Monday, September 13, 2004

Between a Woman and Her Doctor

Reader Søren sends this, a must read for any woman of reproductive age (and the men who love and respect them). As a rule, personal accounts aren't very useful when discussing medical matters, or when you try to make an informed health decisions; they contain too many variables. This one is an exception.

I could see my baby's amazing and perfect spine, a precise, pebbled curl of vertebrae. His little round skull. The curve of his nose. I could even see his small leg floating slowly through my uterus.

My doctor came in a moment later, slid the ultrasound sensor around my growing, round belly and put her hand on my shoulder. "It's not alive," she said.

One of the first thoughts I had when all this "partial-birth" abortion idiocy started was: This will have a chilling effect in ERs across the country. The only certain outcome of combining unclear, political definitions of medical procedures with jail time for physicians will be a significant decrease in the quality of care received by women. I hate that I was right. I'm also very discouraged. It's not clear to me that we physicians can do anything to stop politicians, lawyers, religious zealots, and assorted bureaucrats from hurting our patients. And, if we can't help women, than what good are we? The reader who sent in the article has the last word:

Here in Denmark the pro-life community is - thank god - still on the fringes. It scares me however to see just how well the salami method seems to be working in the US. Abortion is still legal - but slice by slice it is made more and more difficult.

OK, enough existential angst for a Monday morning. Let's switch to something positive and see if there's anything useful we can learn from the article. For example, how much do you know about seaweeds and your cervix? [Now that's a good title.] At one point in the article, the author mentions that:

They inserted sticks of seaweed into my cervix and told me to go home for the night.

These sticks are Laminaria tents, made from the stems of a brown seaweed, Laminaria digitata or Laminaria japonica (sterilized and prepared for medical use). The sticks came in different sizes (small, medium, large) and they are strongly hygroscopic--they draw water from their surroundings and slowly swell up.

Once one/several Laminaria tents are inserted inside the cervical canal, they slowly swell up over hours and they soften and open up (dilate) the cervix. The advantage of this slow dilatation: trauma to the cervix is minimized. Of course, it's not always possible to use Laminaria (there's not enough time). In those instances the cervix is quickly dilated by inserting successively thicker metal dilators--usually, the Hegar dilator (of course, under anesthesia).

The reason the cervix needs to be dilated is in order to allow the products of conception (POC) to pass. This is an important point. For a full term pregnancy, the cervix dilates to 10 cm and effaces--it shortens from ~2 cm to almost nothing and its edges become paper-thin (it's 100% effaced). [Imagine a plump doughnut with a very tiny middle hole. As labor progresses, the center hole gets bigger and bigger, while the body of the doughnut becomes thinner and thinner, until it reaches the thinness of a potato chip, so that in the end you're left with a 10 cm middle hole surrounded by a paper-thin margin.]

Unfortunately, for a preterm delivery, or a spontaneous abortion (ABx) the cervix never fully dilates or thins out. Briefly, this causes a very serious problem: the fetus or the POC can get stuck in the cervical canal. In particular, for a preterm fetus or a late spontaneous ABx the head (always much larger in proportion to the rest of the body) or the bony parts can get trapped. This is very dangerous, because there are major blood vessels in the area, so any tears in the uterine tissue can cause rapid and profuse bleeding. Even in the case of an early spontaneous ABx there's a problem: some of the POC are not expelled and are left behind inside the uterus. This is dangerous because it can lead to infection. The cervix has to be [artificially] dilated and all the remaining POC have to be removed.

Another type of hygroscopic cervical dilators used is Lamicel (a synthetic sponge), and various prostaglandin vaginal gels and inserts (Prepidil, Cervidil).

Update: More on the article at Pharyngula and Respectful of Otters.


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