Searching for a doctor has been an interesting experience so far. I managed to find an OB with good patient reviews who delivers at the hospital I like, and I have an appointment set up for September 22nd, when I will be 7 1/2 weeks along. It’s a solo practice, which I’m not that familiar with—most of my friends have had doctors in rotating practices, so they see a handful of doctors over time. In addition, my doc only has patient appointments on Wednesdays, which seems a little odd; does that mean he’s generally unavailable for emergencies (and what about delivery)? I’ll ask him all of these questions when I meet him, of course. I really don’t know how these things work.
After setting up the appointment, I asked his receptionist if I could come in earlier for blood work. She said no—blood is only drawn when it’s requested by the doctor. Hmm. Here’s my question: if you need blood work to diagnose ectopic pregnancy, among other things, then why isn’t it routine for doctors to draw it early on? Isn’t it a gamble for doctors to just assume that every pregnancy is progressing normally?
To get around the problem—I wasn’t going to take no for an answer!—I contacted my primary care physician, who is in family medicine. Based on what I read in The Perfect Hormone Balance for Pregnancy, I asked if she could give me three tests: one, a quantitative HCG test, since low HCG levels can predict ectopic pregnancy; two, a serum progsterone test, since this too can be used to diagnose ectopic pregnancy and since low progesterone levels can indicate high miscarriage risk, prompting the need for progesterone supplements; and three, a complete thyroid work-up, because I have borderline thyroid issues and my old endocrinologist told me to keep a close watch on things when I got pregnant.
Interestingly, upon asking my physician for these tests, she agreed, but then asked why I needed the progesterone and HCG tests. I’ll admit, I was surprised; she has a special interest in reproductive medicine, so isn’t she supposed to know this? How is it that I’m the expert here (if, in fact, I am—perhaps I have got things all wrong)?
I guess sometimes it’s true: you’ve just got to take your health in your own hands. I’ll let you know how the tests go.
I will answer your questions because it seems that you are stuck between the books and the regular practice of medicine.
First of all I believe that most medical practices are going to model where your physician rotates with other doctors in order to have a physician who is on call. This limits liability and allows them the opportunity to not be called out of clinic on a continuous basis. It may not be the best for continuity of care but it does allow many solo practitioners to survive. I’m not sure why he is only available on Wednesday and yes that does seem odd that a physician would only be in the clinic on one day a week.
With regards to the blood work. Why do you need blood work to diagnose an ectopic pregnancy. We do indeed assume you have a normal gestation unless you have had an ectopic in the past. With those patients that have had an ectopic pregnancy in the past then yes, I would agree that a BHCG is mandatory. Otherwise the BHCG is not ordered unless we are worried about miscarriage because it really does not give us anything that we need. It may sound weird but we already know you are pregnant and you are obviously aware of your LMP so the BHC really will not help us with your gestational age anymore than your history and an ultrasound.
The problem with a progesterone level is that anything between 10-20 is consider nondiagnostic and will not give you reliable information. Many normal pregnancies will be in this range and some ectopics as well. You really can only diagnose the need for progesterone replacement with an endometrial biopsy around the 21st day of your cycle when you are not pregnant. This biopsy then needs to be coordinated with the pathologist to see if it is consistent with day 21. If they say it looks more like then you might have luteal phase defect. I am not aware that you have recurrent spontaneous abortion from your previous posts so this seems like a bit of overkill.
I would have asked the same questions your FP asked because this is not the norm for someone who is pregnant for the first time. The usual tests for the prenatal period are:
Blood Type
Antibody Screen
RPR
HIV
Hepatitis B Surface Antigen
CBC
Urinalysis
glucose screen
tetra screen (optional)
GBS screen
The BHCG and progesterone would not be considered a part of a routine screen because, yes, it is assumed that you have a normal pregnancy.
It is possible that we try to control too many things. It is impossible to control the unexpected outcomes and I would venture to say that some patients want to do too much and sometimes this causes them to question why things aren’t being one when it says something in a book. Sometimes books are merely an opinion piece and I say this as an author and OB-GYN. I think it sounds like they are doing things according to the norm and unless you have a specific medical history then I am not sure they are doing anything wrong. It is interesting to me that you are assuming that they should know something that they do not. Why is this? Why is this their doubt? I ask this because I am curious as a provider.
Thank you, Shawn—this is incredibly helpful. I think my problem stems from reading that book, which insisted I get these tests. I had no idea that they were not regular practice or that were they are not particularly useful! Perhaps I should toss the book…
The other issue that I’m sure is biasing me is that my best friend had an ectopic pregnancy in her first pregnancy (with no abnormal medical history), and doctors diagnosed it with a early blood test. I can’t help but wonder, what would have happened if she hadn’t gotten the test, and also, why was she brought in for an early blood test but not me? Who knows. Anyway, I’m relieved to know that my risks are low and that I’m basically just being paranoid —it’s something I know I am quite good at.
Remember an ectopic is rare and one of the things we are criticized over in medicine is that we practice defensively. If your friend had not ever had the test done then she would have had an 85% chance that nothing would have happened. In developing countries where they have no tests for ectopics women survive 85-90% of the time if nothing is done. In America a 10% mortality rate is not something we like so we get more involved. Most ectopics are diagnosed with ultrasound not BHCG. I wouldn’t toss the book it’s just that you need to trust your doctor or find one that you can trust because that is ultimately what is going to make you feel better and that’s what it’s al about. Enjoy the pregnancy don’t fear it. I am always available to bounce things off if you have any questions by the way. I can also keep my mouth shut.
Yes—what you say makes a lot of sense. It’s also so interesting to learn that in most cases of ectopic pregnancy, nothing bad happens.
I think I’ll feel much better once I meet with my doctor in a few weeks—it’s just strange going through an entirely new health experience without having yet met with one. But connecting with you is really, really helping—thank you again!
And despite what I may sound like, I am definitely enjoying the pregnancy.
Way to take your health into your own hands though! Ironically, I got upset when my husband and neighbor insisted that I have a physician confirm my pregnancy with a blood test–the opposite end of the spectrum from you.
I would also encourage you to shop around for providers. There are more options than just OBs. You could go to an OB, a family practice physician, a certified nurse-midwife, and probably others that I’m not even aware of. I think Our Bodies, Ourselves has a good overview of potential health care providers.
You know the one thing I wish I could have? A sonogram. I went with a midwife, which I’m very happy with, but they don’t send me for a sonogram until 18-20 weeks. It would be comforting to see a heartbeat, a gestational sac, etc. I know everything is most likely fine and dandy, but it would help me to worry less. I’ll get to hear the heart beat at my next prenatal, so that will help.
Actually, I would have reacted the same way if I’d been told that I needed a blood test to tell me I was pregnant! Luckily, my husband trusted me when I said that the two home pregnancy tests were confirmation enough.
I wanted these tests less for confirmation of the pregnancy and more just because of my general paranoia that something might be wrong with the pregnancy. Which, of course, IS just paranoia, because I feel just fine. I’m just a worrier.