Wednesday, August 2, 2017

Pregnancy, AMA

When I last had a baby, I was 35 for the entire pregnancy. I met ACOG's technical definition of Advanced Maternal Age, but my OB never mentioned it. Later, at a yearly appointment, I asked her about it. She said that for someone with my medical history and pregnancy outcomes, she would not consider a pregnancy AMA until age 37 or 38 at the earliest.

As my husband and I discerned over the years about whether another pregnancy would be prudent, I always asked my doctor her opinion on my fitness for pregnancy at my yearly visit. She always was unfailingly positive. Someone with my history should not need to avoid pregnancy for medical reasons. As I crept up in age, she would caution that it might take longer than usual to get pregnant and my risk for miscarriage would be higher, but she strongly felt the odds were overwhelmingly in my favor.

Then we made the decision. It did not take longer than usual to get pregnant.

At the beginning of my pregnancy, while I was a spring chicken of 39, nothing much was different from a medical perspective than with my other pregnancies. My appointments were carried out in the same old way. I didn't have any extra appointments or screenings related to my age. I did have more ultrasounds, but that was due to ectopic concerns and later baby hiding from the doppler, but not my dotage.

In May at my regular appointment, my doctor made note of my 40th birthday in June. She said I should get a phone call from scheduling setting up my appointments for the rest of the pregnancy. I was not alarmed by either comment. I happened to get the phone call in a few days at a bad time. The nice woman on the phone said it wasn't a problem and she was just letting me know to expect a list of my third trimester appointments in the mail. Nothing prepared me for what was in that fat envelope when it arrived the next day.

Appointments. Oh, so many appointments. They had me scheduled for three appointments a week for the last seven weeks of pregnancy. Every week starting at the beginning of August, I was supposed to drive into Nashville for an ultrasound to check fluid and growth on one day plus a regular appointment and then drive back into town another day for a separate non-stress test. I was astounded. I went from being treated like a normal pregnant woman who had been encouraged to pursue a healthy pregnancy to one who it seemed they feared might have catastrophe strike if they didn't see me every few days.

Taken aback by this pile of appointments, I did some research to figure out why so many. (Let's be real, I asked people on FB and then did some other reading aside.) It turns out there is a higher risk of stillbirth in the last couple weeks of pregnancy for mothers over the age of 40. And I guess that's me now. I am frustrated by the notion that if I had had this baby in June instead of September, I likely would have been scheduled for almost none of this.

But the last couple of weeks of pregnancy is a far cry from the last two months. I have other things to consider besides tests being run out of an abundance of abundant caution. First is child care. Where am I to store the other children while I attend appointments that will carve three to four or more hours out of my day twice a week for seven weeks? The second is cost. Being the proud owner of a $5200 individual deductible before the insurance kicks in at a generous 50%, these tests will cost me upwards of $300-$400 a week. That's a pile of money. (How much does an NST cost? Anyone know? Not me.) I have no desire to spend that kind of money without a real reason to be doing it.

At my next appointment I talked to my doctor about my concerns. She explained the elevated stillbirth risks, but agreed that given my health and history, I could postpone these tests a few weeks without much concern from her. She wrote up the order to cancel two week's worth of appointments and I took that trusty piece of paper down to a scheduling nurse.

The scheduling nurse was beside herself. How did I manage to get the doctor to agree to cancel these appointments? Not your business, schedule nurse. She just wasn't too sure about this. I didn't ask your opinion, schedule nurse. She couldn't possibly reschedule a different appointment I had a conflict with because she was already pressing her luck by cancelling the other appointments. Show me your credentials and your understanding of my medical chart and then I might care what you have to say about this, schedule nurse.

I didn't really expect the scheduling nurse to be the source of friction on this topic, but there it is.

At my appointment earlier this week, I saw a different OB than my usual. My OB was on vacation and that's just the way the schedule worked this week. Whatever. My appointment was entirely normal. Appropriate weight gain. Good, which is to say low, blood pressure. Good fundal measurement. Strong heartbeat. This different OB might have used the word 'perfect' several times during the course of our five minutes together.

Then, apparently? something? I don't know?, she must have noticed that I was officially old on my chart. OLD, I tell you. After telling me how wonderful it all was, she then asked if I had an appointment scheduled with the high risk OB. Um, no? You just told me everything was perfect, repeatedly. Now I need the high risk OB? Then she asked if I had a growth scan ultrasound scheduled. Yes. When? In two weeks. Okay, good. We really need to get a growth scan on this baby. If you say so. My belly has grown since my last appointment and baby is kicking the fire out of me, but I guess we can't be too sure that baby actually grew. It's all a coincidence. I suspect my regular OB would not have been so jumpy.

So that's life with a really official AMA pregnancy. Everyone at the OB office thinks it's great, but they also think you might spontaneously combust. Stay tuned...

(Digression: I will be having this baby at the hospital this time. The midwife who lived five minutes away moved out of state. The other midwife I wanted to use couldn't guarantee her arrival within an hour. This is totally understandable. The number one medical concern in my pregnancies is unassisted delivery. If the midwife couldn't get here quickly enough, I'd run a high chance of delivering by myself. So the hospital it is. I know this means I will likely be induced. Meh. But it is what it is. The goal is no interstate deliveries.)


mandamum said...

Wow... I just moved away from my midwife who delivered the last 3 of my 6, and just turned 40 this past spring. My midwife always said the AMA was mostly about the primapars.... but I'm sure it could get very interesting starting over with a new provider at the ripe old age of 41, 42, or even 43!!, should we be so blessed. Good to bear in mind.

Jenny said...

I have heard that other practices aren't so testing intensive and the protocols vary widely. Your new doctor might not schedule so many tests or might think the twice a week testing schedule is a laxity. Who knows?