REPOST: Daily Checkup: Preventive care is the key to dealing with high risk pregnancies

 The saying, "prevention is better than the cure," applies to everyone, most especially to pregnant women. Dr. Joanne Stone, Division Director of Maternal Fetal Medicine at Mount Sinai Hospital, talks about identifying potential threats as a way to avoid adverse outcomes in this New York Daily News article below:

The Division Director of Maternal Fetal Medicine at Mount Sinai Hospital, Dr. Joanne Stone specializes taking care of women who have high risk pregnancies. She has been working in the field for over 20 years. | Image Source: nydailynews.com

The Specialist

The Division Director of Maternal Fetal Medicine at Mount Sinai Hospital, Dr. Joanne Stone specializes taking care of women who have high risk pregnancies. She has been working in the field for over 20 years.

WHO’S AT RISK

What is considered a high risk pregnancy? “While there’s no absolute definition, in general there’s either something about the mother’s condition that places her at high risk or something specific to the pregnancy itself — for instance, if it’s twins, triplets, or there are fetal anomalies,” says Stone. “Age increases a woman’s risk for complications, as do many medical conditions including diabetes, ulcerative colitis and Crohn’s disease, obesity, and high blood pressure.” Pregnancy risks are elevated for women over the age of 35.

Pregnancy risk is assessed on a spectrum. “There are extremely high risk patients — like a woman who has a renal transplant and has had a heart attack,” says Stone. “A healthy 32-year-old woman carrying twins would be a much lower risk situation, but some women will still consider themselves at high risk in that case.”

The idea behind identifying the risk level of a pregnancy is to emphasize preventive care, not to raise expecting moms’ anxiety levels. “Identifying potential problems is a way of preventing adverse outcomes,” says Stone. “For instance, it’s important for women with diabetes to have excellent blood sugar control for two to three months before conception — then their risk of birth defects is no higher than the general population.”

Women who have been pregnant before can also be an increased risk. “A pregnancy is considered high risk if the mother obstetrical history includes premature birth, a prior still birth, multiple miscarriages, or having a baby that was extremely small,” says Stone. “The good news is that for women who have had a prior preterm labor and delivery, we have medications that have been proven to lower the risk of recurrent pre-term birth. For other women who have had a prior small baby or stillbirth, we can do a workup to try to identify and cause and help prevent in from happening again.”

SIGNS AND SYMPTOMS

By identifying high risk patients, doctors hope to prevent them from developing symptoms in the first place. “Prevention and management are our goals,” says Stone. “For instance, if you have a history of blood clots, we can put you on blood thinners to prevent that from occurring.”

If something does go wrong, there are some red flags to look out for. “One symptomatic disorder is preeclampsia, which can cause headache, visual changes, pain in the upper right side, and elevations in blood pressure,” says Stone. “Patients with some medication conditions, like significant kidney disease or diabetes, or who are carrying a pregnancy of multiple fetuses, are more likely to have pre-term labor. Its signs are feeling menstrual-type cramps that are getting worse, leaking fluid, and feeling a lot of pressure.”

TRADITIONAL TREATMENT

Any necessary treatment regimen will depend on the underlying condition or factor that makes the pregnancy high risk. “The management of diabetes is very different for pregnant women — their glucose control needs to be tighter than when they are not pregnant,” says Stone. “If the maternal blood glucose is too high, it crosses the placenta and causes the baby’s pancreas to start producing excess insulin.” These women are also at risk of the baby’s being big, so doctors perform more frequent ultrasounds.

Modern day technology allows doctors to track the fetus’ development much more carefully. “For women who have developed antibodies against the fetus’ red blood cells from a previous pregnancy, we can monitor the blood flow in the fetus’ brain to tell if the baby is getting anemic, in which case we can do an in utero blood transfusion,” says Stone. “In some cases, the fetus can develop a bladder outlet obstruction that can damage the kidneys, which we can fix by placing a shunt.”

There’s a long list of conditions that can raise a pregnancy’s risk of complications, but doctors can hold most of them in check. “There are very very few times when I counsel a patient that they shouldn’t get pregnant — the vast majority of diseases are manageable,” says Stone. “There's so much we can do to optimize the outcomes for patients, and most of them can do very very well."

RESEARCH BREAKTHROUGHS

Doctors are continually pushing forward with research projects. “At this point, we can now do in utero surgery for some babies who are diagnosed with spina bifida, an opening in the vertebral column,” says Stone. “This surgery can make a huge difference. We’re constantly doing research to improve outcomes for the major problems.

Questions for your doctor:

If you’re considering getting pregnant, ask you doctor, “Can I have a pre-conceptual consult?” It’s a good idea to go over your personal history, family history, and any medications you’re taking — for instance, you might need to swap out one of your medications for blood pressure, seizures, and depression. Be up-front about asking, “What screening do I need?” And follow up with, “Are there any tests that I don’t need?”

“Coming up with a management plan can help reduce adverse outcomes,” says Stone. “We now know so much about the diseases and about pregnancy — there’s a lot we can do to help women have the healthiest pregnancy possible.”

WHAT YOU CAN DO

Get informed .

If you have questions about what tests are appropriate for you, check the Choosing Wisely website — part of a campaign to help doctors and patients form a testing plan that is evidence-based, safe, not duplicative, and “truly necessary.” Mount Sinai also hosts a plethora of information on high risk pregnancies (mountsinai.org/patient-care/service-areas/obgyn-and-reproductive-services/areas-of-care/pregnancy-and-birth/maternal-fetal-medicine).

Keep moving.

“Exercise is good for the vast majority of patients — it helps control blood glucose and blood pressure,” says Stone. “Talk to your doctor about what exercise routine is right for you.”

Avoid high-mercury fish-and undercooked hot dogs.

Swordfish, mackerel, kingfish, and tilefish should be avoided entirely, and tuna should only be consumed in limited qualities; undercooked hot dogs are the “No. 1 culprit” for spreading listeria, a common food-borne bacteria.

Moderation is the watchword.

“Most things in moderation are okay — 1.5 cups of coffee a day has been shown to be safe,” says Stone. “And you can take a Tylenol if you have a headache.”

Don’t hesitate to call your doctor.

Raise your questions and concerns directly with your doctor. “There’s some good information on the Internet and some really bad information,” says Stone.

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Understanding morning sickness: Signs and symptoms

Image Source: parentables.howstuffworks.com

According to Morning Sickness USA, morning sickness affects 85% of pregnant women. Symptoms begin to manifest around the 4th week to 6th week of pregnancy. The following are the common symptoms women may experience with morning sickness:

• Nausea
• Sensitive sense of smell and taste
• Fatigue

Morning sickness is defined as a nauseous, queasy feeling in your stomach that may or may not cause vomiting. It is actually a misnomer because morning sickness can happen at any time of the day. It is caused by hormones and increased amount of stress and changes in the body aligned with the pregnancy. Though there isn’t any surefire cure to stop morning sickness, AmericanPregnancy.org created this list of tips to alleviate the feeling of nausea:

Image Source: americanpregnancy.org

• Eat small meals often
• Drink fluids 1/2 hour before or after a meal, but not with meals
• Drink small amounts of fluids during the day to avoid dehydration
• Eat soda crackers 15 minutes before getting up in the morning
• Eat whatever you feel like eating, whenever you feel you can
• Ask someone else to cook for you and open the windows or turn on fans if the odor bothers you

• Get plenty of rest and nap during the day
• Avoid warm places (feeling hot adds to nausea)
• Sniff lemons or ginger, drink lemonade, or eat watermelon to relieve nausea
• Eat salty potato chips ( they have been found to settle stomachs enough to eat a meal)
• Exercise

Generally, morning sickness will not harm you or your baby but there are extreme cases where women experience excessive vomiting and inability to keep food down. This condition is called hyperemesis gravidarum. Unlike common morning sickness, hyperemesis gravidarum can be harmful for the baby and should not be left untreated. You should raise any concerns with your attending gynecologist should symptoms appear and talk about proper treatment.

Image Source: peoplescommclinic.org

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REPOST: Kate Middleton Suffering from Hyperemesis Gravidarum. What Does It Mean?

Vomiting and nauseousness is often attributed to morning sickness among pregnant women but this article from Yahoo raises awareness regarding a more serious condition called hypermeses gravidarum (HG), a condition that even the British royalty is not immune to. Find out more about HG below.

Image Source: yahoo.com

For most people, a bout of vomiting is something akin to torture. So it’s easy to sympathize with pregnant-again Kate Middleton who, it’s just been revealed, is suffering from a debilitating condition called hyperemesis gravidarum (HG), which causes persistent nausea and vomiting to the point of weight loss and dehydration, apparently making standard morning sickness look like a walk in the park.

It’s the duchess’s second bout with the condition. She also suffered through it during her first pregnancy, with Prince George, who is now a year old. And now, not quite 12 weeks into her second pregnancy, she’s being treated for HG once again — which is not all that surprising, since women who have HG in one pregnancy tend to have it again, though often less severely than the first time around. “The Duchess of Cambridge’s second pregnancy with HG is a reminder: Women who experience this condition face an 80% chance of repeat diagnosis in future pregnancies,” noted a statement from the HER Foundation, a grassroots network of HG survivors and an information clearinghouse on the condition. “And while the severity and duration of symptoms vary among women, HG remains a debilitating and even life-threatening medical condition that can have serious consequences for the health of both mom and baby.”

Since the condition is genetic, 20 percent of women who are affected have a sister who also had HG, and 30 percent have a mother who had HG, Marlena Fejzo, of Harvard University, a leading researcher on HG, told Yahoo Health.

“It’s terrible,” said Fejzo, who is an advisory board member with the HER Foundation. Maternal complications of severe HG, she said, can include detached retinas, fractured ribs, blown eardrums and esophageal tears, she said, all a result of frequent vomiting, as well as malnutrition. Fejzo has found through her research that 18 percent of women who suffered through an HG pregnancy wind up with post-traumatic stress disorder, while 37 percent decide to not have any more children because they don’t want to endure HG again. In addition, 15 percent of HG sufferers wind up making the painful decision to abort, often referred to as a “therapeutic termination,” she said. There have also been a few reports of maternal deaths, as a result of stomach tears and bleeding. “So it’s very severe,” she noted.

“It is a devastating condition,” Dr. Irina Burd, director of research for the division of maternal fetal medicine at Johns Hopkins University in Maryland, told Yahoo Health. It’s also quite rare, affecting only about one to two percent of pregnant women. “We try to manage with a patient’s treatment at home, but it often winds up with a hospitalization,” Burd said. “Every patient and every situation requires a personalization of care.” The constant nausea and vomiting can lead to dangerous vitamin deficiencies, weight loss, and dehydration for the affected mom-to-be, which is why hospitalization is so often required, though Middleton has not yet reached that point this time around.

It’s not known what causes HG, although it’s widely understood to be related to rising levels of the pregnancy hormone, hCG (human chorionic gonadotropin), and how, in certain individuals, that may trigger the part of the brain affecting nausea and vomiting. “We are on the cusp [of understanding the root cause],” Fejzo said. “But as far as a genetic study and finding the cure, we’re just getting there.” Other factors triggering HG seem to include rising estrogen levels, gastrointestinal changes, and high-fat diets.

While effects on the fetus seem to be rare, some research has indicated that babies whose mothers suffered an HG pregnancy are more likely to be premature or have a low birth weight, or to be vitamin-K deficient, Fejzo noted.

Treatments vary greatly, Burd said, and often begin with dietary changes and the consumption of small, protein-filled snacks rather than large meals. If weight loss continues, and the patient is hospitalized, treatments can include pyridoxine, a high-dose vitamin B6, and doxylamine, an antihistamine, the combination of which can ease nausea, Burd explained. Reglan and Zofran have also been effective, Vincenzo Berghella, president of the Society for Maternal-Fetal Medicine, told Yahoo Health. “Even ginger, or those acupressure wristbands, like people use for seasickness, can help,” he said, adding that symptoms of HG most often spike between the 10th and 12th week of pregnancy, often subsiding between week 14 and 16. But for those for whom it lingers, life can be difficult.

“I wouldn’t wish hyperemesis gravidarum even on evil people,” wrote Parents blogger Kristen Kemp in a revealing first-person essay during news Middleton’s first difficult pregnancy. “Hyperemesis gravidarum (HG) tried to kill me during both of my pregnancies. I took gobs of medication, checked in for several stays at the hospital and, as a last resort, considered abortion at the suggestion of my ob-gyn.” She managed to move past that idea, although it was a very tough road — one that often had her questioning her sanity. But, she soon realized, “I had a freak illness, but I was not a freak. Just ask Kate Middleton.”

Find out more about the conditions that may arise during pregnancy and how to treat them by following Louis Habash on Facebook.

REPOST: Fetal Pain – When Does Pain Become Pain?

 Expecting mothers usually have a lot to worry about. One of these causes of anxiety for mothers is whether their babies feel any pain. This article from Brain Blogger discusses the subject of fetal pain in depth.

Image Source: brainblogger.com

Whether fetuses do indeed feel pain and, if they do, when do they acquire the ability to feel it are matters of great debate.

Fetal pain is a subject that is particularly prone to controversy, stretching far beyond its scientific aspects. And there is always increased attention to this topic whenever legislative changes regarding the intentional termination of pregnancy are impending.

Research on fetal pain is understandably complicated. The first and most obvious difficulty is that you cannot ask a fetus if something hurts and, therefore, there is never certainty that there is pain. When talking about pain, one must keep in mind its definition, which, according to the International Association for the Study of Pain, is: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

The emotional component of pain entails the need for consciousness to allow the recognition of the unpleasantness of a stimulus. It is this subjective cognitive component of pain that distinguishes it from nociception, which is defined as the neural processes of encoding actual or potentially tissue-damaging events.

Pain is a psychological state and therefore, when trying to infer whether fetuses can feel pain, not only the capacity to detect potentially painful stimuli, but also the capacity to consciously perceive them have to be evaluated. That possibility has to be inferred from data such as fetal anatomy, neurochemistry, behavior, the development of neural circuits, and the production of stress related hormones in response to stimuli. But even these aren’t easily studied.

In order for a stimulus to be perceived as painful, a whole circuitry has to be fully developed: information must travel from spinal cord neurons, whose axons project to the thalamus, which sends afferents to the cerebral cortex. From what research, within its limitations, has been able to determine, functional sensory fibers and spinal reflexes can be found by 20 weeks of gestation, as well as connections to the thalamus. However, this path becomes fully functional only in the third trimester, around 29 to 30 weeks’ gestational age, when mature projections from the thalamus to the cerebral cortex are present.

Although withdrawal reflexes in reaction to cutaneous stimulation are observable at earlier developmental stages, these do not imply effective pain perception since they are not specific to nociceptive stimuli and are not dependent on cortical mediation. Likewise, stress responses such as increased blood flow, heart rate and respiratory rate, as well as neuroendocrine changes that include increased production of catecholamines, cortisol, and other stress hormones, or increased beta-endorphin or noradrenaline release, can also be observed early in the second trimester, but again, these are not necessarily indicative of pain perception.

Overall, amidst the debate, with some arguing that fetusus can feel pain earlier by using subcortical structures, and others arguing that the fetus cannot feel pain by being maintained in a state of sedation in the womb, it is generally agreed that the minimal necessary neuronal pathways for pain are in place by 24 weeks gestation.

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REPOST: Skin-to-skin contact 'all benefits' for moms, babies

Read about the positive effects of skin-to-skin contact between mother and child immediately after birth from this article at Clinicaladvisor.com:
 

Image Source: clinicaladvisor.com

Over the last year, the hospital that I work with has been making strides towards achieving the Baby-Friendly designation.

The Baby-Friendly Hospital Initiative is a program that was started by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) to encourage practices that promote breastfeeding and maternal/newborn bonding. This, in turn improves outcomes for both mothers and newborns.

In order to receive the Baby-Friendly designation, a hospital or birth center must prove that they are providing evidence-based care and following strict the guidelines for best practices, as laid out by WHO and UNICEF. These practices are all focused on early initiation of breastfeeding and maintenance of lactation beyond the hospital stay.

One of my favorite things about striving for the Baby-Friendly Hospital Initiative is the promotion of immediate skin-to-skin contact between a mom and her newborn after birth.

Long supported by midwives, the practice of putting a baby on his mother's bare chest immediately after birth is not a new idea. But for years, hospitals insisted on whisking the baby away to clean, dry, warm, and assess him. Growing research, however, is now proving the benefits of immediate and ongoing skin-to-skin contact between a mother and her infant.

Evidence has shown that skin-to-skin contact immediately following birth promotes a faster and easier transition from fetal to newborn life. These babies have better temperature, respiratory, and glucose regulation and show an overall lower stress level than babies that are separated from their mothers.

On the maternal side, mothers who have their newborns skin-to-skin after birth tend to breastfeed for a longer period of time, have improved maternal bonding behaviors, and less anxiety.

This practice should not be limited to vaginal deliveries. Whenever possible, newborns delivered by cesarean section should be skin-to skin with the mother as soon as possible. This may be more difficult for hospital staff and nurses, because the operating room tends to be crowded and everyone has a designated assignment.

Personally, when I attend one of my patient's cesarean births, I am there purely for the emotional support of the mother, so I am the perfect person to assist with skin-to-skin in the OR.

Every time I've placed a newborn on his mother's skin after a cesarean, I see a remarkable transformation that seems to be more dramatic and pronounced than skin-to-skin after a vaginal birth. Not only does the baby quiet down, open his or her eyes, and begin rooting behaviors, there is an immediate change in the mother. Her continuously monitored heart rate and respirations slow, she relaxes, and becomes less worried about the surgery. She is usually completely focused on her baby.

As long as the mom and newborn are healthy, the practice of skin-to-skin has no risks, and only benefits. In fact, WHO recommends that all newborns receive skin-to-skin care, regardless of the infant's gestational age, birth weight, or clinical condition.

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REPOST: During childbirth, serious anesthesia complications are 'very rare'

 This article from Medical News Today shares the findings of a study on the risks presented by anesthetics to pregnant women:

Image source: http://www.medicalnewstoday.com

For expectant mothers, the decision of whether to receive an epidural, spinal or general anesthesia during labor comes with certain risks to consider. But a new study suggests serious complications from such anodynes are quite rare and occur in only 1 in every 3,000 births.

The study - led by Dr. Robert D'Angelo, of Wake Forest University School of Medicine in North Carolina - is published in Anesthesiology, the journal of the American Society of Anesthesiologists.

An epidural is a local anesthetic that is delivered to the mother through a catheter placed in the back. While a spinal is similar to an epidural and is administered through a needle into the spinal canal, the effects of this procedure are felt immediately.

According to the American Pregnancy Association, epidurals are the most popular method of pain relief during labor; 50% of women who give birth at hospitals use epidurals.

Though these anesthetics provide comfort from the pain of childbirth, they also carry some risks. Some of these include serious complications, such as:

• High neuraxial block - an unexpected high level of anesthesia that develops in the central nervous system
• Respiratory arrest in labor and delivery
• Unrecognized spinal catheter - an undetected infusion of local anesthetic through an accidental puncture of an outer spinal cord membrane.

In the first multi-center study of its kind to look at rates of serious complications linked to anesthesia, Dr. D'Angelo and his team used data from the Society for Obstetric Anesthesia and Perinatology's (SOAP's) Serious Complication Repository (SCORE) project.

This is a large database that captures delivery statistics and tracks complications.

Complications rare, but anesthesiologists 'should remain vigilant'
From 30 institutions between 2004 and 2009, the team found more than 257,000 deliveries where epidural, spinal or general anesthesia was given during childbirth; this included both vaginal and cesarean deliveries.

In total, there were 157 complications reported, and 85 of them were linked to anesthesia.

Though this is a small number of complications given the large sample size, the researchers observed the most common anesthesia-related complications: 1 in 4,336 deliveries resulted in high neuraxial block, 1 in 10,042 resulted in respiratory arrest in labor and delivery, and 1 in 15,435 resulted in unrecognized spinal catheter.

Commenting on their findings, Dr. D'Angelo says:
"We were extremely pleased to find that serious complications such as bleeding, infection, paralysis and maternal death were extremely rare. However, since many complications can lead to catastrophic outcomes, it is important that anesthesiologists remain vigilant and prepared to rapidly diagnose and treat any complication, should it arise."

The team intended to identify risk factors associated with the complications so that they could create formal practice advisories or guidelines, but because serious complications linked to anesthesia were so rare, they say there were too few complications in each category to identify these risk factors.

Even so, the researchers say their findings can be used to guide discussions with patients.

Additionally, the findings will be used to create a national obstetric anesthesia complication registry, as part of the Anesthesia Incident Reporting System. This system will be able to alert anesthesiologists and create new educational materials for patient safety, the team says.

Medical News Today recently reported on a study that suggested changing the way a baby is held before its umbilical cord is clamped could improve rates of iron deficiencies in newborns.



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REPOST: Gestational diabetes may increase heart disease risks for pregnant women

Researchers said that gestational diabetes only occurs during pregnancy and may be associated with atherosclerosis. Read more from this Medicalnewstoday.com article.

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Pregnant women who develop gestational diabetes may be more at risk of developing heart disease later in life, according to new research.


 Image Source: scitechdaily.com
 
Researchers at Kaiser Permanente Northern California in Oakland have published the results of their 20-year study in the Journal of the American Heart Association.

Gestational diabetes only occurs during pregnancy. It happens when hormones activated during pregnancy weaken the effect of insulin, the hormone that normally allows cells to absorb glucose from the blood.

Factors that can make pregnant women at greater risk of getting gestational diabetes include having a family history of diabetes, having previously had an unexplained miscarriage, being older than 25 when they became pregnant or being overweight before becoming pregnant.

Women who develop gestational diabetes are usually able to control their blood sugar without harming their baby's health. But having gestational diabetes does make women more likely to develop diabetes 5-10 years after giving birth.

The new study finds that women who get gestational diabetes while pregnant also have an associated risk of atherosclerosis - where the arteries around the heart become clogged by fatty substances. Because atherosclerosis disrupts the flow of blood to and from the heart, this can eventually cause heart attacks and other cardiovascular diseases.

 
Image Source: whattoexpect.com

Study tracked women's metabolic and heart health over 20 years In the study, 898 women aged between 18 and 30, who later had children, were assessed for heart disease risk factors. Over a period of 20 years, the women were periodically tested for diabetes and other metabolic conditions. An average of 12 years after giving birth, the thickness of the walls of their carotid arteries was also measured using ultrasound.

Overall, 13% of the women in the study developed gestational diabetes. On average, the carotid artery walls of these women was 0.023 mm thicker than those of women who did not have gestational diabetes while they were pregnant.

The thickness of carotid arteries is used by doctors to measure atherosclerosis and predict heart attack and stroke.

The researchers also took into account other factors that might have influenced the thickness of the women in the study's arteries, such as whether the women were obese, or if they had high glucose levels before pregnancy.

"This finding indicates that a history of gestational diabetes may influence development of early atherosclerosis before the onset of diabetes and metabolic diseases that previously have been linked to heart disease," says study lead author Erica P. Gunderson, PhD. "Gestational diabetes may be an early risk factor for heart disease in women."

 
Image Source: cdc.gov

"It's a shift in thinking about how to identify a subgroup at risk for atherosclerosis early," she added.

"The concept that reproductive complications unmask future disease risk is a more recent focus."

Louise Habash is an obstetrician specializing in maternal-fetal medicine. Visit this Facebook page to read more article about pregnancy.