What are the different types of strep infections in newborns?

There are two types of disease–early onset infections and late onset infections.

Early onset disease:

• More common;
• Originates from bacteria normally found in 20 to 30% of all women in the genitourinary and /or gastrointestinal tract with later transmission to the newborn infant during the birthing process;
• Disease occurs within the first 6 days of infant life (1% of the women that colonize this bacterium);
• Infants present with sepsis or pneumonia within 12 to 24 hours of birth;
• Antibiotics given during labor significantly reduces incidence of disease but does not eliminate the disease completely.

Late onset disease

• Infants develop illness within 7-90 days after birth;
• Disease occurs in the hospital, from family, or from the community;
• Infants present with meningitis in over 50% of cases with resulting neurologic impairment (hearing or visual loss, cerebral palsy, hydrocephalus, mild to severe mental retardation);Disease not affected by antibiotics given to mother in labor.

What is the incidence of group B strep in newborns?

The current incidence per 1000 live births is 0.23-0.37 compared to 2002 where the incidence was 1.7 per 1000 live births. If an infant contracts the disease, there is a 3 to 6 % chance of mortality. This corresponds to approximately 7600 cases in the USA with about 310 deaths per year.

What are the most important reasons for this decline?

Screening all pregnant women for group B strep with cultures at 35-37 weeks and the judicious use of antibiotics in labor in woman that screen positive are the single most important reason for this dramatic decline in infant mortality and morbidity. If a woman is culture positive, they have a 25 times greater chance of delivering an infant with early onset infection compared to a woman who is culture negative. Currently about 85% of women in the United States are screened for strep.

What are some of the clarifications in the new guidelines of 2010 compared to those of 2002?

Despite the dramatic decline, disease continues to persist and new guidelines were established by the CDC to try and eradicate even more cases of this treatable disease. Additionally, better laboratory technologies have been developed to enable more rapid identification of GBS. The new guidelines are intended to give clear cut and updated recommendations designed for all newborns to further disease prevention and avoid overtreatment in infants that are low risk for this disease.

NEW RECOMMENDATIONS FOR MATERNAL TREATMENT

Which mothers should be treated?

1) Mothers that have a positive culture within the preceding 5 weeks of delivery (Note: even women scheduled for a repeat c-section should be cultured).

2) Culture status unknown with any of the following risk factors:

a) Women delivering preterm (before 37 weeks);

b) Prolonged rupture of membranes ( greater than or equal to 18 hours);

c) Temperature of 100.4 (38 degrees).

3) GBS bacteria in the urine (greater than a 10,000 colony count) during the pregnancy (no need for further recto-vaginal screening).

4) Mothers who have a history of an infant with previous GBS infection (no need for screening).

Mothers that have been treated should have their infants watched for 48 hours after delivery, looking for any signs of infection. If a mother wishes to go home earlier from the hospital, follow-up care by a pediatrician should occur within 48 to 72 hours.

Should you take antibiotics if your culture is positive before the birthing process begins?

The answer here is NO. Antibiotics given before the intrapartum period is not guaranteed to protect the infant.

Who does not need antibiotics?

Mothers in labor, or with ruptured membranes that have negative cultures done at 35 weeks do not need medication.

How long is B strep testing good for?

B strep testing is good for 5 weeks. If a woman goes postdates, or more than 5 weeks, repeat testing is appropriate.

What is the treatment for group B strep?

Penicillin (ampicillin -2 grams is an acceptable alternative) New CDC guidelines call for a change in the dosage of penicillin. Recommended dosage of 5 million units intravenously should be followed by 2.5-3 million units every four hours.

Cefazolin ( 2 grams) for penicillin allergic mothers providing they do not have severe anaphylaxis with penicillin. ( In the past , erythromycin, clindamycin and vancomycin were given as second line but are now considered inadequate due to the existence of many resistant forms of GBS to these antibiotics.

Clindamycin or vancomycin is given for women with anaphylaxis to penicillin.

All antibiotics should be given, if possible, at least 4 hours before delivery.

NEW RECOMMENDATIONS FOR INFANT TREATMENT

What should be done if an infant is born with no signs of infection but the mother develops infection in the fetal membranes (chorioamnionitis) during labor?

The new guidelines recommend a limited evaluation on the infant which includes a complete blood count, if possible 6 to 12 hours after birth, (no lumbar puncture) and a blood culture looking for infection before initiating antibiotic treatment. Therapy can be started but discontinued if the laboratory and clinical evaluation of the infant excludes infection.

What should be done if an infant shows signs of sepsis (infection) even if cultures were negative for strep?

Any newborn infant with signs of sepsis should receive therapy with antibiotics after undergoing a formal diagnostic work-up, which often includes a lumbar puncture.

What should be done for infants that appear well and whose mothers received no treatment or inadequate treatment, or whose membranes are ruptured less than 18 hours?

Treatment recommendation is solely observation of the infant for any signs of sepsis for 48 hours.

What should be done with well infants to mothers that had rupture of membranes for 18 or more hours with no or inadequate group B strep treatment?

These infants should have limited evaluation with complete blood count, platelet count and blood cultures with observation for 48 hours.

What should be done with preterm infants born to women with no or inadequate antibiotics?

These infants should have limited evaluation and observation for 48 hours.

WHAT NEW DEVELOPMENTS ARE ON THE HORIZON FOR GROUP B STREP PREVENTION?

Cases of group B strep continue to exist in spite of implementation of the new CDC guidelines. Using antibiotics universally is not recommended due to unnecessary overtreatment and the possibility of development of severe allergic reactions in labor along with future development of antibiotic resistant strains. Additionally, antibiotics in labor have not been proven effective for the treatment of late onset disease.

The development of an effective vaccine is on the horizon.

Women vaccinated in the early part of the third trimester of pregnancy develop antibodies that can be transmitted to the baby through the placenta making it highly unlikely for a child or mother to get infected during the time of delivery. This would also eliminate the need for swab cultures, unnecessary and overuse of antibiotics, save lives of infants in addition to preventing some cases of prematurity. Protection will also be long term helping to eliminate the late onset disease. Boosters can be given to mothers to augment the immune response for later pregnancies. Animal studies have confirmed the safety of vaccine use in pregnancy. Expert opinions predict this vaccine to be available within the next five years.

In summary:

Through this blog , Beaute de Maman wishes to reinforce by education to all health care providers and also to pregnant patients the importance of making sure cultures are done at the appropriate time in pregnancy and to also be aware of who should be treated and what the treatment options entail. B-strep will probably never be eliminated but by following the newly published recommended guidelines, there will hopefully be a further reduction in the number of preventable cases of this deadly disease. Development of a safe and effective B- strep vaccine will provide an important disease prevention strategy for the future.

Is your cream or lotion a harmful potion?

Lotions… Can Be Harmful Potions!

Here are some interesting statistics:

* Thirty percent of all cancers in women are due to breast cancer.
* One in eight (12%) of women will develop breast cancer during their lifetime.
* Next to skin cancer, breast cancer is the most prevalent cancer in women.
* Next to lung cancer, breast cancer carries the highest mortality.

There are definite genetic factors that influence a woman’s potential for developing the disease. However, environmental risk factors may also be crucial in determining the level of risk for development of breast cancer.

The role of taking additional estrogen in the development, growth, and progression of breast cancers has been addressed in many studies. However, many women are unaware that pollutant chemicals in the environment entering the breast through the skin, orally, and inhalation can also increase estrogenic activity thereby increasing the probability of developing breast cancer. Breast tissue, in particular, is comprised of fat, and many of these chemicals have an affinity for this “lipophilic tissue.”

Recent articles have shown breast cancer to be associated with chemicals that have estrogenic activity, like parabens.

Pregnancy presents an added challenge, because externally introduced estrogenic compounds add to the risk already imposed by the high estrogen levels manufactured by the placenta. Many of the most popular stretch mark creams currently on the market today use parabens as a preservative. Read the labels, this is important to you!

What are parabens?

Parabens are chemicals used as antimicrobial preservatives in cosmetic products, food products and pharmaceuticals. Chemically they are alkyl esters of p-hydroxybenzoic acid. Recent studies have shown that parabens have estrogenic activity themselves. In addition, they can prevent the breakdown of estrogen in the body allowing levels in the body to remain higher than normal.
It has been found that low level absorption from personal care products applied to the breast region over a long period of time, can contribute to increased tissue levels and blood levels of parabens through skin absorption. In addition, absorption can occur through chemical entry by nicks in the skin from shaving. These exact same esters have been found in breast cancer tissue biopsied from patients.

Are there controls on the amount of parabens in products?

The presence of parabens in products are widespread. Because of the recent discovery of parabens in human blood tissue, milk, urine, and now breast tissue, new controls have been established in Europe.

In the European union, parabens can have a maximum concentration of each type of paraben (methylparaben, propylparaben, butylparaben or benzylparaben) of .4% in cosmetic products, with a total paraben concentration limited to 0.8%. Recent reviews have recommended further reductions. Parabens have also been found in food products and, most recently, there has been recommendation to withdraw all parabens due to reproductive and endocrine toxicity.

The FDA does not regulate parabens in the cosmetic products in the United States. However, the Cosmetic Ingredient Review (CIR) does review ingredients for safety and has limited the use of parabens in cosmetics at levels up to 25%. Most products have in the range of .01 to .3 %. There are no studies assessing the risk parabens pose to the fetus through transfer from the mother.

Is there a relationship between breast cancer and parabens found in cometic products?

Breast cancer can be found in any quadrant of the breast. However, in the majority of cases, tumor is located in the upper outer quadrants of each breast. If environmental chemicals were contributing to the development of breast cancer, one should see a higher incidence of paraben accumulation in the upper outer portion of the breast compared to other regions of the breast.
A study of breast cancer patients, by Barr, was reported in the Journal of Applied Toxicology in January 2012. In 99% of the patients, traces of at least 1 paraben were found and 60% had traces of 5 different parabens in their breast tissue. The majority of the parabens found, appeared to be from a dermal source, since the chemical structure was intact. This is very significant as parabens absorbed through other routes are often metabolized into other derivatives. There were higher levels of parabens found in the axilla area compared to the mid or medial aspects of the breast, which also implicated a local absorption. It is presumed that chemicals absorbed from skin in any part of the body travels through the circulation or lymphatic systems and accumulates in this region. It has also been postulated that dermal application of personal care products directly to the underarm and adjacent upper breast region might also result in long term low dose absorption and local accumulation in the breast region. Regardless of the mechanism, there is a probability of finding higher levels of some parabens, especially n-propylparaben in the axilla areas compared to other parts of the breast in breast cancer patients.

Do parabens cause breast cancer?

Just because a chemical is found in a particular region in higher concentration does not necessarily indicate or prove cause and effect. Breast cancers are multifactorial in origin and it is doubtful that any one chemical would be the predominant cause. However, as parabens have estrogenic qualities, and estrogen has unquestionably been associated with risk of breast cancer, further study may demonstrate that parabens are one or perhaps a predominant component in the pool of substances that generate breast cancer.

Are there other chemicals commonly placed in cosmetic products that may be harmful to women?

Pthalates are another another chemical found in cosmetics, shampoos, fragrances, nail polishes, food, nutritional supplements, drinks, plastic products, building materials and household dust. They are generally not bound to the products in which they are found and are easily released from items such as rubber gloves and plastic wrappings used for food storage. In pregnancy, women from the Netherlands were found to have of pthalates of the variety that is found mostly in cosmetics and other personal care products in the urine.

Pthalates generally do not accumulate in the body as do parabens, but they have been associated with:

•Infertility including low sperm counts and poor sperm motility
•Asthma, allergies, eczema, rhinitis
•Fibroids
•Breast cancer
•Obesity
•Testicular dysgenesis.
•Low birth weights in infants
•Preterm deliveries
•Reduced ano-genital distances in the offspring.
•Premature sexual development( especially breast development) Hypospadias in the male offspring.
•Behavioral and mental changes in children—more aggression, depression
•Decreased alertness
•Diabetes

Conclusion:

Dietary and lifestyle changes can decrease the exposure to pthalates and parabens and proper avoidance may lessen the risk of developing diseases with which they have been associated.
More research is needed to examine the association between parabens and breast cancer. It is known that parabens accumulate in breast tissue and it is yet to be definitively ascertained as to whether parabens present an added risk factor to women. It is possible that the increase in the environmental exposure to estrogenic compounds through cosmetic products accumulating in the breast over a lifetime has adverse effects.

Women should be vigilant in reading ingredient lists on the cosmetics they commonly use and avoidance of preservatives such as parabens and pthalates is highly recommended. Sound advice, especially for pregnant women, is to avoid all cosmetic products with parabens and pthalates that are left on the skin, especially around the breast area. This includes some of the most popular stretch mark creams and nipples gels that are in use.

All Beaute de Maman skin care products, including the stretch mark cream and nipple gel for nursing mothers are paraben-free and phthalate-free. The same applies to all of our bottles, tubes, and other packaging. Our position and philosophy to protect expectant and nursing mothers is to totally avoid the risks presented by parabens and phalates. These substances are not used in any Beaute de Maman products.

You can bet the farm on these cow tips...

You Can Bet The Farm on These Cow Tips…

Many factors have been attributed to the development of asthma and allergy in children.  Proposed causes have included air pollution, personal living environments, hygiene and early infections.  More recently, diet and nutritional factors have been included as one of the possible triggers.

The child’s immune system develops prenatally. Maternal diet allows the transfer of certain nutrients across the placenta to the fetus. Therefore it is possible that intrauterine exposure of certain ingredients in foods to the fetus might effect the development of allergy and asthma later in life. Therefore, of particular interest is the association between dairy products and the development of asthma, wheezing, and eczema.

A recent study by Maslova from the Netherlands revealed that low-fat yogurt eaten once a day in pregnant women is associated with an increased risk of asthma and allergic rhinitis in children. The study on which this was based was very large one incorporating approximately 101,042 pregnancies in the Danish population between 1996 and 2002.  These same findings, however, were not found to be true for low fat or semi-skimmed milk products in this particular study.

The etiology for this allergy remains unclear. One postulate is that it is due to the sugar, artificial sugars, or the protein content of low fat yogurts. Other theories attribute these findings to the conjugated fatty acids known as CLA (conjugated linoleic acids).  These fatty acids have been shown to increase risk of atopy. In fact, products such as margarine , which use CLA to harden margarine, have had reductions in their concentration of this ingredient due to several papers that have shown an increase in allergy due to this substance.

In contrast to the above findings, several studies have shown protective effects with maternal consumption of whole dairy products, calcium, and vitamin D during pregnancy and the later development of wheeze and eczema. Studies by Miyake from Japan in 2010 have shown that maternal intake of whole milk, full fat cheese and calcium during pregnancy resulted in a decreased risk of wheezing in infants aged 16-24 months. Recent findings have also demonstrated that mothers who had increased amounts of vitamin D during pregnancy (4309 ug of vitamin D or more) also had a significantly reduced risk of wheeze and eczema.

Similar findings were noted by Wijga in 2003.  Pre-school children who had frequent consumption of products containing milk fat had reduced risk of developing asthma.  The etiology for this finding is also unclear. The protective effects of many of the dairy products during pregnancy on wheezing in infants is believed to be due to the calcium content or some unmeasured component associated with calcium. Higher maternal intake of dietary calcium can effect calcium fluctuations in the fetus. Calcium influx is important in the various stages of development and maturation of lymphocytes which can effect infant immune responses. Some component of low fat yogurt may interfere with this benefit of maternal calcium.

Conclusion:
Studies have shown evidence for a relationship between nutrition and asthma. Pregnant women and young children might have reduced risk of asthma, allergy and wheeze by consuming whole milk products, yogurt and butter over semi-skimmed milk , low fat yogurts, and margarine.

Perhaps the notable increase in the prevalence of asthma, eczema, and allergic rhinitis may be related to the popular reduction in the consumption of saturated fat and the trend towards the increased consumption of polyunsaturated fatty acids, in particular linoleic acid.  Postnatally, it has been found that high dietary intake of certain polyunsaturated fatty acids has been associated with increased risk of allergy in children so it is conceivable that exposure to the fetus prenatally may also sensitize the fetus to allergy and eczema later in life.

This blog will focus on the remedies that can be used in pregnancy.

Initially I will discuss the preferred non-pharmacologic therapies.  If further treatment is warranted, we will review medications that  are safe to use.

Nonpharmacologic remedies

Sleep Hygiene Education

Educating patients on behaviors that promote sleep may require some changes in lifestyle.

Here are some suggestions:

• Avoid stimulants such as caffeine and nicotine before bed.  Both reduce sleep onset in most people and impair the ability to achieve deep sleep.
• Check with your clinician about other medications that are being taken that may have stimulating effects (asthma medication or thyroid medications) and avoid taking them prior to bedtime, if possible.
• Avoid heavy meals within 2 hours of bedtime.  This can interfere with sleep.  However, a light snack can be sleep inducing.  Some studies have shown that eating food containing carbohydrates before bedtime can improve sleep.
• If heartburn is a cause of insomnia, avoid eating late, avoid spicy food, elevate the head of the bed and use antacids if necessary.
• Avoid drinking excessive fluids in the late evening since pregnant women have to wake up to urinate during the night.(nocturia)
• Regular exercise in the late afternoon or early evening can deepen sleep. However, avoid exercise too close to bedtime which may have a stimulating effect and delay sleep onset.
• The bedroom should be an environment conducive to sleeping–quiet, dark, and comfortable.
• Clinicians may need to recommend an adjustment in bed times and wake times.  Later sleep onset time was associated with poorer sleep and reduced total nocturnal sleep time and sleep efficiency.  Maintaining regular hours and an earlier bedtime will increase time in bed,  assuring a sufficient amount of sleep.   At least 8 hours in bed nightly is currently suggested.
• Advise pregnant women to take no more than one nap a day to avoid compromising nighttime sleep quality.  Improving nighttime sleep patterns would most likely decrease the need for napping.
• Avoid pregnancy associated discomforts that can cause sleeplessness.  Use properly placed pillows and heat to ease back pain.  Avoid sleeping with a top leg compressing the bottom leg and wear support hose to prevent leg cramps.  When sleep on the side, it may be helpful to place a pillow between the legs.

Relaxation techniques

These are relaxation techniques that release physical and mental tension.  Methods may include listening to relaxing music, imagery, meditation, autogenic training, and progressive muscle relaxation.

Behavioral therapies

Sleep specialists have various techniques for breaking the association of going to bed and sleeplessness.
1) Stimulus control therapy

The recommendations are to be in bed only when sleepy and leave the bedroom when awake. This gets repeated as often as necessary throughout the night.

2)  Sleep restriction therapy

(see addendum for details—reading this protocol may induce sleep!!)

Cognitive therapy

The following is a technique to eliminate sleep related fears for people who try too hard to fall asleep.  Some people feel that they “must sleep” or develop significant anxiety or concern that they will be unable to function as a result of not being able to sleep.  Educating patients on the fact that one can still perform with reduced sleep and that individuals vary in their sleep requirements can be helpful.  Maladaptive thinking patterns associated with sleeping difficulties which increase worry, anxiety, and perpetuate the sleep disturbance are eliminated.  Using paradoxical suggestions such as trying to tell the patient to stay awake, rather than sleep can  also be helpful in reducing the anxiety.

Pharmacologic Therapy

Pharmacologic therapy may be considered for short term use in cases that don’t respond to therapies such as those already mentioned.  The obstetrician and patient must have a full discussion of potential risks and benefits. Treatment decisions should be based on the severity of the insomnia.  Medications commonly used for sleep in the nonpregnant state are often category C and D and cannot be used in pregnancy.  History reminds us of the potential harmful effects of drugs like thalidomide that doctors in Europe, Australia, Japan, and Canada used  in the late 1950s to treat anxiety and  insomnia  in pregnant women.  It was withdrawn from the market in the early 1960s when doctors learned that it caused devastating birth defects when approximately 10,000 children around the world were born with major malformations.

There are 2 hypnotic agents that have been designated class B in pregnancy.(fetal harm unlikely)

Zolpidem (Ambien)-a short acting nonbenzodiazepine hypnotic (Benzodiazepines are associated with an increased risk of malformations when used early in pregnancy and with neonatal flaccidity and respiratory problems when administered late in pregnancy.)

Diphenhydramine (Benadryl)- an antihistamine with a strong sedative effect and a longer duration of action.

There is currently insufficient evidence to support the safety and efficacy of herbal therapies for insomnia in pregnancy.

Summary

With growing evidence associating disturbed sleep and detrimental effects on maternal/fetal well being, efforts should be made to maximize restful sleep in pregnancy.  Suggestions  to enhance the  sleep environment along with implementation of  sleep behaviors such as regular bedtimes, dietary modifications, positioning aids to support the gravid uterus and extremities can be helpful.  In addition, obstetricians may refer patients to therapists who are experienced in the use of  relaxation aids along with  behavior and cognitive therapies.  Medications should be the last resort in the most extreme cases and only after careful discussion with the obstetrician.  Research into finding more sleep promoting strategies that are safe and effective in pregnancy is needed.

Addendum, for those still awake!

Sleep Restriction Therapy method:

Calculate average sleep time per night.
Time in bed should be at least 5 hours or the average sleep time–whichever is greater.
Pick a reasonable rise time
Bedtime should be the rise time minus time in bed
Patient should maintain this sleep window for 1 week–going to bed at calculated bedtime and rising at prescribed rise time.(This is called the sleep window).
After 1 week, increase the sleep window based on sleep efficiency
ie. if sleep efficiency is more than 90%–increase bed time by 15 minutes
if sleep efficiency is between 85 and 90%, keep time in bed constant
if sleep efficiency is less than 85% then decrease time in bed by 15 minutes
(sleep efficiency is calculated by time asleep divided by time in bed times 100%)
Keep rise time constant and only adjust bedtime.
Keep making weekly adjustments till optimal sleep efficiency is reached with minimal daytime sleepiness.

Obstetricians are familiar with their pregnant patients complaints of difficulties with sleep.  Sleep disturbances occur throughout the night resulting in fatigue during the day.  The causes for sleep disturbances are attributable to hormonal, vascular, and physical changes that occur in pregnancy.

This weeks blog will discuss the causes and findings associated with sleep disorders in pregnancy.

Why are sleep disturbances important in pregnancy?

Sleep disturbances are associated with increased morbidity and mortality. Deficient sleep has been associated with decreased learning, motor, and cognitive functioning, poor job performance, poor social relationships, deficits in glucose and fat metabolism and mental health issues.  It affects overall quality of life by negatively impacting mood, motivation, and performance.   Impaired sleep is also a common element in patients who are depressed and patients who have psychological and behavioral problems.

In pregnancy, there are additional significant impacts on maternal/fetal health such as :

• Prenatal and postpartum depression
• Premature birth rate is two fold greater
• Prolonged labors
• Increased cesarean section rates
• Gestational hypertension
• Obesity
• Diabetes
• Intrauterine growth retardation

How prevalent is sleep deprivation in pregnancy and the postpartum period?

The sleep requirement specified by the National Sleep Foundation is quoted as 7 to 8 hours per 24 hour period.  We spend one third of our lives sleeping.  Women in general, have a higher level of sleep deprivation than men.  Women are increasingly found to work outside the home while still maintaining the responsibilities of balancing the household needs and  children’s needs.  Sleep deprivation occurs in 52%  percent of all women.  In pregnancy, sleep deprivation is even more frequent, with approximately 75% of women experiencing problems with sleep.  Difficulties start in the first trimester and tend to worsen as the pregnancy progresses.

What type of sleep problems occur in pregnancy and postpartum?

EEG sleep tracings in pregnant women have shown profound sleep changes with decreasing sleep duration and reductions in deep and REM sleep.  Sleep disturbances worsen with each trimester.  Pregnant women have  frequent nocturnal awakenings.  Postpartum, the need for frequent infant care also disrupts the normal sleep pattern.  This often results in frequent daytime napping which disrupts the circadian cycle causing an altered sleep-wake cycle. This normalizes several weeks after delivery.

First trimester– There is an increased requirement for sleep with sleep durations increased by about .7 hours with increased daytime sleepiness.  At 11 to 12 weeks, there was an average increase of approximately 30 minutes of nocturnal sleep.  However, sleep efficiency and the amount of slow-wave sleep decreased significantly compared to the non-pregnant state.

Second trimester–Total nocturnal sleep time decreases further, however, there is a greater amount of slow wave sleep compared to first trimester.

Third trimester–98% of women experience nocturnal awakenings and there is a decrease in the amount of slow-wave sleep (stage 4 sleep) and REM sleep. Most women take daytime naps.

Postpartum– the greatest amount of sleep disturbance occurs in the first month after delivery with an average sleep time of less than 6 hours.  Sleep time and efficiency will gradually increase as the baby sleeps more with resumption of uninterrupted sleep occurring at about the 12th week.

Breastfeeding women tend to have greater deep sleep time compared to bottle feeding women, due to the higher circulating levels of prolactin.

What are some of the causes of sleep deprivation in pregnancy?

Physical discomfort from the rapidly expanding gravid abdomen, back pain, nocturia (frequent urination at night), hormonal fluctuations, heartburn, restless legs, leg cramps, stress and anxiety relating to childbirth, pregnancy employment issues and chronic fatigue all contribute to compromised sleep.

What are some of the mechanisms causing adverse pregnancy outcomes due to sleep deprivation?

Pregnancy is marked by elevated estrogen and progesterone levels, which generate sedation and a decrease in rapid eye movement sleep.  Hormonal metabolites act by binding on the GABA receptors in the brain causing this effect.

Sleep deprivation has been known to alter immune response.  In particular, higher circulating levels of inflammatory markers such as interleukin-1, 2, and 6, tumor necrosis factor, serum cytokine, and C-reactive protein.  It is postulated that elevated serum cytokines cause an elevation of prostaglandins which are associated with initiating contractions and causing preterm labor.

Increased inflammation also prevents normal trophoblast invasion which prevents placental perfusion by the spiral arteries. This is commonly found in pregnancies complicated by preeclampsia, and intrauterine growth retardation.   In addition, increases in cytokines may result in disturbances in neurochemical transmissions which modulate the hypothalamic-pituitary-adrenal axis.  This, in turn, may increase levels of serotonin and catecholamines (norepinepherine, epinephrine, dopamine, and cortisol).  Higher levels of these same inflammatory chemicals have been found in patients who have depression.  Higher levels of these hormones, caused by the inflammatory response, may also cause decreased glucocorticoid sensitivity resulting in increased obesity and diabetes.

SUMMARY:
In summary, women need to be informed about the detrimental effects of sleep deprivation on pregnancy as outlined in this blog.  Obstetricians should ask questions pertaining to the quantity and patterns of sleep their patients are experiencing.  The majority of women do not proactively report their complaints of sleep deprivation to their physicians.  Sleep disturbances could be a prognostic indicator for patients who will be at greater risk of developing emotional disturbances and depression and who should be observed more carefully postpartum. Focusing on remedies for severe sleep deprivation promotes the health and well being of both infant and mother which can improve along with mood and likewise improve performance of the mom-to-be at home and in the workplace.

“ Sleep is the golden chain that ties health and our bodies together.”
Thomas Dekker

Stay Tuned, the next blog will focus on some remedies for sleep deprivation.

Fountain at Schönbrunn Gardens Vienna, Austria

Breast cancer is the most commonly diagnosed cancer in women, aside from skin cancer.  Approximately one out of eight, or 12% of all women will develop breast cancer in the United States.  Next to lung cancer, breast cancer death rates are higher than any other cancer for women.

A new research report from the American Association of Cancer Research has revealed that breast milk may give reliable insight into a woman’s future risk of breast cancer.

Breast feeding women have been found to release abundant sloughed epithelial cells into their breast milk.  Samples can be obtained easily from both breasts painlessly.  These epithelial cells can be tested for cancer markers.  Approximately 80% of all women will give birth at some point in their lives, making these cells readily available from a majority of women for testing in determining relative risk of the developing breast cancer.  Ordinarily, in women who are not breastfeeding, would require aspiration of fluid from breast tissue which is both costly, painful and has a very low yield of cells.

The tumor marker that is being studied is the addition of certain ‘methyl groups’ onto specific genes in the DNA of these epithelial cells.  It has been noted that the addition of these methyl groups disrupts normal cell function.  Women who have increased risk of developing breast cancer have a high amount of methylation in these epithelial cells.

Also of extreme importance is the fact that the methylation of cells is possibly reversible.  This would make it highly desirable to obtain early detection and possible treatment for women that have excessive amounts of these type of cells.  Women who have excessive methylation can be followed more closely since breast cancer risk increases with age.  The possibility of developing routine breast cancer screening tests for all women after they give birth may be a real possibility for the future since trials from the University of Massachusetts at Amherst, by Dr. Arcaro have demonstrated a safe, accurate and inexpensive way of obtaining this extremely valuable information.

Beaute de Maman has recognized the importance of breast feeding to both the baby and now to mom.  Previous blogs on our website www.beautedemaman.com have discussed how breastfeeding can reduce the risk of breast cancer, ovarian cancer, osteoporosis and heart disease in women.

Beaute de Maman’s goal is to provide better and more effective high quality products to enable more women to breast-feed successfully and for longer periods of time, thus improving the health of their infants as well as their own well being.  Our nipple gel has incorporated a natural, herbal, anti-bacterial and anti-fungal herb into the product that has antiseptic and anti-inflammatory properties, with the intention of preventing mastitis.

The base of our gel is a natural, omega 3 fatty acid which has been found to be important for brain and eye development in infants.  The gel is easy to apply and can be left on the nipple until the next feeding.  Beaute de Maman’s nipple gel contains no lanolin, no animal products and is kosher certified. Our aim has always been to raise the bar on available products for pregnant and breastfeeding women.

• Read why Lanolin products should not be used on nipples while breastfeeding
• Ingredients to avoid while breastfeeding babies
• Breastfeeding Cuts Breast Cancer Risk

If given the opportunity, would you want to know the gender of your unborn child within weeks after conception?

Groundbreaking new literature has demonstrated that this is a reality.  Fragments of fetal DNA, or cell free DNA, are found in maternal blood as early as 5 weeks after conception. These fragments can be analyzed and used for prenatal genetic testing. This will undoubtedly revolutionize genetic testing, including gender identification, as we see it today.

Is this information available now?

Companies are now offering kits, sold over the internet, that can be used to obtain this information. These kits are able to pick up, from the plasma of pregnant women, the presence or absence of fragments of DNA from the fetus, which contain the Y chromosome. This Y chromosome determines if the child they are carrying is a male fetus.

Currently, this testing is not routinely done in the obstetricians office. Testing has not been officially approved by CLIA (Clinical Laboratory Improvement Amendments). Patients must find sources from the internet. There is no insurance reimbursement for these tests.

What other information can I obtain from this type of testing?

The advantages of having information about fetal DNA at such an early stage is tremendous. Parents can now screen for certain disorders that are specifically linked to a particular gender at a much earlier stage of pregnancy, in a reliable , safe, cheap, quick non-invasive fashion. Examples of diseases that can be
detected include Hemophilia, Duchennes muscular dystrophy and congenital adrenal hyperplasia. Paternity testing, Rh blood group typing, and fetal sex can also be accomplished through this testing.

How has information such as this been obtained in the past?

During routine prenatal care, obstetricians routinely screen all pregnant women for chromosomal abnormalities. In particular, high risk women are considered to be:

• Those over the age of 35
• Any women with a family history or previous pregnancy with a genetic disorder
• Any pregnancy with a structural defect found on ultrasound or thickened nuchal region
• Abnormal maternal blood screening (alphafetoprotein testing and other biochemical markers).

For a woman carrying a gene for a sex linked disorder, it is common to undergo a procedure to determine the sex of the baby thereby determining if the unborn child will have the designated affliction. Commonly, a chorionic villus biopsy is performed, in which a small biopsy of the placenta is removed vaginally, at about 10 through 13 weeks, and chromosomal determinations are made. Alternatively, a woman can undergo an amniocentesis, usually performed at about 16 weeks.  Both amniocentesis and chorionic villus sampling procedures have been associated with pregnancy loss. Ultrasound alone can be used to  determine fetal sex non-invasively, but usually no earlier than 11 to 14 weeks, with about 86% accuracy at that time.  The ability now to obtain information as early as 7 weeks, accurately, and noninvasively can be of tremendous clinical use. Finding a male fetus would qualify a patient for later invasive testing for the particular disorder, whereas finding out that a female fetus exists would obviate the need to take any further risk of testing for a sex linked disorder.

What type of information can we expect to obtain from this test in the future?

Further research can be expected in the future to produce other tests that will allow prenatal diagnoses of other chromosomal abnormalities and genetic disorders, all non-invasively. These routine tests will probably be incorporated by obstetricians in prenatal care of all pregnant women. Learning ways to distinguish fetal cells from maternal cells accurately is the real challenge.  What types of concerns exist with this test?

New technology is always fraught with ethical, social, and cultural issues.  Guidelines should be established to use information for clinical reasons and not for patient decision-making as to whether to electively terminate a pregnancy in an attempt to “balance a family.” The ability to map the entire fetal genome using this fetal DNA exists. Will people have the ability to screen for insignificant fetal traits and will personal values be the guidelines for a decision on terminating a pregnancy? Should there be government  intervention regulating the use of this kind of testing? Should it be up to the medical provider to make the decision on who qualifies for testing and obtaining this kind of information.  Many questions remain to be answered. Should this testing be commercially available to all consumers or should it be restricted to only those determined to be high risk for a sex-linked disorder? Is this a medical issue, a legal issue, a moral and ethical issue – or all of the above?

Feel free to respond with your opinions.

Smoking during pregnancy is a well known risk factor for increased morbidity and mortality for the fetus. Smoking has been associated with premature birth, intrauterine growth retardation and congenital malformations. Knowing that active smoking presents an increased health risk, the question arises as to whether there are also any increased health risks to the fetus when a pregnant woman inhales smoke generated by others?

What is second hand smoke?

This is the passive or second-hand smoke that may be present in an office setting, restaurant, or home environment. Secondhand smoking exposes a pregnant woman to all of the same toxins and carcinogens, but at lower dosages than smoke inhaled directly.

Sidestream smoke is the major component of second hand smoke that is considered most harmful. This is the smoke coming off the end generated by a cigarette, cigar, or pipe. Sidestream smoke is considered four times more toxic than than directly inhaled smoke due to its higher content of carcinogens. Some of the carcinogens include tar, nicotine, ammonia, benzene, vinyl chloride, arsenic, acetaldehyde, formaldehyde, lead, carbon monoxide, phenol, styrene, butane and toluene.

What harm can second hand smoke present to the fetus?

A recent study published in the March, 2011 issue of Pediatrics by Leonardi-Bee, claims to be the first world review to examine the effects of second hand smoke exposure during pregnancy. They did a combined review of 19 other studies from North America, South America, Asia, and Europe and found a 23% increased risk of stillbirth, 13% increased risk of having a child with congenital anomalies and a higher risk of having a decreased birth weight in newborns by 33 gm.

Spontaneous abortion (miscarriage before 20 weeks gestation) and perinatal and neonatal death (20 weeks to within the first 28 days of life) was not significantly increased by second hand smoke.

How much second hand smoke is dangerous? Currently available studies do not tell us. The effects of second hand smoke at the various stages of a woman’s pregnancy have not been definitively studied and conclusions are not available.

What type of congenital anomalies were found with second hand smoking?

The congenital anomalies that are associated include heart defects, clubfoot, cryptorchidism (failure of descent of the testes), neural tube defects, anencephaly (defect in formation of part of the brain), spina bifida (defect in spinal formation), cleft palate and craniosynostosis (premature closure of the sutures of the skull).

Some of the defects may be due to the exposure of the fetus to toxins through inhalation of sidestream smoke. Other theories have implicated the father’s active smoking causing damage to the genetic material at the time of conception.

Conclusion:

Preventing second hand smoke exposure is important for women both before and during pregnancy. There is no doubt that second hand smoke has deleterious effects on the fetus with both higher risks of stillbirth and congenital malformations. This blog stresses the importance of obstetricians asking and advising, not only the direct smoking history of a patient, but also the passive smoking exposure that a patient experiences during the pregnancy. This includes emphasis on paternal smoking habits, with all efforts being made to suggest programs for smoking cessation and maintaining smoke free workplace and home environment.

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Is the pill safe to use immediately after delivery?

New recommendations by the CDC (Center of Disease Control and Prevention) are that women less than 21 days postpartum not use combined hormonal contraceptives, combined hormonal patch, or combined hormonal vaginal ring. Barring other medical risk factors it is deemed safe to use these methods after this time frame.

What are the risks for using hormonal contraception immediately postpartum?

Oral contraceptives normally cause a slight increased risk of venous thrombosis regardless of pregnancy status.

Postpartum women carry an additional risk of DVT of 22 to 84 fold higher compared to women that were not pregnant in the exact same age group. This added risk is greatest immediately after delivery and declines after 21 days but reaches baseline only after 42 days. This increased risk is probably related to the increase in coagulation factors due to elevated hormone levels. In addition, women that are obese, immobilized due to a cesarean section, age over 35, previous history of blood clots, have had postpartum hemorrhage, preeclampsia, smoking, or previous history of a clotting disorder (thrombophilia) adds even greater risk to the formula.

Does risk of venous thrombosis change depending on whether you are breastfeeding or not?

No, regardless of breastfeeding status, combined oral contraception should not be used within the first 3 weeks after delivering.

Are there other forms of contraception that can be used safely?

Progesterone only pills, progesterone shots, contraceptive implants, intrauterine devices (IUD’S), and condoms can be used safely immediately after delivery.

IUD’s are not recommended in any woman who developed infection after childbirth. IUD’s, both copper-bearing and hormone releasing, can be inserted within 10 min or later after delivery of the placenta.

The cervical cap or the diaphragm can be used generally within 6 weeks of delivery when the cervix has returned to its original configuration.

What are the effects of combined oral contraceptives on breastfeeding moms?

There is no effect on infant weight between breastfeeding mothers using oral contraceptives and those who do not. No adverse effects have been demonstrated on infants exposed to combined oral contraceptives through breast milk although there are few very good, reputable studies. There may be some variation in milk production in women who breast feed and use oral contraceptives.

Summary:

Use of combined oral contraceptive pill within the first 21 days postpartum is not recommended due to the increased risk of venous thrombosis and the unlikely possibility of pregnancy risk at this time.

Women with additional risk factors (under 35 and smoking, postpartum hemorrhage, postpartum transfusion) use of oral contraceptives returns to baseline only after 42 days postpartum and initiation of therapy should wait beyond the 3 weeks. Mothers with a history of pulmonary embolism, cardiomyopathy postpartum, thrombogenic mutations, and previous DVT should not use oral contraceptives postpartum altogether.

Dr. Suzanne G. Kitchen

Pregnant women are amazing in their endurance and strength. Without batting an eye, the majority of pregnant women continue to work right up until their due date, despite all the physical and mental changes that are occurring. They manage to juggle the same level of work, maintain a home with all the associated cooking and cleaning tasks, along with responsibility of tending to other children carrying the same fervor and dedication as when they were not pregnant.

In 28 years of obstetrical practice, my admiration and respect for pregnant women is without limits. However, during pregnancy, sometimes some women may experience symptoms, such as nausea, back pain, limited mobility, circulatory problems, or fatigue, which may affect the ability to perform job duties. When this happens, pregnant women often want to explore various options with their employer, such as making modifications to the job duties or work schedule, while others may want to “go out” on disability. Few patients and obstetricians are familiar with employers’ responsibilities and employees’ rights under federal and state employment laws so I thought this week’s blog might be a good place to broaden everyone’s knowledge. In the US, we have over 4 million pregnant women each year. With at least half of them in the workforce, I am sure you will agree that this topic is pertinent and timely.

Is Pregnancy a Disability?

Let’s start by looking at the Americans with Disabilities Act (as amended). The ADA is a civil rights law that protect people with disabilities from being discriminated against, and require the employer to make “reasonable accommodations” to help the person perform the job duties. Pregnancy, generally speaking, is not considered a disability under these laws. That’s because pregnancy (by itself) does not measure up to the definition of disability under these laws. That definition says: a person must have an impairment that substantially limits one or more major life activities.

Is there EVER a time that pregnancy can be considered a disability?

Some women experience complications caused by pregnancy, or have disabilities in addition to the pregnancy, and these women may be considered disabled under these laws. According to the Equal Employment Opportunity Commission (EEOC) “because pregnancy is not the result of a physiological disorder, it is not an impairment. Complications resulting from pregnancy, however, are impairments.”

If a pregnant woman works for an employer with 15 or more employees, and meet the definition of disability, one could initially request a job accommodation under the ADA. For example, pregnant women may need a lifting aid or an ergonomic chair, a modified schedule, performing the job in an alternative fashion (for example, while elevating the feet), and in some cases, even job reassignment. To learn more about job accommodations for women who are pregnant, or who have other types of disabling conditions, contact the Job Accommodation Network (JAN), a service of the US Department of Labor’s Office of Disability Employment Policy, or read JAN’s article here:

If a pregnant woman is not considered disabled, but has pregnancy-related limitations that affect her ability to work, how should the employer meet her needs?

The Pregnancy Discrimination Act (PDA) is an amendment to the Civil Rights Act of 1964. This civil rights law can apply to pregnant women who have typical limitations associated with pregnancy, such as varicose veins or back pain, and are not protected by the ADA. They still may need some job modifications in order to perform the duties safely and comfortably. The PDA requires an employer with 15 or more employees to treat women with pregnancy-related conditions the same as other employees with other types of temporary conditions (such as a broken bone). According to the EEOC, if an employee is temporarily unable to perform her job because of her pregnancy, the employer must treat her similarly as any other temporarily disabled employee. For example, according to the EEOC, if the employer allows temporarily disabled employees to modify tasks, perform alternative assignments, or take disability leave or leave without pay, the employer also must allow an employee who is temporarily disabled because of pregnancy to do the same. To learn more about the PDA, click here.

If a pregnant woman is forced to leave her job because of pregnancy and/or disability, does she have any measure of job protection?

The Family and Medical Leave Act (FMLA) is a federal law that applies to employers with 50 or more employees. The employee must have worked for 1 year, or 1,250 hours within that year. This law provides 12 weeks of job-protected leave, generally unpaid. So, for pregnant women whose pregnancy-related conditions are severe enough to warrant no longer working during the pregnancy—for example, hypertension or heart disease, FMLA can cover their absence from work, with job security. While many women would like to use all 12 weeks of FMLA post-delivery, sometimes it is necessary to begin using it prior.

Are there monetary or compensation benefits to help pregnant women who cannot work?

Yes, in most states there are plans, and each one is different. Five states have mandated short term disability coverage that can be used for pregnancy: CA, HI, NJ, NY, and RI. Most states will allow a pregnant woman to apply for unemployment benefits, though not every state will award payments. Contact each state’s Department of Labor to inquire about benefits for which you may be eligible: http://www.dol.gov/whd/america2.htm

Some pregnant women may work for employers that provide short-term disability plans through a private insurance plan. Sometimes this benefit is provided, though most of the time it is an opt-in program for which the employee pays a premium. If an employee has a short-term disability policy available, the employee should enquire with Personnel or Human Resources about using it to cover a leave of absence during pregnancy. Most often, such benefits can be used for any short-term condition, pregnancy included.

On occasion, a pregnant woman who is also disabled can apply for Social Security Disability Insurance (SSDI). Eligibility for that program is governed by Social Security Administration (SSA). SSA’s website http://www.ssa.gov can help people determine if and when they should file a claim for benefits. The legal description of ”disability“ varies in private insurance claims, various State programs and the Federal Social Security program. A knowledgeable attorney, working with the physician, knows the descriptions of disability under the various programs and the effects of the medical conditions. They are in the best possible position to assess and advise as to potential qualification for disability benefits.

What should a pregnant woman do if she feels she is being discriminated against in the workforce?

Pregnant women might experience discrimination in the workplace because of pregnancy or disabling condition. They have the ability to file complaints with the EEOC under the ADA or the PDA by calling 1-800-669-4000. Pregnant women who are denied leave under the FMLA can file complaints with the DOL by calling 1-866-487-9243. Statute of limitations for timely filing applies for such complaints.

Conclusion

Though pregnancy is rarely considered a disability, accommodations can sometimes be obtained by using the ADA, but more likely, job modifications can be obtained by using the PDA, and leave obtained by using the FMLA. Helping a pregnant woman obtain adjustments in the workplace that allow her to continue working is ideal, but not possible for everyone. Thus, when necessary, the obstetrician can help a pregnant woman become eligible for disability benefits by writing adequate documentation about her condition. Patients must let the obstetrician know all the signs and symptoms necessary to document the case so it can be provided to the employer and help secure job accommodations or eligibility for special benefits, such as short term disability. Also, it should be stated that pregnancy is not a guarantee of a secure position regardless of how you perform your job, in all instances. If a pregnant woman cannot perform her job properly, even with modifications, an employer has the right to terminate her position despite the fact that she is pregnant.

Thanks to my co-authors:

I want to thank Bernard L. Shapiro, an attorney in private practice in Stamford, Connecticut who specializes in the field of Social Security and other disability claims. He is Chairman of the Disability Law Committee of the Connecticut Bar Association and speaks at continuing education programs for physicians, clinicians and attorneys.

- Contact Bernard L. Shapiro at bls@ssdssilaw.com or visit his website at ssdssilaw.com

I also want to thank Dr. Suzanne Gosden Kitchen, a Senior Consultant for the Job Accommodation Network (JAN), a service of the U.S. Department of Labor’s Office of Disability and Employment Policy. Dr. Kitchen teaches at West Virginia University, preparing American and International students to become leaders in contemporary human resource fields. Dr. Kitchen designs disability awareness activities to educate the public, and enjoys finding new ways to promote disability etiquette in society.

- Contact Dr. Suzanne Gosden Kitchen at Suzanne.Gosden@mail.wvu.edu

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