Wednesday, May 2, 2012

Don't touch the pregnant lady!

Last week, I finally saw a surgical consult for that basal cell carcinoma I was diagnosed with back in March. I had been dragging my feet on it, because (1) I've had other things to think about, and (2) I thought it would be better to handle while not pregnant...and so expecting I would any time find myself un-pregnant again, thought I would wait a bit to see if I miscarried.

But no miscarriage. Which is a really good thing. Really, really good, mindblowing-ly good thing.

But it meant I needed to see someone about this lesion, since the derm who biopsied it said it was a no-go to wait until after delivery.

So last week, I saw a Mohs surgeon in private practice who came highly recommended. It was a strange appointment in that at the beginning he was telling me all about the procedure but about halfway through seemed to change his mind and suggested I see the one Mohs surgeon at my hospital, because really I should be seen in a hospital setting, not that anything adverse would happen, but well, just because it would be best to be on the safe side. It was very strange to watch him switch gears mid-Mohs-pitch. When I went to pay, the admin said that the surgeon had said there would be no charge for the visit.

Wow...he was glad to get rid of me. Funnily...I didn't even tell him about the recurrent pregnancy losses. Can you imagine how fast he would have had me out of there in that case?

So, I went to the one Mohs surgeon here at my medical center Monday. She was very nice. Said the case was very interesting (which made me think that her job must be seriously boring, because this is really not very interesting...we're talking about something between the size of a pencil eraser and a dime...on my back...non-malignant even).

But anyway...She begins with the idea that we should wait until I deliver (still hard not to balk that that word "deliver," as in "to deliver a baby," might ever have anything to do with me). That if we wait until after delivery, it will be easier then. It will be a little bigger, so I'll have a slightly larger scar, but no big deal. I shouldn't wait long after delivery, though, because, well...the longer we wait, the more it is growing...Of course, she said, if the lesion starts growing more quickly than expected, I should come right in. Because it can always be taken care of, no problem! I reminded her that this lesion is on my back, so if it starts growing  more quickly, I probably won't really know it, it being on my back and all...hmmm....

She then went into a big explanation about how after the procedure, because of the lesion's location, I'll need to avoid lifting anything for a few weeks or it will pull open the incision, and also will need to rest a lot for the first four days or so to ensure it heals properly. I asked her, by rest a lot, do you mean get up every two hours to feed a newborn? (no, apparently not). By not lift anything, do you mean to not lift a baby?? (hmmm...turns out she hadn't thought about that either).

We'd reached some major snags in her plan.

Me: Is there any problem with doing the procedure now? Is it unsafe or risky for my pregnancy?

Her: Oh no. It's perfectly safe! It would just be easier later.

Me: Mmmm.... (since we'd already outlined in detail how it wouldn't really be easier later at all).

Me: I could stop the Lovenox, just the night before, to reduce the bleeding, since there's no real medical indication for me to be on it. And then just take it after the procedure is over.

Her: Oh no! You can't stop the Lovenox!!!

Me: Mmmmm....

Me: Well, how about I ask my OB if it's ok by her if you use a small amount of epinephrine to control the bleeding? Since that will only go into local tissues, right?

Her: I won't use epinephrine even if she says it's fine. What if it somehow gets into a blood vessel, travels to your placenta, and clots off the blood flow to your baby?

Me: Mmmmm...ok, then, no epinephrine.

We ended up with scheduling the procedure for next week. It was either then or in July. Sooner seemed better, because I'll have to lie on my stomach for a few hours during it apparently, which already sounds pretty uncomfortable, but soon - if I am lucky - may be impossible.

Her: I can do the surgery with you lying on your side, but the outcome won't be as good.

Me: Mmmmm...

The only big difference to doing it now versus later is that she won't use epinephrine, which is used to reduce bleeding. Between the lack of that and the addition of lovenox and aspirin, this whole thing may look like a blood bath. But not really. I hope.

I told Will about the interaction when I got home, and he said, "What is this, open heart surgery? What's the big deal?"

My thought exactly. The whole consultation - well, both of them actually - was weird. Like they were saying it's fine to do the procedure, but then also saying they didn't want to go forward. Strange contradiction. Hard to try to read between the lines. And also confusing: why did the first derm say absolutely not to wait, and now the surgeons want to wait?

Puzzling. I've become the pregnancy version of the hot potato for dermatological surgeons in New York City. Or at least for two of them.

I'll see what my OB says about all this tomorrow when I see her.


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  1. Yup. Totally my pet peeve - pregnant women often get delayed and substandard care because (perversely) everyone is feeling overprotective. (I write about this a lot in my place,

    Glad you stood up for what you need (and at a good time - second trimester is ideal for procedures in pregnancy, if they should be done).
    Tip: you may not be totally comfortable on your tummy, and it's probably wise not to put too much pressure on it if so. They can usually either use pillows to tilt you (and then airplane the OR bed so you're still flat for the surgeon) or make a little massage-table-hole for your belly using pillows.

  2. Agree with PP, to NOT lie on your stomach for so long. You'll be 15-16 weeks?? That's a big late for tummy lying, in my opinion.

  3. It is interesting. There's this whole "pregnancy is not a disease" thing (which, obviously it's not), and yet we treat pregnant women with kid gloves, like they have some kind of disease. It does seem awfully strange... Be interesting to see what your OB has to say tomorrow.

  4. This is very interesting and odd!!

    My husband had a basal cell carcinoma (non-maligant) on his face a few months ago and was recommended to get the MOHS. His insurance was about to change, and so he had to have the procedure done that day. He found someone who would take him, and the whole thing took a couple hours (they removed part, then biopsied it. They wanted to get clean margins, but take out as little as possible.).

    But from the way he described the procedure, it wasn't a very big deal. He had it done in the doctor's office. He said they numbed his face and then got to work. Anyway, from what I understand, it was a very simple procedure.

    I do get that there are more factors since you are pregnant and on medications... but, I too think they are making an oddly big deal about it. I know he couldn't get his area wet for several days and he had to be careful to not pull the area b/c they didn't want any of the stitches to pop. But, they mainly seemed concerned about the stitches popping and him not having too bad of a scar.

    I think it will be fine! Good luck!

  5. I think that sort of response from 1 dermatologist would leave you feeling like something's off. But two? I hope your OB has some insight to offer.

  6. Just ordinary OPERATE ON A PREGNANT WOMAN freakout. Been there, done that. Caved to waiting since I wasn't willing to dr shop for a surgeon while pregnant. I have ideas for the on the belly part. Will write more when I can. Sick toddler here. :-(

  7. Hmmm, that does seem a bit odd; I wonder what makes your case interesting? I will be quite interested to see what your OB has to say tomorrow. I'm glad that you're getting it taken care of, 'cause you're right that immediately after the baby would be a very bad time with lifting restrictions, etc. Hoping for good things and looking forward to tomorrow's view of the yumster!

  8. Emily Erin, She said it was because this lesion started as a hemangioma 10 years ago, was removed, then formed a keloid scar, that then transformed (?) into a basal cell carcinoma. i still don't think that's so interesting.


  9. I suspect they're just panicking about liability... if something goes wrong with the pregnancy and you or your OB decides to use them as the scapegoat...

    I think getting it done now is the better idea. Aside from any danger the lesion itself presents, having a medical procedure while you have an infant to take care of is just a bad idea (yes, we're assuming a newborn in your future). Besides, it will give you the perfect excuse to rest up and take care of yourself.

    Haven't commented in awhile, but I'm so so glad that all is continuing to be well.

  10. Yep, clinicians (non-ob) get so crazy scared of tests/procedures on pregnant women usually without reason. When I was in my second trimester w a twin pregnancy, I went to the dentist for tooth pain and the dentist REFUSED to perform dental xrays despite the fact that I would wear a full lead shield and the radiation was going to my head and therefore no where near the fetuses to begin with. When I told the radiology tech that I was ok with her doing the films she accused me of 'wanting to kill my babies'....

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  12. Confusing...I'm sure they are being extra cautious because they fear doing anything to harm the baby (and dealing with liability associated with that). But it sounds like you made the right call by doing it now - imagine doing this two weeks after delivering! No way...

  13. Definitely do it now. Get them to put bolsters/pillows on the OR table so that you can lie on your stomach without putting pressure on your uterus. I can't imagine the procedure taking several hours though. Even without the epi (though I agree with you that a tiny bit injected with the local shouldn't make any difference to your placental flow), they'll have access to cautery in the OR to stop any bleeding.
    Would your OB consider letting you switch to heparin BID and just hold the morning dose till after the surgery is done or something? I can't see the issue in not taking your lovenox the night before when you don't actually have a clotting disorder (do you?).
    Hope your OB has some sane suggestions for what to do!

  14. Hi Mo - I can't even think back to where exactly I found your blog link (must have been someone from TTGP on - spent some time there recently)
    I have also spent the last few days at work (much to the chagrin of my company - ssh!) starting, following and catching up on your blog. first - a great big CONGRATULATIONS on your success after the long struggle. I can't even imagine how you're feeling... I just wanted to let you know I admire your strength during everything and will be following (closely) each day of this epic story!

  15. How about getting something like this? I assume they can put a sterile drape over it. Not cheap, but seems a small price to pay for comfort and a little peace of mind. You could probably sell it later on ebay or craigs list. I could also ask the massage therapist at my chiro if she's interested in it or if she knows someone who would want it.

    For me, it was a pain issue, not an abnormal cell issue, but my OB cleared me to have foot surgery while pregnant. She actually thought it was advisable, since of course it hurt more as I got bigger, She even sent me for a consult with an attending L&D anesthesiologist, who agreed that I'd be fine with a spinal block. But the foot surgeon wouldn't do it. He stalled giving me a definitive answer until I was far enough along that he could use the excuse that the ortho hospital would not allow it. Sucked.

    Glad you're scheduled so soon. Get it off the list.

    Sorry to read about the uterine freak out. Sounds like round ligament pain to me. It can be really intense. Interesting comment you got about the endo possibly causing abdominal pain as well. Makes sense.

    Hang in there. You're doing great! xoxo

  16. Hey! Isn't it time for an OB appt update? :-)

  17. Oh yeah, pregnant woman and surgery or meds-- makes MDs break in to a cold sweat. I'm a psych NP, and everyone hates giving pregnant ladies psych meds.

  18. I agree with Dora... hoping for yet another cute u/s pic, or at least Will's take on 'joint' OB appointments.... Sending you good vibes!

  19. I ran across your blog after doing a google search on Mohs Therapy and miscarriage. I had a basal cell carcinoma removed when I was 15 weeks pregnant and 3 days later I was told my baby did not have a heart beat. I was induced shortly after and had an autopsy done which found no abnormalities with my baby girl. All of the tests they ran on me also came back normal. I do not think it was an awful coincidence, I really believe the Mohs surgery had something to do with it. Would it be possible for you to email me your dermatologist's name? If he/she was concerned about doing the procedure I wonder why my dermatologist wasn't concerned about the risks. I hope your pregnancy is going very well! Best wishes to you! -Ally


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