Leaves

Leaves make me sad.  Things tend to go to hell in a handbasket (or more) in the Fall.  I’ve NEVER liked Fall.  Even when I like Fall, I’m wary of Fall.  And for good reason.

Do you see this picture?  I suppose I look happy.  I’m not.

By this time in 2007 I had suffered two consecutive miscarriages.  I was starting to panic.  I was starting to lose it.

This photo also reminds me of our last good day with Alfred, the first dog my hubby & I had together.  We were playing in the leaves that day and with our baby girl.  Life seemed complicated then, but things were good and we knew it.  Alfred died soon after.

Leaves surround me now and make me remember the wonderful things I’ve lost this time of year.  And I’m thinking of a student (and friend) with two young daughters who just lost her husband.  Another loss in the Fall.

These losses also remind me of the many blessings of my life.  I prayed and prayed for another baby . . . and lo and behold I have had 3 more!

Silver linings abound.  Blue skies lurk behind the grey menacing clouds.  If i were more of an optimist, I’d always be looking for those silver linings and blue skies.  However, the wicked past has taught me that the grey menacing clouds return, perhaps more frequently than I would like.  Does the blue and silver merely tease me?  Or does the grey remind me to be thankful for the brilliance of the others?

I continue to ponder this . . . this chiaroscuro that is life.

 

What Can I Say?

I am so out of the loop when it comes to anything having to do with reproduction these days.  I’m not in the loop . . . I’m not in the outskirts or the suburbs.  I’m off the grid.  However, a new comment on my ever “popular” miscarriage and hormones post made me feel compelled to post an update.

Random thoughts about life, birth, and the like . . .

  • My 1/2 acre yard and gardens are in disastrous condition, but I did plant some annuals today; that made me happy!
  • My husband is getting ready to add a second floor to our house – his company is called Aria Construction, and they do fantastic high-end work
  • My youngest is now almost 11 months – I still want to smash her into 0-3 mo. clothes…
  • The twins will be 3 in August, and they are such a joy and such a torment.  I still can’t believe they are mine!!
  • My oldest, age 7, had a stupidly horrible time in 1st grade.  Here’s hoping for rest and recovery this summer and a better experience in 2nd grade.
  • No, I’ve still not written my birth story from July 12, 2011 . . . what’s the hang-up?  Well, I still have issues with G’s birth and with a local care provider.  That’s part of it, I’m sure.

Am I recovered from my birth losses?

Yes and no . . . those losses, in a way, made these last three children possible.  However, I still feel an emptiness that will never go away.

Am I recovered from my birthing losses?

Mostly no.  Physical activity causes the adhesions to hurt.  The unevenness in my lower abdomen (fat layer – scar – fat layer) is something I see and feel every day.  Although my VBA2C was a “success,” I feel quite bitter about the last weeks (from 31 weeks to nearly 42 weeks) of my pregnancy.  From 39 weeks onward, every day was a struggle, emotionally.  The birth was stressful.  I didn’t feel a darned thing and had to be told when and how to push.  I didn’t birth my child, but at least I didn’t have to endure her being cut out of my body.

Birth advocacy . . .

I still feel quite out of sorts about childbirth in Missoula and elsewhere.  Any time I see that someone had a cesarean – primary or repeat – I want to know why.  I wish Missoulians seemed to care more about how they birth their babies.  I feel like people either go the homebirth route and mostly enjoy a rewarding birth experience or people sign up for the slaughter.  I know there are good docs and good nurses out there, but I definitely lack trust.  And people don’t know their rights or don’t care that they have rights or don’t know how to exercise their rights when it comes to their own health care.  Everyone else seems to just mind their own business.  <shrug>  I’m planning a few VBAC Resources and Support sessions this year – wish me luck!

Well, that’s where I am today.  I see that Rixa is blogging about important stuff, of course.  See her latest regarding the Human Rights in Childbirth panel.

Recurrent Miscarriage: My happy endings

I am somewhat pleased and sad to know that my post about Pregnancy Hormones and Miscarriage is consistently one of my top posts.  I wish I could hold everyone who comes by looking for answers.  I remember being there.  It’s still a healing wound that opens up from time to time.  I still grieve that I’ll never know those souls I lost.  Or do/will I?

Nutshell background:

After an uneventful first pregnancy that produced my 6 year-old daughter in 2004, I suffered three consecutive first term losses.  Getting pregnant has never been my issue; staying pregnant was becoming a real problem for my body and my psyche.  The last straw, the one that nearly killed me, was the 10-week loss, and the OB standing over me as I woke from the curetage telling me my uterus was too thin to ever consider a vagina birth, and this same OB wanting to put me on Clomid to treat my losses.  This OB had also refused to test my progesterone levels, saying that even if they were low she’d not treat for low progesterone.

Here’s what I had to do:

  • Change providers – I’m in a small town, so no one is super specialized in this area, but I at least found a doc willing to work with me; he had also dealt with infertility personally
  • This OB did ultrasound to check for PCOS (which he thought he found in me) and HSG to check for uterine abnormalities
    • PCOS markers may include u/s, but that’s not the only determining factor, so I ruled that out myself
    • The HSG showed an abnormality, alright; the OB thought it was a double uterus
    • I decided it was time to find a specialist
  • I found a yahoo group that supports women with Mullerian Anomalies (double uterus is a type of MA)
    • This group has an anonymous consulting doc who looked at my HSG film and believed the anomaly to be either a septum or bicornuate uterus shape
    • This group had a fantastic resource – a database of recommended reproductive endocrinologists and repro surgeons
  • Because I have family in Denver and was planning on being in Denver the Summer of 2008 for a voice science research program, I chose a RE in Denver.  Tough stuff when you’re essentially ‘out of network,’ but thank God we ponied up and did it.
    • The RE looked at my film and didn’t think it was a MA; he was sure it was a fibroid
    • SHG confirmed his suspicions
    • Extensive blood work revealed . . . LOW FRIGGIN’ PROGESTERONE . . . actually, really really crappy luteal phase progesterone (I am still so angry with the OB who refused to test my progesterone; I still blame her for that loss.)
  • The RE also recommended a myomectomy to remove the fibroid
    • He wanted to do it laparascopically which means cutting through connective tissue and the fundus to reach the fibroid
    • I didn’t want the integrity of my uterus further compromised and requested a hysteroscopic myomectomy instead; he agreed
    • Folks, do your research so you can advocate for your needs!!  I can’t stress this point enough!!!!
  • Thank goodness we did the hyst myo because instead of a regular fibroid, he found adenomyosis which he attributed to the PREVIOUS CESAREAN!
    • Hyst myo turned out to be the best way to remove as much of the adenomyosis as possible
    • Otherwise my uterus looked normal, no thin LUS, cesarean scar wasn’t even visible
  • This RE had a drug protocol that worked to address my progesterone deficiency
  • 3 months later my local OB examined my uterus via ultrasound and said that I was healed and ready to TTC!
  • I also made sure that the RE confirmed that the integrity of my uterus was not compromised from the surgery; my OB was nervous about ‘letting me’ VBAC

My happy endings:

I naturally conceived twins in 2008.  Luckily, I was in Denver over Christmas, and the RE was involved with my early pregnancy care.  My HCG levels were abnormally high, and an early early ultrasound revealed twins.  I enjoyed an easy term pregnancy (39 weeks!) with di-di twins!  My twins are such a blessing – can’t believe they’re almost TWO!

I became pregnant again in October 2010.  God has a sense of humor for sure.  I followed (more or less) the same treatment plan for low progesterone.  The first week of my pregnancy was stressful because I was having a hard time getting ahold of my OB and who had different ideas of how to treat low progesterone that conflicted with the RE’s protocol.  Can you believe this RE’s nurse was still supporting me through this stressful time . . . 2 years later?!  I was able to e-mail her and call her and they were willing to oversee my meds for the 1st trimester if I couldn’t get it worked out with my OB.  I had to ‘correct’ my OBs script a couple of times, and thankfully he was compliant.

Again, you have to advocate for what you need.  Right this minute.  Trust your intuition.  Know that infertility and pregnancy loss is more ‘art’ than ‘science’ at this point.  Know that there are widely disparate ‘camps’ when it comes to treating infertility and loss.

Currently, I am 37 weeks pregnant with my Happily Ever After baby.  May you find a way to yours!

Supplementing Pregnancy with Progesterone

It amazes me that OBs can still be resistant to testing for progesterone deficiency and treating it.  After two consecutive losses and a clean blood panel, I begged my OB to test my progesterone levels.  I was pregnant again.  Not only did she refuse to test, but she also said that even if I tested low for progesterone, she wouldn’t supplement.  Her “brilliant” idea to treat pregnancy loss was Clomid!  (You can read tons of stories about women taking Clomid and suffering miscarriages as well as being blessed and challenged with multiple gestation issues.)

I lost that baby at 10 weeks gestation.  It died a few weeks earlier.  I was devastated and so angry.  I’m still angry at that nutjob OB.  For numerous reasons I transfered to a more compassionate OB who had been through infertility with his wife and also seemed to enjoy thoughtful discussions with his patients.  Although he misdiagnosed my problem, he supported me in seeking a second opinion with a reproductive endocrinologist (RE).

The RE discovered low low low progesterone.  The RE also found adenomyosis in my uterus that was distorting the shape of my uterus.  He believes that my cesarean caused the adenomyosis.  He removed as much as he could.

I received the all clear to TTC and quickly became pregnant again.  (Becoming pregnant was never my issue.)  I began supplementing with progesterone via 17-hydroxyprogesterone shots.  An early ultrasound discovered that I was carrying twins.  (Recall the one OB’s suggestion to give me Clomid?!??!!!!!!!)

I continued the progesterone injections and weekly progesterone tests during the first trimester of that pregnancy.  My progesterone levels seemed ok on their own, but it was prudent to continue especially since specialists don’t know what a good level of progesterone is for multiple gestation.  After three consecutive losses, I carried my twins to term. :)

I accidentally became pregnant during my September 23, 2010 cycle.  I suspected it almost immediately after conception, so I began early testing.  By CD 28 I tested positive for pregnancy.  I contacted my OB’s office (my previous lovely OB died the day he cleared us to TTC in 2008) on a Friday, and was frustrated that it took until the end of the business day on Monday to get a script.  In the meantime, I contacted medical friends and even the RE’s nurse.  I was amazed that she got back to me and was still willing to advise me . . . 2 years later and from out of state.  What a blessing.

Your typical OB isn’t always well-equipped to deal with early pregnancy issues.  My OB recommended 100mg oral progesterone.  I double-checked this with the RE’s nurse, and she did NOT recommend this treatment.  My SIL also told me some sketchy stuff about oral progesterone supplementation.  The RE’s nurse said the best thing to do is either go back on the shots or do 200mg prometrium vaginally.  Since prometrium is so accessible and doesn’t require a stick in the bum, I went that route.  I also want readers to know that it took a while to straighten out the script, but by Tuesday I had what I needed thanks to a lovely independent pharmacist, the RE’s nurse, and the OB’s office following through with exactly what I requested.

I just want to offer this information up for those who are struggling to make sense of their losses.  Really, if you think you suffer from low progesterone and/or a short luteal phase, you need a medical script for progesterone supplementation.  It is unlikely that natural supplements will do the job . . . maybe for marginal progesterone?

Someone on one of my advocacy lists said that taking prometrium vaginally seemed “iffy” to her.  I must admit that irritated me, but she doesn’t know anything about me or how seriously I consider my health decisions.  Had I not been directed to this reproductive endocrinologist in 2008, I would probably not have my twins or be 16 weeks pregnant with my fourth and final baby.

Flashbacks

2007 – 2008 were really tough years.  I suffered three consecutive pregnancy losses.  I nearly lost myself.  I look back on those years and shudder.

I was driving down the road the other day and couldn’t get these losses out of my mind.  I gave birth to twin girls in August 2009, but this doesn’t mean that I don’t still grieve for those lost souls.  Ugh, I don’t like thinking about it.

Perhaps these losses are on my mind because I had that evil Mirena IUD taken out last month.  My cycle has returned.  I had my first real menses since 2008.  The blood reminds me of all I have lost and all I have gained.

I’ve just ovulated.  The lovely CM and pains of mittelschmerz remind me of all I could lose and all I could gain.

My heart craves another child.  My body begs to be useful . . . and to be complete . . . and to bring my childbearing years full circle in the comfort of my own home with my husband and perhaps a midwife or doula.

A Note to My Friend

This morning I received an encouraging e-mail from a friend.  She has been through infertility and recurrent losses, but it looks like she finally has a keeper!  Luckily she has found medical providers who were able to come up with a good treatment protocol for her situation.  She has weaned off of the progesterone shots (daily shots of progesterone in oil – owie!) but is still on heparin, I believe, for the duration of her pregnancy.  She is finally in the second trimester!

She mentioned that her fear of childbirth is abating.  Some of that is because she has experienced natural miscarriage, and she has been told that it is like mini labor.  I wanted to share (most) of my response to her.  Of course I could have said much much more, but I really don’t want to be “that crazy friend” who can’t shut up about natural childbirth.

Just remember that the OB is just a person, not a god.  And what YOU want DOES matter.  Ask about birth plans and how the hospital honors them.  I would hire a doula, someone who will be able to advocate for your needs and your desires.  Seriously, that’s the biggest mistake I made – I thought that having a CNM would “save” me from unnecessary intervention, but it didn’t.  The rest is history.


I thought the childbirth education classes at [name removed] were just fabulous.  My only criticism is that I somehow didn’t understand how life altering the cesarean was going to be.  I’m not trying to scare you – the cesarean was a piece of cake for me, and it didn’t mess with breast feeding at all (in my case).  It’s just that I was so shocked when I went in for my 6-week post-partum appointment with the OB who did my surgery and was told about uterine rupture.^  And then last July-August when I was preparing for baby #2 I learned so much about the failings of our maternal health care system, and that’s when I really “cracked.”  I was just so pissed and became somewhat disappointed in [name removed] for not having been more forceful.*

Regarding labor – I didn’t even know I was in labor.  Granted I had a violent stomach flu . . . but I was surprised that I showed up at the hospital 9cm dilated!  Probably one of the most painful things I have gone through was my second miscarriage.  Supposedly subchorionic hematoma miscarriages are pretty bad, and this one was no exception.  And during my last miscarriage I kept nearly fainting from the blood loss.  Labor?  Piece of cake.  You’ll be brilliant!  Remember that the pain is good – it’s there for a reason.  It helps get your baby out and into your arms.

I am just so excited for you.  I am so glad that you’re out of the first trimester!!  And hopefully you’ll really start feeling great, and pretty soon you’ll start feeling your “lemon” move.  That will bring you much comfort and joy.

^ For the record, every laboring women has a small risk of uterine rupture.  Most uterine ruptures in VBACs were historically caused by labor augmentation and induction tactics.  A “window” or a dehiscence (separate terms in my mind) is not the same as a true uterine rupture.

* One thing I forgot to mention to her is that my husband seems to remember our childbirth educators talking about uterine rupture.  Maybe they mentioned it, but again, it didn’t leave the impression that it should have.  I only pushed for 2 hours and then gave in to the cesarean.  I thought it made sense.  Had I known – really known – what a cloud the cesarean would cast over the rest of my childbearing years, I’d have resisted that cesarean.  My baby would have tolerated it – when she was delivered, her APGAR scores were 9 & 9.  Nearly perfect.  Not a baby in distress as I had been told.

Perhaps what childbirth educators could add into their series is a session on how doctors perceive cesarean scars.  Why the medico-legal culture dominates obstetric practices.  Why certain risks (cesarean surgery, amniocentesis, etc.) are acceptable and others (natural birth, especially after a cesarean) seem foolish.

PTSD After Pregnancy Loss

I have taken the bones (and admittedly, most of the meat) from the post, PTSD after childbirth, to construct this post. I know personally and from talking to others that women can experience Post-traumatic Stress Disorder (PTSD) and Post-partum Depression (PPD) following birth losses. We enter our pregnancies with the fear of loss in the background – some worry more than others – but ultimately expect to be holding our beautiful babies in a mere 8 months after getting that BFP (big “fat” positive) on the home pregnancy test. I myself have been pregnant 4 times and have one living child. I have a lot to be thankful for. But 3 consecutive losses were almost too much for me.http://www.flickr.com/photos/parapet/

Yes, women can and do experience PTSD and PPD after miscarriage, pre-term birth loss, and still birth. The Florida Psychotherapy blog applies the DSM-IV-TR to childbirth related trauma. Let me apply the criteria outlined in that post to PTSD after loss(es).

According to the DSM-IV-TR, the following criteria must be met to be diagnosed with Post Traumatic Stress Disorder (PTSD):

A. The person has experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others AND the person’s response involved fear, helplessness or horror.

How a prospective mother views early pregnancy can contribute to PTSD. One of my sister-in-laws had an early loss but wasn’t terribly affected by it. I was shattered after my first loss. How did the prospective mother react to her loss? Did she panic? Did she cry a lot? Does she remember the entire experience? Has she withdrawn from her life? These and other reactions can be stress responses to her loss.

B. The traumatic event is persistently re-experienced in at least one of the following ways:

  • Recurrent and intrusive distressing recollections of the event.
  • Recurrent distressing dreams of the event.
  • Acting or feeling as though the event were recurring (including flashbacks when waking or intoxicated).
  • Intense psychological stress at exposure to events that symbolize or resemble an aspect of the event.

Women who have experienced pregnancy losses can have nightmares about her losses. Strong images and flashbacks may occur at random moments, or she may have trouble NOT thinking about her experiences with pregnancy loss. Women who do participate in support groups and especially on-line forums need to be careful here. By continuing to relive and replay the experience, you may slow down your recovery.

C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the event) as indicated by at least three of the following:

  • Effort to avoid thoughts or feelings associated with the event.
  • Efforts to avoid activities or situations which arouse recollections of the event.
  • Inability to recall an important aspect of the event (psychogenic amnesia.)
  • Markedly diminished interest in significant activities, such as hobby or leisure time activity.
  • Feeling of detachment or estrangement from others.
  • Restricted range of affect; eg, inability to experience emotions such as feelings of love.
  • Sense of a foreshortened future such as not expecting to have a career, more children or a long life.

Here are some examples of how this many manifest. She may avoid places where she is most likely to encounter other pregnant women – play groups, gynecologist, church, heck . . . even the grocery store. She may have trouble relating to other friends with children and friends who are currently pregnant. She may be unable to watch shows that feature pregnancy and birth, look at milk cartons, hear about abused or murdered children, etc. She may no longer find pleasure in activities she once enjoyed. She may avoid sex and/or intimacy with her partner. She may not remember that she was bleeding all over the bathroom and that her young daughter saw the blood . . .

D. Persistent symptoms of increased arousal (not present before the event) as indicated by at least two of the following:

  • Difficulty in falling or staying asleep.
  • Irritability or outbursts of anger.
  • Difficulty concentrating.
  • Hyper-vigilance.
  • Exaggerated startle response.
  • Physiological reactivity on exposure to events that resemble an aspect of the event, eg breaking into a sweat or palpitations.

Moms may have an anxiety reaction when driving past their birth centers or hospitals. They may get anxious when discussing the birth or when birth stories come up in conversation. They may also feel detached from their baby, partner, family, or friends.

E. B, C, and D must be present for at least one month after the traumatic event.

I certainly experienced many of the above symptoms. I had an outright panic attack shortly after my first loss. After my second and third losses I was taking medicine to keep that from happening. I’ve had an incredibly difficult time concentrating since my losses began. I’m doing better now, but last Spring was agonizing.

F. The traumatic event caused clinically significant distress or dysfunction in the individual’s social, occupational, and family functioning or in other important areas of functioning.

Like postpartum depression, PTSD is highly treatable, meaning the woman can get better, sometimes very quickly. Treatment options include

  • talk therapies such as cognitive-behavioral therapy
  • medications and herbs
  • acupuncture
  • body therapies such as Eye Movement Desensitization and Reprocessing (EMDR), biofeedback, and hypnosis

I wasn’t able to recover quickly or easily and was prone to relapses. My last relapse was in August 2008. I went to a therapist and got tired of being told that “this is normal.” There is nothing normal about considering suicide. That is NOT an acceptable response, in my opinion, to any situation – merely “stressful” or absolutely traumatic. There is nothing normal about excessive drinking. There is nothing normal about not wanting to be around your partner or child (children). There is nothing normal about being nearly incapacitated for months and months. There is nothing normal about going out drinking and accidentally getting so drunk that you throw up in public, have to be driven home, black out, and want to kill yourself all over again. Of course, this last paragraph is MY situation, and I’m sure it may seem a normal response to recurrent pregnancy loss, but that doesn’t make it ok. I share these deep dark secrets with you so that you know if you experience these same or similar things, that you’re not alone. It may be normal, but it’s not ok. Please get help!

Additional resources: