Monthly Archives: March 2014

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Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…

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A test for Alzheimer’s Disease…

Now here’s a scientific and epidemiologic conundrum: Suppose you develop a test that will give you advance warning of a fatal disease you can neither treat nor prevent. But that foreknowledge might allow an understanding of the really early aspects of the disease -while it was still asymptomatic- that could eventually lead to a treatment. Especially if the disease, as most are, was potentially more treatable in its early stages. What should you do with the test? You need a lot of people to take the test so you can more appropriately generalize the information obtained and yet you can do nothing for them.  And what are the subjects in the test to do with the information? Suppose it is falsely positive and, despite what the results suggest, despite the worry and possible suicides contemplated, they will not actually get the disease. No test is perfect.

In other words, should you screen a particular population with the test, when the value is not so much for the individual tested as for the knowledge that might eventually be useful to someone else? How ethical is it? How cruel is it..?

People have thought about this, fortunately, and some guidelines were offered in 1968 by the World Health Organization for screening criteria. Among them are the suggestions that, not only should the condition be an important problem, but there should also be a treatment for the condition and an ability to diagnose it accurately. They also suggested the condition should have a latent stage when treatment would be expected to be more efficacious.

The problem I have set forth, of course, is exemplified by the recently announced test for Alzheimer’s Disease. (I have included two articles, the Huffington Post summary being the more easily assimilable of the two.)

http://www.medscape.com/viewarticle/821982?src=iphone&ref=email

http://www.huffingtonpost.co.uk/2014/03/10/dementia-early-detection-blood-test_n_4933188.html

It is obvious that Alzheimer’s disease and dementia are both important health concerns in a time when populations are aging in many countries. It would be helpful to know what facilities might be needed so the appropriate infrastructure could be planned for that particular demographic. But equally, it would be useful to know more about who in that population are particularly at risk so they could be studied. A recent report from the Alzheimer’s Association, for example, suggested that women over 60 are two times as likely to develop Alzheimer’s disease over the rest of their lives as breast cancer:

http://www.alz.org/news_and_events_women_in_their_60s.asp

Perhaps of paramount importance is studying the disease at an early stage to search for the cause. To devise a cure. And yet I can’t help thinking about the helpless laboratory animals in our research facilities, poked, prodded and experimentally assigned… But not for their own good. What constitutes a laboratory animal..?

Under what conditions, then, would it be permissible to undertake such a study? Informed consent is mandatory, of course, but what exactly would the participants be consenting to? To knowing about an inexorable decline in cognitive functioning that would rob them of that which they hold the dearest: themselves? We are our pasts -they are what knit the fabric of our identities into a pattern we and others can recognize from one day to the next. The present is a transient gift that constantly slips behind us so we have to pull it along like a shadow as we walk through time. We collect each present and store it on an accessible shelf like books we’ve read. Without them, we become functionally illiterate. Lost. Wandering endlessly through unmarked time as in a dense mist with no signposts we can see, let alone understand.

That this vision may encompass the tundra that is Alzheimer’s is obviously more pessimistic than may obtain: no doubt it is a condition that varies on a spectrum. But the prospects are not appealing, nor the amplitude of changes likely predictable -and I, personally, would not want to know about it until it has captured me and shrouded my awareness of what I had lost.

I suspect this is the reason for the cautionary statements of the investigators and the thrust of the caveats of the WHO parameters. I’m not sure what to do with the test they describe. It is obviously an important step on the road to understanding dementia and yet… I am reminded of that famous “To be, or not to be” speech by Hamlet in which he talks about death, but describes it in terms the more pessimistic among us might suggest could equally apply to Alzheimer’s disease:

The undiscovered country from whose bourn
No traveler returns, puzzles the will
And makes us rather bear those ills we have
Than fly to others that we know not of
I’m sorry, but I don’t think most of us are ready for the test just yet… Or is it only me?
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Diet in Pregnancy

There was a time when the prevailing dietary wisdom was simple: food contained calories, weight was a function of caloric imbalance. If you used less calories than you took in you gained weight, and vice versa. It was intuitively appealing and it still is; anybody with even an elementary grasp of mathematics understands. But it is becoming increasingly apparent that all calories are not equal. Health uses a different equation than hunger. So should the pregnant woman.

Of course, this comes as no surprise: it has long been apparent that a diet of potato chips and cola does not often foster a healthy newborn. Unfortunately, it has been far too easy to attribute more of the blame to other competing lifestyle factors. And it has always been difficult to separate the effects of smoking, diet, illicit drug use, alcohol, obesity and a myriad other lifestyle factors that have to be teased, strand by strand, out of the morass. They all contribute in their own ways, of course, and yet I sometimes think that we treat food choice as merely a weight regulating phenomenon -caloric intake once again.

But amongst a host of other similar investigations that seem to be appearing recently, the British Medical Journal published a review of over 66,000 women from the Norwegian Mother and Child Cohort Study linking dietary choices to -in this study- premature delivery. Preterm delivery is responsible for a large proportion newborn infant deaths, not to mention health problems both long and short-term. It is a significant problem that has multiple causes to be sure, but diet is one that may be more easily amenable to manipulation.

http://www.huffingtonpost.com/2014/03/05/healthy-diet-lower-preterm-birth-risk_n_4906407.html

The original article was enlightening, albeit a little dense, so I will refer to the brief summary of the parameters of the study from the Huffington Post:

The researchers classified the women’s diets as “prudent,” “traditional” or “Western.” A prudent diet consisted of raw and cooked vegetables, salad, fruit and berries, nuts, vegetable oils, whole grain cereals, poultry and water to drink. A “traditional” diet, by contrast, was mainly composed of boiled potatoes, fish, gravy, margarine, rice pudding, low-fat milk and cooked vegetables. Lastly, a “Western” diet contained a lot of salty snacks, chocolate and sweets, cakes, French fries, white bread, ketchup, sugar sweetened drinks, processed meat products, and pasta.

Anyway, guess which diet was the healthiest? When asked in this rather black and white format, the correct answer is easier to see than in the supermarket or fast-food outlet where cost is often the biggest determinant of choice.

One has to be careful not to attribute cause to something that may be only an associative phenomenon, however. Maybe women who make unhealthy choices can only afford a certain diet -are only exposed to certain ways of eating. Maybe they have other characteristics that might lead to premature delivery. Why one makes certain dietary decisions is often -if not usually- an indication of the river in which the individual is already swimming. And it would be naïve to assume that merely changing what she eats will solve the other health and lifestyle issues that may affect the foetus developing inside her. But pregnancy is a time when most women are motivated and open to suggestions that might help their babies. It is an opportunity that should not be wasted: education has ripples that extend far beyond the health clinic.

It seems to me that food choice is one of those things that can be taught without seeming to impose a moral -or social- structure to the lesson. Wise but economic choices can be outlined and promulgated without seeming to judge other decisions she may have made. It is a confidence building manoeuver which suggests that, however small they might seem, there are things she can do that might have long term benefits for her unborn child. And if this develops rapport and trust, it may help her to make other more difficult choices.

In the health care field, we are not wardens: we carry very few weapons; we depend more on persuasion than force. We are merely guides, educators, comforters, and encouragers. It is not the stick that persuades, but the smile, the attempts to understand her situation, the willingness to listen without undue prejudice, offering suggestions where possible, or expectant patience until a better opportunity arises. This more patient approach does not abrogate the authority inherent in the more traditional antenatal healthcare system -or discourage trying to correct and modify other detrimental behaviours in the pregnancy; it merely acknowledges the necessity of a firm bridge and an open gate to gain access to the other side.

So many factors play a role in prematurity, and correcting just one of them is not likely to be a panacea. But it is a start. A wedge. A present, perhaps, to the next generation.

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Once Upon a Time…

You learn new things every day; sometimes, learning about learning is one of them. I am learning about babies.

As an obstetrician, I deal with them every day -or, more accurately, them as developing organisms- from shortly after conception until birth. Then, as the mother’s needs change -and the baby’s- I kind of lose track of them. But it’s merely a change in expertise rather than a change in interest that fosters the loss. My time with them is truly remarkable, but they are almost a vicarious encounters. Visits by proxy. I see them only indirectly, as it were: as shadows, filtered through the light of their mothers.

Many of the signs we use to assess their health, are really gauges of their mother’s health: blood pressure, urinalysis, weight gain, to name but a few. And especially early in the pregnancy, the mother is the baby in a sense; the baby’s health is usually dependent on her health, for obvious reasons. Later, as activity patterns become more discernible, it seems to be easier -for those of us not carrying the foetus, at least- to appreciate the double entendre that is gestation. Measurements of baby begin to be less indirect, and although always mindful of the mother, less through the mother. Two healths. Two entities -although there always were…

And yet, exciting as this is, when you think about it from a longer -dare I say historical?- perspective, it’s almost as if you had just started reading a book, and intrigued by the first chapters, can hardly wait to read further.

We obstetricians get to start a lot of books, but unless we have our own library, seldom get to read more than what seem like a few pages. Samples. Teasers, really. So I am always fascinated when I discover things not ordinarily in my professional purview. And how a child learns is certainly fascinating. An article in the Economist (of all places) reported on some presentations at this year’s meeting of the American Association for the Advancement of Science.

http://www.economist.com/news/science-and-technology/21596923-how-babbling-babies-can-boost-their-brains-beginning-was-word?frsc=dg%7Cc

The part that intrigued me was the effect that talking to your baby and not just around her had on her subsequent vocabulary -and more speculatively, perhaps on her brain growth and performance as well. But even more interesting, although obvious, was that this effect starts really early -much earlier than, say, the preschool age of around four. I mean, we all seem to know this intuitively, but it was helpful to realize that there are now some more sophisticated ways of measuring the results rather than merely presuming them. I suppose one might think that this is one of those things that is so apparent, so manifest, it doesn’t need proving… But it does, as the presentations demonstrated. Merely talking around toddlers, or sitting them in front of the universal sitter: a babbling television set, doesn’t really engage them to the same extent. Or in the same functional way. You have to address the baby as a receptive host. Too, objective? Okay, you have to talk to your baby and assume a comprehension, or at least an appreciation of the sound, cadence, and intention of the words. And, of course, there is an understanding… And the more words the baby hears, the more they are integrated into the matrix.

As a parent, I have to say that I always talked to my babies. It just seemed the right thing to do -and not surprisingly, they actually appeared to like it. To crave it… But ever aware and embarrassed by the idle pratter and cooing sounds simulating word-talk I’d hear on the bus or even in my waiting room, I must admit that my communication was more of a discussion -no, that’s unfair- a storytelling to my toddlers. Yes, I’m sure the nonsense, but rhythm-rich verbalizations to which I am inadvertently subjected are also important and functional, but we all have to find our own paths. The importance is in the attempt. The verbal attention. The semantic connection…

I can’t help but feel an almost overwhelming sense of awe that such a simple, natural interaction can have such profound effects. And of course that’s just one small part of the plot… The story just keeps getting better.