Category Archives: Pregnancy

Maternal Age and Congenital Anomalies

Pregnant womanThere will likely be a bit of press this week on a study presented at the Society for Maternal Fetal Medicine that found lower rates of congenital anomalies at second trimester ultrasound screening among mothers over age 35 compared to their younger counterparts.

[The] group looked at the routine second trimester ultrasound screenings of 76,156 euploid fetuses over the course of 18 years at Washington University Physicians, and the data were split into younger than 35 and 35 and older.

Overall, 2.4% (1,804) of those screened had a major anomaly. But contrary to previous beliefs, only 1.7% of women of advanced maternal age had a fetus with a major anomaly compared with 2.6% of younger women (aOR 0.59, 95% CI 0.52-0.66,P<0.001).

The study was well done, but the headlines about it  – Older Maternal Age Tied to Lower Risk of Fetal Anomalies – are misleading. That’s because the study did not look at all women over age 35, just those carrying infants with normal chromosomes  who made it to the second trimester and presented for a sonogram.

Risks of chromosomal abnormalities increases with maternal age

One of the biggest risks of advancing maternal age is abnormalities in chromosome number, the most common of which are Down’s syndrome (trisomy 21), as well as trisomies of chromosome 18, 13 and abnormalities in sex chromosome number. Fetuses with abnormal number of chromosomes  have multiple congenital anomalies of the heart, genitourinary, brain and GI tract.

The risk for trisomy increases from around 1 in 500 at age 22 to 1 in 200 at age 35 , 1 in 65 at age 40 and 1 in 20 at age 40. Those risks are probable an underestimate, since the majority of a fetuses with abnormal chromosome numbers will  miscarry early in pregnancy, an explanation for the higher miscarriage rates in older mothers.

miscarriage and ageMost miscarriages occur in the first trimester of pregnancy, which is why a study that only looks at pregnancies in the second trimester will miss a low of abnormal pregnancies. If you then confine your study further to only those pregnancies with normal chromosome number, you’ve eliminated the majority of infants with congenital anomalies.

Bottom line

This study is not adding much to what we already know about pregnancies in older women, other than to tell us that pregnancies in older women who have had normal chromosomal screening and make it into the second trimester are in general going to do well. Even better in some ways that that of a younger woman.

Think of it as survival of the fittest. The older woman’s fetus has had a harder row to hoe and made it this far.

It is one tough little cookie.

The Death of Queen Jane

One of the saddest songs from the Coen Brothers wonderful new movie “Inside Llewyn Davis” is “The Death of Queen Jane”.

It is a traditional folk song that Davis (Oscar Isaac), on the down and out from the NYC folk scene, chooses to sing in an impromptu audition  for Chicago music producer Bud Grossman (F. Murray Abraham). Given that Davis is still mourning the death of his musical partner and reeling from the knowledge that he has fathered a child, the song choice is not surprising. But like almost every choice Davis makes in this movie, it is a poor one.

The song is the legend of King Henry’s second wife Jane Seymour, who died in 1537 after giving birth to Prince Edward I. After laboring for nine days, her attendants so tired that they can no longer attend her, the Queen begs King Henry for a Cesarean section, which he at first refuses for fear of losing both mother and child – “If I lose the flower of England I shall lose the branch too”. But eventually, the Queen swoons, a C- section is done, and later, she dies.

Grossman listens intently as Davis sings (watching Abraham is itself worth the entire film) and when the song is done, utters a single sentence –

“I don’t see a lot of money here.”

He’s right, of course. Maternal death doesn’t sell records. It’s just too depressing.

What is even more depressing than Llewyn Davis’s song choice is the fact that today, almost 500 years since the death of Queen Jane, some 350,000 women worldwide still die each year as a result of giving birth, almost all from preventable causes.

That rate is half what it was a decade ago, but we still have a long long way to go before childbirth is for every woman the joyous event it should be.

Lest you think maternal deaths are Africa’s problem, know that maternal mortality here in the US has actually doubled in the past 25 years. Despite all our advanced and expensive healthcare, the US ranks 50th in the world in maternal mortality, with the highest rate of all the developed countries. The major causes of maternal death in the US are preeclampsia, hemorrhage, embolisms and cardiovascular disease, with death rates 3-4 times higher in African American women.  Reasons for the rise are complex, but include increased C section rates, multiple births and higher rates of underlying maternal diabetes and cardiovascular disease.

Approaches to reducing maternal morality here in the US include reduction in C section rates, protocols for rapid response for transfusion for maternal hemorrhage, and team training to respond to obstetric emergencies. Here in New York State, ACOG has instituted the Safe Motherhood Initiative, developing and implementing standardized protocols for tackling maternal hemorrhage, hypertension and venous thromboembolism in hospitals across the state.  Using lessons learned from the airline industry, states are beginning to take a  centralized approach to data collection and response to adverse events.  It’s a multi-pronged approach to a complex problem that has the potential for a real and lasting impact.

Inside Llewyn Davis is a fabulous movie that will be getting lots and lots of press in the upcoming month as Oscars approach. Here’s hoping that some of that limelight will get cast on the problem of maternal mortality, and lead to conversations about more than just folk music.

The Death of Queen Jane

Queen Jane lay in labor full nine days or more
‘Til her women grew so tired, they could no longer there
They could no longer there

“Good women, good women, good women that you may be
Will you open my right side and find my baby?
And find my baby

“Oh no,” cried the women, “That’s a thing that can never be
We will send for King Henry and hear what he may say
And hear what he may say”

King Henry was sent for, King Henry did come
Saying, “What does ail you my lady? Your eyes, they look so dim
Your eyes, they look so dim”

“King Henry, King Henry, will you do one thing for me?
That’s to open my right side and find my baby
And find my baby”

“Oh no, cried King Henry, “That’s a thing I’ll never do
If I lose the flower of England, I shall lose the branch too
I shall lose the branch too”

There was fiddling, aye, and dancing on the day the babe was born
But poor Queen Jane beloved lay cold as the stone
Lay cold as the stone


More Reading

Caring for Pregnant Disaster Victims – Lessons Learned in Haiti and Japan


Israeli Defense Forces deliver a baby at field hospital in Haiti

In a landmark article in this months Green Journal, Israeli and Canadian Ob-Gyns who deployed with international relief efforts to Japan and Haiti earthquake areas have summarized the lessons they learned in the field there.

The objectives of this report are to emphasize the often overlooked need to include obstetrics and gynecology personnel among essential medical aid rescue teams and to provide recommendations and guidelines for obstetrician–gynecologists who may find themselves working under comparable extraordinary natural disasters.

The article includes a list of recommended supplies (and amounts) to bring, and a layout for an Ob-Gyn field hospital. While I urge you to read the entire article, here are excerpts from their 10 essential lessons learned –

1. An obstetrics and gynecology team is invaluable however scarce its resources, because the provision of even the most basic prenatal care plummets after a natural disaster. many as 10% of the victims seeking medical assistance may need an obstetrician–gynecologist.

2. The mix of cases that the obstetrics and gynecology team will confront requires that they are highly trained specialists prepared for and trained in dealing with emergencies in a suboptimal environment.  Miscarriages, premature deliveries, intrauterine growth restriction, low-birth-weight neonates, gender-based violence, and undesired pregnancies increase after natural disasters….Approximately 50% of the cases the Israel Defense Forces hospital team encountered in Haiti were complicated deliveries.

3. Preparations for treating extreme prematurity should be made before departure to the disaster zone. … increased seismic activity could increase delivery rates and preterm births up to 48 hours after an earthquake and a significantly higher rate of premature births was reported over a 7-month period in the wake of the earthquake in Japan.

4. Foreign aid relief teams operating in a disaster area will inevitably encounter unique and difficult ethical dilemmas, often arising from insufficient medical resources. … not every victim in need would be able to receive the necessary treatment. … the dilemma of whether to impose a minimum weight threshold for preterm neonates to receive treatment is an ethical issue, which obstetrics and gynecology teams operating in natural disaster conditions should be prepared to deal with.

 5. Obstetrics and gynecology teams treating pregnant women under natural disaster conditions should be especially sensitive to the catastrophic environment’s effect on maternal mental health.

6. Indications for cesarean delivery in a field hospital … will differ from the typical paradigm. … For example, fetuses in breech presentation with estimated birth weight less than 3,500 g were to be delivered vaginally. …with only one available fetal heart rate monitor, monitoring had to be carried out intermittently, possibly meaning some abnormality might have been missed. Potential contingencies such as these must be addressed and discussed before the team is deployed.

7. The delivery “suite” should be prepared for emergent cesarean deliveries in the event that a designated operating room may not be immediately available.

8. The likelihood of quickly obtaining additional equipment and medications is remote once the team has arrived to the disaster zone; …a list of recommended essential equipment and medications for obstetrics and gynecology relief teams is provided.

9. An outreach obstetrics and gynecology team with a portable mobile ultrasound machine including vaginal and abdominal probes not only detects problematic pregnancies, but also provides enormous psychological comfort to pregnant disaster victims.

10. The team must be briefed by someone knowledgeable about local cultural sensitivities and taboos, including local volunteers who serve as translators.

Kudos to the authors for providing an essential global resource for disaster planning.

Image from Wikipedia

Non-Invasive Fetal Chromosome Testing – Confirm Results Before Acting on Them

This well-written article in todays WSJ should be required reading for expectant parents considering prenatal testing to identify chromosomal abnormalities in their child.  New testing that identifies placental (fetal) chromosomes in the maternal bloodstream is being advocated as a safe alternative to more invasive testing such as CVS or amniocentesis, with the additional advantage of being available as early as 10 weeks.  But, false negative and false positive results can and do occur.

In one case published online by the American Journal of Obstetrics & Gynecology, a positive result from one of the new tests—together with preliminary results from another less-precise invasive measure—prompted a patient to terminate her pregnancy without undergoing a confirmatory amniocentesis. Testing of tissue from the aborted fetus showed the pregnancy was normal, the report said.

Though companies say patients should confirm positive results with invasive procedures, such case studies show “that message isn’t driven home enough,” said Athena Cherry, director of Stanford University Medical Center’s cytogenetics laboratory. In her lab, Dr. Cherry said she had found four out of six positive results for Trisomy 18, or Edwards syndrome, which the tests also detect, appeared to be false alarms after follow-up testing.

Bottom line – No test is perfect.  Abnormal antenatal blood chromosome results should be confirmed with amniocentesis before acting on them.


ACOG Committee Opinion and Press Release on Noninvasive Prenatal Screening with Cell Free DNA

Prenatal Tay Sachs Screening – Not a Perfect Test

This week’s NY Times has a most powerful and beautiful essay written by Emily Rapp, entitled “Notes From a Dragon Mom”, in which she describes what it is like to parent a child who is destined to die. Rapp’s 18 month old son Ronan has Tay Sachs disease, a progressive and incurable neurologic disorder that will result in his death within a few short years of life.

How do you parent without a net, without a future, knowing that you will lose your child, bit by torturous bit?

Depressing? Sure. But not without wisdom, not without a profound understanding of the human experience or without hard-won lessons, forged through grief and helplessness and deeply committed love about how to be not just a mother or a father but how to be human.

Rapp’s essay is a foray into the true connection between parent and child, and, in a way, a celebration of how that relationship is all the more special because it is devoid of the pressures of perfect parenting for the perfect future.

Ronan has given us a terrible freedom from expectations, a magical world where there are no goals, no prizes to win, no outcomes to monitor, discuss, compare. But the day-to-day is often peaceful, even blissful.

As a mother, I want to thank Rapp for her wisdom as she shows us all how to be better parents, and wish her continued strength and joy as Ronan’s mom.

As a doctor, I’d like to address the section of the essay where Rapp talks about Tay Sachs gene mutation screening.  It’s a short paragraph with just enough information to answer the question the reader probably has, which is – “How did this happen, when we have prenatal testing for Tay Sachs?”. Unfortunately, it is also just enough information to confuse and even frighten women who have had or are considering having prenatal screening for Tay Sachs.

The prenatal test I took for Tay-Sachs was negative; our genetic counselor didn’t think I needed the test, since I’m not Jewish and Tay-Sachs is thought to be a greater risk among Ashkenazi Jews. Being somewhat obsessive about such matters, I had it done anyway, twice.  Both times the results were negative.

Oy. Let’s see what I can do here…


What is Tay Sachs?

Tay Sachs is a genetic disorder caused a recessive mutation in the gene for hexosaminidase-A, an enzyme that catalyzes the breakdown of fatty acids in the brain. In the presence of defective Hex-A, fatty acids accumulate in the brain, causing permanent damage and progressive neurologic decline and eventually, death.

Babies born with Tay Sachs carry two copies of the defective gene, one from each parent. Parents who are carriers of recessive genes can be detected though prenatal genetic screening. This screening has been concentrated to date in high risk groups, which in the US are primarily Ashkenazi Jews, who have a carrier incidence of 1 in 30.

Who Should be Screened for Tay Sachs?

At this point in time, prenatal Tay Sachs screening is recommended to be offered to individuals from groups with increased mutation carrier incidence  – Ashkenazi Jews, French Canadians, Louisiana Cajuns and Pennsylvania Dutch. Rapp is of Irish descent,  a group with a mutation carrier incidence somewhere between 1/50 and around 1/200.

Of course, a major reason why couples screen for Tay Sachs, and for other genetic disorders, is because they want the option to terminate an affected pregnancy. An indeed, with the advent of prenatal diagnosis, the incidence of Tay Sachs among children born in the Ashkenazi Jewish population has plummeted.

In addition to using screening prenatally, some Jewish communities screen much earlier, and actually maintain online databases of Tay Sachs carrier information, so that couples can log on and screen out one another before embarking on a courtship, in an attempt to reduce marriages between two carriers. In Montreal, voluntary high-school based Tay Sachs screening programs have led to a 90% decline in the incidence of Tay Sachs in high risk communities.

Tay Sachs – Not Just a Jewish Disease 

Rapp has also written an essay on Salon entitled ” Tay Sachs is not a Jewish disease“, in which she argues that the panel of Tay Sachs genes tested should be expanded beyond the most common mutations found in the Ashkenazi Jewish populations.

…we need to consider more carefully who should get tested for what, and why. As it turns out, there are about a hundred mutations of the Tay-Sachs gene. Unfortunately the common, standard prenatal screening only detects the nine most commonly detected mutations – commonly detected among those of Ashkenazi Jewish descent , like my husband.

…Until gaps like this are rectified, until the testing catches up with the facts, and until insurance companies are willing to redefine the “standard” array of tests, more families will suffer this kind of horrific loss and the great potential of prenatal screening will never be achieved.

In Rapp’s case, she and her husband indeed would have qualified for screening, and I am assuming from the fact that she was tested twice that they knew in advance that her husband was a mutation carrier.

Tay Sachs Carrier Screening

There are two ways to determine if a parent is a carrier for a Tay Sachs gene mutation – DNA testing (carrier screening) and Hexosamindase -A activity levels.

DNA Carrier Testing

Among Ashkenazi Jews, DNA carrier testing will detect up to 99% of carriers. In the case of a couple where only one is Ashkenazi, initially carrier screening the Jewish member of the couple is thus a good way to go, since the DNA screening tests perform so much better in that population.  Then, if that individual screens positive, the next step is to screen the non-Jewish member of the couple. And that’s where the DNA test falls short –  in non-Ashkenazi individuals, it detects at most 60% of affected individuals. In Rapp’s case, the gene she carried was a rare one indeed, having” last surfaced in 1997, among people of Moroccan descent”.  Thus, it is not surprising that Rapp, despite being a mutation carrier, would have had a negative carrier test result using the available DNA testing.

There are to date over 100 known mtutations in the Hex-A gene that can lead to Tay Sachs disease, and we just do not as yet, nor are we likely soon, to have commercially available screening test for every mutation known to date. In the case of a non-Jewish individual married to a Jewish carrier, non-DNA screening for Hexosaminidase-A activity provides a better alternative to DNA testing.

Hexosaminidase-A Activity Testing

Individuals who carry Hex-A gene mutations, while phenotypically normal, have lower than normal levels of Hex-A serum activity on a simple blood test. This test actually formed the basis of the first screening for Tay Sachs, before we had DNA testing, which is thought to me more specific.

In some ways, though, DNA testing is too specific – it’s like searching for 1 of 100 needles in a haystack. And when you only know how to find 9 of those 100 needles, maybe you’re better off using a magnet – Hex-A Activity testing. It may not tell you which gene you have, but at least it tells you whose haystack has the needles. At that point, you would proceed to testing the baby.

Some might even use Hex-A testing as first line testing in an Ashkenazi individual, or combine it with DNA testing to get as close to 100% certainty as possible even in that population. And, as populations diversify through intermarrriage, Hex-A activity levels are being suggested as a better screen that DNA testing.

Of course, even hex-A activity testing isn’t perfect . But it’s pretty darned good.

Testing the Baby

Remember, that even if both members of the couple are carriers, there is only a 25% chance that the child will be affected. So if both members of the couple are Tay Sachs carriers, or if one is a carrier and the other uncertain, then testing the baby is done using CVS or amniocentesis to test for Hex-A activity, DNA or both. CVS and Amnio are both invasive tests with a small but real risk for miscarriage. Preimplantation genetic testing is also available for couples undergoing IVF who wish to screen for Tay Sachs.

But even these test are not perfect. Which, in the end, was the whole point of my writing this post. So let me say it again –


We can talk about how to make Tay Sachs screening more effective. We can expand the number of genes we test for, and the number of individuals who are offered screening, in order to come closer to realizing, as Rapp puts it “the great potential of prenatal screening.”

But we cannot, and must not, set up the expectation among women and families that the technology exists and is available that will guarantee them a perfect child. We cannot set up the expectation that technology exists to detect every child with Tay Sachs, or any other genetic disorder, prenatally.

Or, as the National Tay-Sachs and Allied Disease Organization so eloquently puts it –

We are all carriers of recessive genetic diseases but standard healthcare practice does not screen everyone for all diseases because the technology does yet exist to accurately and cost effectively screen everyone.

Which, in the end, brings me back to Rapp’s most excellent essay, which teaches us to love our children for who they our for as long as we have them – whether that is three months, three years, or a lifetime.


For more information on Tay Sachs Screening

Biologic SuperGlue for Repair of Childbirth Lacerations

Bio-adhesives are a reasonable alternative to sutures for repair of perineal lacerations sustained during childbirth, according to a poster presentation at last week’s annual meeting of the Society for Maternal Fetal Medicine. Researchers at the Hadassah Hebrew University Medical Center in Jerusalem randomized women with first degree perineal tears to either 2-octyl cyanoacrylate (Dermabond) adhesive glue or suture for wound closure. While healing and incisional pain was similar, women who received the adhesive closure were more satisfied than those who were sutured.

In Portugal, bioadhesives have been studied for closure of the top skin layer of an episiotomy repair, and found to shorten the duration of the procedure with similar outcomes to suture in terms of pain, healing and infection.

Biologic adhesives are chemically related to Superglue, which is ethyl-cyanoacrylate. Midwives have been using Superglue for perineal wound repair for some time, according to Anne Frye, who has authored a book on wound closure for midwives, and who gives instructions for its use in repair of perineal lacerations. Apparently Superglue was also used by the military during Vietnam for wound closure.

A Pub Med search on Dermabond finds multiple studies of its use, from plastic surgery to mastectomy, surgical wound closure, retinal surgery, lung and gastric leak closure, and even on esophageal varices. RL Bates mentions Dermabond as an option to repair skin tears in elderly patients. This stuff is turning into the duct tape of the medical profession…

It’s important to remember that adhesives are only for superficial skin closure, as use in deeper layers can cause irritation and burning of tissues. Side effects of their use include irritation and allergic reactions, and of course wound infections and pain can always occur no matter how one closes a wound.

Folic Acid Supplementation – Too Much of a Good Thing?

Folic Acid

Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.

But too much folic acid may lead to an increased risk for colon cancer.

So says UK researcher John C Mathers, who summarizes the current evidence for this conundrum in a well-written review article in this month’s Genes and Nutrition, and highlighted in the Chicago Tribune.

Folic Acid and Neural Tube Defects

Folic acid deficiency is a leading cause of spina bifida and other neural tube defects in newborns, and can be prevented by taking folic acid supplementation during pregnancy. The problem is that the vitamin must be repleted early in pregnancy when the neural tube is forming – a time when many women may not even know they are pregnant. While women attempting pregnancy are advised to get enough folate or take an supplement, almost half of pregnancies in the United States are unplanned, and less than a third of pregnant women get adequate folate

So in the late 1990’s the FDA mandated the addition of folate to bread and cereal products in the United Sates. Other countries worldwide have followed suit. The result has been a decline in the incidence of neural tube defects.

Given early data that folate might prevent colon cancers as well, studies were done to assess the use of higher doses for that very reason.

High Dose Folic Acid and Colon Cancer

Randomized trials of high dose folate supplementation were performed in individuals with a history of precancerous polyps of the colon. Not only did the supplementation fail to protect against polyps (in the absence of aspirin, a known protector against polyps), it doubled the risk of recurrent polyps. In addition, there were more prostate cancers among those who took high dose folate.

Epidemiological data from the US and Canada show a blip up in colon cancer cases after the introduction of folate-fortified foods (mostly breads) in these countries, further supporting the idea that high dose folate supplementation may not be such a good idea.

When it comes to vitamins, more is not necessarily better

Along with recent data on the risks of high dose Vitamin E, this folic acid data is yet another warning that when it comes to vitamins, more is not necessarily better, and can actually cause harm. It’s something to remember as we watch Vitamin D come into vogue as the vitamin to end all vitamins.

What should you do?

Stick with the current recommendations for Folic Acid intake, which in pregnancy and in women trying to conceive is 400 ug daily. ( In women at high risk for having a child with a neural tube defect, the recommended daily dose is 1 mg. ) Your maximum daily intake should not exceed 1 mg.

Read the labels of the foods you buy to be certain that you are not exceeding the daily recommended dose. I checked my bread label, and it only has 2% of the RDA for folate per slice, so I’m not concerned. Cereals can be be higher (especially Total), but vary significantly.

If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.

Pregnancy – Week by Week or Pound by Pound?

Natasha Courtney Smith is photographed weekly during her pregnancy, and writes about her experience at the Daily Mail Online.

I loved the photos
Smith is beautiful. Seeing her body change week by week, with that baby growing inside her, filled me with such joy and awe at this miracle of life.

The essay made me so sad.

It is the typical story of the modern woman’s experience of her body during pregnancy. A journey that begins with joy but quickly turns to self-loathing and sadness –

Almost from the moment I found out I was pregnant, I felt hugely fat…. When I finally had to accept, at the end of month four, that I was now a whole dress size bigger, I actually cried – and went out to buy a pair of size 12 jeans.

This is a woman carrying her first child, and instead of joy, she feels – fat. It’s just wrong. (And yet who among us has not felt the same way?…)

Fortunately, by her fifth month, Smith begins to enjoy her pregnant body.

Bizarrely, though, I suddenly felt hugely confident….I even started to get a thrill from seeing the needle on the scales inching its way towards the 131/2 stone where it would end up… Friends would say reassuringly that most of that extra weight was the baby, and I actually felt rather gleeful as I replied that, no, the baby inside me weighed just a few pounds – and any extra weight was in fact me.

Well, Ms Smith, I think I need to correct you there. Technically, yes, much of the added weight was you. But much more than a few pounds was related to the baby.

Don’t believe me? Here’s how it breaks down in a normal singleton pregnancy –

Weight Gain in Pregnancy

  • Baby – 7.5 lbs (more or less)
  • Placenta – 1.4 lbs
  • Amniotic fluid – 2 lbs
  • Increase in uterine weight – 2 lbs
  • Increase in breasts – 2 lb (more for some)
  • Increase in blood volume – 3 lbs
  • Increase in extracellular fluid (no edema ) 4 lbs

That’s over 20 lbs right there without a single ounce of extra fat gained. Most women will gain about 7 pounds of adipose during pregnancy, for a total normal weight gain of about 30 pounds. But I’d give Natasha another 5 lbs or so for those swollen ankles in her last few weeks.

Now, Smith did gain a bit more than 30 pounds.

She went from about 130 lbs to 188 lbs, for a total gain of 58 pounds. And yet, by 5 months post partum, she’s dropped all but 14 pounds of her pregnancy weight!

I’d say she’s doing just fine. Once she starts to sleep a bit more through the night, it’ll all be gone.

Why do I say that? Well, studies have shown that mom’s weight at one year postparum is inversely related to how many hours her baby is sleeping through the night at 6 months of age. Given that Smith still has a few extra pounds on her, I’d wager little Finn is still up for nightime feeds.

Bottom Line

Our obsession with weight is ruining our experience of our own pregnancies, whittling away little pieces of joy during one of the most special times of our lives.

Instead of worrying about our weight while we are pregnant, we should be finding ways to help new moms get the sleep they need.
Photo by Caroline Marks at The Daily Mail online

Who’s Your Mommy?

Apparently, more and more women are nursing each other’s babies, a practice called Cross-Nursing.

I think that it’s just not been our social norm,” said Morgan McFarland, who has been breast-feeding her friend Sarah Griffith’s son since he was just 3 months old. “In some cultures, it is, and you would think nothing of, you know, nursing your neighbor’s child if something happened, or nursing your sister’s baby if she has to go to work.”

While I can understand this practice in primitive societies where refrigeration and infant formula are not affordable or available, or for the rare woman who cannot breastfeed for medical reasons, I see no reason for such practices in the modern society, especially for the reasons cited in this article, namely “community and convenience”.

Breast feeding is an intimate, bonding act between Mother and Child. Why would anyone want to share that with another woman?

Are there Health Risks?

There is little to no data on long term outcomes for infants fed with breast milk from someone other than their own mother. One should not assume the benefits are the same as for infants fed with mom’s milk.

Breast milk contains antibodies unique to Mom and shared to some extent genetically with her child, not to mention growth factors and other proteins. What are the impacts of exposing a child to these proteins from an unrelated individual? No one knows.

More concerning for me is that infections such as TB, HIV and hepatitis can be transmitted via breast milk. In addition, medications taken by the nursing woman also find their way into breast milk.

So if you are going to share your child with another woman, you better be pretty darned sure she is free of infection and not taking any medications that could harm your child. I for one would not be willing to take that risk with my child.

Bottom Line

I see no reason why, in today’s society, a nursing mother needs to share nursing with anyone. There are potentially serious risks and no proven benefits.

If you want community and convenience, then join your neighborhood food coop.

(Okay, Commenters, let loose…)

Not Your Typical Water Birth

California teen gives birth in shower, walks to hospital

LONG BEACH, Calif. (AP) — A 17-year-old girl gave birth secretly at home, then walked four blocks to a hospital with the baby still attached by its umbilical cord.

“I was just a little nervous” when the labor began, Xochitl Parra said Friday from St. Mary Medical Center as she cradled her 8-pound, 3-ounce son, Alejandro.

The boy was normal and “eating like a champ,” said Dr. Jose Perez, director of the Neonatal Intensive Care Unit.

The teenager said she was alone and taking a shower around 5:30 a.m. Wednesday to get ready for school. Then the contractions took over.

“I felt his head coming, so I sit down and pushed so he could come out,” she said.

Parra did not call 911 because the home phone was disconnected, and she did not want to wake the neighbors because it was so early. Instead, she wrapped the baby, got dressed and went to the hospital on foot. (More of the story and a photo at Yahoo News)

Lots of folks find it hard to believe a teen could hide a pregnancy for 9 months, but it’s not as unusual as you might think. You can’t do it if you are rail thin, but heavier teens have an advantage in that folks just think they are gaining more weight. The oversize t-shirt look helps, too.

I had one teen patient some 20 years back who managed to hide her pregnancy even as she made time trials for the swim team one week before delivering a full term infant. This young woman was tall and stocky to start, and the coach just thought she was gaining weight. Her pediatrician didn’t even consider the diagnosis of pregnancy when she presented to him in labor – he sent her to the ER as a possible appendicitis.

By the way, she also managed to keep her A average throughout the pregnancy. As I told the shocked and ashamed mom, this was one pretty amazing girl. I don’t think I could have accomplished what she had at age 16 while pregnant, let alone holding that secret for 9 months.

A Clorox Moment

A woman I know has a second home in the mountains that she rents out when she and her family are not using it. In the house, they keep a guest book for renters to sign and write remarks, thank you’s, suggestions etc.

Recently she and her family were at the house and she decided to look through the guest book. In doing so, she came upon this entry from a recent tenant which read something like this –

“We had a wonderful stay at your lovely home. It will always be part of our family memories. While we were here, I gave birth to my third child while in the jacuzzi overlooking the mountains. It was an experience I will never forget.”

Neither will my friend, after spending an hour cleaning the afore-mentioned birthplace with clorox before she would let her kids use it that weekend.

I don’t know if there are any rules of Jacuzzi Etiquette, but if there were such a thing, this has to violate it. Plus, I thought “home” birth means you do it in your home, not someone else’s.

Time to add some new language to the rental agreement…”No home births, please.”

Treating Infertility by Flushing the Tubes

It’s one of those interesting phenomena that most gynecologists have seen in their practice at least once. You do an HSG, and the woman with longstanding infertility becomes pregnant the very next cycle!

HSG – that’s short for hysterosalpingogram, a study in which dye is injected through the uterus into the fallopian tubes to see if they are blocked or open.

Post-HSG pregnancies happened often enough that we all thought thought it must be a real effect of the HSG. We theorized that the flushing of the tubes must be opening up a previously undiagnosed blockage of the tubes. But we secretly wondered whether what we were really doing was flushing out the bad humors.

As it turns out, our experiences were indicative of a real phenomenon, and our secret theory was not so crazy. In the past decade, several randomized studies have confirmed that doing nothing but performing an HSG increases pregnancy odds by as much as two to three times. (Cochrane review here). Studies have also confirmed that tubal flushing decreases the concentration of cytokines and other inflammatory proteins in the fallopian tube, and reduces sperm phagocytosis (ie, bad humors).

Now, some docs are wondering if flushing of the tubes could become more than just an observed phenomenon but a planned part of infertility treatment.

Researchers at the Karolinska Insitute in Stockholm have published a nice little study in which they randomized couples with unexplained infertility to one of two treatment arms – (a) Clomid (a drug that stimulates ovulation) plus intrauterine insemination or (b) the same plus pertubation (flushing) of the fallopian tubes with an anesthetic solution just prior to insemination.

Among the 67 patients whose tubes were flushed, there were 10 clinical pregnancies (15%) vs only 2 (3%) in the 63 women whose tubes were not flushed, a statistically significant difference.

But before you get yourself too worked up about these results, it’s worth noting that a fertility-expert friend of mine says that the pregnancy rate in the control group was unusually low, and suspects that this may make the intervention look better than it really is.

In addition, the authors point out that the overall pregnancy rates using this technique are significantly lower than the 30% pregnancy rate expected with IVF in the same population of patients. But their lower tech method is cheaper and faster, and they propose that it may be appropriate for couples who either don’t want IVF or want to do something while they are waiting for IVF.

It’s an interesting idea that needs a bit more study before implementing it outside a research setting. Stay tuned…

Disclaimer – I am NOT a fertility expert, just a plain-old gynecologist reading the latest literature and doing a little wondering. My little musings should not be mistaken for medical advice. The best person to decide your teatment is your doctor, not me.

Cellphone Use – Does it Affect Male Fertility?

Your mobile carrier’s Family Plan may not be so family friendly.

That’s what researchers at the Cleveland Clinic suggest in a research study published this week showing that increasing cellphone usage is correlated with decreased sperm count and semen quality in men.
But don’t put down that IPhone just yet.

This study, while intriguing, has a few very significant limitations. First, and most importantly, the study population was drawn from men who were undergoing fertility evaluations – not a normal male population. The average age was 38, also not a normal age distribution. To do this study right, one should use males drawn from the general population, which would include both normal and infertile subjects.

Secondly, the researchers relied on self-reported estimates of phone usage. Not sure why, when they could have gotten accurate data from participants mobile phone bills.

Finally, the researchers did not collect information about occupational history or use of other devices that emit electromagnetic waves that they hypothesize are responsible for the effects of cellphone usage on sperm quality.

Still, the study results are intriguing, and worth following up in a larger, better controlled study. In the meantime, use the landline, okay honey?

Make Sperm, Not War

The Civil War in Lebanon caused a decrease in sperm count, according to a study published this week in Fertility and Sterility.

Researchers at the American Hospital in Beiruit retrospectively reviewed records of couples receiving fertility treatment between 1985 and 1995, and compared the results of semen anlyses performed on samples collected during the war (1985-89) and after the war (1991-95).

Sperm concentrations were significantly lower during the war compared with the post war period, although sperm volume and motility remained the same. Sperm morphology was actually more abnormal after the war. (Whether this latter result was due to toxic exposure during the war or a change in how semen anlayses are reported is unclear, but the latter seems more likely.)

The authors suggest that the stress of war leads to a decline in sperm production, possibily through a depression of testosterone levels via the effect of stress hormones on the hypothalamic-pituitary-gonadal axis.

Although a longitudinal study of men before, during and after war would have made a better case, these results are interesting to say the least, and give us one more reason to make love and not war.