Wednesday, November 12, 2014

Week 25 new complication: Macrosomia

What a way to celebrate HB's 35th birthday - two doctors appointments and a trip to the dealership service shop! With the exception that he wonderfully took the whole day off of work to enable us to be together as a family, it was definitely one of those days that you wish you could be granted a do-over.   Fortunately, he's the best sport on the planet and, hands down, the most amazing supportive husband and daddy ever so while I would have been mortified by the days events effects on my birthday, he stood unwaveringly by to make the most of the day's misadventures.

About two weeks ago we purchased a new car to accommodate the growing family and to replace the truck HB purchased just a few weeks after we began dating in 2006.  Having purchased used, our new Yukon has a couple parts that the dealership needed to order before replacing - which we were under the impression would be installed today.  So getting up extra early to fight the commuter traffic along I-95 North, we started the day with an hour and a half of sitting in what I can only describe as the quietest waiting room I've ever been in at a dealership... there were several many serious looking business suits sitting about the room focused on books or laptops and, of course, because I'm that Mom, I stressed the entire time about GW and GV's behavior so as to be courteous to these other patrons.  For the most part the kids did a good job of keeping the ruckus to a dull roar by looking out the windows at the various cars on lifts, but if HB hadn't been there to help me wrangle at those particularly loud moments I am quite sure my head might have exploded.   Anyway, we eventually had to approach the front desk reiterating that we were on a schedule with doctors appointments and couldn't afford to wait longer for our vehicle to be returned only to learn they hadn't done a single fix to the car in that time frame and the parts that were needed had to be ordered.   Oui.

So frustrated with the morning, we proceeded to the Perinatalogist's office for our 25 week appointment.  It's the first appointment in weeks that we've brought GW to as his school schedule and the baby's appointment schedule haven't been compatible, but knowing how much he enjoys the sonograms and how excited he is for his new baby brother it only made sense to include him in the day's "festivities."  We had just piled into the waiting room where the kids promptly fought over a few magazines and a specific chair next to Dada when I was called back into the triage area for my vitals check.   Pulse - check! Blood pressure - check! Weight - WTH!?!

"Okay, you'll be called back for the sonogram shortly."

Reporting to HB that my weight registered as five pounds heavier than the scale at home did just a few hours prior, I tried to shake off my weight-consciousness and focus what positive attention I could on the kids as they leafed through the various baby and parenting magazines.  Shortly there after, we were called back as a family to the sonographer's room.

"Can I help you?" GW asked of the sonographer as she squirted the warm goo on my growing belly.

"Sure, can you hold the wand steady?" the sonographer asked.

Taking the wand and prodding the baby bump with a bit too much enthusiasm, GW willingly accepted assistance from the pro and images of Baby #3 began to appear on the screen.   Things looked fine from what I could tell - the heart beat sounded right, the parts were in the right place and there weren't any particular spots on which the sonographer abnormally lingered.  Handing me a towel to clean up and GV the pictures to carry - "carefully!!" - we packed up and went back to the waiting room for some more, you guessed it, sitting.

Fortunately this doctors office is spot on with their scheduling and it wasn't too long before we were called back to talk with Dr. Khoury, the MFM at the office who appears to be taking point on my case this go around.  Upon inviting our tribe in, GV promptly walked to his knee requested up and sat quietly through out the appointment.  GW on the other hand seemed to think that the sofa in his office resembled a tumbling mat - which, as you can imagine, did nothing positive to assist the appointment along in my eyes.  Dr. Khoury, who is apparently ready to have grandkids, didn't seem to mind terribly, but still...

"So, correct me if I am wrong, but have you gained 42 pounds this pregnancy?" he asked bluntly.

"Well, the scale at home says 37, but yes, I've struggled much more with quick weight gain this go around." I responded.

Going on to inquire about my blood sugar control ("are you chasing lows?"), my exercise routine ("are you able to exercise?") and a smattering of other weight-relevant questions, he launched into a new diagnosis as he typed in my electronic chart:

"Well, your baby is macrosomic and, unless you can get this weight gain under control, you're going to have a c-section."

I've known since GV's pregnancy that most diabetic pregnancies result in overly large babies - macrosomic babies - that cannot be delivered safely through vaginal delivery, however, I've also known that tight blood glucose control (which is measured by the HgA1C) can prevent this over padding of fat on the fetus.  What I didn't know was that there may also be a coorrelation between maternal weight gain during pregnancy and macrosomia regardless of diabetes.  Awesome.  So while I've been thoroughly on top of my glucose levels with a recent A1C of 5.5 (well within normal limits), my seemingly uncontrollable weight gain is causing some of the exact problems that I've been trying so hard to avoid.   Granted, my glucose control is helping in other areas like organ formation and an absence of birth defects, but you can imagine my frustration...

I might be considered abnormal for this, but one of the best parts of pregnancy that I have previously enjoyed and that I am actively looking forward to is labor.  The pain is terrible, but the way my body knows what to do and how quickly I progress through active labor (30 minutes with GW and 15 minutes with GV) is a source of pride that I take incredibly personally and even the mention of a c-section makes my heart just crumble with a sense of loss.  I know that in emergency situations it's unavoidable and many women haven't had the option to pursue vaginal delivery, but wrapping my head around Dr. Khoury's words sent me into a self-depraving sense of grief... I've been working so hard to keep Baby and me healthy and now this?!

Maintaining as much composure as possible, we scheduled our follow-up appointment for week 28, walked to the car and I promptly burst into tears.  Consoling me as much as he possibly could, HB held my hand and repeated words of encouragement as I pulled up the Mayo Clinic information pages on fetal macrosomia.  While a c-section will prevent much of the structural damage that could endanger both me and Baby and, at the end of the day, a healthy baby is a healthy baby for which to be thankful, there are several complicating factors as a result of macrosomia that make my mind reel:

For Baby the risks, even with c-section, are immediate as well as having longer term implications:

  • Baby faces the likelihood hyperglycemia and impaired glucose tolerance at birth - the exact opposite of concerns for blood sugar levels we faced with GV.  With her, we were concerned with her glucose levels being to low (which they were), which was easily fixed by feeding her.  With Baby, I don't know what the doctors will need to do to address elevated glucose levels or if they can do anything. 
  • Baby faces a higher likelihood of suffering from childhood obesity as research indicates some degree of link between higher birth weights and excessive weight gain in school age children. 
  • Baby faces a higher probability of suffering from a variety of conditions - such as increased blood pressure, high blood sugar and elevated cholesterol - that, when combined, directly lead to a heightened risk of heart disease, diabetes and stroke. 

For Mama the risk for complications increase if future pregnancies are considered (which, yes, future pregnancies are something for which HB and I are hoping):

  • The risk for fetal macrosomia increases with each pregnancy, especially those for male babies.  So Baby #4, should we be able to have another, is not only at a higher risk for a higher birth weight due to birth order, but given that we're struggling with macrosomia with Baby #3 he or she will be at an elevated risk because of my maternal history with the condition. 
  • Given my history of placental abruption and the compounding issue of a potential c-section, my risk for uterine rupture with future pregnancies is heightened due to the damage I'd sustain to the anterior wall.  This also decreases my candidacy for a vaginal birth after cesarean (VBAC), for which I emotionally am holding out. 
I can rationalize that a c-section isn't the end of the world and I can also rationalize that I have two, soon to be three, beautiful children that I've been blessed with by God, but the picture I have in my head of what I want and expect out of life versus the rationalization of what options and outcomes are just not in my hands are two irreconcilable things.   I understand how fortunate I am to live in the United States and to have access to the comprehensive medical care that so closely monitors me and Baby.  I understand that it's up to me to curb weight gain for the remainder of the pregnancy and that the chromosomes and genetics involved are beyond my control.  I can understand that my crying in the car today has absolutely no correlation whatsoever to what happens with delivery of Baby come d-day... I get all of that, but for the time being, I'm miserable.  I'm overwhelmed.  I'm scared.   I don't know exactly what I'm going to do or how best to go about it, but so help me God I've fought this hard to have a healthy baby in the way I want to that I'm not about to give that up now.

The only thing I can possibly say about the day that is remotely positive is that HB and the kids were exactly where I needed them and that I couldn't have gotten to this point of writing about all of this without their love and support.  I am beyond grateful for HB's consistency, GW's compassionate hugs and GV's constant attempts to make eye contact with me and inquire about "Mama happy?"  Without them, I'd be in ball somewhere suffering from complete self-loathing rather than actively working to acknowledge the good that exists in my life already.

I wish it could have been a better birthday appointment, HB, but thank you for everything you did today and simply embody in spite of it all.  

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