prenatal care

Medical Monday: Breaking News from the World of Obstetrics and Gynecology 

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There is some sobering news in this week's collection. 

Findings from Sweden published in the Lancet indicate that babies from women who gained a large amount of weight in pregnancy are at increased risk of stillbirth and infant death compared to others. This work is an impetus to study the issue in more depth, since there is no clear indication of why this is it the case. 

A study presented at the World Diabetic Congress has shown that about 10 % of teens with type 2 diabetes in the study got pregnant over at 6.5 year period. Any women with diabetes in pregnancy are at high risk for complications. Pregnant teens with diabetes are at especially high risk. It was noted that these pregnancies frequently have poor outcomes. 

A study published in the Journal of Clinical Electrophysiology has indicated that women who were overweight at age 18 have a greater risk of sudden cardiac death. This persists irrespective of later weight loss. Those with a body mass index (BMI) in the high 20s have a 33% greater risk.. Those with  BMI over 35 quadruple their risk. 

New research indicated that 62% of all Ob/Gyns are now women ! That even counts the old ones : )  

Speaking of doctors, new research published in JAMA, the Journal of the American Medical Association indicates that about 29 % of all medical residents have depressive symptoms or depression during their training. The general population comes innate about 6.7 %. Of course this is all about long stressful work, sleep deprivation but also about hierarchical structures and bullying. In my opinion, a lot would have to change for this to be different. 

Omigosh this post is so dismal it is sounding like a parody but I kid you not, researchers from Oxford, namely statisticians and medical epidemiologists, have now asserted that happiness has no direct effect on mortality. They say the idea that unhappiness causes illness is a really a case of illness causing unhappiness. 

Data crunching at the CDC has concluded for 2010 and from 1976 until 2010 pregnancy and abortion rates have fallen to record lows. 

Dame Sally Davies (Yes, ladies she is a Knight of the British Empire ), the Chief Medical Officer in England, has declared obesity the greatest threat to women’s health and to that of future generations. She has declared it a national priority. 

Finally, in a bit of progress, the FDA has updated the required pregnancy and breastfeeding labelling for prescription medications. 

Maybe the world's researchers wanted to get all the bad news out of the way before the holidays. I can't wait for next week. Stay tuned. You can't make this stuff up. 

 

 

 

 

 

Medical Monday: Breaking News from the World of Obstetrics and Gynecology 

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California and Oregon will soon allow pharmacists to screen patients and prescribed birth control pills. While the American College of Obstetricians and Gynecologists considers this a step in right direction, they believe they should be available over-the-counter, plain and simple. While it is true that low dose combination birth control pills can have medical complications in a very small percent of people, by and large their health benefits far outweigh their risks.

As most of you probably are already aware, hepatitis C has a new medical treatment which provides a cure in a very high percentage of people. However, hepatitis B has remained a challenge, and in particular, we have had to deal with the problem of vertical passage of the virus from mother to baby during pregnancy, labor and delivery. However recently at the meetings of the American Association for the Study of Liver Diseases, new research was presented. In the course of a randomized controlled trial, a drug called Tenofovir was shown to be able to reduce vertical transmission. 

Beautiful happy mother breastfeeding outdoor.jpg

Yet another encouraging recommendation about exercise in pregnancy has been released. According to the American College of Obstetricians and Gynecologists, nearly half of US women gain too much weight while they're pregnant. We all know that women who gain too much weight in pregnancy are very uncomfortable. However they also have higher rates of miscarriage, premature birth, stillbirth, and babies with birth defects. They’re also more likely to have heart problems, sleep apnea, gestational or pregnancy associated diabetes, preeclampsia also known as toxemia, and abnormal blood clots. They are at higher risk for cesarean section. So there are ample reasons to find ways to control this weight gain. 

The new memo released by ACOG advises pregnant women to exercise regularly and more often than they currently do. The memo states that while walking is the best exercise, jogging, Pilates, yoga, cycling, swimming, and other forms of exercise are perfectly acceptable. ACOG cautions against contact sports such as skiing, and other specialized sports such as scuba diving.

More good news: it appears that breast-feeding for two months or more reduces a gestational diabetic’s risk of developing type II diabetes later in life by 50 %. Moreover, the risk of diabetes lessens as the patients breast-fed longer.

Finally, here is some good news that initially sounds a lot like bad news. Since 2010, there has been a significant increase in the number of women under age 26 who have received a diagnosis of early-stage cervical cancer. In the next age group, 26-34, the numbers were unchanged. What changed for the younger age group? The answer is the availability of insurance. One of the features of the ACA, The affordable care act, was to allow children to stay on their parents insurance plans through the age of 26. Most likely the increase in diagnoses came from increased compliance with recommended screening, i.e. pap smears. Once again, we are reminded that appropriate screening leads to early diagnosis, which leads to less invasive treatments, fewer complications, and higher rates of cure. 

Stay tuned for more breaking news from the world of OB/GYN next week on Medical Monday.



Medical Monday: Breaking News from the World of Obstetrics, Gynecology and Women’s Health 

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Happy Monday ! This week, in addition to reading the news and doing your normal workweek, you get to start seriously preparing for the holidays.  Enjoy the process !

Postpartum depression is in the news again, and this is a good thing. “ Shots” blog by NPR ( National Public Radio ) has run a story about a woman, Paige Bellenbaum,  who went through this. She has since recovered and has become an activist on the subject, and helped to write a bill in New York “ aimed at educating more families on the symptoms of maternal depression.” The bill also promotes screening through the Pediatrician's office. Early treatment for postpartum depression is, of course, more effective. 

Research findings presented at the NCI ( National Cancer Institute’s) annual conference underscored that increasing parity ( the more children you have ) reduces risk of ovarian cancer. The first child reduces the change of this cancer10% and each subsequent birth reduces it 8% more. While no one would decide the number of children they wanted based on this, it is interesting and may spur further research about how ovarian cancer comes into being the first place. Hopefully this will ultimately yield clues on how to prevent and treat this awful disease. 

New research published in the Journal of Diabetes Care indicates that women with central obesity (higher levels of abdominal fat) are more likely to develop pregnancy associated diabetes here. Of course it is also known that women who get gestational ( pregnancy associated diabetes) are more likely to get Type 2 Diabetes later in life. Moral of the story: Get in good shape and at your correct weight before pregnancy and in-between each delivery. 

Also hot on the trail of gestational diabetes (GDM), s study presented at the Conference of the Society for Endocrinology indicates that women who are sedentary in the first trimester are more likely to get GDM. They defined sedentary as sitting more than 6.5 hours per day. Has anyone ever tried a standing desk ? Personally I think the best thing at work is to alternate siting and walking about at frequent intervals. Also naps, mid afternoon. Wouldn’t that be cool ? 

The CDC ( Center for Disease Control) reports that half of pregnant women are gaining too much weight in their pregnancy. IOM ( Institute of Medicine ) recommendations indicate women with a normal BMI ( body mass index) gain about 18.5 an 24.9pounds. Smaller women should gain more and larger women should gain less. 

Wow this week's news sure had some common themes. 

To help you stay in the know very quickly, don’t miss Medical Monday.

Medical Monday: ACOG weekly news

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Today I'm going to do Medical Monday like a good old fashioned news cast. I am going to take the weekly news items of most importance to the American College of Obstetricians and Gynecologists and summarize them for you. What's  important to ACOG is important to us. Let me know if you like this format. 

 

( newscaster voice here... ) 

Medicare, which is for those over 65 or who are officially disabled, "will now pay for women to get a joint Pap smear and Human papilloma virus test every 5 years to screen for cervical cancer. " Never mind that ACOG and The American Society for Colposcopy and Cervical Pathology (ASCCP) state they should be done this way every 3 years. 

A Yale study found that the cost of a delivery varies from $1200 to $12,000 depending on the hospital. Unpacking this revealed that birth was costlier at poorer facilites that served higher percentages of Medicaid moms. They also found higher complication rates in those same higher cost hospitals. CBS news reported on this, and opined that this contradicts the notion that more spending leads to better outcomes. Never mind that poorer patients have been less well served in their lives, are unhealthier and have higher risk pregnancies on average. Maybe the complications come before the high cost but what do I know. 

The European Journal of Preventive Cardiology published the obvious in saying that women who smoked and had preterm deliveries went on to have higher risk of heart disease. Had they not yet heard that smoking is associated independently with both preterm birth and with heart disease ? 

Of importance, the FDA nows states that use of NSAIDS like ibuprofen and Aleve are associated with increased risks of heart attack and stroke. Discuss this with your doctor and buy stock in Tylenol's parent company. 

The Salt Lake Tribune, right in the heart of the conservative Mormon heartland, featured an editorial, which among other things, advised that the best way to reduce abortions was to provide contraceptive choice ! Well done Salt Lake. 

Stay tuned until next week. 


Wellness Wednesday: Bathing

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Did you know the in the Middle Ages, bathing was considered unhealthy? Indeed, they were not called the Dark Ages for nothing. 

Bathing has had a long history, dating back to ancient India, where it was done more than once per day for ritual reasons.  Elsewhere in the ancient world, Greece developed the ritual of bathing into a way of life, where it was integrated with the tradition of athletics and the life of the the gymnasium. Roman baths are famous as a social institution, where gossip and politics took place amidst the steam and the towels. Later as Christianity took hold, public baths went out of favor as being immoral, since they were associated with debauchery and hedonism. Bathing itself fell out of favor during the time of the plagues, as Medieval physicians felt it opened the pores and let in disease. Farther north, the Nordic people maintained a tradition of saunas, and unlike the other public bathing environments around the world, theirs bore no association with immorality or disease. 

During these dark times others kept the practice of bathing alive. European explorers marveled at the cleanliness of the Mesoamerican people. Across the sea, Japan had a rich bathing culture, using rock pools, furnace baths, and heated rocks with seawater to make steam. In later years the Japanese would refine the art of the public and the private bath, requiring separate cleansing beforehand, then a clean soak to establish tranquility before family dinner time. 

Today we use baths for cleanliness, relaxation and therapy. It is a simple intervention with pleasant results. With only a few precautions, baths are a great strategy. The precautions are these: 

Pregnant women in the first trimester should not take hot baths. This is because there is an association between elevation of core body temperature with failure of the neural tube to close, and conditions like spina bifida. 

No bath should be very hot, since this increases risk of heart attack and fainting in the susceptible. Very hot baths also dry the skin and can precipitate headaches. 

Bathing in warm plain water is best. However a tiny bit of scented essential oil or salt may be used. Bubble baths are hard on our tissues as is the use of soap, which should be restricted to the shower only for truly dirty or greasy skin, and never the perineum. The face should be cleansed twice a day with cleanser, not soap, and should be moisturized before fully dry. 

Enjoy bathing as a stress reliever. As Sylvia Path once said, 

"There must be quite a few things that a hot bath won't cure, but I don't know many of them."

 

References: 

http://www.history.org/foundation/journal/autumn00/bathe.cfm

http://www.brainyquote.com/quotes/quotes/s/sylviaplat107968.html

https://www.aad.org/dermatology-a-to-z/for-kids/about-skin/taking-care-of-your-skin/washing

 

Medical Monday: Are there really any low risk pregnancies ?

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In today's post I report on some recently presented work which questions the validity of classifying pregnant women into either low risk or high risk groups. 

These categories have been important to women and their caregivers since they have used the information to determine the most appropriate site for delivery, from freestanding birth center, to community hospital to university medical center. 

But while Obstetricians have gone along with the use of the category " low risk", we know from anecdotal experience that ANY patient can unexpectedly have complications with out any warning or risk factors. A cross sectional investigation published in the American Journal of Obstetrics and Gynecology, February 7th, 2015, has shown us in precise numerical terms just how often this happens. 

Please note that in this study, those with no prenatal risk factors were classified as low risk. Those with one or more risk factors were classified as high risk. 

Here are their results: 

Of 10,458,616 pregnancies analyzed, 38% were identified as low risk, and 62 % as high risk. 

It turns out that 29% of those classified as low risk had unexpected complications. 

It is not surprising that high risk pregnancies had complications. It turns out that 57% percent of them did. However, 29%, almost a third of the low risk patients had complications. For certain outcomes, like use of vacuum, forceps, meconium and infection, so called low risk pregnancies had a higher incidence than those in the high risk group. 

If you look at all pregnancies and add the 62% who are high risk to begin with and the 29 % of the remaining low risk 38% group who ended up having complications despite their low risk designation, it adds up to 73% of the total group. 

So, according to this large study, 73% of all pregnant women can either be classified as high risk from the get go, or are low risk and going to have a complication. This 73% of all pregnant women are those that belong in the care of Obstetricians or Certified Nurse Midwives working in the hospital under the care of Obstetricians.

Here's the problem. While we can select out those in the high risk group for higher level hospital care, it is not so easy with those classified as low risk. When we consider the low risk group, who are over the third of the whole group, we know about a third of them will have complications. WE JUST DONT KNOW WHICH WOMEN THEY WILL BE. That is the problem. That is why, in my mind, all women deserve access to a high level of care in a congenial but fully equipped setting...the hospital. 

It is imperative that birth be congenial but even more critical that it be safe... 100% of the time. To achieve both does not require taking birth out of the hospital realm, instead it means transforming the hospital birth environment to be all that it needs to be.. comfortable, accommodating, beautiful, as well as fully equipped for any medical or surgical contingency. 

Here is the link to this current research: 

http://www.ajog.org/article/S0002-9378(15)00268-9/fulltext

 

 

Wellness Wednesday: Common Illnesses in Pregnancy

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I was inspired to write this post in light of the significant spring cold season we are now finishing. It is common knowledge on the medical hill that this spring's common cold was a bad one.  For most people, the cough lasted several weeks, even though the illness itself was over. It was not pertussis, it was not flu. It was just a garden variety virus that hit hard. 

 

So I am going to take a moment and talk about prevention. Prevention takes three forms: 

1. Vaccinate for what you can: Pertussis, and Influenza

2. Hand washing and avoiding the sick. 

3. Keeping up on self care with exercise, sleep and nutrition. 

They really are immensely effective. 

Outside of pregnancy, when we get a cold or stomach flu, we doctor it ourselves. But in pregnancy it is different. In pregnancy, it is a good idea to touch base with your doctor about your symptoms if they are anything more than slight. She can give you a few guidelines and recommendations, even if no antibiotics are prescribed. On that note, just as a reminder, most of these common infections are viral, and as such, do not respond to antibiotics. That said, some viral infections can be followed by a bacterial infection. This may be the case if one gets better, and then worse again. Additionally, some viral upper respiratory infections can set off asthma and we can help with this too. 

I set up a page for common illnesses in pregnancy HERE and I couldn't help but notice that in all cases, treatment included, lots of liquids, like tea, soup, and water. Self care included tylenol, since ibuprofen is not recommended in pregnancy, rest and lots of baths and steamy showers.

Perhaps we shouldn't wait for an illness to take good care of ourselves. 

Structure Sunday: The Structure of Mothers

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In my practice, we do gynecology, surgery, prenatal care and deliver babies.  However, sometimes I think we are helping to make mothers. Usually we spend 30 weeks with a woman and then go through some very intense and uplifting experiences with her. Along the way, we learn all about their background. We help them face challenges that arise. We try to address whatever needs addressing from eating habits to referrals for domestic violence. We try to uplift, we try to empower. We try to help them become good mothers. 

At the beginning, I tend to notice the things I need to address, the problems.  But as the weeks pass, I notice the things that are unique and special about each patient. Somehow, the problems and the virtues are all wound together. These complex dynamic women most always do their best, learn a great deal, and are sent home with a newborn, who will respond to everything they are, and the new world they inhabit.

These worlds are seldom perfect. I think back to my mother, the last of 8 children, born in 1917 in Oklahoma to a poor coal miner's family. Her father, once a foreman, had saved his team of men after an explosion deep in the mine. He suffered severe burns and disfigurement. Thereafter, the family descended into poverty. When she was 14, she was married off to an alcoholic older man. I later learned she endured extensive abuse. 

When I was adopted, she was already 45 and remarried to my dad. She was not easy to be with. Even as a young teen, I knew she was not like my friends' mothers. It was only as a young doctor that I began to understand what she had gone through, and the effect it had on her. Without a doubt, she had PTSD. She was angry, insecure and sold herself short. I could go on. I was angry and disappointed at her for not trying harder in life. 

As my medical career developed, I saw more women like her. As my role as their doctor taught me compassion, I developed a compassion for her. But of course, this was near the time she passed in 1990. At the time I lived with her, dealing with her difficult behaviors made it hard to experience the good things about her. Of course there were good things. I can see them better now.

I can remember the joy she had shopping for nice clothes for me, something she never had when she was a girl. I can remember how she liked high heels and going out to dinner. She made excellent pie crust. She admired Jackie O. She loved the sound of black women singing. She loved Christmas, and carols, and gave lots of gifts. She told me my education would make it so I would never have to rely on any man. 

After she escaped her first husband and before she married my dad, she worked in a factory assembling bombers. She was a real Rosie the Riveter. After that, she became a bookkeeper at a firm in Los Angeles. She looked ten years younger than her age, even though she picked up smoking as a young women in order to look elegant and independent. She quit smoking cold turkey on post op day one after her quadruple bypass, but died of heart disease anyway eight short years later. 

I am looking back through time so you can too. I am also looking back so perhaps you will look at the present differently. Your mother may not be perfect. But it is still incumbent upon you to see the good with the bad, to see her as a whole person with understanding, compassion, and appreciation.

I also write to remind us that there is a good mother inside all of us. She just may need a little help coming out. 

Wellness Wednesday: The Postpartum Period

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So much attention goes into preparing for labor and delivery. I'd like to take a minute and focus on the next important period: the postpartum period. With forethought, preparation and help, the postpartum period can be made enjoyable and smooth. 

First you needs to know what to expect in the postpartum period. Next, you needs to know how to prepare for it. Finally you need to know when to reach out about concerns and questions. 

Learn more HERE.  

Wellness Wednesday: Induction of Labor

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Induction of labor is a hot topic. Some patients are dead set on avoiding it and some are begging for it. Induction of labor simply means using medicinal or mechanical means to start labor before it has on its own.

Inductions may be elective (by choice) or medically indicated. They may be accomplished by a variety of medicines and techniques. Induction of labor is an important tool in the Obstetric tool box.

Get a balanced perspective on induction of labor HERE. 

 

Structure Sunday : Abnormalities of Amniotic Fluid

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Consider the standard prenatal visit. Sometimes I think it doesn't seem like we do much. We obtain weight and vital signs, dip urine, and measure the belly in a decidedly 19th century way, with a tape measure. But we learn more than you might imagine. We can get a sense of whether the baby's interval growth is tracking, and whether or not there is a lag or an acceleration. Any concerns raised at this simple low-tech appointment can lead to further more intensive, high tech studies, such as ultrasound. At ultrasound we can not only see the various measurements of the baby but we can also see features of the placenta albeit more subtly.  Finally, we can see the amniotic fluid. The amniotic fluid reveals a great deal about the pregnancy. Most of the time we check amniotic fluid, it is in the normal range. However, it is not uncommon to find abnormal levels of amniotic fluid, either high or low. High amniotic fluid is called polyhydramnios, whereas, low amniotic fluid is called oligohydramnios. Amniotic fluid is an early indicator of the well-being of the pregnancy and the baby. You might say it is our canary in the coal mine. Learn more HERE.