What Will Prenatal Care Look Like in the Future?

In today’s tough U.S. economy, healthcare is in the forefront because of the three trillion dollars spent each year. Patients are not seeing their money’s worth and neither is the U.S. government who writes the check for a large percentage of it. The cost of women having babies too early or prematurely costs our society $26 billion dollars each year. Something has to give.

Women’s health is the topic of great political debate as you may well be aware if you listen to the news or watched both political parties’ national conventions during the past two weeks. Do women control their destinies? Do we and will we continue to have control over our bodies? These are the questions at hand. While there’s great chatter about this topic as the U.S. election nears, there’s also a quiet revolution occurring in our healthcare system that will directly affect pregnant women.

Prenatal care as we know it will begin to change, especially if you receive Medicaid or government sponsored insurance. The current trend is to visit your healthcare provider’s office individually and wait to be seen. In the future, you will be seen by your healthcare provider as a member of a group, not as an individual. This is called enhanced prenatal care with group appointments and will be the wave of the future.

Groups of 10 pregnant women will be seen at the same time for approximately 10 prenatal visits that will last approximately 90 minutes. It is anticipated that 2 healthcare providers will not only take your vital signs, listen to your baby’s heartbeat, but will also allow you to interact with the other patients in this group setting to discuss prenatal issues, receive health education information and any concerns that you may have. Believe it or not, this model of care is not new.  The concept was called Centering Pregnancy and was developed by nurse midwife Sharon Shindler-Rising in 1989.

In the future, doulas and social workers along with midwives will become more prominent in terms of prenatal care as things continue to evolve. Are you ready for group prenatal visits?

Oh, No! Michelle Duggar is Pregnant Again

OMG, Michelle Duggar is pregnant again.  Is she competing with the wife of Feodor Vassilyev?  Vassilyev was pregnant 27 times between 1725 and 1765 and gave birth to 16 pairs of twins, 7 sets of triplets and four sets of quadruplets. 67 children survived infancy making her the woman who had the most documented number of children in the world. Vassilyev had a history of multiple births. What’s Duggar’s excuse?

I’ve written about Duggar before out of genuine concern and received over 2,000 comments on the Basil and Spice website.  Many were unkind.  People like Duggar because of her affable personality but want to ignore the facts: with each subsequent pregnancy, her life becomes fraught with danger.  Her last pregnancy was extremely high-risk, complicated by pre-eclampsia and the emergency premature delivery of her daughter who only weighed 1.3 pounds at birth. It was a very close call. According to Answers.com, the Duggar family gets paid an estimated $25,000 to $75,000 per episode on the reality television show on Channel TLC. So, is it perhaps the show’s ratings that have prompted this 45 year old mother of 19 children to have yet another child? Is it the Baby-Doll syndrome where women have multiple children because they like the baby doll effect of having a newborn? I’m still scratching my head. However, I would be remiss if I did not, as an obstetrician offer some advice (albeit unsolicited) regarding the dangers of extreme parity (aka a great number of pregnancies). It was the same advice I offered almost 2 years ago.

  1. Mrs. Duggar, you are 45 years old and have what’s known in obstetrics as Advanced Maternal Age. This condition predisposes you to several high-risk conditions including pre-eclampsia, preterm labor and a host of other issues.
  2. You’ve carried 19 children in your uterus and its muscles are stretched to the max. Post-partum hemorrhage lies high on the list as a future complication and is the most common cause of maternal death in the industrialized world.
  3. You’ve also had a cesarean section and now have the potential to have a placental abruption (early placenta separation from the uterus) as well as a placenta accreta (the placenta sticks to the uterine incision and is extremely difficult to remove).

The Bible says to go forth and multiply and you’ve followed directions well. Now pat yourself on the back and give your body a well deserved rest. You escaped serious harm because of Divine Intervention and a skilled medical staff. Please, do not push the envelope.

Why Itchiness During Pregnancy Should Not Be Ignored

If a pregnant woman finds herself scratching and itching during the third trimester, these symptoms should not be ignored. Each year, approximately 0.1 to 15% of pregnant women are affected by a liver disorder called Intrahepatic Cholestasis of Pregnancy or (ICP). ICP patients tend to develop symptoms of itchiness of their hands and feet that becomes progressively worse and then spreads all over their body. The itchiness usually worsens at night and if untreated can cause jaundice and several life-threatening complications to the unborn fetus. When a pregnant woman complaints of itchiness (pruritus) all over her body, the first order of business is to determine whether a rash is present. If a rash is absent, ICP should be suspected.

The liver is the largest gland in the body and in addition to filtering harmful substances such as alcohol it is also responsible for processing fats, carbohydrates and proteins. To process fat, the liver makes bile salts. In ICP, bile salts are increased which contributes to the symptoms of itchiness. Affected women will not only be plagued by pruritus but their unborn babies are at risk for stillbirth, preterm labor, fetal distress and abnormal heart rates. South American women and especially those from Chile have a greater risk of developing ICD as do women from South Asia and Sweden.However, North American born women in the U.S. have also been affected as well as women with Hepatitis C.  Female hormones such as estrogen and progesterone contribute to the development of ICP as does genetics. The diagnosis of ICP is made by specific laboratory tests. Once the diagnosis is confirmed, the patient should be referred to a maternal fetal medicine specialist for further management.  ICP is a high risk condition and the baby usually has to be delivered early because the mother cannot tolerate the intense itching. There is a special medicine that can be prescribed to reduce the elevated bile acids but it should be given under the supervision of a high risk physician.
A complaint of severe itching that develops during the third trimester should not be ignored or given Benadryl if the symptoms have lasted for more than 3 business days. At minimum, lab work should be ordered. Remember, a healthy baby doesn’t just happen. It takes a smart mother who knows what to do.

Watch TSMG video to educate yourself TODAY!

10 Rules of Engagement Every Pregnant Woman Needs to Know

I read an article in my local newspaper the other day that gave me reason to pause. The State of Florida intends to hand over 3 million Medicaid patients to managed care companies who will reduce payments to physicians and hospitals. In exchange for accepting these low payments for professional services, doctors are guaranteed through pending legislation that no matter what egregious errors they make, the patient will only receive a maximum of $250,000 in a medical malpractice lawsuit. This is definitely a “lose-lose” situation for patients.

Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that? Here are a few suggestions that are taken from The Smart Mothers Guide to a Better Pregnancy:

  1. Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending
  2. If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
  3. If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request  a referral to a high-risk specialist
  4. If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc.
  5. If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
  6. Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
  7. Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
  8. Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
  9. If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) http://www.jointcommission.org/
  10. Trust your instincts. I can’t emphasize this enough.

Prevention is the key to reducing medical injury, not taking away someone’s right to sue.

Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do. Check out the video below for my information and pick up a copy of The Smart Mother’s Guide

What is a Cerclage and Can it Help Pregnant Women with a Weak or Short Cervix? (Part 1)

Courtesy of A.D.A.M

Although the cervix is supposed to hold a pregnancy until term things sometime go wrong.  Women can lose an otherwise healthy baby because of a weak or short cervix. When cervical tissue becomes weak, this condition is known as Cervical Insufficiency (CI) and affects approximately 0.1 to 2% of all pregnancies. Women who have a history of painless bleeding in the second trimester or complain of pelvic pressure followed by the delivery of a fetus most likely have CI. Also, women who have had three or more pregnancy losses in the second trimester have CI as well. Patients with these types of histories have traditionally been treated with a procedure called a cerclage. Think of a cerclage as a stitch in the cervix that keeps it closed so that the baby can continue to grow.

There are many reasons why women develop CI and include women who have a short cervix, collagen disorders, uterine abnormalities and cervical lacerations.  Some women are born with a short cervix while others acquire it because of surgical procedures such as a cone biopsy, LEEP (loop electrosurgical excision procedure) or laser ablation. Voluntary pregnancy terminations can also shorten the cervix and increase the risk for a preterm birth. The collagen disorder such as Ehlers-Danlos syndrome can so as well.

Can cervical insufficiency be diagnosed before pregnancy? Unfortunately not, however, the use of a patient’s history, physical exam and ultrasound can help tremendously. Visualization of membranes seen during a speculum exam is extremely suspicious for CI and requires a cerclage if the patient is less than 24 weeks.  Any cervical length of less than 15 mm is diagnostic of CI and requires a cerclage.

The average length of the cervix at 20 and 22 weeks is 40 mm; at 32 weeks it’s 35 mm. A woman who has a cervical length of less than 25 mm will most likely get a cerclage if she has a history of a three previous second trimester miscarriages. A woman less than 23 weeks with a cervical length of less than 25 mm might be offered a cerclage or progesterone treatment.

Part 2 of this article will discuss what happens if a woman without symptoms of preterm labor is found to have a cervical length less than 25 mm and when and where should the cerclage be removed? What lifestyle changes should be made with a cerclage?

Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.

Why is Magnesium Sulfate a Super Hero for Pregnant Women?

A dear friend of mine has a quote that bears repeating: “in simplicity, there is genius.” Such can be said about the mineral compound, magnesium sulfate (commonly known as Epsom salt).

In the world of obstetrics, magnesium sulfate or “mag” sulfate ranks high as an invaluable tool that has helped both obstetricians and their patients for almost 50 years.  Magnesium sulfate is the first line of defense in a pregnant woman with pre-eclampsia, a condition that includes high blood pressure, swelling and protein in the urine.  Magnesium sulfate is given to reduce the possibility of having a stroke or bleeding in the brain, and it is also given to delay or reduce episodes of premature contractions. Untreated or unsuccessful treatment of premature contractions can lead to premature births which accounts for 12.6 percent of all U.S. births. The advances in technology have improved the survival rate of infants who weigh less than two pounds but have also created new challenges. Low birth weight infants have a five-time greater chance of developing cerebral palsy than babies who are born full-term.

Cerebral palsy is a condition that affects body movement and muscle coordination. It usually occurs when there has been damage to the brain that has occurred before, during or after birth. 35 percent of cerebral palsy cases are caused by preterm births but all is not lost. Recent medical studies have demonstrated that mothers of preemies weighing less than 3 pounds or born before 32 weeks were protected from developing cerebral palsy if they received magnesium sulfate. How amazing. Less is sometimes more. Back in April, I discussed how a cooling blanket can prevent brain damage to a full-term newborn with low APGAR scores and it now appears that magnesium sulfate can do the same for preemies.

As an obstetrician, I am grateful and humbled by these new developments. An “imperfect” beginning can still have a happy ending. Thank you, magnesium sulfate.

An Unbelievable Tale Of Revenge

Just when I think that I’ve seen and heard it all, I read yet another bizarre story that proves me wrong.  Last month CNN reported a story about a woman who had attempted to end her rival’s pregnancy Woman Tried to End Rival’s Pregnancy, Prosecutor Say in a most deceptive way.

Kisha Jones was arrested for allegedly tricking Monique Hunter, her husband’s pregnant lover into taking an abortion-inducing drug. Jones allegedly forged a physician’s prescription and prescribed a medication that would induce early labor. She told the pharmacist that the medicine was for “a procedure.” She then called Hunter and convinced her that her physician had prescribed an important medication and she should pick it up and take immediately.  Hunter complied.  Shortly thereafter, she was soon rushed to the hospital and delivered a premature baby boy two months early.

While Hunter’s baby was still in the intensive care unit, an unknown man brought what he claimed to be breast milk for the baby and it was later determined to be poison. The hospital staff called the police and Jones was arrested on a host of charges including criminal impersonation. The facts of this case suggest that either Jones was familiar with labor inducing medications or knew someone who was. The “abortion-inducing drug” referred to by CNN was probably Mifepristone.

Mifepristone is a medication that’s used for early first-trimester abortions and to induce labor with fetal demises. Since its inception back in the late ‘80’s, I have disagreed with it being prescribed as an outpatient medication. Any medicine that causes bleeding and the evacuation of the uterus should be done in a controlled environment under the supervision of medical staff to avoid complications.  Unfortunately, the FDA has reported several deaths of women who had taken this medication at home.

While this story has all of the makings of daytime drama, the bigger tragedy is that an innocent newborn was almost killed. I think the FDA should reexamine its policy regarding Mifepristone. People like Kisha Jones should never be allowed to strike again.