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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I Am Ready to Race Again; Is It Too Soon? Pregnancy Interval

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For any of you who have competed in a long-distance competition (be it a run, a swim, a hike, or a bike), you know what it feels like to cross that finish line. Total euphoria—combined with a fair amount of exhaustion, pain, and lots of blisters! The first thought that runs through your head, after the “I can’t believe I actually made it” moment is either “When can I do it again?” or “I am NEVER doing that again!”

The first group is already planning their next race, mapping out their training schedule, and thinking about how they could have done it better. While the “Okay, I can check that off my bucket list group” is looking for the nearest bar, a bath, and a bed. In many ways, pregnancy, labor, and having a newborn is very similar to the training and racing of a long-distance competition.

While the “Yes, let’s do it again” and the “No, I am so out” camps in pregnancy and parenthood are more fluid than the participants in long-distance competitions, (hard-core Group B members may move into Group A), people usually have a pretty set idea about how many times they want to be pregnant, how many times they want to give birth, and how many children they want.

Most of us even have a pretty good idea about how close together we want our kids to be (medically termed birth spacing). Whether you want them back-to-back or you prefer to space them apart is a personal decision. But how soon you can hop back on the baby machine is dependent on more than just your feeling ready. It also depends on factors out of your control such as if you had a C-Section or a vaginal delivery, if issues like high blood pressure or diabetes complicated your pregnancy, and if you required any additional procedures post-delivery. These all can hold you up even if your heart is ready to race again.

Regardless of what went down during your pregnancy, the time between delivery and a pregnancy should be AT LEAST 18 months. Any shorter inter-pregnancy interval can increase the chance of preterm delivery, premature placental separation (placental abruption), pre-eclampsia (high blood pressure in pregnancy), placenta previa (particularly after a C-Section), low birth-weight babies, and autism.

While the definitive reason behind why these events occur more frequently is debatable, fingers seem to point towards the “maternal depletion hypothesis.” Pregnancy and the stressors of a newborn takes a lot out of you, and your body needs time to re-fuel and re-energize before it starts the race again. Stressing the system before it is ready to function can interfere with its ability to do its job well.

Among the organs in the body that need a break, the uterus is at the top of that list, especially after a C-Section. The uterus is a muscle, and a muscle that is injured (particularly cut and sewn back together) needs to heal. Without adequate time to heal, there is a higher chance that it will open (a.k.a. rupture which is life threatening to  you and the baby) in the subsequent delivery. Furthermore, women who had a C-Section and want to try for a vaginal delivery in their next pregnancy (vaginal birth after cesarean section=VBAC) need extra-extra time to rest their uterus before it is pushed to push.

You don’t have to decide which group you are going to side with moments after crossing the pregnancy finish line (#delivery). Labor can be long and exhausting. Give it some time before you wave the “Yes, I want another baby” or “No way; I am done” flags. Even if you are raring to go moments after the race is over, give it time before you line up at the next start line. Hydrate, stretch, rest—do whatever it takes to get you ready to go again. The time off will do you good—and your next pregnancy.

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

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

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

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

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

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

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

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

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

GIMME SOME LEG POWER – THE QUAD SCREEN:

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

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

 

STEP BY STEP – USING THE BEST OF BOTH WORLDS:

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

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

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

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

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

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

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

GREY’S ANATOMY [SCAN]:

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

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

Doing It at Home: Labor and Delivery in Your Bedroom

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When most of us think about the birth of our baby, we ask questions like Who do I want in the room? Which doctor/midwife do I want at the delivery? and Will I have a bowel movement while pushing (don’t stress if you do; it’s super common)? Until recently, very rarely did the question At home or in the hospital? cross our minds. However, over the past few years, home birth has gained some serious followers.

More and more women are opting to deliver their baby in their bedroom rather than in birth centers or hospitals. In fact, rates of home birth were up from .79% in 2004 to 1.3% in 2012. Fear of C-Sections and the medicalization of birth (monitors, medications, and modest autonomy) have collectively driven women out of hospitals and into their homes. While there are certainly benefits to home births (minus the cleanup factor—labor can be quite messy), there are some major downsides as well. Here’s what to consider if you are considering a home birth.

First, deciding to deliver at home is a BIG, BIG, BIG decision that should not be made alone. While we get that women have been delivering babies for centuries, things can still go wrong, very wrong and very fast. That’s why it’s super important that you speak with a medical practitioner (OB/GYN or midwife) to make sure that you are a good candidate for an at-home delivery. According to the ACOG, the following women are on the no-fly list when it comes to at-home births: a previous C-Section, babies who are not head down (medical term: fetal malpresentation), and multiple gestations (more than one baby in their uterus at one time). It is just way too risky.

Second, if you are good to go for it at home, make sure you are not alone. Seek out a midwife who is licensed and experienced in doing home births. You want to make sure that this is not their first rodeo. Knowing when to throw the towel in and trek over to the nearest hospital is essential.

Third, have a good idea of your surroundings. And while we aren’t referring to the nearest grocery store, we are referring to your local hospital. Being close to a medical facility can be the difference between a horrible and heroic outcome.

Why do we care so much? Well, we care about you and your baby’s safety—big time. And although most home births go off without a hitch, when compared to hospital deliveries, home births carry a significantly higher risk of bad outcomes. A large study that was recently published in the JAMA (the Bible of all good medical research) showed that death, neonatal seizures, and neurological impairment were nearly 2.5 times more likely to occur when babies were delivered at home as opposed to in the hospital. Additionally, mothers who delivered at home were more likely to need a blood transfusion. But to be fair, the data wasn’t all down on home births. Women who delivered in a hospital were way more likely to have their labor augmented (a.k.a. enhanced with drugs like Pitocin) and have a C-Section.

As doctors, we have opinions…lots of them. Most of these are rooted in research, data, and years of medical education and training. But despite our degrees, we are not dictators. We are, in many ways, nothing more than trusted advisors. Therefore, while we can give our advice and render an opinion, we can’t tell you what to do. That’s up to you. You take the information we give you and with it make an educated and informed decision.

But we’re not going to lie; on this issue, we side with the ACOG and truly believe that the safest place to deliver a baby is in the hospital or in an accredited birth center. In our opinion, the potential downsides of the at-home birth far outweigh the potential downsides of the hospital birth. And while bad things can happen anywhere, we would rather you go where they happen less.

We also get that the labor and delivery of a child is one of the most intimate experiences in one’s life. You want what you want. We know; we were patients, too. Our advice is to find a practitioner (OB or midwife) whose vision for labor and delivery is close to yours. While on D-Day what you expected while expecting and what happened may be very different, at least you are staring from a place of togetherness.

Labor is as unpredictable as the weather in the tropics. Things can change faster than you can imagine. Get ready to roll with whatever rolls in…it will allow you to weather the storm safely. Make sure you have a life jacket and safety net (a.k.a. good medical practitioner on your side) should the seas get rough.

Check Your Gas Tank Meter…It Might Be Time to Refuel: The Thyroid

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In many ways, the thyroid is like the man behind the curtain. You have never seen him and are not really sure what he does, but you know he’s there. You’ve heard about him, blamed him for your weight gain and for sleeping through your alarm clock, and considered that errors in his way are keeping you from getting pregnant. But how he is masterminding all of this remains unclear.

While the intricacies of the thyroid are more delicate than a lace shirt, the basics come down to a simple Goldilocks type of situation: the thyroid is working too fast, too slow, or just right. When it’s really off, you usually feel really off. Simply stated, when your thyroid is running on empty or very close to it (think flashing red light telling you to pull over ASAP), you will feel like a car without gas, putt putt puttering through your day, being tired, cold, and constipated, with dry skin and hair loss, to name a few.

On the flip side when your tank has been topped off just a bit too much, you feel like you had one too many shots of espresso. You experience insomnia, diarrhea, palpitations, hot flashes/sweating, anxiety…

However, sometimes the deviations are subtle, and your thyroid is just slightly off (medically termed subclinical). But you may not know it unless a doctor checks. While the subclinical part will usually not cause you any noticeable symptoms, it can increase your risk of miscarriage and infertility and lead to negative pregnancy outcomes. Bottom line: if your thyroid is off, it’s not only your bottom line that will suffer but also your plus one.

As a result, fertility MDs are somewhat fixated on hitting the thyroid hormone level sweet spot! We check it on nearly all of our patients pre-pregnancy and then again during pregnancy. We are somewhat OCD in getting it to the perfect point and will labor over when to start some additional medication, when to increase or decrease it, and when to stop it.

What and where is this elusive “gas producer”? The thyroid is a small butterfly-shaped gland that sits at the base of the neck. In most women who are free from thyroid disease, the thyroid is small and cannot be felt. The thyroid produces thyroid hormones (T4 and T3); these hormones travel through the blood throughout the body to target organs. Almost all of your vital organs are target organs in desperate need of a little thyroid juice! The ovaries and the uterus are also quite “thirsty.”

Thyroid hormone plays a role in regular ovulation, pregnancy implantation, and miscarriage. Additionally, babies don’t start to produce their own thyroid hormone until about 13 weeks of age (in utero). Therefore, for the first trimester of pregnancy, babies rely exclusively on their mothers. If you are borderline low making thyroid hormone, they will be super low. And given that thyroid hormone is essential for brain development, this is not an area you want to be lacking in! It is for this reason that doctors will frequently start a thyroid supplement early before the situation hits rock bottom.

While your thyroid may not be to blame for all of your problems, it’s under (termed hypothyroidism) or over production (hyperthyroidisim) may be the cause of some serious ailments. And like most autoimmune conditions (where the body basically attacks itself), women are about six times more likely to be diagnosed with thyroid disease; most of those diagnoses will be made in the reproductive years (30s and 40s).

Not only is the thyroid important for pregnancy and fertility, but the start of it’s decline often occurs during the reproductive years.  So while your tank may be running on empty because you’re burning the candle at both ends, it is always a good idea to have your thyroid level checked, particularly when contemplating pregnancy. Who knows? You may just need a little refueling to help put an end to those annoying symptoms!

Better Late Than Never: Post-Date Delivery

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News flash: pregnancy is 40 weeks. Divide 40 by four ( ≈ four weeks to a month), and even we math novices know that equals 10. You heard it here first: pregnancy is actually 10 months! We know it’s like they just added a few more miles to the marathon once you thought you’d reached the end, but get out your Gatorade because, for some women, the race won’t end for another two weeks. Definition time: a post-term pregnancy is a pregnancy that is ≥ 42 0/7 weeks. The “start” line is first day of your last period, while a late-term pregnancy is one that falls between 41 0/7 and 41 6/7 weeks. Knowing your exact due date is super important because this will be the basis for all the D dates to come.

As OB/GYNs, we love to talk “dates.” And although we do appreciate hearing about the one you went on last night (did he or she really say that?), we want to focus on the date of your last period. The first day of your last menstrual period is probably the most frequently asked question to a pregnant woman. By the end of your 10 months (ugh, sorry to rub it in), your partner will be able to spit this number out in their sleep, it will be mentioned so many times! The reason we ask it over and over is because it determines what your due date is. It also determines if your baby is growing appropriately, if things are developing on track, and if a delivery must be planned or induced when it should or can be done.

Pregnancy and fetal development are based on “weeks.” You rarely ever hear an OB/GYN define a pregnancy in terms of months; our first and only language is weeks. Weeks of pregnancy correspond to the size and maturity of your baby’s organs, particularly the baby’s lung development. So, we will jump through hoops to make sure that your “dating” is accurate and that we know exactly how many weeks pregnant you are and how old your baby is!

Why some babies show up on time, some early, and some late is often very hard to figure out. There are risk factors for each, but most of the time, it’s sort of the luck of the draw. First-time moms, those carrying a male fetus, and women who are obese more commonly carry a baby past their due date. Additionally, if you went over with your first child, you are more likely to go the distance the second time around.

Other than discomfort and major ankle swelling, why do we care how long pregnancy continues? Well, several studies have shown that both late-term and post-term pregnancies have a higher risk of fetal complications. Factors like low amniotic fluid, stillbirth, admission to the NICU, passing meconium (babies’ first bowel movement) in the uterus and swallowing it (a.k.a. aspirating), and seizures occur at a higher rate in late-term and post-term pregnancies. In addition, the longer they cook, the bigger they get. Pregnancies that are past their due dates are more than two times likely to be macrosomic (a fancy way to say BIG!). You guessed it; a big baby is more likely to get stuck on its way out. This leads to a higher chance for an operative vaginal delivery (forceps or a vacuum) and a C-section.

So, when is it time to call it quits? A lot of this depends on your personal history: your age, how you got pregnant (fertility treatments), your medical history, your previous OB/GYN history (have you had a C-section before) and your baby’s development (size, fluid etc.). Not every delivery plan and timeline fits every pregnant woman. In most cases, labor induction cannot be planned prior to 39 weeks of pregnancy (one week before your due date). This is done to ensure that your baby is as ready as possible to take on the world when he or she makes that first appearance. While most OB/GYNs are okay with labor inductions after 41 weeks of pregnancy (the ACOG gives it the green light), they are almost all on board by 42 weeks. In fact, after 42 6/ 7weeks your baby is not only ready for preschool, but according to the ACOG, it is mandatory evacuation time.

There are ways to “get the party started,” including sex, dancing, a bumpy car ride, spicy foods, nipple stimulation (yup, we just said that), raspberry tea, and something called evening primrose oil (sounds super fancy, but really, it’s just a vaginal tablet). The cervix is the gate to the uterus. It will soften, become thinner, and ultimately open and dilate as labor gets closer. Depending on the readiness of your cervix, some of these home activities can help move the process along. Unfortunately, no matter how badly you want to meet your little one, labor often happens on its own schedule.

Once you hit the magic 40 and nothing is happening, your OB will likely initiate more fetal testing to ensure that the baby is just “chillin’ out” and is not stressed. Make sure to be in constant communication with your OB. The more surveillance you have at the end, the safer both you and your baby will be.

If things seem off (you are not feeling well or your baby is moving less), don’t stay silent. We want to hear from you, even in the middle of the night. Trust your intuition. Moms are usually right!

Cervical Mucus: A Marker for Ovulation and a Must for Pregnancy?

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For many of us, there is nothing more off-putting than the thought of tracking your cervical mucus day after day, month after month. It’s not easy knowing what you are looking at, why you are staring at your underwear, how long this exercise needs to go on, and what you will do with this information.

Egg white versus watery, creamy versus sticky. Are we baking a cake or making a baby? While in many ways, it’s sort of a little bit of both, tracking your cervical mucus is not a prerequisite for detecting ovulation or having a baby. The changes that occur over the course of those approximately 26 to 36 days can provide helpful hints on both if and when you are ovulating. However, while it is important and does serve as a reservoir for sperm, it is much lower on the fertility pecking order.

The cervix is the lower part of the uterus (a.k.a. the womb); it is the conduit between the uterus and the vagina. When not pregnant, the cervix measures about 2 to 3 cm. During pregnancy and particularly as its end is near, the cervix begins to shorten, thin out, and ultimately dilate. Think of the cervical mucus as the pond at the base of this conduit. It serves as a reservoir for sperm by providing it with nutrients and safety for several days (up to five, to be exact!). While the majority of sperm is in the tubes minutes after ejaculation, the pond holds on to the stragglers. Over the course of about three to five days, sperm is released into the uterus and the tubes, hoping to meet its mate and make an embryo.

Much like the variability in the uterine lining during the approximately one-month-long menstrual cycle, the cervix and its mucus also go through a host of changes. After bleeding has stopped, the cervical mucus is usually scant, cloudy, and sticky. This lasts for about 3–5 days. What comes next is the stuff that you are taught to look for.

In the three to four days leading up to and after ovulation, the mucus changes to clear, stretchy, and fairly abundant. Following ovulation, the cervix becomes somewhat quiet, and cervical discharge remains scant. The “stage hands” behind the curtain setting the scene for the changes observed in cervical mucus are estrogen and progesterone production. Altering levels of estrogen and progesterone results in major modifications in mucus content and production.

If the cervix falls short on producing and maintaining its reservoir (a.k.a. mucus), problems can arise. However, while cervical factor infertility used to be considered a serious and real problem, today the cervix and cervical mucus production are hardly ever the cause of infertility (only about 3% of infertility cases are due to the cervix). Because of this, tests to evaluate the cervix/mucus are no longer needed.

Traditionally, a postcoital test (nicknamed the PCT) was performed to seek out cervical dysfunction. Now, picture this: fertility doctors used to obtain a sample of cervical mucus before ovulation and after intercourse and check it out under the microscope. They were looking for the presence (or absence) of moving sperm. Although this is sometimes used in couples that cannot have a formal sperm check, it is otherwise one for the ages. The subjectivity, poor reproducibility, and very inconvenient aspect of it have eighty-sixed the PCT in the land of fertility medicine.

In cases where the cervix has been previously cut, burned, or frozen, a narrowing of the cervical canal can arise (medically called cervical stenosis). Cervical stenosis can make procedures that require access to the uterus difficult (picture trying to pass something through a really narrow hole—it doesn’t fit!). Therefore, prior to undergoing any fertility treatment, a cervical dilation (that is, a widening of the cervix) may be required. This allows your doctor to then put sperm or embryos back into the uterus.

However, while the narrowing can make infertility procedures somewhat more challenging, the width is not what’s causing the entire problem. Cervices that have been exposed to trauma like surgery can have difficulty producing mucus. No mucus equals not much of a place for the sperm to hang out (cue IUI or IVF).

While the cervix may not be playing the feature role in the fertility play, it does serve as an important role. In addition to providing a respite to sperm, it also helps maintain a pregnancy to term. When a cervix shortens or dilates before time’s up, it can lead to a snowball of negative events: preterm labor and preterm delivery, to name a few. Bottom line, it’s not only a reservoir but also a roadblock. Until that nine-month mark has passed, it should not let anything out that front door!

Think about your cervix and cervical mucus but don’t drive yourself nuts. Yes it is a way to confirm ovulation but no it’s not the only way. While we are advocates of knowing your body and being aware of what’s going on with your cycle, obsessing over what’s going on won’t change what’s coming out. We have ways to get the sperm to meet the egg even if the cervix isn’t cooperating!

I’m Pregnant. Now What?

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Month after month of unhappy faces, single lines, and not-pregnant responses… When you finally see a smiley face, a double line, and/or (likely and, because most of us take about 20 tests to make sure it’s right) a pregnant message, you almost pass out. After the excitement, shock, and joy subside, anxiety, confusion, and uncertainty set in. What do I do now? And while we may not be on your speed dial, we can share with you a few of the pointers we point out to those that are!

First things first, take a deep breath. There is a lot that will happen over the next nine months, and you want to try and remain as calm as possible. (Good energy is transferred through the placenta!) After a few good, deep breaths, a bunch of OMGs this might actually be happening, and a call to your plus one (or best friend), the next step is to purchase a prenatal vitamin (if you aren’t already on one). Generic or brand, it really doesn’t matter. You just want to make sure that your body is chock full of nutrients and essentials to start nurturing that little one. If you haven’t already been taking one, there is no need to stress. You have not caused any damage or done any harm.

Additionally, if you have had a few cocktails, colored your hair, or partook in any activities that are off limits during pregnancy, don’t sweat it. The first weeks between ovulation and early pregnancy are what we OB/GYNS call the “all-or-none” interval. Your actions will either have absolutely no impact on the pregnancy, or they will result in a non-pregnancy/miscarriage type of situation. Simply stated, there will be no long-term effects on the fetus!

While the “all or none” gives you a get-out-of-jail-free card, you do want to start to alter your habits. Hang up your love of unpasteurized cheeses, your obsession with tuna (that one was hard for us, too!), and your passion for cold cuts. While you can still eat cheese, tuna, and cold cuts, the quantity needs to be reduced and the way they are cooked slightly altered. For example, cold cuts should be warmed before eating.

But don’t obsess about what you are eating in those first few weeks. Nausea is at its peak during this time, and whatever you can keep down is all you and your baby needs. Don’t stress if only grilled cheese, bagels with butter, and saltines are all that you are craving. Your lack of greens, veggies, and fruits won’t harm your little one. Your tastes will change shortly, and you can stock up on good things at that time.

It’s also a good idea to buy yourself a water bottle and make sure you are constantly sipping. The changes in blood volume that occur during pregnancy can make you dehydrated pretty quickly. To avoid that “Oh no, I am going to pass out” feeling, drink lots of fluid. And while we are on the drinking subject, it’s totally cool to continue with caffeine. A cup or two a day is definitely not a no-no. Furthermore, the occasional glass of wine, flute of champagne, or bottle of beer is not a big deal. While there is no safe amount of alcohol that can be consumed during pregnancy, a few drinks (over the nine months, not one day!) is certainly not going to do any damage.

From food, we transition to fitness. For all of you die-hards out there, pregnancy does not mean you have to hit pause on your fitness habits. Exercise in pregnancy is totally okay. You may need to tailor your exercises and taper the intensity, but staying active is A-ok. With that being said, the only things we are not fans of are the activities performed in 100 degree-plus heat (e.g., hot yoga). That temperature is not only going to seriously dehydrate you but also may not be so good for your baby’s developing organs. It is always a good idea to let your exercise instructor know that you are expecting. Most studios/fitness clubs have done a good job at training their teachers on how to modify and be mindful of moms to be.

After food and fitness, most women usually want to know about sex and personal grooming. Here’s the deal: sex is okay. Unless you start bleeding, there is really no reason to go on pelvic rest (aka- no sex). If bleeding should occur, we usually recommend resting (no sex, no exercise, and nothing in the vagina) until you are blood free for about 48 hours. After that, it is okay to give it another go. Most bleeding after sex is from the cervix or from the development of a tiny blood clot around the placenta, neither of which routinely cause a miscarriage.

In terms of personal grooming, continue pushing forward: bikini waxes, manicures, pedicures, facials, and massages are all good. Hair coloring is the only questionable practice on the list. We usually suggest sharing your news with your colorist and asking him or her to switch to a more suitable dye for pregnancy.

And finally, we arrive at family (a.k.a. whom should you tell and when). The telling part is totally up to you. While we always recommend that our patients share their news whenever and with whomever, remember that a positive test does not equal a baby. You may not want your 300+ Facebook friends to know that you just peed on a stick and saw a smiley face. However, you probably do want to tell your parents your sister and your BFF should anything go wrong and you need support. In general, most women wait until the one-third mark (about 12–13 weeks) before telling their employer and their Instagram. But bottom line is that this is a personal decision. Do what is right for you.

Make friends with a good Internet source (like Truly, MD!), buy a good book, and make sure you like your OB. He or she will serve as a guide during the next several months. You want to be comfortable and confident with your baby team. If someone or something is not working for you, kick them off, quickly! Your OB/GYN is like the coach of this team, so if you are not jiving with the coach, start looking for another team captain. This game is a big deal. These nine months, even for those of us who are not pregnancy lovers, are sort of sacred. There are only so many times in women’s life that they will be pregnant. So relish the good stuff—the first time you hear your baby’s heartbeat, the first time you feel movement, the first time you see your baby on the ultrasound, and the first time you hold your baby. You are in for a lot of firsts. Let us be the first to say congratulations on your pregnancy!

Under Pressure! Pre-Eclampsia

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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-eclampsia. For 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!

Lighting up Will Make You Lose Your Eggs!

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There are not many things in this world you can be sure of. In the words of Ben Franklin (shout out to all our fellow Penn alums), “In this world, nothing can be said to be certain except death and taxes.” And while we love you, Mr. American, we would like to add a third: cigarettes are bad for you! Despite the Marlboro Man’s best efforts, we all know nothing good can come out of lighting up. The litany of negatives when it comes to tobacco is so long, it couldn’t even fit on one page! Brain, lungs, heart, blood vessels, esophagus, stomach, hands, and feet are all victimized by the tar and tobacco filling that little white stick. While this may have been obvious to you, you may not have known how bad smoking is for your reproductive system.

Simply stated, smoking sucks for your reproductive system. Years of data have shown that smoking can lead to infertility and early menopause. In fact, women who smoke will go through menopause one to four years earlier than nonsmoking women. (Who wants hot flashes, headaches, and vaginal dryness before you need them?) And it seems that, the more you smoke, the more damage you do; with every puff you take, you are not only burning out your lungs but also your egg supply. Additionally, women who smoke are more likely to miscarry once pregnant. The chemicals in cigarettes can damage the DNA (genetic information) inside your egg and lead to a miscarriage. But it’s not only eggs that fizzle in the face of cigarettes; the fallopian tubes also sustain damage. Think of the tubes as tunnels. Their job (most of us have two!) is to transport the sperm to the egg and the fertilized embryo to the uterus. If blocked or damaged, the sperm or egg either never get together, or if they do, the embryo is more likely to get stuck on its way to the uterus. That’s called an ectopic pregnancy (pregnancy located outside of the uterus). Ectopics can be life threatening if not treated appropriately. How and why does this happen? Well, there are little hairs called cilia (we have them in our nose as well) that line the inside of our tubes. Imagine a car wash; think of the wipers that come beating down on the car when the wash first starts. That’s sort of like what the cilia look like, but rather than beating the dirt off your car, they are propelling the sperm to the egg and the embryo to the uterus. If they don’t work, you have a problem.

But get this. Even if you don’t smoke but your partner does, you are also in trouble. There are significant effects on a woman’s fertility from passive smoking (a.k.a. second-hand smoke). The effects of smoking on male infertility are less clear. Sperm function tests are poorer in smokers. There is not clear, conclusive evidence that men who smoke are more likely to be infertile, but given the impact it has on your female partner, guys, we urge you to put it out!

So let’s say you can’t quit and you find yourself pregnant and smoking. Then what? What impact is your habit having on your unborn child? If you have ever taken biology, you probably guessed it: not a very positive one! Babies born to women who smoked are at risk for growth restriction (stunted growth) inside the uterus, small birth weight, early/preterm delivery, stillbirth, and problems with the placenta.

But we get it. Despite all that, going cold turkey can be hard. Habits, no matter how bad, are hard to break. And because of all the “yuck” that is inhaled, it is actually not only okay but preferable to start nicotine replacement therapies (the patch, the gum, etc.) during pregnancy and when trying to conceive rather than continuing to smoke. Yes, they have their effects and are no prenatal vitamins, but they are way better than the tar and tobacco that you are inhaling. There are no ifs, ands, or buts about it, butts are bad for your lungs, bad for your heart, bad for your brain, bad for your skin, bad for your ovaries, and unbelievably bad for your unborn baby. You will burn through your wallet, your lungs, and your eggs. So take it from us. Put out that cigarette, and never pick one up again!