CHAVI EVE KARKOWSKY - HIGH RISK a doctors notes on pregnancy, birth, and the unexpected.

high risk

Dr Chavi Eve Karkowsky is a maternal-foetal medicine specialist. She completed medical school in New York City at Mount Sinai School of Medicine and then completed her residency at Harvard. After two years as a generalist obstetrician-gynaecologist, she entered fellowship at Montefiore Medical Center/Albert Einstein College of Medicine, where she is currently an assistant professor in the Department of Obstetrics & Gynecology and Womens Health. She is also the medical director of the largest teaching OBGYN clinic within their system. She is an active member of both the American College of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine, and is fully board-certified in both OBGYN as well as maternal-foetal medicine. In addition to her clinical practice, she has published essays and op-eds in The Daily Beast , The Atlantic , Health Magazine , Slate , and The Washington Post .

Scribe Publications
1820 Edward St, Brunswick, Victoria 3056, Australia
2 John Street, Clerkenwell, London, WC1N 2ES, United Kingdom

Published by Scribe 2020

Copyright Chavi Eve Karkowsky 2020

All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.

The moral rights of the author have been asserted.

High Risk is a work of nonfiction. All patient names and potentially identifying details have been changed, along with the names and descriptions of certain other individuals.

9781925849974 (Australian edition)
9781913348083 (UK edition)
9781925938258 (e-book)

Catalogue records for this book are available from the National Library of Australia and the British Library.

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Contents

INTRODUCTION:

FIRST TRIMESTER

Did We Save Enough of Your Life?

Scut Is Love

Everything Is Probably Okay

SECOND TRIMESTER

Incidentalomas

THIRD TRIMESTER

A Necessary Story

TERM PREGNANCY

Accept and Reject Intervention

When We Talk about Birth, We Need to Talk about Death

GOING INTO THE HOSPITAL
(OR STAYING OUT)

Sign Here and Dont Ask Too Many Questions

How Institutions Save You or Fail You or Both

POSTPARTUM AND BEYOND

Implicit, Complicit

CONCLUSION:

Introduction

No Little Thing

I met Yvonne Donaldson when she was 8 weeks pregnant. Her other doctors couldnt quite believe it: she was over 40 and had almost no working organs in her body. Her lifetime of severe diabetes and hypertension had left her with renal failure, heart failure, strokes, and a myriad of other diseases. She was on dialysis three times a week. And yet here we were, with a small flickering shape on the ultrasound.

I rarely counsel any patients toward termination if the pregnancy is desired. I recommend it only if I really, truly think that there is a high chance of the woman dying because of the pregnancy or delivery. But Yvonnes body was barely managing day - to - day function; a pregnancy was risky and delivery almost definitely life - threatening . Then there was the fetus: Yvonne was on multiple medications that were terrible for developing hearts and brains. Nobody had ever discussed changing them because none of her doctors seemed to have thought of her as someone who could become pregnant as someone who had sex, who desired and was desired.

Now, with Yvonne 8 weeks pregnant, I had met her twice. I had met her husband and seen her older kids sitting in the waiting room. When I had finally gathered all the information that I could about her besieged body, I told her what I saw as the truth: the path to an actual live baby was narrow, and we might well lose her along the way. I recommended that she think seriously about termination of pregnancy in order to save her own life. She smiled at me, the way someone smiles who has been told shes going to die by many people for many years. Dr. K., no offense. But aint no little thing gonna happen.

After each hours - long session with her and with her family, answering questions, predicting bad outcomes, feeling that Yvonne didnt take me seriously, I would drag myself off to my office, drained and exhausted. I would say to my fellow doctors, Shes wrong. Because every little thing is going to happen. Every. Little. Thing.

As it turns out, we were both wrong. And we were both right.

SOMETIMES YO U KNOW youre going to need a maternal - fetal medicine doctor; youve always known. Perhaps youve had an autoimmune disease for years, or a heart condition, or a kidney transplant, and you knew that if you ever got pregnant, you would be high risk. Maybe your last baby was born early or youve had multiple miscarriages and are finally ready to try again. In these cases, you know you are going to need a doctor like me, a maternal - fetal medicine specialist (also known as an MFM specialist, a perinatologist, or, more colloquially, a high - risk pregnancy doctor); were obstetrician - gynecologists who have undergone further training to become specialists in maternal and fetal high - risk conditions. If were really prepared, perhaps we even met with you long before you got pregnant and planned your medications and your management so that everything could be as healthy and calm as possible.

But often, thats not who you are. Often, you didnt know you were going to need us; you were completely, boringly healthy and having a completely, boringly routine pregnancy until all of a sudden, you were not. Sometimes youre a - year - old having your second baby when an ultrasound finds something not quite right about the shape of the fetal heart. Sometimes your water breaks at 27 weeks despite having no risk factors and no warning. Sometimes youre a woman in a clinic who thought she just had a heart murmur, but the endurance event that is pregnancy reveals a complicated cardiac condition that makes carrying and delivering your pregnancy life - threatening . Sometimes youre a - year - old newly postpartum mom, bleeding too much too fast; now you are a high - risk pregnancy, after the birth, despite the low - risk status of everything up to this moment.

Taking care of any of that of all of that is my work.

I WROTE THIS book because I think I have the most interesting work in the world. When I decided to become a doctor, part of what I learned about myself a heretofore mild, book - loving nerd is that I am a bit of an adrenaline junkie. I thought I was going to be a psychiatrist or a pediatrician. I thought I would be someone who sat in a room with a clipboard: more talk, less action. But once I was involved in medicine, I was immediately addicted to the action (though I still love to talk). I wanted to be part of the muchness of it, the everyday drama and blood and terror and joy.

I think this muchness is appealing for a lot of high - acuity specialties trauma surgery and emergency medicine are two other examples anything where life and death things happen, and happen quickly. But I think I chose MFM because there is a way in which it is a field that has the most of this muchness. This is partially a result of the pace and volume of obstetrics, but also because it is a funny mix of routine (so much of the world has a baby, and everyone has been one) and awe (which even an uncomplicated delivery can provide).

As the name implies, maternal - fetal medicine is a specialty that deals with pregnancy, yes, and birth, and the medical and obstetric complications therein. But thats just the beginning of what we do. Our work includes the wide spectrum that is reproductive life: infertility, pregnancy loss, terminations of pregnancy, contraception. We are dealing with birth, but also death. We are dealing with the most private of parts of the body and sometimes the heart. We are dealing with the vulnerable, the beloved, the doted - upon , and the neglected. We are dealing with a life cycle event about which people have expectations in a way that they dont about appendectomies or MRIs. Wrapped up in that life cycle event are strong feelings about gender, sexuality, family, and almost every aspect of being human.