Pregnancy Dos and Don’ts

Pregnancy is a great time, an exciting time, but it’s also a time of endless questions. Women have access through social media, television, print media, Internet searches, and their friends to much information about pregnancy, but sometimes it can be confusing or wrong. There are many questions about all facets of life including eating, drinking, sleeping, working, travel, exercise and having sex.  We are often asked these questions by our patients, and in the recent issue of our professional publication, Obstetrics and Gynecology (April 2018, p713), Dr. Fox wrote a nice summary about current, science-based recommendations regarding these topics. I’m going to summarize them for you in this article.

Prenatal Vitamins

Prenatal vitamins are designed to meet the needs of pregnant women. However, except for folic acid, iron and Vitamin D, it’s unknown if taking them makes a difference in outcome. For women with well-balanced nutritious diets, they are probably not required. Folic acid deficiency is associated with fetal birth defects, so women who don’t have it in their diet should be on 400-800 micrograms a day. Women who have had a history of a previous pregnancy complicated with a neural tube defect should be on 4,000 micrograms a day. Iron supplementation is advised to increase the mother’s blood count to avoid becoming anemic at birth.  It is more needed if the mother’s blood count is low to begin with. Vitamin D deficiency is associated with pregnancy problems including pre-eclampsia and premature birth. While testing for Vitamin D levels is not routinely recommended, taking Vitamin D (usually 200-600 IUs) daily is. Calcium supplementation has been shown to decrease high blood pressure in pregnancy. Women should be sure to consume through diet or supplements at least 1,000 mg of calcium per day. Some prenatal vitamins don’t have that much.

Nutrition and Weight Gain

Pregnant women should eat a healthy, well-balanced diet and usually should increase their calorie intake in the second and third trimesters by only a small amount, about 350-450 calories per day. A good nutrition resource is a website run by the U.S. Department of Agriculture at www.chooosemyplate.gov. Women with higher pre-pregnancy weight should not gain as much as women with normal or low weight.

Alcohol

High alcohol intake in pregnancy has been associated with fetal malformations. Studies in Denmark and Australia have found no association between a low level of maternal drinking (less than one drink per day) and developmental cognitive abilities in children. However, the threshold for safe drinking is not known, and it can’t be concluded that a small amount of drinking is safe. All major health organizations recommend abstaining from alcohol completely during pregnancy.

Artificial Sweeteners

There is no evidence that aspartame (NutraSweet), sucralose (Splenda), acesulfame potassium (Sunett), stevioside (Stevia) or saccharin (Sweet N Low) cause birth defects.

Caffeine

Most studies in humans show that low to moderate caffeine use is not associated with any adverse outcomes. Some animal studies suggest that high caffeine intake (greater than 10 cups per day) slightly increases the risk of miscarriage.

Fish

Eating fish conveys both benefits and potential risks. Benefits are that studies have shown eating fish in pregnancy resulted in improved neurodevelopment in children, and also lowered the risk of premature birth. However, fish is also a potential source of mercury exposure and mercury can cause harm. Therefore pregnant women should try to consume 2 to 3 portions weekly of fish that are high in long chain polyunsaturated fatty acids and low in mercury, such as anchovies, Atlantic herring, Atlantic mackerel, mussels, oysters, farmed and wild salmon, sardines, snapper, and trout. Other safe fish which have less fatty acids include shrimp, pollock, tilapia, cod and catfish. Women should avoid fish with higher mercury content such as king mackerel, shark, swordfish, marlin, and tilefish. For women who do not consume 2 to 3 servings of fish a week, there is no clear evidence that supplementation with omega-3 fatty acids improves outcome in children, but they are unlikely to be harmful.

Most health organizations advise women to avoid raw fish in pregnancy. However, the fish that typically makes up sushi (tuna, salmon, yellow tail, snapper, flounder) rarely carries parasites. Therefore, the risk of infection from eating well-prepared sushi in a clean and reputable establishment is not significant.

Other Foods to Avoid

Food restrictions in pregnancy are designed to minimize exposure to harmful infections such as toxoplasmosis and Listeria.  To lower the risk of toxoplasmosis, avoid eating raw and undercooked meat, and wash all fruits and vegetables before eating them. To lower the risk of Listeria, avoid unpasteurized dairy products, raw sprouts, unwashed vegetables, and unheated deli meats. While Listeria outbreaks were linked to deli meats in the 1990s, recently outbreaks were caused by ice cream, cantaloupes, hummus, and unpasteurized dairy products, so it’s difficult to make a list of safe foods without becoming overly restrictive.

Smoking and Nicotine

Smoking in pregnancy is harmful to both maternal health and to fetal health, causing many possible pregnancy complications. Although some of the adverse effects of smoking are due to nicotine, nicotine products designed to aid in smoking cessation are acceptable as part of a smoking cessation program, since nicotine in gum or a patch would reduce exposure to other toxins in cigarettes and in second hand smoke.  Other interventions such as bupropion and varenicline are thought to be effective and safe, but data is limited. Electronic nicotine delivery systems such as electronic cigarettes and vaporizers deliver high amounts of nicotine and could potentially be harmful, but less is known about them.

Marijuana

Marijuana is the most common illicit substance used in pregnancy. Current evidence shows that marijuana use in pregnancy is not associated with premature birth, low birth weight, or an increased risk of birth defects. Doses of it are not regulated and could vary significantly. Current recommendations are to avoid marijuana in pregnancy due to concerns about fetal neurodevelopment.

Exercise and Bedrest

Women with normal pregnancies should engage in regular aerobic and strength conditioning exercise. It is prudent to avoid exercise with a higher risk of injury such as contact sports, downhill skiing, and horseback riding. Women should try to moderately exercise 20-30 minutes four to five times a week. Moderate exercise is at the level at which women can still talk while exercising.

Bedrest, or activity restriction, is associated with several risks and has not been shown to be beneficial in pregnancy. Activity restriction has not been shown to be beneficial for women with high blood pressure, premature rupture of membranes, fetal growth restriction, or placenta previa.

Avoiding Injury in the Car

Pregnant women should continue to use three-point seatbelts in pregnancy. The lap belt should be placed across the hips and below the uterus. While airbags can also reduce the risk of injury, deployment of an airbag itself can also cause injury. It’s unclear if they are beneficial or harmful.

Oral Health

Oral health and routine dental procedures should continue as scheduled during pregnancy, including cleanings, extraction, root canal and fillings. X-rays can be done if the abdomen and thyroid are shielded.

Hot Tubs and Swimming

Hot tubs have the potential to increase body temperature, which is considered a risk for miscarriage and birth defects. It is thought to be more potentially harmful if it is done within the first 4 weeks from the last menstrual period, or if it is done more often.

Swimming pools are typically maintained below normal body temperature, and their use is not associated with harmful outcomes.

Insect Repellents

Topical insect repellants can be used in pregnancy because they are not associated with adverse fetal effects. As a result of the risk of mosquito-borne illnesses including Zika virus, their use in high risk areas is recommended.

Hair Dyes

Most studies on exposure to hair dye relate to the profession of cosmetology, and studies are mixed as to whether or not there is increased risk of pregnancy loss in that setting. Data on safety is limited, but for an individual pregnant woman, exposure to hair dye results in minimal systemic absorption, so hair dyes are presumed safe in pregnancy.

Travel

Airline travel is considered safe in pregnancy, but it is prudent to take precautions to lower the risk of a blood clot by periodic walking.  Pregnant women may go through security metal detectors. The radiation exposure from the newer backscatter units is also safe. In regard to travel destinations, women should be aware of the potential infection exposures (including Zika virus) as well as the availability of medical care at their destination. As the length of the pregnancy advances, the risk of travel increases, but there is no exact gestational age at which women cannot travel. In our office, it’s our policy to not allow distant travel in the last two months.

Sexual Intercourse

Sex and orgasm are not associated with an increased risk of pregnancy complications or premature birth. For women with vaginal bleeding or ruptured membranes, the risks of bleeding or infection may increase. Although there is little data to support it, most authorities recommend avoiding sexual intercourse after 20 weeks of pregnancy if a placenta previa is present.

Sleeping Position

Women are frequently advised to sleep on their sides, especially the left side. Several retrospective studies (limited by recall bias) have shown an increased risk of stillbirth when sleeping flat on one’s back. Considering the limitations of these studies as well as not knowing more about the benefits of side sleeping, it’s unclear if side sleeping conveys a benefit, how much it reduces risk and when. It’s our office policy to not recommend sleeping flat on your back in the last 2 months of pregnancy. Sleeping on your side or on your back being tilted up by additional pillows should be safe.

 

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Should I have a birth plan?

 

by Bailey K. Cannon, MD

We get this question a lot. You may have heard about birth plans from your friends, the internet, or even the hospital. What is a birth plan? It is a document that states your wishes for delivery. That sounds like a nice idea but when it comes to labor and delivery the only person who is in charge is the baby. Have you ever planned a family vacation and you have the great plan of how things will go, what restaurants you’ll eat at, and the sights you will see? Then only to find the roads are under construction, the restaurant you really want is closed, and the parks are closed for maintenance. You may still have had a great time but feel a little let down because “not every went as planned.” The same is true with birth and plans for it.

In our office we do not encourage birth plans. Our ONLY plan is for a healthy mom and a healthy baby. Additionally, a vaginal delivery is also always our first wish for you. We certainly care about your preferences and will discuss any ideas you may have. You are welcome to bring any music, scents, clothes, etc. that you would like. Additionally, during labor if there is a choice: we will always give you that choice. Such as: Would you like an epidural or not? That choice is 100% up to you – we are happy either way. We may use our medical education and training to suggest an intervention that we feel will help you, but as long as it is safe – you are welcome to decline. If ever you or the baby are in danger we will immediately make a medical decision and we hope you will agree.

While we do not encourage birth plans, should you desire a birth plan we will be happy to review it in the office and discuss what is reasonable or what things may be unsafe. There are many unsafe recommendations on the internet. We have included a birth plan from the March of Dimes that we think is a good choice in birth plans.

Our only plan for you is a healthy baby and healthy mom. We look forward to achieving this goal together.

Click on the following to see a sample birth plan:

 

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Finding Breast Cancer

One in eight women in the United States will be diagnosed with breast cancer. The longer someone has breast cancer before it is detected, the more difficult the treatment becomes and the worse the odds of survival. One of the best ways to find breast cancer earlier is by self-exam.

The Worldwide Breast Cancer organization has come out with a nice campaign using photos designed by a breast cancer survivor to help increase awareness of how to find breast cancer.

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what-am-i-feeling-in-a-bsehow-to-find-cancer

 

This campaign gets the point across effectively and can be used in social media posts to help spread the word. The original photo has been shared nearly 35,000 times and seen by more than 3 million people. Just think about how many lives can be saved!

If you find anything like this in your breast self exam, please let your doctor know about it!

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Long or Short, Which is Better?

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A study was just released which will be coming out soon in the American Journal of Obstetrics & Gynecology ( http://dx.doi.org/10.1016/j.ajog.2016.08.033 ). It looks at two different groups of reversible birth control methods, long acting and short acting. Long acting methods of birth control include the Nexplanon implant, the Mirena IUD and the Paraguard IUD. Short acting methods include the pill, the patch and the ring.

To see if there is a difference in success rate based on which women choose long versus short acting methods, the women who chose to participate in the study were assigned one of these groups randomly and received their contraceptives for free. Women who did not agree to randomization still submitted their results but did not receive the medication for free.

The results were striking. Of 916 participants the study, after 12 months there was an unintended pregnancy rate of 6.4% in those who were not randomized and instead chose a short term method, 7.7% in those who agreed to randomization and were assigned to the short term method group, and 0.7% for those who were randomized to the long term contraception group.

The study shows, comparing the two different classes of methods, women who use short acting birth control methods such as the pill have a ten times greater chance of becoming pregnant by accident compared with longer acting methods such as the implant or the IUD. This is true whether a person prefers one type of method or is randomly assigned to it. This may be related to the greater requirements of being on short term methods, with many more opportunities for failure to take it every day and on time. Longer acting methods have less opportunities to make mistakes.

It appears that most women are not aware of the large difference in effectiveness between these two types of birth control methods. If this information were more widely known, more women would choose the type of method with a less than 1 percent failure rate in a year rate compared with one that fails 6 to 7 percent over the same amount of time.

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Chronic Vaginal Infections

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I’m at 2016 ACOG!

I recently heard an informative lecture at the 2016 ACOG Annual Clinical Meeting about new research and treatment of chronic vaginitis. Dr Chemen Tate from the Indiana University School of Medicine spoke about the different causes of chronic vaginal infections. While most people associate vaginal infections with yeast, the actual leading cause of vaginal infections is Bacterial vaginitis, which comprises 50% of infections, compared with only 25% for yeast.

Bacterial vaginitis causes an increased discharge with a bad smelling odor. It is usually not associated with inflammation. There is found to be a reduction of the amount of lactobacilli, which usually serve to protect the vagina. (Those are the same helpful bacteria that are found in yoghurt). BV can weaken the body’s defenses and promote other infections including herpes, chlamydia, trichomonas, HIV and gonorrhea. It is highly recurrent, and 30% of women who are treated for it will have a return of symptoms within 3 months, or 3 to 4 episodes a year. This can be very distressing. Return of symptoms may be due to reinfection or a failure of treatment. Why does this happen?

Research has determined that bacterial biofilms are organized microcolonies on a surface that create a protective mode of growth allowing for survival in a hostile environment. For example, electron microscopy of the surfaces of infected medical devices have shown the presence of large numbers of slime-encased bacteria. Tissue taken from chronic infections have shown the presence of biofilm bacteria surrounded by a protective exopolysaccharide matrix. Other examples of biofilm infections include dental carries, prosthetic device infections and cystic fibrosis lung infections.

Biofilm infections are resistant to antibiotics and host defense mechanisms. Antibiotic therapy typically reverses the symptoms caused by the infection but may fail to kill the biofilm. Bacterial Vaginosis is a biofilm infection. An adherent vaginosis biofilm persists on the vaginal epithelium after standard treatment with oral metronidazole. What new treatments can be successful against this resistant infection?

We should council our patients that in many cases bacterial vaginitis is chronic and will come back. When the infection returns treatment needs to be adjusted to be more effective. New recommended treatment is longer treatment, and includes Metrogel, oral metronidazole, tinidazole, or clindamycin vaginal for two weeks. For a patient who has a previous history of long term symptoms, the two week treatment is to be followed by once weekly Metrogel, or twice weekly oral metronidazole or tinidazole for six months. Using the appropriate treatment for this chronic problem can be expected to cure it 80% of the time. Investigation is ongoing in this field and future therapies that attack biofilms directly may show even better results.

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Zika

Zika was reported in May 2015 in South America and since then has spread throughout the Americas. The CDC and Pan American Health Organization (PAHO) websites maintain and update the list of areas where Zika virus transmission has been identified.

The virus spreads to humans primarily through infected Aedes aegypti mosquitoes. ZikaOnce a person is infected, the incubation period for the virus is approximately 3-12 days. Symptoms of the disease are non-specific but may include fever, rash, aching in joints, and eye inflammation. It appears that only about 1 in 5 infected people will have these symptoms and most will have mild symptoms. It is not known if pregnant women are at greater risk of infection than non-pregnant.

Zika during pregnancy transmissionhas been associated with birth defects, specifically significant microcephaly (small fetal head). Transmission of Zika to the fetus has been documented in all trimesters; Zika virus RNA has been detected in fetal tissue from early miscarriages, amniotic fluid, babies and the placenta. However, much is not yet known about Zika virus in pregnancy. Uncertainties include the incidence of Zika virus infection among pregnant women in areas of Zika virus transmission, the rate of transmission to the fetus, and the rate with which infected fetuses have complications such as microcephaly or demise. The absence of this important information makes management in the setting of potential Zika virus exposure (i.e. travel to active areas) or maternal infection, difficult. Currently, there is no vaccine or treatment for this infection.

 

Prevention Guidance:Protect yourself

  • Avoiding exposure is best. Pregnant women should delay travel to areas where Zika outbreaks are ongoing when possible. Women considering pregnancy should discuss with their obstetricians the advisability of travel. See the CDC and PAHO websites for updated lists of affected countries.
  • When traveling to areas where Zika has been reported, women should take all precautions to avoid mosquito bites including the use of EPA-approved bug spray with DEET, covering exposed skin, staying in air-conditioned or screened-in areas, and treating clothing with permethrin.Repellents
  • Sexual transmission of Zika virus has been reported in a few cases but the frequency and efficiency of this route of infection is uncertain. Based on limited data, there is a theoretical risk of sexual transmission through exposure to semen of males with Zika virus disease. Given the potential risks of maternal Zika virus infection, pregnant women whose male partners have traveled to countries in which Zika is reported or have Zika virus infection should consider using condoms or abstaining from sexual intercourse.

 

Summary of Updated Guidance:

  • Antibody testing for Zika virus is now recommended for all pregnant women who have traveled to or lived in affected area regardless of the presence of clinical illness.
  • Physicians should discuss reproductive plans, including pregnancy planning and timing, with women of reproductive age considering the potential risks associated with Zika virus infection.
  • Women of reproductive age with current or previous laboratory-confirmed Zika virus infection should be aware that there currently is no evidence that prior Zika virus infection poses a risk of birth defects in future pregnancies.
  • Although the presence of Zika in breast milk has been reported, it is in very small amounts and unlikely to be harmful for the neonate. The benefits of breastfeeding likely outweigh the potential neonatal risks. Therefore, the recommendation is that women should continue to breastfeed.

Tropics

If you are pregnant or planning for pregnancy check with us before traveling to areas of the American tropics and strictly follow steps to avoid mosquito bites during your trip.

 

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Improving your Sexuality

sex6I recently attended the Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists, and heard a very nice talk from Dr. Maureen Whelihan who is a sex therapist in West Palm Beach, Florida. She talked about how to maintain a good sexual relationship. Her are some of her tips:

Orgasm: 90% of her patients have had an orgasm, and most have them at least 50% of the time. In most cases clitoral stimulation is needed to achieve orgasm – manual, oral or vibration. An inexpensive vibrator she recommends is the Oral B pulsar toothbrush. sex5Use the back (smooth) side for clitoral stimulation. Lelo is another brand of vibrator, better made, unbelievably powerful, available in many versions (some remote controlled, waterproof, USB rechargeable) and available online at www.lelo.com. 10% of women can have a vaginal orgasm-a much deeper, whole body orgasm that is difficult for most to achieve. In menopause orgasm gets less intense. Laying a warm wet washcloth across the vulva for 10 minutes before sex can increase the blood flow.

Kissing: The most important sexual activity, Dr. Whelihan calls it “the key to getting women naked.” It’s the number one thing that turns you on. It signals a wanting or craving that will make your partner think about you differently. Married couples should try to kiss at least for one minute a day! Make it a good kiss too! Having good oral hygiene is important. Use a mouthwash or brush your teeth if you have bad breath; avoid cigarettes and chewing tobacco.

Male Partner: Doctors should ask about the male partner. Erectile dysfunction is common in older men and very manageable with Viagra or Levitra. sex8Helping men to maintain an erection longer gives women more time to enjoy an orgasm instead of rushing it. Premature ejaculation can be due to anxiety condition, and an antianxiety medication can help. Low testosterone is common in aging and can decrease desire in men. All women need to understand that men need sex. It is number one throughout their life. If the woman loses her enthusiasm for sex, the man does not understand. It is a need and ignoring it can lead to an unhappy end to the relationship.

Children: Will suck the life and energy from women. Recommend that any 2 nights a week the partner is responsible for “kid duty” all the way until bedtime. She has a free evening to exercise, get her nails done, have a glass of wine or read a sexy book and she will meet you in bed and have sex. “I can’t believe he did all those things just to have sex with me!” It teaches mutual respect for the work the other partner is doing. You must respect the other’s role in the relationship. You can also try to desensitize the kids that mom and day can be alone in their bedroom without interruption. sex4First go into the bedroom for 1 minute and lock the door. Tell them “it is a private time for parents, please do not knock on the door.” You can gradually increase that alone time and get the kids used to not interrupting you and wondering what’s going on in the bedroom. Finally you get 15 minutes and that’s all the time you need to get sex done if you are married and motivated.

Medications: Don’t discount the negative effects of some medications on sex drive. Birth control pills and other hormones may decrease desire. Opiates are sex inhibitors. Get a good night’s sleep.

Lubes: Sex is friction in inadequately aroused women. Silicone lubes stay on the surface longer. Wet Platinum, Eros, Astroglide and Pre-Seed (for women trying to conceive) are recommended. Coconut oil, olive oil and vegetable oil work fine especially with a glass of wine and sex in the kitchen! Be very careful to not slip if it gets on the floor!

Gay sex: assuming people are straight and finding out they are not embarrasses us. We should think of “partner” instead of “husband.” The more comfortable we are with asking, the more likely patients are to tell. We need to be in a judgment-free zone.

Books: “The Guide to Getting it on” by Paul Joannides is an all-encompassing guide. “Best of Best Women’s Erotica” by Marcy Sheiner is a good collection of female erotica. “How to be a Great Lover” by Lou PagetGreat Lover is a great book about improving sex technique from the female point of view. “Every Man Sees You Naked” by David Mathews is a great guide for women about why men behave the way they do.

Incorporating Technology: Podcasts: www.PleasureMechanics.com – “Speaking of Sex” is fun, direct, and informative. It can be uploaded and sent to your lover to let them know what is on your mind. Apps: “Pocket Kamasutra” gives ideas (visual cartoons) on sexual positions and sex games. Upload to a text or email and let your lover know what you want to try next.

Final Thoughts: sex2Doctors need to let patients know that they are interested in their sexual concerns. We should promote sexual pleasure as another component of overall wellness and good health. Your patient will be forever grateful.

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Getting Pregnant!

Fertility FriendBecoming pregnant can be fun, happy, exciting, or sometimes unplanned. Knowing how it happens is very useful information to make it easier to achieve when desired, and to be avoided if that is the goal.

 
The average menstrual cycle lasts for 28 days and can range from 21 to 35 days. In an average cycle ovulation occurs on day 14. Signs may include a cramp in the lower abdomen or back, breast tenderness, increase in a clear vaginal discharge, or an increase in sexual desire.

 
SpermFor pregnancy to happen, sperm must be present in the fallopian tubes and meet with an egg. When a man climaxes during sex millions of sperm go into the vagina and some can make their way through the cervical mucus and into the uterus and from there into the fallopian tubes. Sperm can live inside a woman’s body for 3 days or more, but an egg’s life is much shorter, only 1 day. So pregnancy can occur if an egg is already present when you have sex, or if you ovulate within a day or two after you have sex. This means that your fertility time is limited. You are fertile from 3-5 days before ovulation to 1 day after ovulation. Trying to time intercourse so that you have sex just before ovulation seems to be a good way of thinking about it. There is also a new theory that ovulation is not just a random event. Research has discovered a special protein in semen that can actually cause ovulation.

 
Knowing when you are fertile can be a challenge. There are different methods to predict it. For planning purposes, there are phone apps that can be helpful such as Fertility Friend or My Days. These apps calculate your expected next period and make predictions based upon it. The predictions are less accurate if your cycles are less regular. You can also go to the drug store and purchase an ovulation predictor test kit such as Ovutime or Ovutest. These urine tests indicate when the hormone LH becomes present. When LH rises in your circulation it causes ovulation and this hormone can be detected in your urine. When the ovulation test turns positive, this means you should have intercourse that day and the next day for best results. You may also notice changes in your cervical mucus where it becomes increased in amount and more clear and watery in quality. To promote pregnancy you should time intercourse to be daily or every other day when good quality cervical mucus is present. It should not be less often than every other day or more frequent than once a day for the best fertility results. You can also track your temperature with a special thermometer to measure your basal body temperature. Your temperature rises after you ovulate and stays up by a small amount for 2 weeks. This method is not that useful in that by the time you discover you have ovulated, it’s already too late for timing of sex.

 
You can start trying for pregnancy soon after you stop using a birth control method, but not too soon. If you are using the pill or a similar hormonal birth control method, it is a good idea to wait at least a month or two to allow your body to return to normal. If you get pregnant in the first cycle after stopping the pill you will have double the chance of having twins. While that may sound exciting, having one baby at a time is a much safer way to go, and much more manageable for taking care of children later on. We recommend stopping the birth control method, waiting 1-2 months before trying for pregnancy, and being on vitamins that contain iron, folic acid and DHA. In a given cycle the chance of success is only 20%, and it is normal to take months for pregnancy to happen. Do not be discouraged if it does not happen right away. With normal fertility you will become pregnant within 1 year, and 85% of couples will be successful in having this happen. 15% of couples will take longer than a year (that is called infertility), but only 1% of couples are unable to conceive. If you are trying for pregnancy and it seems to be taking too long, don’t worry about it. Sometimes you can be trying too hard for pregnancy. Increasing your anxiety about it is not helpful for fertility. Relaxing and having a good time is usually the best recipe for success.

 
First signs of pregnancy include feeling very tired, feeling nauseous, having breast tenderness, and your period being late. If you think you may be pregnant, doing a home test is helpful. If positive, these tests are usually reliable. If a test is negative it may be accurate or not. Sometimes the level of pregnancy hormone is elevated by too little to be detected by the urine method. If you really need to know (for example when a tubal pregnancy is suspected), then a blood test is much more reliable to detect an early pregnancy. Blood tests and ultrasound are also very helpful if you are bleeding and concerned about a possible miscarriage.

 

When you have a positive test, call us to make an appointment to come in and confirm your pregnancy. If you are at least six weeks and one day from the first day of your last period, we should be able to see the fetus and its heart beat by ultrasound. Once we see the fetal heartbeat the chance of successfully having a baby goes up to 85%! Then you are on your way to having a new life in your family. Good luck!

 
This article is partially based on information in ACOG’s book, Your Pregnancy and Childbirth, Month to Month.Your Pregnancy and Childbirth

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Menopause and Hormone Therapy – What’s New?

estrogen replacementIt was only about 100 years ago that the average woman’s life expectancy increased to the extent she would live past the time of menopause. Now with the average life expectancy into the 80’s, a woman may live more than 1/3 of her life in the menopause. The number of women in the menopause is increasing and expected to go up even more. The consequences of menopause include hot flashes, night sweats, insomnia, skin changes, mood changes, depression, anxiety, irritability, loss of libido, vaginal atrophy, cardiovascular disease and weakened bones. How can hormone therapy be safely used to help treat this problem affecting so many women?

We need to put hormone therapy in perspective, and also consider risks and benefits of treatment. Although there is a lot of controversy in the media, patients look to their doctors to be their advocates and give good advice about treatment. It’s our duty as doctors to be informed and advocate for our patients. We need to treat disease in a preventive way, rather than wait for the damage to be done. Disease often starts off in a pre-clinical way, and with some diseases it can be difficult to detect early on. Many diseases that occur have their roots decades before they can be detected, and similarly their treatment may take time to demonstrate a benefit.

Menopausal symptoms

Hot flashes are one of the most bothersome symptoms of menopause. 50% of women have them longer than 4 years, 23% more than 13 years. Temperature regulation helps your body maintain the proper temperature by causing sweating when you are hot and chills when you are cold, thus maintaining a neutral zone of comfort. Hot flashes are a disturbance of this system which are thought to be due to a change in the temperature regulatory system where a decrease in estrogen causes a decrease in the size of the normal thermo-neutral zone in-between sweating and shivering. The end result can interfere with your sleep and your comfort.

Benefits and risks of treatment

Combination estrogen and progestin therapy is FDA approved to treat menopausal hot flashes, prevent osteoporosis, treat vaginal atrophy, and provide other benefits to reduce insomnia, irritability and short-term memory loss. Hormone therapy is highly effective to relieve hot flashes, both their amount and intensity. In women who have a uterus, estrogen alone therapy can increase the risk of uterine cancer, but the increased risk is removed once progesterone therapy is added to estrogen. In 2002 the Women’s Health Initiative study came out and revealed risks of this treatment, including an increased risk of heart disease, stroke, blood clots and breast cancer when both estrogen with progesterone are taken. This had the effect of scaring women into avoiding estrogen therapy even though the absolute risk was only 8 per 10,000 women and the study was based on doses higher than are in use today. This risk is roughly equivalent to the risk of dying in a car accident, and is relatively rare. Rather than being misled by percentages of change, it’s more scientific to consider the absolute risk, and when the risk is less than 1 per 1000 you must weigh that small risk against the improvement in relieving symptoms you get with the right treatment. Other variables to consider include age and method of treatment. Women receiving hormones in the age group of 50-59 have a much less risk of coronary heart disease, stroke, and breast cancer than those in the 70-79 age group. Also women who receive estrogen through a transdermal patch have a significantly reduced risk of a blood clot compared with oral treatment, possibly due to a more stable delivery system and avoiding metabolism by the liver where clotting proteins are made.

Having a uterus makes a difference

Having had a hysterectomy means that hormone replacement therapy need only include estrogen, which is the hormone that conveys most all of the benefits and very little risk. This good hormone decreases the risk of heart disease, protects against breast cancer, and reduces damage to blood vessels with benefits in the brain leading to less risk of Alzheimer’s disease. Women who don’t have a uterus are in a much better position because the only major risks to consider are those related to blood clots and much of this risk can be reduced by getting estrogen through transdermal medications that don’t affect the liver where clotting proteins are made. There are benefits in vaginal lubrication, increased vaginal thickness, better sexual function, better support of the bladder, improved bone strength and decreased cancer of the colon.

Having a uterus makes treatment more complex, because an progestin needs to be added to treatment to decrease the risk of uterine cancer. But what if there were a medication available that can still provide estrogen benefits without the progesterone risk? Well, there is a new type of estrogen now available called a SERM, or selective estrogen receptor modulator, and when combined with a traditional estrogen, its called a TSEC, or tissue selective estrogen complex. The new estrogen has been designed to have some progesterone-like beneficial effects on the uterus (but without a progestin) and also when combined with a traditional estrogen conveys an improved quality of life, more satisfaction with treatment, improved vaginal health, improved sleep, improved bone density, significantly less hot flashes, with less breast pain and less bleeding. The new medication, Duavee, combines an estrogen with a synthetic “designer” estrogen called Bazedoxifene and represents an improved hormone therapy for those women who have a uterus.

While combined traditional hormone replacement therapy can still be used for the majority of women being treated, there are groups of women who are particularly good candidates for this new approach, including women with a family history of breast cancer, women who have had a problem with combined therapy such as tender breasts, those with increased breast density, or if they have had bleeding issues.

Conclusions

We need safe and effective treatment for menopausal symptoms. The risk of breast cancer is slightly increased with hormone therapies that combine estrogen with progesterone, but not with estrogen alone or in combination with a new estrogen (called a SERM). TSECS combine an estrogen with a SERM to provide relief of menopausal symptoms without the increased risks caused by progestins and offer a new, safer treatment for menopause. These new developments in hormone therapy are just the beginning of designing new safe treatments that provide more benefit at less risk.

This information is from a course “Menopause and Hormone Therapy” given at the 2015 ACOG Annual Clinical Meeting and was presented by Drs Hugh Taylor and JoAnn Pinkerton.

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Apps for Pregnancy, 2015

Apps can be useful and fun. I’m always asking my patients which apps they like for pregnancy. These are some apps that have been recommended to me:

  1. My Days – Period and OvulationIMG_3685

This free, accurate app has is very helpful for determining the best days of fertility and improving your chances of becoming pregnant more quickly. It tracks periods and uses this information to predict fertility in the upcoming month.

Or… it can be used as a birth control rhythm method by knowing which are the most important fertile days and avoiding intercourse at that time.

  1. Perfect OB WheelIMG_3686

Comprehensive pregnancy wheel contains information about conception, length of pregnancy, due date.   It’s simple, fast, free, and has input flexibility, allowing you to put in the last menstrual period, the conception date, the estimated date of confinement, or the number of weeks and days of gestation based on ultrasound dating.

  1. IMG_3678What to Expect Pregnancy

This very popular app includes a due date calculator, week-by-week details on your baby’s development, weekly baby illustrations, updates on your changing body, and countdown to your due date. You get daily tidbits of advice and it also includes helpful information for dads. It’s from the popular book “What to Expect When You’re Expecting” and works on the iPhone, iPad and even the Apple Watch!

  1. IMG_3679Contraction Timer by iBirth

The value of a contraction timer is in its simplicity and ease of use. This app makes timing of contractions during labor easy. It has a simple interface, tracks the duration of each contraction, tracks the intervals between contractions, and has a history report for tracking labor progress over time. It’s great for tracking information that your doctor will want to know in assessing if labor has begun.

  1. IMG_3680Baby Names!!

For people who would like some help in choosing a name, this app will show you the name’s meaning, pronunciation, gender and origin. It also includes graphs of a name’s popularity over time. For example, the most popular girls names now are Sophia, Isabella, Emma, Olivia, Ava and Emily! It links to Wikipedia and gives you oodles of information of more than 30,000 names. It has a feature that chooses names that fit with those of parents.

  1. IMG_3684Sex Life – 100+ Positions

This fun guide to sex positions may add some variety to your life!   This app has a contemporary style and can help you try different positions, rate them, keep track of what you have tried, and choose favorites.

A score board gives you an overview of your progress.

  1. IMG_3681First Aid.                                       A useful guide to quick treatment of many different medical emergencies from the American Red Cross, including allergic reaction, burns, poisoning, broken bones, choking, heart attack, heat stroke, seizures, shock, insect bites, unconscious and not breathing. The app has much useful information that can help you take care of an emergency by yourself or while waiting for help to come.
  2. IMG_3682LactMed.

LactMed is part of the National Library of Medicine (NLM) Toxicology Data Network and is a database of drugs and dietary supplements that may affect breastfeeding. It includes information of the levels of substances in breast milk and how they could adversely affect the nursing infant.

These apps can be very helpful.  But you have to be careful when getting health related apps because some of them may superficially appear reliable but actually are not based on medicine or science. A recent article “Identification of iPhone and iPad applications for obstetrics and gynecology providers” performed a scientific search for quality ob/gyn apps with results described as “finding a needle in a haystack.”

The good news is that more apps are being written every day. As time goes on, I’ll report back on other apps I have found useful and based on reliable information.

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