Obstetrics FAQs

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We date pregnancies from the first day of the previous menstrual cycle. Actual conception usually occurs around two weeks after that day. Sometimes, it is difficult to remember the last menstrual period, or the last period may have been atypical which calls into question the true gestational age. We do ultrasounds to confirm dates whenever there is any question. You can predict your due date using the following formula: Take the first day of your last menstrual period. Subtract 3 months, then add 7 days. For example, if the first day of your last menstrual period (LMP) is June 14, subtract 3 months March 14. Add 7 days. March 21 is the estimated due date.

 

First of all, congratulations! We are excited about this miraculous event and look forward to sharing this exciting time with you. You need to call for a new OB appointment. We recommend the first OB appointment occurs within the first 12 weeks of pregnancy. Of course, we recommend you discontinue smoking and drinking any type of alcohol. You should take a prenatal vitamin with adequate folic acid. Most commercial prenatal vitamins contain a full milligram. This folic acid is most important in the first month of pregnancy.

Prenatal nutrition is a vital issue and in my opinion does not receive enough emphasis. Given the multi-variable nature of human pregnancy, issues regarding nutrition are difficult to test. It is reasonable to assume that maternal nutrition can play a vital role in the baby’s future development. Most experts recommend supplemental intake of vitamins. The woman even considering pregnancy, or who is pregnant or breastfeeding should consume a healthy diet that is low in saturated and trans fat. She should consider supplements containing adequate folate, calcium, Vitamin D, essential fatty acids, and perhaps iron among other vitamins.Folate, or folic acid is important during human development. Folate supplementation during pregnancy can prevent 80-90% of neurotube defects (NTDs) ie spina bifida. It usually takes 3 months to achieve and maintain adequate folate levels; therefore, it is preferable to be taking folate before conception. Embryologically, the neurotube has closed by the 28th day of development. This is before many even know they are pregnant. Folate continues to be important for development throughout life. Folate is typically derived from dark leafy vegetables, beans, nuts and whole grains. The US Public Health Service recommends any woman of reproductive age to supplement with 400 ug of folate per day. Most over the counter multivitamins and prenatal vitamins have adequate folate. The patient should not try to increase the folate by taking several multivitamins. The CDC recommends any woman with a history of prior NTD supplement with 4mg of folate per day.

There is now compelling evidence to suggest the benefit of certain poly-unsaturated fats in fetal brain and eye development. DHA or docosahexanoic acid is an omega 3 fatty acid derived from fish. It has been found to be vital in the development of the nervous system. The omega 3 FAs are not consumed in adequate amounts in the modern American diet. The daily recommended intake of DHA is 200-300mg. The problem with that is given the mercury content in fish, we recommend the pregnant patient limit intake to 12 oz of fish or less per week. Therefore, we recommend she supplement her intake with a fish oil (mercury content in fish oil is negligible). Many prescription prenatal vitamins include this. The patient also has the option of adding a supplemental fish oil. Most supplements contain 1/3 DHA, thus taking 700mg of fish oil will achieve the recommended 200mg of DHA.In summary, any woman who is considering pregnancy, or may become pregnant should take a supplemental multivitamin or prenatal vitamin containing at least 400ug of folate. There are numerous over the counter prenatal vitamins. There are also prenatal vitamins available by prescription. I also now recommend patients supplement their prenatal vitamin with 700mg of fish oil.

The universal disclaimer on medications during pregnancy is no medication has been studied completely. No study could take into account all the variables of human development that pertain to the specific medication. That being said, avoid taking unnecessary medications. This is most important during the first eight weeks of the pregnancy. Certainly, there are chronically prescribed medications such as anti-depressants, anti-hypertensives and thyroid medication, to name a few, which can be very important to the mother’s well-being during pregnancy and will be continued. Sometimes, a medication will be changed to a safer alternative. Specific questions regarding medications can be handled at clinic appointments.

The following are generally acceptable during pregnancy.

 

Pain or headache: Tylenol (acetaminophen); Ibuprofen (Advil, motrin) up to 32 weeks pregnant. Tylenol and motrin may be used together. To alleviate a migraine headache, drink a caffeinated beverage with Tylenol and motrin, though we don’t advocate the regular consumption of caffeine.

 

Cold, runny nose:
  • Vaporizer at bedside
  • Vicks VapoRub
  • Nasal irrigation: ? tsp. salt, ? tsp. baking soda in 8 oz. warm water. Irrigate nasal passages 3-4 times daily
  • Cepastat lozenges or throat sprays
  • Afrin (oxymetazoline)—theoretic precautions in IUGR cases
  • Antihistamines
    • Zyrtec(Cetirizine)
    • Chlor-trimetron (chlorpheniramine)—after 12 weeks pregnant
    • Sudafed (pseudoephedrine)—after 12 weeks pregnant
    • Novahistine—after 12 weeks pregnant
    • Tylenol cold and sinus—after 12 weeks pregnant
    • Advil cold and sinus—after 12 weeks and before 32 weeks pregnant
    • Claritin (loratadine)—after 12 weeks

Cough:

  • Robitussin (guaifenesin)—after 12 weeks pregnant
  • Delsym (dextromethorphan)
  • Any over the counter cough/throat lozenge

Sinus tenderness:

  • Vaporizer/Vicks VapoRub
  • Antihistamines as above
  • Saline nasal spray/irrigation
  • Afrin (oxymetazoline)
  • Warm packs to eyes and sinuses

Heartburn/Gastroesophageal Reflux Disease (GERD):

  • Tums
  • Maalox
  • Pepcid (famotidine)
  • Zantac (ranitidine)
  • Prescription: nexium (esomeprazole), protonix (pantoprazole), available in some cases and considered safe during pregnancy
  • Pepto Bismol: do not use during pregnancy

Nausea and vomiting*:

  • Strategies
    • Avoid odors and triggers
    • Avoid spicy and fatty foods
    • Omit iron supplement
    • Eat bland, dry high protein foods
    • Eat small frequent meals with fluids between
    • Avoid an empty stomach
    • Keep crackers at bedside; eat before rising
  • Alternative therapies
    • Ginger: ginger ale or capsules (250mg 4 times per day taken orally)
    • Vitamin B6
    • P6 elastic wristband (acupuncture point)
  • Antihistamines available without a script
    • Dramamine (dimenhydrinate) 50mg 4 times per day
    • Antivert (meclizine) 25mg 3 times per day
    • Vistaril (hydroxyzine) 25-50mg 4 times per day
    • Benadryl (diphenhydramine) 25mg 3 times per day
  • Prescription medicines available if indicated

Diarrhea: (You may follow these instructions if symptoms are acute and no alert signs such as fever, bloody diarrhea or weight loss have occurred.)

  • Clear liquids/bland diet until symptoms resolve
  • Kaopectate
  • Imodium AD

Constipation:

  • Water consumption should be at least 8-10 glasses of water per day
  • High fiber diet
  • Fiber laxatives such as Metamucil, Citrucel, Fibercon
  • Milk of magnesia
  • Magnesium Citrate—120 to 240 mL orally
  • Mineral oil—may decrease absorption of fat soluble vitamins
  • Glycerine suppositories

Hemorrhoids:

  • Increase fluids
  • Increase fiber through diet or supplementation as above for constipation
  • Avoid straining with defecation and avoid prolonged times on the toilet
  • Use sitz baths to soothe
  • Try topical therapies—will not cure, but may decrease symptoms, for example, Tucks, Preparation H, Hydrocortisone and epi-foam

* adapted from Niebyl. “Management of Nausea and Vomiting in Pregnancy: A Clinical Perspective”. Academy for Healthcare Education. Nov. 2002 pp.6-9.

 

Nsaids such as motrin, ibuprofen, advil, naprosyn, and aspirin to name a few have generally been considered safe when taken during pregnancy before 32 weeks gestational age. We encourage caution in the use of nsaids especially during the first trimester. There may be a small association with the use of these agents and the formation of cardiac septal defects and orofacial cleft defects in the newborn.

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy.

Fish is a vital source of very-long-chain polyunsaturated fatty acids known also as omega 3 fatty acids as well as protein. Many are now aware that fish is also a source of a pollutant known as methyl mercury. Given the concern over mercury, the FDA/EPA recommend limiting weekly fish intake to 12 ounces(2 meals) during pregnancy. In addition, the pregnant patient will want to avoid eating large predatory fish that is high in mercury such as: shark, swordfish, albacore tuna, king mackerel, and tile fish. Chunk light tuna should be fine. Given this limitation, the patient will need to supplement omega 3 fatty acids.Also, many ask if they may eat shell fish and sushi. I recommend patients avoid any uncooked meat. So, shellfish is fine as long as it has been cooked. The concern with undercooked meats is listeriosis.

The answer to this question depends on you pre-pregnant weight:Underweight (bmi <20)———-28 to 40 lbs.
Normal weight (bmi 20-25)——25 to 35 lbs.
Over weight (bmi 25-30)———15 to 25 lbs.
Obese (bmi >30)——————-15 lbs
Twins——————————–35 to 45 lbs.

 

There is a marginal increase in calorie requirement during pregnancy of perhaps 250 calories. This is not a lot of calories…ie a fudge sundae every night would definitely be over doing it! Many patients will actually lose weight during the first trimester. Unless the patient was significantly underweight, this is not usually a cause for concern. I typically expect the normal patient to gain around 10 lbs by 20 weeks.

No there isn’t. The vegetarian does need to make sure she consumes adequate protein and supplements vitamin B12, iron and vitamin D.

The concern here is listeriosis. This is a bacterial infection or food poisoning the mother can pass to the fetus. It causes a flu like illness and babies may also be infected. Listeriosis may be avoided by taking certain precautions: (taken from WebMD)

  1. Shop safely. Bag raw meat, poultry, or fish separately from other food items. Drive home immediately after finishing your shopping so that you can store all foods properly.
  2. Prepare foods safely. Wash your hands before and after handling food. Also wash them after using the bathroom or changing diapers. Wash fresh fruits and vegetables by rinsing them well with running water. If possible, use two cutting boards-one for fresh produce and the other for raw meat, poultry, and seafood. You can also wash your knives and cutting boards in the dishwasher to disinfect them.
  3. Store foods safely. Cook, refrigerate, or freeze meat, poultry, eggs, fish, and ready-to-eat foods within 2 hours. Make sure your refrigerator is set at 40F or colder. However, listeria can grow in the refrigerator, so clean up any spills in your refrigerator, especially juices from hot dogs, raw meat, or poultry.
  4. Cook foods safely. Use a clean meat thermometer to determine whether foods are cooked to a safe temperature. Reheat leftovers to at least 165F. Do not eat undercooked hamburger, and be aware of the risk of food poisoning from raw fish (including sushi), clams, and oysters.
  5. Serve foods safely. Keep cooked hot foods hot [140F or above] and cold foods cold [40F or below].
  6. Follow labels on food packaging. Food packaging labels provide information about when to use the food and how to store it. Reading food labels and following safety instructions will reduce your chance of becoming ill with food poisoning.
  7. When in doubt, throw it out. If you are not sure whether a food is safe, don’t eat it. Reheating food that is contaminated will not make it safe. Don’t taste suspicious food. It may smell and look fine but still may not be safe to eat.
  1. Do not eat hot dogs, luncheon meats, or deli meats, unless they are reheated until steaming hot.
  2. Do not eat soft cheeses such as feta, Brie, Camembert, blue-veined cheeses, and Mexican-style cheeses such as “queso blanco fresco.” You can have hard cheeses and semi-soft cheeses such as mozzarella along with pasteurized processed cheese slices and spreads, cream cheese, and cottage cheese.
  3. Do not eat refrigerated pâté or meat spreads. However, you can eat these foods if they are canned.
  4. Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish such as a casserole. Examples of refrigerated smoked seafood include salmon, trout, whitefish, cod, tuna, and mackerel. You may eat canned fish such as salmon and tuna or shelf-stable smoked seafood.
  5. Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk, such as some cheeses.
  6. Avoid eating salads made in a store, such as ham, chicken, egg, tuna, or seafood salads.

Morning Sickness is the nausea and vomiting suffered by 50-90% of women especially early in the pregnancy. It is called morning sickness because it tends to be worse in the morning. Typically, signs first occur between weeks 4 and 7. Symptoms tend to peak by week 10 and will subside for most by 16 weeks. Most women have a manageable level of nausea and vomiting, meaning, they have symptoms early in the day, and if they are able to keep their stomach settled and avoid triggers, manage the rest of the day. Less than 1% of patients have a severe variant called hyperemesis gravidarum. These patients are unable to tolerate anything orally and frequently will need to go to the emergency room for IV hydration. Some will require hospitalization.

Strategies to treat nausea:
  1. Avoid odors and triggers
  2. Avoid spicy and fatty foods
  3. Eat frequent small meals and fluids between meals, avoid an empty stomach
  4. Eat bland, dry, high-protein foods
  5. Keep crackers at the bedside, eat before getting up

Over the Counter Alternatives to Treat Nausea:

  1. Vitamin B6 supplementation
  2. Ginger/ Ginger Ale
  3. Acupressure (p6 elastic wristband)

Over the Counter Anti-histamines

  1. Doxylamine (found in Unisom 2, Somnil, Dozile) it is the first choice. It is safe during pregnancy. It is sedating.
  2. Diphenhydramine (Benadryl 25 to 50 mg 3 times per day)
  3. Meclizine (meclizine 25mg 3 times per day)
  4. Dimenhydrinate (Dramamine 50 mg 4 times per day)
  5. Hydroxyzine (Vistaril 25 to 50 mg 4 times per day)

Prescription anti-nausea meds are sometimes necessary.

If the vomiting is so extreme, conservative interventions are not working, and the patient is not tolerating even water, then a visit to the ER may be appropriate. This is especially true if the patient is urinating infrequently, or notes highly concentrated urine. If the urine is dilute, then hydration is likely not a severe issue. In general, a slight decrease in weight is not an emergency.Adapted from Niebyl, “Management of Nausea and Vomiting in Pregnancy: A Clinical Perspective.” Academy for Healthcare Education. Nov. 2002, pp. 6-9.

This is a frequent question during pregnancy. Some exercise is not safe during pregnancy. Some high risk patients should not engage in exercise during pregnancy. In general, healthy, low risk patients may safely engage in a wide variety of exercise during pregnancy. Some caveats include:

  1. Pregnant patients should avoid over-exertion. The exerciser should be able to easily carry on a conversation during the activity.
  2. The target heart rate will be in the 140 range.
  3. Avoid hyperthermia, especially early in pregnancy. You are allowed to sweat, just don’t over exert in a hot or poorly ventilated area.
  4. Avoid contact sports and be aware of changes in balance as the pregnancy advances.
  5. As the pregnancy advances, avoid lying flat on your back, this may impede blood flow back to the heart.
Flu Season runs from October through May with the peak December through March. Every year 200,000 people are hospitalized with the flu and 36,000 die. Pregnant women have higher rates of illness and death from the flu. The Federal Advisory Committee for Immunization Practices and ACOG (American College of Ob/Gyn) recommend all women be immunized with the flu vaccine. There are some patients that should not receive the vaccine. They include those with egg allergy as well as those who have had bad reactions to the vaccine in the past.There has been concern in the past about vaccine that contains Thimerosal. This is a mercury containing anti-bacterial compound found in most of these vaccines. It has not been found to be harmful to the developing baby. The pregnant patient should in fact receive the intramuscular injection with killed virus. There is a nasal spray made with live weakened virus. This is not approved for use in pregnant patients.The flu vaccine may cause soreness, redness, swelling at the injection site as well as low grade fever and body aches. Rarely, it may cause a severe allergic reaction.

 

Most people understand that Down’s syndrome is a group of problems caused by having an extra 21st chromosome (3 instead of 2). These children have numerous issues including mental retardation. The risk of having a baby with Down’s syndrome increases with maternal age.The risk at…
  • Age 20 is 1/1,667
  • Age 25 is 1/1,250
  • Age 30 is 1/952
  • Age 35 is 1/385
  • Age 40 is 1/106
  • Age 45 is 1/30

All women are offered screening options during pregnancy. All women 35 and over are considered to be high risk and are offered diagnostic services as well. I add this one caveat. Think about what you will do with information before you obtain it. Are you getting this information so that you may avoid having a Down’s baby with a potential abortion? Is it valuable to you to know the answer to this question before delivery, just to be prepared? Just because there is testing available doesn’t mean you have to do it.

 

  • OPTION 1: No screening/testing. You don’t care to know or, it doesn’t matter to you and you don’t see where testing will change the outcome for you. You don’t want any testing. This is your choice.
  • OPTION 2: Mid-trimester quad screen. This a blood test done on the mother between 15 and 20 weeks. Closer to 15 weeks is ideal. According to the blood level of the 4 analytes measured along with the age and risk factors identified, a risk level is tabulated. If that risk level is equal to or greater than the risk a normal 35 year old has given her age, that patient is considered high risk and is offered further testing. Important to note, a positive test DOES NOT indicate a baby that is affected by Down’s Syndrome. It only determines which mothers should be offered further testing. The test is designed so around 5% of the tests will be positive (depending on individual patient’s risk). Only a fraction of those mothers with positive tests have an affected baby. In the event of a positive screening result, the patient is counseled regarding the risks and ultimately offered referral to a sub-specialist called a perinatologist. This physician is able to perform diagnostic tests such as targeted ultrasounds and amniocentesis. This is a test where a needle is inserted into the uterus and a sample of the fluid is sent for evaluation. Amniocentesis is considered the gold standard for diagnosis but, is not without risks.
  • OPTION 3: A combination first trimester and mid-trimester test or, integrated test is available. In an attempt to increase the sensitivity of the testing ( pick-up rate) without increasing the false positives, strategies have become available to combine 1st trimester ultrasound measurement of the fetus’s nuchal (neck) skin fold and blood analyte levels with 2nd trimester analyte levels i.e. the quad screen(above). This strategy improves the pick up rate or sensitivity from 70% to 80+%. It also decreases the false positive rate from 5% to 1%.

Mother 35 years old or older at the time of delivery (the high risk patient):

  • OPTION 1: No screening/testing. You don’t care to know or, it doesn’t matter to you and you don’t see where testing will change the outcome for you. You understand the implications of age and don’t want any testing. This is your choice. Of note, the risk for a 35 year old to have a Down’s baby is much less than 1%. Risk is likely around 1/380 (at term).
  • OPTION 2:Given your “high risk” status, you are offered referral to a perinatologist. That sub-specialist will offer counseling and will likely discuss the same tests available to the younger patient such as the nuchal fold testing and maternal blood analyte testing. Ultimately, they are able to perform diagnostic tests so the mother can be sure. Those include:
    1. Chorionic villus sampling (invasive first trimester test where placental samples are obtained for testing)
    2. Amniocentesis (second trimester test where a needle is introduced into the uterus to obtain a sample of the amniotic fluid)
  • OPTION 3: Despite the counseling that the age makes a patient a high risk patient, some patients seek reassurance from the screening tests. They are not denied these options. They may seek either strategy as described for the younger patient above. That includes an integrated approach with 1st trimester sonogram and blood tests plus a 2nd trimester blood test versus just the 2nd trimester blood test. The patient needs to keep in mind that their age already makes them a high risk patient.

 

Currently, ultrasound is not a good screening method for Down’s risk. If features of Downs Syndrome are seen on ultrasound, rarely are they diagnostic and false positive rates are intolerably high. In the event suspicious features are seen, the patient is offered referral to a perinatologist for possible diagnostic testing. Really, the utility of ultrasound is as an adjunct for patients who are already determined to be high risk by age or positive screening results.

No, this blood test can also test the risk of other trisomies such as Trisomy 13 and 18. These are much rarer than Down’s. The testing can also help in the diagnosis of neurotube defects ie. spina bifida.

The answer to that question depends on the type of screening test that was done and the individual patient. If you had a mid-trimester blood test only, the test has an intolerably high false positive rate of 5%. This means 5/100 patients tested have a positive test and a normal baby. The incidence of Down’s Syndrome in general terms is closer to 1/1000 births. In this example, If 50/1000 have a positive test, that means 98% of those with a + screening test actually have a normal baby. As you can imagine, this is the source of considerable anxiety. The integrated screening protocols are much more accurate. If you had a first trimester sonographic nuchal translucency done along with a blood test and then a 2nd blood test in the 2nd trimester, this strategy has a false positive rate of 1%. A positive test here is much more worrisome.Any patient with a positive screening test is offered referral to a perinatologist. This is a OB subspecialist with expertise in antepartum diagnosis. The perinatologist will offer targeted sonograms, counseling and ultimately amniocentesis. This is a procedure where the baby’s fluid is sampled via a trans-uterine needle. That fluid is then studied to determine the karyotype(chromosomes) of the fetus. This is the gold standard test.

The glucola is a screening test for gestational diabetes. This test is done because the hormones made in increasing levels during the course of the pregnancy will overcome some patient’s ability to handle sugar. Those patients can become overtly diabetic and that can affect the pregnancy. It is typically administered to all patients (except known diabetics) between 24 and 28 weeks. It involves drinking a concentrated sugar solution and then testing the blood glucose level an hour later to make sure the mother is not becoming diabetic. If the screening glucola is positive, the patient will be scheduled for the diagnostic 3 hour test.To prepare for the glucola:

  1. Avoid eating concentrated sweets the day before and the day of your glucola (i.e. candy, donuts, anything by Hostess)
  2. Drink 1 bottle of glucola 1 hour before your appointment time and drink the entire amount within 5 minutes. Note the exact time you start the drink.
  3. DO NOT EAT, DRINK or SMOKE after you drink the glucola. (No mints, No chewing gum)
  4. Allow an hour at the lab.

In the first trimester (before 12 weeks): This is very common. It occurs in more than 30 percent of pregnancies. Our greatest concern is that this would be a sign of an ectopic or tubal pregnancy which can be a medical emergency. Fortunately, tubal pregnancies are uncommon (less than 2 percent).

The next and more common concern is: Does this mean the pregnancy is not viable? Is it the sign of an impending miscarriage? Around 50 percent of the time, this is the case. Nonviable pregnancies may be diagnosed via ultrasound. If the pregnancy is too early for ultrasound, serial blood determinations of the HCG level may be done over several days. During office hours, we typically perform an exam and ultrasound and obtain blood samples.

If bleeding occurs after hours and you are concerned about the volume of bleeding or the possibility of tubal pregnancy, we will direct you to the emergency room. If bleeding volume is light, the patient is encouraged to follow-up during the next office hours where an evaluation can be done. It is important to note that in the case where bleeding is seen, there is no intervention that can change a nonviable pregnancy to a viable one.

Finally, whenever there is bleeding. Patients who are RH negative need a current dose of rhogam. If you don’t know your blood type (typically ordered at the new ob appointment) , you will need a blood typing within a few days.

Bleeding in the second and third trimester (after 12 weeks): A small amount of bleeding and spotting is normally seen at term after cervical exams and as the cervix thins. Commonly, it represents trauma or irritation of the vascular cervix especially if it occurs after intercourse. However, bleeding can be a sign of preterm labor especially if accompanied by regular uterine contractions or menstrual-type cramping.

Bleeding can also be the sign of placenta previa. This means the placenta is blocking the cervix. This is evaluated and ruled-out during the ultrasound around 20 weeks.

Lastly, bleeding could represent abruption of the placenta. This means the placenta separates from the wall of the uterus. This occurs most commonly in women with high blood pressure. It can also be the result of trauma to the abdomen.

If you have been diagnosed with a nonviable pregnancy or impending miscarriage in the first trimester (less than 12 weeks), you have our heartfelt condolences. This is never an easy thing to get through, and we know that substantial mourning is normal. If diagnosed, you will be given the option of passing the pregnancy naturally or undergoing a procedure called a suction dilation and curettage. If you opt to pass the pregnancy naturally, this can take a variable amount of time, even weeks. If bleeding and cramping has already started, then the end is likely in sight. You will experience a crescendo of cramping and bleeding followed by the passage of tissue and cessation of cramping and a significant decrease in the bleeding. This can be an unnerving process and many patients end up in the emergency room. The cramping is synonymous with labor pains. The cramps open the cervix so the pregnancy can be passed. Occasionally, only part of the pregnancy will be passed and the bleeding and cramping will continue. In these cases, a dilation and curettage will need to be done.Dilation and curettage is a safe procedure, although no procedure is completely free of potential complication. Of course, medical attention should always be sought for profound bleeding and pain. Also, expectant management (passing tissue naturally) should not occur when a tubal pregnancy (no pregnancy seen in the uterus on ultrasound) is considered a possibility.

This is a difficult question to answer succinctly. It is even harder to answer when you are significantly preterm. Bottomline, if you think something is wrong and it is not the sort of thing that can wait and/or you are not satisfied with the helpline’s answer, go to the hospital! I will address a couple of issues/ problems:

 

Preterm Labor/ Preterm Contractions: This is probably one of the most dreaded complications of pregnancy and we have made very few strides in the last 30 years in preventing preterm birth. One of the difficulties is differentiating between the mother who is experiencing actual preterm labor and the mother who is experiencing normal Braxton hicks contractions. We try to use some generalities to guide our advice. Some patients we already know are at increased risk of preterm delivery.

Those would be patients with:

  1. Prior history of preterm birth ( risk 25%+)
  2. Multiple Gestations
  3. Uterine Anomalies
  4. Polyhydramnios (too much fluid) In some cases, we can halt the course of preterm labor.
  5. These patients are going to be asked to go to the hospital more readily.

If you are less than 35 weeks and experience 6 or more contractions an hour, you are advised to hydrate to the point where your urine has little to no color and to rest. If the contractions continue or worsen, it is likely you will need to go to the hospital for evaluation. If you are having additional symptoms such as vaginal spotting, or you think your water has broken, you should go to the hospital for evaluation.

Bleeding: This is one of the scariest things for an expectant mother to experience. What it can mean depends on when we see it:

  • 1st Trimester: Anytime we see bleeding in the first trimester, we call it a “threatened miscarriage” This is not necessarily an ominous sign. If this occurs early in the pregnancy before any sonogram has been done, the prognosis is 50/50. Half the patients will go on to have a miscarriage, half will go on to have a “normal” pregnancy. This is not usually an emergency and the patient can generally wait to be evaluated but, you will want to call the office as soon as possible to get in for evaluation. Some patients may progress rapidly to miscarriage. If the bleeding progresses to cramping and the bleeding gets heavier and heavier, you may be having a miscarriage. The general course is for patients to experience a crescendo in their cramping and bleeding. This is the uterus laboring and the cervix opening to deliver the pregnancy. The cramping and bleeding culminate in the passing of the pregnancy tissue. Then the bleeding and cramping should subside. Sometimes it is hard to differentiate it from the clot. Many patients go to the emergency room during these events.

It is important to keep in mind, first trimester bleeding can be a sign of a tubal or ectopic pregnancy. This is can be an emergent condition.

This is seen when the pregnancy has not implanted inside the uterus but, up in the tubes. The tubal pregnancy quickly out grows the tubes ability to accommodate the growing pregnancy. It can result in rupture of the tube and subsequent hemorrhage. Patients typically present with vaginal bleeding and pain. That pain is usually lateral side pelvic and constant. If you suspect you may have an ectopic pregnancy, call immediately, or go to the emergency room.If you have already had an ultrasound which showed a pregnancy in the uterus, there is a very small chance of a concomitant pregnancy in the tubes(1/35,000) and thus we generally don’t consider the bleeding a medical emergency though, it will most certainly be distressing to you! If you have had a sonogram that showed a embryo with a heartbeat then, the bleeding is not likely to be ominous. It may be cervical in orgin (ie traumatic from sex), or it may be what we call “implantation” bleeding or a subchorionic hemorrhage (bleeding under the placenta). Either way, the prognosis is much better with 85+% going on to have a “normal” pregnancy. If this is your situation, call the office and arrange an evaluation. I will want to do a sonogram and a speculum exam.

  • 2nd Trimester (12 to 28 weeks): Fortunately, bleeding in the second trimester is uncommon. It should never be deemed normal. If you have bleeding during this time, you need to be evaluated. Before 20 weeks, I am less likely to recommend presentation to the hospital. I will want to see you in the office. At this stage, we can see vaginal infections, cervical irritations, placenta previa (placenta implanted over the cervical opening), cervical incompetency, miscarriage. Between 20 and 23 weeks is a gray zone where, some will be directed to the hospital for evaluation. As we approach 23 weeks, I start to become concerned about bleeding being a sign of preterm labor and timely intervention is essential. It is also more possible to see placental abruption. I will detail this in the next section.
  • 3rd Trimester (28 weeks to delivery): There are 3 primary concerns for bleeding in the third trimester. All of which deserve immediate evaluation. The first is placental abruption. This is a condition where the placenta becomes detached from the wall of the uterus. This is going to be most common in patients with high blood pressure and/ or preeclampsia. We also see it in patients who experience abdominal trauma. Abruption will generally be accompanied by pain and/or contractions. The second issue is placenta previa. This is when the placenta implants over or in very close proximity to the opening of the cervical os. If you have received prenatal care and had a second trimester ultrasound and weren’t told about placenta previa, you probably don’t have it at this stage in the pregnancy. The third possible source of bleeding in the 3rd trimester is the cervix. It can be a sign of labor (see above about preterm labor). It could simply be a sign of cervical irritation or trauma after sex.

Fetal movement is usually noticed by 20 weeks. By 24-28 weeks, fetal movement should be noted almost hourly. At this point, it is abnormal to feel no movement. If no movement is noted, the most likely scenario is that you have not been paying close attention. If you are concerned, eat something or drink something sweet and lie on your left side and count movements. Any movement is reassuring. Four to five discrete movements in an hour is normal.Babies sleep 20 to 40 minutes per hour and there may be certain times of the day where they seem more or less active and there is really no such thing as a baby that moves too much. In the event that this observation has not satisfied you that your baby is doing well and you are 24 weeks or more, you are directed to labor and delivery for evaluation. If you are less than 24 weeks, we are hesitant to recommend coming to the hospital for evaluation especially in the absence of other extenuating circumstances because obstetric intervention for fetal indications before 24 to 28 weeks is quite rare. However, if there is any question, the heart tones can be checked either in the office or on labor and delivery.

Headache is a very common complaint, and a very difficult problem to deal with via the internet, or any “call-in” type scenario. The vast majority of headaches in reproductive aged women are going to be benign and self-limited. First, one must clarify what type of headache you have. In clarifying the type of headache, we must be mindful of danger signs that mandate presentation to an emergency room. Some of these might be:

  1. First time headache. The patient has never had headaches before.
  2. High intensity headache. Described as the worst headache of a person’s life.
  3. Severe persistent headache which reaches maximal intensity within a few seconds.
  4. Altered mental status or seizure accompanying the headache.
  5. Concomitant infection ie sinus infection, fever.
  6. Visual changes.
  7. Headache with exertion.
  8. Patients being followed for high blood pressure especially in the third trimester. May have swelling, visual changes and even abdominal pain.

If the patient has a history of migraines and the headache is typical, then we usually conclude that this is a migraine though many patients will notice an improvement in migraines during pregnancy. Tension headaches are very common during pregnancy. Typically, we recommend Tylenol 1000mg and before 32 weeks gestation, ibuprofen (ie advil,motrin) 800mg. We also recommend drinking a caffeinated beverage such as 12 oz. soda. Though we don’t advocate regular caffeine consumption, episodic use is not contraindicated in this situation. We do not recommend using your midrin, or imitrex. If you call the on-call physician, you will likely be told to go to the emergency room for evaluation and pain medications.

Nsaids such as motrin, ibuprofen, advil, naprosyn, and aspirin to name a few have generally been considered safe when taken during pregnancy before 32 weeks gestational age. We encourage caution in the use of nsaids especially during the first trimester. There may be a small association with the use of these agents and the formation of cardiac septal defects and orofacial cleft defects in the newborn.

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy.

 

 

The URI or upper respiratory tract infection is a catch-all term used to describe the common signs and symptoms of the “common cold”. Most of these infections are viral in nature and they resolve spontaneously. Occasionally, a patient will have a bacterial infection involving the sinuses or the throat, such as strep throat. These patients require antibiotic therapy. It can be difficult to differentiate the common viral infection from the more serious bacterial URI or pneumonia. If the symptoms are of new onset ( • Vaporizer at bedside)

  • Vicks VapoRub
  • Nasal irrigation: ½ tsp. salt, ½ tsp. baking soda in 8 oz. warm water. Irrigate nasal passages 3-4 times daily
  • Cepastat lozenges or throat sprays
  • Afrin (oxymetazoline)—theoretic precautions in IUGR cases
  • Antihistamines:
    • Zyrtec (cetirizine) 5-10 mg po qd.
    • Chlor-trimetron (chlorpheniramine)—after 12 weeks pregnant
    • Sudafed (pseudoephedrine)—after 12 weeks pregnant
    • Novahistine—after 12 weeks pregnant
    • Tylenol cold and sinus—after 12 weeks pregnant
    • Advil cold and sinus—after 12 weeks and before 32 weeks pregnant
    • Claritin (loratadine)—after 12 week

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy.

Heartburn is very common during pregnancy for a couple of reasons. The hormones of pregnancy slow the transit of stomach contents, the hormones also relax the muscles and render the “sphincter” at the top of the stomach less functional. Also, the enlarging uterus displaces the stomach upward further interfering with the normal function of this “esophageal sphincter”. There are a number of strategies that are useful:

  1. Elevate the head of the bed 6-8 inches
  2. Avoid foods that trigger the problem ie fatty foods, chocolate, and peppermint. Also avoid foods that specifically irritate such as acidic drinks and spicy food.
  3. Don’t smoke
  4. Don’t lie down after eating
  5. Chew gum, to promote salivation

Some useful medications:

  1. Tums
  2. Maalox
  3. OTC acid blockers such as pepcid(famotidine), and zantac(ranitidine)
  4. Prescription: nexium(esmaprazole), protonix(pantoprazole)
  5. Do not use Pepto Bismol during pregnancy

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy.

Patients who are pregnant can acquire a gastroenteritis just as a nonpregnant woman can. It may be related to “food poisoning” or other source. The treatment is the same whether you are pregnant or not.Consider the following if the symptoms are new onset and not associated with alert signs such as fever, bloody diarrhea, and weight loss:

  • Clear liquids, bland diet until symptoms resolve
  • kaopectate
  • Imodium AD

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy

Constipation is a common complaint during pregnancy. The high progesterone levels encountered cause a slow down in the transport of material through the digestive tract. This leads to problems ranging from heartburn to hemorrhoids. Constipation can be further exacerbated by vitamins and iron.

  • Water consumption should be at least 8-10 glasses of water per day
  • High fiber diet (25 to 35 grams per day)
  • Fiber laxatives such as Metamucil, Citrucel, Fibercon
  • Milk of magnesia
  • Magnesium Citrate—120 to 240 mL orally
  • Mineral oil—may decrease absorption of fat soluble vitamins
  • Glycerine suppositories

Patients should take medicines during pregnancy only as a last alternative. Many medicines are considered “safe” when taken during pregnancy, and are described as such here; however, these declarations are usually made via observational studies of populations. They are rarely made as the result of rigorous study. Thus, caution and restraint should be exercised in starting any medication, prescription or over the counter, during pregnancy.

Preterm delivery is a profound problem in obstetrics, affecting 7-10 percent of pregnant women. The causes are multifactorial and the presentation varied. In general, we are much more tolerant of contractions after 34 weeks. Before 34 weeks, we are much less tolerant of contractions that occur more than 6 per hour. If you are having contractions and think they could be labor contractions, you will be instructed to rest on your side, drink 32-64 oz. of water and observe the contractions. I am having swelling. Is that normal?Seventy-five percent of pregnant patients experience swelling or edema. It is usually worse in the lower extremities, and tends to be worse at the end of the day or after prolonged standing. Generalized swelling can be noticed: rings do not seem to fit or your face may seem puffy. We recommend drinking adequate water. We do not recommend salt restriction. For lower extremity swelling, elevation is effective. Support hose can be obtained based on your prepregnancy weight. There is still the challenge of putting on hose while pregnant.Sometimes swelling is considered abnormal. Unilateral, or one-sided swelling, especially of the lower extremity is a possible sign of deep venous thrombosis. This will usually be associated with calf discomfort. Swelling is also seen in preeclampsia. This is a high blood pressure problem seen most frequently in the third trimester. You are evaluated for this each appointment. Your blood pressure is evaluated and your urine checked for protein. If you are concerned about the possibility of preeclampsia, you should have your blood pressure checked.

It is standard obstetric practice to screen all pregnant patients at or around 36 weeks gestation for GBS or Group B streptococcus. GBS is bacteria carried in the bowel of 10-30 percent of all women. It is not pathologic to the carrier although it can be harmful to a baby. GBS can cause a sepsis syndrome that can be life-threatening to a newborn. Thus, all carriers are treated with IV antibiotic while in labor. There is no use in treating at any other time. Of note, neonates affected by GBS sepsis are infrequent; therefore, if no test results are available, it is acceptable to treat patients based on risk factors. These risk factors include: prematurity, prolonged rupture of membranes, maternal fever, history of previous GBS affected baby and GBS UTI during pregnancy.

Depression is a very common disorder and is seen frequently during pregnancy and in the postpartum period. Feelings of depression such as loss of hope, interests, inability to concentrate and emotional instability should be discussed with your health care provider and considerations for treatment weighed.

Any patient who feels she wants to harm herself or her baby should immediately contact her health care provider or report immediately to the emergency room. This can be treated.

 It is appropriate to treat depression medically during pregnancy. As is the case with any medication, the risk of taking the medication must be weighed against the risk of not taking the medicine and the potential benefits. SSRIs are the class of drugs most often employed to treat depression and there is some controversy regarding their safety during pregnancy. Though they are thought to be associated with preterm birth, decreased birth weight, and neonatal syndrome, they have not been associated with major congenital defects or long term developmental deficits in childhood. There may be a small association with persistent pulmonary hypertension in the newborn. The absolute risk is very small and PPHN would be found in less than 1% of babies born to mothers taking SSRIs in the third trimester. Thus, the benefits of taking an SSRI during pregnancy will typically outweigh the risk. That being said, there are many options for treatment of depression and that treatment should be individualized. There are some signs which make the possibility of preterm labor higher. Those include foul smelling or blood tinged discharge or suspected rupture of membranes.

There are four main reasons to go to the hospital:

  1. Membranes/ water ruptured- This is frequently obvious, sometimes, it is not. If you feel wet on a single occasion, there is a strong likelihood this represents urine. If you feel constantly drenched, rupture of membranes becomes more likely.
  2. Vaginal Bleeding- Spotting vaginally is normal while in labor. Heavier bleeding would be a reason to go to labor and delivery.
  3. No fetal movement- Fortunately, it is rare that a baby stops moving because it isn’t doing well but, it does happen. If you feel your baby isn’t moving and you are concerned, most practitioners will tell you to eat something and then do fetal kick counts. You should feel some movement over the course of an hour. If you feel no movement and it is after hours you will be encouraged to go to labor and delivery for a nonstress test. If it is during office hours, this test may be done at the office. Of note, some patients have higher risk pregnancies such as suspected growth restriction. If you are a patient who is receiving 2 times per week nonstress tests, I am a little less tolerant of waiting for an evaluation. I am more inclined to recommend immediate evaluation.
  4. Labor- Knowing when to go to L&D due to labor is sometimes a difficult call because sometimes patients have very strong, regular contractions and they aren’t in labor. In general, contractions will be 4 to 5 minutes apart. They will be very strong and getting stronger, even when sitting down. Generally, the patient is breathing hard through the contractions, she is not talking and not smiling. Obviously there are exceptions for some patients.

Rupture of the membranes commonly causes a significant gush of clear fluid. It can also be seen when the patient has persistent wetness. Frequently, ongoing uterine contractions will occur. In certain scenarios, patients mistakenly think they have ruptured because of small episodic leakages, which is often urinary incontinence. Remember the uterus is sitting right on top of the bladder. Also, vaginal discharge can be profound at term. This problem is evaluated in the clinic or labor and delivery after hours.

If you are greater than 36 weeks, you may experience contractions repeatedly. Most often, you will be instructed to go to labor and delivery if the contractions are profound (having trouble walking and talking during the contractions and occurrence is every 5 minutes). Labor does not typically diminish when you rest. There are exceptions to this guideline: the patient with a history of rapid labors or the patient who lives a long distance from the hospital. If you suspect that the membranes have ruptured, come directly to the hospital.