Friday, March 10, 2017

An Rh Sensitized Pregnancy (Part 3)

Somewhere between 30 & 31 weeks

 About 28 weeks into my pregnancy, my baby started to show potential signs of anemia.

At that point, we'd been doing weekly ultrasounds for quite some time (I've honestly lost track of how long exactly). Half of those ultrasounds were at my normal doctor's office, while the other half were in the hospital where I've been seeing a different specialist, one who has a lot more experience with my particular medical condition (Rh sensitization).

As I explained in my last post on this topic, they've been monitoring four things in particular:
  • the MCA, or how fast the blood is flowing through a particular artery in the brain (faster blood flow = thinner blood, which could indicate anemia)
  • the presence of hydrops, or excess fluid around certain organs or under the skin
  • swelling of liver or spleen, both organs that deal with old red blood cells (larger organs = baby's body is working harder to deal with the red blood cells that my immune system is attacking)
  • level of amniotic fluid

Any of these is considered a soft marker for anemia in a baby or fetus; the presence of two or more of these signs is much more indicative of a problem.

At about 28 weeks, the MCA shot up. Before that, it had been staying on a nice curve (it naturally increases speed as baby grows) well within the "acceptable" limits. They've been tracking it on this nice-looking chart (I wish I had a picture of it to share, but I do not) that shows my numbers and what's considered both too slow and too fast. As my doctor once explained, a high MCA doesn't necessarily mean anemia, but he's never before seen a baby with anemia whose MCA wasn't above that acceptable limit. So once my baby's MCA became borderline too high, my doctor immediately ordered cordocentesis. Yes, it was only one of those markers mentioned above, but when dealing with fetal anemia, it's much better to be conservative and to do more tests than it is to watch and wait.

Because one of the potential risks of cordocentesis is early delivery, I was required to have two shots of a corticosteroid ahead of time, which helps speed up the development of baby's lungs. I had the first after that fateful 28 week ultrasound, and the second on the following day at my regular hospital. Both are shots to the butt, so I probably don't need to say anymore about the unpleasantness of it.

Cordocentesis is known by several other names: fetal blood sampling, or percutaneous umbilical cord blood sampling (PUBS). It's a test used to detect certain abnormalities in a baby or fetus; in my case, the goal is to obtain the baby's complete blood count (CBC), a number that can be obtained within minutes, which then indicates, among other things, how many red blood cells baby has (red blood cell count, or RBC). A low number for RBC is a definite marker for anemia. Additional blood tests are also done with the sample collected, but I'm not sure what all else they did.

So here's the basic procedure for cordocentesis. It's an outpatient procedure, so I wasn't checked into the hospital. I got to stay in my regular clothes. They created a sterile area around my stomach with drapes and cleaning solutions, then gave me a shot of local anesthetic to numb the area. Using ultrasound as a guide, a larger needle was inserted through my abdomen and into baby's umbilical cord. Then they took a few small vials of blood, did the red blood cell count with some of it, and kept the rest to be sent to the lab later. The initial CBC did not show that baby was particularly anemic, so that was that.

After the procedure, I had to spend 20 minutes being monitored electronically; they were watching baby's heart rate, to make sure baby had no issues from the procedure, and they were monitoring me to make sure the procedure hadn't set off contractions.

There are definitely risks to cordocentesis, but they're generally pretty small. There's a risk of internal bleeding, hemorrhaging even, since they are sticking a needle inside me and inside baby's umbilical cord. There's a risk of preterm labor. There's a risk of baby reacting badly to the procedure, which might necessitate immediate (cesarean) delivery. There's a small risk of baby dying. But those risks are all small, and (in my mind) they were definitely outweighed by the benefits of knowing for sure if baby was anemic or not.

We spent the better part of the morning in the hospital, then left, ate lunch, and headed home.

The following week, I went back for my normal ultrasound (I'll be getting all of my scans at the higher risk hospital from here on out). Apparently, the MCA had jumped up further above that acceptable limit, so my doctor came in and told me that after cordocentesis the following week (which was already the plan, since we needed to see how baby was holding up over time), it was almost certain that we'd be doing a blood transfusion as well.

Intrauterine blood transfusion. It's exactly what it sounds like: a blood transfusion to a baby (or fetus, depending on how far along the pregnancy is) while it's still in the uterus.

Suddenly, my upcoming appointment was a whole lot more nerve-wracking. My appointment time was moved up and I knew it would be a longer day.

Of course, I now realize I really had no idea what to expect from this new procedure. Sure, I had talked to specialists and read everything credible I could get my hands on, but the theoretical just didn't quite match up to the reality. I assumed they'd do it all at once, cordocentesis followed immediately by intrauterine blood transfusion, and that since they wanted me to arrive sooner it'd all be done fairly early. Instead, we spent pretty much the entire day in the hospital.

The morning started with a blood draw for me (yay?), followed by the usual ultrasound. MCA was still high; still no sign of hydrops, stressed organs, or abnormally high amniotic fluid levels. Then, I was checked into the hospital. Formally. Intrauterine blood transfusion carries much the same risks as the cordocentesis does, but the numbers are higher. This time, the procedure would be inpatient, performed in one of the operating rooms just in case there was an immediate need for a cesarean.

I was brought up to labor and delivery and checked in. We managed to sneak my husband and son up (well, bend the rules a bit might be a better description; the hospital recently instigated a "no visitors under 18" rule, and technically my son wasn't supposed to be there at all. If I had known that, both of them would have just stayed home all day!), and I was put into a labor room. I had to change into a hospital gown (ick) and they gave me an IV (double ick; also: ouch). I was not allowed to eat or drink anything (yay for nil per os? Except not, since it's an outdated and non-evidence based policy) because of the slight risk of immediate delivery under general anesthesia. They wiped my belly down and shaved it (also in case of cesarean). They had me sign lots of consent forms. They even wanted to give me a catheter, but I managed to put that off unless actually necessary, since it literally only takes a few minutes to do. And they put the monitoring belts on me. I was all but prepped for a cesarean.

So there I was, stuck in bed for HOURS, waiting until the blood was ready for the baby (and for me too, just in case). My husband and son got to stay for part of it, but once they left to get lunch, they couldn't come back. Finally, at some point after lunchtime, they were ready. I at least got to walk myself over to the OR, where the setup was much the same as with the cordocentesis. Sterile area on my belly, drapes, me lying there crying (because that's what I do when I'm anxious). Lots of doctors and nurses crowded around. Ultrasound machine on, and a quick scan to make sure everyone knew exactly where they were aiming. The local anesthetic, which my doctor described as a "bee sting," hurt a lot. The needle through my abdomen hurt even more (because I was only numbed on the surface).

Not a lot of pain from the procedure itself; instead, I felt a lot of pressure and tugging. I kept crying off and on, but I tried to focus any tension I had on gripping my kleenix box (since I couldn't hold my husband's hand this time; next time, I'm bringing a stuffed animal!) so that I could keep the muscles in my belly loose. Lots of yoga breathing, and I like to think that the essential oils I applied just before leaving my room helped me stay calm, too.

Turns out baby was more anemic than last time, but not as anemic as the doctor was expecting her/him to be. Consequently, the blood transfusion was rather small; they just gave baby a little boost with some fresh, thick, healthy blood. Everything was all over relatively quickly, thankfully.

I was walked back to my room (yes, at least I got to use my own legs again!) for recovery. After an hour on the monitoring machines, I was allowed to eat lunch (which my wonderful husband brought, although my nurse had to go downstairs and get it from him), and the simple fact of consuming real food made me feel so, so much better. I hadn't been lightheaded or anything before, since I'd been receiving IV fluids, but there's something to be said for a good, hearty salad and a nice chunk of bread.

Apparently, the norm for intrauterine blood transfusions is to continue monitoring mom and baby for at least three or four hours post-procedure. I managed to talk them down to two hours; I wanted to go home and be with my family, and there were absolutely no signs of distress in the baby or pre-term labor in me. And it's a long drive home. So after a few dull hours of sitting in bed--monitoring belts attached, peaceful music on the TV, book in hand... you'd be surprised at how weird and boring this was for me--I was finally able to sign my discharge forms. The dreaded IV was removed, I got to put on my real clothes again, and my little family and I began the long drive home.

And guess what? Before too much longer, I get to do it again. And probably again a few weeks after that. And again every two or three weeks until baby is term enough for induction to be safer than another transfusion. This is the reality of an Rh sensitized pregnancy. It's not pretty. It's far from fun. But it's necessary to keep baby healthy and strong. Ideally, I won't be induced until 38 or 39 weeks, but we'll see how the reality plays out.


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  1. Screaming inside at this description!! Ughh!!

    First off what's with the awful hospital gowns I mean really. Do people just think it's normal to have our butts in the breeze or what? I like how you said in the next part, that you ask for two. Smart!

    Getting a needle in the abdomen sounds AWFUL. Aside from all the anxiety about the procedure going well, the whole stabbing factor is just incredibly painful sounding.

    And yet. You have carried on through all this with your remarkable poise and courage. Truly admirable!!!!!!

    1. I don't know! I hate hospital gowns. Hate, hate, hate. The nurses are always cool about bringing me a second one, thankfully. The nurses are pretty cool in general, actually.

      And the needle through the abdomen really is awful. They give me the local anesthetic first, but that burns as it goes in/spreads out, and it only numbs the surface layers. I can't even describe how it feels when the needle actually pierces my uterus. At least I don't feel much of anything once it's actually in there; it's mostly just pressure and tugging at that point. Such an unpleasant procedure, and the anxiety leading up to it each time is pretty hard to handle. (Thank goodness for EOs to help with that!)