December 12, 2011
Sometimes Fate has to shout in order to be heard, especially when the voice of reason is ignored. Michelle Duggar was pregnant with her 20th child to the aghast of many including this author. We squirmed in our seats. We moaned. We groaned. We blogged. The combination of Duggar’s 19 children and her advanced maternal age of 45 is enough to make any obstetrician or midwife cry, especially when she becomes pregnant, yet again. Not surprisingly, Duggar experienced a miscarriage with pregnancy number 20. According to media reports, when the Duggars presented for their ultrasound, a fetal heart beat could not be obtained. What occurred in obstetrical vernacular was a missed abortion or an early fetal demise. Based on the Duggars’ press release, his wife probably had no symptoms prior to receiving the ultrasound. The cramping, spotting, abdominal and back pain was probably absent. An early fetal demise without symptoms or missed abortion means the baby stopped growing because there was a condition present that was incompatible with life. Did Duggar’s age increase her chances of having a miscarriage? Absolutely. 93.4% of woman who are over 45 will have a miscarriage. Or put another way, only 6% of pregnant women over age 45 will deliver a baby. 7% of all women Duggar’s age will have an ectopic (tubal) pregnancy and 8.2% will have a stillbirth. One out of 19 pregnant women who are age 45 will have a baby with Trisomy 21 or Down’s syndrome. So should we be surprised that Duggar had a miscarriage? No. And no one is gloating over her misfortune. A miscarriage for any family, even those with 19 children is lamentable. However, most pregnant women who have experienced a miscarriage will attempt to conceive again. In the case of Duggar, this would be a profound tragedy. Mrs. Duggar, you have our condolences regarding your miscarriage. Millions of people enjoy coming into your home each week and think you are delightful. However it is out of our profound concern for your well-being that prompts us to implore you. Please don’t push the envelope any further. Please give your uterus a well-deserved rest.
September 14, 2011
Every year there are approximately 4 million babies born in the U.S. and most will arrive in a hospital or a Birth Center. However, there are moments when this may not be the case. In the past 4 years the number of home births has increased by 20% and these births will hopefully be attended by a midwife or someone skilled in childbirth. But then, there are those unexpected births that no one was prepared for; the ones that occur at the most inopportune time and place, even on an airplane in flight. These are the ones that the mother never “saw” coming, although she might have experienced warning signs but didn’t take heed.
Most unexpected deliveries occur because of prematurity. What are the signs that a pregnant woman should not ignore?
- Low back pain that lasts for greater than an hour. This is typically how premature labor begins.
- Abdominal pressure that lasts for greater than an hour
- Leaking fluid from the vagina
- A sudden urge to have a bowel movement
Any of these signs requires an immediate trip to the labor and delivery suite as soon as possible.
If you are bleeding (especially passing clots), get off your feet and attempt to lie down on your left side while someone prepares to take you to the hospital. If the blood is bright red, this is a medical emergency because the placenta might be separating and the baby might be depleted of oxygen.
If your membranes rupture (water “breaks”) and there is a rope-like structure hanging from your vagina, it could be the baby’s umbilical cord. Call 911 immediately and do not allow the cord to be squeezed or manipulated. Lie down, preferably with your feet lifted on pillows with the cord undisturbed. This is ca cord prolapsed which means the baby’s in a breech position (feet first) and is an obstetrical emergency.
If you have a strong urge to have a bowel movement at home that is associated with contractions or abdominal pain, be aware that this could represent an impending delivery. Sit on a bed or floor with your knees separated to see if someone can visualize the head of the baby. If so, call 911 for guidance and further instructions. If the baby should be born unexpectedly, gently rub its back to stimulate crying and keep it warm in a blanket until the emergency technicians arrive.
Although you assume that your delivery will be “normal,” it never hurts to be prepared for the unexpected. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
April 20, 2011
The Federal Drug Administration (FDA) recently issued a new warning about a medication that has been used for years and it has sent shock waves throughout my specialty. Terbutaline is an FDA approved medication that is used for asthmatic patients or patients who have significant narrowing of the airways. However for years it has been used as an “off-label” medication to treat preterm labor but now that’s about to change. An off-label drug means it hasn’t been approved for that specific use by the FDA.
According to the FDA, the injectable form of Terbutaline should only be used for a maximum of 24 to 72 hours because the drugs association with heart problems and death. The FDA goes on to say that the oral version (pills) should not be prescribed to treat preterm labor because it’s ineffective and can cause similar problems. As an obstetrician, I feel utterly betrayed. The medication clearly had side effects that included shortness of breath and a racing heart. As resident physicians we were taught that the benefit outweighed the risks of having a premature baby and the patients should try to adjust to the medication.
We now learn that there have been 16 maternal deaths from 1976 until 2009 that have been associated from the use of Terbutaline. In 1997 the FDA issued a warning about its prolonged use but the prescribing patterns by physicians did not appear to change. There have also been 12 reported cases of mothers with serious heart conditions that were also associated with the use of Terbutaline; hence, the need for a repeat warning.
There are maternal fetal medicine specialists that think Terbutaline should not be abandoned completely and cite clinical conditions such as an over stimulated uterus, the need for a relaxed uterus and transporting a patient from one institution to another while in preterm labor as a reason for the short-term use of Terbutaline.
In view of the FDA warnings, it is important for all pregnant women to be aware of the medications they are receiving, especially if they develop preterm contractions. Terbutaline should only be given in a hospital for a maximum of three days and never taken at home.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
December 13, 2010
A recent medical study reported a fairly unique finding: pregnant women who snore frequently are at an increased risk for developing gestational diabetes. The Associated Professional Sleep Societies (TAPSS) reported that 24 percent of habitual snorers had an official diagnosis of gestational diabetes as opposed to 17 percent of nonsnorers. As gestational diabetes affects 4 to 6 percent of all pregnant women, this study is significant according to Louise O’Brien, Ph.D who is associated with the department of neurology at the University of Michigan, Ann Arbor.
Snoring is nothing new among women but it becomes more pronounced with the onset of menopause or weight gain. Approximately one-third of all women in the U.S. are obese according to USA Today and are at risk for snoring and sleep apnea. Being overweight can cause bulky throat tissue which then physically blocks air flow. Up until the publication of the University of Michigan study, the health risks associated with snoring included: greater than 10 seconds of interruptions of breathing; frequent waking from sleep; potential strain on the heart which then results in hypertension, increased risk of heart attacks and stroke. Now the tide has changed.
A study involving 1,221 pregnant women were questioned as to whether they snored three or more times a week and nearly 31 percent of women were habitual snorers in their third trimester. The snorers had formal diabetic screening tests that confirmed the diagnosis of gestational diabetes. So, what does this mean clinically? Ideally, pregnant women who are snorers should receive patient education literature that discusses the importance of the one-hour glucose screening. Obese pregnant women who snore three or more times per week should be tested sooner rather than later for gestational diabetes. A confirmed test of gestational diabetes should prompt a visit to the high-risk maternal-fetal specialist at the patient’s earliest convenience.
As medicine continues to advance so does the opportunity for greater patient awareness and education. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 24, 2010
Pregnancy is certainly not the optimum time to have a surgical procedure however there are certain conditions when it is necessary. The most compelling reasons to have surgery while pregnant include acute appendicitis, gallstones that block the bile duct, torsion or twisting of an ovarian tumor and trauma to the abdomen that results in damage of an internal organ, bleeding or the threat of harm to the unborn fetus.
Appendicitis is sometimes difficult to diagnose during pregnancy however the location of pain is helpful regarding making the diagnosis. Patients with appendicitis sometimes have fever and abnormal lab results but this is not always the case. Although the appendix is usually on the lower right side of the abdomen during pregnancy is shifts towards the middle. Therefore, when attempting to make the diagnosis, a physician will examine the patient lying down and also tilted to her left side. If the pain shifts to the left side, the pain is probably from the uterus and not the appendix.
The safest time for a pregnant woman to have surgery is during the second trimester. An epidural or spinal anesthesia is safer than general anesthesia for many reasons. It is more difficult to place a breathing tube down a pregnant woman’s throat because hormone’s make the throat smaller. The patient also has an increased risk of aspirating or having food or liquid in her windpipe as opposed to her stomach.
There should always be an obstetrician and pediatrician consultant on hand prior to and during the surgical procedure, especially if the patient is in her third trimester. According to the latest medical literature, there are no anesthetic medications that cause birth defects to the unborn fetus, provided the surgery is not done during the first trimester. The heart tone of the fetus should always be monitored during surgery. Because a pregnant woman has an increased risk of developing blood clots, it is strongly advisable to wear “compression” stockings during a procedures. These stockings are available in the hospital and compress or squeeze the blood vessels in the legs to promote better circulation.
Following these suggestions will greatly improve your chances of having a surgical procedure that will not adversely affect your pregnancy. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 4, 2009
Just when I think I’ve heard and seen it all, something pops up that proves me wrong. Both Amy Gates” article, Home birth advocate’s baby dies during free birth: Do you blame or show compassion? And Cate Nelson’s Unassisted childbirth one woman’s story, gave me reason to pause. Both journalists discuss the March 27th death of Janet Fraser’s infant daughter and the controversy regarding unassisted childbirth.
Fraser is an Australian advocate of the unassisted childbirth movement that encourages pregnant women to deliver babies alone without the benefit of a midwife, a doctor, or a hospital. She used phrases such as “birth rape” to describe a delivery assisted by a healthcare provider. Please. As a descendent of a slave midwife and an obstetrician I am highly offended. Birthing is in my genes. There is nothing more satisfying than assisting in the delivery of a healthy and crying baby be it by midwife or physician. Heck, even a cow gets a c/section when necessary.
Cate’s article described a woman who had an “orgasmic” unassisted delivery during the birth of her daughter and then made frozen smoothies out of the placenta that she ate for the next thirty days. A placenta smoothie?
A reality check is in order. Forty percent of women died in childbirth during the 19th century but less than one percent, or 520 women today; and even those deaths are preventable. Do we really want to proceed in reverse? Perhaps members of the “unassisted” crowd would like to trade places with women in Sierra Leone and Afghanistan, who have the world’s highest number of childbirth deaths.
We need our babies born healthy and alive. All of them, without exception. The adverse outcome of the Fraser’s “unassisted” delivery speaks for itself. Here’s hoping she’ll never experience it again.
March 11, 2009
The MSNBC article “Autopsies Urged to Unravel Tragedy of Stillbirth” (Associated Press, March 2, 2009) struck a painful chord. The worst experience any obstetrician wants to go through is admitting a pregnant woman into the hospital to deliver a dead baby. Stillborn deliveries are the ultimate dread in obstetrics and they affect twenty-six thousand women in our country each year.
While the article focuses on autopsies of stillborn babies as a means of diagnosis, we also need to seek a means of prevention. Although one-third of stillbirths occur for unknown reasons, a heightened sense of awareness of fetal movement is priceless. Live babies move. The most important question that I ask every patient during each prenatal visit is, do you feel your baby move? After twenty-three weeks, a patient should feel her baby move at least ten times within a four-hour period and once every ninety minutes during the third trimester. If the baby does not move within these periods, than the provider should be contacted immediately. If a provider is not available, the patient should go to the hospital as fast as she can. Fetal movement is extremely critical, yet as obstetricians, we don’t emphasize this point enough.
Watch, watch, watch is the key to a successful pregnancy, and there are tools that can assist along the way. A kick chart is a tool that helps monitor a baby’s movement and can usually be obtained from a healthcare provider’s office. This chart helps patients focus on baby’s movements. Pregnant women also need to be aware of tests such as non-stress tests and biophysical profiles that monitor the baby’s heartbeat, movements and breathing on an ultrasound for approximately thirty minutes.
Fetal movement is always a beautiful thing and reassures you that your baby is alive.