Well I'm certainly a lot late on this post, seeing as I was actually 24 weeks back on January 12 and am now 28 weeks along in this pregnancy. Time seems to be flying by now that I'm back to work (after a fantastic month off) and we are counting down the months/weeks/days until she arrives.
Not only am I late on the post...my belly feels about 3 times this size already!
It's definitely time for an update after the blog post that I did after my 20 week ultrasound. At that time it was determined that I for sure had placenta previa and they also suspected that I had placenta accreta. I wasn't sure what those complications were so I did some research and I'm not sure if this was a good thing...or a bad thing! I was (and am) scared, but also feel like having the knowledge is better than going in blind and just hoping for the best.
After lots of reading and deciphering I have come up with some simple descriptions. Placenta previa is when your placenta implants somewhere either close to or directly over top of your cervix. It is very common for this complication to resolve itself when it is found at the 20 week ultrasound but for me that was never part of the equation. It is a fairly common complication and many cases of placenta previa will resolve as your uterus grows and the placenta moves up and away from the cervix. My doctor said that was very unlikely to happen due to the suspected presence of the placenta accreta and the fact that my placenta was completely covering my cervix. The most common side effect of this complication is bleeding (ranging from light spotting to heavy hemorrhaging) in the second and third trimesters. This bleeding can be dangerous to mother and baby and can cause preterm labour if the bleeding is severe and warrants baby being born. If a complete previa is present after 34 weeks then the mother will be almost always be required to deliver via c-section to reduce the risk of severe bleeding. The c-section part was fine with me as this baby was always going to be born that way after both of my previous sections. Once this complication is found it is suggested that the mother does not do any heavy lifting, excessive exercising or participate in any sexual activity for the remainder of their pregnancy. Boo to the lifting and sex, but could honestly care less about the exercise part :)
Placenta accreta on the other hand is a much less common and much more serious complication where the placenta actually starts embedding itself deeply into the wall of the uterus. In some cases it can go all the way through the uterine walls and start attaching to the bladder or surrounding organs. The risk of hemorrhage during the c-section can be very high and can be life threatening to the mother and the baby if not caught early and planned for appropriately. In many cases the suggested treatment plan to deal with placenta accreta is a hysterectomy done immediately following the delivery of the baby. From my understanding, when the doctor goes in to deliver the baby they have to cut right across the placenta (huge risk of bleeding) and then after the baby is delivered and the placenta should detach itself, it just doesn't. By removing the uterus you eliminate the issue of the placenta being stuck and potentially cut down on the amount of blood loss. Now for a 3rd time mother like me the thought of losing my uterus and my ability to carry more children does not concern or sadden me at all (honestly not even a little bit)...but I can imagine if it was a first time or even a second time mother (unsure about wanting more kids) how traumatic that could be. There are ways that the doctors can try to save the uterus, but it can be quite tricky and risky to the mother. And even if they appear to be successful you can end up having to have a hysterectomy down the road anyways. This complication usually has no side effects during pregnancy and only comes into play at delivery time. As Dr. Strydom says "it's just going to make for a complicated delivery and recovery for you....but the baby is growing beautifully!" Really that is the most important thing in all of this and even if the next paragraphs of this blog make me sound like a whiner and that I am for even a second not considering the baby's or my health, I assure you that's not the case. I would take a delivery complication over a baby growth complication any day! Yes the risk to me is higher, but I know she is safe and sound and growing and that is the most important thing in the end.
So, now that I've explained what the two complications are I can go forward with where we've been to determine our next steps in my pregnancy. On January 11 Jim and I went down to BC Women's Hospital for an ultrasound and an appointment with a fetal maternal specialist to discuss what they saw on their ultrasound because they felt they weren't sure of things based on the ultrasound that was done here on December 20. Here is my belly picture taken that day at one day shy of 24 weeks.
And here is our little lady doing some yoga poses for us. We were happy that the tech at Women's confirmed again that it is in fact a girl, because you hear horror stories of ultrasounds being wrong, but after two different sources saying it's a girl I'm feeling much more confident now!
Even during our ultrasound the tech was honest and said that although she could absolutely see the placenta previa clearly, she was still unsure about whether they could determine completely whether the placenta accreta was present or not. She said there were multiple doctors looking at the ultrasound pictures and calling their colleagues at other hospitals to ask their opinions too. It made me feel good about how thorough they are, but I'm also one of those people that doesn't really like the not knowing for sure part.
After the ultrasound we headed over a few departments for our fetal maternal appointment and were pleasantly surprised at how thorough the Dr. and her two residents were in asking questions about both my Crohn's disease (which was a surprising part of the discussion) as well as about my previous c-sections and bowel resection and appendectomy surgeries. Dr. Lalji at Women's was phenomenal and did confirm the placenta previa but did admit that although the accreta couldn't be 100% confirmed that they weren't seeing a definite line on the ultrasound that would indicate that the placenta WASN'T attached to the uterine wall, so to be safe she was going to refer us to either a doctor in New West at Royal Columbian Hospital or to a doctor in Nanaimo (if she could find one that agreed to take me on as a patient). This meant that my dreams of a PR delivery were gone and now we had to decide if we wanted to deliver in Vancouver or Nanaimo. It ended up being a tough decision for us because I thought at first it would be better to be in Nanaimo closer to Jim's family, but then upon talking it through more Jim and I decided that we felt more comfortable going with Dr. Ubhi in New West as he seems to be the doctor that specializes in this complication. He is the doctor that Women's always refers to for accreta patients. The thought that Dr. Lalji wasn't even sure if she would find a doctor on the Island that would agree to take us made me unsure of how often they would even see this complication and we both wanted the safest and best option for both me and baby girl. The other variable that we discussed was the possibility of pre-term labour due to bleeding from the placenta previa and RCH has one of the best NICU's in BC. Plus, my step brother and sister-in-law live just 10 minutes from RCH so it would be easy for me to stay with them if the doctor thought I should be in Vancouver for a few weeks before her delivery.
We left Vancouver after the appt at Women's Hospital and I can admit that I was both super sad and very worried about how the next few months would go for me and our baby girl. I spent a lot of time in the next 12 days thinking and over thinking all of the possibilities of what Dr. Ubhi would say when I met with him on January 24th. The day before that I managed to get in to see Dr. Strydom because I felt like I needed to talk to her before I saw Dr. Ubhi to see if what I remembered from my appt with Dr. Lalji was what she had interpreted from the report from Women's. I went into that appointment and she barely had the door closed before I burst into tears and spent the rest of my 15 minutes with her in some state of tears. I was scared and anxious and just felt really unsure of what the future held. I felt like my brain was swirling with so many possibly outcomes and just wasn't sure how I felt about any of them. I was scared that Dr. Ubhi would want me to stay in Vancouver for an extended period of time before her delivery. I was scared that I would start bleeding and would have to be flown to Vancouver. I was worried about continuing to work when all I feel like doing is resting to ensure her safe delivery as close to 37 weeks as I can get her. I couldn't stop thinking about how bed rest, or an extended stay in Vancouver would impact the boys, Jim and my parents (who would take on a huge amount of responsibility in helping Jim with the boys). And of course I couldn't stop thinking about the delivery itself and how scared I would feel in a big hospital, surrounded by people I didn't know, possibly having to share a room with another mom and baby, and how having a hysterectomy would impact my recovery time. I'm not kidding when I said I would wake in the middle of the night and even though I was absolutely exhausted, I just couldn't turn my brain off. A lot of those 12 days is a blur to me and I hope to never feel quite some unsettled again.
That day in Dr. Strydom's office she was as wonderful of a doctor as I have heard for many many years and have experienced since meeting her back in October. She listened to my concerns and questions and gave me the straight up honest truth as best she could based on what she had read from the report. She agreed that Vancouver was the best place to deliver and indicated again that the hospital in PR just doesn't have the resources to deal with a complicated delivery like that. No blood bank or extensive adult ICU would mean that if something went south during the delivery I would have to be flown to Vancouver immediately and that was not a risk that anyone should want to take. In fact Dr. Lalji told Jim and I that they wouldn't even deliver a confirmed or suspected accreta patient at Women's Hospital because they don't have the resources that they feel are adequate to take care of a mother with the worst case scenario of that delivery. I next asked Dr. Strydom what the risk of bleeding from the previa was and she indicated that yes it was high (up to 70%) BUT just because I started bleeding it did not mean that baby girl would need to be delivered immediately (which had been a fear of mine). She said that as soon as I have any bleeding I am to go to the hospital immediately and I would be monitored closely from there. She indicated that as soon as I was ready to finish working she was fine with that, and that if a bleed happened she would recommend not returning to work after that. I told her I was still hoping to work until mid-March and she just smiled and said "we'll see how that works out for you." She did not say bed rest would be required, unless of course the bleeding was severe enough to warrant that. I have read many cases where women bled daily for weeks and still made it to their goal of somewhere between 35-37 weeks before delivering their totally healthy babies. This made me feel a ton better and made me feel more mentally prepared to go into my appointment the next day with Dr. Ubhi. I can only imagine how that would have gone if I hadn't seen Dr. S the day before. I would have felt sorry for the poor man with me in tears...although I'm sure he's seen it all what with being an OB/GYN and dealing with pregnant and hormonal woman all day long :)
The next morning I was up bright and early at 3:15 am to shower and get ready for my parents to pick me up at 4:30 for the ferry to Vancouver. We stopped in North Van for breakfast with my aunt and uncle and headed off to New West with tons of time to spare. We got to the office more than an hour early but were lucky he had a no show and I was seen just moments after arriving. We were in and out of there in less than an hour and headed straight back for the ferry. We had packed bags in case he wanted me to do an ultrasound or MRI but thankfully we didn't need them at this visit. We left PR at 5:30 am and made it back home by 6 pm. Got super lucky with ferry connections that day for sure! Any long term resident of PR can appreciate how seldom this would happen!
Anyways, back to my appointment with Dr. Ubhi. So I will admit that I went into it wondering what he would be like and didn't actually do much research on him before hand because I wanted to make up my own mind when I met him. Well, let's just say he doesn't disappoint. He is a super funny man with an amazing bedside manner. He joked with us but also answered my questions thoughtfully and thoroughly. His medical student that took my history before hand was great too and I felt very well taken care of. I was surprised that in my talk with him that he didn't mention the placenta previa at all and only focused on the placenta accreta as that is the complication that poses the most risk to me during the delivery.
We went over the possibility of a hysterectomy and I made my feelings known that I am more than fine if that is the course of action they need to take after her delivery. He said that sometimes you can go into an anticipated accreta delivery and "the placenta can just come unattached as normal and pretty much smack you in the head" so he tends to prepare for the worst but of course hope for the best. If the hysterectomy isn't necessary I asked him about tying my tubes and he said that they would instead just cut them out as they do nowadays. Either way I am okay with no longer having the ability to bear children. I don't feel the need to go through another pregnancy after the stress of this one and I know that once our little girl is born I will feel like our family is fully and finally complete!
I was very saddened to hear that there is a possibility that he won't be able to find an anesthesiologist that will agree to let me stay awake for her delivery and then put me to sleep for the rest of the surgery, but he did say he would try and for now that's enough for me. He said there are a few of them at RCH that he thinks he may be able to convince to do it and he would try his best to get one of them on my surgery. He jokingly said to my mom and I when we were talking about me being awake "trust me, the last thing you want to be awake to hear me say is, holy shit look at that." Yup he's right, I don't want to hear that while I'm wide open on the table....but I would really like to hear my daughter's first cry and see her pretty little face before I'm knocked out for however many hours it will take to complete what could end up being a complicated procedure. He indicated that the team of doctors that he would put together for the delivery would be himself, a doctor for the baby, the anesthesiologist, a urologist and a radiologist. I can't remember why he said the radiologist but the urologist is because he said the fear at this point is that the accreta may have gone through the wall and attached to the bladder so the urologist would need to be there to do that repair. It sounds like it will be quite the environment, and certainly very different than the quiet and small team of people that brought our boys into the world here in PR. There would also be a supply of blood on hand in case of severe hemorrhaging.
After answering my questions he stated that he wanted to take my weight, height, blood pressure, etc. He also said he was very curious to see my belly to look at the scar from my bowel resection surgery that was done in 2010 shortly after I had James. I told him it was a strange looking scar that goes around my belly button and to me looks a bit like a question mark. As soon as I laid down on the table and bared my belly I heard the words I was dreading "oh, hmmm, yeah I'm going to have to do the surgery down from your belly button to your pubic bone." Even though I have two previous c-section scars along my pubic bone, this is exactly where they believe the placenta has implanted so of course it makes more sense to cut away from the placenta to try and cut down on the risk of severe bleeding from cutting directly through the placenta. He did say to me that he felt badly because he knew that the incision that way would be way more painful and would have a much harder recovery than a cut along the pubic bone...but he also said that if he did it along the pubic bone and something happened and things were worse than anticipated and he ended up having to cut me up towards the belly button as well I would end up with what is referred to as anchor cut which would be even worse of a recovery. I am okay with the decision as the safety of baby and me are the highest priority but I will admit my fear skyrocketed after that because I remember the pain of waking up from my bowel resection surgery and I can easily say that it was far more painful than both of my sections put together. I want the day of her birth to be a great one, not one that I remember as being incredibly physically painful. I'm hoping that the high of meeting her and having the boys meet her will get me over those tough first few hours.
I was very relieved when Dr. Ubhi said that as long as I don't have any significant bleeding that I can stay home in PR until the day before the scheduled c-section. The next part of the plan is to go back at 30 weeks (February 23) for a follow-up appointment. He asked that I have another ultrasound here at home before seeing him again so mom and I are going to see our little lady on Valentine's Day morning and those results will be sent to him for my appointment the following week.
Dr. Ubhi indicated that by the time of the 30 week appointment he may have picked a date for the c-section because it sounds like it may take some coordinating to get it scheduled with all of the necessary doctors there. The only day in April I requested it not be is April 13...even if James is okay with sharing his day with another family member (remember he already shares with Grandpa Barrows), I'd prefer that they both end up with their own day separate from their siblings! I imagine it will be scheduled somewhere between April 10-12 as that is the week that I will become 37 weeks pregnant so considered full-term. And considering that the 14th is the start of the Easter long weekend I don't imagine he'll let me wait through that to have her the following week (although I wouldn't be opposed to that plan either!). I will also be okay though if they decided to do it the week before too :) I am very excited to not have to make it through those awful 37-40 weeks of being pregnant when all you want to do is cry from being so big and uncomfortable! But on the other hand I'll be really happy if we make it to 35 weeks so she has a really good chance of no time spent in the NICU!
Dr. Ubhi's only request/order was that of course if I start to bleed to head to the ER immediately for my own doctor to evaluate me and determine if I need to go to Vancouver immediately for delivery. He also said that when I reach 34 weeks he will have me back down to Vancouver for another appointment and at that time he will do another ultrasound and an MRI to try and determine the severity of the accreta at that time. Jim and I plan to go to that appointment prepared for any outcome, just in case it is severe and they decide to deliver her shortly after that. I do know if they determine she needs to be delivered sooner rather than later they will give me steroids to strengthen her lungs for an early delivery. We will definitely have our bags packed and the car seat installed too just in case! Nana and Papa will have the boys at their house and we will send bags with them too just in case they end up making the trip with them to meet their little sister!
I left the appointment with Dr. Ubhi feeling much more settled knowing that there are plans in place for her safe delivery, but I will also admit I left feeling really sad and overwhelmed by the possibility of not seeing her birth and of the decision to do the incision up and down rather than the less invasive pubic bone incision. It makes me really sad that I may miss seeing Jim meet his little girl and that by the time I meet her she could be hours old already. I'm nervous of a loud and big delivery room with unfamiliar people and have a really unsettled feeling of not knowing what to expect. I'm not scared of the hysterectomy but the pain of the recovery definitely scares the shit out of me! I'm kind of excited about the hysterectomy actually as it means no more periods...ever! And if you are wondering about menopause...that won't happen unless for some reason they have to take my ovaries out too but that is certainly not part of the plan and shouldn't need to happen.
I was still feeling sad and nervous when I went back to see Dr. Strydom on February 1 but as always talking through everything with her made me feel so much better. And this time I made it through the whole appointment without shedding a single tear :) When I told her I was surprised that Dr. Ubhi didn't really mention the placenta previa she said it was probably because it is a common complication that they would see all the time and isn't super serious usually but the accreta isn't seen as often and is the one that needs to be dealt with cautiously to ensure mother's safety after the delivery. She was pleased with his plans and said that it was definitely in my best interest to be delivered in Vancouver.
I told her that I just really wished she could be there with me to take care of my little lady and she laughed and said "I doubt they would give me privileges." :) In the past few months I've thought a lot about the fact that if I'd had Dr. Strydom when I was pregnant with Jordie I believe that I would have been much more open to attempting a VBAC delivery which MAY have saved me from having this complication this time. Maybe not, but maybe it would have as I do know my risk factors were higher because of my two previous sections (oh and of course that damn advanced maternal age thing!) Her calm and reassuring manner would have been exactly what I needed to believe in myself that I could handle a VBAC. Nothing against Dr. Naude or Dr. DuPlessis but both were more than happy to let me have my repeat c-section without really strongly encouraging me to try a VBAC delivery. They asked me if I would be open to it if I went into labour naturally but both assured me several times that I wouldn't be forced to do anything I didn't want to do. And although I know Dr. Strydom would have told me the same thing I do believe she would have been very encouraging and supportive in helping me come to terms with the fear I felt at a VBAC delivery. I do remember Dr. DuPlessis mentioning that the more sections you have the more likely you are to have complications in subsequent pregnancies, but that wasn't a concern I felt at that time (because remember I was pretty sure Jordie was a girl and I was done having babies after that....hahahahaha!)
When I mentioned how sad I was feeling about maybe missing her delivery she told me that most likely with the drugs I would need to be given immediately following her birth to put me to sleep for the rest of the surgery would likely have an amnesia type affect and I probably wouldn't remember much about it afterwards anyways. She did say though that she understood how sad I would be to miss hearing her cry and seeing her face, but that if that was the way it was safest then that was the best bet in every circumstance. And while I do understand that completely, it is still something I am struggling with. My mom says she never saw her kids being born because all 3 of us were born via section and she was sound asleep for all of us, but as I keep reminding her, I HAVE seen two of my children being born and got to experience those special moments and the thought of not having that this time is upsetting to me. And even though it may be necessary, I can't see this being something that I ever really come to terms with and be okay with, although I will always be grateful just for the fact that she was delivered safely and we live in a world where that is even possible.
The last thing we discussed was the incision and while she agreed that it wasn't ideal, she did say if it was her she would rather they do the incision further away from the placenta to help lessen the chance of severe hemorrhaging and would chose to do the up and down cut rather than risk a pubic bone cut that had to then be cut upwards as well because of lack of access to the area. Although I knew all of this stuff, and was working my way through these feelings, it did help to talk it over with her. I can't say I'm not still sad, but I'm resigned and committed to doing whatever I need to do in order to have my little girl delivered safely and to still be alive myself at the end of my surgery. If I have a longer recovery it just means that I will need to ask for more help and ensure I take the time I need to recover properly. Either way it's going to make for one hell of a birth story for baby girl!
So, if you made it to the end of the this post I give you credit! It was a long one that I've been trying to write for weeks now, but really had to come to terms with some of my feelings before I sat down to put them here for others to read. I'm sure there are still some tough days ahead emotionally and I don't think for one second that things are going to be super easy for the next 9 weeks but I am very hopeful to get through the next 5 weeks of work (2 more full-time and 3 of part-time) and then get to enjoy my last month with my boys. I am hopeful for no big bleeds or hospitalizations but also feel very comfortable and fortunate that if it does happen that I have the best support in my family and doctors to make the best decisions for the health of me and baby girl!
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