Posts Tagged ‘obstetrician’

The Importance of the First Prenatal Visit

Tuesday, November 9th, 2010
OB/GYN Prenatal Visit

Come in to see your OB/GYN as soon as you think you're pregnant. Honestly, there is nothing more important for getting you and your baby off to a great start!

You just found out you’re pregnant! You rush to call your husband, then your mother, email your Aunt Annie and text your BFF. Excitement, celebration, hugging and kissing!

But before the excitement cools, there’s still one more person that wants to hear your good news… your OB/GYN.

Don’t delay. Here’s why.

The purpose of prenatal care is to optimize the chances of a healthy baby while ensuring the physical and emotional health of the mother. In order to best accomplish this, it is essential that there is early initiation of the first prenatal visit. Reports from Center for Disease Control have shown that delayed or no entry into prenatal care can result in a higher rate of complications with resultant severe maternal morbidity and or mortality. In addition, for the baby, studies have shown a direct association between early comprehensive prenatal care and increased birth weights.

What are some of the important reasons for having an early prenatal visit?

  • Establish more accurate dating
  • Counsel and educate patients about diet and exercise
  • Obtain a detailed medical history and physical so medical conditions both current and from previous pregnancies can be detected and managed early in the pregnancy
  • Discussions about avoidance of dangerous medications and harmful habits such as smoking, drinking, and the use of drugs
  • Detect early signs and symptoms of miscarriage or possible ectopic pregnancy

Unfortunately, recent studies have shown a trend that women are delaying the scheduling of their first prenatal appointments.

Several reasons why pregnant women delay early care:

  • Mothers sometimes avoid scheduling early appointments due to non-recognition of the pregnancy
    Over the counter pregnancy tests are extremely accurate so make sure you know the signs of early pregnancy. It’s very easy to ignore these signs but it’s very important that you are seen before the fetus begins developing.
  • Difficult work schedules
    Inform your employer that you are pregnant. Perhaps they can help rearrange your work schedule to find time for your very important prenatal visits.
  • Financial considerations
    Ask the physician’s billing department if the practice offers terms for newly pregnant families. Make sure you understand your insurance policy and if not, call your carrier and have them go over your options in detail.
  • Difficulty in the doctor’s office accommodating the new pregnant mother
    If the receptionist can not accommodate an early appointment, make sure the doctor knows you believe you are pregnant. Your doctor may have some slots available for a newly pregnant woman. If you can’t get an appointment with the doctor, ask if they have a physician’s assistance, midwife or a nurse practitioner to initiate your prenatal care. Alternatively, some practices now have Group Prenatal Care for low risk patients and multiple people can be seen together for the preliminary visit. This can be fun, a great way to meet other pregnant women and you can obtain the early, very important information and advice you need.

It has been found that over one quarter of all first prenatal visits are occurring after 8 weeks gestation when all the organ systems have already developed in the fetus and toxins or certain medical conditions have already taken their toll.

If you’re not yet convinced:

In a recent article, Sept 2010 in the American Journal of Obstetrics and Gynecology by Arnold Cohen, a suggestion was made to have a mini-triage system established for all pregnant patients who called the office for a first prenatal appointment by a competent and skilled health care provider. By asking certain key questions that pertain to dating the pregnancy, and known risk factors such as medical illness, medications, and previous pregnancy complications, it can be decided which patients take precedence and require very early initial prenatal appointments and which patients are more routine and can be delayed. In this way, more time and effort can be expended to improve prenatal care to those who most need it. Too often the questions currently being asked revolve solely around patient insurance issues and hospital coverage.

Summary:

In a country that spends 35% of all US infant spending on prematurity and also ranks at the bottom of the developed countries in the world on infant mortality, I think it is very reasonable to try and identify high risk pregnancies very early in the game in the hopes of preventing adverse outcomes through education and careful, frequent monitoring by a qualified health professional right at the very beginning of the pregnancy. In this way, we might be able to see an improvement in prematurity, adverse maternal outcomes, congenital anomalies, and low birth weight infants in the future.

The Sly Masquerader: Thyroid Disease During Pregnancy

Wednesday, June 30th, 2010

A 26 year old, newly-pregnant woman sits on the exam table in her obstetrician’s office. She is excited about her pregnancy and does not want to complain about her nausea, vomiting, weight loss, anxiety, difficulty sleeping, and fatigue. The obstetrician can tell just by looking at her that she seems to be suffering the normal symptoms of pregnancy and is not overly worried. After all, nausea and vomiting occur in 50–80% of all pregnant women, especially between the 5th and 13th week. The doctor reassures the patient that this is normal, and encourages her to hydrate and rest. Sometimes the physician will suggest a medication, or a supplement, to reduce the symptoms of nausea and vomiting.

Is it possible that this woman is experiencing something more severe than the normal, early pregnancy symptoms?

One of the great masqueraders for pregnant women is thyroid disease. Many of the symptoms that women experience in the early stages of pregnancy are the exact symptoms that occur with thyroid problems. Women will commonly experience fatigue, weight gain, constipation, insomnia, and lethargy. Health care providers will often reassure patients that this is normal and these symptoms are due to the hormonal and physiological changes that one expects with the early stages of a healthy pregnancy. However, one must be on the alert that these same symptoms could be representative of a much more serious underlying problem; one that could have major, negative ramifications on the pregnancy and the newborn infant. Left undiagnosed and untreated, hypothyroidism (low thyroid hormone) could result in serious, high-risk conditions during the pregnancy. Prematurity, preeclampsia, placental separation (abruption), and/or serious consequences in the child such as congenital cretinism (mental retardation, deafness, muteness).

This weeks blog will focus only on hy-PER-thyroidism (when you have too much thyroid hormone.)

Next week we will review hyp-O-thyroidism. (when you have too little thyroid hormone) and its effects on pregnancy.

Who should get screened for thyroid disease in pregnancy?

The current American College of Obstetrics and Gynecology guidelines state that thyroid functions should be checked only in women with a personal history of thyroid disease or symptoms of thyroid disease. It is NOT universally recommended to test all pregnant women even though there are cases of women who have disease that do not have symptoms (subclinical cases).

How does maternal thyroid hormone effect the fetus?

The fetal brain is completely dependent on maternal thyroid hormone until about 12 weeks gestation. At that time, the fetus is able to manufacture its own thyroid hormone in conjunction with the maternal hormone that crosses the placenta. Diminished levels of thyroid hormone in the mother impair fetal brain development. Elevated levels can also cross the placenta and cause excessive production in the fetus. (Graves disease.)

What is hyperthyroidism?

The thyroid is an endocrine gland located in the neck that controls metabolism. It receives a message (TSH) from an area in the brain called the pituitary which releases thyroid hormone (T4).

When the gland produces more hormone than it is supposed to, hyperthyroidism is diagnosed (elevated thyroid hormone T4 and low TSH.) This can occur in about .2% of all pregnancies. The most common form of the disease is Graves disease where certain antibodies are made by the body that stimulate thyroid hormone production. Other causes can be multinodular goiter, subacute thyroiditis, an extra thyroid source of hormone production (certain tumors of the ovary or pituitary), thyroid adenoma.

What are the symptoms of hyperthyroidism?

  • nervousness
  • tremors
  • tachycardia
  • frequent stool
  • excessive sweating
  • heat intolerance
  • weight loss
  • goiter
  • insomnia
  • palpitations
  • hypertension
  • eye changes-lagging of the eyelid and retraction of the eye lid

What are the risks to the mother and the fetus if hyperthyroidism is left untreated?

If left untreated, hyperthyroid can cause:

  • preterm delivery
  • severe preeclampsia
  • heart failure
  • fetal loss
  • low birth weight infants
  • stillbirth
  • fetal hyperthyroidism

How do you treat hyperthyroidism in the mother?

A classification of drugs called thioamides are used to treat hyperthyroidism.

  • PTU
  • methimazole

These drugs prevent the manufacture of the thyroid hormone by preventing a needed substrate iodine from attaching to the thyroid molecule and it also blocks the the manufacture of of another active form of the hormone T3.

These drugs do cross the placenta and can effect the fetal thyroid, although it is generally transient. Generally, these drugs are safe to use in pregnancy but rare side effects of the drug can include fever, sore throat, hepatitis, rash, nausea, loss of taste and smell, loss of appetite and a very serious and rare side effect called agranulocytosis (less than 1%) which is an abnormal condition of the blood characterized by a severe reduction of white blood cells (fever, prostration and bleeding ulcers of rectum, mouth, and vagina.)

Infants must be observed carefully after birth with mothers on antithyroid medication since newborns have been known to have neonatal hypothyroidism and goiter in mothers who have been treated. Babies are ultrasounded during pregnancy looking for fetal goiter and growth problems which can present problems at delivery due to the hyperextension of the neck.

It is generally considered safe to breast feed on these medications.

Other drugs used to treat hyperthyroidism are beta-blockers (propranolol) which act to reduce the rapid heart rate that can occur. Side effects from this drug can include growth retardation in the fetus, fetal bradycardia (slowed heart rate) and hypoglycemia in the infant (low blood sugar).

Radioactive iodine is never used in pregnancy since it can ablate the fetal thyroid. A patient was treated with radioactive iodine prior to becoming pregnant, should avoid becoming pregnant for at least 4 months. If all medications fail, or allergy to the medications exist, thyroidectomy, or surgical excision of the thyroid is recommended.

What is subclinical hyperthyroidism?

In about 1.7% of women there are asymptomatic women with normal thyroid hormone but a low TSH. This condition generally has been found to have no effect on the pregnancy since it is the maternal T4 level that is critical for fetal brain development, regardless of what the TSH level is. However, these women should be observed for osteoporosis, cardiovascular morbidity and progression to overt disease or thyroid failure in the future.

What is thyroid storm?

Thyroid storm is an acute obstetrical emergency that occurs in about 10% of women with hyperthyroidism. Symptoms include a change in mental status, seizures, nausea, diarrhea, and cardiac arrythmias. Patients are placed in the intensive care unit for constant monitoring and observation since there is a high risk of maternal heart failure. Thyroid storm can be precipitated by an acute surgical emergency, infection, diabetes. anesthesia, and noncompliance with thyroid medications. In addition to the usual treatment of hyperthyroidism as described above, steroids are commonly given.

Can thyroid disease present itself right after delivery?

About 6 to 9% of women with no history of thyroid disease can present with disease after delivery, generally within the first year postpartum. This is common in women that have previously known thyroid antibodies that are not activated until after the delivery, or women with a strong family history of diabetes or other autoimmune disorders. Most women have transient hyperthyroidism which then converts to hypothyroidism requiring treatment. About 77% of women will completely recover but 30% will continue with thyroid disease permanently. Many women that recover will develop this disorder again with subsequent pregnancies.

Summary:

Because of the close similarity of symptoms that occur with a normal early pregnancy, be sure to ask your health care providers if you should be screened for thyroid disease. Discovery and correction of this condition can have beneficial ramifications to ensure a happy, healthy mother and baby. As stated in many previous blogs, pregnancy can be the crystal ball of future medical conditions and by being vigilant, pregnancy can help a woman avoid diseases and conditions from surfacing later in life.

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Swine Flu in Pregnancy Update—Get Vaccinated

Tuesday, October 20th, 2009

pumpkin

(Because… Swine Flu is Scary)

Is it advisable for pregnant women to get the 2009 H1N1 Flu Vaccine?
Pregnant women are at a greater risk of complications due to infection with swine flu. The CDC recommends all pregnant women be vaccinated. The swine flu vaccine is a separate flu vaccine from the seasonal flu shot.

Is it OK for a pregnant woman to receive the Flu Mist nasal spray?
It is not recommended for pregnant women to use the nasal spray since it is a weakened live virus. Only the vaccine, which is a killed virus should be given in pregnancy.

Is the flu vaccine dangerous for pregnant women?
The H1N1 vaccine is similar to all the other flu vaccines that have been given in the past to pregnant women and does not have any increased side effects.

Will I get the flu from the vaccine?
You will not get the flu from the vaccine. Generally mild side effects can include headache, muscle aches where shot was given, fever, and nausea and rarely an allergic reaction can occur (should not be given to people who are allergic to eggs).

Should I take acetaminophen prior to taking the flu vaccine?
Prophylactic acetaminophen to prevent side effects from the vaccine has reduced the immune response in infants who have received other types of vaccines such as pneumococcal disease, Haemophilus influenza, diphtheria, and tetanus. Therefore , it is not recommended to use antipyretic drugs routinely.

Can seasonal flu vaccine and H1N1 flu vaccine be given at the same time?
Yes, it is possible to give both vaccines at the same time but separate sites on the body should be used.

What trimester is it safe to give the vaccine?
Any trimester is safe for the H1N1 vaccine.

If I am breastfeeding can I get the flu vaccine?
Breastfeeding moms can get the flu vaccine for both their own protection and the protection of their newborn who will receive the antibodies made from mom that is transported into breast milk.

How long is a person infectious after contracting swine flu?
It has been found that people infected with swine flu shed virus longer than expected. People should wait at least 3 or 4 days after symptoms resolve before resuming normal activities and exposure to other people.

Circumcision — The Cutting Edge

Wednesday, May 20th, 2009

The debate over circumcision is centuries old. Worldwide, about 25% of males undergo this procedure. In the United States, over 60% of males are circumcised. New evidence has recently emerged that brings forth additional benefits of this procedure, making it more appealing to new parents.
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Have a happy, healthy and Beauté de Maman pregnancy.

Saturday, May 2nd, 2009

Being an obstetrician, I have the greatest job in the world. Pregnancy and delivery is undoubtedly one of the supreme highlights in a woman’s life and I have the distinct pleasure of being able to share this moment with my patients on a daily basis.
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