When You See Red, Don’t Panic: First Trimester Bleeding

     There is nothing more disconcerting than looking down and seeing red. Whether it’s dark or bright, light or heavy, it can make you hold your breath and start praying. Blood is viewed as the harbinger of very bad things to come. (For all of you Game of Thrones fans, it’s like winter is coming!) But the reality is that blood, be it red or brown, with or without cramping, does not mean this pregnancy is case closed. It could mean absolutely nothing at all.

     And while we get that this is hard to believe and even harder not to panic over, bleeding in early pregnancy is incredibly common. In fact, it is the most common call an OB/GYN gets. It occurs in up to 40% of all pregnancies! It is so common that we can recite the list of dos and don’ts, shoulds and shouldn’ts, whys and why nots in our sleep (which is good, because these calls usually come in the middle of the night!).

     First things first, bleeding in pregnancy is not always pregnancy related. Pregnant women still have intestines, vaginas, and cervices that will bleed irrespective of that baby on board. So while the first finger everyone points is towards your belly, we need to make sure that the uterus is really where things are coming from. Things like cervical polyps, cervical irritation, vaginal tears, and vaginal warts can cause vaginal bleeding. While they are not harmful for you or your pregnancy, identifying them early can ease anxiety and allow us to treat them. In very rare cases, such bleeding can be indicative of a cervical or vaginal cancer, so a good look inside by your OB is important.

     On a slightly different note, the rectum can bleed for a number of reasons during pregnancy. Pregnancy is marked by constipation, pressure, and changes in our bathroom habits. This can exacerbate or lead to things like hemorrhoids, anal fissures, and polyps (not fun). And not only can they cause pain, itching, and discomfort, but they can also bleed. Rectal blood is often mistaken for vaginal blood. While no blood is good blood, rectal bleeding has nothing to do with the health of the pregnancy.

     The big three of early bleeding in pregnancy are the following—miscarriage, ectopic, implantation or physiologic bleeding (a.k.a. nothing to worry about). How we differentiate between the three usually requires both a good chat and a good check. During the chat part, we will ask you questions about timing, quantity, pain, and the events that preceded the bleeding (intercourse, activity, etc.). We will also want to know when your last period was, if you took fertility medications, and if you have recently seen an OB. This will allow us to narrow down the culprit. The “check” part will include both a pelvic exam (who doesn’t love that speculum?) as well as an ultrasound and blood work.

What we are looking for are things like:

  • Is the cervix open?
  • Can we see a pregnancy in the uterus?
  • Is there blood surrounding the pregnancy (subchorionic hematoma) or in the pelvis?
  • Is your pregnancy hormone appropriately elevated?
  • What is your blood type?

These checkpoints, combined with a good chat, will clear the way for a diagnosis (and hopefully a cease fire to this bleeding).

     Sometimes the reason behind bleeding in pregnancy isn’t so clear. And while we certainly don’t want to torture you, it can take a few visits and even a couple of weeks to answer the questions where it is coming from and if this pregnancy is going to be a go. Oftentimes, we need to take a second or third look with the ultrasound and at the pregnancy hormone before we can comfortably call it. During this time, we may ask you to take it easy (no exercise, no intercourse), stay close to home (no major travel), and keep us on speed dial. We want to know what’s going on, as this may get us to make the diagnosis quicker.

     Bleeding in pregnancy not only brings women anxiety but also guilt and blame (almost all of which we point towards ourselves). However, whether bleeding happens for no identifiable reason or because of a miscarriage, in neither case is it a result of something you did, something you ate, or something you didn’t do. Bottom line, it is not your fault. Say that in your head ten times over until you truly believe it. Unfortunately, sh–t happens. And while that may not be eloquent, it is the truth.

     Although you probably found us through a Google search, an Instagram post, or a Tweet, the Internet can be a dangerous place (particularly in the middle of the night when it comes to bleeding and pregnancy). And while we too have our “Google MDs” (in everything non-OB/GYN related) and like to browse and self-diagnose, we caution you from putting a lot of stock into what you read and what you see. It may do nothing more than make you crazy and keep you from getting a good night’s sleep (which every expecting mother needs)!
     To put it bluntly, we have seen women soak their beds with bright-red blood who go on to deliver healthy babies and those who notice one spot of dark-brown blood who go on to miscarry. Nothing is predictive. So doctor’s orders (after you read this): close your computer. Pull out a good book, or put on a funny movie. Getting your mind off of what’s going on below is the best way to pass the time. Laughter certainly won’t make matters worse. Let your doctor focus on the detective work.

Ten Tips for First-Time Moms: What to Do in That Last Month!

Take everything we say in this post with a grain of salt. Most of it has minimal medical basis and maximal learn on the job-type tips. Pregnancy can be amazing and awful all at the same time—yes, we just said awful and pregnancy out loud together!

When you head into the home stretch, the physical pain usually gets worse, as does the anticipation and anxiety, especially if it’s your first time at the rodeo. First, all the emotions you are feeling are totally NORMAL. We totally give it up to Brooke Shields, who broke barriers by sharing her postpartum experiences. It’s important to know that joy is not the only emotion you’ll be feeling at the end of pregnancy and the beginning of mommyhood…

Here are our top 10 pre-delivery tips.

  1. Get groomed.
    While we are not telling you to run from the nail place to the waxing place and back to the hair salon, we are telling you to treat yourself! Make time for you before the baby arrives. A spa visit and some good R&R is the best way to do it. Besides, who doesn’t like to be pampered?
  2. Make a delivery playlist.
    Labor is not called labor because it comes and goes in the blink of an eye! Much to the chagrin of the family members camped out in the waiting room, it can be a LONG process—especially for your first! We recommend bringing along some good music, downloading some good movies, and maybe even packing a good book. Nothing takes your mind off things like laughter and light tunes.
  3. Plan a dress rehearsal.
    It’s never a bad idea to map out the best route to the hospital. Know where you are going and how to get to the labor and delivery floor. While it may seem silly to make a dry run, it will likely ease anxiety when game time comes. On that note, it’s also not a bad idea to have your “costume” (a.k.a. overnight bag) ready to go. The last thing you need when those contractions start is to be searching for your favorite sweatpants!
  4. Breast milk vs. formula.
    We are NOT here to pass judgment or tell you which is better for you or the baby. In our opinion, what works best for you will work best for your baby. But if you do think that you want to give this breastfeeding thing a whirl, make friends with a good breast pump, and a find a good lactation consultant (or someone in the know). This will help you prepare for what’s to come and increase your chances of getting the milk flowing.
  5. Bag the birth plan?
    We get it…you know exactly what music you want to be playing, exactly where you want your partner to be sitting, and where the baby should be placed right after delivery. And while having a birth plan is important, be FLEXIBLE with your bullet points. For sure know if you want an epidural, if you want a doula, and if you want a vaginal delivery or a C-Section—but unfortunately, labor and delivery don’t follow a plan. Be prepared for things to deviate from the script…the show will still go on!
  6. Know who you want to be there at the final push!
    Who you want to hold your legs and wipe your forehead is a very personal decision. Don’t be bullied by parents, your in-laws, or your friends—only people you want in the room should be there. It’s okay to want privacy during your special moment.
  7. Eat your heart out!
    While we want you to be careful about how many pounds you add during your pregnancy the night before you go into the hospital (if being induced, having a C-Section or as labor is starting), we recommend going all out in the food department. Treat yourself to a decadent dinner with your significant other. You will not only need the energy to push, but you will also want to enjoy the last moments of being kid free.
  8. Be mindful of unsolicited advice.
    Everyone is an expert when it comes to all things pregnant, and they are not afraid to share it. While most mean well, the advice can become moderately annoying. Listen to what you want to, and shut out what you don’t want to hear. Your doctor and medical team have probably done this several hundred times; they have got you covered and know what’s best.
  9. Accept the unacceptable.
    So many times, we hear women saying through tears and sobs, “This is not how I planned it. I feel like such a failure.” Unfortunately, no matter how hard you try to control what happens on D-day, you can’t. Nature doesn’t care if you dreamed of delivering in a bathtub in the dark with classical music in the background—if your baby’s heart rate drops, you’re having an emergency C-Section under the bright lights, no questions asked. The number-one priority is your and your baby’s safety; trust us, when you hold that baby in your arms, the plan will be nothing more than a moment in the past.
  10. It’s ok to want to quit—at least several times a day.
    Motherhood is the only job you don’t get to call in sick to, you don’t get to resign from, and you don’t get fired from. You can’t clock out, and you don’t get a paycheck. But even with all the exhaustion, the frustration, and the anxiety, it is the most amazing experience you will ever have. Labor is TIRING. Pushing is HARD. But quitting is not an option—you are stronger than you know.

Chew on This: What Pregnancy Can Do to Your Teeth

Pregnancy is like the ultimate detective. It leaves no stone (or body part) unturned. It will make your hair fall out, your skin stretch, and your feet grow (say goodbye to many of your pre-pregnancy shoes!). And the fun doesn’t end there. Pregnancy also takes a hit on dental health; cavities, gingivitis, periodontitis, and tooth erosion are on the list of pregnancy pleasures.

Here’s what can be on the to-do list of your teeth…

  1. Gingivitis (Gum Disease): Just like your hands and feet, your gums can swell during pregnancy. An increased inflammatory response to plaque can cause your gums to swell and bleed. Those who enter pregnancy with their dentist already on speed dial (a.k.a. you had gum disease before pregnancy) are more likely to experience a worsening during pregnancy. If this is you, make sure to pay particular attention to what your teeth and gums are doing!
  2. Loose Teeth: Due to an increase in hormones, flexibility in your joints and ligaments increases during pregnancy. And while this may make you excel in yoga, it makes your teeth super loose. Beware of sticky foods!
  3. Tooth Erosion: Your teeth like food. Your teeth like water. Your teeth don’t like vomit. Vomit contains gastric acid, and gastric acid can eat away at the enamel of the tooth, causing tooth erosion. Therefore, women with serious morning sickness are at risk for serious tooth erosion. Rinsing your mouth with a basic solution (baking soda + 1 cup of water) can help neutralize the acid.
  4. Cavities: What you take in and what your mouth puts out change during pregnancy. The pH of the mouth shifts to a slightly more acidic level. This acidity, combined with pregnancy cravings (a.k.a. more sweets and sugary foods), increases the risk of cavities. Don’t go to bed without brushing and flossing!
  5. Periodontitis: When gingivitis is ignored, it can become periodontitis. Simply stated, when bacteria make the gums their permanent home destroying the gum and the teeth, you have yourself a case of periodontitis. You can look forward to loose teeth, lost bone, and sometimes, even bacteria in the bloodstream. The latter, in the worst-case scenario, can lead to preterm labor. Don’t let it get to this point. If your gums don’t feel right, go right to someone to check them.

There is a lot about pregnancy that makes you smile and a lot that makes you frown. Whichever way your mouth is going, don’t forget about the 30-plus structures that stand behind them. Your teeth need to last you through pregnancy, postpartum, and beyond. Make sure to take care of them. After age 12, the tooth fairy brings nothing but a bill and a big-time headache!

When to Cut the Cord

While we can’t tell you how long your kids will hang on to you for support, we can talk a little bit about when to cut the umbilical cord! Delayed umbilical cord clamping has become all the rage these days—almost as popular as those fidget spinners!

What’s all the buzz about delayed cord clamping, and what does it mean?

After your baby is delivered, the umbilical cord (what connects Baby to the placenta, an organ that feeds Baby while inside Mom) is often clamped and cut soon after delivery, usually around 15 to 20 seconds afterwards.

However, studies have shown that blood is still transferred from the placenta to the baby during those first few cries after delivery. As long as Baby is doing okay after delivery, those extra few ounces of blood can give your newborn a leg up on iron and blood stores.

In pre-term babies (those born before 37 weeks), this can mean a better transition to life on the outside, fewer blood transfusions for low red blood cell counts, and a smaller chance of a few other complications of prematurity.

For term babies (those born after 37 weeks), waiting to clamp and cut the cord can also increase iron stores and decrease your baby’s chance of having anemia (low red blood cells) in the first few months of life. Giving your baby a few more red blood cells post-delivery may increase his or her chance of needing therapy for newborn jaundice (think those UV lights newborns are sometimes under), but that chance seems to be small, based on the studies so far.

So, delayed clamping seems to be great for Baby, but what about mom? Mothers seem to do just fine, with no increase in bleeding or postpartum hemorrhage (see our post here) in studies.

How long is long enough? It seems 30 to 60 seconds should be good. Some people like to wait until the cord stops pulsating, but it seems most of the benefit from delaying clamping happens in the first minute of Baby’s life.

Now, what if something happens during your delivery and you can’t delay cutting the cord? Remember, the main goal is a healthy mom and baby. If Baby needs some extra attention from the pediatricians after delivery, that may mean you can’t wait to clamp and cut!

Think of it as one of the first of many compromises you make as a parent. While, of course, we always want to give our kids the best of everything, sometimes we can’t always do things by the book.

What Are You Wearing to PPROM?

When you hear the word prom, your mind immediately goes to dresses, dancing, and corsages—those awkward high school days when who your prom date was felt as important as who was running for president. And while we would love to relive what we wore and who we wore it with, the PPROM we are here to discuss is premature preterm rupture of membranes (a.k.a. breaking your water before you’re in labor and way before your due date!).

Before we delve into the details of PPROM, let’s take a step back. From the moment of implantation, your plus one spends his or her days and nights swimming in a pool. This pool is in your uterus and is called the amniotic sac. When your water breaks, be it at six months or nine months, it signifies that the amniotic sac has opened and your amniotic fluid (a.k.a. water) is leaking. When this happens at or around your due date, it’s game on. Pack your bags; let’s go have a baby!

And while there is excitement (#babyontheway), there is generally no cause for concern. However, when your water breaks before you have reached the full-term mark (37 weeks), we put on a full-court press to stop things from moving any further. And depending just how early in pregnancy you are, we may pull out all the stops to stop labor from progressing. Preterm delivery can be dangerous: think lung problems, brain problems, GI problems, and beyond. That’s why we will do our very best to stop it.

Because of the what-ifs and the what-cans that often follow premature babies, women with PPROM can anticipate a lot of attention. You, your uterus, and your fetus will take center stage on the labor floor, which will become your new home until the baby is born. And depending on how things go (Do you develop an infection? Does your baby appear to be in distress? Have you reached a safe gestational age for delivery?), the curtain may not fall for several weeks. In short, our goal is to keep you pregnant for as long as we safely can. When it comes to fetal development, days matter. Although the neonatal intensive care units (NICUs) have come a long way, there is no better home for a developing baby than in your womb.

Why your uterus decides to go to PPROM earlier than it should is often unknown. While most cases occur because of an underlying infection, in many cases, we aren’t sure what set the system into motion. However, given that infection is the no. 1 culprit, we will routinely start antibiotics to treat a potential infection and to hold off what might come next (a.k.a. full-blown labor). We will also keep a close eye on your temperature, your white blood cell count, and your baby’s heart rate to make sure that an infection is not arising or, if already present, getting worse. Additionally, if the PPROM occurred at less than about 34 to 36 weeks, your OB/GYN will administer a dose of steroids to help your baby’s lungs reach maturity.

Many of us have had many water-breaking false alarms during pregnancy. The kind when you realize, “Oops, I just peed on myself.” And while it can be hard to distinguish amniotic fluid from urine (for the non-OB/GYNs amongst us), when symptoms like cramping, pressure, and bleeding are present, it is usually the former.

However, the only way to know is to go (we purposely made that rhyme so it sticks in your head!). Going to your OB’s office or the labor floor is the only reliable way to know exactly what that liquid is. And while no one wants to be the boy (or girl) who cried wolf, it is always better to be safe than sorry.

The good news is that most of us won’t show up for the prom early. In fact, only about 3% of all pregnancies in the US are complicated by PPROM. However, women with a previous PPROM are at increased risk for another PPROM. To avoid an encore performance in your next pregnancy, your care might be transferred to a high-risk OB. Such individuals are specifically trained to take care of women with previous pregnancy complications. Furthermore, they may suggest taking weekly progesterone injections, starting at 16 weeks of pregnancy and twice-monthly cervical length checks to reduce the chance of the preterm delivery happening again.

Additionally, if fertility treatments are being used in the future, we strongly recommend that your doctor employ all and any techniques to reduce the risk of multiple gestations. After all, if your uterus had a hard time making it to the end with one, why stress the system with two?

The good news is that while your courtship (a.k.a. pregnancy) may be cut short, the “prom” usually ends on a high note. With early attention, immediate treatment, and a team approach (OB, pediatricians, nurses, and support staff), most babies born following PPROM will do great. And not unlike the prom that they will attend nearly 17 years down the road, while their time in the NICU will be beyond stressful for us as parents and family members, most “kings” and “queens” leave the PPROM none the wiser.

Welcome to parenthood!

Don’t Be So Negative….What Your Rh Status Means for You and Your Baby

There are “blood type” diets, “blood type” personalities, and even “blood types” that are tastier to mosquitos (apparently if you are type O, you should go out and buy some more bug spray!). And while most of us have no idea what A, B, AB, or O mean until we visit our first American Red Cross blood drive, your blood type is actually pretty important in the land of obstetrics. Although most of us don’t think past those three letters (and four groups), the plus or minus that comes after the A, B, AB, and O is equally as important as the letter. The negative or positive denotes the Rh factor. If there is a mismatch between the negative and positives in a pregnant woman, just like those AA batteries you are always in need of, this system won’t work the way it is supposed to.

Let’s start with the simple stuff…

1. There are four basic blood groups; A, B, AB, and O. What distinguishes A from B or AB from O are the antigens (a.k.a. the proteins) on the surface of red blood cells.

2. The symbol, plus or minus, which follows the letter is referring to the presence (+) or absence (-) of the Rh factor. Rh stands for rhesus, and Rh or Rhesus factor is another antigen that is found on red blood cells. Rh antigen is present or + in Rh (+) individuals and absent or – in Rh (-) individuals.

Moving on to a couple of fun facts that will make you look smart at a cocktail party…

3. The most common blood type is O+.

4. The universal blood donor (you can give to anyone) is blood type O-.

5. The universal blood recipient (a.k.a. you can take from anyone) is AB+.

6. You inherit your blood type from your parents, and you will pass your blood type on to your children.

Last, the essential stuff for anyone who has been or will be PREGNANT….

7. Rh-negative women need special attention. If untreated AND pregnant with an Rh-positive baby, they have the potential of forming antibodies against the Rh factor that is covering their baby’s red blood cells. And while this may not be a big deal in their current pregnancy (antibodies are like Rome; they were not built in a day), it will be a major deal in future pregnancies. Therefore, all Rh-negative women should receive a medication called RhoGAM (a.k.a. RhoD or Rh immune globin) during their pregnancy to prevent the formation of these antibodies.

8. RhoGAM is an injectable medication that contains a small amount of antibodies pooled from blood donors…it works to kill off any Rh-positive blood cells lingering in the immune systems of Rh-negative women. Think of RhoGAM as a stun gun to the immune system of an Rh-negative pregnant woman. Basically, it will “daze and confuse” her immune system so that she doesn’t have a chance to make antibodies to the Rh factor her body is seeing during pregnancy. Problem solved. And in the past, this was a big problem that not only cost a lot of perinatal morbidity but also mortality. So kudos to those who racked their brains and “birthed” RhoGAM.

9. When it comes to most things pregnancy, it takes two to tango. Therefore, just because you are Rh-negative doesn’t mean that your baby will be. If your partner is Rh-positive, there is a good chance your little one will be too (and that’s when you have a problem on your hands)! To be safe, all Rh-negative women will be given RhoGAM during pregnancy (remember, we won’t know your little one’s Rh factor until birth). The good news is that the majority of pregnant women will only need to roll up their sleeves and stick out their arms twice, once at 28 weeks and once following delivery. This is because in most cases maternal and fetal blood don’t say, “It’s nice to meet you” until delivery. However, because this introduction may speed up to the third trimester in about 2% of pregnant women, we give a precautionary dose at 28 weeks.

10. Unfortunately, two times may not be the “RhoGAM charm.” If bleeding should occur during the pregnancy or if you undergo an invasive procedure such as a CVS or an amniocentesis, your blood and your baby’s blood might get mixed up. Therefore, to be extra careful, we recommend you get another shot within 72 hours of the bleeding or the procedure.

11. Rh-negative women that are NOT given RhoGAM are at serious risk during their NEXT pregnancy. So while many of us have the “I will deal with that tomorrow” attitude when it comes to things that don’t impact us immediately but can hurt us in the future (think not paying your bills and dealing with your credit score later), you really shouldn’t mess around with RhoGAM. Antibodies to Rh take some time to form. Therefore, while your current passenger might pass through without a problem, the next baby on board could be at serious risk if a woman is NOT given RhoGAM during the current pregnancy. Don’t push this one to the side; this sort of credit your next child can’t afford!

Given that 85% of individuals are Rh+, this incompatibility issue does not come up every day. Simply stated, most moms and their babies are in sync when it comes to Rh status. However, given the serious impact an untreated Rh mismatch can have on a woman and her future children, it is something that we OBs get pretty pesky about. We have to be doubly POSITIVE so that nothing NEGATIVE happens. And while we can’t validate the stuff out there which suggests that As may be “more responsible and patient” while Bs are more “passionate and creative,” we can tell you that your blood type means a lot for your baby (and the babies that you may have to come). That much, we are triply super positive about!

On the Road to Delivery…GBS

While the title may have you doing a double take (and maybe even looking for some directions on how to decode GBS), rest assured, you are not lost out there on the road. You are in your home, your apartment, your office, or maybe even in the car (although hopefully not driving and reading!) hanging with your girlfriends at Truly, MD. But if you are nearing the end of pregnancy, you are probably getting pretty good at navigating the streets between home base and the hospital. And although we may not know the quickest way to get you to the labor floor, we definitely know how to get you up to speed on all things third trimester. First stop: Group Beta Streptococcus (a.k.a. GBS).

GBS is a type of bacteria. And although it may not be on your daily bacteria radar (think strep throat or staph skin infection), it is pretty important to us OBs. GBS took center stage in the OB world of the 1970s when it was identified as a culprit in the land of perinatal morbidity and mortality—that is, newborn illness and death. The newborns of pregnant women with GBS in their vaginal canal who were not given antibiotics during labor were at risk for some pretty heavy hitters. Think sepsis, meningitis, and death. Pregnant women were not immune to the negative effects of GBS. They, too, were at risk for things like UTIs and uterine infections.

Despite its bad-guy tendencies during pregnancy, GBS lives fairly peacefully within the vaginas and the rectums of non-pregnant women. Don’t bother me, and I won’t bother you. Given its Jekyll and Hyde persona, we only start to look for the presence of GBS in a woman during the latter half of pregnancy, when it can really turn into Hyde. To uncover whose vagina/rectum is “covered” in GBS and whose is not, your OB will perform a screening test on you between 35 and 37 weeks. And although it may sound scary, it’s no more than a cotton swab test of the vagina and the rectum. Those that test positive are given antibiotics during labor. Those that test negative are not. Pretty simple.

The ACOG has made it their business to get in the business of all pregnant women when it comes to GBS because, like the old adage says, when GBS is bad, it is very, very bad. Anything that can be done to decrease the bad is a major bonus…cue screening for GBS. The universal screening of all pregnant women has done a very, very good job at stopping most widespread GBS infections in newborns, particularly in the first six days of a baby’s life. In fact, since national guidelines for screening and treating pregnant women who test GBS positive were implemented, there has been nearly an 80% reduction in early onset (the first six days of life) neonatal sepsis due to GBS. Pretty impressive stuff.

Women who go into labor before their GBS test was performed (a.k.a. preterm labor), women who have previously given birth to a GBS-infected newborn, or women who test positive for a GBS UTI during pregnancy are automatically treated with antibiotics for GBS during labor. Basically, in these cases where the risks are high, it’s better to be extra safe and add an extra layer of protection. It’s sort of like extra insurance for a driver with lots of points on his license. While he may never speed or get ticketed again, given that his chances are higher, you want extra protection—we’re not saying we know anyone like this!

For most women, the GBS test comes and goes without a bump in the road. It’s sort of like passing a yield sign on the road. You know it’s there. You slow down somewhat, but you don’t really pay it much mind (we didn’t say that we offered good advice on driving!). Don’t fear the results. Positive or negative, we are pretty good at directing you to the right path. No one gets lost out here on this road; think of us as your GPS for your GBS!

When There Is More Than Your Plus One in Your Pelvis

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain.  However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

  • Increased risk of miscarriage.
  • Preterm delivery and labor.
  • Abnormal fetal position.
  • Fetal growth restriction.
  • Placental abruption.
  • Labor dysfunction (and the need for a C-Section).
  • Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

The Lowdown on What to Do When You Can’t Get Anything to Stay Down: Nausea in Pregnancy

Praying to the porcelain god, hugging the bowl, or tossing one’s cookies—whatever you want to call it, vomiting is not fun. In fact, it may be one of the most un-fun bodily processes. Add to that unremitting nausea, and you have got yourself quite a pair. And while this dynamic duo is usually only welcomed after select occasions—a stomach virus, food poisoning, or after a serious night out on the town—in pregnancy, it can be a daily event. The hormones secreted by pregnancy (a.k.a. hCG and estrogen) can make you pretty sick—so sick, even getting out of bed to brush your teeth may seem impossible.

Nausea and vomiting in early pregnancy is VERY common. Nearly 75% of women will feel nauseous or vomit at some time during their pregnancy. However, the extreme cases (medically termed hyperemesis gravidarum) are VERY rare. And although nausea and vomiting in pregnancy can happen to any lucky lady, it is more likely to happen in women who are pregnant with multiples (more placenta = more hormones = more nausea), have a history of hyperemesis in a past pregnancy, have a family history of hyperemesis, are prone to motion sickness, or have a personal history of migraines.

Although persistent nausea and vomiting won’t kill you, it will likely make you feel like you’re dying. You can’t work, you can’t work out, and you can barely move. So, what can you do to give the baby barfing the boot?

First, if possible, start taking a prenatal vitamin at least three months before you conceive. Some prep time can help prevent the nausea that women can experience with prenatal vitamins.

Second, try to limit the time you spend around smells that make you sick (goodbye, garlic!).

Third, trade in three large meals for six small ones. The less you need to digest, the less likely you are to lose it!

Fourth, stay away from spicy and fatty foods, and fifth, shelve any pills with iron.

Last, think about investing in ginger pills. Not only has ginger been shown to be beneficial for your immune system, but studies also show that it may be the secret to curtailing your nausea. And although the medical jury is still out on acupressure, acupuncture, and electrical nerve stimulation to the inside of the wrist, it can’t hurt to try.

When simple measures fail and you are still BFF with your toilet bowl, it’s time to bring out the big guns (a.k.a. medications). Your OB will likely start with something like vitamin B6 or vitamin B6 plus doxylamine. If this doesn’t do the trick, they may amp it up with prescription anti-nausea medications. However, before you go this route, it’s important to have a chat with your OB about what’s coming up and when before you take anything else down.

If this still doesn’t cut it and you’re cutting weight like a wrestler before a big fight, your OB may consider admitting you to the hospital for intravenous nutrition. Severe causes call for serious measures. Nutrition can be delivered through an IV if need be.

Although it is very rare for this fight to go the distance, if you find yourself still battling nausea in the second trimester, consider adding an antacid or reflux medication. Often, women start to experience reflux in the second trimester. As your little one grows, so does your uterus. As your uterus grows, the space between your uterus and your upper abdominal organs (think stomach) shrinks. Pressure on the stomach can cause things to come back up (a.k.a. reflux), which can lead to nausea and even vomiting.

In cases where nausea and vomiting start after nine weeks or there are other atypical symptoms (abdominal pain, fever, headache), it’s important to reach out to your doctor—ASAP. Not all nausea and vomiting in pregnancy is normal. Sometimes it can indicate that something serious (appendicitis, kidney infection, kidney stones) is going on.

The good news about nausea and vomiting is that, while it can make you miserable, it usually doesn’t do anything miserable to your body or to your baby. Even when the only thing your stomach can stomach is saltines and ginger ale, your baby will be just fine.

Whether you call it “puking,” “barfing,” “hurling,” or “vomiting,” we call it no fun. But it will pass, and we will do our best to get you through it, one day at a time!

“I’m Ready for My Close Up” – Preparing for Baby’s First “Screen” Test

Pregnancy brings with it a battery of tests – not just those that your doctor requests. Sleep disturbances, food cravings, and fatigue may make some of us want to put a “pause” on pregnancy!

One of the many tests your doctor will recommend is baby’s first “up close and personal” – a screening test to make sure baby’s chromosomes (translation – what holds genetic material) and anatomy is a-ok. #babysfirstselfie.

We talked a bit about screening versus diagnostic testing and invasive versus non-invasive tests in our “Gone Shopping” post (LINK). As a refresher, the goal of this screening test is to identify moms with babies who may be at higher risk than normal for certain abnormalities. But, remember, like using an Instagram filter, a screening test doesn’t give us the clearest picture. If your screening test indicates you may be at higher risk for something fishy, your doctor will recommend a definitive test to make the picture crystal clear. Screening tests are “non-invasive” in doctor-speak, meaning a simple blood draw or ultrasound is usually all you need!

As if there aren’t enough decisions to make in pregnancy, there is a laundry list of different methods to screen for chromosomal abnormalities. Your doctor will talk to you about the pros and cons of each and what he or she usually does or recommends.

To prep for that visit, we’ll break it down for you. Let’s start at the very beginning – a very good place to start!

DOES THE EARLY BIRD GET THE WORM? FIRST TRIMESTER SCREENING:

If you want to start the screening early (think 10–13 weeks), you may get a special ultrasound, called a nuchal translucency, and a blood test to look at two markers.

The pros of the method are that you get risk assessment early. The cons are that sonographers must be certified in nuchal translucency scans, and this isn’t the best test to assess the risk of certain structural anomalies, like spina bifida.

GIMME SOME LEG POWER – THE QUAD SCREEN:

The quadruple (a.k.a. “quad”) screen is a blood test done in the second trimester. The combination of these four blood markers assesses the possibility of both chromosomal and certain structural problems.

To be clear, by “structural,” we mean things like spina bifida or other abnormalities affecting the spine. This is assessed with one of the blood tests available (called AFP), but will also be checked for during your anatomy scan, which happens around 20 weeks.

 

STEP BY STEP – USING THE BEST OF BOTH WORLDS:

By using a combination of blood tests in the first and second trimester along with an ultrasound (in some cases), you can get an assessment of your risk for both chromosomal abnormalities and structural problems. This approach is a bit better at detecting problems, but you have to wait until a little bit later in pregnancy to know.

There are a few ways of using this step-by-step approach – integrated, stepwise, and sequential. Your doctor will help guide you on this decision if you choose this method.

THE NEW KID ON THE BLOCK – CELL-FREE DNA:

Cell-free DNA is the most accurate “cell-fi” available (see what we did there?).

This test looks for DNA from the baby’s placenta (the organ your body grows to feed the baby!). Since it will be different (hey – 50% of baby’s DNA comes from someone else!), the test looks for the baby’s DNA and makes sure the chromosome numbers are correct.

While this NKOB is pretty cool, here are a few caveats to consider:

  • The strong suit of this test is picking out those at high risk for three of the most common chromosomal abnormalities – Trisomy 21 (a.k.a. Down Syndrome), Trisomy 18, and Trisomy 13.
  • This test has been most studied in women at high risk of abnormalities, like moms over the age of 35. So, if you’re not one of those high-risk individuals, you may have a higher chance at a false positive, meaning the test might detect a problem when there is none.
  • This test will not assess risks for certain structural defects, like spina bifida.

GREY’S ANATOMY [SCAN]:

Last but not least, your doctor will likely recommend a detailed ultrasound to look at the baby’s anatomy somewhere around 20 weeks. This is considered a part of your prenatal care checklist that is separate from the above blood tests, but we felt it was worth a brief mention!

This bird’s eye view (we just scratched the surface of each test!) of general screening for the baby should hopefully give you a primer for when it’s time to decide what is #truly best for you and baby. And, remember, you’ll have your best supporting actor or actress (your doctor!) guiding you through this process.