Pregnancy Journal

I got a call yesterday from the nurse at my ob/gyn.

"We just heard from the perinatalogist with results from your exam and tests."

A little pit of panic opened up inside. The perinatalogist did blood work and the in-depth 3D ultrasound. The US photos looked good, but were the blood tests pointing to a problem?

"Based on your history of pre-term labor, they want you to start Makena shots as soon as possible."

What? My history? I have had 6 children. The first one was born at 35 weeks. The others were, in order, 38 weeks (an estimate because I never menstruated before he was conceived), almost 41 weeks, 41 weeks, 41 weeks and 40 weeks.  Yes, the first was early. But he weighed 6 lbs 11 oz, and other than being a little jaundiced, having some reflux, and being born with no eyebrows, he was fine.

He was born 3 days after I returned from a trans-Atlantic flight to England with my mom. We spent a week traipsing about the Cotswolds with my sister who was spending a semester at Oxford.  Flights were only $300 from Boston, and we were living in Rhode Island at the time.  I begged permission from a doctor at the Navy base (silly to say "my dr" because I never saw the same person twice) who said, "If you were 36 weeks, I'd say no, but go ahead and have a good time."  It was too wonderful of an opportunity to pass up.  One of the most memorable moments was my mother pronouncing the word "uterus" as we crossed paths with a group of young male students out for some ale. We were having some conversation about what would happen if I fell down, and my mom was explaining how the water in the uterus protected the baby.  I also discussing with my sister making a pit stop near the White Horse of Uffington. It was so foggy that we could have just squatted in the grass with privacy. No need for shrubbery. Did we or didn't we? And then there was the day we were exploring a little village and happened upon a church and an old rectory. I think it was the parish of Katherine Mansfield, but I've been known to mix details.  As we were strolling through the garden, the elderly inhabitant of the Olde Rectory shooed us away, informing us that visitors were welcome at the Rectory, not the Olde Rectory.

So anyway, I came home after a grand week, and turned right around to head back to Boston to meet up with my husband's brother and best friend from college. If I had had any understanding of contractions, I might have recognized signs of prodromal labor as we did the historical Boston walking tour, miles of it.  In retrospect, I might have prevented pre-term labor with an little sit-down and water.

But nonetheless, since then, I have never been encouraged to take progesterone or its new commercial variety, Makena, during any of my other pregnancies. In fact, I remember being told not to worry too much about being pre-term with the second one.  Of course, medical policies shift and change (no soft cheeses or sprouts?), but I see this recommendation as an example of why our medical system is broken.

Some issues:
1. I had never heard of Makena, so I did a little research.  These shots, given weekly starting around 20 weeks, cost about $700- $1440 a piece, and could run upwards of $30,000 per pregnancy for 18-20 shots. Meanwhile, shots of compounded progesterone are about $15 - so a total pregnancy cost of around $300.  Apparently these are now hard to find.  I have government healthcare through the military. Why should I pass on this cost to the taxpayers if I don't really need these shots?

2. One of the side effects of the shots is that they could cause pre-term labor and miscarriage, which they are supposed to prevent.  I know these lists of side effects are legally required and could be very rare if nonexistent. I don't doubt that the shot can help people who are at high risk of pre-term labor.  But I don't truly believe that I am high risk.

3. The perinatalogist offered me at least 4 different tests for genetic disorders. I could have said, let's do them all right there. Instead I agreed to do the AFP test, which I have declined in the past because of its high rate of false positive results.  If something amiss is indicated, then maybe we'll opt for additional testing, although another ultrasound may be sufficient to determine if we need to be prepared for anything unusual at delivery. He pointed out that one test comes from two different companies, one of which is significantly cheaper if our insurance declines to cover the other.  I get the feeling he can order up any test he wants and pass off the cost to insurance companies.

4. Why haven't my other doctors warned me of preterm labor or prescribed weekly shots? Am I really at risk or should I have stayed home back in 1997?

5. I intend to decline the shots. But as I was thinking about my little bit of research while I was jogging yesterday, I felt a little uncertain. What if I do go into preterm labor? Every pregnancy is different.  If I start having contractions and then deliver at 34 weeks or earlier, how awful will I feel about turning these shots down?  Doctors have a corner on emotional blackmail. If you don't do what they recommend and the worst comes true, you are responsible for whatever terrible outcome occurs.  I've thought about pointing out that these shots shouldn't be taken by someone with diabetes, and since I have tested on the border of gestational diabetes 3/6 times (I've failed the 1 hour glucose test every pregnancy), this is a pretty good excuse.

6. Pregnancy is a time of great anxiety, much of it irrational, and I'm sure doctors feel pressured to make sure everything turns out perfectly for their patients because of the history of parents pursuing legal action for those times when things aren't perfect.  The last time I saw a civilian doctor, with number 5, I had to start paying an extra $15 "education fee" halfway through the pregnancy because the doctor's malpractice insurance kept going up through no fault of his own. Another dr. friend told me about how a lot of OB doctors are leaving the field or not doing high risk deliveries anymore for the same reason.  So I get why doctors feel obligated to offer these tests and preventative medications.  I just wish they would give a straight answer about the real risks and benefits.

7. I was questioned by the nurse at my first appointment about why I didn't come for care until my 13th week. I couldn't really go into the whole reason - Well, I thought I was only 12 weeks, and my appointment originally was scheduled for the week before, and I hesitated before making the appointment because I thought I might miscarry/didn't want to admit I was pregnant, etc, etc. And I wasn't in a hurry to start the monthly dr's appointments.  -  So I told the nurse that I had trouble getting an appointment that fit my schedule. I knew not much happened at that first appointment. I had already picked up my prenatal vitamins weeks before at the clinic on base, so I was taking vitamins. Do you really need more than one appointment in your first trimester? Probably only if you might potentially terminate the pregnancy.

8. Found myself at a coffee shop table with a new mom in the spouses' book club.  I asked her where she delivered and which doctor she saw. Her dr. is in the same practice as the doctor I went to see.  She proceeded to tell me a lot of information about her birth plan, her labor, what she thought went well and what she would've preferred to have been different. She obviously had done a lot of research on pregnancy and delivery. I felt a little deceptive because I didn't admit that I have six other kids and that I'm probably 15 years her senior. Maybe she knew. I also kind of like pretending this is my first baby when I'm standing in line in the grocery store while the kids are in school, even though by the overflowing abundance of my cart it should be obvious that I have other kids at home.  Every baby is kind of like a first baby. This is my first baby as an AMA patient (advanced maternal age - shouldn't that be older than me?)

9. It seems to me that there's a lot of unnecessary procedure in maternity care - not to mention unnecessary stuff in maternity/baby productland. The only things I've really want to buy are a baby jogger and a car seat.  But I'm also susceptible to anxieties and fears for this baby and for myself.  Like every pregnant lady, I really kind of appreciate going to the doctor monthly for the reassurance that everything is fine, the baby is growing, your body is working as it should, even though for a normal pregnancy, those appointments seem a bit unnecessary.

10. I think I have begun to feel the baby move - or is it just a gas bubble? I want to trust that this pregnancy, labor, and delivery will be just as unremarkable and have the same happy ending as the others. But being out of practice and much older has me undeniably worried that some misfortune will befall us this time around. We have been incredibly blessed with healthy kids and uncomplicated deliveries. May the blessings continue.