Showing posts with label pregnancy. Show all posts
Showing posts with label pregnancy. Show all posts

Thursday, May 4, 2017

Boards, wards and...umbilical cord?

This is going to be one long rambling post. I know I've been mia (sorry KC). After finishing first year I just didn't have anything to write about. All I wanted was time to myself and with my family. Then second year came and went. I was able to stop pumping at lunch and ate lunch like a normal person (read: in the library, eating over my laptop, looking at slides). During winter break this year, we went on our usual family vacation to visit my in-laws and I spent two weeks loving life. I felt rejuvenated and was ready to attack the second half of 2nd year plus everyone's favorite, Step 1. Yes, I can do this, I am awesome and wonderful and multitasker extraordinaire. Want to see my color-coded Excel spreadsheet with my study schedule?

A few days into January, I felt funny. Funny, not like haha funny but rather oh shit I might be pregnant funny. I only had an expired cheapo Amazon pregnancy test. I don't think the second line could have appeared any sooner. It's just faulty, it's expired anyway (note: clearly scientific brain was not working at this moment.) My poor husband ran to CVS at 10pm at night and got me two real pregnancy tests and the first one I took turned positive just as quickly as the expired one. And then, I cried. We both didn't know what to say the rest of the night. We have two kids, we're living in student housing in a 3 bedroom apartment. I'm a medical student, staring down Step 1 and going onto the wards. He works full time and is doing a part time MBA. How would this even work? And for the next few days we honestly didn't know if we were going to go through with it and I found myself dumbfounded that I would be in this position, thinking about termination. Me, pro-choice advocate, having to decide for myself what my choice would be. I'll save you the drama and the back and forth, but long story short, we decided not to go down that route and we warmed up to the idea of having 3 (and by warming up, I mean we've accepted it and we're now excited but have no idea how we are going to deal with it come September). But can I just say how amazingly privileged am I to have been able to make a choice for myself, about my body? And equally important, privileged enough to have the resources to actually support another child. End political rant.

My first trimester was a blur of keeping up with school and keeping down my food. I had a meeting with my Dean and asked about what would happen to my third year "if one was to get pregnant." Luckily I was able to get a relatively decent rotation schedule and I start medicine during my late second trimester and finish with family and ambulatory before I go on leave. I just have to take my family shelf 2 days before my due date; I've already told my ob not to touch me during the month of September. I finished my last block of second year, which signified the end of my preclinical years. Somewhere along in there I had an NT ultrasound and my lovely doctor indulged me in a potty shot that revealed a penis, which after two girls, was amazing and surprising. I started studying for Step just as my second trimester began and the fog of nausea and fatigue magically lifted as if it was meant to be (but really, thank you placenta).

Alas, after weeks of studying, not seeing my family ever and having to rely heavily on the support of my husband, my mom and my nanny, I sat for the exam with baby belly, braxton hicks and stretchy pants with no pockets (so they don't make you turn them out during security checks!). I definitely felt a few kicks during the exam, cramped up a few times, but surprisingly 7 hours of testing with a fetus sitting on my bladder went by pretty quickly. And now, I have a few days off before 2 weeks of bullshit pre-wards orientation that are mandatory and then we're off to the wards.

I received an email today from the school letting me know I can't go to one of my doctor's appointments during said bullshit pre-wards orientation, that it's against policy. Because, you know, from 7:30am-5:30pm they're going to keep us prisoners with no breaks, no time for lunch or for me to slip out and see my doctor across the street. That I can do my glucose screen and prenatal check at another time (read: while I'm on call. On internal medicine. At the county hospital. An hour away from campus.) because that makes so much more sense. What bothers me most is this. I don't expect any sort of special treatment. Never in my 2 years at this school have I lamented about being a parent in medicine. I've never asked about more time for studying, I've never been absent. I haven't even taken a sick day. I've passed every single one of my exams and I've always made adjustments on my end to make things work on their terms. My school has ironically created a program called Parents in Medicine. Whoever goes to these events I'm not sure. I don't really know what the program actually is because if you're truly a parent in medicine, you don't have time to go to these things. While I appreciate that they're thinking of us, they're really not thinking of us the right way. We don't need to have events to talk to other parents in medicine and commiserate together about the system. Sure, having a fun family day is nice, but I can do that on my own. What we need is academic support and administrative support. I need to be able to go to a damn doctor's appointment, not have a 2 hour get-together in a park that I can't even attend because I'm studying. I need someone to answer my email that I sent out months before the start of said orientation about scheduling a doctor's appointment. End pregnant-lady hormone-driven rant.

Drama aside, I am excited to get on the wards and finally be closer to "practicing" medicine, but I'm also slightly terrified. I'm afraid of looking dumb, looking too pregnant, looking dumb and pregnant. Being away from my family and missing important events. Oooh and giving birth on the wards or during my shelf exam because I insist on finishing. Ironically the first rotation I'm on when I'm back from maternity leave is ob-gyn, so essentially I'll deliver baby boy huffing, puffing and screaming and then join the team a few weeks later - hey guys, remember me and my vagina? I'm already done with my birth plan. It reads like this: "No medical students please." Sorry guys, but let's be honest, it will be hard to pretend I don't know you.

Hopefully I'll have some time to write about being pregnant on rotation. I'm sure I will have some lovely stories to share.

Thursday, January 19, 2017

How did you manage pregnancy symptoms at work? Share your stories!


Pregnancy is not an illness. It’s usually a joyful time in one’s life. But man, can it make you feel AWFUL. Morning sickness, fatigue, swelling, brain fog... Everyone experiences these things differently, but almost everyone is going to have something. Rare is the mom who can rosily exclaim “Gee, I felt WONDERFUL throughout my entire pregnancy!

Even in the same person, pregnancy can present differently. With Babyboy, I had very little nausea; rather, I had weird intense cravings for salty things (like sardines). So, when I learned I was pregnant with my second, I went out and bought cans and cans of sardines. Surprise! Not only did the mere whiff of sardines make me nauseated, that’s how I felt for the whole nine months.  

“Morning sickness”, which, in my experience, can last all day, is different for everyone. It can mean queasiness, or hurling. I have friends who required admission for hyperemesis gravidarum. All the ginger tea and Zofran on the planet doesn’t help, sometimes. 

I got through by only eating what I could tolerate: carbs. Sixty pounds later...

Swollen legs, incredible fatigue, brain fog... these are some of the other symptoms I experienced. I finagled "pregnancy parking" close by work at the end of my first pregnancy, when the summer heat made walking unbearable. I've heard of doctor-moms who managed to steal naps here and there... And for brain fog? I don't have any ideas what can help. 

What about you? Share what symptoms you had, and how you managed them. The info can help another doctor-mom!

Thursday, December 29, 2016

(all is not) lost

There was a heartbeat. I saw it on the ultrasound, but I knew immediately something wasn’t quite right. Was it too slow? Yes, the ultrasound tech said she noticed that too and gave me the wise, all knowing look of a Black grandma who can’t quite tell her granddaughter that something is wrong.

And then there was none at the ultrasound 2 weeks later. I asked the next ultrasound tech to angle the screen when I didn’t see movement. Saw the look on the Radiologist's face and then the Fellow. No heartbeat. The tears began to flow. My body began to shake. I held in the sob knowing if it began here with these strangers it wouldn’t end until I was safely tucked away at home.

You were there. I saw you. You were there. And now you’re not. When did you leave me? My heart breaks. I type through my tears.

I am at home. Grieving. Surrounded by loved ones.

I cry now as I type.

“Mama, are you crying? Did you have a nightmare? Are you frightened?” I stifle my tears. Say to Zo through closed door “I’m okay. Mama’s okay.” He calls out for me and O from his room after bedtime. O goes and comforts him and calls me into his room.  I gather myself, wipe my tears, blow my nose. Zo rushes into my arms “Mama, are you okay? I was having a good dream but then I woke up. Why are you crying? Everything will be okay.” As he gently rubs my face with his amazingly soft 5-year-old hands. As he pats my back. As he rubs my belly. As our family holds one another.

All is not lost in spite of this major loss. You were there. I saw you. You were with me. Now you are not there. But my husband is here. And my Zo is here. Their hearts are strong. My heart is strong.

The stories from friends poured in over the last few years. We are all in our 30s. Gut-wrenching stories of second trimester terminations due to fetal diagnoses incompatible with life. The heartbreaking call telling us of a stillborn nephew. Friends with years of infertility. A family member with seven losses. Stories of rainbow babies after loss. Countless miscarriages. Flashbacks from medical school of being present with sobbing women in the antepartum unit when their ultrasounds showed the absence of heartbeats. I didn’t understand then how the loss of something (a baby? A fetus? I didn’t know what to call it then) not yet realized could cause these women to sob uncontrollably. But I do now. From the moment I saw the positive sign I was hooked. Head over heels. Then the heartbeat. My growing belly. Zo’s “mama, is there a baby in there cuz I think there is.”

I was so excited to tell him he was going to be a big brother but I didn’t because I knew things weren’t quite right and it was all too soon, too early, too many things could go wrong - and they did. But he knew. He knew yet we feigned ignorance.Told him I would go to the doctor to find out.

All is not lost. You were there. We were together. Our family is still here and you will always be with us. We will go on. For we are not lost.

Wednesday, October 5, 2016

Would You/ Did You Deliver In Your Own Hospital?

Genmedmom here.

I could not have imagined going anywhere but the OB/GYN office down the hall from mine. My lovely OB was a clinical instructor in the same course as me, and I ran into her at the medical school from time to time, in between my prenatal appointments. She'd seen my cervix and God knows what else was going on down there, and yet we would find ourselves standing around pleasantly chatting about curriculum changes while sipping lukewarm coffee. I didn't care.  

Just take good care of us.

Still, with my first, I went a little psycho around delivery. I created an annoying three-page natural-no-epidural birth plan with all sorts of stipulations: no med students, minimal residents, no male anybody.

Ha. When the meconium hit the fan, there I was being wheeled into an O.R. crowded with every level trainee and both genders well-represented, and I didn't care.  

Just take good care of us.

Babyboy had to be rapidly and forcefully extracted: hauled from above and pushed from below. But he was born and he was healthy and all was good.

For my second, I had no plan. I was so traumatized by how violently OPPOSITE everything had turned out from what I had envisioned the first time around, I couldn't make any decisions at all. So my lovely O.B. firmly (but nicely) guided me through a successful VBAC.

I've seen her around since and we are very friendly. I've probably also run into multiple nurses, residents, and students who were witness to my howling hysteria in one or the other delivery, but I can't remember who was there from either so who cares.

Personally, I'm glad that I delivered with a physician I know professionally and admire. I could never have managed going to any other hospital but my own anyways, too inconvenient. 

But not everyone feels the same way. The question occurred to me: Where do OB/GYNs deliver? Do you guys generally prefer your own or a different hospital?

How about other specialties- OB anesthesia, what about you? Does it vary at all by specialty?

Maybe it just has more to do with individual comfort level with the total, supreme lack of privacy, and knowing you will be definitely be observed if not at your worst, then at least, perhaps, not at your best.

I'm very curious about this, as I am covering this topic for a doctor-mom writing project. Please, share your perspectives! Inquiring minds will want to know.


Wednesday, March 9, 2016

MiM Mail: Share your anecdotes about pregnancy and maternity leave

Hi fellow mothers in medicine, I'm currently a resident and pregnant with baby #2. I must say that the attitudes I have encountered throughout this pregnancy from my attendings and peers have been discouraging. I'm working on writing an op-ed piece about attitudes toward pregnancy and maternity leave among US physicians and would love to have more quotations and anecdotes from your experiences. Positive and negative comments are welcome (please comment below)! Sadly, mine have been mostly negative. Thanks so much!

Tuesday, March 1, 2016

Let the Mystery Be

Our little man will hopefully make his appearance (hopefully in a much shorter and less painful way!) in the next few weeks… I hit 37 weeks a couple of days ago, and for me, this is uncharted territory as I went into labor with our daughter at 37 days on the dot. This has really felt like a milestone- as residents, we live our lives in month-long blocks, and the past two blocks have been the most intense physically and hours-wise rotations we have in our pathology program. We're all still in one piece though, and for that I am grateful. We met with our volunteer doula this past weekend, finally acquired a car seat, and took inventory of all the leftover clothes I had stashed from my daughter (mostly gender neutral, thankfully!) that we’ll be able to use again. This is finally feeling like a reality.


I wanted to share the strangest experience I had this weekend which I haven’t been able to shake. I’m sure many with multiple children relatively close together can commiserate over how different subsequent pregnancies are from the first…  Beyond our work, our focus has been survival and spending as much quality time as possible with our daughter and being a family of 3. It’s been easy to forget about the pregnancy, and actually I’ve done a pretty good job at ignoring it so I don’t worry haha.. But this time, there have been no photo diaries week by week, no journal entries to my fetus, no shopping trips to buy anything special.


One experience we really treasured the first time around was going to one of those recreational 4D ultrasound places to find out the sex and see her face. We actually went twice- once around 15 weeks and once later on, maybe 25 or 26 weeks. I remember how much we stared at those photos- we even had one framed which I brought to my delivery haha. Her face was so beautiful... I still love looking at those photos in utero and seeing her face in them, her little button nose and full lips. Anyway a couple weeks ago, while feeling guilty realizing how little time was left and how little we had done, my husband and I decided to try to find a similar U/S place in the city we live in now. The place with the best reviews was far- over 30 minutes away- but we thought we owed it to our fetus to be appreciated for a morning and to let our daughter see him, haha. But it was actually disappointing… it was sort of a weird sterile office, not at all a warm fuzzy baby-friendly environment like we experienced back in California. Also, previously, we had to sign that we were receiving prenatal care and write down the name of the hospital and Ob practice in case there were any abnormalities that needed to be reported;  at this place, all they took was our name and EDD. And unfortunately, our little guy was totally covering his face with both hands and feet at the session, so they invited us to come back for another look in a couple weeks.     


So this weekend we went back to test our luck, and while in the waiting room, the doctor/owner of the business (radiology IMG, not practicing here; his wife seems to be the ultrasound tech) came out and asked if I could come help him with translation issues with his current Brazilian client that couldn’t speak English. He knew I had an MD, but I was caught off guard. Without thinking too hard, I shrugged and said, sure, I only had patchy Spanish and Italian to offer but maybe it could be a bridge to their Portugese. I entered the room to find a young couple with their two older sons, maybe 7 and 9. The woman looked scared. I started to feel scared. According to her LMP, she should have been around 10 weeks along. No cramping, no bleeding since. Regular periods prior. Apparently, no insurance and she hadn’t seen an Ob or PCP- only positive HPTs. The problem was that no heartbeat was detected, and she was measuring only around 5 weeks. My heart sank. It was clear they had all come to share the joyous occasion of seeing the baby for the first time as a family. I was so sad for them as I had been in the same position a year prior, the ultrasound planting the first seed in my heart of the possibility of miscarriage to follow. We tried to explain as gently as possible that time will tell whether the pregnancy will continue. But I was upset that I was in this unexpected position. I was upset that she didn’t have a doctor of her own. I was upset that she was receiving this information in this setting. I tried my best to encourage her to establish care with an Ob as soon as possible, but it seemed unlikely that it would happen.


I keep thinking about her today and wish the best. I truly hope this is a dating issue and that her pregnancy will progress. I keep thinking of my own miscarriage, the ordinariness and near universality of the experience and how isolating, unique, and devastating it still feels. I think of the miracle of our family now ready to welcome a boy just a year later. Of all the health we take for granted. I think of the fragility of our children, that this is all the beginning… by gaining so much in love we also have so much to lose. But I remind myself that the alternative, of not opening our hearts to the potential of more love and family, is also a sort of loss. I was reminded of this old song by Iris DeMent, called “Let the Mystery Be,” which expresses her coming to terms with rejecting organized religion (she grew up in a big religious family I believe) in a really beautiful way... I often sing this to myself when I feel like I need to let go and not worry... so much unexplainable mystery in life.     

Here is the brief and only glimpse our little one gave us of his face in the two ultrasound sessions. He wants to stay a mystery and I accept that. I just can’t wait to kiss those chubby cheeks and lips and see what the rest of him looks like… well, maybe I can wait just a couple more weeks :)  



Sunday, February 14, 2016

Linea Nigra

I'd learned of it in medical school but never thought I'd have one. I looked for it all throughout my pregnancy, staring down along the midline of my gravid belly. Some telltale signs were there - the nausea, shortness of breath, tender breasts, swollen feet... But I never developed a huge, round, glorious belly that announced the joy of impending birth. Even with the twisting movement of a fetus anxious to emerge, it was hard to believe that this was all real. After years of wanting, of shots and procedures and waiting, it was finally here. But would she come out ok? What would she look like?

Then one day she arrived and they placed her on my belly, now saggy from where she was growing. She was beautiful, and I was immediately in love. Nothing else mattered. The nurse came into the room and announced, "It's time to mash on that uterus, shrink it back down!" It was then that I saw it: a faint, fine, dark line running from my belly button to my pelvis.

It's the tattoo of motherhood, one I never wish to erase, but I know they usually fade after birth. For this year, it's a gift to me from my daughter. A most perfect Valentine.

Monday, January 25, 2016

The Birth Plan

I was 37 weeks pregnant and had just completed a busy Monday in the OR, my last scheduled shift before maternity leave. While relaxing in front of the TV that night, I found my fetal kick count to be significantly lower than normal. I spoke with the on-call OB team, and after going back and forth, we decided it was best if I go to the hospital for further monitoring. I threw on my slippers and jacket (was already in pajamas) and said, "See you in an hour or so," to my husband. I never made it home that night, and six days later I brought my baby girl home from the hospital!

The fetal non-stress test showed that she was ironically doing well, but my blood pressures and urine sample showed that I had developed preeclampsia. My leg swelling was increasing over those last few weeks, but things just got real. My husband dutifully showed up with my pre-packed bag and birth plan. Yes, I had a birth plan - but not the long, detailed essay that some women present to eye-rolling hospital staff, replete with all sorts of unrealistic demands involving birthing balls, hot tubs, candles and music. As an anesthesia resident on the obstetric service, we used to joke that those women with the most detailed and rigid birth plans would inevitably be the women who ended up with "emergency" epidurals at 3 AM, or worse in the OR for a crash C-section.

Instead, what I provided was a one-page sheet with an outline of my complicated medical history and a few important preferences for my care. Because I have adrenal insufficiency and am steroid-dependent, it included a regimen for stress-dose steroids from my endocrinologist. I made it clear that I desired an epidural and that I was ok with all monitoring and testing deemed necessary. I listed a few if-then decision statements regarding vaginal birth vs. C-section. For instance, if I had a vaginal delivery I wanted immediate skin-to-skin contact and delayed cord clamping... if baby is stable.

The feedback I got from nursing and on-call staff about my birth plan was good; they seemed appreciative of the precise and explicit set of preferences that could be passed on through numerous shift changes. I will say, however, that even with my minimal birth plan as a "good luck charm", things still didn't go the way we had originally hoped. And yet, once my daughter was born, none of that mattered one bit. Meconium was present on delivery so she was handed off for resuscitation instead of immediately placed on my chest as I had hoped, we couldn't do delayed cord clamping, etc. But she was healthy! I was lucky to have a smooth albeit slow induction with no complications and a quick period of active labor (only 45 minutes of pushing). We didn't have to go to the OR. I only needed two stitches post-delivery. Again, she was alive and she was healthy! After experiencing a pregnancy loss, I admit that a fear had persisted deep inside me even into the late months of gestation that I would lose her without getting to see her face.

Nothing went exactly as expected, and yet everything turned out fine. Nothing went exactly as expected, and yet everything turned out fine. This is my new mantra, and it would be a good one for all pregnant women to adopt. Because in the instances of labor and childbirth, resistance and rigidity pose potential risks to both mother and baby.

Have you had an experience with a birth plan, either yours or a patient's?

Monday, November 23, 2015

MiM Mail: Making residency safer for pregnant residents

Mothers in Medicine! I am seeking your advice/expertise on the difficult subject of how to treat pregnant residents. A little background: I am a chief resident at a busy anesthesia program that takes frequent and draining 24 hour calls in the OR. Those calls are such that, most of the time, the call room is a distant fantasy. I am also a mom to an active preschooler and pregnant with #2. All was going well until after a particularly exhausting 24 hour call, when I started having frequent, regular contractions at 20 weeks. I had to take several days off work and (thankfully!) things calmed down. I'm now trying to ease myself back into the OR call rotation.

My question for all of you who have been through a resident with tough, frequent 24 hour calls or night shifts... how did your program handle pregnant residents? I've heard from friends at other programs about policies that were put in place to limit calls because so many pregnant residents were going into preterm labor. Other programs limited night shifts for the same reason. Obviously, these changes put strain on non-pregnant residents. Was there widespread resentment to enacting such restrictions?

Amazingly, I'm the first resident to be pregnant at our program in over a decade, but I know there are many women behind me hoping to do the same. I'm hoping to find some common sense changes that can be made to keep pregnant residents working, but in a safe way for mom and baby.

Thanks in advance!

Monday, October 19, 2015

Hormones and shots and procedures, oh my! What is it like to undergo IVF?

People are having children later in life, whether the reason is pursuit of career aspirations, travel, or riding the asymptotic curve to financial security. This truth is never more evident than in the field of medicine, where more and more women are taking the long road of training to become physicians. Some of us (like me) even choose this training as a second career, rendering us older from the start. You've heard saying such as "40 is the new 30", etc., but the reality is that a woman is born with all of her eggs and those eggs age with her. She may follow a perfectly healthy lifestyle and appear younger than her real age in many ways, but her eggs are as old as she is.

As eggs age, their quality declines in the form of DNA damage, which negatively effects their ability to make a healthy embryo that will grow into a healthy baby. By the age of 40, the percentage of eggs that have DNA damage incompatible with healthy embryo formation is approximately 75%! On top of this immutable fact, aging brings the possibility of medical issues that can affect fertility in both a mother and a father. The chance of a naturally-occurring pregnancy during any given monthly cycle of a 40 year old woman is approximately 5-10%, and due to the DNA damage I already mentioned, the chance of a live birth resulting from that pregnancy is even lower. It is truly a miracle in my opinion that women over 40 have spontaneously-conceived, healthy pregnancies.

Enter in vitro fertilization (IVF). IVF is a long and detailed process, requiring lots of resources, money, time, and patience. The first stage of a typical cycle involves, ironically, taking oral contraceptives to reset the hormone milieu and force all eggs into a senescent, follicular stage. The second stage involves stimulating the ovarian follicles with daily doses of a hormone cocktail. It is usually some combination of FSH, LH or an LH inhibitor depending on timing, and possibly GH. There is quite a bit of monitoring at this stage, including almost daily ultrasounds and blood draws to evaluate the growth and maturation of the eggs. The third stage is egg retrieval, in which all fluid-filled cysts within a certain size distribution are aspirated for the contained egg. The eggs are then fertilized with the intended sperm (by various methods depending on the presence or absence of male-factor infertility) and are allowed to grow for 3-5 days into multi-celled embryos. The last stage is embryo transfer, in which selected embryos are injected back into the uterus for implantation. This may occur using the aforementioned, freshly grown embryos approximately 5-6 days after the transfer, or the embryos can be frozen for testing and/or later transfer. Once an embryo transfer occurs, it's up to fate (and continued hormonal supplementation)... after the dreaded "two-week wait", it's time for a pregnancy test!

As you can imagine, the process is not for the faint of heart, nor is it for the person with no flexible time and no extra money. I had to do IVF to get pregnant, and these are my experiences.

Time: If a fresh embryo transfer is planned, all of the steps mentioned above take approximately 6-7 weeks to complete (not including the two-week wait). If the embryos are intended to be tested or frozen, the first three stages themselves take 5-6 weeks. After the egg retrieval, the ovaries must rest and the enlarged follicles must resorb over time. This is achieved by having a period and going back on oral contraceptives for at least 3 weeks. Then the uterine lining is augmented with estrogen supplementation for another 3 weeks prior to the embryo transfer. During this time, other testing may take place for the patient (such as a hysterosalpingogram, hysteroscopy, or endometrial biopsy) and/or for the embryos (such as preimplantation genetic screening for aneuploidy or diagnosis of genetic diseases).

Not only does each pregnancy attempt take a significant portion of a year (during which time a woman's eggs undergo further aging), but each cycle also requires quite a few appointments for monitoring, lab draws, procedures, etc. Although I sometimes had to apologetically make my schedule requests after my practice group's time deadline, I was lucky to have enough vacation time built into my yearly clinical commitment that I could take as much time off as I needed. Not everyone would need to take the entire day off for an hour-long morning appointment, but as an anesthesiologist I found that it was the only way to make things work. A physician who sees patients in a clinic might be able to shift her clinic hours back a bit to make morning appointments - which occur every other day and at times every day during the stimulation phase of a cycle. And at my fertility clinic, the egg retrievals were conveniently performed on the weekends.

Money: With some exceptions, IVF is commonly not covered under health insurance in the United States. That said, I found that certain ultrasounds, lab tests, and medications would occasionally be covered by my insurance based on the fact that they were recognized as appropriate interventions for my preexisting infertility diagnosis. Prices for IVF vary slightly depending on the part of the country where the fertility clinic is located, the medications prescribed, etc. A typical cycle including the stimulation period, monitoring ultrasounds, and the egg retrieval procedure runs $12,000 on average, not including medications (another $3000 - $5000). A frozen transfer at a later date is approximately $3000 - $5000. Preimplantation genetic testing of embryos adds approximately $5000 - $8000 to any particular cycle. A portion of these costs can be offset using "batching" techniques or multi-cycle discounts, tax deductions (in some cases), and an FSA; however, IVF in its many forms is undoubtedly going to present some financial stress for any patient.

"Heart": Egg retrievals are performed across the country using different modes of anesthesia. At the IVF clinic I used, it was treated as a moderate IV sedation procedure with fentanyl and midazolam; however, there are some clinics that do deeper sedation or even general anesthesia. An embryo transfer, regardless of whether it is fresh or frozen, is usually done with oral diazepam, and the patient does not need to be NPO. Prior to either of these procedures, an IVF patient can expect to have many transvaginal ultrasounds, which can be uncomfortable for some women. There are other diagnostic procedures that may figure into an infertility workup or IVF journey treatment plan as well, such as hysteroscopies, biopsies, hysterosalpingograms, etc. In addition to these procedures, the patient must receive daily injections of hormones during the follicle stimulation phase and sometimes additional daily shots after implantation. Most of these shots are subQ, but some of them are IM. I must admit that I myself am somewhat squeamish when it comes to being a patient, but I found the invasive nature of IVF to be tolerable. The mental aspect of the uncertainty, the waiting, the rescheduling of life so that appointments and cycles can be completed, etc. was much more difficult. But if you are a person who does poorly with procedures, this may be an important factor in your IVF decision path.

Speaking of decisions, IVF can take a toll on personal relationships - friendships, family bonds, and romantic relationships. This usually presents in the form of differences in opinion on direction of care, number of IVF attempts, or ethical issues with genetic testing/embryo selection/possibility of multiple gestation/etc. Going through IVF can also impact your feelings about yourself; many women complain of feeling unwomanly, and I was not immune to this myself. It is difficult to accept that you need assistance achieving something that is so basic to human life as reproduction. I dealt with this through therapy, quiet time/meditation, and journaling, but everyone differs in terms of what works for them to manage such stress. I recommend to every woman undergoing IVF that she at least attempt to get therapy for herself, if not couples therapy for her and her partner.

IVF is a physically and mentally involved endeavor. Copious time, financial allocation, and mental fortitude are required. But for many patients with complex infertility issues, it is their only path to genetic parenthood (as it was mine). I'm 32 weeks pregnant now and I am very happy with the path I took to get here. As a "success story" with a little girl on the way, it was all worth it!

Tuesday, August 25, 2015

Pregnant in the OR: Potential Hazards

Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren't given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:

Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.

Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.

Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement... I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).

Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.

Stress. This is the most difficult "hazard" to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.


I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.

For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!


References:

Keen RR et al. Occupational Hazards to the Pregnant Orthopaedic Surgeon. J Bone Joint Surg Am. 2011;93:e141(1-5).
Fowler JR and L Culpepper. Working During Pregnancy. UpToDate, 2015.
Radiation and Pregnancy: A Fact Sheet for Clinicians. http://emergency.cdc.gov/radiation/prenatalphysician.asp

Monday, June 15, 2015

Pregnant in the OR: When to Tell


I was 5 weeks pregnant and working in the spine room. Just as I finished my intubation and secured the airway, I turned to set the ventilator and administer some important medications. The surgery fellow started to position the fluoroscope near the patient's cervical spine, about a foot away from where I was working. "Please don't use the Xray right now; I need to put on a lead shield first," I said. "Yeah, ok... whatever..." he said, as he continued to fine-tune its position. Thirty seconds later he sighed, then started pushing some buttons and eyeing the screen. I looked at him sternly and said, "I'm serious. Don't do it. I'm pregnant."

After coos and congratulations from the fellow, resident, nurse, and scrub tech, I felt a bit awkward. Of course, I myself had just learned of my pregnancy; I hadn't even seen a heartbeat on ultrasound yet! This wasn't the way I expected to tell people my good news, and I really wish I hadn't been forced to do so in that situation. That being said, I really didn't want the radiation exposure at that time. I suffered a miscarriage a few weeks later and then had to engage those same people in some very awkward conversations.

The decision of when disclose a pregnancy in any situation is a highly personal one. Unfortunately, there is a lot of misguided shame surrounding miscarriage in our culture, and thus many expectant moms often wait until their first trimester has passed in order to disclose the good news. But in my line of work, there are clear benefits to telling others earlier rather than later. First, anesthesiology (like surgery and many other specialties for that matter) is a relatively physical practice. Say you're feeling faint during a procedure, battling nausea, needing frequent snacks, or have a constant urge to urinate. People are going to think you're having issues and might worry about your work performance... unless of course they know you are pregnant, in which all of these situations are commonplace and understandable.

In terms of shift scheduling, call assignments and specific work days for any given week are often determined well ahead of time. Usually, requests for days off or vacations are done so about 1-2 months in advance; however, because I work in an academic hospital, the summer poses a major scheduling challenge due to new resident orientation/training. If a baby is due in the summer, special arrangements need to be made so as to not impact the delicate balance of staffing during the transition period for brand new residents. In a private practice situation, far advanced notice might be necessary if the due date is around a major holiday. Therefore, alerting the appropriate vacation/call schedulers to a pregnancy earlier rather than later may affect your entire practice group.

In addition, pregnancy status may impact daily work assignments. At my institution, the schedulers try to avoid giving pregnant women assignments that involve consistent or high doses of radiation, such as what is encountered in the interventional radiology suite or cath lab. (I hope to address this more in a future blog post.) It's difficult to avoid assigments in orthopedic rooms since these cases are so ubiquitous, but you might want to also alert the nurse and scrub of your status so that when they mix the methacrylate joint glue, you can step out to avoid the fumes. And you definitely want your protective lead suit if a fluoroscope is in sight!

Just like disclosing a disability at work, it's a "know when to hold 'em, know when to fold 'em" situation. The right point to fold will be different for each individual. Because my first pregnancy (the one in the story above) ended in miscarriage, I was initially keeping things much quieter with my current pregnancy. However, a similar situation with the fluoroscope still happened again at 7 weeks! I got zapped twice in one day despite my veiled warnings, and after the second time I frustratingly blurted out my news to everyone in the room. Of course they paused, congratulated, and then took things much more seriously in the radiation department. It shouldn't have to be that way, but unfortunately most people are very nonchalant about radiation exposure.

Aside from that incident, I waited until about 10 weeks before I was open about my pregnancy. After I had a couple of ultrasounds under my belt and my IVF docs told me that my miscarriage chance was very low, I notified our anesthesia scheduling partners of my status. They have respectfully given me lower-exposure, lower-stress assignments (like fewer, less physical cases per day with limited fluoro, etc.) As far as other pregnancy symptoms are concerned, I have had my days of nausea and moving slowly, but it hasn't seriously affected my performance at this point.

Has anyone - trainee or practitioner - experienced issues with disclosing a pregnancy? Share your thoughts with us!

Thursday, May 14, 2015

MiM Intro: PracticeBalance

Full disclosure: I am not a mother... yet. But I will hopefully (finally) be one soon!

Like many women in the medical profession, I delayed my plans for starting a family until late in my residency training. I initially worked as a chemical engineer, and I also traveled extensively to rock climb prior to deciding on medicine. In addition to entering the medical field a bit later than average, I frankly wasn't ready to be a mom when I was a medical student. I found the amount of work ahead of me to be exciting but also overwhelming in the face of a potential pregnancy/childbirth/parenting etc.

About half-way through my anesthesiology residency (coinciding with my 35th birthday), my husband and I decided it was time to start trying. Only one thing stood in the way: I hadn't had a period in several months. I had always been irregular, but those irregular intervals had increased during internship to an eventual standstill of menstruation. After ignoring this warning sign for a while, I finally sought the help of a reproductive endocrinologist. This initiated a long journey with many blood draws, tests, and time off which finally revealed that I had a large pituitary tumor causing severe hormonal disregulation. My experiences managing both physical and psychological stresses during medical training prompted me to start my own blog, PracticeBalance.com, in 2011. I continue to write regular posts there about stress management, being a patient, and self-care issues.

After my tumor removal, I have suffered from continued hormone deficiencies, which means that I need to use assisted reproductive techniques to get pregnant. I started following Mothers in Medicine a few years ago, around the same time that we actively began trying to conceive. I work three days per week as a purely clinical anesthesiologist (no research or teaching responsibilities) in a large academic hospital - what I'm hoping will be the perfect setup for balancing a career and motherhood!

So now here I am, currently expecting my first child - three years, one miscarriage, and thousands of dollars later. I hope to bring a perspective to the MiM community about what it's like to be an expectant mom (and then eventually a new mom) while working in the operating room. I could also write about what it's like to be an IVF patient (who happens to be a medical professional), if there is any interest in that. Currently I am experiencing a lot of apocalyptic worry regarding all that could go wrong in my pregnancy - feelings born out of both having had a miscarriage in the past and having work-related experience with all the "bad things" that can happen.

Please let me know what you'd like me to write about by leaving a comment below. I'm excited to be here and look forward to hearing from you!

Saturday, May 9, 2015

Hello from CaliMed

Hello MiM!
I'm excited to be joining this fantastic community that has helped me tremendously from the time I started thinking about medicine to now, 12 weeks shy of starting my first year of medical school. A little bit more about me, my background is in finance, but after a few years on Wall Street I knew I was going down the wrong career path. After having my first daughter in 2011, I realized if I really wanted to go for medicine, I had to get on it. I am extremely lucky to have a supportive husband and thus started my post-bac when my daughter, SK, was 1. Because I was a finance major in college I had to take all the pre-reqs and although I've always loved school, I learned that studying with a toddler in tow was a completely different experience than my undergrad years. (Like that time SK accidentally locked me in the garage like a prisoner before my organic midterm...)

Now said princess is turning 4 in June and we are expecting another in a matter of weeks. It was my plan all along to squeeze another child in before the start of school, but the window was limited and tricky. At one point I was clearly delusional and considered being a "little bit" pregnant for the MCAT, but thankfully came to my senses. I am sad that baby #2 will still be tiny when school begins, but I know I am luckier than most to have the flexibility that comes with being a student.

I am really looking forward to sharing my journey through school with you all. I have to confess, I feel like quite a newbie - I've done the mom thing for a while now, but I've just started the medicine part. And with so many wonderful members in this community who are much more advanced in their careers than I, I am curious what others would like to see from me. Please let me know!

And now I will leave you with my brilliant plan for the next 12 weeks before I take the plunge into medicine:
1. Pack up house and move most of our stuff to new city.
2. Rent out current place.
3. Host fantastically awesome Rapunzel birthday party for SK at 38 weeks pregnant.
4. Pop out baby #2.
5. Move the rest of our stuff and drive down to med school.
6. Get situated (make sure SK likes school, find nanny (!), get to know area, figure out transition from life with 1 kid to life with 2, oh and unpack)
7. Start school and balance marriage, 2 kids and student-life like a boss*

* TBD. May need help with this one, but absolutely thrilled to be pursuing my dream.

Cheers all!

Edit: I wrote this post before I saw Cutter's post from yesterday. After reading it and all the comments below which seemed to offer a resounding and unanimous "no" to her question, I realize my post may sound slightly manic and also maybe naive. But I am honestly very excited for this new experience that lies ahead and think it would be wrong even, to make such a drastic change in my life and not put everything into it. I have so much respect for Cutter and all the women in this community who have taken the path that I am just now embarking on. And I would be lying if I said I was not affected by some of the comments. But I was also very encouraged by the fact that many of you absolutely love what you are doing. I know I have a lot to learn and I may feel differently down the line, but for right now, I can't look back and can only look forward and say yes. 

Thursday, December 22, 2011

The 20 Stages of Pregnancy

1: Disbelief
"How did what we did that other night create a human life? Is that possible?"

2: Panic
"OMG, how am I going to manage a whole other person?"

3: Denial
"I'll bet my period will come any day now. 30% of pregnancies end in miscarriage."

4: Panic 2
"Oh no! I'm spotting! What if I lose the baby??!!"

5: Fatigue
"I'm so tired all the time. How am I going to manage a whole other person?"

6: Discovery
"Maternity clothes are so cute! Even I look good in them. And I love my Bella Band."

7: Emerging love:
"Aw, she's hiccupping. That's so cute. I love her."

8: Acceptance
"Pregnancy isn't bad at all! I kind of like it! And I get to eat everything I want!"

9: Anxiety:
"Oh god, I'm gaining too much weight. I need to stop eating everything I want."

10: Panic 3:
"I don't feel the baby moving. When I last feel her move? Oh god, oh god. I'm going to press on my stomach and bother her till she moves."

11: Weariness
"For the millionth time, it's a girl, and yes, I AM tired. Should I wear a sign on my chest?"

12: Disgust:
"Look at my giant belly. Nobody will ever find me attractive again."

13: Living it up:
"Let's go out to dinner since we won't be able to do it once the baby comes. Let's see a movie too. An R-rated movie."

14: Dread:
"I won't be able to do anything once the baby comes. This is so depressing. Why did I destroy my life this way? Things were so good before."

15: Cuteness overload
"Lookit these teeny baby clothes! So cute! I can't believe I'm going to have something teeny enough to fit into these teeny clothes!"

16: Fear:
"What if I need a C-section? What if the epidural doesn't wear off? Labor is going to hurt a lot, isn't it?"

17: Weariness 2:
"This baby needs to come out of me RIGHT NOW. I literally can't stand it another minute. I'm going to have sex, eat a jalapeno, and jump up and down till I give birth."

18: Nesting:
"OK, I'm finished cleaning the entire house, assembling the crib, and painting the baby's room. Now I'm going to finish writing my novel."

19: Acceptance 2
"You know what? Whatever happens, I'm good. The baby can come any time she likes."

20: Panic 4:
"Oh no, I'm going into labor! I'm not ready! This is going to HURT!!!!"