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.

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.

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!

Does My Positive Pregnancy Test = Baby?

When the stick starts to smile, reads pregnant, or gives you a double line, most of us have to do a double take. After we double check (in the form of another test; trust us, we all do it!), we usually pick up the phone and call our plus one, our best pal, or our partner in crime. Whether you were waiting for this for years or just started trying a month ago, finding out that you are preggers can be pretty overwhelming. The emotions can be as volatile as the weather in the tropics. Even if you have a child (or children), adding to your clan can make you clamor.

For most of us, those first few minutes/hours after that positive test are dominated by questions—and the majority are about the very distant future (a.k.a. nine months away). When is my due date? Will this baby be a girl or a boy? Do we have enough space in our home? When should we tell our family and friends? And while we, too, love a good future plan, unfortunately, there is not all that much that we can make of or plan for after one positive pregnancy test. The reality is that, from the pregnancy test to the postpartum unit, there are A LOT of hurdles. In fact, a good chunk of positive pregnancy tests don’t even make it past the first week or so.

Although many of us blame that box we lifted or that bike ride we took, in most cases, early pregnancy losses have nothing to do with our actions. It has everything to do with the embryo that implanted. The majority of early pregnancy losses are the result of abnormal embryos (an extra or missing chromosome). In the land of embryos, fetuses, and human genetics, 46 is the sweet spot. We get 23 chromosomes from our mom and 23 from our dad. Anything more or less than 46 is considered abnormal.

While not all pregnancies with abnormal chromosomes miscarry or don’t make a baby, the majority does not make it very far. Very few abnormal derivations of 46 chromosomes are even compatible with life. And luckily for us, the body knows this and puts up a big red STOP sign to the pregnancy.

We in no way mean to rain on your pregnancy parade. A positive test definitely means something, and for many, it is the beginning of a long and fruitful journey. And while we, too, get super excited at the pregnancy texts and emails our patients and friends send us, we want to remain cautiously optimistic.

Tempering your emotions can soften the blow when things don’t go right. Remaining realistic in the beginning of a pregnancy is key. While we certainly don’t recommend you walk around with your head and heart low, we do suggest that you hold off posting your pregnancy test on Facebook. Give it some time; see how things progress. Let your doctor confirm that he or she sees fetal development and a heartbeat before you let your heart go crazy. It can prepare you for those potential skipped beats.