Heart Rate, Shmart Rate: Pregnancy and Exercise

There may be no greater taboo topic (other than who you voted for and what God you believe in) than pregnant women and exercise. Finger pointing, whispering, and gasps are the norm when a visibly pregnant woman hops on a treadmill. For some, it evokes the same feeling as a pregnant woman who smokes a cigarette. “How can she do that; doesn’t she know she’s hurting her baby?” No major fitness brands cater to pregnant women, and clothing lines for the pregnant athlete are scarce. It’s close to being off limits. News flash, world: the data on no exercise for pregnant women are old and no longer relevant. It’s time to turn things up and break a sweat. Here’s why.

Exercise is Excellent for Everyone. Young, old, pregnant, and postpartum, exercise is a good thing. Physical activity has a positive impact on almost every organ and organ system in your body: hearts, lungs, brains, and bones. It also is a major weapon in the war against obesity, which we are currently losing big time as a country. Additionally, those of us who move on a daily basis not only look better but also feel better. (The chemicals that bring you up are released into the brain during and after exercise. They will keep you flying high for many hours post-workout).

Exercise in pregnancy achieves all of the above benefits, plus some others. Women who get to the gym when expecting should expect a lower chance of gestational diabetes, macrosomic (large) babies, high blood pressure, and excessive weight gain. And we OB/GYNs are not the only ones endorsing exercise in pregnancy. The US Department of Health and Human Services recommends that healthy pregnant and post-partum women participate in at least 150 minutes per week of moderate-intensity aerobic activity. They are also cool with women who like to take it up a notch, which means those who engage in vigorous-intensity aerobic exercise can keep it up.

While we are not telling you to go out and achieve your PR in the marathon or train for an iron man (or woman!) in the dead of summer, we are telling you to get out, get active, and stay fit. You will have to make modifications in your regimen. You will have to share your big news with your fitness instructor. You will have to stay extra hydrated and wear loose, breathable clothing. But if given the all clear by the OB, you won’t have to sit on the sidelines.

In pregnancy, our bodies change big time (no brainer). But it’s not just that belly that we acquire; it’s also a shift in the point of gravity, laxity of the ligaments/joints, increase in blood volume, and decrease in vascular resistance. The last two are what can make you feel lightheaded and your legs swollen. Be conscious of these differences. Your awareness will keep you out on the track, in the studio, or on the mat longer.

Not every pregnant woman can bike, spin, or lift weights. Some pregnancies are more complicated, and the pregnant woman can’t exercise ad lib. For this reason, it’s important to be as open and honest with your OB/GYN about what you want to do as you would with your trainer as to what you want to build. We need to know what you’re doing so that we can tell you what is okay to do.

There are certain medical conditions (restrictive lung disease, severe anemia, heart disease) as well as specific obstetrical conditions (incompetent cervix, placenta previa after 26 weeks, premature labor) where exercise is prohibited. In addition, if you were a couch potato before pregnancy, it’s probably not the best idea to start doing boot camps once you pee on the stick. A more gradual progression into exercise is probably the way to go.

No one really knows where that magical 140 (maximum heart rate for a pregnant woman) number came from. We have searched textbooks (both online and in print) to find out why this number?? We got nothing good! And that’s because it was never based on any real data. The new recommendations from the American Congress of Obstetricians and Gynecologists on Eexercise and Pregnancy no longer stipulate that heart rate be used to assess how hard a woman is working when she is working out. We now recommend using “ratings of perceived exertion” to monitor exercise intensity (a 15-grade scale; very, very light → very, very hard).

Using the “talk test” is another way to measure exertion. (We prefer the “sing test”: can you sing the song playing on your iPhone?) Although we don’t want to hear you belting out the lyrics to “I Will Survive,” we do want to know that you will survive this workout class. If you can sing or talk, you can breathe, and if you can breathe, your baby is getting oxygen—and then you are all good.

Exercising in pregnancy has been viewed as selfish. Here’s what they say: Women who exercise care more about their bodies than their babies. Women who exercise are vain and self-centered. Women who exercise are not good mothers-to-be. This is downright bogus and simply BS. Studies show that babies actually like exercise just as much as their mothers do. While their heart rates increase, their birth weight does not decrease. In fact, babies born from mothers who exercise see benefits, from their brains to their bodies to how they are birthed (C-Section vs. vaginal delivery).

Exercise is good for both parties, mother and baby. While we may not be there to run beside you during this pregnancy, we can offer you a few parting pieces of advice:

  • Make sure to stay cool (don’t exercise in a 100-degree basement!).
  • Make sure to stay well hydrated.
  • And make sure to stay well nourished, with adequate caloric intake.

Other than that, lace up your sneakers, clip into the saddle, or roll out those yoga mats. It’s time to get moving!

Achoo…F-F-F Flu! The Flu Vaccine and Pregnancy

Break out the tissues, start brewing the tea, and swallow that Echinacea, because winter is coming! No, this is not an episode of “Game of Thrones,” but a chill is in the air. When the temperatures drop, anxiety over the flu rises, as does our consumption of vitamin C. Hand washing becomes an obsession, and coughing or sneezing without covering one’s face is the biggest faux pas. Despite what may feel like a lot of hype, the flu is the real deal, especially for women who are pregnant.

Because the flu can be way more than a one-day couch-lounging event, any method to prevent catching it is of the utmost importance. In addition to good hand washing and sanitary practices, the flu vaccine can significantly reduce one’s chance of getting the flu. Given changes in the immune system and respiratory system, pregnant women are at increased risk for not only getting the flu but also getting the flu with a vengeance.

Along with the muscle aches, runny nose, and headaches, pregnant women are at a much higher risk for all the negative and serious complications that come with the flu: ER visits, hospital admissions, intensive care stays, and even mortality. Simply stated: the flu and pregnant women do not mix.

Because of this oil-and-water situation, it is crucially important to receive the flu vaccine once it becomes available, no matter what trimester or “pre” trimester you’re in. The flu vaccine in pregnancy is at the top of every OB’s list, so it should be at the top of yours as well.

Additionally, research shows that the babies whose mothers received the flu vaccine while pregnant have a lower chance of developing the flu as an infant. The flu vaccine is not approved for use in babies younger than six months; therefore, the best way for these babies to receive protection is through their mothers (antibodies against the flu will pass from mom to baby through the placenta and protect the baby for up to six months of age). Simply stated, the best way to prevent and protect both you and your baby from being sidelined in a serious fashion from the flu is to receive the flu vaccine at the outset of the flu season.

The flu vaccine USED to come in two formulations, a shot and nasal mist.  The nasal mist was NOT safe in pregnancy (it was live weakened virus).  But the CDC pulled this version from circulation as it was not found to be effective.  So currently, all formulations are safe before, during, and after pregnancy.

There has also been some controversy on the use of thimerosal, a mercury containing preservative used in some vaccines, and autism.  There is no solid scientific data to support a link with thimerosal causing autism in children born to women who used these vaccines.  Thimerosal-free formulations of the flu vaccine do exist but the ACOG and CDC do not necessarily recommend pregnant women use only these formulations.

Bottom line: if you are not getting the vaccine from your OB/GYN, make sure to share your big baby news with the healthcare provider who will be administering the vaccine.

Getting the flu while pregnant is no joke. While it’s totally normal to be extra cautious about what you eat, take, or do while pregnant, the flu vaccine gets the double thumbs up.

Come Out, Come Out Wherever You Are: Ectopic Pregnancy

A positive pregnancy test brings with it big-time butterflies, big, bright smiles, and a big bag of unknowns. But very rarely does it bring the big question “Wow, I wonder if this pregnancy is located in the right place.” We all just sort of assume that, when we find out we are pregnant, the pregnancy is within the uterus. Unfortunately, this is not always the case. Pregnancies located outside of the uterus, better known as ectopic pregnancies, are not uncommon (and unfortunately never viable). In fact, about 2% of all pregnancies are located outside of the uterus. Bottom line, ectopic pregnancies are a big deal, and if misdiagnosed, can cause a big problem.

While it’s hard to find anything positive to say about ectopic pregnancies (they are a serious foe for any OB/GYN), the good news is that most ectopic pregnancies pick the same hiding spot…again and again and again! The majority of ectopic pregnancies can be found within the fallopian tubes (about 97%).

The remaining spots where ectopic pregnancies like to hide include the ovaries, the cervix, the abdomen, C-Section scars, or the uterine cornua (the uterine horn). Unfortunately, even when ectopic pregnancies hide in the same place, they are not always immediately visible. When they are small, they can escape even the shrewdest of physicians. It is for this reason that we use both pregnancy levels (hCG), weeks of pregnancy, symptoms (pain and bleeding), and the ultrasound pictures to determine if there is a pregnancy hiding where it shouldn’t be. During this “come out, come out wherever you are” phase, it is important to stay close to home and be in constant communication with your OB/GYN. Keeping us posted will allow for a speedier end to this game of cat and mouse.

Another key player in the ectopic hiding game is knowing who is most likely to have an ectopic. Identifying those at risk allows us to send out the search party early (a.k.a. watch a woman who has risk factors for an ectopic the moment she tests positive for pregnancy). Such risk factors include women who have a history of an ectopic pregnancy, previous surgery on one/both of their tubes, a history of PID, STDs, infertility and/or infertility treatments, smoking, or previous pelvic/abdominal surgery. They serve as hints or flashing red lights for OB/GYNs when patients complain of vaginal bleeding and/or abdominal pain in the first weeks of pregnancy.

Knowing what might be lurking outside of the uterus allows us to keep our eyes open and our minds ready to act. Intervening early in the game (when the ectopic pregnancy is small) can minimize the damage that an ectopic pregnancy can cause.

Once an ectopic pregnancy has been discovered, we move pretty quickly to make sure it doesn’t go back into hiding. We initiate treatment immediately and act fast to put an end to this problem. Treatment can be medical, surgical, or in some cases, simple observation. Which is right for you depends on many factors: a woman’s medical and surgical history, the size of the ectopic pregnancy, the pregnancy hormone level, how far along the pregnancy is, and the symptoms one is feeling. After analyzing these factors, the decision to administer methotrexate (the medical treatment) or undergo a laparoscopy will then be determined.

Make sure you have a thorough discussion with your MD about why he or she has selected the specific treatment plan. Although your pregnancy may be hiding, you should not be kept in the dark about what’s going on inside of your body and why a certain treatment is being used.

Ectopic pregnancies are no joke. If untreated, they can lead to massive bleeding and even death (#1 cause of death in pregnant women in the first trimester). It’s because of this that we OB/GYNs get very worked up over even the possibility of one and will stop at nothing until they are found. We will send blood tests on you every two to three days, bring you in for multiple physical exams, and even ask you to undergo repeat ultrasounds to help us figure out where the pregnancy is and how to make it go away. While the follow up can be annoying, it is essential.

In this game of hide and seek, it’s important that we play together (patient + physician) on the same team. Ultimately, no hiding spot is immune from an ectopic. As a united front, we find it quicker and make sure it doesn’t go back into hiding. So let’s uncover our eyes and start searching!

Gone Shopping: What You Pick Up From a CVS Or an Amnio

When most of us hear CVS, we think of the store—shampoo, cotton swabs, bandages, vitamins. We rarely ever think of first-trimester genetic testing, unless you are an obstetrician! But CVS goes way further than your local drugstore and stands for more than Consumer Value Stores. In the land of OB, it means Chorionic Villus Sampling, and the information we get out of it is way more valuable than any Super Savings discount your local CVS has ever offered.

CVS and amniocentesis (a.k.a. amnio) comprise what we traditionally call invasive diagnostic genetic testing. They get answers that are highly accurate and therefore shed a lot of light about your little one’s chromosomes and genetics. Whereas in the past we only offered it to women based on their age (older than 35) or their risk factors, nowadays anyone who wants invasive diagnostic testing can have it. You just have to know about it and ask for it. And while prenatal genetic screening (what we can test for) has “come a long way, baby,” the options for diagnostic tests (a.k.a. how to get the cells to get the information) have remained the same. Let us give you the lowdown.

However, before we can delve deep into the depths of CVS and amnio, it’s important to clear up two key concepts:

  1. A screening vs. a diagnostic test
    Simply stated, a screening test is used to check for the possibility of a disease. Most of us get several of these a year (think Pap Smears, mammograms, colonoscopies) depending on our age. In most cases, the screening test is the end of the rope—see you next year! It is only when the screening test is positive and suggests that something is up that we need to move on to the bigger guns, otherwise known as the diagnostic test. A diagnostic test confirms if what was seen on the screening test is really there.Bringing this back to prenatal testing, screening tests include both blood tests (PAPP-A, hCG) and an ultrasound (nuchal translucency) that is usually done at about 11 to 13 weeks. When these look off, it’s a good idea to move on to more definitive and accurate tests. Cue the invasive tests.
  2. A non-invasive vs. an invasive test
    This one is probably a bit more straightforward but still needs some explanation. While a non-invasive test may require a blood draw or an ultrasound, the pregnancy itself (a.k.a. the amniotic sac, the chorion, or the placenta) is not being disturbed. An invasive test will break more than your skin. It will require that a needle be passed either through the vagina or the abdomen to obtain tissue. Given the more involved nature of the invasive test, it carries greater risk. However, it also carries greater reward; that is, it is accurate 99% of the time. Accuracy is key when couples and individuals are making difficult decisions

Now that we cleared that issue up, we can get down to the nitty gritty of CVS and amnio: when they are done, how they are done, and what you can expect. So if your screening test came back abnormal, e.g., an elevated risk for chromosomal abnormalities or if you chose to skip screening and go right to diagnostic—which some women do, it’s your choice!—you have two options…

  1. CVS
    • The cells (a.k.a. information on the genetics) are obtained from the placenta.
    • We can get these cells in one of two ways: either by passing a needle through the abdomen or the vagina. The approach varies based on physician preference and skill.
    • The test is usually performed between 10 and 13 weeks.
    • The results are not only super speedy (the cells are processed quicker after a CVS than an amnio) but also the test is performed early in the pregnancy.
    • There are risks. And just like any procedure, the risks must be weighed against the benefits. In terms of CVS, our no. 1 concern (and yours truly, too) is fetal loss. Good news is that the numbers are reassuring, and the risk of loss following the procedure is very low (1 in 455).
  2. Amniocentesis
    • The cells are obtained from the amniotic sac (the fluid that surrounds the fetus).
    • We can get these cells one way and one way only—by passing a needle through the abdomen.
    • The test is usually performed between 15 and 20 weeks but can also be done later in certain situations.
    • The results are more like snail mail than email. It takes the lab about 7 to 14 days to come up with a final answer (CVS takes about 5 to 7 days). Additionally, it is done later in the pregnancy.
    • There are risks here, too. But here the risk of fetal loss is somewhat lower at about 1 in 800.

Admittedly, we just barely scratched the surface of prenatal genetic testing (#weLOVEtheTRUTH). The specifics of what can be tested for, in what lab, and what it really means goes way, way deeper. However, in most cases you don’t even need to walk past the shallow end to get what’s going on. But before you take the plunge into the CVS or amnio pool, make sure you have lifeguards on deck (a.k.a. a genetics counselor and your OB). Even the “best swimmers” can get lost, confused, and overwhelmed without someone watching over them.

Just as you wouldn’t swim in rough waters alone, don’t venture into invasive diagnostic testing without a guide. This stuff can get complicated quickly. No matter where you swim, safety always comes first!

Should Pregnancy Put a Pause on Your Gym Membership?

Run, work, eat, sleep, repeat: this pattern plus/minus a few other key activities is the daily routine of many women we know…including ourselves. While fitting it all in can be a challenge, remaining fit is at the top of many of our lists (which for most of us tends to be very long!) Although the physical benefits are a plus, for many, the primary reason to pound the pavement while everyone else is still sleeping is the mental release these 30 minutes offer. Tuning out from the daily grind, forgetting about the constant to-do list, and the stress of trying to balance it all are key.

For us, a commitment to exercise started in college. In many ways, although it took fuel to power through a workout, the workout itself provided us with the mental clarity and physical strength to get through the 15 years of education to become a fertility specialist. The juice your brain gets from a run, a swim, or a bike ride can be as invigorating as a Starbuck venti (and cheaper!).

For all these reasons, plus many others, we maintained our exercise regimens during pregnancy. While there were definitely some double takes as our bellies bounced in and out of the saddle at cycling class, we both continued to go strong until the very end. So, as both moms who have done it and doctors who have spent a lot of time researching it, we are here to say pregnancy is not a reason to pass up peddling, paddling, or pushing on.

Let’s share some facts. The American College of Obstetrics and Gynecology (ACOG) makes it clear that, in the absence of either medical or obstetrical complications, moderate exercise for at least 30 minutes or more is recommended on most, if not all days of the week. So if the gurus of all things pregnancy give it the green light, why does exercise during pregnancy still conjure up so many negative emotions? Why do we rarely see a picture of a pregnant athlete? And why does a model that is fit and posts pictures of herself while pregnant cause so much negative buzz? Whatever the reason for the dirty looks, there is a widespread misconception that pregnancy is a handicap and women who continue to live their normal lives and engage in their normal routines are doing harm to their unborn child. They will cause themselves and their babies problems and should just relax. This is so NOT true. Yes, there will always be certain situations (see below) when an OB advises a patient to sit on the sidelines, but that is more the abnormal than the norm:

  • History of preterm delivery
  • History of short cervix/incompetent cervix
  • Significant maternal heart disease
  • Restrictive lung disease
  • Persistent bleeding in your second and third trimesters
  • Placenta previa after 26 weeks
  • Premature labor
  • Premature rupture of membranes
  • Pre-eclampsia
  • Growth-restricted fetus (IUGR)

As avid athletes, OB/GYNs, and women who have worked out with a plus one in the womb, we are constantly asked by friends, patients, and even strangers at the gym, “What can and can I not do during pregnancy?” as it relates to exercise.

So here are the most frequently asked questions and our well-rehearsed answers….

I am a fitness fanatic…is there a time when I should stop exercising?

While you may have been given the green light to continue exercising during your pregnancy, you should consider stopping in the following scenarios:

  • You start to experience vaginal bleeding.
  • You are having difficulty breathing with exercise or feel dizzy, or
  • You experience chest pain, muscle weakness, or headaches with exercise. You should also stop exercising ASAP if you note uterine cramping or leakage of any vaginal fluid, and consult your OB if these symptoms develop.

I like to hang glide, sky dive, and rock climb…are there any exercises that are dangerous?

Most exercise regimens are a go in pregnancy. However, any sport that can lead to abdominal trauma should be avoided after the first trimester. This includes extreme sports as well as contact sports like basketball and soccer. Additionally, while many skiers chose to continue swooshing down the slopes throughout their pregnancy, it is generally not recommended due to the risk of falling or collision, which can result in significant abdominal trauma. Furthermore, the higher altitudes associated with skiing can be more difficult to tolerate when pregnant. Don’t hold your breath: scuba diving is also not recommended during pregnancy. The risk of decompression syndrome (related to pressure changes) is real and therefore not a wise choice. Lastly, don’t forget that your center of gravity shifts while pregnant; this places pregnant women at slightly higher risk for falls. So put the tightrope down. Pregnancy is not the time to take that walk!

I want to achieve my personal record during pregnancy…Do I need to modify my workout during pregnancy?

Probably yes. But the best advice we can give you is to listen to your body. It will tell you when it’s had enough. Pregnancy is not the time to push your pace or take your athletic endeavor to the next level. Your heart, lungs, and circulation are working for two, and you will feel changes as early as that missed period. The physiologic changes that occur in the first trimester will make you feel more winded and short of breath. Hear what your body is saying, and take some time to cool down.

I never eat before I work out…should I start to snack before?

Talk about changes in metabolism and energy storage! During pregnancy, while your body feels heavy and full, it is less equipped to handle dehydration and drops in your blood sugar. Therefore, you need to pull out those water bottles and hydrate up. In addition, make sure to chomp on something before and after your workout. In general, pregnant women need to consume 200 more calories a day. If you are going to exercise while pregnant, just be aware that you need to fuel and then refuel your tank more frequently than when not pregnant.

I used to dream about my Sunday long runs, now I dread them…is something wrong?

Nope, your change of heart is normal. As pregnancy continues, what feels right and good will change (not to mention what tastes good!). As avid runners, we found running much less comfortable in the late second and third trimesters, causing muscle strain in the lower abdomen and groin. The hormones of pregnancy cause laxity (loosening) of your ligaments and muscles that can lead to discomfort and possibly injury. Be smart. If it’s a really hot and humid day, you may want to second guess that long run in the park during prime sun hours. Likewise, if it is very cold and icy, it’s probably not the right time to check out a trail run. Again, listen to your body…it knows what it wants and does not want to do!

I bought a heart rate monitor…Does my heart rate have to stay below 140 while I work out?

Old school ACOG guidelines (pre-1992) recommended that pregnant women keep their heart rate under 140 beats per minute. News flash…this dictum was removed over two decades ago, as there was NO scientific basis to support it. All women enter pregnancy in different cardiovascular shape. If we start differently, we will likely be able to achieve differently; some can go above 140, some below, and some way below. We like to recommend what we call the Talk Test. If you can talk or sing (sorry for all of those who have to listen to us belt it out off key) as you go about your workout, you are all good.

I just entered my third trimester…do I have to stop exercising?

Not really. Keep going unless you don’t feel right or if your obstetrician or midwife advises you that it is no longer safe due to a pregnancy complication. Otherwise, many women will exercise up until the day they give birth (we both did!).

Other than fitting into my skinny jeans sooner after delivery, are there other benefits to exercise in pregnancy?

Short answer is: yes. Fit moms who maintain their exercise regimen during pregnancy are less likely to develop gestational diabetes (diabetes during pregnancy), preeclampsia (high blood pressure), excessive weight gain, needing a C-Section, and low back pain. It also seems that women who peddle paddle and things in between push for a shorter amount of time and have a higher likelihood of a vaginal delivery. It should come as no surprise that if you are fit enough to make it through a cycling class, you are more likely to be fit enough to make it through labor.

Are there any risks to my fetus if I exercise during my pregnancy?

Despite the negative buzz and the whispering that goes on, no, not if you follow the advice of your doctor and exercise safely. In fact, you can tell those finger pointers to point somewhere else. There is a good deal of data to the contrary suggesting stronger cardiovascular systems in newborns of mothers who exercised during pregnancy. Additionally, the babies born from moms who move seem to have a lower incidence of obesity and diabetes.

When can I work out after I give birth?

Here are the “deets” on when you can get down and dirty again. While the general recommendation has always been six weeks, it’s not a mandatory sentence. If you had an uncomplicated vaginal delivery (no major tear), you can probably start back much sooner. Let’s face it, the first couple weeks post-delivery, you and your body are in survival mode. Your priorities are feeding your newborn and yourself and getting as much rest as possible. Exercising even for the most hard core is not at the top of your list. Ease back into it when you feel your body is ready; whether that is two weeks or six weeks, it’s up to you.

The bottom line is that exercise during pregnancy will not only keep your bottom line a bit trimmer but also have big-time benefits for you, your pregnancy, and your baby. While no one is expecting you to PR in a race, you can continue to move. Moms on the move are everywhere. Join the movement!

Key words: Exercise, pregnancy, heart rate, cycling, dehydration, nutrition, fitness, fit pregnancy, preeclampsia, gestational diabetes, postpartum

The Buzzz on Zika

It’s hard to remember a day in recent months that the word Zika hasn’t come out of our mouths, come off our desks (a.k.a. a letter to an airline or hotel explaining why a woman can’t make her trip to the Dominican Republic), or caused a whole lot of fear for anyone who is pregnant or thinking about having a baby.

Like that insect buzzing in your ear, no matter how much you swat it away (no pun intended), it just keeps coming back. And while Zika might become “blood sisters” with everyone it lays its lips on, this virus has not made many friends. From reproductive-age women to OB/GYNs to pediatricians, Zika has become Public Enemy Number One. And while much of Zika is changing faster than Larry King changes wives, here’s what we know and don’t know today.

Here’s what we know about Zika:

  1. Zika said “Hello, world” in 1947. It made its first marks in monkeys who “swung out” in the Zika forest (hence how it got its name) in Uganda.
  2. Although Zika may have made its mark on the world in early 2016, it’s been a pesky pain since 1952. The first human infections were reported at this time, and since then, outbreaks have been identified in Southeast Asia, the Pacific Islands, and tropical Africa.
  3. Fast forward nearly 65 years, and Brazil reported the first Zika virus infection. Shortly after this, the WHO (World Health Organization) went all WHOAH over Zika, declaring it a public health emergency (a.k.a. this is some serious stuff). And while the current epidemic started in Brazil, other countries and territories have reported active Zika virus transmission.  As of September 2016, local transmission of Zika has been confirmed in Miami-Dade County, Florida marking the spread to the continental US.  
  4. Although most of us know little more about a mosquito than when it bites, it itches, these blood suckers are not all created equal. Different species carry different viruses. When it comes to Zika, it’s the Aedes species that is making all of the noise. And these guys like to hang out and breed in water-holding containers.
  5. Aedes has an appetite—a big appetite. They are fairly aggressive eaters and will feed both indoors and outdoors.
  6. Humans and primates are prime meat when it comes to Zika. They serve as the reservoirs (i.e., holders) of the virus. And while the virus moves mosquito to man or woman, it can also go mosquito A to person A to mosquito B to person B. So even if mosquito B was buzzing around blissfully without Zika, if person A had Zika and was bitten by mosquito B, mosquito B would now have Zika. Therefore, whoever is mosquito B’s next meal will be infected with Zika. We know…pretty crazy…
  7. Most people who are bitten by Aedes and infected with Zika are none the wiser;  they are completely asymptomatic. Those that do feel it feel the following: a fever, a rash, joint pain, muscle aches, headaches, and conjunctivitis. In most cases, the symptoms are mild and gone within a week.
  8. While most people feel little pain from their Zika infection, pregnant women, not so much. Medical evidence indicates that Zika is very likely to be a cause for microcephaly.
  9. Zika gets around—and not just via a mosquito. Zika can be transmitted to people through sexual contact, through a blood transfusion, or from mom-to-baby at birth.
  10. As of today, there is no vaccine or medication to treat Zika. Like most viruses, it just takes time to work its way out of your system.

Here’s what we don’t know about Zika:

  1. Where it will go next? (That is, what will that Zika map look like in a few months?)
  2. How long does the Zika virus persist in the semen of infected men? Although we are recommending men to abstain or use condoms for six months, is this too long?
  3. Can infected men who are asymptomatic spread Zika to their sexual partners?
  4. Do infected women have the ability to transmit Zika to their sexual partners just like men do?
  5. Once people are infected with Zika, are they protected for life (like chicken pox), or can you get Zika twice?
  6. Are pregnant women at higher risk for being infected with Zika than non-pregnant women?
  7. If a pregnant woman is infected with Zika, what is the chance that her baby will develop microcephaly?
  8. When will we discover a vaccine, AND who should get it?

Zika has made quite the buzz over the past several months. Its bite is big. From the news to the media to the medical journals, it’s all over the place. And while we know a lot more today than we did yesterday, we will almost certainly know more tomorrow than we did today.

Bottom line: the Zika recommendations are constantly changing. In the words of the NYPD, if we see something, we will say something. So keep checking the CDC, ACOG, ASRM and the Truly, MD, websites for updates. Until then, buy a lot of bug spray, stay away from Zika-infected areas, and stay in constant communication with your OB/GYN. This is one mosquito you don’t want to mess with.

A Third, A Third, and A Third: The Trimesters of Pregnancy

For any journey you take, breaking it up into pieces, sections, or parts (except for long layovers in airports!) makes the trip a whole lot more tolerable. Knowing you are halfway done or three-quarters into it can often give you the needed umph to kick it into high gear and finish the race.

In many ways, pregnancy and the three trimesters are no different. Looking at a pregnancy from start to finish can be daunting.  Not only does the overall distance feel shorter when viewed as thirds, but also what you need to expect and do changes as you inch closer to your due date. We share with you our take on the trimester system known as pregnancy.

While your body will look most similar to itself during the first trimester (most won’t even know you are pregnant), it is usually the most emotionally challenging. The prospect of pregnancy brings a lot of fear and anxiety. It’s just like how you feel in the first couple miles of a race or points in a match; you are working on finding your footing. Getting a sense of the course, your opponent, and yourself can take some time.

The first trimester of pregnancy is no different; your body is testing this gestating thing out. Don’t be alarmed by odd sensations: cramping, bloating, breast tenderness, fatigue, and an increased urge to eat, drink, and pee are totally normal (so is a decreased need to poop—constipation is super common). You won’t feel like yourself very early on in the game; as the pregnancy hormone levels rise, so do the changes. Be kind to your body, and don’t beat yourself up if you need to take a break. There is a lot going on.

In addition to the changes your body is experiencing, it is also in a state of flux over if this pregnancy is going to be a go—meaning, does the embryo that is growing inside you have what it takes to make a baby (e.g., does it have the right number of chromosomes, are there major organ problems, are there other functional issues)? The body is smart, and when things are not right, in many cases it knows pretty quickly and a miscarriage will follow.

To make sure that your body is not sleeping on the “checking job,” a host of genetic screening tests are performed in the first trimester. They will give insight into what’s up with the pregnancy in terms of chromosome number (a.k.a., are there 46 chromosomes?). In addition to the blood tests, in the latter half of the first trimester, an ultrasound that measures the thickness of the back of the neck (medically termed the nuchal translucency) is performed. The nuchal is not the place where more is better—a thicker nuchal is associated with chromosomal abnormalities (most commonly Trisomy 21, a.k.a. Down’s).

There is a lot to do and a lot that can be done in the first trimester, particularly making sure that we have an accurate due date (it is based off the first day of your last menstrual period) (article: Let’s Dish on Dates.) For this reason, the earlier you go to see your OB, the better. While you don’t need to be seen the day you pee on the stick, you do want to get in within the next few weeks. Early evaluations can pick up things and point you in the right direction early (for example, do you need a high-risk OB?).

At the first visit, there is usually a lot of talking. Minus the awkward silences, in many ways, it is like a first date. Do you like your OB, and do you want to commit to him or her and their group for the next nine months? We will ask a lot of questions about your past and family’s past during this meeting so that we can make a game plan for the rest of the pregnancy. We need to know it all: the good, the bad, and the ugly. Honesty is key to a good OB-pregnant lady relationship.

Following the gab session, we will start the exam (height, weight, blood pressure, and pelvic exam). In most cases, the icing on the cake during this first visit is the ultrasound to check for fetal size and heartbeat. If all looks good, the next stop is the lab for blood tests (cover your eyes if you don’t like needles; we will take a lot of blood at the first meeting). Things like your hemoglobin level, your blood type, your immunity status (are you immune to things like chicken pox, the measles, and the mumps?), thyroid level, and what (if any) inherited genetic conditions you are a carrier for are essential for a safe pregnancy. We will also screen you for STDs such as HIV, Hep B, Syphilis, Gonorrhea, and Chlamydia. The menu of tests is not fixed. Based on your background and history, we will add in a few “specials”—this is why the convo that we commenced with is so key!

Basically the beginning third of pregnancy is marked by a lot of unknowns and unpleasant sensations, like nausea and vomiting. Things will start to sort themselves out as you hit the 13-week mark. We will also use this time to give you the lowdown on all things pregnancy—vitamins, food, fitness, sex, travel, habits, and medications. There will be a lot of information, so try to take it one step at a time. In most cases, things will get smoother and more second nature as the weeks pass. It just takes some time to sort itself out. Trust us, we’ve got you covered!

At almost every visit, your doctor will do the following: check your blood pressure, weigh you (oh joy!), check your urine for an infection, assess for protein and blood, measure the size of your uterus, check the baby’s heartbeat, chat about the last few weeks (travel, illness, stressors), and ask you about fetal movement (second and third trimesters). Think of these like the OB checklist. Hitting each mark will ensure that both you and your baby are hanging in there. They will be maintained throughout the tris, and you should expect them every time you pass through your OB’s door.

Okay, one-third down and two-thirds to go. The second trimester is like the sweetheart phase, the newlywed phase, and the “Wow, pregnancy is really wonderful phase.” And while it is fairly short lived (about 13 weeks to be exact), for most women, it is a pretty positive time. Going back to our sports analogy, you are now in the groove. The kinks have been worked out, your body is warmed up, and you are in the zone. While your visits to the OB will become slightly more frequent (about once every three weeks to a month), it is by no means onerous. Your schedule is still pretty free. Most activities are still doable (with modifications), and your eating habits have returned to normal. (You are no longer a carbohydrate-ingesting machine.) You are comfortable sharing your news with others and more easygoing about the process.

The highlights of the second trimester include the anatomy scan, the onset of fetal movement (first kicks are pretty incredible), the gender reveal moment, and the popping of your belly—hello, world, I am pregnant! You can also expect some more blood tests from your OB, most notably one that looks for neural tube defects (commonly spina bifida). If problems were identified on the anatomy scan (which is traditionally done at about five months of pregnancy), there may be follow up recommended (a closer peek at the heart, a fetal MRI, or a meeting with a high-risk OB). The anatomy scan gives all the organs more than a once over, and for this reason, this is the most common time that abnormalities are identified. While most pregnancies are uncomplicated and enter the home stretch without a hitch, the ones that are becoming more problematic usually let us know around this time.

Coming around the bend, you enter the third trimester and are inching towards the end. This is when things feel real and many women start to get really uncomfortable. Your baby is getting bigger, and your uterus is pushing on everything from your bladder to your back to your diaphragm. It’s hard to find a position that feels comfortable. The third trimester is a strong dose of reality hitting. I may never sleep past 6 a.m. on a Sunday morning for another 5 years! Given the proximity of your due date, you start to see your OB every other week to every week. They will want to check that the baby is in the head-down position and he or she is not over the weight limits for a vaginal entry into this world. Babies that are measuring very large may need to take the abdominal route out, that is, a C-Section. We will once again check your blood levels. This time, there is one that follows a sugary orange drink that makes most of us want to vomit (checking for diabetes in pregnancy, or gestational diabetes).

A GBS (Group B beta-hemolytic streptococcus) test is performed on every pregnant woman in the latter half of the third trimester. GBS is a common culprit for neonatal sepsis/meningitis (life threatening infections). Women who are colonized with GBS need antibiotics while in labor to prevent passing GBS to their baby. Screening for GBS in the third trimester has drastically reduced the incidence of disease in newborns.

Last, get ready for some of the most uncomfortable pelvic exams of your life (sorry, we just want to be truthful!). As the weeks march on, your OB will check your cervix every week to make sure that it’s ready to give its passenger the all clear to exit. If it is not, we may need to talk about scheduling an induction.

The end of pregnancy is also the time to talk seriously about your next beginning. Preparing you for what labor will be like is key to demystifying an understandably frightening experience. While your labor may not follow your birth plan script, having a good idea about what you want the plot to be will help you make decisions when the time comes. Although pregnancy seems long, it will be done before you know it. For those who loved it, you will be eagerly anticipating the next time you are expecting, and for those who sort of hated it (and you are not alone), you will be contemplating if you will ever do that again. Either way, getting to the end of those ten months (yes, pregnancy is ten months!) is a major accomplishment.

And once the bell rings and labor starts, you may still have a couple of days ahead of you. In many ways, these days are longer than all of the trimesters combined. Labor and delivery are not easy. But just think: when that final push is over, you will have the greatest gift anyone could bestow upon you. Holding that baby will trump any push present your mind could dream of! You are a mother, and your life will forever be changed. Let us be the first to welcome you to the club; there is truly no greater.

A Fishy Situation: Safe Seafood for Expecting Moms

Eating when you are pregnant can be a tricky situation. What you want and what you can have don’t always jive. Menu choices can become a bit complicated, particularly when it comes to fish and seafood. While we want you to get the good stuff fish has (think Omega-3s, protein, and vitamins), we don’t want you to take in too much mercury. For those of us who are sushi addicts or fish fanatics, you may have to modify what you eat and how often you eat it to make it ok during pregnancy. Here’s how to modify the menu to make fish, sushi, and seafood acceptable during pregnancy.

Simply stated, mercury is not a mother-to-be’s best friend. While you may be close to it after or before pregnancy, during pregnancy (and while breastfeeding), you need to put your relationship on hold. The reason for this temporary breakup is the potential negative impact high levels of mercury can have on your growing baby. Mercury turns into methylmercury, which is a toxin to the developing brain/neurologic system of a fetus as well as the future vision and hearing of a child.

While you can be exposed to mercury in many ways, it is most frequently found in fish, particularly large fish. For this reason, swordfish, shark, king mackerel, and tilefish are totally off limits during pregnancy and while breastfeeding. Fish that is low in mercury (think shrimp, wild salmon, trout, catfish, cod, tilapia, canned light tuna) should be on your table at least once a week. In general, about 8 to 12 ounces (2–3 servings) of low mercury fish/week is recommended. White albacore tuna can be added to the list above, but consumption should be limited to 6 ounces a week.

Fish caught in local waters are a slippery situation. You can check with your state or local health and environmental agencies to find out what the mercury content is, but if there is no answer, you should probably limit your intake to 6 ounces/week.

A discussion about seafood would not be complete without the temperature situation (a.k.a. raw vs. cooked). And while the CDC and the FDA say no to raw fish, this is one area in which we have set sail in a slightly different direction. Although undercooked, seared, or raw fish has a higher chance of harboring a parasite, a bacteria, or a virus, women from other parts of the world have been consuming raw fish for centuries without a problem (think Japan).

Additionally, because most of the fish used in sushi in the United States has been flash frozen before it makes its way to your local jaunt, the majority of parasites and bacteria have already been eliminated. However, while we may let raw fish slide (or swim!), what we don’t deviate on is where you consume this raw or undercooked food AND the type of raw fish you choose to eat.

Make sure you are getting your food from a reputable establishment that not only handles and stores food properly but also serves it soon after purchasing it. Last, choose the low mercury menu choices (a.k.a. fresh or wild salmon) rather than the high mercury options (farmed salmon and the like).

Your taste buds will change faster than your body. One week, you will be obsessed with shrimp, and the next, just the sight of it will make you want to vomit. It’s totally normal. The tides of eating and cravings move fast in pregnancy. Make sure to chat with your captain (a.k.a. your OB/GYN) before you embark on a new food journey. Safety is first no matter where you choose to set sail.

Let’s Dish on Dates: Last Menstrual Period (LMP)

When most of us hear the term dating, we think back to those days when we had butterflies in our stomach every time we imagined meeting our plus one for dinner and drinks. Questions from what should I wear to what should I say to when is it okay to stay flooded our minds. Fast-forward a few years, and now flings are out and fertility is in. Dates are now dictated by the arrival of our period and the most promising days to have sex.

The calendar is littered with red Xs and black circles rather than dinner reservations and drink locations. And while your chicken scratches can start to look like hieroglyphics, here’s why those “X marks the spot” notations really matter!

Pregnancies are dated (a.k.a. the due date of a pregnancy is calculated) based on the first day of a woman’s last menstrual period (LMP). Your chart will refer to this date as your EDC, a precise 40 weeks from your LMP.  This date is used to calculate when you ovulated and, therefore, when your egg met sperm. To confirm that you are spot on with when you saw that first “spot,” your OB/GYN will perform an early ultrasound measuring the length of the fetus (medically termed the crown rump length) to confirm that your date is consistent with the dates being picked up on the ultrasound. The two need to jive for the due date to be written in stone (or at least in your medical chart in black marker!).

In cases where there is a serious discrepancy, your OB will often re-date the pregnancy (that is, calculate a new due date based on the measurements noted on the ultrasound). Re-dating is dependent on how pregnant you are measuring at the time of the ultrasound and how discrepant the ultrasound findings are with respect to your LMP. Here’s when things need to change…
If you are 8 weeks pregnant based on your LMP but you are measuring 6 ½ weeks pregnant on the ultrasound, then your due date will need to be pushed back by 1 ½ weeks (you ovulated and conceived a little later than you thought!)  Additionally, if you are 10 weeks pregnant based on your LMP but your ultrasound measurement shows you to be 11 weeks and 3 days pregnant, then your due date will be pushed up by 10 days. While we don’t expect you to do this math alone we do want you to be comfortable with the numbers and the changes that might occur. Take a look below to see when things needs to be modified:

Pregnancy Weeks based on LMP Ultrasound measurement discrepancy
Less than 9 weeks If > 5 days off, change due date
9-14 weeks If >7 days off, change due date
14-16 weeks If > 7 days off, change due date
16-22 weeks If > 10 days off, change due date
22-28 weeks If > 14 days off, change due date
28+ weeks If > 21 days off, change due date

However, a change is only permanent if confirmed by a second ultrasound. In fact, every due date needs to be confirmed twice (sort of like sending a text and an email to say we will meet at 8PM!). Even in cases where you are for-sure positive about your last menstrual period (a.k.a. LMP), we will confirm it with an ultrasound.

In cases where you don’t have a clue in the world about when you conceived, we will use two ultrasounds to create and then confirm your due date. This is particularly true for women with irregular cycles. Additionally, in pregnancies conceived after fertility treatments, we will use dates such as the day of ovulation, the day of the IUI, and the day of the ET to help us decide when the infamous D-Day (a.k.a. due date) is.

So even when you find yourself seeing a plus sign or a smiley face, don’t throw that calendar out. What you have written down, even if illegible to anyone but you, matters. It will help your OB pick your due date and know when measurements are off (say, the baby looks too small or too big). Dating is the real deal for us OBs—so make sure to keep us in the loop about those Xs and Os, no matter how hectic your schedule!