38. In My Country, Part IV

I asked S to return, to discuss results of antepartum screening. Four pregnancy "hormones" are measured and in a complex equation compared with the results of other women whose outcome is known. The results: for every 71 women the same age and weight as S, with the exact same results, 70 had normal babies and one had a baby with Downs syndrome. So her risk of having a baby with Downs Syndrome estimated at one out of 71. Using age alone as the predictor, one would estimate her risk for Downs at about one out of 200. I offer her an amniocentesis--withdrawing fluid from the amniotic sac, containing cells sloughed off from the fetus, which can be nurtured, after a couple of weeks yielding enough DNA to give a definitive answer. Problem is that the procedure has a 1/400 risk of miscarriage. It's always a tough call. S immediately declines the amniocentesis, a decision entirely consistent with her earlier request for an elective cesarean delivery. Baby comes first.

37. In My Country, Part III

After our discussion about the Prenatal Risk Screen, S asked me to evaluate the recent onset of leg pain. It seems that several years ago in Peru she received an injection of silicone into her buttocks for cosmetic reasons. S has a normal weight and body shape; I'm not sure and didn't ask the exact location and rationale behind the injection. Anyway, she reports past episodes of this leg pain which her doctors attributed to the spread of the silicone into her thigh, with relief obtained by injections of steroids and/or antibiotics.

Today she has a 4 by 6cm firm, mildly tender swelling on the lateral right thigh, with just a blush of erythema (redness). There are no breaks in the surrounding skin that would suggest an infectious process. I have no idea what this is, but will obtain an ultrasound. Either that or tell her to take a couple of tylenol and see me next week.

36: Pheromes, part II

While we're on the subject, a recent study from Florida recruited young men to opinionate on t-shirts worn by women while sleeping on three consecutive nights. There were three groups of t-shirts, one set from around the time of ovulation (when there would be an evolutionary advantage to attract sexual partners), a second set from a time distant from ovulation, and a control set.

The men rated the ovulation t-shirts as most appealing. Testosterone levels were higher when the ovulation t-shirts were being evaluated.

An earlier study showed that exotic dancers received more tips around the time of ovulation. Many factors here, visual, auditory as well as olfactory, the t-shirt study being just olfactory, but the conclusion is the same: we can't entirely escape our evolutionary destiny, too much of it is unconscious.

35. "In My Country"

"In my country women of my age [36] always have Cesarean deliveries. They say it's safer for the baby." I told S that in our experience, women over 35 can delivery vaginally without putting the baby at risk. Then she explained that she is very anxious about labor and "just couldn't handle it."

It is not uncommon to receive and accept requests for scheduled Cesarean deliveries based on physical health issues other than a previous Cesarean, even though I often wonder if an underlying fear of labor may be the unspoken but stronger motivation. It's all out in the open with S: she acknowledges that it is all about anxiety and fear.

So is fear a valid reason for an elective Cesarean? Most of the health risks of Cesarean deliveries are for those performed after a long labor. There is not much evidence that a vaginal birth is safer than a scheduled Cesarean delivery. Easier recovery, yes; less expensive, yes; safer? perhaps not.

34. Pheromones

Women who live together may find that their menstural cycles synchronize, presumably due to pheromones (olfactory signals). This menstrual synchrony is generally accepted as real, though with many factors influencing menstrual timing, it may not be apparent for all groups of women living in proximity.

Now consider Mrs. H. who experienced a year without menses, which is the definition of menopause and totally expected for this 56-yr old. Then her daughter and family moved in with Mrs. H. and her husband. After a few months, Mrs. H's menses resumed, the timing synchronous with that of her daughter's menses. The daughter recently found a house to rent and may be moving out in a month or so. I'll be curious to see then what happens to Mrs. H's menses.

33. Grouchy

"Menopause makes me grouchy," she said.

Half-tongue in cheek I countered, "What makes your husband grouchy?"

"He's a guy, it comes naturally."

Actually the hormonal shifts of menopause do not increase depression or the irritability that is often the harbinger of depression.
Health issues that arise in the 50's (the knees, the back), kids leaving (or not leaving) home, careers of husband and wife at a plateau, and the earthly departure of friends and relatives--these are the triggers of acute depression. Along with existential angst as one considers, "is this as good as it gets?"

32. Breech

Near the end of the day I met K. for the first time. She is 38, about a month before her due date. Three years ago she adopted a Nepalese infant who suffered some brain trauma at birth (not sure whether or not K knew this at the time of adoption, I think yes, but not the extent). K thinks it may have been a vaginal breech delivery, a not uncommon source of birth injuries.

So of course she is worried whether this baby might be breech. My impression from an abdominal exam was that the baby was head first and I confirmed that with an ultrasound.

She was visibly relieved: "You've made my day."

"I wish it were always this easy," I noted. And we both laughed.