it. This post came out of that brainstorming session as we thought about what worked and what didn't when it came to managing blood sugars during pregnancy.

I had a few ideas about how to manage blood sugars to keep my babies at a reasonable size after my second pregnancy, based on a post I read from the Navelgazing Midwife, but I have to be honest: very few of those ideas have panned out for me this time around. On the other hand, a lot of Lauren's wisdom had real credibility and a really practical application, based on my own experiences. We hope our experiences help you get through it, too!

LOWS ARE UNAVOIDABLELink
Beth: As I've mentioned a few weeks ago, it's amazing how often your blood sugar ends up below 60 when you're aiming for 100. The best thing is just to learn how to deal with it. After all, lows might be more frequent when you're pregnant, but they can happen any time you're not pregnant, also. With two kids at my feet, asking for my attention, I often just have to stop at the first sign of a low blood sugar and check it, no matter who's crying (we're all worse off if I end passed out on the floor, after all), and no matter what, don't try to take a shower and in case you're tempted to try it, just know that fasting really will probably mess things up. I'm fortunate that I can always detect low blood sugars coming, and sometimes I can even tell when my blood sugar is dropping quickly but still at an acceptable level (90-100). Also, when I leave the house these days, I try to make the outings short, and I always bring more food (or Gatorade) than I think I'll need.

Lauren: With respect to avoiding lows, I would say that unfortunately they were unavoidable, especially during my first trimester. I had many, and my endocrinologist was constantly on my case to keep them higher. I use a Dexcom CGM, and I cannot fathom getting through a healthy type 1 pregnancy without it. I set my alerts very conservatively (in my opinion) for 80 on the low end and 140 on the high end. This was super annoying since it beeped constantly. However, it enabled me to fend off potential lows (and highs, although these were less frequent) before they occurred. I consumed MASSIVE amounts of lemonade and Starburst candies, which are my preferred hypo correctors. I just always had these handy and was willing to stop whatever I was doing to treat a low or high. I never went anywhere without one of these immediately available to me.

MEALS and FOOD

Beth:
I feel like I've finally hit my stride with food now, at the end of my second trimester of my third pregnancy. The key for me this time? I'm trying to keep meal times to 60 carbs or less. I can always grab a snack (and may, in fact, have to) an hour and a half or two hours after a meal. It's a pain when I want to indulge in a nice dinner out, but it helps keep the dramatic lows and highs to a minimum. As far as I can tell, it has also helped me keep my weight gain down this pregnancy, and I'm keeping my fingers crossed that this baby might turn out just a wee bit smaller. I liked Lauren's idea about eating a very predictable diet, too, and have found that this helps particularly when I have lows. If I know exactly what Gatorade will do to my blood sugar (and how much and how fast), it makes it easier not to over-correct a low.

Lauren: I gave a bolus for all meals at least 30 minutes before eating, usually 45 minutes. Also, I ate an absurdly predictable, repetitive diet. As in, the same exact breakfast every day for the entire pregnancy. Lunches varied slightly. Dinners I had more flexibility, but I cook virtually all of our meals, so I could control everything that I ate. This way it was simpler to eliminate "problem" foods for my blood sugars (white rice and bread, "mystery" sauces, high sugar fruits, added sweeteners, etc...). I'm a human being, so I indulged in some "bad" foods, but extremely rarely. I don't think that this kind of limitation is necessary for everyone, but for me, it was truly the only way to be able to reasonably predict the response of my blood sugars.

CHECKING BLOOD SUGARS

Beth: I couldn't ever figure out how to calibrate the darned continuous glucose monitor (I had a Minimed one for a few months). I mean, my blood sugars are pretty good, but half the time, early in the morning, right after I wake up, is not a good time because my blood sugars would rise immediately and dramatically upon waking. The other half the time, my blood sugar is too low in the morning to calibrate. As for reliably having a post-dinner fasting blood sugar that was not too high, too low, and had been stable for 20 minutes? Forget it. I was usually in bed by the time that happened (sometimes I go to bed kind of early). So what I do during pregnancy is just check my blood sugar all. the. time. Including almost every time I wake up in the middle of the night to use the bathroom. Jenn tipped me off to the fact that truly, insurance companies want you to have a healthy pregnancy and a healthy baby, so it's OK to ask for strips to check your blood sugar 10 times per day (and that's about average for me during pregnancy). Sometimes I don't wait the full 2 hours after a meal, especially if I suspect I might be high or low. And I will sometimes check an hour or an hour and a half after that (even if I've eaten something small) just to make sure I'm still on track.

Lauren: As I mentioned, I use a Dexcom CGM, and I cannot fathom getting through a healthy type 1 pregnancy without it. I started using my CGM right before I conceived, so at that point I had no idea what my blood sugars were doing throughout the day, with the exception of the 5-7 times (or sometimes 3-4 times) per day that I tested. So basically I was seeing the roller coaster sugars on the CGM for the first time and concurrently learning that I was pregnant and my baby's well-being depended on leveling out that roller coaster. It scared the heck out of me! So I became hyper-vigilant about food; far more than my pre-pregnancy self.

Like many Type 1 diabetics, my pregnancy was closely monitored by a team of wonderful doctors. In terms of blood glucose management, I did find the very frequent visits to my endocrinologist and perinatologist helpful. My endocrinologist and I were constantly tinkering with basal rates and bolus ratios, as these changed at different times in the pregnancy. My perinatologist visits were helpful as well in managing blood glucose, though in a less direct way. With the frequent ultrasounds and measurements, he helped me to stay motivated in my BG management and not get hung up on a particularly bad day with ugly numbers. He often said things like, "Look at that healthy baby! He doesn't know your postprandials were high today!" This perspective I think helped to preserve my sanity!

Like Beth, I would definitely recommend requesting more supplies from your doctor, such as test strips and insulin. My bolus ratios got quite a bit higher when insulin resistance kicked in around 24 weeks, so I needed a higher daily dose to stay level. Also, my insurance approved raising my number of daily test strips from 5 to 8 (still insufficient, since my endocrinologist wrote a prescription for 10/day, but I took what I could get). You will need A LOT of test strips. There's just no getting around it.

EXERCISE

Beth:
I noted in my last post about uninterrupted sitting that even light levels of activity (the difference between a Saturday morning taking care of the kids and a Saturday morning bumming around on the couch, which sometimes looks the same to people without children but are, in fact, very different!) can help keep 2-hour postprandial readings down. I haven't had regular exercise this pregnancy, and I did during my last two, but I still feel that my blood sugars have generally been better this time than before (with a few notable exceptions. It's kind of painful to be reminded of it! But I really don't think the last two pregnancies were significantly better). Now that the weather is getting warmer, though, I do hope to get outside for walks.

Lauren: Although I am not a particularly athletic person, I did make efforts to stay active throughout my pregnancy. I believe that maintaining moderate levels of consistent exercise helped fend off some BG peaks. I love to do yoga, so that was my exercise of choice, but I would imagine just walking more and sitting less would encourage BG stability as well.
Link

Friday, March 16, 2012

Week 27: Insulin Resistance and Growth Spurts

Has anyone else noticed that they have growth spurts every 3-4 weeks during pregnancy? If someone goes without seeing me for a month, it's almost guaranteed that, upon seeing me again, they will comment on how much larger I look.

I notice it when I look down at my belly, too. Every few weeks, over the course of a day or two, I will look down and notice that my belly is more...forward. It's poking out a little more, and I can't get quite as close to the sink as I used to. And then a few days after that, some difficulty controlling blood sugars and a somewhat increased appetite, I'll notice that my belly is now more forward AND wider. After that, I hop on the scale, and sure enough, I've put on about 3 pounds.

That happened this week. I raised my bolus ratios and basal rates for the first time in a few weeks, since my postprandials were a little high and my regular afternoon fasting period (which isn't a strict fasting period, but I go longer between lunch and dinner than I do between breakfast and lunch) was also a little elevated.

I hope the little man inside is growing, too, and not just my abdomen!

Tuesday, March 13, 2012

How Pregnancy Might Actually Be Good For You

When I found out I was pregnant the first time, I had been on a Minimed pump for about a year. I'm not sure how, but somehow my A1C was still 8.0. It was so long ago that I just don't remember what I was doing (or not doing) that kept my blood sugars higher than they have been ever since...

And that's part of the point that I want to make in this post. Maybe, just maybe, perhaps in some women, even though it comes with some extra lows, the motivation that a pregnant, Type I diabetic woman has to regulate her blood sugars is so strong that it will stand her in good stead for the rest of her diabetic life? I mentioned that I can't remember why my A1C was high when I found out I was pregnant for the first time, and that's because it hasn't been that high in 3 1/2 years. In fact, I can't remember the last A1C I had that was higher than 6.5. I definitely haven't had one higher than 7.0 since that fateful day. Pregnancy teaches self-discipline (upon pain of hurting your unborn child) that might be hard to come by any other way.

I heard four birth stories from another Type I diabetic with four children who told me that her doctor used to joke that she should keep having babies because it was so good for her blood sugar!

Don't rule it out. There are other hidden advantages to the life of a diabetic (even pregnant!) mother. :)

Endocrinologists and Obstetricians

When I wrote the distinctively un-creative title for this post, for some reason it made me think I should prepare a poem. Perhaps a haiku, or a limerick.

Doctors have different approaches
To how each subject they broaches
OBs love babies
Endos are 'fraidies
The only word I can think to use now is "roaches"

...Or perhaps

OBs and endos are
different when assessing
risks in pregnancy

...Or perhaps not.

"Poet" is probably out as a potential career path for me, but I do think I've made some worthwhile observations about the differences between OBs and endocrinologists. I talked through some of this the other day with my mother, who is herself an ER physician, and we came up with some possible reasons for the discrepancy.

So far, in my short life as a childbearing woman, I've not had any OBs express disapproval about my choice to have children, despite the fact that I am a "high-risk" patient with diabetes. I do tend to choose my OB carefully, since I like to do pregnancy and childbirth with fewer interventions than might otherwise be standard protocol. There may be some selection bias at work here.

Endocrinologists, on the other hand, seem way stressed out by pregnancy. You can read about my interactions with endocrinologists on this topic here, here, here, here, and here. As you can tell, my experiences with these doctors have been...memorable.

When I talked to my mother about this apparent discrepancy, we came up with two possible explanations. The first is that endocrinologists, especially those who were trained more than 10 years ago, have not been fully able to assimilate how much insulin pumps have transformed blood sugar management and made it possible to have A1Cs regularly under 6.5 or even 6.0, during pregnancy and otherwise. We could call it the Steel Magnolias effect. I'm sure that endocrinologists, particularly those trained several decades ago, have seen individual patients with more bad things happen to them than have happened to Jenn and I combined during 6 pregnancies. We are grateful for so many developments of modern medicine, and know that healthy pregnancies would be much harder without them.

The second possible explanation that I came up with is the emphasis in obstetric medicine on "choice." While the language of choice has permitted the infiltration of some morally illegitimate developments, such as abortion, it has also placed obstetricians less in the role of decision-makers and more in the role of supporters. Of course, the whole natural childbirth movement seeks to grant women even more freedom to make their own decisions about pregnancy and childbirth (within moral reason), so there is still work to be done in this field. However, when it comes to the decision to become pregnant, obstetricians just don't seem to be quick to meddle.

As a final note: I'm not opposed to doctors making recommendations about pregnancy based on a woman's health. But I have heard far too often that being pregnant is not a good idea for me, without adequate evidence to support the recommendation. I have diabetes, but I have repeatedly been told that pregnancy does not pose any long-term risk to my health (and haven't been able to find any evidence to the contrary). I don't currently have any complications of diabetes (circulatory, renal, or opthalmological). In fact, pregnancy doesn't even pose much of a short-term risk to my health, besides the risks that all healthy pregnant women experience. Low blood sugars are a risk, but need to and can be managed in or out of pregnancy.

The one exception to this rule is the endocrinologist I had in St. Louis, Missouri. If you live there, go see Kim Carmichael at the Center for Advanced Medicine. He was awesome. He told me I could have as many children as I wanted. :) While I'm at it, I'll go ahead and recommend my obstetrician, Shanon Forseter. He's a solo practitioner, and trained in maternal-fetal medicine (for those of you who want a doctor with high-risk experience), but very friendly to natural childbirth.

What do you all think? Have you noticed a difference in the way your endocrinologists and your obstetricians treat you as a pregnant woman? I was told by another woman (the same diabetic woman with four children) that she got the same vibe from her endocrinologist. I'm not sure what Jenn's experiences have been like. Anyone's experiences disprove the rule?

Monday, March 12, 2012

Uninterrupted Sitting

Odd title for a post, I know, but I'm just not that creative.

When I was pregnant with the Pious One, I was working at a desk job. One unfortunate consequence of this kind of work is that I spent a lot of time sitting, uninterrupted except for walking to and from the restroom and to and from the kitchen for snacks. I tried to compensate for this relative inactivity by rising early in the morning (5:30a) to go for a 2-or-so-mile run. I did this until I was 28 weeks pregnant and put on precautionary bed rest for two weeks. Unfortunately, even with the morning exercise, and particularly so after the morning exercise routine was abandoned, I struggled with high blood sugars after breakfast all throughout that pregnancy. Despite excellent A1Cs, those high 2-hour post-breakfast blood sugars were a major thorn in my side.

According to this new study, postprandial blood sugars in diabetic adults may benefit from periods of light or moderate activity (they used walking, but I imagine many different kinds of activity would suffice) to interrupt long periods of sitting.

I love it when I read research that confirms my anecdotal experience, because it makes the science seem that much more believable! In this case, I have noticed that 2-hour post-breakfast readings during my last two pregnancies, and this one in particular, have been much easier to manage. The reason I'm beginning to suspect, partly on the basis of this research? Because I'm chasing around a toddler or two all morning. I wish I could say I'd figured out a way to work regular exercise into my life as a mother to two children under the age of 3 (I haven't), but apparently the consistent activity of picking up a two-year-old, putting down a one-year-old, getting them dressed, fetching breakfast, toting laundry up and down the stairs, and changing diapers has been enough to keep the problem subdued.

I've noticed this contrast particularly on two Saturday mornings when my husband took on the childcare responsibilities. On both days, I slept in and sat on the couch all morning while my husband picked up toys, washed dishes, and broke up sibling fights. The result was that my blood sugars, two afters after breakfast, were well over 200!

So, taking care of my kids is apparently good for more than just distracting me from tending
to low blood sugars, it's actually helping to keep them where they should be. Hooray for babies!
Link

Tuesday, March 6, 2012

Chapter 3, in Which We Are Given a New Diagnosis and Again Told That There Is Nothing To Be Done About It

Some of you may have been following my saga of ultrasounds which seem to be turning up some indication that there might be something wrong with our little Statesman that we can't really do anything (morally legitimate) about.

Well, the third in the series came on Friday. In addition to the bilateral hydronephrosis (dilation of the renal pelvis), which is stable, it appears that some rather large cysts have developed above the right kidney. The cysts do not appear to be communicating with the renal pelvis, which leads the doctor to believe that the baby might have unilateral multicystic dysplastic kidney. Usually, with this condition, the kidney on the affected side functions minimally, if at all, and it may eventually lose function all together.

Unfortunately, it's looking like the baby will grow up with only one functional kidney. Fortunately, it's looking like the baby will grow up with a functional kidney!

Apparently, people with only one kidney have a normal life expectancy. In fact, a very few of you may be walking around with only one right now without even knowing it. My sister-in-law told me a story about a man that her mother worked with: He took his son's high school class on a field trip to the hospital to show them where he worked. When he demonstrated ultrasound to them, using his son as an example, he discovered, for the first time, that his son's one kidney was alone!

Other good news from the ultrasound is that the amniotic fluid level is good and growth is good, which means that at least one (if not both) kidney(s) is/are functioning well enough to keep him healthy. I'm still, of course, hoping that this extensive imaging will turn out to be smoke and mirrors, this problem will go away all together, and my Statesman will have a kidney that he can give away in the future, but I am very relieved to know that the worst case scenario is...well, definitely something we didn't really need to know about, possibly ever.

The maternal-fetal specialist also told me that she would not make any special treatment recommendations on the basis of the diagnosis, meaning that pregnancy and delivery will likely be unaffected. The baby will probably receive an ultrasound after birth, which I don't have a problem with. Some pediatric urologists recommend surgery to remove the affected organ, but others recommend not messing with it until some other symptom indicates a need to remove it (repeat UTIs, or malignancy most likely).

We'll meet with a pediatric urologist to discuss more about what this means for the Statesman's life in the long-term, but it sounds like it's more important to file it away in the memory banks and just bring up if there's a problem or need for treatment in the future.

We'll keep you posted on this increasingly unimportant development. :)

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?