The Short Life of the Pregnant Fetus

The news of Mary Lambert's pregnant fetus spread like wildfire across the intertubes, the flames fanned by social media.

A pregnant woman in Portland, Oregon was hospitalized this week with extreme stomach pains, and doctors were extremely shocked at what they discovered.

Mary Lambert, who is 8 months pregnant, went to Silverstein Memorial Hospital in Portland when she thought she might be going into labor. Doctors examined her, and initially could not figure out what was causing Lambert’s pain. After an ultrasound to check on her baby, they were taken aback to find that her unborn daughter was also pregnant.

“I have never in my life seen anything like this.” Said Dr. Joseph Goldsmith, a pediatric surgeon at Silverstein. “I don’t think anyone has. This is the first time that an unborn baby has become impregnated. It’s so far beyond rare that we didn’t know it was possible.”

There was an obvious reason that this complication is so rare - it's a Hoax.

... But, of course, the report is fanciful nonsense. No unborn baby is pregnant, in Oregon, or anywhere else. The fictional report originates from the fake-news website, Empire News.

In fact, nothing published on Empire News is true. A disclaimer on the site notes: Empire News is a satirical and entertainment website. We only use invented names in all our stories, except in cases when public figures are being satirized. Any other use of real names is accidental and coincidental.

The internet is replete with tall tales and rumor-mongering. It pays to check out the sources before passing on incredible stories. Be careful out there.

One final note - there is a condition called Fetus In Fetu which can occur as a complication of embryogenesis during a twin pregnancy. In this condition, a nonviable twin fetus becomes enclosed within a normally developing twin fetus. This condition became the inspiration for Stephen King's The Dark Half. This, however, is far from the short-lived saga of the pregnant fetus.

For more information or to schedule a sonogram, please call (718) 925-6277.

Autism and Labor Induction: ACOG Weighs In

In October, a study by Gregory et al using North Carolina birth records reported a possible association between labor induction or augmentation with an increased risk for autism. Because of the increased incidence of autism and the frequency of oxytocin use in labor, this study resulted in quite a bit of both media buzz and alarm. Many, including both the authors and one recovering obstetrician, commented on the problems with this study and urged caution in interpreting the study's findings.

In the May issue of the journal Obstetrics and Gynecology, the American Congress of Obstetricians and Gynecologists (ACOG) weigh in with a Committee Opinion also endorsed by the Society for Maternal-Fetal Medicine (SMFM.)

...Although the Gregory study suggested an association between ASD and labor induction or augmentation, the study design could not determine if such findings were truly a result of cause and effect. This was recognized by the authors, who noted that interpretation of their findings was limited by missing data regarding important potential confounders, the use of education as a proxy for socioeconomic status, and a lack of data regarding induction indications and methods. They concluded that the “results are not sufficient to suggest altering the standard of care regarding induction or augmentation…though additional research is warranted” (20).

Subsequent to its publication, the Gregory study has been criticized because of limitations in defining the exposure and the outcome of interest (21). Critics note that investigators did not know the specific individual or combination of agents that were used for labor induction or augmentation. The critics also note that the American Psychiatric Association reported an editorial error in the criteria listed for the diagnosis of pervasive developmental disorder not otherwise specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV); an error potentially leading to overdiagnosis during much of the time covered by the Gregory study (21).

The ACOG publication concludes:

Current evidence does not identify a causal relationship between labor induction or augmentation in general, or oxytocin labor induction specifically, and autism or ASD. Recognizing the limitations of available study design, conflicting data, and the potential consequences of limiting labor induction and augmentation, the Committee on Obstetric Practice recommends against a change in current guidance regarding counseling and indications for and methods of labor induction and augmentation.

Stay tuned.

Five Prenatal Tests Women Over 35 Should Consider

The other day, this piece on prenatal diagnosis appeared in my inbox.

While the CDC reports almost 15 percent of all U.S. babies -- or 1 in 7 -- were born in 2010 to women 35 and over, much tongue-clucking persists about women waiting to have a baby at "advanced maternal age." The reason may stem from data that shows certain risks (such as having a baby with Down syndrome) can increase with age. However, many women are happily embracing motherhood later on.

That said, certain tests and procedures are often recommended for women over 35. Here, 5 prenatal protocols these expectant moms may want to consider and what "older" moms who've been through them say about their experience.

The article goes on to list the 5 tests -

1. amniocentesis
2. nuchal translucency screening
3. Noninvasive Prenatal Testing (NIPT)
4. chorionic villus sampling (CVS)
5. midtrimester ultrasound

While this is a useful article as it provides background prep for moms to be for conversatons with their OB's and midwives, it lumps screening tests together with diagnostic tests, losing some perspective.

So let's look at this issue in another way. Put simply, a screening test is one which is relatively noninvasive, provides odds and stratifies risk, but does not tell you yes or no. A diagnostic test is often more invasive with real risks and answers specific questions. For example, a screening test for Down's Syndrome would yield a risk in the form of odds. A diagnostic test for Down's would yield a definitive result.

Amniocentesis and CVS are diagnostic tests. While they usually provide definitive results (with a few, thankfully rare exceptions,) nuchal translucency, NIPT and midtrimester ultrasound are more screening tests.

Also, some of these are performed in the first trimester, others in the second. NIPT, nuchal scan, and CVS are first trimester tests. The advantage here is that the earlier this hurdle is jumped, the less stressful the longer remainder of the pregnancy is.

Finally, a few words about ultrasound. IMHO, both first and second trimester ultrasound will remain standard in prenatal care, similar to early newborn physicals and the more comprehensive baby visit a month or so after birth. Many abnormalities and syndromes do not have a basis in chromosome complement, thus a test designed to screen for a chromosome issue such as Down's would not find cases of spina bifida, for example.

Prenatal ultrasound is also more than just looking at structure. It keeps pregnancy real in a tangible way for not only mom but also for dad.

For more information, or to schedule an ultrasound, please call: (718) 925-6277.

Nature Or Nurture

We all have heard the saying, "You are what you eat." Now there may be evidence that statement may apply to developing fetuses too. Research shows that a mother's diet around the time of conception can permanently influence her baby's DNA.

... Scientists followed 84 pregnant women who conceived at the peak of the rainy season, and about the same number who conceived at the peak of the dry season.

Nutrient levels were measured in blood samples taken from the women; while the DNA of their babies was analysed two to eight months after birth.

Lead scientist Dr Branwen Hennig, from the London School of Hygiene & Tropical Medicine, said it was the first demonstration in humans that a mother's nutrition at the time of conception can change how her child's genes will be interpreted for life.

She told BBC News: "Our results have shown that maternal nutrition pre-conception and in early pregnancy is important and may have implications for health outcomes of the next generation.

"Women should have a well-balanced food diet prior to conception and during pregnancy."

What's going on here? Epigenetics, functionally relevant changes to the genome that do not involve a change in the nucleotide sequence.

...One such modification involves attaching chemicals called methyl groups to DNA.

Infants from rainy season conceptions had consistently higher rates of methylation in all six genes studied, the researchers found.

These were linked to various levels of nutrients in the mother's blood.

But it is not yet known what the genes do, and what effect the process might have.

The study, published in Nature Communications, demonstrates that a mother's diet can have epigenetic effects.

So which is it - Nature or Nurture? The answer may truly be both.

For more information, or to schedule an ultrasound, please call: (718) 925-6277

Dad's Magic Moment

Everyone knows that the prenatal ultrasound provides the opportunity for mom to bond with her baby to be. Even before she first feels movement, seeing that tiny heart's beating, watching those movements, makes it all real. There is ample literature to describe the maternal bonding experience. But what about dad? Few have studied his reactions to the process - that is until now. Dr. Tova Walsh and colleagues at the University of Michigan interviewed 22 expectant fathers after they viewed a midtrimester ultrasound.

They found that the ultrasound experience was an important moment for men, establishing the reality of the coming child, and reassuring them that all was going well with the pregnancy.

It also caused the men to reflect on their roles in the life of mother and child, making it an important practical and psychological preparation for parenthood. The study noted that the men’s “plans and dreams alike extended beyond the immediate future of infancy and across the child’s lifespan.”

One man told the researchers, “Now that we know that it’s a girl, you know, now I’m thinking about ... walking her down the aisle someday, you know, (I’m) thinking that far ahead ... which is crazy, but I mean, it’s like my brain went from bringing her into the world and taking care of her and making sure she is taken care of (as) to her future and everything ...”

Another had more immediate worries: “I need to make sure I have a steady job because my child eating depends on me. If I don’t work, he don’t eat. And I’d rather my child eat before I do.”

Dads have magic moments too.

Walsh is a Robert Wood Johnson Foundation Health & Society Scholar at the UW School of Medicine and Public Health. Her study, “Moving up the Magic Moment: Fathers’ Experience of Prenatal Ultrasound,” is being published in the winter 2014 edition of the journal "Fathering".

For more information, or to schedule an appointment for an ultrasound, call: (718) 925 - 6277.

My Placenta Is Low-Lying. Now What?

Now that most pregnant women have a midpregnancy ultrasound, they are often alerted to findings of uncertain significance. One of the most common of these involves the placenta. A placenta is low-lying when the lower edge extends to within 2 centimeters of the internal cervical opening or os. This is different from a placenta previa which actually covers the internal os. A group of investigators at the Brigham and Women's Hospital in Boston reported on their experience with the eventual outcome of pregnancies complicated by these low placentas.

Here's the short answer: Most of these situations resolve by the end of the pregnancy.

In total, 1220 of 1240 low-lying placentas (98.4%) that had sonographic follow up resolved to no previa before delivery; 89.9% of placentas cleared the cervix by 32 weeks, and 95.9% cleared by 36 weeks.

A small minority were not so lucky.

Twenty patients (1.6%) had persistent sonographic placenta previa or a low-lying placenta at or near term, including 5 complete previas, 7 marginal previas, 5 low-lying placentas, and 3 vasa previas; all had cesarean deliveries.

So, about 98/100 times all turns out well. In about 2/100 cases, the situation persists. Moreover, a very few unfortunate women were found to have vasa previa, a condition in which fetal blood vessels actually cross that internal os in front of the baby. Think about that for a moment. If the baby descends toward the birth canal and puts pressure on these blood vessels, those vessels can tear, resulting in a fetal hemorrhage, often severe.

So what should be the plan if they do find a low-lying placenta during your ultrasound? The authors suggest a repeat sonogram after 28-30 weeks to confirm resolution, repeating again at 34-36 weeks if the situation remains the same. During those studies, a search for vasa previa can also be conducted.

So if you're told you have a low-lying placenta, you should be optimistic but should follow up. The late Ronald Reagan said it best: "Trust but verify."

For more information or to schedule an ultrasound, please call: (718) 925-6277.

New UK Project To Improve Prenatal Detection of Birth Defects

Presently, most if not all pregnant women undergo at least two sonograms during pregnancy for the purpose of screening for serious birth defects - the first at 11.5 - 14 weeks and the second at about 20 weeks. While some abnormalities are virtually always detected, many still are missed for a variety of reasons. For one thing, mom's with increased weight gain pose a technical imaging problem as the ultrasound frequency necessary for sufficient penetration may not yield the optimal resolution. Another factor is the fetal position - "if the baby has his back to the camera, you don't get a good picture." For these reasons and more, a groups of investigators at Kings College London are trying to see if technology can solve these issues.

Professor Reza Razavi and colleagues at King's College London, as part of King's Health Partners Academic Health Sciences Centre, have been awarded funding under the joint Wellcome Trust and EPSRC Innovative Engineering for Health scheme to develop a fully automated and computer-guided ultrasound system, which will allow midwives to acquire three-dimensional images of a whole baby in a much higher resolution than is currently possible. The team are also aiming to develop computer software that will be able to automatically analyse the images acquired. These techniques should substantially improve detection rates of congenital abnormalities.

Professor Razavi, who is Head of Imaging Sciences at King's College London and Director of Research at King's Health Partners, said: "Identifying birth defects at an early stage is essential both for medical professionals and for the parents themselves. Current ultrasound scans are relatively crude and many serious abnormalities are not detected, leading to these babies becoming very ill soon after birth, and substantial delay before a diagnosis is made and they can be transferred to a specialist centre for appropriate treatment.

"We are developing a radically new approach to fetal screening, largely removing the need for experts to acquire and interpret the images. It will allow the initial screening scans to be done in a few minutes, and provide a consistently higher detection rate for major abnormalities."

I wish them well.

For more information or to schedule an appointment for an ultrasound, call: (718) 925-6277.

Maternal Weight And Stillbirth

This past week in the Journal of the American Medical Association, a statistical analysis of 38 studies of moms' weight either prior to pregnancy or in early pregnancy showed a relationship between maternal BMI and risk of stillbirth. The loss of a wanted pregnancy at any gestational age is tragic but the worst has to be a fetal death in the few weeks prior to birth. The nursery has been set up. The birth announcements prepared. Often, the room is packed with gifts from the baby shower. All this adds to the immense suffering of the loss of a child.

So how is maternal weight linked to stillbirth? The authors suggest the possibility that the increased amount of adipose tissue may exert metabolic effects which affect placental function. We already know the effect of weight, fat, and type 2 diabetes, for example. A similar altered biology may be at work here as well. Another possibility is that heavier women become less sensitive to fetal movement and are thus less apt to pick up on the signals of decreasing fetal movement. The lack of this alarm mechanism may miss that narrow window for life-saving intervention.

So what should a woman considering having a baby do in light of this information? The best, obviously, is to get as close to ideal body weight as possible prior to conception. When this is not possible, early prenatal care would be essential, with a special emphasis to nutritional counseling. As pregnancy enters the "home stretch," certain tests of fetal well-being can be considered - monitoring or non-stress tests, serial ultrasounds for fetal growth, and biophysical profiles. Additionally, fetal kick counts can be done at home which require no sophisticated equipment.

Moms to be should voice any concerns with their Obstetricians. For more information, or to schedule an appointment for an ultrasound, you can call my office at: (718) 925 - 6277.

JWoww's Pregnancy Scare

Jenni Farley aka JWoww of "Jersey Shore" fame (or infamy) described the impact of learning about a minor abnormality in her prenatal ultrasound.

Jenni reported on her blog recently that a routine ultrasound turned into a moment of pure terror when her doctor informed her that he identified what may be a cyst on the fetus' brain. "At this point I honestly can't tell you what he's saying because I go numb and tears are just flowing," Jenni wrote of the incident. A scary diagnosis, to be sure, but using her trademark tenacity, Jenni secured an appointment with a specialist who delivered some good news: Jenni writes that the new doc informed her: "It's called choroid plexus cyst and over time the cyst should go away." She added, "Honestly I was happy but still my heart felt heavy. And even though I know I did nothing to cause it, I felt guilty and so helpless." Well, apparently Jenni has developed a skill for suspenseful storytelling during her months of sobriety because she ends the blog post by revealing that this all happened several weeks ago: "Fast forward to this check-up which brings me to 25 weeks aka 6 months," JWoww writes. "My daughter's cyst went away!"

There are a variety of findings whose significance seems relatively minor to obstetricians and sonographers yet strike fear in the hearts of moms to be. Choroid plexus cyst is one of these findings. Choroid plexus cyst or CPC is a small fluid-filled structure found in the choroid tissue in the ventricle of the developing fetal brain. CPC's are found in about 1 - 2% of all fetuses so these are quite common. While earlier descriptions found an association between CPC and Trisomy 18 (an extra copy of chromosome 18,) this association has not panned out in further investigations. CPC's do not cause swelling on the brain or hydrocephaly. They are not in and of themselves a major abnormality and have no effect on mental development. In the absence of other risk factors for chromosome problems, eg. age, family history, previously affected children, or other malformations, these should not warrant either worry or further investigation. In fact, most, as in Ms. Farley's case, resolve spontaneously.

For more information, or to schedule an appointment, please call my office: (718)-925-6277.

A Better Blood Test For Down's Syndrome?

Presently, moms-to-be are offered prenatal screening for a third chromosome number 21 by either blood tests, ultrasound, or a combination of the two. Recently, a newer blood test was cleared for use in women at higher risk - eg. older women or those with abnormal ultrasound findings. The use of this test, involving examining the cell-free dna in mom's circulation, for women at lower risk is still considered investigational. As such, the test, called Noninvasive Prenatal Testing or NIPT, in low risk women is not recommended by specialty societies and not covered by insurance plans.

Yesterday's publication by Drs. Diana Bianchi, Rajeevi Madankumar and many other investigators in the New England Journal of Medicine brings this test one step closer to more widespread usage.

In conclusion. our head-to-head comparison showed that noninvasive prenatal cfDNA testing performed better than standard screening methods, with an improvement by a factor of 10 in the positive predictive value for trisomy 21 in our predominantly low-risk patient population. The major advantage of using cfDNA testing was the reduction in rates of false positive results. A consideration of cost-effective ways to incorporate cfDNA testing into general obstetrical practice26 is beyond the scope of this study. Our findings, however, suggest that cfDNA testing merits serious consideration as a primary screening method for fetal autosomal aneuploidy.

It is still far to early to recommend widespread introduction of this test. The study was not meant to be a head to head comparison of present screening practice vs NIPT. The test was less predictive in one major chromosome syndrome other than Down's. Nevertheless, NIPT's lower false positive rate would mean fewer anxious moments, fewer invasive procedures, and fewer losses of normal wanted babies.

Faster, please.

Gestational Calendars: The Wheel Deal

Obstetricians are familiar with the cardboard/paper wheels used to calculate the duration of the pregnancy and the due date. In the February issue of the American Journal of Obstetrics and Gynecology, Drs. Chambliss and Clark tested the familiar wheels against downloadable electronic apps for both 2013 and the leap year of 2012.

... The last menstrual period was set at Jan. 1, 2013, and the estimated date of confinement obtained was compared with the estimated date of confinement of Oct. 8th if the pregnancy completed 280 days. The process was performed on 20 electronic APPs downloadable to cell phones. The process was repeated for both for the leap year of 2012.

Thirty-one paper wheels from a variety of sources were collected. Ten wheels (35%) were consistent with the standard pregnancy duration of 280 days. Among the wheels surveyed, the largest discrepancy was 4 days short of 280 days. Two wheels gave an estimated date of confinement that differed from each other by 7 days. Wheels from the same source did not agree with each other. Twenty electronic gestational age calculators were examined. All 20 gave an estimated date of confinement of Oct. 8 consistent with 280 days. None of the paper gestational wheels but all of the APPs corrected for a leap year.

The authors found variability of the paper wheels compared with both electronic apps and among each other. Since many clinical decisions, eg. timing of delivery, depend on knowing the gestational age, the use of these wheels becomes problematic. Therefore, Drs. Chambliss and Clark argue for their abandonment.

There is one problem, however. The length of a term pregnancy is actually quite variable. The Early Pregnancy Study found that human gestational length varies considerably even when measured exactly (from ovulation).

These investigators offered the following:

Variability in the length of human gestation limits the ability to predict delivery dates. Nonetheless, it is common clinical practice to assign pregnant women a due date based on 280 days from the LMP. A more evidence-based approach might be to assign a range of due dates (perhaps the interquartile range, in which half of women will deliver) or to describe the due date as a median (before which half of women will deliver).

So don't throw those wheels away so fast.

Do I Really Need Those Prenatal Vitamins?

During the course of a prenatal ultrasound, the mom asked me, "About those vitamins - do I really need them?" The short answer is Yes and here's why: Mom and her developing baby come as an entry - they both have needs and metabolic demands. While obviously, a health diet is essential, even the healthiest eaters often fall short in a few key areas specific to pregnancy. Mayo Clinic lists two:

•Folic acid helps prevent neural tube defects. These defects are serious abnormalities of the brain and spinal cord.

•Iron supports the baby's growth and development. Iron also helps prevent anemia, a condition in which blood lacks adequate healthy red blood cells.

Some other important nutrients are worth asking your doctor or midwife about - Calcium and Vitamin D which among other things are essential for healthy fetal bone development and also Omega-3-Fatty acids, usually found in ample supply in fish. Since many pregnant women are concerned about mercury in fish, you may also wish to talk to your doctor or midwife about omega 3's as well.

Mayo also has a nice list of what to look for in a prenatal vitamin.

Generally, look for a prenatal vitamin that contains:

•Folic acid — 400 to 800 micrograms
•Calcium — 250 milligrams
•Iron — 30 milligrams
•Vitamin C — 50 milligrams
•Zinc — 15 milligrams
•Copper — 2 milligrams
•Vitamin B-6 — 2 milligrams
•Vitamin D — 400 international units

Remember, vitamins are supplements to a healthy diet, not substitutes. Choose wisely for the future may depend on it.

Autism - Much Heat But Little Light

Just a mention of the word Autism to an expectant mom is enough to cause terror. In today's parlance, autism is not one disorder but a spectrum of disease - ranging from the savant of Rain Man to those afflicted with Asperberger's Syndrome. Merriam Webster  defines autism thusly:

 a developmental disorder that appears by age three and that is variable in expression but is recognized and diagnosed by impairment of the ability to form normal social relationships, by impairment of the ability to communicate with others, and by stereotyped behavior patterns especially as exhibited by a preoccupation with repetitive activities of restricted focus rather than with flexible and imaginative ones.

The recently developed DSM V criteria for outlining the diagnosis of autism may be found here.

But what causes autism? The truth is that by and large, the cause is unknown. This is not for lack of theorizing, however, as there is quite a laundry list of usual suspects and some unusual, including:

vaccines
prenatal ultrasound
rainy climate
valproic acid during pregnancy
cosmetics
nail polish
shampoos
air pollution
household chemicals
labor induction
birth spacing
antibody proteins
television
low levels of glutathione
diet
intestinal flora
genetics

All of these putative causes have their proponents, some with great celebrity, but as of yet, the cause remains elusive. That's the real sticky part. Humans can obviously handle good news. Humans can also handle bad news if given time to fully digest. The one thing we handle poorly is the unknown. And that is truly what makes autism so frightening. A good deal learned recently from the human genome project suggests that there are genetic variations which may either directly cause or predispose to much of the autism spectrum. But this is not the whole story, There are undoubtedly sporadic cases which arise out of the blue, without any warning from family historical data. Many groups of investigators are working to piece together the puzzle that is autism. One such group (in which I have no part) has begun the Earli Study.

EARLI is a network of research sites that will enroll and follow a large group of mothers of children with autism at the start of another pregnancy and document the newborn child’s development through three years of age. The EARLI Study will examine possible environmental risk factors for autism and study whether there is any interplay between environmental factors and genetic susceptibility.

I wish all groups godspeed and good luck in their hunt to unmask the culprits underlying these disorders.

Faster please.

Universal Noninvasive Prenatal Testing for Down's Syndrome?

Today's NY Times returns us to Noninvasive Prenatal Testing for Down's Syndrome. 

... The newest screening test, highly accurate and noninvasive, relies on fetal genetic fragments found in the mother’s blood. Available commercially from four companies, this test is so accurate in detecting Down syndrome that few, if any, affected fetuses are missed, and far fewer women need an invasive procedure to confirm or refute the presence of Down, according to studies in several countries.

The new test, done late in the first trimester of pregnancy, can also detect other genetic diseases, like extra copies of chromosomes 13 and 18, and a missing sex chromosome. It is not yet approved by the Food and Drug Administration, however, and the American College of Obstetrics and Gynecology currently recommends it only for women at high risk for having a baby with a chromosomal abnormality.

The author then cites Tufts' Dr. Diana Bianchi as claiming that a "low risk" woman can get this test done if she's willing to pay for it. Actually, that may not always be true. NY State still tightly regulates laboratories' offering these tests and has been restricting the use of this technology to those at highest risk - age, history, or finding on ultrasound.

There are some drawbacks to these tests. 

... In a recent article in The New England Journal of Medicine, however, Stephanie Morain, a doctoral candidate at Harvard who studies medical ethics, and her co-authors said the fetal DNA tests have some disadvantages. They miss some chromosomal abnormalities detected by standard screening techniques, and they are “not widely covered by insurance.” Prices for the tests range from about $800 to more than $2,000, although some companies offer “introductory pricing” specials at about $200.

The high variation in pricing suggests that as the technology is offered to those women at lower risk, the price should come down to the lower range. It's my belief that insurance coverage may actually serve to keep prices higher rather than lower, but that's for another day.

While the article goes on to say the  tests are only  valid only in singleton pregnancies, some labs are performing the test for women who are carrying twins.

Some caveats - the first being that these tests presently only test for specific chromosomes so that a normal result does not mean a normal baby. In fact, there is no normal baby test. Conversely, an abnormal test result should be confirmed by an invasive test before making any final decisions. Having personally witnessed a mistaken result, I cannot emphasize this enough at the present time.

Finally, I agree with Dr. Bianchi  that the recent research findings in mice give hope that the day that Down's Syndrome can be ameliorated by prenatal therapy may be sooner rather than later. 

Faster Please.

Flu Shots For The Expectant Mom?

It's that time of year again and the drug store chains are all advertising flu shots. But for expectant moms, safety is a prime consideration. So what about flu shots in pregnancy? Are there any special risks during pregnancy? And are these vaccinations safe for mom and baby?

The CDC has a great deal of useful information on Flu Shots in Pregnancy.

Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. Pregnant women with influenza also have a greater chance for serious problems for their unborn babies, including premature labor and delivery.

But are they safe? Again, the CDC has the answer

Yes. The seasonal flu shot has been g.iven safely to millions of pregnant women over many years. Flu shots have not been shown to cause harm to pregnant women or their babies.

There is one caveat - the nasal spray vaccine is not recommended for use during pregnancy.

The CDC has more at the link.  Read the whole thing.

Surviving The Unsurvivable

Today's amazing "feel good story" involves Abigail Rose Beutler, born after a prenatal diagnosis of invariably fatal renal agenesis. Faced with this terrible diagnosis, Abigail's parents, Daniel Beutler and Congresswoman Jaimie Herrera Beutler of Ohio, elected to embark on an experimental therapy - weekly treatments of amnioinfusion, instilling solution into the amniotic sac, to replenish the meager fluid surrounding the fetus in an attempt to allow some semblance of normal lung development. After five weeks of therapy at John's Hopkins, little Abigail was born, weighing in at less than three pounds. 

A day after the fifth infusion, the congresswoman went into preterm labor. After four days of trying to prevent preterm delivery, the baby arrived.

“The doctors and nurses were prepared for the worst, but immediately after she was born, she drew a breath and cried,” Herrera Beutler said. “After a few minutes, it was clear that her lungs were very well developed for a baby born so early.  The infusions had stopped the Potter’s Sequence.”

To be sure, Abigail still needs to overcome significant hurdles including kidney transplant. However, this remarkable case is truly historic.

But riddle me this - how would little Abigail have fared had PPACA's IPAB been in place to review the cost/benefit ratio of fetal therapy? 

The Moving Finger writes; and, having writ,

Moves on: nor all thy Piety nor Wit

Shall lure it back to cancel half a Line,

Nor all thy Tears wash out a Word of it.

The Rubaiyat Of Omar Khayyam

When All Else Fails, Blame The Obstetrician

Now that the vaccine-autism link has been debunked again, Jenny McCarthy notwithstanding, everything but the kitchen sink is being put forth as potential causes of this affliction. The latest out of Duke finds a connection between autism and induction of labor.

... Overall, the likelihood of autism increased by 23% in association with induced or augmented labor as compared with children whose mothers had unassisted labor, Simon G. Gregory, PhD, of Duke University, and colleagues reported inJAMA Pediatrics.

Induction only, augmentation only, or the combination all were associated with significantly increased odds of autism. The magnitude of increased risk was similar to that associated with fetal distress, meconium, prematurity, and maternal diabetes, they said.

Curiously, this linkage seemed to hold predominantly for boys. The connection for females was more tenuous.

While this is certainly interesting, remember that association hardly proves cause and effect. Emily Willingham in Forbes gives this article a thorough review and notes some quite strange findings. For one thing, moms' having a college education increase the odds of her child attending special education. Yes, you read that right. Also, maternal smoking apparently decreases the risk of later autism diagnosis. So should we infer that women should drop out of school and commence smoking? Hardly.

While the dust settles around this study, remember that there have been numerous studies linking various genetic factors and autism, the latest trumpeted by the New York Times. Here's a thought - perhaps whatever genetic or epigenetic factor which may lead to autism spectrum may also predispose to a situation which subsequently require induction of labor. 

Remember that as Mark Twain ( often attributed to Benjamin Disraeli) said, there are "lies, damned lies, and statistics." I learned in high school that statistics are like bikinis - what they reveal is suggestive but what they conceal is vital. 

When Is The Baby Due? It's Complicated

While intellectually, most expectant mom's understand that the due date is only accurate within an up to two week window, folks still want to know a specific estimated time of arrival. Now from Medpagetoday.com comes news of this research, concluding that mom's may do better with a range of dates.

... A cohort of pregnant mothers who were followed from conception to birth showed that, despite a median gestational period of 268 days, length of pregnancy varied by 37 days even after excluding mothers who gave birth preterm, according to Anne Marie Jukic, PhD, of the Epidemiology Branch of the National Institute of Environmental Health Sciences in Durham N.C., and colleagues.

Factors affecting length of pregnancy included length of time to conception, rate of progesterone rise, the mother's age, birth weight, and length of pregnancy in previous births, they wrote online inHuman Reproduction.

The authors noted that despite an estimated pregnancy period of 280 days from the mother's last menstrual period routinely assigned to mothers, only 4% of pregnancies fall on that date, while 70% occur within 10 days of that estimate "even when the date is estimated by ultrasound."

Here's what I've learned from my patients - nobody seems to worry if the baby arrives a week early. But one or two days late is quite a different story. There's also evidence to suggest that the medical equivalent of eviction proceedings aka induction of labor at 41 weeks results in fewer Cesareans and better perinatal outcomes than just waiting. Of course you won't know when 41 weeks is reached unless you know a due date.

Finally, as I tell my patients, due dates are like train schedules. Just because the train is expected doesn't mean that's when it pulls into the station.