Vehicular Obstetrics

Here I am in New Zealand, land of narrow roads, one lane bridges, and at least for us North Americans, the necessity of switching our cultural allegiance from the right to the left hand side of the road. Personally, my greatest struggle is remembering to get into the car through the correct door. Everything seems mirror-imaged, including the controls on the dashboard –you can tell tourists at a crossroad because their windshield wipers start up before their turning signal.

But of course, that’s what I love about the country; I drive a lot when I come here, so traffic always is in my mind, if not in my heart. The ever-distracting scenery seems to require more attention than back home, despite the smaller population .

It all reminds me of a Canadian study reported in the Canadian Medical Association Journal (CMAJ) of July 8/14  http://www.cmaj.ca/content/186/10/742.full  which  ‘compared the risk of a serious motor vehicle crash during the second trimester to the baseline risk before pregnancy.’  It was a large study which used the women themselves as their own controls before and during pregnancy. Interestingly, the relative risk of motor vehicle accidents rose by 42% in the second trimester of pregnancy. As the authors state: ‘The increased risk extended to diverse populations, varied obstetrical cases and different crash characteristics. The increased risk was largest in the early second trimester and compensated for by the third trimester. No similar increase was observed in crashes as passengers or pedestrians, cases of intentional injury or inadvertent falls, or self-reported risky behaviours.’

In other words, there seems to be something, not so much about pregnancy per se, as about the second trimester. It’s obviously only one study and more research has to be done to substantiate the findings, but there is some corroboration mentioned in a Commentary on the report in the same issue: ‘A population-based study from North Carolina found that the highest risk of a motor vehicle crash during pregnancy occurred at 20–31 weeks’ gestation, with a marked decline in the risk of a crash thereafter,3 which is similar to the current study’s results.’  http://www.cmaj.ca/content/186/10/733.full

Pregnancy has long been coloured by reports of altered memory, concentration, sleep deprivation and fatigue, but why does the second trimester seem to be the time of greatest risk? The authors recognized the difficulties and used an interesting set of criteria to help explain it: ‘with all observational studies, it is difficult to make causal inferences. In this article, we assess the associations shown in the study in light of the criteria proposed by Hill:2 temporality, consistency, biological plausibility and evidence of a dose–response effect.’ In other words, do the study findings satisfy these conditions? By and large, they feel they did, with reservations you can address through the links.

As an obstetrician of many years, I can’t remember being asked about the act of driving while pregnant. About being more careful, yes; about where to position the seatbelt, yes; and even about whether or not to report to the hospital if there is a relatively minor accident –more of a bump than a crash. If asked, I’m sure I would have pointed out the altered anatomy and how it might not fit as comfortably behind a steering wheel as pregnancy advanced, but I don’t think I would have singled out the second trimester as being the time of greatest concern. So I’m intrigued by the findings.

The authors have been diligent in pointing out the limitations of their study –such things as distance travelled, frequency of travel, and that after an accident, a pregnant woman might be more likely to report to a hospital because of worry about her foetus even if she weren’t injured herself. It still doesn’t explain the seeming preponderance of risk in the second trimester, however.

I shall certainly be watching for any further analysis of the data, or any follow-up studies this engenders. And with my now heightened curiosity piqued, I may even include a warning to my pregnant patients to be extra careful behind the wheel. I’ll  certainly be more careful if I see one of them get into a car…

 

 

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You Got Me Pregnant!

Some things seem to go unappreciated don’t they? They’re background noise. Shadows in the moonlight. You might think that this doesn’t apply to medicine, but it does. Much of what we do is taken for granted –or at least taken for expected… appreciated, but for a variety of reasons, not publically acknowledged. And that’s fine with me; I’m certainly publically humble. Shy. I seek shadows not spotlight. I’m not certain I would know what to do on a pedestal.

Besides, I don’t do what I do for accolades –I embarrass easily. And I’m content with smiles, or even a face that signals thanks; I probably should have gone into Pathology, or some other solitary field where the propensity to blush is not a handicap. They didn’t teach us how to accept praise in Medical School; they didn’t even mention blushing –or maybe I just missed that class.

But, not to diminish the appreciation I do receive –I’m an obstetrician, and in the fullness of  l’accouchement  there are congratulations all round. Thanks in spades. It is enough -it is their moment after all, not mine.

And anyway, I forget things –forget people, for example. I may have seen them every month for a year, and yet on the street, they are sometimes just faces that smile at me when I pass, and like most faces, vaguely familiar… Maybe. Some eyes seem to ask for more than just a fleeting nod but these are requests to which I dare not accede lest I be required to remember something of their past… I don’t do pasts the justice they deserve sometimes. Pasts matter; they are what knit the fabric we wear and to ignore them is to ignore the coloured  patterns that make the present so vibrant. The future so hopeful.

Memory was a given in Medical School –it was what you had to have to get there in the first place. It was not so much educere –a Latin word suggesting drawing out or eliciting something already there- as inducere –putting something in that they wanted you to have… But I digress.

I have carried this neural handicap with me my whole career: my memory seems selective at times.  I am prone to remember things I don’t need –a hair style on an elderly lady, a lilting way of speaking, the eyes of a woman looking at her newborn baby… Interesting things that help to flavor the roiling stew of facts and numbers I’ve stored behind the eyes I try so hard to keep neutral in the office. Things that disguise the otherwise unadorned potpourri of diseases and anatomical discrepancies hidden beneath the words that stagger so reluctantly from my patient’s lips. Things –flowers- so precious in the world of suffering my job is wont to assess.

I need to escape sometimes: long walks along the beach, a movie, dinner with friends… or dinner alone. They’re all tricks to dampen down the past. Too much past, and you’re condemned to live there –or at least visit uncomfortably often. And for me, dinner in a nice, crowded little restaurant at table along the wall is the perfect anodyne. Like a bodhisattva, I am of the world, but comfortably without as I sit, hidden in the corner, sipping casually on a glass of wine, watching others do the same. I am peacefully alone in the crowd, digesting my thoughts in joyful anticipation of the ritual of food.

I was at one such place a few months ago. The room was crowded, and quietly boisterous  as I was shown to a table by a window overlooking… Well, it was so dark outside, it overlooked the reflection of the room –a double room, in effect -perfect for inspecting plates on other tables and who was sitting in front of them. Everybody was dressed as if they knew others would be watching them: the woman nearby in the designer jeans, so tight she looked unable to move, with only  a salad in front of her; and her partner, casually elegant, tucking into some sort of pastivorous mixture that steamed as he forked it. They were quietly avoiding something –communication, likely. Others nearby were toasting each other with sloppy, uncertain gestures, waving napkins at one another as each attempted to prevent the inevitable spills. Everyone seemed engaged in something; everyone was alive and enjoying it.

My eyes were drawn to the aisle where I’d entered. The room was full to overflowing –nobody was leaving- but I could see one of the servers staring at me. She was a tall young woman with her blond hair pinned back into an attractive bun, and as usual there was something familiar about her face. She was talking excitedly to a man behind the bar and nodding in my direction. At first I was flattered; I thought perhaps she had noticed that my wine glass was almost empty. Great place, this, I thought and smiled back at her. She returned the smile with an expression I’d seen before. Then a puzzled look attacked her face, as if my smile had confirmed something. She bowed her head for a moment, as if thinking it through, and suddenly her eyes opened wide and I could see her take a deep breath.

Then, as luck would have it, there was one of those stochastic diminutions of sound that seem to occur in restaurants from time to time as people decide to pursue their dinner for a moment rather than their conversations.

“You got me pregnant!” the server screamed in her excitement, pointing at me and walking towards my table with an intense but unreadable look on her face. I couldn’t tell if she was angry or bent on revenge. Me? I just hoped she was mistaken.

The restaurant was muted when she said it. Completely silent when she’d finished. Everyone turned to stare at me, the accused, as if I’d abandoned her after a night of debauchery. I could see the look of disapproval on the woman in the designer jeans. Perhaps she was regretting her choice of partner for the evening but I couldn’t tell because she was staring at me with a malevolence I’ve only seen in movies. People began to whisper to each other and I could sense, as much as hear, guffaws and sniggers. Caught, I could hear them think. Serves him right!

I could tell they were all waiting to see what the server would do once she reached my table. There was a palpable silence when she did. They were preparing themselves for a battle. Deciding what to do. How to react. What is the appropriate protocol to be followed in such a raw and unusual circumstance anyway? Grab me and pin me down? Call 911? Take a video of me with their cell phones and post it on YouTube? I thought about all this as she approached, but my social skills had never been stretched that far before.

In the eternity of those last few steps before she reached me, I could feel my face redden, and my mind racing like it is said to do in the moments before an impending and inevitable accident. I scoured mental relationship files and flipped through the disappointing ones in the blink of an eye, desperately searching for some mistake I’d made. An indiscretion, perhaps. A date I’d forgotten –or blocked from conscious memory. Anything. But, for some inexplicable reason, there was nothing to exculpate. In terms of the reaction I was provoking, my life was undeserving. Banal, if not entirely flawless.

Suddenly she was there, standing excitedly in front of me in the tomb-like silence of a room full of frowns. Their eyes, their expressions, their postures –all were balancing on a knife’s edge. Hoping for a resolution of the tension and yet dreading, what was to come.

She stared at me for a moment, teetering on the edge of a conflicting internal debate on what she should do now that she had an unanticipated and, no doubt, unwanted audience. Then her eyes twinkled and her face dissolved into a smile so large it hardly left room for ears; so genuine, I thought she might faint with ecstasy; and so intense I had to stand to acknowledge it. She grabbed my hand and squeezed it until it hurt. And then, putting her arm around me, turned to the crowd and said, “Sorry folks. I didn’t mean to disturb your dinners. It’s just that I never did thank my doctor for solving my infertility problem!” She pulled me close and kissed me on the cheek and then promptly blushed when the room erupted into applause. “I’m so impulsive sometimes,” she said and backed away, still holding my hand.

The room slowly settled back into its usual rhythm after that, and she walked quickly back to the bar to see if her next order was in. Later, when I was simply a mildly diverting memory in the drunken crowd, my own server –fortunately one with an unfamiliar face- presented me with a bill with a smiley-face drawn on it, and a big zero where the charges should have been. But the vaguely familiar-faced owner accosted me as I left.

“I’m sorry about that, doctor,” he said, looking embarrassed as he shook my hand. “My wife gets so excited about things now that she’s a mother… Never rests any more -even here. She’s always finding something to do.” He looked at me for a moment as if he wanted to tell me something else and then smiled and turned away. As I reached the door, however, he spoke again. “Can you get us a boy next time, though, doc..? The girl we got never seems to sleep.”

Autism and Obstetrics

I’m an obstetrician caring for worried mothers. They’re worried about things that might put their developing foetuses at risk for a whole range of issues and ask me for advice. Obviously I’m neither a paediatrician nor a child psychologist, so questions about autism leave me alone in troubled waters. There are so many rumours of risk, so many studies that seem to implicate everything from diet to anaerobic exercise in pregnancy, vaccinations to mercury in calcium supplements.

I wish I knew more about autism; I wish I knew anything indisputable about it… Well, that’s probably a bit harsh. I know that it’s now referred to as ASD (Autism Spectrum Disorder) and that it’s a neurodevelopmental disorder with problems in at least two areas: social impairments –things like communication and interaction- and behaviour abnormalities like repetitive patterns of  activities and that sort of thing. But it all seems rather vague. Especially the social components. At the severe end of the spectrum it’s an unmistakable impairment, and yet at the milder end…

http://www.ninds.nih.gov/disorders/autism/detail_autism.htm#268283082

It may be a sensitive set of criteria that bundles all the right things in it, and yet it’s rather spotty on the specificity. An example might help. Let’s say you’re a fisher and you want to improve your ability to catch salmon so you’ve designed a special net. You pull it up and there are a hundred fish in it, so it works –it catches lots of fish, but only one salmon. But, it did catch a salmon so it’s sensitive for salmon, but not very specific for them.

I also know the DSM-5 criteria of ASD –I’ll quote them from a more readable source: the 2014 UpToDate data base we have in our hospital. ‘ASD is characterized by 1. persistent deficits in social communication and interaction (eg. deficits in social reciprocity; nonverbal communicative behaviors; and skills in developing, maintaining, and understanding relationships) and 2. restricted, repetitive patterns of behavior, interests, or activities.’ They also say that the symptoms must be present early in childhood development, but may not become manifest until social demands exceed limited capacities. And there are three levels of severity rated separately for social and behavioral characteristics.

Okay, I understand those criteria –sort of- but coming from a medical specialty that is used to more concrete, objectively provable, and investigatable symptoms, they still seem rather vague. And there remain the difficulties that I have with including the milder, vaguer, less impaired end of that Bell curve distribution of characteristics –the end that may include variations of normal, idiosyncratic behaviors which may represent other issues –parental, social, even poverty-related stresses that might impinge on the child’s behavior.

I suppose it’s the boundaries that trouble me. There seems to be a wide variability of the reported prevalence of ASD and some indication that it is increasing of late, perhaps related to changes in definition as well as increased awareness. But how valid is that?

I’m all for increased awareness of ASD, just as long as we can be sure it is ASD that we’re aware of. This is important for interpreting the studies that purport to assess various causes of autism. For example, a BBC article reported a study from the Harvard School of Public Health which implicated air pollution as yet another cause. But, as the article suggests: ‘Experts said pregnant women should minimize their exposure, although the link had still to be proven.’

http://www.bbc.com/news/health-30521255

Good advice, I’m sure –pollution likely has many adverse effects on a developing foetus. One more wouldn’t be much of a surprise. Avoid pollution when you are pregnant by all means. But place that in the context of a pregnant woman who lives in a city where she cannot avoid it, and then add the additional worry of a possible link to autism in her unborn baby and you have sewn the seeds of an intractable anxiety. Helplessness. Despair. The fact that it is as yet unproven gets buried in the message; the statement that it is biologically possible does not.

As the aforementioned UpToDate 2014 data concludes: ‘The pathogenesis for ASD is incompletely understood. The general consensus is that ASD has a genetic etiology, which leads to altered brain development, resulting in the neurobehavioral genotype. Epidemiologic studies indicate that environmental factors account for few cases.’

I realize that there is a fine line between informing the public, and frightening them unnecessarily (or inadvertently), and I recognize and accept that we should all have the right to know what is being said in scientific circles about topics that affect us. Clearly it is difficult to balance whether or not to publicize information that is still in the process of being assessed and integrated into a coherent and testable theory, versus information that has been collated into a more accepted and validated model, but I think it would be a sensible, albeit challenging, step. It is a serpent’s egg, and reminds me of the warning of Brutus in Shakespeare’s Julius Caesar: ‘a serpent’s egg, which, hatch’d, would as his kind grow mischievous.

I’m certainly not advocating censorship –maybe just awareness. Prudence… Judgment.

The Unexpected

What I like about the unexpected is that you never expect it. It’s a surprise. A gift. And the world is filled with this stuff. Each day at work –I’m a gynaecologist- there are little treasures hidden within appointments, presents in names. Especially the unpronounceable Persian names that unravel when I try to work at them one syllable at a time to call some nervous woman from the waiting room. But she inevitably understands my bumbled attempt, smiles, and when she sees my embarrassment, immediately forgives.

And there are cross cultural surprises that don’t anymore. Surprise, that is. There are some people for whom a question has to be asked with a lot of forethought. It cannot merely trip off of the tongue; it must be planned well in advance. A simple query in taking her history such as “You’re not married, are you?” might elicit ‘yes’ –meaning either ‘Yes I am married,’ or ‘yes, you are correct in saying I am not married.’ I love it.

Or consider the argumentative patient who doesn’t want to tell you why she is there. Her name provides no advance warning, nor does the note from the referring doctor. The first clue is usually the defiant, silent stare, and the arms tightly enfolded across her chest as if to prove that coming to see me was definitely not her idea. I suspect the behaviour is a punishment, although for whom I’ve yet to determine. And what do I usually do? I ignore the theatre and simply ask her why her doctor sent her. If that doesn’t work, I sit back in my chair and smile at her, hoping the time will allow her to acclimatize. Relax. Sooner or later, of course, she realizes she has to do something  or pay for extra parking, so she will sigh, undo her arms, unlock her eyes and either apologize or leave. I never know which way it will go.

But sometimes I am caught off guard. Something unexpected happens that even I did not anticipate. That something happened only a few months ago in fact: a movie star. Well, sort of…

It was just before lunch, and my stomach was rumbling. I had only one patient to see before I could escape for the morning, so I quickly glanced at the referral note. ‘Pain’ was all it said. Damn! I suppose the family doctor was in a hurry, but even an adjective, a descriptive, might have pointed the word in a more helpful direction. I shrugged mentally and then let it go –after all I was the detective, not him.

I walked down the corridor to the waiting room rehearsing her name. “Jojo?” I said with a little uptick at the end to indicate that I wasn’t entirely sure I’d got the name right, or whether it was a name only her closest friends used.

An unsmiling woman with short hair stood up and walked over to me. She shook my hand, but I could tell she didn’t really want to touch me. She wouldn’t make eye contact either. That made me a little nervous, but I assumed that she was just shy and understandably anxious. But I have to confess that apart from that, my initial impression of her was, well… absent. Nothing about her cried out for attention. She was average height, average build, with a pleasant but decidedly unstriking appearance –we are all beautiful in our own ways, but sometimes it is easier to notice, I suppose. I dislike the adjective ‘plain’ when applied to people, but occasionally it’s difficult to find another word without seeming patronizing. Let us just say she was neither attractive, nor unattractive but somewhere on that hazy continuum verging on, well, average.

She sat rather primly on the chair opposite my desk, eyes fixated on something on the wall to the left of my head. I fought the temptation to turn and see what she was looking at and distracted myself by asking her why she’d come to see me.

“Pain,” she said simply, without moving her eyes.

I waited what I thought was a polite interval for her to continue, but when she didn’t  I fidgeted with a pen on my desk -a signal, I hoped.

She glanced briefly at her hands and then her eyes flew back to their accustomed branch on the wall. “It’s been interfering with work lately,” she said, as if she had unlocked a door.

I felt I was getting somewhere. “In what way?” I asked, smiling to reassure her that I would understand.

She stared even harder at the wall and said, without a hint of embarrassment, “I get terrible pain when he…” I could actually see her adjusting words in her head. “When he enters…” She seemed pleased with the word she’d chosen and smiled for the first time –at the wall, mind you, but I figured it was a rapport starter. Suddenly she appeared to reconsider. “No, not ‘enters’ exactly… when he’s, uhmm…” -this seemed to be a real challenge for her- “…you know, in there and looking around.” I could tell she wasn’t exactly happy with her description, but she didn’t offer any more metaphors and resumed the neutral expression she had worn coming into the office.

I assumed I had simply misinterpreted the temporal juxtaposition of  her personal life and work, so I let it pass without further comment, although I did make a few mistakes typing it into the computer. The rest of the history was easier for her and even the subsequent physical examination, despite the pain, didn’t appear to bother her unduly. After she had come back into the office from the examination room, she seemed more relaxed than I’d seen her. “You found it, eh?” she said after sitting down and making more comfortable eye contact with the now familiar space on the wall behind me. “The part he hits,” she added to make sure I knew what she meant.

I smiled and nodded in agreement.

“So, what do you think?”

I’d felt a rather large and tender ovarian cyst in her pelvis -probably from endometriosis, judging from the rest of her history. “Well…” I tried to frame my response in a non-frightening fashion, but it was difficult. Ovarian cysts are always frightening. Threatening. “The area that was the most tender was around your left ovary. It seems larger than it should be –a cyst, maybe…” I thought the ‘maybe’ might diffuse the fright I could see in the eyes that now sought mine. “I’d like to get an ultrasound first, though, before we decide what to do.”

“You mean, like it might be… cancer?” I could tell it was difficult for her even to fashion the word in her mouth.

I smiled disarmingly. “No, more probably endometriosis.” I was about to elaborate on the word when her face turned sour and her eyes fled to the wall again.

“So, if it is a cyst, what are you going to have to do about it?” She sounded angry, but her face grew expressionless.

“Well, if it is a cyst, we’ll have to remove it.”

Her eyes immediately saucered and focussed on the front of my shirt. “You mean surgery?” I could almost see the italics. “Sorry, I don’t do surgery, doctor!” Her face changed; it was no longer unreadable.

“Why don’t we just wait to see what the ultrasound finds and then decide what we…”

But she was already putting on her coat. “You don’t understand, doctor.” She was having trouble fitting the two sides of the zipper together, so it gave me time to ask why she seemed so upset. She sighed, left the zipper for a moment and actually looked at me. Me -not the wall, not my shirt, not her hands- me. “It’s my work… I can’t have any scars for my work.” She stood up and walked to the door, still unzipped.

“The scars from a laparoscope are really quite small, Jojo. I…”

But she stopped at the door and turned to face me as she interrupted irritably. “Any scars. I can’t have any scars! That’s what they told me…”

“Who told you?”

“My producers.” I couldn’t keep the concern off of my face, so she continued. “No scars –that’s what they said.”

My face relaxed. “Producers? So you’re an actor? In the movies?” I must have looked impressed because she nodded modestly and leaned seductively on the door frame. “But… they’d be tiny little scars. And most of them would be lower down on your abdomen. Even the skimpiest little bathing suit would hide them.”

She cocked her head and allowed herself a tiny smile before she left. “I never get to wear one for very long,” she said as she disappeared down the hallway.