Establishing OB care

About 75% of women will establish care by 12 weeks. This may be with an OB practice they will continue to see, or with a "convenient" one that provides services they need currently, before they decide who to continue pregnancy under. Here's some common scenarios:

• Schedule with an "in network" OB as soon as you find out you are pregnant and see them for initial visit, labs, ultrasound
• Wait until 12 weeks to see "if it sticks" and only schedule an OB visit if you start to have bleeding
• Spend time researching practices and birth options before establishing care, doing consults and applications for care at a birth center or with a homebirth midwife
• Self-schedule an ultrasound to reassure yourself, either at a pregnancy resource center or private ultrasound clinic

There is no correct way to do this! What do you feel you need? Space and time and ability to research? Or immediate confirmation with labs and ultrasounds? 

Financial note-- if you have good in-network benefits and want or need an early ultrasound for dating, you'll likely go to an OB practice that's on your insurance's coverage plan. It's convenient to get the in-office ultrasound at that first visit. However, if you are just going to be working toward your deductibles, and are considering choosing a midwife or birth center that is out-of-network, your cheapest route is likely to establish directly with them. Often my clients will even pay cash for labs and ultrasounds because it's a cheaper amount than what the insurance bill will be when applied to the deductible. I encourage you to call your insurance now in order to understand your benefits.

Confirming the pregnancy, due date and viability

The first trimester visit is called a "Confirmation of Pregnancy" (COP) visit and is billed separately by the midwife/OB practice than prenatal care. During this visit, we are indeed confirming your pregnancy, reviewing and determining due date, deciding whether confirmation labs are indicated and whether an early US is indicated. I offer this visit through my clinic, and you can schedule when you are 4 weeks or 10 weeks! Here's some info on "confirmation" things we may do, in additional to focusing our visit on preparing for a health pregnancy, reviewing lifestyle recommendations, supplements, and nausea remedies.

Due Date determination

We review your menstrual cycle pattern and early pregnancy indicators, determining if we can feel confident in using the LMP (period) dating or an early ultrasound is needed to confirm dates. 

HCG labs

The earliest measure to indicate a growing pregnancy is the hcg level. We would have to check this level 48hr apart to see if it doubles. This is not routine, and it can be inconvenient to get these multiple blood draws done, but it's one measure of seeing if a pregnancy is growing appropriately. 

Early ultrasound

If we need an ultrasound, our goal would be to get it done between 6-10 weeks for accurate dating (meaning at least two weeks after your missed period or first urine pregnancy test was positive). Before 6 weeks we cannot see the fetus, and after 10 weeks there is a larger error in due date determination. I do not have an in-office ultrasound, so I refer to ultrasonography locations. Large OB offices may be able to scan you on the day of your first visit. 

If you are concerned about ultrasound radiation on the fetus, let me reassure you that it is safe and that having an accurate due date is important. The flip side- it is a high frequency sound wave, babies do "run away" from it, and so I recommend only ultrasounds that have a medical indication. We also find things that can raise temporary concern, worrying you, and then they resolve so it was undue excess worry. If you are in a worried state, or have bleeding or history of miscarriage, ultrasounds are often reassuring. If you feel at peace and have no need for dating ultrasound or investigation into bleeding issues, I recommend you don't do these investigational measures (like ultrasound and hcg levels). 

You can self-schedule ultrasounds at several locations in Atlanta:

• https://preciouspeeks.org/
• https://procareultrasound.com/
• Local pregnancy resource centers

Progesterone level

In cases where there is a clinical suspicion of progesterone deficiency, we may check a progesterone level to determine if supplementation would potentially be beneficial. Here's the problem with this being a routine test though- a progesterone level may be low because the pregnancy is not healthy and therefore the corpus luteum isn't pumping out the full P amount. So how do we know whether the problem is the woman or the pregnancy? Experienced clinicians can usually map a woman's hormone problems based on her body type and her cycle history. If you have PCOS, infertility, or menstrual cycles less than 26 days, you may need progesterone support- but I suggest you already be working with a fertility specialist for this rather than trying to get a progesterone prescription based on a low P level after conception. As a naturopath, we try to address the reasons for low P holistically prior to conception.

Miscarriage

Diagnosis

The first sign may be bleeding and cramping, but that can also be a part of many healthy pregnancies. Usually we recommend an ultrasound to investigate, and sometimes we need more data, or repeat ultrasound. There is clinical judgement in whether just one piece of information is diagnostic enough or whether it should be paired with other data. For example, an ultrasound that is very clear and does not match gestational dating can be used conclusively. But in other cases, where the ultrasound could potentially be off by a week or two, a repeat ultrasound may be suggested, or I may suggest  following hcg levels in bloodwork to see if they are rising like a healthy pregnancy.

Management

We are challenged as providers to guide you through the physical aspects of miscarriages, while respecting that your day-by-day emotions of processing a pregnancy loss change. A woman may one day want to wait for natural passage, and the next day want medication or surgery. There are no clear protocols from the medical field, nor from our experience of learning women’s desires. I usually recommend to do nothing for a few days, which seems to be the shock period. Then, I find that women often will call and ask for help to pass the miscarriage. I generally feel that waiting and allowing natural processes of releasing and expelling is best in most cases where there is not a fetus over 10wk size. The larger fetus’ may be harder to pass and scheduling a D&C procedure may be a safer and easier process. It is best to be under clinical care by a midwife or OB so that we can guide you. I try to offer a range of options from herbal to medication management. You may also want to establish with a medical practice so that you can be schedule a D&C. If you are bleeding heavy, utilize your local ER for urgent care. One local clinic that offers in-house hcg labs, ultrasound and D&C's is Kindbody.