This morning started out with a pretty rough case. A woman we had briefly seen yesterday and reassured that she was probably fine, came back this morning with a partially completed miscarriage. It was especially distressing because she trying for her first baby and was running out of time on her biological clock. She was pretty upset when the doctor broke the news.
It was hard being in the room as the ultrasound was being done. She and her husband were holding hands nervously and awaiting the results while the two residents and I looked at the monitor. I am not at all qualified to read one of these yet, but even I could see something was very wrong from the scan. It's weird to be standing there, hoping you're wrong, just like the patient who is sitting beside you with just a bad feeling.
As I briefly mentioned before, when women reach 35 years old, they are considered "advanced maternal age." Older age during pregnancy puts women at higher risk for complications and having a child with genetic conditions such as Down's syndrome. First trimester miscarriages are usually due to fatal chromosomal anomalies like trisomies (having three of a chromosome instead of the traditional 2 (or 1 for Y)). Trisomy 21 causes Down's, but only a few other chromosomes are able to be duplicated and produce babies that survive to birth. These are 13, 19, 21, X and Y. The general rule is that chromosomes are sorted by size with the smaller ones being higher numbers, so if you duplicate one of the lower ones, you're more likely to run into problems by overexpressing all the genes encoded by the DNA. That being said, for whatever reason, chromosome 16 is the most common defect seen in spontaneous abortions.
One of the most important things to remember when you're diagnosing a spontaneous abortion is to be very clear with the woman that there is nothing she did to cause it. There is no one to blame. The egg was simply not viable. I feel like that is an important distinction too. They did not lose a healthy baby because of their body being old; their body was doing exactly what it was supposed to do - stopping a process that would never have led to a living baby.
I had a more pleasant moment of realisation later in the day. After staring at the fetal heart rate monitor at the nurses station, I noticed that one patient had a blue line tracing on the monitor alongside the red one I am used to seeing. In the labor side of the unit, a blue line usually means that a intrauterine probe has been placed after the membranes have been ruptured. But 1) this woman was nowhere near labor, and 2) there is no need for the external line once the internal has been placed.
I was asked to bring the woman some water, so I brought her a pitcher and some glasses. After she sat up to drink, we had to wait for the monitors to re-calibrate. As the lines reappear on the screen she says, "There's baby one... and... baby two!" And then I finally get that there's two lines because she's having twins.
TIL: We are somewhat handicapped regarding providing pain management to a pregnant woman. Tylenol is totally safe, but if that's not doing enough all we have are opiates, which though not very well studied in pregnant women are generally thought to be not very good for the baby on a long term basis. Of course, if the woman is in excruciating pain then the benefit might outweigh the somewhat unknown risk. I shall be researching this more...
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