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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!

Under Pressure! Pre-Eclampsia

Pregnancy increases your pressure in a whole bunch of ways. For all of you ladies who have ever waddled through your home cities on hot days, you know that the pressure in your feet, your legs, your fingers, and your hands is way more than just some mild swelling. It can get so bad that some women can’t wear their shoes, their rings, and even their watches; it’s no joke. And don’t even get us started on the bladder situation. It’s hard to go anywhere without knowing where the nearest bathroom is. But the pressure that we are going to address in the next few paragraphs is that of your blood pressure and a condition unique to pregnancy called pre-eclampsiaFor those of you who either didn’t have this problem, didn’t know anyone who suffered from this condition, or have never been pregnant, you might be thinking PRE what? Your eyes are glazing over, and you are considering closing your computer. Stop! Pre-eclampsia is a very serious condition, and although we don’t expect to make you into board-certified OB/GYNs in the next several minutes, you should know what it is, what symptoms to look for, and when you need to shake a leg to the labor floor.

Pre-eclampsia is unique to pregnant women and newly post-partum women. It is a disorder that occurs in the last half of pregnancy and is characterized by new onset high blood pressure (a.k.a. hypertension) and protein in your urine (a.k.a. proteinuria). While it may be the first time you are looking at this word, it is actually not so uncommon. About 5% of pregnancies are affected by pre-eclampsia. Women who are having their first baby, are older, have a personal history or a family history of pre-eclampsia, have pre-existing medical problems (kidney disease, diabetes, obesity, a history of elevated blood pressure), or who have multiples are more likely to get pre-eclampsia. Why it happens is a bit unclear. While we know it involves both maternal, fetal, and placental factors, which ones, how much, and when they develop are still unclear. We do know that placental development early in pregnancy is probably a big contributing factor. The diagnosis is usually made in one of two ways—either you get picked up “coincidentally” when your doctor checks your blood pressure at a routine visit OR when you call with the scary symptoms.

The symptoms are pretty specific and usually cause your doctor, midwife, and/or nurse to quickly check your blood pressure and then check you into the hospital. Blood pressures are usually somewhere between the 140/90 to 160/110 mm Hg range—and trust us, this is not a place that you want to score high. The higher the blood pressure, the more severe the situation. (Same goes for the amount of protein in the urine; more is not better here!) To make the pre-eclampsia cut, your top BP number must be greater than 140 and the bottom greater than 90. In terms of the protein situation, you must have equal or greater than 0.3 grams in a 24-hour collection. (Yup, get out your bucket, and start peeing. We want all the urine you make for one whole day!) Other common symptoms include headache, blurry vision, flashing lights, abdominal pain (specifically in the center or the right upper abdomen), nausea and vomiting, shortness of breath, chest pain, and change in mental status (a.k.a. fuzzy thinking). If we feel pretty sure that you are headed for the pre-eclampsia party (elevated blood pressure, protein, and/or symptoms), we are likely going to send you an invitation to the labor floor. Regrets are not accepted. Here, you will find your place card with your room number on it. You will probably be sitting here all night! We will send some bloodwork on you to see how serious the situation is.

Just like most things, there are degrees of pre-eclampsia (mild to severe). We use your blood pressure, your urine, your symptoms, and your blood work to help us decide where you fall. Those that land at the severe table will not be leaving this party anytime soon. They will also likely not be leaving the hospital pregnant. Severe pre-eclampsia is often an indication for delivery. When a baby is delivered (at how many months/weeks pregnant) and how a baby is delivered (vaginal delivery vs. C-Section) are dependent on the severity of pre-eclampsia and the status of both Mom and Baby. When the baby comes out, the blood pressure usually comes down (or pretty shortly thereafter). Therefore, the best treatment for pre-eclampsia is delivery. However, while we are getting that baby to make its big debut, we have to protect you from seizures (no longer pre-eclampsia but now eclampsia) and other really unpleasant things. That’s why we give IV Magnesium. While the magnesium in many ways can be a miracle worker, it can make you feel many things other than good. You will feel hot; you will itch. You will be out of it; you will feel loopy. You will feel like you are having an out-of-body experience. It is not fun, but it is necessary. In most cases, we will also give you medications to lower your blood pressure. It will be a full-court press to protect you from the bad stuff associated with pre-eclampsia.

Most cases of pre-eclampsia occur after 34 weeks of gestation (about 8.5 months); however, some cases develop earlier. However early or late it comes, to be pre-eclampsia, it cannot come before 20 weeks (5 months) of gestation. And staying on the subject of timing, when you have had it once, you are more likely to have it again (and possibly) earlier than you got it last time. Unfortunately, there is no way to prevent the big P from making a return performance. Although newer scientific evidence shows that we can reduce the chances somewhat by giving aspirin, the data are not definitive. The data are even looser when it comes to things like extra calcium, anti-oxidants, vitamins C and E, and fish oil. Some say it can reduce the chances of having a repeat pressure performance, while others say it will do no more than a placebo pill.

We make a big deal out of pre-eclampsia because it is the real deal in terms of poor pregnancy outcomes. In fact, worldwide, about 10–15% of all pregnancy-related deaths are from pre-eclampsia and its nasty side effects (kidney failure, brain bleeds, strokes, heart muscle damage, liver failure/rupture, fluid overload in the lungs, seizures, and placental abruption). And in OB we have two patients (Mother and Baby), and pre-eclampsia does not spare either. It could cause serious problems for your plus one as well (growth restriction, low fluid, preterm delivery, and death). Pre-eclampsia can cause a precarious situation and therefore deserves our prompt attention.

Whenever we hear the word pressure, our brains automatically go to that Billy Joel song “Pressure.” You can hear those lyrics and that piano chord almost immediately. And with the opening vocals, up goes your blood pressure. You start thinking about all you have to accomplish in one day. It seems impossible! And the words of another musical great, David Bowie, remind us that we are always “Under Pressure”: pushing down on you/pushing down on me. But while normally these tunes pull you up a hill as you jog or are entertaining you on a car drive, when you are pregnant and your pressure rises, you can’t simply hum away the symptoms. Pre-eclampsia is not a song that can be changed or skipped; it’s here to stay. So make sure to share your symptoms and your medical history with your OB. We can rework this play list to make it something we can all listen to!