Having been an OB/GYN for over twenty years I’ve fielded so many questions from expecting parents and parents with kids. Often a question asked by one mother could apply to any mother, so this column is dedicated to discussing mom and baby related topics that could help all expecting and new moms.

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The answer is definitely YES for pregnant women to get a flu vaccine this season.   The flu shot is your best protection against serious illness as a result of the flu.  The flu is more likely to cause serious illness in pregnancy compared to those women who are not pregnant.  In pregnancy there are changes in the immune system, heart and lung function that make pregnant women more prone to severe illness from the flu which can lead to hospitalization or even death.  Other problems as a result of the flu include dehydration, miscarriage and preterm labor.  A flu shot can protect pregnant women, their unborn babies and even the baby after birth.  When given in pregnancy, the flu shot has been shown to protect both the mother and her baby, up to 6 months old from the flu.  The flu shot is safe during pregnancy and can be given at any time.   The nasal spray vaccine should not be given to women who are pregnant.

The flu virus is thought to spread easily person to person through coughing, sneezing, or talking to someone in close proximity that has the flu.  Other forms of viral transmission is when people touch something with the flu virus on it then touch their mouth, eyes or nose.  People infected with the flu may be able to infect others as early as Day 1 before symptoms develop and up to 5 to 7 days after becoming sick.

Everyday preventative behavior can help slow the spread of the flu virus include:

1. Cover your nose and mouth with a tissue when you cough or sneeze.
2. Wash your hands often with soap and water and if soap and water are not available use an alcohol-based hand rub.
3. Avoid touching your eyes, nose and mouth.
4. Avoid close contact with sick people.
5. If you or your child gets sick with the flu, limit contact with others as much as possible to help prevent spreading illness.  Stay home (or keep your child home) for at least 24 hours after fever is gone except to seek medical care or for the necessities.

For more information, visit www.cdc.gov, or call 1-800-CDC-INFO

This is a bit technical but it is informative for those who are interested in the more medical explanation! Serum beta–human chorionic gonadotropin (hCG) is the hormone produced by the syncytiotrophoblast beginning on the day of implantation, and it rises in both the maternal blood stream and the maternal urine fairly fast. The serum hCG test is the most sensitive and accurate, and this hormone can be detected in both blood and urine by 8-9 days after conception. This test can be performed quantitatively or qualitatively. Urine pregnancy tests differ in their sensitivity and specificity, which are based on the hCG units set as the cutoff for a positive test result, usually 2-5 mIU/mL.

Urine pregnancy tests can produce positive results at the level of 20 mIU/mL, which is 2-3 days before most women expect the next menstrual period. The kits are very accurate and widely available. The test can be completed in about 3-5 minutes. The kits all use the same technique—recognition by an antibody of the beta subunit of hCG. Falsely high readings of the hCG hormone can occur in cases of hydatiform molar pregnancy or other placental abnormalities. Also, test results can remain positive for pregnancy weeks after a pregnancy termination, miscarriage, or birth. On the other hand, false-negative test results can occur from incorrect test preparation, urine that is too dilute, or interference by several medications.

Serum pregnancy tests can be performed by a variety of methods. The enzyme-linked immunosorbent assay (ELISA) is the most popular in many clinical laboratories. This test is a determination of total beta-hCG levels. It is performed using a monoclonal antibody to bind to the hCG; a second antibody is added that also interacts with hCG and emits color when doing so. This form of ELISA is commonly called a “sandwich” of the sample hCG. Radioimmunoassay (RIA) is still used by some laboratories. This test adds radiolabeled anti-hCG antibody to nonlabeled hCG of the blood sample. The count is then essentially determined by the amount of displacement of the radiolabeled sample.

The hCG level doubles approximately every 2-3 days in early pregnancy. However, it should be noted that even increases of only 33% can be consistent with healthy pregnancies. These values increase until about 60-70 days and then decrease to very low levels by about 100-130 days and never decrease any further until the pregnancy is over.

Nausea? Vomiting? Fatigue?

Missing a period is usually the first sign of a new pregnancy, although women with irregular periods may not initially recognize a missed period as pregnancy. During the first few weeks of pregnancy, many women experience a need to urinate frequently, extreme fatigue, nausea and/or vomiting, and increased breast tenderness. All of these symptoms can be normal and are expected in the beginning of new pregnancy.   In fact, if you are not having these typical symptoms there might be concerns that you are not having a normal or viable pregnancy.  Most over-the-counter pregnancy tests are sensitive 9-12 days after conception, and they are readily available at most drug stores. Performing these tests early helps to avoid confusion and guesswork. You can also go see you health care provider or Obstetrician and get a serum pregnancy test which can detect pregnancy 8-11 days after conception.

A patient of mine asked me this “medical trivia” question the other day so I began a medical search and this was what I found.  Although there may be some skeptics out there Beulah Hunter’s name came up a few times with this remarkable medical story.

The normal human pregnancy lasts around 280 days, 10 lunar (4 week months) months or slightly more than nine months.  Traditionally a term pregnancy for a singleton is 38 to 42 weeks.  In 1945 a 25 year old woman, Beulah Hunter, gave birth after 375 days of being pregnant.  This is almost a year and a half.  It was substantiated by a physician who first documented her last menstrual cycle and the first time she tested positive for pregnancy.  These same physicians claim that the cause of this long pregnancy was the extremely slow development of the fetus.  Beulah Hunter’s pregnancy is the longest known in which a living and healthy child was born.

Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder and bowel.   There are many reasons why you can weaken your pelvic floor muscles, from pregnancy and childbirth to aging and being overweight.  The effect of weakening the pelvic floor results in your pelvic organs dropping and creating a bulge into your vagina.  When this occurs it is called pelvic organ prolapse.  Symptoms from a prolapse range from an uncomfortable pelvic pressure to leakage of urine.  Kegel exercises can help delay or even prevent pelvic organ prolapse and other related symptoms.  On a side note,  Kegel exercises, along with counseling and sex therapy, may me helpful for women who have persistent problems reaching orgasm.

How to do Kegel exercise?

Kegel exercises are easy to do and can be done anywhere without anyone even knowing.  I tell my patients the easiest way to identify your pelvic floor muscles is to urinate and while doing so stop the flow of urine midstream and hold it.  Hold the contraction for 3 seconds then relax allowing the flow of urine to continue.  Repeat this a couple of times and you will have identified your Kegel muscles. You should feel your pelvic muscles squeezing your uretha and anus if done correctly.
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Another way to identify your Kegel muscles is to insert your first two fingers in the vagina, squeeze you pelvic muscles as if you are holding urine.  You should feel your vagina tighten and your pelvic floor move upward.  Then relax your muscles and feel your pelvic floor return to the starting position.

Once you have identifies your pelvic floor muscles you can perform Kegel exercises.  Before you do them, empty your bladder and sit or lie down.  Contract your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds. Try it four or five times in a row.   Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.

Be careful not to flex the muscles in your abdomen, thighs or buttocks. Avoid holding your breath.  Instead, breathe freely during the exercises. Aim for at least three sets of 10 to 15 repetitions a day.

If done correctly and repeatedly over time, you can avoid symptoms such as stress and urge incontinence caused by childbirth, aging and obesity.  Kegel exercises can also make sexual intercourse more enjoyable for you and your partner. For all these reasons, Kegel exercises should be a permanent part of your daily routine.

We can all agree that the postpartum period is a tough one both physically and mentally.  The sooner that you can begin an exercise regimen the better you will feel.  Having a vaginal delivery tends to afford you with more mobilization then having a cesarean section.  A Cesarean section is a major surgical procedure.  It takes 4 weeks for the sutures to dissolve following a C-section.  With this in mind, an exercise regimen can be initiated based on the same criteria as mentioned above with a vaginal delivery.  Light walking , stretching exercises, and Kegels can always be incorporated during the first two weeks after delivery.  Four weeks after a C-section you can increase the intensity of your workouts including cardiovascular exercises with your doctor’s approval. Ideally, waiting to do more intense cardiovascular exercises should occur until after your 6-week postpartum visit with your health care provider.

How soon you resume your exercise regimen after a vaginal delivery will vary according to your physical and mental condition, previous exercise history prior to and during pregnancy, and your delivery experience.  If you had a traumatic delivery or/and had an episiotomy, you may not be able to start even the easiest of exercises until 3 to 4 weeks postpartum.  Sutures that are used in repairing an episiotomy typically dissolve within 4 weeks. If you begin a strenuous workout sooner than your body is able to handle, you will have a major setback in your postpartum recovery. Therefore you do not want to overextend yourself prior to the full healing of your episiotomy.  For example, you would not want to ride a bicycle for at least 6 weeks following an episiotomy repair.  However, if you had an uncomplicated delivery with minimal trauma to your perineum than you can start light exercises as soon as one week after delivery.  Walking is an excellent exercise as you transition into the more advanced cardiovascular forms of your workout regimen.  You have to remember that your joints are still loose during the first 6 weeks postpartum which will interfere with your coordination and balance so you want to start slowly and with your health care providers blessing.

The American Academy of Pediatrics (AAP) has recently made recommendations ensuring that your newborn baby has a safe sleeping environment thereby reducing the risk of sudden infant death syndrome (SIDS).

In 1992, the AAP recommended that all babies be placed on their backs to sleep which decreased the incidence of deaths from SIDS, However, sleep-related deaths from other causes, including suffocation, entrapment, and asphyxia, had increased.  As a result, 3 important changes have been recommended. First, is the recognition that breastfeeding protects against SIDS.  Second, there needs to be a greater emphasis on immunization.  If your baby is immunized its risk of SIDS drops by 50%.  Third, the AAP wanted to focus not only on SIDS but on other deaths that can occur.  They recommend against the cushions that go along the sides of the crib stating that children can be suffocated by them.

Other key recommendations are:

Always use a firm sleep surface. Car seats and other sitting devices are not recommended for routine sleep.
The baby should sleep in the same room as the parents, but not in the same bed (room sharing without bed sharing).
Keep soft objects or loose bedding out of the crib.
Wedges and positioners should not be used.
Offer a pacifier at nap time and bedtime.
Avoid covering the infant’s head or overheating.
Do not use home monitors or commercial devices marketed to reduce the risk for SIDS.
Supervised, awake tummy time is recommended daily to facilitate development and minimize the occurrence of positional plagiocephaly (flat heads).
The AAP’s focus is on preventing accidental deaths. In addition to SIDS death  many emergency rooms are seeing an increase in the number of babies that have suffocated because someone rolled on them or they have ended up underneath a pillow or got trapped between the mattress and the wall.  Many feel the “adult bed” is not a safe place for an infant.

These are helpful guidelines to ensure a “safe sleep” for your infant.

Pregnant women need to drink between 8 to 12, 8- ounce glasses of water each day whether you are thirsty or not. During pregnancy your blood volume increases by 40%.  The growing fetus demands that you stay well hydrated in order for this to be accomplished successfully.  Drinking this large volume of water helps with your digestion, avoiding constipation, prevents urinary tract infections and reduces premature contractions.  Drinking a lot of water also assists in preventing dry skin, building new tissue, carrying nutrients, flushing out wastes and toxins and helps keep excessive water retention under control.  Limit you intake of soda, (sugar full or sugar free) as well as beverages containing caffeine.  To the best of your ability, space out your water intake, steadily drinking throughout the day.   In general avoid drinking too much water after dinner so that you won’t spend your sleeping hours getting up to use the bathroom!

Definitely one of the more uncomfortable problems that can be exacerbated during pregnancy, constipation is a common complaint.  Between the hormonal effects of progesterone slowing down the motility of your intestines, the iron and calcium in prenatal vitamins, the displacement of the intestines by a growing uterus and the changes in our diets during pregnancy all lead to a disruption in bowel function.  Some have bowel changes consistent with a softer and more frequent stool, others have hard “rabbit” pellets and many others have bowel movements every 2-5 days.

Constipation during pregnancy can be prevented with the following lifestyle changes:

Drink plenty of fluids. Water is the best choice and I would recommend drinking at least 8-10, 8 ounce glasses a day. Fruit juice, especially prune juice, will help regulate your constipation.  Drinking warm liquids in the morning is also effective.

Physical activity and exercise should be a part of your daily routine.  Daily walks, lasting 30-45 minutes, and other aerobic activities can help prevent pregnancy constipation.  Exercising regularly aids in our digestion and makes you feel physically and emotional stronger and more energetic.

Include more dietary fiber in your diet. Choose high-fiber foods, such as fruits, vegetables, beans and whole grains.  Fiber helps bring water into the intestines, softening the stool and allowing it easier to pass.  With your health care provider’s OK, consider a fiber supplement, such as Metamucil, Citrucel and Miralax.
Stool softeners, such as Colace, moistens the stool allowing easier passage. I encourage most of my patients to take 50mg to 100mg of Colace two times a day throughout the duration of the pregnancy.

Bulk forming laxatives such as fiber supplements are the gentlest on your body and safe to use during pregnancy.  Metamucil, Citrucel and Miralax are examples of this and are recommended throughout pregnancy.  Stimulant laxatives, such as Ex-Lax and Senokot are the hardest on your intestines and should not be used during pregnancy.

There are remedies and solutions for this serious and uncomfortable side effect of pregnancy.  As always consult with your health care provider

What is all the hype about Vitamin D?

Vitamin D is critically important to women’s health.  The main source of Vitamin D is from sunlight, food and supplements. We produce it ourselves, in our skin, as long as we get enough exposure to the sun.  This is how it became known as the “sunshine vitamin”. There are 5 forms of vitamin D, of which Vitamin D3, is the more effective form used by humans

Studies show that as many as 3 out of 4 Americans suffer from Vitamin D deficiency.   It’s thought to be the most common medical condition in the world, affecting over 1 billion people.  In the United States, 51 million children were found to have Vitamin D insufficiency. Many none-too-shocking factors contribute to what scientists perceive as an “epidemic” of vitamin D deficiency; our indoor-oriented lifestyles, limited sun exposure during cold-weather months, and frequent sunscreen use.

Can we get vitamin D from food? While obtaining nutrients from food is generally the best route, dietary sources of substantial vitamin D are few and far between. Limited amounts of vitamin D can be found in fortified dairy products and cereals, as well as sardines, cod liver oil, salmon, and eggs yolks.

The sun is your best source of Vitamin D. If you go outside, remove your clothing, defy recommendations to use sunscreen, and stand outside soaking up UV rays for about 15 to 20 minutes, you will satisfy your Vitamin D daily requirements.

Vitamin D is essential to good health, helps build strong bones and teeth, prevents diabetes, and helps fight off infectious diseases.  Observation studies also support reproductive health and preparation for pregnancy.  In studies related to pregnancy, Vitamin D3 2,000 IU greatly reduced the risk of pregnancy associated complications, including gestational diabetes, preterm birth, pregnancy induced hypertension, and infection.  Additionally, women who took the higher doses of Vitamin D during pregnancy were the least likely to have deficient or insufficient blood levels of the Vitamin, as were their newborn babies.

Overall benefits of Vitamin D:

o   Protects against heart disease, high blood pressure and strokes
o   Helps with neuromuscular function and immune system strength
o   Reduces complications associated with pregnancy such as hypertension, gestational diabetes, preterm labor
o   Supports reproductive health and prepares you for pregnancy
o   Osteoporosis prevention
o   Higher levels of Vitamin D have an “anti-cancer” effect with breast, colon, and prostate cancers
o   Contributes to bone and teeth health
o   Promotes healthy cell development
o   Protects against chronic diseases

Prenatal vitamins contain the RDA (Recommended Daily Allowance) of Vitamin D which is 600 IU’s.  It is extremely important for your health care provider check your Vitamin D level to know how much you should be taken during pregnancy, lactation and beyond.   Normal range of Vitamin D 25-OH is between 30-100ng/ml.  Studies show a level of 40ng/ml is required to receive the maximum benefits of Vitamin D.

How much vitamin D do we need from supplements? Factors such as age, obesity, and skin color all influence our vitamin D requirements. Supplementing 1,000 IU of calcium D3 (cholecalciferol) is generally considered safe. The recommended upper limit for vitamin D is 2,000 IU per day especially if you are pregnant.  Although toxicity is rare, vitamin D is fat-soluble, therefore can be stored in the body for long periods. So before you start supplementing, consult your doctor. My best advice is get your Vitamin D 25-OH levels checked so you know where you stand in the Vitamin D deficiency epidemic.

The hype surrounding Vitamin D is ongoing and controversial.  Physicians and researchers have varying recommendations based on the ongoing studies taking place around the world.  What we do know is that there are valid studies showing that there is a true Vitamin D deficiency occurring worldwide and Vitamin D has a profound impact on our health.

Is it easier to care for the circumcised penis or uncircumcised penis?
 
The circumcised penis is generally easier to keep clean. An uncircumcised boy should be taught to clean his penis with care. Cleaning of the penis is done by gently, not forcibly, retracting the foreskin. The foreskin should be retracted only to the point where resistance is met. Full retraction of the foreskin may not be possible until the boy is 3 years old or older.

What is the relationship between circumcision and urinary tract infections?
 
The incidence of urinary tract infections in male infants appears to be lower when circumcision is done in the newborn period. It was first reported in 1982 that urinary tract infections (UTIs) are more common among infant males than they are in infant females (this switches later on in life). In this study, it was revealed that about 95% of the infected infant boys had not been circumcised. This risk is especially significant in infants less than 1 year of age. Many studies have shown that uncircumcised infants have a tenfold increased risk of developing a UTI than circumcised infants.

To Circ or Not to Circ, that is the question!

Routine circumcision remains a constant topic of controversy and confusion when you find out you are having a boy.  According to the most recent policy on the male circumcision policy from the American Academy of Pediatrics there is “insufficient information to recommend routine circumcision.” Most major medical societies have taken an “impartial” view of the procedure, neither recommending nor renouncing the practice.

What is a circumcision? Boys are born with a covering over the head of the penis called the glans. This covering is also called the foreskin. During circumcision, the foreskin is surgically removed, exposing the glans of the penis.

Neonatal circumcision is one of the most commonly performed procedures in the United States. Religious and cultural circumcision is commonly performed.  In the Jewish and Islam religions circumcision is widely practiced within days of the birth of a son.

Infant circumcision was recognized in the United States around 1900.  The United Kingdom was one of the first countries to critically look at neonatal circumcision. In 1949, the United Kingdom’s National Health Service removed infant circumcision from its list of covered services, and circumcision has since been an out-of pocket expense to parents.

Circumcision statistics in the United States are difficult to gather because of the many locations in which circumcisions are performed. Different sources provide varying rates, and circumcision frequency varies from year to year. In the late 1940s and early 1950s, 76% of boys were circumcised, of which, approximately 80% were Caucasian and 45% were African American.

The American Urological Association (AUA) believes that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. AUA also notes that when circumcision is being discussed with parents and informed consent is obtained, medical benefits and risks, as well as ethnic, cultural, religious, and individual preferences, should be considered. The risks and disadvantages of circumcision are encountered early, whereas advantages and benefits are prospective.

The World Health Organization (WHO) takes a more pro-active stance toward circumcision in certain populations, stating that male circumcision should be considered an effective intervention for human immunodeficiency virus (HIV) prevention in countries and regions with heterosexual epidemics, high HIV, and low male circumcision prevalence.  Recently, however, several large studies revealed a 60% decrease in HIV transmission in circumcised males compared to uncircumcised males.

Complications associated with circumcision in male neonates, infants, and children, are rare. However, complications were seen, especially when circumcision was undertaken at older ages, by inexperienced providers, or in non-sterile conditions.  Complications included bleeding, hematoma, urethral laceration, removal of too little tissue or an incomplete circumcision, infection and injury to the glans and frenulum.  Advantages to having a circumcision include a protective role against penile cancer, HIV, HPV and other STD’s in the higher risk populations.

The procedure can take from 5 to 20 minutes and will usually be performed before leaving the hospital. Your baby will be placed in a padded restraint chair and usually be given anesthesia, either topical lidocaine cream or a lidocaine injection. Since there are several different types of possible procedures, you should ask your health care provider to explain the type they will be using. Procedures include the Plastibell, the Gomco clamp or Mogen clamp which all require the use of a scalpel. These procedures first separate the foreskin from the glans with a device followed by surgery with the scalpel to remove the foreskin.

On the simplest level, some parents will base their decision to circumcise their male infant based on if the father is circumcised.  Keeping all the males in the home “looking the same” helps minimize future questions regarding differences in the male anatomy.

Neonatal/infant circumcision rates in the U.S. vary geographically and have fluctuated in accordance with guidelines set forth by various medical groups, including American Academy of Pediatrics. Over the years, there has been a trend in favor of a decreasing prevalence of circumcision. When counseling parents regarding the pros and cons of circumcision, it is important to discuss the potential impact of circumcision on HIV and STD risks, particularly as they apply to higher risk populations.

Managing Allergies in Pregnancy

Allergies affect 18-30% of women in the childbearing age groups.  Allergic diseases that complicate pregnancy include conjunctivitis, acute urticaria (hives, rash), anaphylaxis, food and drug allergy.  These disorders represent the most common group of medical conditions that complicate pregnancy.  The diagnosis of an allergy in pregnancy is often found through a detail medical history and assessing the symptoms experienced.  Once the diagnosis is made there are many things that can be done to treat the condition.

Avoid triggers. Limit your exposure to anything that triggers your allergy symptoms.
Try saline nasal spray. Over-the-counter saline nasal spray can help ease nasal dryness, bleeding and congestion. Use the spray as often as needed.
Rinse your nasal cavity with a neti pot. Neti pots are available in most pharmacies. Once or twice a day, fill the neti pot with an over-the-counter saline nasal solution. Then tilt your head over the sink, place the spout of the neti pot in your upper nostril and gently pour in the saline solution. As you pour, the saline solution will flow through your nasal cavity and out your lower nostril. Repeat on the other side. If you’d rather make your own irrigation solution, use water that’s distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller. Also be sure to rinse the neti pot after each use with similarly distilled, sterile, previously boiled and cooled, or filtered water. Leave the rinsed neti pot open to air-dry.
Include physical activity in your daily routine. Exercise helps reduce nasal inflammation.
·         Use nasal strips at night. Over-the-counter adhesive nasal strips — such as Breathe Right and Breathe.

If none of these work, allergy medications are often given safely to women and include Claritin, Alavert and Benadryl.   Before you take any medication always discuss alternatives with your obstetrician or healthcare provider.

Heartburn During Pregnancy

More than 60% of pregnant women have symptoms of severe heartburn beginning in the second trimester and continuing throughout the third trimester.  Heartburn is also known as acid indigestion and feels like a burning sensation in the esophagus caused by reflux (comes back up) of the stomach contents.  The reason heartburn in pregnancy occurs is due to the changing hormone levels which affect the muscles of the digestive tract.  These muscles “relax” allowing stomach acids to splash back up into the esophagus.  This action along with an enlarging uterus can crowd the abdomen pushing stomach acid upward resulting in heartburn.

To reduce heartburn during pregnancy you can do the following:

·         Eat several small meals a day instead of three large ones

Eat slowly.
Avoid fried, spicy, or rich foods, or any foods that seem to cause relaxation of the lower esophageal sphincter and increase the risk of heartburn.
Drink less while eating. Drinking large amounts while eating may increase the risk of acid reflux and heartburn.
Don’t lie down directly after eating.
Keep the head of your bed higher than the foot of your bed. Or place pillows under your shoulders to help prevent stomach acids from rising into your chest.
Medications such as Tums or Maalox help coat the esophagus minimizing the burning sensation and are safe in pregnancy.  Other over-the-counter medications that help with the symptoms include Zantac and Pepsid AC.  These medications should be taken 30 minutes before each meal and before bedtime for optimal results.  Rarely, prescriptive medications are needed to control severe heartburn symptoms.  As always consult with your Obstetrician or health care provider.
Wear loose-fitting clothing. Tight-fitting clothes can increase the pressure on your stomach and abdomen.
The good news is that heartburn usually disappears following childbirth

Why am I experiencing nosebleeds?

During pregnancy your heart pumps 40% more blood volume to support the growing fetus that you are carrying. As a result of this increase in blood volume and changes in blood cells/vessels in your body, nosebleeds can occur.  Tiny blood vessels in your nose can become engorged, dry out and rupture causing your nose to bleed.  It is the combination of increased blood flow in the nose and sinus area and dryness that make nosebleeds more common.  One of the ways to prevent dryness is to use a humidifier in your bedroom while you sleep.  Additionally, you can use a saline nose rinse to keep the nasal passages moist and petroleum jelly around your nostrils before going to bed.  When you blow your nose be extra gentle and use a soft tissue around the nasal area.  If you experience a nosebleed treat them in the usual way by applying pressure and something cold over the nose.  You can insert a tampon into your nose and apply pressure for an alternative strategy to stop the bleeding. It is very unusual for nosebleeds to occur as a result of a serious medical condition such as high blood pressure or a bleeding disorder.  Pregnancy related nosebleeds usually subside quickly, but if you cannot stop the bleeding, call your Obstetrician or health care provider.

Why do pregnant women feel tired?

One of the earliest signs of pregnancy is feeling exhausted or fatigued.   In the beginning of pregnancy this is considered completely normal and often expected. Many hormonal changes are occurring as pregnancy develops, and women experience fatigue and an increased need for sleep. In the second and third trimester of pregnancy, lower blood pressure levels, lower blood sugar levels, hormonal changes due to the sleep-inducing effects of progesterone, metabolic changes, and the physiologic anemia of pregnancy all contribute to fatigue. Your body is working harder to accommodate the fetus that is growing inside of you and as a result the feeling of fatigue can be overwhelming.  Plenty of rest, staying adequately hydrated and eating a well balanced diet will boost your energy levels. Women should check with their Obstetrician or health care provider to determine if an additional work up, prenatal vitamin changes, and/or supplemental iron would be beneficial.

Managing Allergies in Pregnancy

Allergies affect 18-30% of women in the childbearing age groups.  Allergic diseases that complicate pregnancy include conjunctivitis, acute urticaria (hives, rash), anaphylaxis, food and drug allergy.  These disorders represent the most common group of medical conditions that complicate pregnancy.  The diagnosis of an allergy in pregnancy is often found through a detail medical history and assessing the symptoms experienced.  Once the diagnosis is made there are many things that can be done to treat the condition.

Avoid triggers. Limit your exposure to anything that triggers your allergy symptoms.
Try saline nasal spray. Over-the-counter saline nasal spray can help ease nasal dryness, bleeding and congestion. Use the spray as often as needed.
Rinse your nasal cavity with a neti pot. Neti pots are available in most pharmacies. Once or twice a day, fill the neti pot with an over-the-counter saline nasal solution. Then tilt your head over the sink, place the spout of the neti pot in your upper nostril and gently pour in the saline solution. As you pour, the saline solution will flow through your nasal cavity and out your lower nostril. Repeat on the other side. If you’d rather make your own irrigation solution, use water that’s distilled, sterile, previously boiled and cooled, or filtered using a filter with an absolute pore size of 1 micron or smaller. Also be sure to rinse the neti pot after each use with similarly distilled, sterile, previously boiled and cooled, or filtered water. Leave the rinsed neti pot open to air-dry.
Include physical activity in your daily routine. Exercise helps reduce nasal inflammation.
·         Use nasal strips at night. Over-the-counter adhesive nasal strips — such as Breathe Right and Breathe.

If none of these work, allergy medications are often given safely to women and include Claritin, Alavert and Benadryl.   Before you take any medication always discuss alternatives with your obstetrician or healthcare provider.

Why does acne increase during pregnancy and how can I safely treat it?

Acne in pregnancy is extremely common and it is often more difficult to treat.  “Pregnancy acne” is not a special form of acne.  Pregnancy acne occurs due to the overproduction of sebum oil which happens from all the hormonal changes.  Unfortunately, some women are more susceptible than others. Some studies show that as many as a third of cases actually improve in pregnancy but most women will report some worsening.  The various forms of treatment include the following:

1.      Wash your face twice a day.  You can use a mild cleanser with warm water and gently wash your entire face.

2.      If you have oily hair, shampoo daily.  Be careful to keep your hair off your face.

3.      Avoid picking, scratching, popping or squeezing acne sores.  These types of habits can spread infection and potentially cause scarring.

4.      If you use cosmetics, stick to oil-free products.  Descriptions such as water-based, noncomedogenic or nonacnegenic.

5.      Avoid resting your face in your hands.  This can trap skin oils and sweat, which can irritate acne.

Medication is the second line of treatment for pregnancy acne.  Erthromycin (Erygel) or clindamycin (Clindagel) is often the drug of choice of pregnancy acne.  Azelaic acid (Azelex, Finacea) is another option.  Both of these medications are applied to the skin as a lotion or gel and are available by prescription.

Other more controversial and less studied products include benzoyl peroxide and other over-the-counter or prescription strength benzoyl peroxide during pregnancy.

Medications to avoid during pregnancy include isotretinoin and other retinoids, minocycline, doxycycline and other tetracyclines.

Initially you should consult with your obstetrician or health care provider for first line treatments.  If those prove to be unsuccessful consult with your dermatologist.  Together you can weigh the benefits and risks of various treatment options.

What are some of the reasons that my doctor may put me on bed rest?

Some of the reasons a doctor may put you on bed rest include preterm labor or excessive uterine irritability, poor fetal growth, low or high amniotic fluid levels, and hypertension of pregnancy.  The basic idea is to limit your activity that will take away from the blood flow to your growing fetus or reduce your activity that might stimulate the uterus to contract.

What can I expect in the hospital if I go into pre-term labor?

If you develop symptoms of preterm labor such as uterine contractions or irritability before 37 weeks your obstetrician will recommend that you go to labor and delivery for observation.  When you arrive to the hospital you will be place on a fetal monitor to see how often you are contracting.  An intravenous line will be placed in your veins to give you hydration since a common cause of uterine activity is due to dehydration.  The nurse will check your cervix to see if you are dilating or if your cervix is thinning.  If your cervix is changing and/or you are having regular and frequent uterine contractions you are in preterm labor.  Depending on your gestational age you may be given a tocolytic which is a medication to relax the uterus and see if the contractions will go away.  The tocolytic can be given intramuscular, in your muscle, or intravenously, through your veins.  Often, intravenous hydration and the use of tocolytic stop the signs and symptoms associated with preterm labor.  You may be sent home on bed rest until you reach 37 weeks of pregnancy.   It is at 37 weeks that the lung development of the fetus is complete and it would be safe to deliver.

Is epidural anesthesia advised during labor or is an non-medicated labor an option for us?

This is a personal preference for each pregnant woman and the couple as a whole.  If you decide you want a form of pain relief during labor, I personal advise my patients to choose an epidural since it is only a nerve block and therefore doesn’t affect the fetus during labor.  The patient loses the pain sensation to the area of the uterus so you do not feel any pain from the strong force of uterine contractions. Lighter dosed epidurals are called “walking epidurals” and are used for those women that prefer less sedation.  You do not have any problems feeling drugged or foggy as you would with Intravenous sedating medications.  With an epidural, when the time comes to push the baby out you still can feel the rectal pressure that assists you in pushing effectively.

If you are interested in a non-medicated delivery, I suggest you learn the various alternatives that will assist you in handling the pain associated with labor such as breathing techniques, meditation,  hypo-birthing, yoga positions and other modalities that help you deter focusing on the pain associated with labor.  Ultimately it is you and your partner’s decision.  I encourage plenty of research and open and honest conversations with your obstetrician.

What is a Perineal massage?

Perineal massage is the practice of massaging a pregnant woman’s perineum around the vagina in preparation for childbirth. Perineal massage can be done by the pregnant woman or her partner.  You should be in a comfortable place, sitting or reclining that allows you to access the skin around the vagina. It can be done for 10-20 minutes a day during the last 4 to 6 weeks of pregnancy.  Typically, perineal massage is done using massage oil or a water-based lubricant, which lubricates the tissue making it softer, more supple and improving is flexibility. The idea is to attempt to prevent tearing of the perineum during birth, the need for an episiotomy or an instrument delivery such as a vacuum or forcep fetal extraction.  Clinical trials show that perineal massage is effective in reducing vaginal episitomy’s in about 6 percent of the cases.

Are home births safe? What is the American College of Obstetrics and Gynecology’s (ACOG) position on home births?

Many pregnant women often ask me about the safety of home births.  The American College of Obstetrics and Gynecology  (ACOG) is the non-profit organization of women’s health care physicians advocating the highest standards of practice for practicing Ob/Gyn’s.

The ACOG recognizes that both labor and delivery “while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth.”  The ACOG’s statement continues to specifically state that “these hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation.” They contend that “the hospital is the safest place to give birth because capabilities of the hospital setting and the expertise of the hospital staff are immediately available if a complication arises suddenly.”

The ACOG supports those actions that improve the experience of the family while continuing to provide the mother and her infant with accepted standards of safety available only in hospitals. These safety standards are outlined by the American Academy of Pediatrics and ACOG. Women considering home births should research the standards of the midwifery or birthing organization to which the birth attendant belongs.

On the other hand, the American College of Nurse Midwifery is more flexible, supporting home births within certain defined parameters. They refer to this as a “planned home birth.” They support the provision of protocols by hospitals, physicians, and insurers which define strict guidelines for the care of patients at home.

As one mother wrote in her concerns with a home birth, “Things can go wrong in childbirth regardless of where you give birth,” But the difference between home birth and hospital birth lies in having quick access to care should an unforeseen complication emerge.

For those women that are interested in having a “home birth” labor experience, I advocate that both goals of a minimally physician guided birth with comfort and privacy can occur in the safety of a hospital environment.

Should women restrict work during pregnancy?

Nowadays, women do not have the option of not working during pregnancy.  The good news is that it is completely safe to work during pregnancy.  Working during pregnancy is usually not a problem unless a woman has risk factors, such as hypertension, or a complicated pregnancy, such as preterm labor. Women should check with their healthcare providers for specific restrictions. With an uncomplicated pregnancy, working close to or near the due date should not be a problem. Pregnant women should always wear comfortable clothing, move around frequently if sedentary, drink plenty of fluids, and have time to rest and take breaks. Women with strenuous jobs, those who work with heavy machinery, or those who work with toxic chemicals should consult their healthcare providers and their job’s occupational department for restrictions or concerns. Pregnant women who maintain an active and productive lifestyle help make time pass faster and add to a feeling of personal well being.

What are stretch marks and can they be prevented?

Stretch marks (striae) are pink, reddish or purplish indented streaks that often appear on the abdomen, breasts, upper arms, buttocks and thighs.  Unfortunately, stretch marks cannot be prevented during pregnancy. The degree to which a woman experiences stretch marks is determined genetically. If your mother got them during pregnancy, you probably will too.  Stretch marks usually occur when weight is lost or gained quickly. Using creams and gels rarely make a difference. Fortunately, stretch marks fade with time and become silvery white or red.  Once you are done with your pregnancy, you can manage your stretch marks with new medical laser technology.   They will often fade to light pink to grayish stripes but rarely disappear completely.

Why does back pain and postural changes of pregnancy occur?

Patients tell me all the time as they get further along in pregnancy their back pain worsens.  More than 50% of women complain of back pain during pregnancy.  The additional weight gain in pregnancy can affect the centre of gravity which leads to backaches and back pain. Women experience a progressive increase in the anterior convex shape of the lumbar spine during pregnancy. This change, better known as lordosis, helps keep the center of gravity stable and over the legs as the uterus enlarges (see below). Late in pregnancy, aching, weakness, and numbness of the arms may occur secondary to an expected change of an anterior positioning of the neck and hunching of the shoulders in response to exaggerated lordosis.  As a result of these positional changes traction on the ulnar and median nerves causing numbness in the arms and hands.

Lumbar lordosis of pregnancy.

 
Other postural changes that occur are joint laxity and shifting center of gravity which contribute to an increase in gait unsteadiness.  Some have described this as if “they have just gotten off a horse”.  These changes are most exaggerated in later pregnancy.  The pelvis and the ligaments that support it are stretching and expanding in anticipation of delivery.  For those women that have debilitating back pain, massage, heat, back strengthening exercises, acetaminophen, and physical therapy can serve to ease the pain.  Always discuss any unusual, persistent or worsening symptoms to your health care provider.

Is feeling the heart racing a common occurrence during pregnancy?

During pregnancy your heart works much harder, especially during delivery!  Since your blood volume increases by 30-50% throughout pregnancy, your heart has to increase how much it pumps, or its cardiac output.  In addition to having an increase in cardiac output, the heart rates increase by 10-20 beats per minute.  The changes involving your cardiovascular system peak during 20-24 weeks and usually resolve completely within 6 weeks of delivery.  As a result of these changes with your heart you may experience flutters or a racing feeling better known as palpitations, shortness of breath and a reduced tolerance for prolong periods of exercise.  If you notice these symptoms it is important to tell your health care provider to ensure these are the normal symptoms related to all the cardiovascular changes.

Should We Store our Newborn’s Cord Blood?

During the delivery of your baby a small amount of umbilical cord blood is taken to obtain routine labs on your newborn.  Once the blood is taken the remainder of the cord blood and placenta are discarded.  However there is an option to collect a large volume (2 cups worth) of umbilical cord blood that can possibly be used for your baby in the future.  Umbilical cord blood is collected and stored away by either private or public cord banks.  The purpose of storing umbilical cord blood is to use it in the future for your child to treat a number of genetic, blood, and cancer conditions in children such as leukemia and immune disorders.  Examples of such condition include acute and chronic leukemia, lymphoma, aplastic anemia, sickle cell anemia, and thalassemia major. It is important to know that there are no accurate statistics or studies on the likelihood of your child someday needing their own stored cells.

The American Academy of Pediatrics (AAP) “discourages storing cord blood at private banks for later personal or family use as a general insurance policy.”  Instead the AAP encourages families to donate their newborn’s cord blood to a cord blood bank or other individuals in needs.

Private cord blood banking is storing the baby’s cord blood for his/her own use in the future or for a family member should it be necessary.  Public cord blood banking is a way to donate the baby’s cord blood in a public bank which makes it accessible to anyone in need of a transplant or used for research purposes.

An instance where private cord banking would be used is if there was knowledge of a full sibling in the family with a medical condition that could potentially benefit from cord blood transplantation.

Public donor cord blood banks can be difficult to find in the United States since there are only a few in existences.  Public cord blood banks are usually non-profit, although a few for profit cord blood banks bank both privately and publically.  Private donor cord blood banks are for-profit and are more accessible in most major cities.  The costs vary from bank to bank and generally the fees tend to account for the private storage of cord blood which includes both the collection and the storage.  Private cord blood banks supply the family with a collection kit, the obstetrician will collect the umbilical cord blood during the delivery and within 24-48 hours the cord blood is mailed to the banks storage facility.  The average cost is $1,600 with a yearly storage fee of approximately $125.

If you are interested in donating your newborn’s blood or storing it privately with a blood bank discuss the pro’s and con’s with your health care provider and future pediatrician.  Even though statistically it is unlikely that your baby will ever need to use his/her own umbilical cord blood, many feel it is an expense they are willing to spend for an extra “insurance policy” on their greatest gift!

Can I exercise in pregnancy?

Exercise is a must in pregnancy!  Your body is changing, you’re tired, feeling uncomfortable, swollen, and just not liking how pregnancy has taken over your body.  Regular exercise not only helps build your muscles, gives you energy, keeps you healthy but it mentally helps you through the 9 months of expected bodily changes.  Being active and exercising at least 30 minutes 4-7 times a week can benefit your health in the following ways:

Helps reduce backaches, constipation, bloating, and swelling
May help prevent or treat gestational diabetes
Increases your energy
Improves your mood
Improves your posture
Promotes muscle tone, strength, and endurance
Helps you sleep better
Improves your ability to cope with the pain of labor.
Will also make it easier for you to get back in shape after the baby is born.
Pregnancy affects joint stability, balance and coordination and heart rate fluctuations.  Before beginning your exercise program talk to your doctor/health care provider to make sure that you do not have any restrictions on activities chosen. Most forms of exercise are safe during pregnancy.  Brisk walking, swimming, recumbent cycling and strength training are excellent sources of exercises.  Exercises that should be avoided include snow skiing, contact sports such as soccer and basketball and scuba diving.

Stop exercising and call your doctor if you get any of these symptoms: Vaginal bleeding, dizziness or feeling faint, increased shortness of breast, headache, muscle weakness, calf pain or swelling, uterine contractions, decreased fetal movement or fluid leaking from the vagina.

Exercise during pregnancy can help prepare you for labor and childbirth.  Exercising afterward can help you get back into shape.  There is no question that the benefits of exercising during pregnancy outweigh the risks.

When should I feel fetal movement?

Most women feel the beginnings of fetal movement before 21 weeks gestation. In a first pregnancy, this can occur around 18-21 weeks gestation, and in following pregnancies it can occur as early as 15-16 weeks gestation. Early fetal movement is felt most commonly when the woman is sitting or lying quietly and concentrating on her body. It is usually described as a tickle or feathery feeling below the umbilical area. As the fetus grows in size, these feelings become stronger, regular, and easier to feel. Studies found that the fetus is most active between 9pm and 1am during the day/evening.   The medical term for the point at which a woman feels the baby move is “quickening”. Woman may notice that they feel more fetal movement right after meals or snacks.  Fetal movement should be noticed throughout the day and night.  As the baby grows and gets larger the perception of movement will change and might be less noticeable.  Following your baby’s “kick counts” are a way for you to ensure that your baby moves 10 movements in an hour, at least twice a day.  If you notice that there is less movement during the day you should drink a large glass of juice and lay on your left side to see if your baby will be more likely to move with a sugar boost and hydration.   If you have concerns about fetal movement becoming less noticeable you should contact your health care provider/obstetrician.  This is extremely important since fetal movement can directly correlate to the baby’s well-being.

What is the recommended weight gain in pregnancy?
How much weight you should gain in pregnancy can depend on a number of important variables.  Are you pregnant with one (singleton) or two (twins) or three (triplets) babies?  What is your age and what is your pre-pregnancy weight?  Do you have any additional medical conditions such as gestational diabetes or hypertension that will affect the overall recommended weight gain.
It’s clear that gaining the right amount of weight during pregnancy involves eating a healthy and balanced diet so that your baby is getting all the nutrients he or she needs and is growing at a healthy rate. In general you will need to consume 100 to 300 more calories a day to meet the needs of your growing baby.  You should gain about 2 to 4 pounds during your first three months of pregnancy and 1 pound a week for the remainder of your pregnancy.

Guidelines for weight gain during a singleton pregnancy are as follows:
Underweight women (BMI < 18.5) should gain 28-40 pounds.
Normal-weight women (BMI, 18.5-24.9) should gain 25-35 pounds.
Overweight women (BMI, 25-29.9) should gain 15-25 pounds.
Obese women (BMI, 30 or higher) should gain 11-20 pounds.
It is important to ask your health care provider how much weight you should gain during pregnancy. A woman of average weight before pregnancy should gain 25 to 35 pounds during pregnancy. Underweight women should gain 28-40 pounds during pregnancy. Overweight women may need to gain only 15-25 pounds during pregnancy.

Where Does the Extra Weight Go During Pregnancy?

Baby                                   8 pounds
Placenta                            2-3 pounds
Amniotic fluid                 2-3 pounds
Breast tissue                    2-3 pounds
Blood supply                    4 pounds
Fat stores for delivery and breastfeeding      5-9 pounds

Uterus increase               2-5 pounds

Total                               25 to 35 pounds

I find that some women in my practice have a difficult time pacing themselves as the pregnancy goes along on how much weight to gain and at what intervals.  It’s a challenging time to see your body completely morph over a 9 month time period.  I always remind women that this is a temporary time period when you need to allow your body to grow and develop in a healthy way.  Once you are done with pregnancy and nursing you can have the body you once had before this wonderful journey began!

I am frequently asked if Ultrasound (US) during pregnancy is safe.  Prenatal ultrasound is high frequency sound waves used to evaluate a pregnancy.   It can be done transvaginally where a vaginal probe is inserted into the vagina to assess an early pregnancy or abdominally for a later pregnancy.

US is used throughout pregnancy to evaluate the growth and health of a fetus as well as looking at the ovaries, placenta and amniotic fluid.

US is typically done in the first trimester to evaluate an early pregnancy and establish the dating of the pregnancy.  It is also done between 16-20 weeks to assess the structural anatomy of the fetus as well as its gender.  US can also be done throughout the pregnancy to asses fetal growth, positioning and fluid levels.  It is extremely helpful during a woman’s pregnancy to have access to fetal US throughout a pregnancy.

Most importantly, US is completely safe to the mother and fetus.

Chorionic Villus Sampling or CVS is an accurate prenatal test performed between 11 and 14 weeks of pregnancy to check for birth defects, such as Down syndrome and other chromosomal abnormalities. Under Ultrasound guidance a small amount of the placental tissue is removed from the gestational sac and tested for chromosomal analysis. Chromosomal disorders such as Down Syndrome (Trisomy 21), Trisomy 13, and Trisomy 18 can be ruled out. Other genetic diseases that CVS can access are Sickle Cell Disease, Cystic Fibrosis, Tay- Sachs and neural tube defects such as spinal bifida. CVS can also determine the gender of your baby. It offered to women 35 years of age of older. The main advantage to CVS testing versus amniocentesis is that you can determine the chromosomes and gender of your baby as early as 12 weeks gestation. CVS testing is helpful for women who know they are carriers of genetic diseases, such as Cystic Fibrosis, or for those who need to determine paternity. The complication rate of CVS is approximately 1 in 300.