A Frank Ob/Gyn's Message

An honest assessment of all things medical and ethical.

Archive for the category “Obstetrics”

Am I having a boy or girl?

This week, we’ll discuss the routine anatomy ultrasound of the baby that is generally obtained around 20 weeks “gestation” (or 18 weeks since fertilization and conception).

For many women, the only obstetric ultrasound that I find useful is this 20 week anatomy survey. By analyzing the reflection of sound waves through fluid, the ultrasound device gives us a sort of window into the womb of the mother. In fact, this remarkable technology is one of the greatest advances in obstetric medicine. In essence, it allows us to obtain the baby’s first physical exam months before he or she is born! The most memorable aspects of this exam for the mother and father are discovering their child’s gender and seeing more recognizable images of their child’s face, hands, and feet. I believe that this halfway point in the pregnancy is a milestone where the mother benefits greatly from and is encouraged by such pictures of the child whose hidden movements she is now feeling.

The clinician, however, is more focused on the assessment of the particulars of the child’s major organ systems often with a sharp focus looking for any structural signs of a possible genetic abnormality. For instance, I often receive reports pointing out an “echogenic” (more highly reflective of sound waves) areas in the brain, heart, stomach, or bowel. These findings are usually associated with healthy babies, are transient, and are of themselves medically irrelevant. In fact up to 17% of healthy (i.e. “normal”) babies will have some of these findings which are called “soft markers.” However, these findings are more frequently found in the rare cases of genetic anomalies such as Trisomy 21, also known as Down’s Syndrome. Such information of itself can be authentically useful for the mother and her physician even when the option of induced abortion is unthinkable to both. Sadly, though, much of the modern approach to obstetric care has put an inordinate amount of valuable time and resources into this antepartum (before birth) detection of aneuploidy (chromosomal abnormality). Especially in the countries where abortion on demand is legal, there has emerged a veritable “search and destroy” mission that tends to dominate the resources of routine care and academic research within obstetric medicine. In fact, in many nations, led by the U.S. example, abortions are routinely performed after 20 weeks and even beyond 24 weeks when most babies would survive a premature delivery. Suspected chromosomal abnormalities or other anatomic defects are a frequent motive of these late-term abortion procedures.

Nonetheless, I stated earlier that I do find this 20 week anatomy ultrasound to be helpful–though certainly not out of a desire to brutally dismember and destroy any child I suspect may have a genetic disease. On the contrary, certain conditions will affect how I treat the mother and preborn child for the rest of the pregnancy with an aim to preserve the health of them both. For example, an ultrasound diagnosis of a certain fetal conditions like growth restriction may require closer monitoring and even early delivery. Some structural defects can even be treated with in-utero surgery a specialty centers. Such an attitude toward promoting life has always been the noble goal of diagnosis in the Hippocratic medical tradition of “Primum Non Nocere” (Do No Harm). Recall my description of the 20 week ultrasound as the preborn baby’s first exam. Can you imagine a physician scheduling the execution your 2 year old child after he diagnoses a genetic disease during a routine physical exam? Induced abortions should be just as unthinkable.

–Dr. Frank


Is my baby going to be alright?

In the last post, I reviewed the importance of establishing a due date. The next issue we address early in the pregnancy entails assessing the woman’s overall health with particular attention to any medical problems that may affect her health and that of the baby during the pregnancy.

We start by obtaining a detailed medical history. Assuming there are no preexisting conditions such as diabetes or hypertension, we then proceed to run a series of routine blood tests. The only ones that are really necessary for most women is a blood type, blood count, and urine culture. The blood typing will assess for any risk of developing antibodies against the baby’s blood cells. This is a serious complication that could occur during a second pregnancy if the woman’s Rh type is negative. Fortunately, this condition called “hemolytic disease of the newborn” is now very rare precisely because we test for and preventively treat women who may be susceptible. Women who are “Rh negative,” will receive a medication called “Rhogam,” around 28 weeks gestation in order to prevent her body from developing antibodies against her preborn infant’s blood cells. The success of this routine test and treatment is truly one of the best success stories in modern obstetrics, wherein the incidence of hemolytic disease of the newborn is rarely seen anymore. Next, the blood count test will assess for any underlying anemia which may need to be treated. Finally, the urine culture will test for any undiagnosed urinary tract infection which during pregnancy is more likely to spread to the kidneys.

The other routine testing is controversial and often lacks sound scientific rationale. These can be divided into two categories. The first is that of infectious disease testing (for the variety primarily transmitted by sexual contact).

In the U.S., most obstetricians will routinely test for gonorrhea, chlamydia, hepatitis B, syphilis, and HIV. In my experience, it is highly unlikely that a woman will have any of these infections if she lacks both symptoms and potential exposure based on her history. The pertinent history is whether she has abused IV drugs like heroin or whether or not she is in a mutually monogamous sexual relationship (as in a faithful marriage). Rather than utilizing the rational approach of simply basing our testing on the individual patient’s actual risk factors, we have resorted to the politically correct yet inefficient, wasteful, and unscientific approach of assuming all our patients are IV drug abusers routinely engaging in sexual relationships with multiple partners. I have never even met another physician who has diagnosed HIV, syphilis, or hepatitis B in a woman based on these “routine,” tests alone in a woman without known risk factors. Ye,t we continue to use this approach rather than run the risk of being labeled “ judgmental,” for utilizing these tests only on the women known to be at risk. During an era of ballooning health care costs, this obvious waste or resources should certainly be addressed. We may even have to let go of our social engineering agenda of treating all manner of sexual activity and perversions as normative. To do so, however, would run the risk of exposing the common sense truth that certain behaviors entail commensurate risk that pose real physical danger to a woman and her preborn child.

The second type of routine prenatal testing is even more problematic in terms of medical legitimacy. I am speaking here of those tests used to supposedly assess the risk of having a child with a genetic or other congenital defect. Among these are the “triple screen” (recently replaced in most areas by the “quadruple screen”), nuchal translucency ultrasound (often done in combination with a serum PAPP-A test and HCG), amniocentesis, and chorionic villus sampling. These tests can be grouped into two categories.

The first would be that of the non-invasive “screening” tests, which will actually only provide a statistical number giving a particular % risk of having a child with Down’s Syndrome for instance. Among this first group are the “triple screen,” the “quadruple screen,” and the nuchal translucency (NT) ultrasound combined with a PAPP-A/HCG blood tests. The relative advantage of these tests is that they are non-invasive in that they pose no direct risk of harm to the baby. The major drawback to this group of tests is that they are very inaccurate and misleading. For example, a cut-off of 1/250 or 0.4% is often used to give a woman an “abnormal result.” In other words, 99.6 % of women given this “abnormal” test result have perfectly normal children; yet, for the rest of their pregnancy they live with the fear and anxiety that something might be terribly wrong with their child. Many, if not most, of these women will feel obliged to proceed with the next level of testing–the invasive and diagnostic.

The only definitive prenatal testing that is truly diagnostic is also invasive and poses risk to both the mother and baby. The most widely available test in this category is amniocentesis. This procedure requires piercing the woman’s abdomen, uterus, and the fetal amniotic sac with a long needle in order to obtain fetal cells from the amniotic fluid. This test poses risk of infection to mother and baby as well as the risk of miscarriage. The next test is even more invasive and entails inserting a long cannula through the cervix to obtain a piece of the placenta for testing purposes. While this test is more accurate and can be done earlier, it also carries even greater risk to mother and baby.

Why, one might ask, would we recommend such tests to our patients? The answer is quite simple, yet unpleasant. We offer them out of fear that a woman might have a child born with a genetic defect who would then sue us for wrongful life! This sort of medical liability would be based on the woman not being offered all of her “options,” in regards to prenatal testing. In the U.S., an entire field of “pseudoscience” has been dedicated to various techniques and schedules of prenatal screening and testing. They have as their end, the earliest detection possible of genetic or congenital abnormalities. They exist directly as a result of legalized and widely available induced abortion. The early detection emphasized because more abortionists are available to perform and women are lest resistant have to early abortions. Therefore, women should be aware that if induced abortion is not a procedure they would consider, there is no good reason to procure one of these early screening tests. We must acknowledge, however, that it has been argued that information by itself is a good and even an abnormal result could be helpful for the mother not pursuing abortion by allowing her to prepare emotionally. Unfortunately, this argument overlooks the problems of inaccuracy associated with the non-invasive tests and those of risk associated with the invasive tests.

In summary, I routinely inform my patients of the availability of all these tests, yet I advise against their use. I do, however, advise them to obtain a routine 20 week anatomy ultrasound which serves the legitimate purpose of a physical exam of sorts for the preborn baby. If there are any medical conditions for which we can meaningfully intervene or prepare for, we are typically able to detect them during this ultrasound. My patients are most appreciative of this frank, no-nonsense counseling that treats them as responsible adults able to make informed decisions. Contrast this with the overbearing “paternalism” imposed by the wasteful “one-size fits all,” approach promoted by the mainstream medical profession. Next time, we’ll step into the much less controversial matters of the diagnosis and treatment of diabetes in pregnancy.

Sincerely yours,

Dr. Frank

When is my baby due?

This first series of topics will address the most common and routine part of my clinical practice–that of prenatal obstetric care. The most important thing we need to establish early on in the patient’s care is the gestational age of the pregnancy. Hence, this week’s column will explore this matter in some detail.

Since we don’t routinely perform a prenatal ultrasound until about 20 weeks gestation, most of us rely on the patient’s recollection of her menstrual cycle to establish the estimated date of conception and subsequent due date. However, if she has any risk factors for ectopic pregnancy (the tragic situation where the embryonic child remains in a place outside the uterus), we do actually obtain an early ultrasound exam by around 7 weeks to establish the location and confirm a fairly accurate age of the pregnancy.

A curious matter, however, I will address right away is the terminology used for describing the age of said “pregnancy.” Most obstetricians still use a calendar method based on the first day of the woman’s last menstrual period (LMP) to establish the “gestational age” or more accurately termed the “menstrual age” of the pregnancy. Two great ironies come into play here. The first is that this method of dating the pregnancy makes a very bold assumption. It assumes that the woman has regular 28 day cycles and that she conceived on day 14 of her cycle. Day 14 may be the historic average day for conception among women with regular 28 days cycles, however most women do not ovulate or conceive on day 14. If,however, the woman has been tracking her fertility with any of the modern methods of fertility awareness (a.k.a. natural family planning or NFP), we can much more accurately date the pregnancy. Incredibly, most people dismiss these modern natural family planning methods as the “rhythm method” (a term adopted to disparage the calendar method of NFP promoted in the 1930’s). Even more ironic is the fact that those physicians who know least about natural family planning (and therefore are most likely to reject its validity) are the ones actually relying most on the out-dated calendar method of NFP that they have long derided as the “rhythm method.” Thus, when talking about NFP to my patients, I frequently need to reassure them that the medical providers still relying on the so called rhythm method do so unwittingly to date pregnancy even as they reject the modern reliable methods of fertility awareness which have long replaced the more accurately termed “calendar method”.

The second great irony is that the conventional description of pregnancy age adds 2 weeks to the actually “embryonic or conceptional” age, i.e. the actual age of the embryonic human life. Therefore, when a woman delivers a baby on her due date at “40 weeks gestation”, the child is only 38 weeks old, not 40 weeks old. Another related issue that I will mention briefly is that curious practice in western medicine of describing the newly born child’s age as if his or her life began at the time of birth. Certainly, the most basic level of common sense and logic confirms that the child is not 1 second old at the time of delivery. Perhaps in prehistoric times, before days and time were systematically recorded, this would have been understandable. However, for at least the past 2,000 years, we’ve easily understood that human life begins long before birth. And modern embryology has proven definitively that a new human life does indeed begin at fertilization that occurs on average 38 weeks before the child is born. After our first child was born, for some time I tried to tell friends and family our baby’s actual age (based on modern science and medicine). I was surprised at the confusion, bewilderment, and even ire this generated. Imagine trying to explain to someone who asks how old your obviously newborn child is that “he was born 2 weeks ago, so he is about 9 months old now.” For the sake of peace and good will, by the time our 2nd child was born, I sadly gave up trying to use scientifically accurate time frames to share our children’s ages.

One final note of clarification I’d like to make about dating pregnancy is that in addition to the rare occasion of concern or potential ectopic pregnancy, there are other occasions where early ultrasound measurements are also used determine or confirm the embryonic child’s age. This is also for example, when we recognize that the woman has irregular cycles (and she is not using NFP to track her fertility) or when she does not remember when her last period started. Even in these situations, however, the calendar method of dating based on LMP is the date we use unless there is a certain degree of discrepancy. For example most providers only switch to the ultrasound-based date when it is at least 5-7 day difference from the LMP date. If the woman has progressed to more than 12 weeks by the time the ultrasound is performed the LMP date takes precedence unless there is a 10-14 day discrepancy. By the time the woman has reached the 3rd trimester, the LMP is used unless there 21 or more days difference. This progression is based on the increasing margin of error with ultrasound dating as the child grows. This progression continues even after birth. Imagine for example how much more accurately you could estimate a one year old’s age by measuring his or her height than you could by measuring an 18 year old’s.

I hope that you have found this discussion both interesting and enlightening. Next week, I plan to discuss some of the routine blood tests routinely drawn in the early prenatal visits.

Sincerely yours,

Dr. Frank

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