Ugggh!!!

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blythe
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Re: Ugggh!!!

Postby blythe » Sat May 26, 2012 09:18 am


I think that maybe before the intervention (push to limit early term deliveries), physicians were delivering ANYONE who might have a slight indication for delivery, as evidenced by the lack of maternal risk factors for most pre-intervention stillbirths. And then after the intervention, patients with indications warranting elective delivery were being missed.


Lemons, thank you *so much* for the summary of the full text and the analysis!
Heather, mom to
#1 7-18-03 - 5#8oz 37 weeks PE/PIH
#2 8-11-06 - 6#14oz 37 weeks PE/PIH
#3 9-10-09 - 5#10oz 37 weeks PE/PIH

lemons
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Re: Ugggh!!!

Postby lemons » Fri May 25, 2012 11:36 am

mom29 wrote:
I think we make a choice between dwelling on the difficult things in our lives or being thankful for the good things.


I agree with you. And I am glad that your daughter is thriving these days and that your boys are able to enjoy being big brothers! I know how hard an early delivery and NICU stay (58 days) are, and I definitely questioned the decision to deliver, and still do to some extent. But I know that my husband and I are incredibly lucky to have our daughter here with us. That is our focus these days :)

And thank you for your comment about my signature- I was devastated when I lost my first baby, but I like to think that that baby helped prime my uterus to be able to support his/her little sister (my 30 weeker). Especially, once I found out about the two year theory and uterine artery remodeling.
Diana, happily married since 2007.
Miscarriage at 10 weeks (June 2009).
DD at 30+0 weeks weighing 2lbs 9oz (October 2010) due to PE and IUGR. Today, a happy and healthy toddler.

lemons
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Re: Ugggh!!!

Postby lemons » Fri May 25, 2012 11:22 am

I have read the full text of the research article in question (Ehrenthal, et al. Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation. Obstet Gynecol 118(5):1047–1055)

To provide some answers:

1. The "intervention" for the study was to educate OBs and MFMs about the American College of Obstetricians and Gynecologists recommendations to limit early term (37-38 completed weeks gestation) elective deliveries. These recommendations allow for delivery in cases of either maternal or fetal indications, including: PIH, preeclampsia, HELLP, gestational diabetes, and many others.

2. The data did NOT exclude pregnancies that were complicated by these maternal or fetal indications. Instead, the data include ALL births that completed 37 weeks gestation.

3. Of the 7 stillbirths at tern (37+ weeks) that were recorded PRIOR to the intervention- 4 were due to cord accidents (one was a two vessel cord), 1 was due to placental insufficiency, and 2 were unexplained. Of the stillbirths due to cord accident, there were no maternal risk factors identified. The stillbirth due to placental insufficiency was in a postdated pregnancy (41 completed weeks gestation). One of the unexplained stillbirths was in a mother with the risk factor of "advanced maternal age" (greater than 35). Point being that none of the stillbirths were to mothers with indications of PIH, preeclampsia, or other hypertensive related conditions.

4. Of the 15 stillbirths (which excludes 2 stillbirths related to chromosomal or congenital abnormality) at term (37+ weeks) recorded AFTER the intervention- one was unexplained with a maternal risk factor of gestational diabetes, one was unexplained with a maternal risk factor of chronic hypertension, one was unexplained with a risk factor of prepregnancy diabetes, one was due to IUGR presumably from cocaine exposure, one was due to fetal infection after the in utero repair of a congenital heart defect. All of these 5 pregnancies should have been considered high risk and should have been candidates for early delivery according to the ACOG recommendations. I am not going to provide the rest of the results unless one of you really wants....

And now for my own take on the results-
The take home that I concluded and was subsequently pointed out in comments on the original article, is that apparently, the recommendations from the ACOG were not being effectively implemented. I think that maybe before the intervention (push to limit early term deliveries), physicians were delivering ANYONE who might have a slight indication for delivery, as evidenced by the lack of maternal risk factors for most pre-intervention stillbirths. And then after the intervention, patients with indications warranting elective delivery were being missed.

Overall, I think this study is a great indication of why the Preeclampsia Foundation has such an important role to play in safe guarding the health of both pregnant women and their babies- education, education, education, of care providers, pregnant women, and their partners/families. Hopefully, this has helped. I am happy to answer more questions regarding the actual study. But due to copyright restrictions, I can not distribute the actual article.
Diana, happily married since 2007.
Miscarriage at 10 weeks (June 2009).
DD at 30+0 weeks weighing 2lbs 9oz (October 2010) due to PE and IUGR. Today, a happy and healthy toddler.

angieb
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Re: Ugggh!!!

Postby angieb » Thu May 24, 2012 10:33 pm

blythe wrote:

Mom29, thank you so much for that study (and thank you for your poise in not debating a blog here.). Does anyone have full-text access for the study? I'm wondering if women with hypertensive issues were included in that study - I've always been told that hypertensive issues were medical reasons for inductions and would therefore be left out of the studies that count "elective" deliveries - making the number of stillbirths that much more alarming, especially because those should have been "normal" pregnancies.


I didn't have access to the full-text but I believe that the blog (from an OB) did quote some parts from the full-text article. In it, it specifically mentioned that the researchers were surprised with the tripled stillbirth rate and therefore went back through all of the cases to make sure that none of the cases should have been early deliveries for indicated reasons like hypertension, etc., at least from what I understood. I will PM you the blog link, but here is the quote I am referring to:

[this part is the blog author's commentary: Because this increase in stillbirths is so large, the authors reviewed each stillbirth to be sure that they were not the result of risk factors that would have triggered a medically indicated induction.

This part was in a quote which leads me to believe it was from the full-text article:

The authors carefully reviewed the medical records of each stillbirth to identify cause of death and the presence of a maternal risk factor ... No definitive cause-of-death pattern emerged.
Me (29) DH (30)
#1-Olivia Caetlyn-9-28-09-9-28-09, 23+2 wks, emergency classic c-section, class I HELLP, IUGR
#2- Lucas Oliver (rainbow baby)- April 2011, 36+2 wks, HELLP and pre-e free! (lovenox and LDA pregnancy)
#3-Matthew, late October 2012...mostly normal, 37 wks, (lovenox and LDA again)
My blog: http://www.butterflies-and-rainbows.blogspot.com/

blythe
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Re: Ugggh!!!

Postby blythe » Thu May 24, 2012 08:23 pm

Strongmom, feel free to look through the archives at my early posts. Almost nine years ago I felt very similar - induction for what I thought was doctor convenience and a tiny baby in the NICU, when everyone assured me that 37weekers do fine. After about 4000 hours of reading I came to the reluctant conclusion - in my case, your case may very well be different - that my doctor did exactly the right thing and I am grateful to her.

I can't comment on your actual diagnosis, if you didn't meet criteria when they induced you and it was against your wishes I am very sorry. What I can tell you is that the diagnosis of preeclampsia does not require bad labs, only two readings, taken at least 6 hours apart, of 140/90 or higher with 300mg protein in a 24-hour urine collection. (And at 37 weeks many doctors I know of won't bother with a 24-hour collection, they'll induce on bp alone.) Bad labs would not diagnose PE, you only need bp and protein for that, bad labs indicate HELLP, an especially severe form of PE.

One of the problems in timing delivery with preeclampsia - or as HYPITAT found, just hypertension - is that the average time from diagnosis to delivery is two weeks, but that encompasses women who limp along stable for months -- and women who get very sick or die or have abruptions or stillbirths within hours. And no one can predict who will be the slow moving case and who will have the sudden nuclear meltdown. It is not a case of risking your health instead of risking an early delivery, as Angie b said, it is risking your health *and* your baby's health by staying pregnant in a compromised pregnancy. Again, if your pregnancy truly was normal my heart goes out to you, no one should have to worry over a NICU baby, but once we preeclamptics get sick enough to diagnose - and sometimes even before we reach the official diagnostic criteria - we are ticking time bombs. Time bombs that don't explode often, true, but doctors are balancing rare *death* over a transient NICU stay. And Caryn's point is very well taken - she links to articles and studies that show that the factors in our blood that are especially elevated in preeclampsia are elevated up to 6 weeks before diagnosis (and I've heard of some predictive tests that might actually detect issues much earlier). The "soft" neurological issues are shown to be correlated, they aren't shown to be causal with early delivery. It may be that the early delivery caused the issues, or it may be that our pregnancies were compromised from the beginning and that the same thing that made us deliver early was the cause of the "soft" issues.

I'm surprised that your hospital had many 37 weekers in the NICU, on these boards, in nine years, I can think of maybe two other 37 week babies (other than my firstborn and yours) who needed NICU time. It seems like most of "our" babies, induced or sectioned, do fine - it's common around here for 35+ weekers to room in with no NICU time. I'm so sorry your baby, like mine, got the short straw.

Mom29, thank you so much for that study (and thank you for your poise in not debating a blog here.). Does anyone have full-text access for the study? I'm wondering if women with hypertensive issues were included in that study - I've always been told that hypertensive issues were medical reasons for inductions and would therefore be left out of the studies that count "elective" deliveries - making the number of stillbirths that much more alarming, especially because those should have been "normal" pregnancies. Lemons, thank you for your math and for reminding us about the families behind those stillbirths. **edited to add - huge thanks to lemons in a subsequent post later in this thread for a full text summary and analysis, my guesses and assumptions here were incorrect!**

Strongmom, I am so sorry your birth and your son's NICU time gave you PTSD, I hope our comments can be helpful and I am very sorry if they are not. I wish you peace after your difficult experience.
Heather, mom to
#1 7-18-03 - 5#8oz 37 weeks PE/PIH
#2 8-11-06 - 6#14oz 37 weeks PE/PIH
#3 9-10-09 - 5#10oz 37 weeks PE/PIH

mom29
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Re: Ugggh!!!

Postby mom29 » Thu May 24, 2012 08:07 am

Diana,

I like your tag line acknowledging the loss of your first child AND rejoicing in your daughter's good health. It makes life sweeter to overcome the difficult things. That is amazing she started out so incredibly tiny and is doing well today!

"Miscarriage at 10 weeks (June 2009).
DD at 30+0 weeks weighing 2lbs 9oz (October 2010) due to PE and IUGR. Today, a happy and healthy toddler."

mom29
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Re: Ugggh!!!

Postby mom29 » Thu May 24, 2012 08:01 am

lemons wrote:mom29- I'm so sorry that you lost your son. I can't imagine how difficult that is. And then to have PE and a 33 weeker... My heart goes out to you.


Thank you. I think we make a choice between dwelling on the difficult things in our lives or being thankful for the good things. It was hard having my daughter in nicu for 10 days, but that was such a short stay compared to how long other babies stay. 33 weeks is good in terms of preemie births, so many life threatening problems were avoided by that gestational age. I'm truly thankful both of us came out of that pregnancy okay. It took a bit of time to process the experience, but now we just marvel at the photos that show how tiny she was. She is 7 months old and feels like a moose at 15 pounds now :lol: We are loving having this little person in our lives and all her siblings dote on her. My little boys are happy I actually let them pat her head without making them wash their hands first.

lemons
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Re: Ugggh!!!

Postby lemons » Wed May 23, 2012 08:33 pm

mom29- I'm so sorry that you lost your son. I can't imagine how difficult that is. And then to have PE and a 33 weeker... My heart goes out to you.
Diana, happily married since 2007.
Miscarriage at 10 weeks (June 2009).
DD at 30+0 weeks weighing 2lbs 9oz (October 2010) due to PE and IUGR. Today, a happy and healthy toddler.

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JB
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Re: Ugggh!!!

Postby JB » Wed May 23, 2012 07:27 pm

mom29 wrote:JB, That is WONDERFUL the nicu your daughter was in enabled 24/7 rooming in for you. I didn't anticipate having an early baby so I didn't even consider going to another hospital in our area that has a brand-new nicu with this option. How long was your daughter in nicu?

The blood clots scared me a bit more than having pre-e. Five weeks of lovenox shots took care of it though and I am so very very thankful for modern medicine!


My daughter was in the NICU just over 7 weeks. I have since learned that our NICU is pretty state-of-the-art when it comes to patient amenities. They are one of the few places that has a window between the receiving pods and the birth center surgery room (they call it their "drive-thru window"), which allows babies to be handed immediately into the NICU without a trip down the hallway. While we were there I saw them giving tours to other hospital administrators who were interested in setting up their NICUs the same way. The only things they didn't do there were open major surgeries. The micro preemie in the room next to ours had to be transferred downtown to have eye surgery.

At the beginning of this pregnancy my OB said that if I had to transfer my primary care to the MFMs I would have to go to the hospital downtown where they have privileges (they have a satellite office down here south of the city for consults, but only do their primary care out of their main hospital and offices). I was pretty worried about that, because we loved our NICU so much (the doctors and nurses were all really great) and it and was so convenient for us (we live literally up the road from the hospital, so it was easy to come whenever we wanted). Since I have made it to 36 weeks so far without preeclampsia my OB now says that if things go south I can go ahead and just deliver here with her.

Blood clots are very, very scary. You are lucky that they were detected and you got treatment for them!
1st - miscarried at 11 weeks in Dec. 2009
2nd - baby girl born Mar. 2011 at 29 weeks 6 days due to severe PE
3rd - baby boy due June 19th, 2012

mom29
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Re: Ugggh!!!

Postby mom29 » Wed May 23, 2012 06:43 pm

lemons wrote:mom29- Thanks for posting the actual study.


You are welcome. Thanks for catching the math error.
You are so right there are actual families behind the statistics, we lost a son at 14 months so we have first hand experience.


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