Windows On The Womb

  Windows on the Womb

Select any one of the techniques listed below to find out more about it. The weeks during which doctors commonly use such techniques are listed with each technique.

Enhanced Alpha FetoproteinAmniocentesisChorionic Villus SamplingDoppler deviceFetal EchocardiographyUltrafast fetal MRINuchal Translucency TestUltrasound scanning

Enhanced Alpha Fetoprotein or the Quad (AFP)15 to 18 weeks A protein produced by the baby's liver, alpha fetoprotein (AFP) normally enters the mother's bloodstream. In this test, blood drawn from the mother is examined for AFP; the amount of AFP in her blood determines the level of risk for disorders such as Down syndrome, neural-tube defects, abdominal-wall defects, and Edwards syndrome. High levels may mean a neural-tube defect or that some or all of the baby's brain material is missing. A low level can be an indication of Down syndrome. Because this is a screening test, showing only the baby's level of risk, follow-up testing for an abnormal level is recommended. There is no risk to the baby, but because as many as 5 percent of all women test positive, further testing often results. The vast majority of these women turn out to carry healthy fetuses.Amniocentesis16 to 18 weeks Obstetricians typically recommend the use of amniocentesis for women more likely to be carrying a baby with abnormalities, such as older women (35 and above) or women with a family history of genetic diseases. An ultrasound prior to the test determines the baby's location, and then a specialist uses a small needle to withdraw about a tablespoon of the amniotic fluid surrounding the baby. Cells from the baby found floating in the fluid are cultured and examined to look for chromosomal disorders. Doctors use the test primarily to detect spina bifida or Down syndrome, but also Rh disease, fetal anemia, sickle-cell anemia, and to determine the baby's sex. Late in pregnancy, doctors use amniocentesis to find out if the baby's lungs are sufficiently developed and thus able to withstand, if necessary, a medically required premature birth. The U.S. Centers for Disease Control and Prevention estimates that the rate of miscarriage following amniocentesis is between one in 200 to 400 procedures.Chorionic Villus Sampling (CVS)10.5 to 13 weeks As with amniocentesis, obstetricians may suggest using CVS, short for chorionic villus sampling, to detect genetic disorders such as Down Syndrome. In CVS, specialists perform an ultrasound to determine the position of the fetus and then remove fetal tissue by placing an instrument through the cervix or abdomen. Unlike amniocentesis, which can also detect Down syndrome, this test can be carried out much earlier in pregnancy, and test results are also available sooner. That means that if parents decide to terminate a pregnancy based on the results, they can do so as much as nine weeks earlier than in the case of amniocentesis, creating fewer risks to the mother's health. There is a 1 to 2 percent risk of miscarriage following the procedure.Doppler device6 weeks to term A Doppler device is a small, portable machine that uses ultrasound waves to detect and magnify the baby's heartbeat. Doctors use this test during most office visits to verify that the baby is alive. After about the tenth week, a baby's heart rate can vary between 120 and 170 beats per minute. In the third trimester, obstetricians may use a variation of this test, known as umbilical cord Doppler, to examine the flow of nutrients between heartbeats, to ensure that the baby is receiving adequate nourishment. There is no known risk to the baby or the mother with this test.Fetal Echocardiography14 weeks to term This test is essentially a very detailed ultrasound focussing on the structure and function of the heart. Doctors use it only when either siblings or parents have a history of heart defects, when other tests such as amniocentesis have produced abnormal results, when the mother has diseases that can affect the heart (such as diabetes or phenylketonuria), or when the fetus has been exposed to certain drugs. Most experts conduct the test between the 20th and 22nd week to ensure that they can see the heart clearly. There is no known risk to the baby or mother with this test.Ultrafast fetal MRIsecond or third trimester MRI (magnetic resonance imaging) relies on a magnetic field and radio waves to "eavesdrop" on the body's electromagnetic transmissions. An MRI image can clarify the diagnosis of a fetal abnormality observed in an ultrasound and better prepare parents and their doctors for any interventions that may be needed to help the baby before or immediately after birth. It is especially helpful for examining certain tissues, such as the brain, that are encased in bone and would be difficult or impossible to see using ultrasound. MRI is not as widely available as ultrasound. It poses no known risk to the baby or mother.Nuchal Translucency Test (NT Scan)11 to 14 weeks This test uses ultrasound to examine the fold of skin on the back of the baby's neck. At this early stage of development, the skin is so thin that fluid accumulates between it and the underlying structures. More fluid, which produces a thicker fold, can be a sign that the baby has a chromosomal abnormality, such as Down syndrome. This test is available at a number of university medical centers around the U.S. As with ultrasound, there is no known risk to the baby or mother.Ultrasound scanning5 weeks to term Many women will have at least one ultrasound during their pregnancy. High frequency sound waves are directed at the fetus and the returning "echoes" form a live-action picture of the baby. Typically performed between 16 and 18 weeks, an ultrasound provides a general check of the baby's anatomy and can also help to date the pregnancy. Later on in pregnancy, ultrasound can gauge the baby's growth and development, determine the location of the placenta, and measure the amount of amniotic fluid. Three-dimensional ultrasounds, which are now becoming available at some health centers, provide a much clearer, more photographic image and make it possible to observe the baby from any angle, regardless of what position the baby is in during the procedure. There is no known risk to the baby or mother.

Windows on the Womb—Glossary

Down syndrome—In most cases caused by a third chromosome 21, Down syndrome results in mental retardation and other abnormalities. Children with Down syndrome have a widely recognized characteristic appearance.

Neural-tube defects—An NTD occurs in the neural tube, the part of the fetus that becomes the brain or spinal cord. NTDs result in the partial or complete absence of the brain, or in an opening of the spine. They are among the most common of all serious birth defects.

Abdominal-wall defects—Abdominal-wall defects feature a soft bulge of tissue or a small, localized swelling on the abdomen, most often caused by a hernia. A hernia is an area where muscles are weak enough to allow internal organs to protrude.

Edwards syndrome—Also known as trisomy 18, Edwards syndrome is associated with a third chromosome 18, which causes multiple physical abnormalities and severe mental retardation. Few infants survive beyond their first year.

Rh disease—When the baby is Rh-positive and the mother is Rh-negative, the mother's antibodies can cross the placenta and attack the baby's red blood cells, resulting in jaundice, anemia, brain damage, heart failure and death. Rh disease occurs only when the mother has previously been sensitized to Rh-positive red blood cells and has developed antibodies to them.

Fetal anemia—Fetal anemia occurs primarily when the mother's blood type is incompatible with the baby's, leading to the destruction of red blood cells in the baby's blood. This in turn results in an oxygen deficiency for the baby.

Sickle-cell anemia—In this chronic inherited disease, the normally round red blood cells become sickle- or crescent-shaped. When these abnormally shaped cells move through small blood vessels they can clog blood flow or break apart, causing sudden severe pain in many areas of the body, damage, or anemia.

Diabetes—Diabetes is a life-long disease in which the body produces too little insulin or is unable to use the insulin properly. The result can be dangerously high blood-sugar levels, which, when untreated, starve cells of energy and over time can damage the eyes, kidneys, nerves or heart.

Phenylketonuria—Phenylketonuria is a rare genetic disorder in which the body is unable to properly metabolize the amino acid phenylalanine, one of the eight essential amino acids found in protein-containing foods. The accumulation of phenylalanine in the blood and body tissues can cause severe mental retardation and developmental delays if not treated.

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John Hilton Edwards 1928–2007

Credit: courtesy of Ross Shipman

John Edwards, formerly Professor of Genetics at Oxford University, died on October 11 of metastatic cancer of the prostate. Over the last 50 years, he was an important contributor to human genetics in a variety of areas, particularly linkage mapping, allelic association with disease predisposition and comparative gene mapping.

The son of a London surgeon, Edwards was educated in medicine at Cambridge University, with clinical qualification at Middlesex Hospital Medical School in London. John's physician wife, Felicity, was a medical school classmate, having come to Middlesex from Oxford at the same time that John came there from Cambridge. Pediatrics was John's specialty within clinical medicine.

On his return from a stint as ship's surgeon on the Antarctic survey vessel John Biscoe (1952–1953), John was found to have a tuberculous lesion at the apex of one lung. He used the enforced bed rest of several months to teach himself statistical methodology. In 1956, after hospital training, Edwards assumed appointments in Thomas McKeown's Department of Social Medicine and The Institute of Child Health at Birmingham University. His associations with Birmingham continued until 1979, with interludes at Oxford (in Alan Stevenson's Medical Research Council (MRC) Unit on Population Genetics, 1958–1960), at Children's Hospital of Philadelphia (1960–1961) as geneticist, and at the New York Blood Center and Cornell Medical College (1967–1968). During his time in Birmingham he rose through the ranks, from lecturer to Professor of Human Genetics (1968) and on to head of a new department of clinical genetics (1969). In 1979, he succeeded Walter Bodmer as Professor of Genetics at Oxford. Earlier that year he had been elected Fellow of the Royal Society for "contributions to human cytogenetics and genetic epidemiology including elucidation of the threshold model for multifactorial traits and pedigree linkage analysis."

One of John's first publications was a letter (Lancet 1, 579; 1956) suggesting that antenatal detection of hereditary disorders could be achieved by application of the linkage principle to test material obtained by amniocentesis. Amniocentesis had just been introduced for detection of Rh hemolytic disease of the fetus.

During his time at Oxford, Edwards seized the opportunity to learn about chromosomes from Charles Ford and David Harnden at Harwell. In that period, he was spending a morning a month at the Children's Hospital in Birmingham. It was there that he recognized a potential chromosomal aberration in a newborn—he called it "trisomy, type unknown." He obtained postmortem tissues and delivered them to Harwell, where Harnden demonstrated trisomy 18, or Edwards syndrome, as it came to be known (Lancet 1, 787–790; 1960). He also made major contributions to the delineation of X-linked hydrocephalus, the most common inherited form of congenital hydrocephalus. In 1961, he published two back-to-back papers on the topic. One described a large pedigree with 15 affected members (Arch. Dis. Child. 6, 481–485; 1961), and the second was a general discussion delineating the disorder (Arch. Dis. Child. 36, 86–93; 1961).

Edwards was very productive during his period in Birmingham, and his contributions were wide ranging. He contributed to the early technology of clinical chromosomology and reported on the epidemiology of birth defects, on 20 cases of Cornelia de Lange syndrome and on the meaning of blood group and disease associations.

Edwards was undoubtedly influenced by Lancelot Hogben, who was in the Department of Social Medicine in Edwards' first years in Birmingham. He admired Hogben and was amused by his idiosyncrasies. R.A. Fisher referred to John as Hogben's Edwards and to John's younger brother as Fisher's Edwards, according to the latter, the Cambridge statistical geneticist A.W.F. (Anthony) Edwards.

John was a regular and important participant in the international Human Gene Mapping Workshops held between 1973 and 1991. His input was in relation to linkage analysis and reporting and to comparative mapping, particularly of mouse and man. After he went to Oxford in 1979, he pursued comparative mapping in these two species in collaboration with colleagues at Harwell, including Mary Lyon, Tony Searle and others. This led to the design of his famous Oxford Grid, which gave a graphic representation of conservation of synteny between mouse and man.

Edwards' collaborations in comparative mapping and genetic pathology extended to scientists at The Jackson Laboratory in Bar Harbor, including Thomas Roderick. They also included the Faculty of Veterinary Science at the University of Sydney, specifically Frank Nicholas, who created and maintains OMIA, Online Mendelian Inheritance in Animals, the equivalent of OMIM for farm and companion animals. In Sydney, the extensive "Oxgrid Project" (http://oxgrid.Angis.Org.Au), inspired and advised by Edwards, has Oxford grids comparing the human with many other species.

David Weatherall characterizes Edwards as "one of the nicest and cleverest of our field." John was of quick wit, in both senses of that word. His humor was rarely if ever malicious or unkind. Among his colleagues his absentmindedness was legendary; 'John Edwards stories' abound. These characteristics enhanced rather than detracted from the respect in which his colleagues held him.

I first met John in 1961 when he participated as a 'student' in the second annual session of "The Bar Harbor Course." Officially named the Short Course in Medical and Experimental Mammalian Genetics, it was first given in 1960 as a joint effort of The Jackson Laboratory and Johns Hopkins University. Since 1961, my contacts with John were numerous and always stimulating and instructive, through the gene mapping workshops, through those occasions when he lectured in the Bar Harbor Course and through visits by my wife Anne and me to Felicity and John in Birmingham and Oxford and their reciprocal visits to us in our Baltimore home or in our old farmhouse in Nova Scotia.

John maintained an exceptionally vigorous life until a year or so before he died. This vigorous activity included gliding and skiing and even taking down trees and chopping them up for firewood on recent visits to Tom Roderick in Bar Harbor.

John is survived by Felicity, his wife of 54 years, and by their four talented offspring.

Days Of Desperation: The Diary Of A Woman Forced To Flee Texas For An Abortion

Below is the journal of Lauren Miller, 36, a Texan who unexpectedly found herself needing abortion care shortly after Roe v Wade was overturned one year ago. When she first started writing the diary, Miller had no idea of the obstacles she was about to face. Now, she is suing the state of Texas with the Center for Reproductive Rights alongside 14 other plaintiffs for being denied access to life-saving abortion care.

Miller came to the Guardian wanting to publish the journal – a real-time diary of the twists and turns of going from discovering a very wanted pregnancy, to navigating the need for a termination in a state where abortion is now banned. It has been edited and condensed.

26 July 2022: 'I'm ecstatic'

Here we go again!

This morning, we had my first son Logan's, one-year check up. Mr Nugget is healthy – still on the tall side (shocker given that Jason is 6ft 8in …) and in the 50th percentile for weight.

On the way home, I started burping. Like frat boy burping. The kind of unholy belches I've only ever done while pregnant.

"You're pregnant!" Jason teased.

Lauren and her husband, Jason, at their engagement photo shoot in 2014. Photograph: Don Mears/Lauren Miller

I completely dismissed him. After 10 months of trying for Logan, it just didn't seem like it would happen on the first go this time around.

Well, looks like Jason was right!

I used one of the tests that say "pregnant" or "not pregnant", so there was no room for doubt.

I'm ecstatic, but can't believe it!

It's always such a strange shift to realize that you're pregnant. I feel like the focal point of my consciousness drops 3ft from my head into my abdomen. It's like I've adjusted volume controls so that the pregnancy is ramped up, while everything else is muted.

But life goes on around me.

I hope (especially with the fall of Roe v Wade) this pregnancy is as uncomplicated and normal as my pregnancy with Logan. If it's not, I want to be able to share what I'm going through. I hate the "don't tell anyone until the second trimester so you don't have to tell about a miscarriage" mentality. Why are we telling people to bottle up and not unburden themselves of something terrible?

Rant finished … hopefully, that won't be something that we have to worry about!

27 July

Today has been ROUGH. It's amazing how much worse I feel than just 24 hours ago. I hope this isn't a sign of things to come!

It's early, but since the pregnancy confirmation visit isn't until eight-10 weeks (yet another reason why those ridiculous six-week "heartbeat" bills are so outrageous!) I sent my OB-GYN a message to give her a heads-up.

I'm really nervous about being pregnant in Texas right now. I can't imagine what it would be like to have a doctor who you didn't trust.

I just spoke with the schedulers. We will see "Dos" on 29 August at 8.40am. Can't come soon enough!

20 August: first trip to the ER

This baby is murdering me. Like actually.

I started throwing up at 5 yesterday morning and it won't stop. I can't even keep down crackers.

Water, tea, coffee, juice? Threw it up. Pedialyte? Threw it up.

Our fabulous nanny tried to make water with lemon for me to settle my stomach and that didn't stay down either. At least it smelled nicer when I vomited that.

21 August: twins!

After hours of vomiting, a doctor friend told me I should go to the ER to get rehydrated.

My doctor friend was set to clock out of her shift at midnight, but she said she had to be the one to give us the news. I will definitely never forget how the next conversation went!

[ER doctor friend]: Well, I wanted to let you know that everything on the ultrasound looks fine. You do have hyperemesis gravidarum, but that's something that's fairly common with multiples because of the higher hormones …

She paused, beaming.

"… Because you're having twins!"

She showed us the ultrasound photos and sure enough – two little beans in there.

Jason and I had a range of reactions, among them, "We're going to need a bigger car" and "we're definitely going to need a night nurse this time".

We told our families this afternoon. Jason's mom just said, "Holy shit," as Jason's dad called out in the background, "Your nanny's gonna quit!!"

My mom was typical, "Oh what a blessing." My dad, who was at the ranch and necessitated his own call, just goes "oh shit. I'm so sorry."

I think that may be more where we are at the moment!

29 August: first prenatal appointment

We got our first pictures of Los Dos! Eee! They're really in there! Like last time, we got a dark blue folder after the visit with the hospital's standard hand-outs for pregnancy. Last time, I had labelled the folder "Burpy". This time, I very proudly put "Los Dos". Not just one, but two!

Ultrasound image of the Miller twins. Photograph: Lauren Miller

My OB-GYN was fabulous as always. We did have a sobering conversation about the Texas laws though. As she put it, "The laws in Texas are a little kooky right now." That's an understatement.

We understand this will be a higher-risk pregnancy because of the multiples and should the worst happen, it's good to know we can trust her. She said that we should always ask and if she feels a need to pause the conversation, (I assume she meant because of the legal risk) to let her do that, but not to hesitate to ask her anything. That's very nice of her, though I certainly hope that we're never in that situation!

23 September: bad news

Not a good day. The Maternal Fetal Medicine specialist informed us Baby B (who I still think is a girl and A is baby boy) has a two cystic hygromas on her brain. I don't need a doctor to know the brain isn't supposed to be half fluid.

The doctor said she suspects Baby B may have Turner syndrome or Down's syndrome, rather than one of the clearly fatal chromosomal abnormalities like Edwards Syndrome. She said cystic hygromas can resolve themselves, but she was careful not to be too optimistic.

I don't need a doctor to know the brain isn't supposed to be half fluid

I had a bad feeling even before the appointment. I told Jason when we were standing outside the elevators waiting to go up that I was worried about Baby B.

When the ultrasound tech said she needed to check she got all the photos she needed, I knew something was wrong. They didn't do that for Logan.

She's going to refer us to another doctor. She also offered that we could wait a few weeks for amniocentesis, but we both immediately agreed we can't wait that long. This is devastating. I need to know what is happening with my baby.

26 September: 'Our boy has no chance'

I feel sick. We just got the NIPT test. It's so much worse than I imagined.

Trisomy 18. Edwards syndrome.

I want to throw up. I can't even come up with words to describe how devastating this is. This is the prognosis for Edwards syndrome per Wikipedia:

"About 95% of pregnancies that are affected do not result in a live birth. Major causes of death include apnea and heart abnormalities …

Half of the live infants do not survive beyond the first week of life. The median lifespan is five to 15 days. About 8-12% of infants survive longer than 1 year. One percent of children live to age 10."

'I will never not miss him. Every day of this pregnancy will be a reminder.' Photograph: Lauren Miller

They're not talking about a happy, fulfilling life. They're just talking about surviving infancy. Surviving. That doesn't mean independent, pain free, happy. Our boy has no chance.

Yes, boy. I was wrong. Our twins are boys. Found that out from the test, but it's hollow news. Telling them apart won't matter.

I'm going to throw up and for the first time in weeks, it's not the hyperemesis gravidarum.

Later that morning

I spoke with the genetic counselor from my OB's office. There's no good news. It just gets worse. Every day he continues to develop, he puts myself and his twin at greater risk for complications. She can't say much because of the new Texas laws. She said that when she was in New York, they would do a single twin reduction (ie, an abortion of one twin), but she couldn't give me any more information.

We have to scramble. We don't even know what we're doing and we have to make plans. I feel blind and confused and scared and I hate all of this. I want my baby to be OK and he will never, never, never be OK.

27 September: meeting with genetic counselor

I just feel like everything is worse and worse.

We met with a second genetic counselor and a new specialist. She was super nice but you can just tell they're all so over this law.

The Texas legislature has turned her job from saying: "I'm so sorry – these are the options for your situation" to: "I'm so sorry – hope you don't die. Oh and by the way, I hope you have tons of time, money, and resources to support your child should it live!"

And … that's all she can say. We can no longer freely discuss healthcare options in Texas without fear of retribution.

'I didn't put our plans in writing'

After the genetic counseling, we went back for another ultrasound. If I thought Friday's ultrasound was bad news … I don't even know how to describe this one.

"Bad" doesn't begin to cover it.

Devastating. That may be closer to the word.

Baby A was fine.

The abnormalities that Baby B has are heartbreaking.

Cystic hygromas where most of the brain should be. Single artery umbilical cord. Incomplete abdominal wall. Abnormal heart. It's just one thing after another.

None of them are any sort of life for Baby B. And when combined?

We didn't even need to attempt the CVS. The doctor was frank about that. Honestly, his directness was refreshing. Of course, being data people, we thought that since we were there, we might as well do it. I wish we hadn't even tried.

This baby isn't going to make it to birth. You need to go out of state.

The process for trans abdominal CVS is pretty straightforward, even if unpleasant: a massive, thick needle, approximately a foot long, is inserted through the belly and uterus, and into the placenta. A second smaller needle is moved through the larger one in order to take the sample.

As the needle gets to the uterus, the uterus does what uteruses do: it contracts. Not just a little contraction. I've been through labor before. It was on that level. My uterus didn't want to cooperate either. Getting answers is an excruciating process.

After multiple attempts, the doctor finally gave up. Throwing his gloves in the trash, he was very blunt:

"Look, I can try all day, but I'm just causing you a ton of pain and your uterus isn't going to let me through. This baby isn't going to make it to birth. You need to go out of state."

I guess I'm lucky. If you have out-of-state resources, thousands of dollars at your disposal, time to take off work, childcare, ability to travel, you can find the abortion that you need. But for everyone else? You're screwed.

I texted my family to let them know what had happened.

I didn't put our plans to go to Colorado in writing though.

1 October: second ER visit

Yesterday was rough. I was vomiting bile (or dry heaving as there was nothing left in me) the entire way to the ER.

I can't help but think how I was directly put in this situation because of Texas's restrictive abortion laws. The doctor could have performed the termination on Tuesday in a world where we still had access to healthcare.

This has been miserable.

Lauren Miller volunteering at the polls for the Funky East Dallas Democrats on election day in 2022. Photograph: Lauren Miller Eight hours later

Finally, after almost eight hours in the ER, I was released.

I want the hyperemesis to end. I want this pain to end. But we're not there yet. On some level, I'm glad for that. I cradle my growing belly and talk to my boys in there. We don't have much longer now.

Nothing anyone could say could make me doubt that we're doing the right thing. I just wish that we weren't in this situation at all and that both of our twins were healthy. I would take hyperemesis through the rest of this pregnancy and infinite ER visits in that cold, uncomfortable chair if it meant I could have my twins be healthy, with the ability to live long, happy lives.

I can't have my own doctor who I know and trust to help me through this, I have to rely on a stranger

This is the most painful option for me, but the best for Thomas (as we've now named Baby B) and Baby A. It makes me even more appalled at those who oppose abortion. The sheer selfishness of causing someone ongoing pain because of your beliefs will never cease to amaze me.

3 October: packing for Colorado

I don't want to pack for Colorado. I don't want any of this. I want to be home snuggling Logan.

Everything is so much more heartbreaking and depressing now that I have to travel for care. It cuts me off from my usual medical care team and my support people. It keeps me from being able to find a therapist. I can't have my own doctor who I trust to help me through this, I have to rely on a stranger. I just want to be able to stay at home.

3 October: liftoff

It's happening. I want to sit here on the plane and cry, but I couldn't.

Instead, my nose is clogged with the sickly sweet smell of ketchup from the Whataburger that the guy next to me is eating. It's nauseating, but at least masks his body odor.

There's no dignity in this process. I want to be home holding Logan and cherishing this last night with Thomas. Instead, we're taking off into the night in an escape from the backwards legislation of Texas. No wild blue yonder, just ink black darkness.

4 October: day of the abortion

Today's the day. Jason took a last photo of me with the twins. By this afternoon, we won't have twins. Just one twinless baby. It's taking everything not to break down crying every time I breathe.

I keep hoping it's all been a terrible mistake. But I know it's not. And I don't know how to make peace with that. I keep trying to remind myself that we are lucky. We will still have Baby A, but I don't want Thomas to go. I wish that I was selfish enough to carry him until he passes so I could keep him longer. But that wouldn't help him and would only hurt Baby A.

I try to take comfort in the fact that all he will ever know or have known is the coziness, warmth and security of being in his mommy's belly. My belly.

I love you so much, little one. And I'm so, so sorry that we will never know you and that something as small as a genetic mutation means you have no future. You will always be with me.

The procedure

We're in the ultrasound room and just met with the sonographer. I managed to get through my lunch without crying in my bagel and cream cheese.

I guess I'll check in when we're on the other side so I can take these last moments with my Dos.

Later that day

The procedure was straightforward. They did an ultrasound to confirm the abnormalities and the issues were all very clear. I took an Ativan and used the restroom one last time while they prepped. Jason sat in the room as they got set up.

'I took one last photo of the screen. They had given us an ultrasound photo before the procedure, but I needed anything I could get.' Photograph: Lauren Miller

Soon came the big needle. It was about the same as the CVS, with some terrible cramping.

"It's done," one of the doctors informed us as he squeezed my knee comfortingly. The nurse rubbed my ankles to offer comfort. The tears started falling then.

The cleanup was fast. The entire process had taken less than 30 minutes.

Once the needles were out, they wanted to do a final check on Baby A and asked if I would like to see. I could tell they were trying to keep Thomas off screen as they showed our little Tigger bouncing around, but I needed to see.

The sonographer turned the screen further and we could see Thomas there, peacefully suspended.

This was the most mercy that we could offer.

The doctors said they felt honored to help us and all of the women escaping the laws of Texas. They thanked us for putting our trust in them.

After they stepped out, I broke down sobbing against Jason. All the despair and sadness and stress came out. I cried for me and Jason and Thomas and Baby A, forever a twinless twin now, and for Logan, who doesn't even know what has happened. I cried and cried and cried.

After a while, we left. I took one last photo of the screen. They had given us an ultrasound photo before the procedure, but I needed anything I could get.

4 October: the aftermath

I feel at peace. The worst part of any test, presentation, meeting, was always the stress before. And what stress did we have. Unnecessarily too.

It was chilly in that crisp fall way when we got outside. The Uber was about 10 minutes away, so we wandered through the wildflower garden by the parking circle. As Jason gave me a hug, a leaf fell on me. He kept it. Our last memento.

I will never not miss him. Every day of this pregnancy will be a reminder. As Baby A hopefully grows up healthy and happy, I'll always remember that he had once been part of a pair. If we have the third that we want, I will fear that pregnancy and think of Thomas all along the way. But maybe there will be a day that it's less painful.

Goodnight, sweet darling. Goodnight, Thomas Oberon Miller.

5 October

We are home. I am writing this finally back in my own bed, with two snoring dogs next to me and my son snoring in his crib down the hall.

6 October

With every additional day, I have such a strange mix of emotions.

I find myself wondering how I will feel when I feel those first bubbling sensations that will soon become kicks. Or when I'm nursing my baby. Will Thomas's absence become unbearable sometimes in those moments? That chest-crushing, breath-taking gasp of knowing how badly something is missing?

I have been thinking of my grandmother a lot the last few days. She lost three of her babies, each at such different times. I can't even fathom the absolute soul-crushing pain of carrying a baby all the way to birth only to lose it either immediately or within a few years. I don't know how she went on. How could you recover?

How is this something that the state of Texas tried to force me to do?

I couldn't have Thomas and know that I was waiting for the day to lose him.

24 October: first social media post

I finally made a public post. We had to say something. This past weekend, at a friend's wedding, it was horrible seeing people who didn't know congratulating us and making comments about twins. I can't keep doing that.

For the post, I shared the last ultrasound photo that we had of our boys alive together, with this note in a series of screenshots:

Ultrasound image

The response has been overwhelming. I hate how dehumanized this issue has become, but I am glad I can do something about it.

Every time I see or think anything about twins, I feel a pain in my gut (or is it heart?). Maybe one day it will stop happening. Maybe one day, I will see two little twins toddling around together and not feel pain at knowing what we've missed. Maybe there will be a day when I don't think about this. But I don't think that day will come for a long time.

26 October : first scan after procedure

Well, this has been a relief. Baby A is looking healthy.

It was hard to see Thomas in there. He's so little now in comparison to Baby A. The sonographer took a few measurements of him. When she took Baby A's heart rate, the screen lit up yellow and you could hear the machine. For Thomas, it stayed blue and silent.

I will explain that mercy can be heartbreaking. I will explain that the abortion for their brother was out of love

She stepped out of the room for a minute, claiming a coughing fit. She came back, took a few more measurements and images and I just squeezed Jason's hand in silence. Finally, she asked: "How much do you know about Baby B and the NIPT test?"

Moment of truth … Or something along those lines.

"We know about Trisomy 18 and the abnormalities and there was only one heartbeat at the last appointment. I see he doesn't have one now either. We were expecting this."

Technically, all true, but I was still scared.

It's like we all speak in code now.

25 October: one month since my abortion

In a few days, I will have made it a month since the hardest day of my life.

Someday, I will hold my boys and tell them that I love them and that for a few weeks, they had a little brother named Thomas. Thomas who never lived, but will be with us forever. I will explain that mercy can be heartbreaking. I will explain that the abortion for their brother was out of love.

June 2023: postscript

The rest of my pregnancy was marked by stress and fear. I worried for my remaining twin and about Texas's vigilante system, which allows members of the public to hunt out those they suspect of aiding abortion, and sue them in civil court.

Lauren and her husband welcomed Baby A, named Henry, into the world three weeks after filing a lawsuit against Texas. Photograph: Lauren Miller

Three weeks after filing the lawsuit against Texas, we welcomed Baby A, named Henry, into the world. He has been a delight and our toddler loves to pet the little tuft of hair on the top of his head while chanting "Baby".

Thomas's ashes sit in a glass cabinet in my office, a daily reminder of the other son we wanted and for whom we suffered more than necessary at the hands of the state of Texas. A state where my family has lived for generations. A state that held agency over my body and over my medical advice once I became pregnant.

I continue to document this journey with the hopes that someday, I will be able to look back at these restrictive healthcare laws and they will be a distant memory. Until then, I am proud to be standing among the other women in this case as we try to save other pregnant people from the trauma and harm that we have faced.

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