obstetrics

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Tragically Wrong: When Good Early Pregnancies Are Misdiagnosed As Bad

An ultrasound of a pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman's missed period.) The pregnancy sac  is outlined by four short arrows within the uterus and the embryo is within the pregnancy sac. (Courtesy P. Doubillet)

An ultrasound scan of a normal pregnancy at six-and-a-half weeks (meaning that it was done two-and-a-half weeks after the woman’s missed period.) The pregnancy sac is outlined by the four arrows and the embryo is within the pregnancy sac. (Courtesy P. Doubilet)

A beautiful, supremely talented young friend of our family recently fell victim to a terrible medical mistake. Newly married, she was having some pelvic pain and bleeding, and the doctor who saw her diagnosed a probable ectopic pregnancy — an embryo that develops outside the womb. Concerned that such pregnancies can turn life-threatening, the doctor prescribed the standard treatment: methotrexate, a drug used for chemotherapy and to help induce abortions.

When our friend returned to be checked a few days later, the imaging revealed that in fact, the pregnancy had not been ectopic; it was in place, in her uterus. But because she had taken the methotrexate, a known cause of birth defects, her pregnancy was doomed.  She soon miscarried. What may have been a perfectly healthy pregnancy had been ended by well-meant medical treatment.

I assumed her horrifying case was an exceedingly rare medical fluke — until now. A paper just out in the prestigious New England Journal of Medicine shows that such misdiagnosed pregnancies are part of a pattern — a pattern that needs to be changed. “Considerable evidence suggests that mistakes such as these are far from rare,” it says.

When I told our friend’s story to the paper’s lead author, Dr. Peter Doubilet, he responded that he knows of “dozens and dozens and dozens of similar cases that have come to lawsuits, and that’s probably the tip of the iceberg.” There is even a Facebook group, Misdiagnosed Ectopic, Given Methotrexate, run by a mother given methotrexate whose daughter was born with major birth defects.

The New England Journal of Medicine paper stems from a panel of international experts who resolved to change medical practice to stop such misdiagnoses. I spoke with Dr. Doubilet, who is senior vice chair of radiology at Brigham and Women’s Hospital and a professor of radiology at Harvard Medical School. Our conversation, lightly edited:

Before we get into the nuts and bolts of the problem, what’s the upshot for women of child-bearing age? What’s your message to them?

When a woman gets pregnant, a number of serious complications can occur early in pregnancy, including miscarriage or ectopic pregnancy. When a doctor diagnoses these problems within the first two to three weeks after her missed period, it’s very traumatic to the patient and it’s critically important that the woman and the doctor are confident that the diagnosis is correct, because the steps that will be taken would harm a normal pregnancy if one is present.

Dr. Peter Doubilet (Courtesy)

Dr. Peter Doubilet (Courtesy)

It’s become apparent over the past two to three years that errors in diagnosis of miscarriage and ectopic pregnancy occur more frequently than they should, and that’s why we put together a multi-specialty panel of expert doctors from radiology, obstetrics-gynecology and emergency medicine to come up with new, more stringent guidelines for diagnosing these complications, taking into account the most recent research on the subject.

And just to simplify, when a woman in very early pregnancy has been told that it appears that she has an ectopic pregnancy or a failed pregnancy, it would very rarely be overly risky — and often be wise — to wait a couple of days and be sure of the diagnosis before acting?

Yes. That’s a very important message. In 2010,  I, together with Dr. Carol Benson, wrote an editorial in The Journal of Ultrasound in Medicine entitled “First, do no harm to early pregnancies,” and that was the key message: Unless the doctor is sure that the woman has a miscarriage or an ectopic pregnancy, the doctor should err on the side of waiting, as long as the woman is stable and shows no signs of serious internal bleeding.

If the patient meets definite criteria for a miscarriage or ectopic pregnancy, there’s no reason to wait, but if there’s any degree of uncertainty, the prudent thing is to wait. Continue reading

Response To High U.S. Birth Costs: You Get What You Pay For

pumicehead/flickr

pumicehead/flickr

What a quick point and counter-point! First, The New York Times published its latest feature on high U.S. health costs, headlined “The American Way Of Birth Is The Costliest in the World.”  It opens with the disturbing description of a pregnant New Hampshire woman whose health insurance does not cover maternity care, and who must shop around and haggle over each treatment and test. Ugly. Here’s a taste:

Midway through her pregnancy, she fought for a deep discount on a $935 bill for anultrasound, arguing that she had already paid a radiologist $256 to read the scan, which took only 20 minutes of a technician’s time using a machine that had been bought years ago. She ended up paying $655. “I feel like I’m in a used-car lot,” said Ms. Martin, a former art gallery manager who is starting graduate school in the fall.

Now, Slate has just published a riposte, headlined: Yes, Childbirth Is More Expensive In The U.S. But You Get What You Pay For. It’s the tale of two women, both doctors, who get pregnant, one in the U.S. and one in Canada. The subhead sums it up:

“The Canadian woman couldn’t get her first appointment for eight months, although it was free. The American got an appointment right away, but it cost a fortune.”

To wit: The American shelled out more than $12,000 for an ever-available OB. And by the way, the Canadian did manage to finagle some obstetric care earlier than the 8-month mark.

Readers? Which would you choose? I’m thinking neither system is sounding very appealing at the moment…

Is It ‘Unethical’ To Prescribe Bed Rest For Pregnant Women?

(cscott2006/flickr)

(cscott2006/flickr)

It seems so intuitively right. You’re facing the risk of delivering your baby early and the doctor prescribes bed rest. What could be more cozy and safe? Why wouldn’t you endure a little extra annoyance (you’re pregnant, after all) if it would help keep your tiny, oh-so-vulnerable fetus floating inside the fortress of your womb as long as possible? Even the words “bed” and “rest” feel so inherently soothing and therapeutic.

Think again.

Bed rest, a growing body of research suggests, may be bad for you.  And for physicians to blithely prescribe it is, in a word, “unethical,” argue a trio of doctors from the University of North Carolina School of Medicine.

In a paper called “‘Therapeutic’ Bed Rest in Pregnancy: Unethical and Unsupported by Data” recently published in the journal Obstetrics and Gynecology, Dr. Christina A. McCall and her colleagues make a powerful case against the practice many perceive as cuddly and innocuous.

They cite the medical paradox in which bed rest remains widely used despite no evidence of benefits and, on the contrary, “known harms.” They further suggest that in its current form, strict bed rest should either be discontinued or else viewed as a “risky and unproven intervention” requiring rigorous testing through formal clinical trials.

“If we have anything to learn from the history of medicine it is that instincts and good intentions are a highly fallible compass without the check of scientific controls.”

In an email exchange, Dr. McCall clarifies that she is talking about strict bed rest here and adds:

“If a woman feels that increasing her daily rest lessens anxiety or improves symptoms (whatever they may be), then we are not suggesting this should be discontinued. We are merely suggesting that every woman receive INFORMED CONSENT regarding the literature on bed rest and the autonomy to make her own decision.”

Research suggests that the potential harms for women on bed rest (a broad term that can include everything from total inactivity to limits on strenuous endeavors like household chores, exercise and sex) can be significant. They range from potentially dangerous blood clots and bone demineralization to muscle and weight loss, financial harship due to restrictions on working and a range of psychological suffering, notably depression. Continue reading

What Not To Say To Parents Of Twins

“Did you do IVF?”

“You had a C-section, right?”

“Are they natural?”

Questions that may seem odd—even offensive — to some new mothers. Unless you are the mother of twins. Then you’re used to them.

The “babyrazzi” can be relentless, and the appearance of multiples in public can create an instantaneous barrage of questions. Earlier this year, I was in line at the Mothers of Twins sale (a huge biannual event in Winchester that is akin to the running of the bulls) comparing notes with other moms. Some of the more seasoned moms were used to the forward questioning, while the rest of us were still adjusting to the public’s keen interest in our multiples and our pregnancies.

Here’s my favorite. Upon seeing my boy and girl twins, “Are they identical?”

So when the hilarious cartoon above appeared in my Facebook feed on Mother’s Day, I didn’t mind the peering grandmothers at Costco later that afternoon. It captures just about every inquiry I’ve ever received and somehow it was validating to know that I’m not alone. I must say, all in all it’s a pretty special club.

Readers, any other cringe-worthy twin questions or comments you’d like to share?  

Pregnancy Dilemma: Premature Delivery Or Risk Of Stillbirth?

This is like a card game with the highest stakes in the world, I thought as I read Boston-based science writer Eugenie Reich’s harrowing story of the choice she faced when she was carrying a fetus whose growth was badly lagging. It’s on Slate: “When is it right to let your unborn baby die?”

Pregnancy can be full of dilemmas that require you to weigh the odds. Do you have an invasive genetic test even if there’s a small chance it will cause a miscarriage? If labor is progressing poorly, do you have a Cesarean section?

But I had never before heard of the either-or that confronted Eugenie: She could choose to deliver early, very early, and her child would face all the likely complications and disabilities of extreme prematurity. Or she could continue to carry the fetus, thus risking a high probability of stillbirth.

eugenie reich

Boston-based science writer Eugenie Reich

I wince at the very thought of it: Every day you keep the fetus in, you increase the child’s chances for a less-disabled life, but you also risk losing the pregnancy altogether. It’s quality of life vs. risk of loss. Every day is a roll of the dice, or maybe poker is the better metaphor: Do you hold or do you fold?

I don’t think it gives away too much to say that Eugenie chose to remain pregnant, and embarked on an exploration of the world of other women who made similar decisions — but who don’t usually talk or write about it except in anonymous online exchanges. Continue reading

The Pessary For Prematurity: An OB’s New Look At An Old Technique

Dr. Adam Wolfberg, a specialist in high-risk obstetrics, knows more than most about the highly technical world of maternal-fetal medicine and the extreme interventions often required to save infants born prematurely. About half a million babies — 1 in every 8 — are born pre-term in the U.S. and much of Wolfberg’s work focuses on how to prevent and manage such births.

Lately, though, he’s been thinking about a particularly low-tech, centuries-old device that is getting new attention as a method to prevent premature delivery: the pessary, described by researchers as “a tiny inverted cereal bowl with a hole cut in the center” more typically used hold up sagging pelvic organs. Writing in the Huffington Post, Wolfberg details the latest, promising research:

In this excellent study, published in the prestigious British journal The Lancet, obstetricians at five Spanish hospitals randomized 385 women with a short cervix to use of pessary or nothing. Pessaries are centuries-old devices that women place in their vagina to support their uterus and pelvic organs and prevent symptoms of pressure when these organs “fall” (prolapse) typically later in life. A handful of small studies using pessaries to prevent preterm delivery (the idea is that the pessary supports the cervix or lower uterus) have been published over the past 50 years, but none has had the size or scientific rigor to convince the obstetric community.

The cervical pessary (The Lancet)

In their study, the Spanish group used the Dr. Arabin pessary, named after the German scientist who developed it… The Dr. Arabin pessary is approved for sale in Europe but not in the U.S…”

Continue reading

Two-Year Prison Sentence For Hungarian Doc, Home-Birth Advocate

Dr. Agnes Gereb, obstetrician and home-birth advocate, was sentenced to two years in prison.

Home births are up in the U.S. according to the CDC, due in part to organized efforts by groups like The Big Push for Midwives to educate the public and help legalize midwives in more states.

But things don’t look so great for home-birth supporters in Hungary. This week, Dr. Agnes Gereb, an obstetrician and home-birth midwife who had been sentenced to two years in prison for malpractice, lost her appeal and got hit with even tougher sanctions, CBS News reports. (Her supporters say she has been singled out for punishment due to her role assisting and championing home-births.)

Budapest’s Court of Appeals also banned Dr. Agnes Gereb from working in her profession for the next 10 years, increasing last year’s court ruling, which had banned her for five years. Continue reading

What You Need To Know About New DNA Down Syndrome Tests

The news recently broke that prenatal testing is entering a new era: DNA tests able to detect Down syndrome in a fetus just by testing the mother’s blood are now hitting the market.

Below you’ll find a nuts-and-bolts Q&A with a leading researcher on such tests: What’s the state of the science? Who should get one? How much are they?

But first, a brief editorial: This is good news for the great many parents-to-be who want the chance to know in advance if a fetus has Down syndrome. As an older mother, I would have been overjoyed to have a near-definitive, non-invasive test. If the women who come after me have that chance, and it looks like they will, I’ll consider it quite a boon of the genomic era.

Much of the coverage has struck me as oddly “balanced.” If you search on nytimes.com, for example, the headline says the new type of test “raises hopes and questions.” Questions? Well, sure, it’s a new technology: Will it live up to its initial promise? But the Times story also cites concerns “that use of such tests early will lead to more abortion of fetuses with minor abnormalities, the wrong sex or an undesired father.” It quotes Dr. Brian Skotko of the Down syndrome program at Children’s Hospital Boston, whose sister has Down syndrome. He “pointed out that these tests could encourage more people to end their pregnancies, causing a decline in the numbers of people with the condition and leading to diminished support for them.”

I remember it as: ‘Do I want to avoid Down syndrome badly enough to risk this whole precious pregnancy?’

We’re all entitled to our points of view. But let’s look at the tests from the perspective of the parents-to-be.

These DNA tests could bring about the end of the heart-wrenching pregnancy decision on whether to get an invasive test like an amniocentesis despite the small risk of miscarriage. (I remember it as: “Do I want to avoid Down syndrome badly enough to risk this whole precious pregnancy?”) Continue reading

10 Scary Reasons To Fight Obesity Before Pregnancy

Please forgive the piling on. There’s already enough pressure to lose poundage if you’re obese. And pregnant women already have plenty of worries, inflamed by crazymaking compilations of all that could go wrong like “What To Expect When You’re Expecting.”

But talk to the researchers at MIRI, Tufts Medical Center’s Mother Infant Research Institute, and you come away bowled over by all the powerful reasons to aim for a normal weight before pregnancy.

It turns out that obesity in pregnant women heightens risks in ways that you might never suspect: It increases the chances of stillbirths, birth defects, infections, even pediatric asthma — and the list goes on.

You also learn from the MIRI researchers that even if you do enter pregnancy obese, you can still make a difference by watching your weight during those critical months.

Doctors have long focused on women’s weight gain during pregnancy. But recent research has clarified the importance of a woman’s weight upon entering pregnancy as well, said Dr. Sarbattama Sen, a Tufts Medical Center neonatologist and researcher. “As time has gone on,” she said, “it’s become more and more clear that so many of the forces that are affecting fetal health are being exerted very early in pregnancy, before women even know they’re pregnant.”

At the same time, the obesity epidemic has spread, as well. At Tufts Medical Center, as at many hospitals, one in every five pregnant patients these days is obese — not just overweight, but obese — and the obstetrics department has had to add new beds made for larger mothers.

Dr. Errol Norwitz

Dr. Errol Norwitz, the hospital’s chief of obstetrics and gynecology, offers these first five reasons to lose weight before pregnancy, based mainly on risks to the mother’s own health; then Dr. Sen will add five focused more on the baby.

1. The most dangerous complications of pregnancy, the life-threatening ones, are far more common in obese women.

The two medical complications that are highest risk to the mother are blood clots in the legs that go to the lungs, and a condition called pre-eclampsia. They account for nearly 40 percent of all maternal deaths during pregnancy, and both are much more common in obese women.

Pre-eclampsia, for example, occurs in 5-8% of women overall, but 15-24% of morbidly obese women (those with a Body Mass Index over 40.) And as with many of these risks, there does appear to be a “dose effect:” the more obese you are, the higher the risk. Deaths are still exceedingly rare, but the danger does rise.

2. The risk of stillbirth also triples in morbidly obese women. Continue reading

Top Maternity Hospitals in Mass. Stop Early Elective Deliveries

By Martha Bebinger
WBUR

Many of us know a mom who chose to have her baby before its due date. There are lots of reasons why one might choose to do this: the health of the mom or the baby, her doctor’s schedule, the demands of her husband’s work, or even to hit a specific birthday. But if that perfect day falls before the 39th week of pregnancy, and there’s no medical reason for an early delivery, many hospitals in Massachusetts are saying no, you have to wait.

Jennifer Brickley, with her daughter Audrey, says too many women plan deliveries as they do hair or spa appointments. (Martha Bebinger/WBUR)

The number of early deliveries, from induced labor or C-sections, has been on the rise across the country for more than a decade now, including in Massachusetts. One reason is that we’ve come to expect that babies born “a little bit early” will be fine.

“Before the benefit of the neonatal intensive care unit, people were very conservative and would not induce or do repeat C-sections before 39 weeks,” says Dr. Glenn Markenson, the director of maternal and fetal medicine at Bay State Medical Center in Springfield. “But as they saw how well babies were doing with pediatric care, and they were getting pressured by patients because of social situations, there was a creep down from 39 weeks to 38 weeks, sometimes 37 weeks.”

With access to such excellent care, we overlook the facts — babies are in these expensive neonatal units because they’re having problems.

“Early-term infants have higher rates of respiratory distress. There are also issues with feeding,” says Dr. Lauren Smith, medical director at the Department of Public Health. “The most recent evidence shows that babies born before 39 weeks may also have developmental issues, so when you add up the increased risks and you weigh that against a situation when it’s purely elective, then you really can’t justify it.”

A growing number of hospitals in Massachusetts, and across the country, are saying no to elective inductions and C-sections before 39 weeks. The change is happening quietly and some new mothers don’t like it.
Continue reading