pregnant

Stages of Pregnancy: Week by Week

Posted by

0


How long does it take for a baby to be born? A typical pregnancy lasts 40 weeks from the first day of your last menstrual period (LMP) to the birth of the baby. It is divided into three stages, called trimesters: first trimester, second trimester, and third trimester. The fetus undergoes many changes throughout maturation.

How Soon Can You Tell If You Are Pregnant?

A missed period is often the first sign that you may be pregnant

A missed period is often the first sign that you may be pregnant, but how do you know for sure? Many women use home pregnancy tests to tell if they are pregnant; however, these tests are more likely to be accurate when used at least one week after a woman’s last period. If you take the test less than 7 days before your last menstrual period, it may give you a false result. If the test is positive, it is more likely that you actually are pregnant. However, if the test is negative, there is an increased chance that the test is wrong. Your doctor can do a blood test to detect pregnancy sooner than a home pregnancy test can.

Pregnancy Weight Gain

The amount of weight a woman should gain during pregnancy depends on her body mass index (BMI) prior to becoming pregnant.

The amount of weight a woman should gain during pregnancy depends on her body mass index (BMI) prior to becoming pregnant. Women who are a normal weight should gain between 25 and 35 pounds. Women who are underweight prior to pregnancy should gain more. Women who are overweight or obese prior to pregnancy should gain less. The recommended caloric intake for a normal weight woman who exercises less than 30 minutes per week is 1,800 calories per day during the first trimester, 2,200 calories per day during the second trimester, and 2,400 calories during the third trimester.

Pregnancy Weight Gain Distribution

Women gain weight all over their bodies while they are pregnant.

Women gain weight all over their bodies while they are pregnant. Fetal weight accounts for about 7 1/2 pounds by the end of pregnancy. The placenta, which nourishes the baby, weighs about 1 1/2 pounds. The uterus weighs 2 pounds. A woman gains about 4 pounds due to increased blood volume and an additional 4 pounds due to increased fluid in the body. A woman’s breasts gain 2 pounds during pregnancy. Amniotic fluid that surrounds the baby weighs 2 pounds. A woman gains about 7 pounds due to excess storage of protein, fat, and other nutrients. The combined weight from all these sources is about 30 pounds.

Pregnancy Complications

Pregnant women may experience certain complications and symptoms as the fetus grows.

Pregnant women may experience certain complications and symptoms as the fetus grows. Anemia, urinary tract infection, and mood changes may occur. An expectant mother may experience high blood pressure (preeclampsia), which increases the risk of preterm delivery and other potential dangers for the baby. Severe morning sickness or hyperemesis gravidarum causes persistent nausea and vomiting, particularly during the first 12 pregnancy weeks. This may lead to first trimester symptoms of weight loss and dehydration, requiring IV fluids and antinausea medication. Pregnant women should be aware of the possibility of developing gestational diabetes. It causes symptoms like excessive thirst and hunger, frequent urination, and fatigue. Obesity and excessive weight gain are possible, especially as the pregnancy progresses. Women are supposed to gain weight during pregnancy, but excessive weight gain may be associated with symptoms that put mother and baby at risk. Ask your doctor how much weight you should gain during your pregnancy.

The Three Stages of Pregnancy
(1st, 2nd, and 3rd Trimester)

Illustration examples of the first, second, and third trimesters of pregnancy.

Conception to about the 12th week of pregnancy marks the first trimester. The second trimester is weeks 13 to 27, and the third trimester starts about 28 weeks and lasts until birth. This slide show will discuss what occurs to both the mother and baby during each trimester.

First Trimester

First Trimester

First Trimester: Week 1 (conception) – Week 12

First Trimester: Early Changes in a Woman’s Body

A woman with a home pregnancy test examines her stomach in the mirror.

The early changes that signify pregnancy become present in the first trimester. A missed period may be the first sign that fertilization and implantation have occurred, ovulation has ceased, and you are pregnant. Other changes will also occur.

First Trimester: Physical and Emotional Changes a Woman May Experience

An exhausted woman (top left), woman with morning sickness (top right), woman eating a pickle with ice cream (bottom left), and woman weighing herself (bottom right).

Hormonal changes will affect almost every organ in the body. Some signs of early pregnancy in many women include symptoms like:

  • Extreme fatigue
  • Tender, swollen breasts. Nipples may protrude.
  • Nausea with or without throwing up (morning sickness)
  • Cravings or aversion to certain foods
  • Mood swings
  • Constipation
  • Frequent urination
  • Headache
  • Heartburn
  • Weight gain or loss

First Trimester: Changes in a Woman’s Daily Routine

A pregnant mom letting her son touch her belly.

Some of the changes you experience in your first trimester may cause you to revise your daily routine. You may need to go to bed earlier or eat more frequent or smaller meals. Some women experience a lot of discomfort, and others may not feel any at all. Pregnant women experience pregnancy differently, even if they’ve been pregnant before. Pregnant women may feel completely differently with each subsequent pregnancy.

First Trimester: The Baby at 4 Weeks

Development of embryo at approximately 4-6 weeks.

At 4 weeks, your baby is developing:

  • The nervous system (brain and spinal cord) has begun to form.
  • The heart begins to form.
  • Arm and leg buds begin to develop.
  • Your baby is now an embryo and 1/25 of an inch long.

First Trimester: The Baby at 8 Weeks

An eight week old human embryo.

At 8 weeks, the embryo begins to develop into a fetus. Fetal development is apparent:

  • All major organs have begun to form.
  • The baby’s heart begins to beat.
  • The arms and legs grow longer.
  • Fingers and toes have begun to form.
  • Sex organs begin to form.
  • The face begins to develop features.
  • The umbilical cord is clearly visible.
  • At the end of 8 weeks, your baby is a fetus, and is nearly 1 inch long, weighing less than ⅛ of an ounce.

First Trimester: The Baby at 12 Weeks

Human fetus in utero at twelve weeks.

The end of the first trimester is at about week 12, at this point in your baby’s development:

  • The nerves and muscles begin to work together. Your baby can make a fist.
  • The external sex organs show if your baby is a boy or girl.
  • Eyelids close to protect the developing eyes. They will not open again until week 28.
  • Head growth has slowed, and your baby is about 3 inches long, and weighs almost an ounce.

Second Trimester

Second Trimester

Second trimester: Week 13 – Week 28

Second Trimester: Changes a Woman May Experience

A pregnant woman starting to show.

Once you enter the second trimester you may find it easier than the first. Your nausea (morning sickness) and fatigue may lessen or go away completely. However, you will also notice more changes to your body. That “baby bump” will start to show as your abdomen expands with the growing baby. By the end of the second trimester you will even be able to feel your baby move!

Second Trimester: Physical and Emotional Changes in a Woman

A pregnant woman with back pain (left), pregnant woman with stretch marks and line running down her belly (center), and woman with melasma (pregnancy mask) on her cheek (right).

Some changes you may notice in your body in the second trimester include:

  • Back, abdomen, groin, or thigh aches and pains
  • Stretch marks on your abdomen, breasts, thighs, or buttocks
  • Darkening of the skin around your nipples
  • A line on the skin running from belly button to pubic hairline (linea nigra)
  • Patches of darker skin, usually over the cheeks, forehead, nose, or upper lip. This is sometimes called the mask of pregnancy (melasma, or Chloasma facies).
  • Numb or tingling hands (carpal tunnel syndrome)
  • Itching on the abdomen, palms, and soles of the feet. (Call your doctor if you have nausea, loss of appetite, vomiting, yellowing of skin, or fatigue combined with itching. These can be signs of a liver problem.)
  • Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling or if you gain a lot of weight quickly, call your doctor immediately. This could be a sign of a serious condition called preeclampsia.)

Second Trimester: The Baby at 16 Weeks

The human fetus at about four months showing the head and upper limbs and the umbilical cord which connects the fetus (at the navel) to the placenta.

As your body changes in the second trimester, your baby continues to develop:

  • The musculoskeletal system continues to form.
  • Skin begins to form and is nearly translucent.
  • Meconium develops in your baby’s intestinal tract. This will be your baby’s first bowel movement.
  • Your baby begins sucking motions with the mouth (sucking reflex).
  • Your baby is about 4 to 5 inches long and weighs almost 3 ounces.

Second Trimester: The Baby at 20 Weeks

Human fetus near his fifth month of development.

At about 20 weeks in the second trimester, your baby continues to develop:

  • Your baby is more active. You might feel movement or kicking.
  • Your baby is covered by fine, feathery hair called lanugo and a waxy protective coating called vernix.
  • Eyebrows, eyelashes, fingernails, and toenails have formed. Your baby can even scratch itself.
  • Your baby can hear and swallow.
  • Now halfway through your pregnancy, your baby is about 6 inches long and weighs about 9 ounces.

Second Trimester: The Baby at 24 Weeks

Human fetus at approximately 24 weeks showing details of his closed eyes, nose, mouth, and facial hair.

By 24 weeks, even more changes occur for your growing baby:

  • The baby’s bone marrow begins to make blood cells.
  • Taste buds form on your baby’s tongue.
  • Footprints and fingerprints have formed.
  • Hair begins to grow on your baby’s head.
  • The lungs are formed, but do not yet work.
  • Your baby has a regular sleep cycle.
  • If your baby is a boy, his testicles begin to descend into the scrotum. If your baby is a girl, her uterus and ovaries are in place, and a lifetime supply of eggs has formed in the ovaries.
  • Your baby stores fat and weighs about 1½ pounds, and is 12 inches long.

Third Trimester

Third Trimester

Third Trimester: Week 29 – Week 40 (birth)

Third Trimester: Changes a Woman May Experience

A pregnant woman stretching her back while sitting.

The third trimester is the final stage of pregnancy. Discomforts that started in the second trimester will likely continue, along with some new ones. As the baby grows and puts more pressure on your internal organs, you may find you have difficulty breathing and have to urinate more frequently. This is normal and once you give birth these problems should go away.

Third Trimester: Emotional and Physical Changes a Woman May Experience

A pregnant woman holding her stomach.

In the third and final trimester you will notice more physical changes, including:

  • Swelling of the ankles, fingers, and face. (If you notice any sudden or extreme swelling or if you gain a lot of weight really quickly, call your doctor right away. This could be a sign of a serious condition called preeclampsia.)
  • Hemorrhoids
  • Tender breasts, which may leak a watery pre-milk called colostrum
  • Your belly button may protrude
  • The baby “dropping,” or moving lower in your abdomen
  • Contractions, which can be a sign of real or false labor
  • Other symptoms you may notice in the third trimester include shortness of breath, heartburn, and difficulty sleeping

Third Trimester: Changes as the Due Date Approaches

A doctor examines a pregnant woman's belly.

Other changes are happening in your body during the third trimester that you can’t see. As your due date approaches, your cervix becomes thinner and softer in a process called effacement that helps the cervix open during childbirth. Your doctor will monitor the progress of your pregnancy with regular exams, especially as you near your due date.

Third Trimester: The Baby at 32 Weeks

The human fetus at 8 months, almost full term.

At 32 weeks in the third trimester, your baby’s development continues:

  • Your baby’s bones are soft but fully formed.
  • Movements and kicking increase.
  • The eyes can open and close.
  • Lungs are not fully formed, but practice “breathing” movements occur.
  • Your baby’s body begins to store vital minerals, such as iron and calcium.
  • Lanugo (fine hair) begins to fall off.
  • Your baby is gaining about ½ pound a week, weighs about 4 to 4½ pounds, and is about 15 to 17 inches long.

Third Trimester: The Baby at 36 Weeks

Human fetus in utero at approximately 36 weeks.

At 36 weeks, as your due date approaches, your baby continues development:

  • The protective waxy coating (vernix) thickens.
  • Body fat increases.
  • Your baby is getting bigger and has less space to move around. Movements are less forceful, but you will still feel them.
  • Your baby is about 16 to 19 inches long and weighs about 6 to 6½ pounds.

Third Trimester: The baby at 37 to 40 Weeks

A mom looks at her newborn child.

Finally, from 37 to 40 weeks the last stages of your baby’s development occur:

  • By the end of 37 weeks, your baby is considered full term.
  • Your baby’s organs are capable of functioning on their own.
  • As you near your due date, your baby may turn into a head-down position for birth.
  • Average birth weight is between 6 pounds 2 ounces to 9 pounds 2 ounces and average length is 19 to 21 inches long. Most full-term babies fall within these ranges, but healthy babies come in many different weights and sizes.

Sources: 

This tool does not provide medical advice. See additional information: 

© 1996-2024 WebMD, LLC. All rights reserved.
Source slideshow on OnHealth

Health Solutions From Our Sponsors

Menopause and Perimenopause Symptoms, Signs

Reviewed on 8/10/2021

What Is Menopause?

Menopause is not a disease, but rather the point in a woman's life at which she is no longer fertile, and menstrual periods have ceased.

What is menopause like? Menopause is not a disease, but rather the point in a woman’s life at which she is no longer fertile, and menstrual periods have ceased. During this time, ovulation stops and estrogen hormones drop. Menopause can be accompanied by physical symptoms in some women, like hot flashes or night sweats. Menopause is the time point at which a woman has not had a menstrual period for 12 months. Perimenopause is the time leading up to menopause, and the symptoms of the transition can take two to ten years. Menopause can be seen as a positive beginning of a new phase of life, with opportunities to take preventive action against major health risks.

Menopause Causes

A graph of the menstrual cycles over a woman’s lifetime.

Age is the most common factor that influences menopause. The ovaries gradually lose their ability to produce hormones and ovulate with advancing age. There are other causes of menopause, since some surgeries and medical treatments can induce menopause. These causes include removal of the ovaries, chemotherapy for cancer, and radiation therapy to the pelvis.

When the uterus is removed (hysterectomy) without removing the ovaries in a premenopausal woman, menstrual periods cannot occur, but the hormonal changes characteristic of menopause will not occur.

When Does Menopause Start?

The average age for natural menopause is 51, but it can occur earlier or later.

The average age for natural menopause is 51, but it can occur earlier or later. Rarely, women may reach menopause as early as 40 or as late as 60 years of age. Women who smoke cigarettes tend to have earlier menopause than nonsmoking women. There is no way to predict in advance precisely when a particular woman will reach menopause. Menopause is confirmed when a woman has not had menstrual periods for 12 consecutive months.

How Long Does Menopause Last?

The beginning of perimenopause to the time of menopause typically lasts two to eight years. Some women go through the transition quicker than others.

What is Perimenopause?

A graph of perimenopause.

The transition to menopause and the time approaching menopause are referred to as perimenopause. Perimenopause means “time around menopause”. During this time the ovaries are still working, but their function has started to decrease. It’s still possible for a woman to become pregnant, even if she is showing signs of perimenopause, because she may still ovulate. Estrogen levels also rise and fall during this time.

Perimenopause Symptoms

A group of three mature women, experiencing menopause.

Perimenopause symptoms vary from woman to woman. Menstrual irregularity (irregular periods) is a common symptom that women may experience during perimenopause.

List of Perimenopause Symptoms

  • Hot flashes
  • Breast tenderness
  • Worsening of premenstrual syndrome
  • Lower sex drive
  • Fatigue
  • Irregular periods
  • Vaginal dryness
  • Urine leakage when coughing or sneezing
  • Urinary urgency
  • Mood swings
  • Trouble sleeping

Consult your doctor if you are experiencing any of the following symptoms, since perimenopause might not be the cause:

  • Periods are very heavy, or have blood clots
  • Periods last several days longer than usual
  • Spotting between periods
  • Spotting after sex
  • Periods happen closer together

Signs of Menopause: Period Changes

Different sizes of tampons.

With approaching menopause, a woman’s menstrual periods may change. They may get shorter or longer, lighter, or heavier. The interval between periods may increase or decrease. During perimenopause, it is common for women to have a period after going several months without one. It can take years of irregular periods before a woman reaches menopause. Pregnancy is possible during perimenopause, until a woman has had a full year without periods. If you have concerns about changes in your periods, talk with your doctor. Sometimes, conditions other than menopause can also cause changes in your period.

Menopause Symptoms: Hot Flashes

Hot flashes are a common symptom around the time of menopause.

Hot flashes are a common symptom around the time of menopause. A hot flash is a feeling of warmth that tends to be concentrated around the face and neck. It can cause flushing or reddening of the skin in these areas as well as the chest, arms, or back. Hot flashes vary in their intensity and can be followed by sweating and/or chills. Night sweats, waking up drenched in sweat a night, may also occur during hot flashes. Hot flashes at night are a common occurrence for women experiencing the symptoms of menopause.

How Long do Hot Flashes Last?

Hot flashes last anywhere from 30 seconds to 10 minutes, and they may start before menstrual irregularities. Hot flashes may last up to 10 years, but 80% of women will not have any hot flashes after five years. The exact cause of hot flashes is unknown, but they are most likely linked to the hormonal and biochemical changes brought on by decreasing estrogen levels. Women can help reduce the symptoms of hot flashes by dressing in light layers, exercising regularly, using a fan, managing stress, and avoiding spicy foods.

Menopause Symptoms: Sleep Issues

Menopause-related sleep problems, including insomnia, are common during this transition in a woman’s life.

Menopause-related sleep problems, including insomnia, are common during this transition in a woman’s life. Insomnia during the menopausal transition can be caused by night sweats, hot flashes that occur at night. Sweating and hot flashes can make it very difficult to sleep. The changes in a woman’s estrogen and progesterone levels can also alter her sleep quality.

Relief from Night Sweats

The following tips can help you sleep well if you are having night sweats:

  • Use lightweight bedding
  • Use a fan in the bedroom
  • Wear lightweight, cotton pajamas or gowns
  • Use a damp washcloth to cool off your face, and keep one handy at bedside

Menopause Symptoms: Sex Problems

Menopause symptoms can affect sexuality.

Menopause symptoms can affect sexuality. Along with menopause, women experience lower levels of the hormone estrogen. One of the effects of lowered estrogen levels is a decrease in blood supply to the vagina, which causes vaginal dryness. This can result in painful or uncomfortable intercourse. Water-soluble lubricants can help overcome this problem. If lubricants are not effective, contact your doctor. Vaginal creams and suppositories can be prescribed to ease vaginal dryness.

Another effect of hormonal changes is a change in libido, or sex drive. This may improve or worsen, but it is important to remember that other factors besides menopause can affect libido. Stress, sleep disturbances, medications, and anxiety can all affect sex drive. Your doctor can help you find ways to manage the changes in your sex drive if they occur.

Finally, although fertility ends at menopause, women of all ages are still susceptible to STDs, so safe sex is still important.

Menopause Treatment for Severe Symptoms

Hormone therapy is a menopause treatment option that can help alleviate many troublesome symptoms for some women.

Hormone therapy is a menopause treatment option that can help alleviate many troublesome symptoms for some women. Low-dose oral contraceptive (birth control) pills are one option for perimenopausal women to help treat irregular vaginal bleeding and relieve hot flashes. Local vaginal hormone treatments can be applied directly to the vagina when treating symptoms of vaginal estrogen deficiency.

Examples of local vaginal hormone treatments include the vaginal estrogen ring, vaginal estrogen cream, or vaginal estrogen tablets (taken orally). Antidepressants have also been used to treat hot flashes associated with menopause. Other potential treatments that can help relieve symptoms include blood pressure medications, anti-seizure medications, and lifestyle modifications. Hormone therapy is not without its own risks, your doctor can help you weigh the risks and benefits of this treatment.

Language Delays Linked to Acetaminophen Use During Pregnancy

Posted by

0


Summary: A new study reveals a potential link between acetaminophen use during pregnancy and language delays in early childhood.

The research involved continuous monitoring of pregnant women’s acetaminophen use and precise language development assessments in their children at ages 2 and 3. Increased acetaminophen use, especially during the third trimester, was associated with smaller vocabularies and shorter utterances in 2-year-olds.

Each use of acetaminophen in the third trimester was linked to a two-word reduction in vocabulary in 2-year-olds, raising concerns about its impact on fetal brain development.

Key Facts:

  1. The study tracked acetaminophen use throughout pregnancy and assessed language development in children at ages 2 and 3.
  2. Increased acetaminophen use during the third trimester was associated with significant language delays in 2-year-olds, especially in males.
  3. Fetal brain development, particularly language development, occurs during the second and third trimesters, making this period critical for potential impacts.

Source: University of Illinois

Acetaminophen is considered the safest over-the-counter pain reliever and fever reducer available during pregnancy. Studies have shown that 50%-65% of women in North America and Europe take acetaminophen during pregnancy.

A new study from researchers at the University of Illinois Urbana-Champaign explored the relationship between acetaminophen use during pregnancy and language outcomes in early childhood. It found that increasing acetaminophen use was associated with language delays.

This shows a pregnant woman.
The findings need to be tested in larger studies, the researchers said. Until then, people should not be afraid to take acetaminophen for fever or serious pain and discomfort during pregnancy. Credit: Neuroscience News

The findings are reported in the journal Pediatric Research.

Earlier studies have found associations between acetaminophen use during pregnancy and poorer child communication skills. But those studies used measures of language development that were less precise than the methods applied in the current study, said Megan Woodbury, who led the research as a graduate student with U. of I. comparative biosciences professor emerita Susan Schantz.

The work was conducted as part of the Illinois Kids Development Study, which explores how environmental exposures in pregnancy and childhood influence child development. Schantz is the IKIDS principal investigator. Woodbury is now a postdoctoral researcher at Northeastern University in Boston.

“The previous studies had only asked pregnant people at most once a trimester about their acetaminophen use,” Woodbury said. “But with IKIDS, we talked to our participants every four to six weeks during pregnancy and then within 24 hours of the kid’s birth, so we had six time points during pregnancy.”

The language analyses involved 298 2-year-old children who had been followed prenatally, 254 of whom returned for further study at age 3. 

For the 2-year-olds, the researchers turned to the MacArthur-Bates Communicative Development Inventories, which asks a parent to report on the child’s vocabulary, language complexity and the average length of the child’s longest three utterances.

“We wanted to collect data at that age because it’s the period called ‘word explosion,’ when kids are just adding words every day to their vocabulary,” Schantz said.

The vocabulary measure asked parents to select words their child had used from a list of 680 words.

The parents assessed their child again at 3 years, comparing their language skills to those of their peers.

The analysis linked acetaminophen use in the second and third trimesters of pregnancy to modest but significant delays in early language development.

“We found that increased use of acetaminophen – especially during the third trimester – was associated with smaller vocabulary scores and shorter ‘mean length of utterance’ at two years,” Woodbury said.

“At age three, greater acetaminophen use during the third trimester was related to parents ranking their kids as lower than their peers on their language abilities,” Schantz said. “That outcome was seen primarily in male children.”

The most dramatic finding was that each use of acetaminophen in the third trimester of pregnancy was associated with an almost two-word reduction in vocabulary in the 2-year-olds.

“This suggests that if a pregnant person took acetaminophen 13 times – or once per week – during the third trimester of that pregnancy, their child might express 26 fewer words at age 2 than other children that age,” Woodbury said.

Fetal brain development occurs throughout pregnancy, but the second and third trimesters are especially critical times, Schantz said.

“Hearing is developing in the second trimester, but language development is already starting in the third trimester before the baby is even born,” she said.

“It’s thought that acetaminophen exerts its analgesic effect through the endocannabinoid system, which is also very important for fetal development,” Woodbury said.

The findings need to be tested in larger studies, the researchers said. Until then, people should not be afraid to take acetaminophen for fever or serious pain and discomfort during pregnancy. Conditions like a very high fever can be dangerous and using a drug like acetaminophen will likely help.

“There aren’t other options for people to take when they really need them,” Schantz said. “But perhaps people should use more caution when turning to the drug to treat minor aches and pains.”

Pausing Long-Term Breast Cancer Therapy to Become Pregnant Appears to Be Safe

Posted by

0


Many young women who are diagnosed with early-stage breast cancer ask their doctors about the possibility of becoming pregnant in the future. New results from an international clinical trial may help inform these discussions.

Shayla Johnson was diagnosed with early-stage breast cancer just as she was planning to start her family. She became pregnant with her son, Ronin, during a pause in her hormone therapy.

The trial focused on the use of endocrine therapy (hormone therapy), such as tamoxifen. Hormone therapy is typically given for 5 to 10 years to women who have been treated for early-stage breast cancer to help prevent the cancer from coming back.

The study found that women could temporarily stop their hormone therapy for up to 2 years as they tried to conceive without raising the risk of a recurrence in the short term.

Most of the 518 women in the trial became pregnant and delivered a healthy baby during the treatment pause. A total of 365 babies were born during the study, according to results presented at the San Antonio Breast Cancer Symposium (SABCS) on December 8.

“This [study] is great news,” said Carlos Arteaga, M.D., who directs the University of Texas Southwestern Simmons Comprehensive Cancer Center and moderated the SABCS press conference at which the trial results were presented. 

The POSITIVE clinical trial included women under age 43 who desired to become pregnant. These women had undergone surgery for early-stage hormone receptor (HR)-positive breast cancer and had received at least 18 months of hormone therapy.

The trial participants will be followed for at least 10 years after study enrollment. This additional follow-up will be needed to assess the recurrence risk over a longer time among women who paused hormone therapy, Dr. Arteaga noted.

For many young women with breast cancer, questions about fertility are of “paramount importance,” according to Ann Partridge, M.D., M.P.H., of the Dana-Farber Cancer Institute, who co-led the trial and presented the results at SABCS.

Women with early-stage HR-positive breast cancer may initially be treated with surgery, radiation, and/or chemotherapy, followed by 5 to 10 years of additional, or adjuvant, hormone therapy.

Hormone therapy slows or stops the growth of HR-positive breast cancers. These treatments block the body’s ability to produce hormones or interfere with the effects of hormones on breast cancer cells.

But many young women are reluctant to receive hormone therapy because the treatments may make it harder for them to conceive, noted Dr. Partridge.

Many successful pregnancies, no increase in cancer returning

The POSITIVE trial, which was conducted on four continents, was the first prospective study to follow women who paused hormone therapy as they attempted to conceive.

“Most of the women had at least one pregnancy” during their treatment pause, Dr. Partridge said, noting that most became pregnant within two years.

She and her colleagues tracked the pregnancy status of 497 women from 20 countries in the trial, which was funded in part by NCI. Of this group, 368 (74.0%) had at least one pregnancy and 317 (63.8%) had at least one live birth.

These rates of conception and childbirth were similar to or higher than rates in the general population, according to Olivia Pagani, M.D., of the International Breast Cancer Study Group, who co-led the trial. 

By 3 years after their initial treatment, the cancer had come back in about 9% of participants. That recurrence rate was nearly identical to what was seen among a similar group of premenopausal women participating in a similar study but that did not include a treatment pause.

The trial results will likely help patients, their families, and their doctors feel more comfortable about pursuing a pregnancy, according to Dr. Partridge. She stressed that the approach involves interrupting rather than stopping hormone therapy.

In the trial, at a median follow-up of 3.4 months, about 76% of the women had resumed hormone therapy and 15% had not resumed hormone therapy. About 8% of the women had a recurrence, a new cancer, or had died before they had resumed their hormone therapy.

After completing the study, participants will continue to receive hormone therapy for up to 5 to 10 years. Each woman’s treatment will be determined in consultation with her physician based on her risk of a recurrence.

Celebrating an important birthday

In San Antonio, Dr. Partridge thanked the women who participated in the trial, noting that they did not have to join a research study to pause hormone therapy. “Their participation in the trial was very altruistic,” she said.

Shayla Johnson, who is 40 years old, joined the study with the hope that the results could help other women “feel a little more secure about starting a family.” She was diagnosed with early-stage breast cancer 6 years ago, just as she was planning to start her family.

Shayla, and the many friends and family members who supported her, celebrated Ronin’s first birthday in January 2023.Credit: Used with permission from Shayla Johnson

Her diagnosis led to a double mastectomy and eight rounds of chemotherapy. Johnson eventually became pregnant through in vitro fertilization during a pause in her hormone therapy. Today, she cannot imagine life without her son, Ronin, and wants to share her story.  

“You shouldn’t have to choose between a treatment to help save your life and starting a family,” Johnson said, adding that “cancer can be very complicated, especially for young women.”

When Ronin turned a year old this month, the many friends and family who have supported Johnson for the last 6 years attended the party. These people are also Ronin’s biggest fans.

“After all I’ve been through, they think my son is a miracle,” Johnson said. “And everyone wants to be around a miracle.”

Vast Majority of Women With Epilepsy Able to Get Pregnant

Posted by

0


The vast majority of women with epilepsy are able to get pregnant, with relatively few issues, new research shows.

“There has been the notion and some evidence in the past that fertility is reduced in women with epilepsy compared with the general population, but what these findings suggest is that 90% of women with epilepsy can get pregnant,” study investigator Andrew G. Herzog, MD, professor and director, Neurology, and Neuroendocrine Unit, Beth Israel Deaconess Medical Center, Wellesley, Massachusetts, told Medscape Medical News

The study was presented here at the American Epilepsy Society (AES) 72nd Annual Meeting 2018.

Registry Data

The researchers used retrospective data from a web-based epilepsy birth control registry. Any woman with epilepsy can complete the online survey and get educational materials on safe and effective contraception.

From this registry, researchers had reproductive data on 978 women aged 18-47 years with epilepsy. This included demographic, epilepsy, anti-epilepsy drug (AED), contraceptive, and reproductive data.

The investigators analyzed three outcomes:

  • Infertility rate: The percentage of women who had unprotected sex but did not achieve pregnancy after 1 year.
  • Impaired fecundity rate: The percentage of women who were infertile or did not carry a pregnancy to live birth, excluding abortions.
  • Live birth rate: The percentage of pregnancies that resulted in live births, excluding abortions.

A total of 411 women attempted to become pregnant. Of this group, 373 had 724 pregnancies resulting in 445 live births.

The mean age at pregnancy was 24.9 years, but women who became pregnant ranged in age from 14 to 44 years.

Some 72.6% of the women had a live birth at first pregnancy and 89.0% had at least one live birth in their first two pregnancies.

Of the 411 women, 38 tried but were unable to become pregnant at the end of 1 year, for an infertility rate of 9.2% (95% CI, 6.7 – 12.4). In contrast, the infertility rate among the general population is 6.4%, as estimated by the Centers for Disease Control and Prevention (CDC).

About 20.7% of the women had impaired fecundity, which included the 38 individuals who were infertile and 46 pregnancies that did not result in a live birth.

Impact of AEDs Unclear

Investigators also examined the potential impact of AEDs on fertility. They compared no AED to monotherapy and polytherapy, and no AED to specific classes of AED, including enzyme-inducing, non-enzyme-inducing, enzyme inhibitory, and glucuronidated drugs.

They found that for women on any AED, the rate of infertility was twice that of those not taking an AED (10.3% vs 4.2%), although the sample sizes in this interim analysis were too small to be statistically significant, said Herzog.

Devon MacEachern, BS, who presented the data at a Platform Session during the meeting, said the study would need more than double the participants in the any AED category for the study to be adequately powered to make meaningful conclusions about the potential impact of AEDs on fertility.

The impaired fecundity rate was also almost two times greater for women on any AED than for those not taking an AED (22.2% vs 13.9%; relative risk [RR], 1.79; 95% CI, 0.94 – 3.11; P = .08).

Comparisons of various individual monotherapies to polytherapy were not significant.

In addition, the live birth rate was similar for women on any AED (73.9%) compared with those not taking an AED (79.1%).

However, when investigators examined the impact of specific drugs on fertility, the analysis showed that women on lamotrigine had a significantly higher live birth rate than their counterparts on valproate (89.1% vs 63.3%; RR, 1.41; 95% CI, 1.05 – 1.88; P = .02).

Physicians have numerous issues to discuss with their female patients with epilepsy during office visits. These include seizure management, safety and risks of individual AEDs, as well as contraception, which is “often not adequately addressed,” said Herzog.

A limitation of the study is that the information was self-reported. Also, the women who completed the registry surveys were younger and better educated than the general population, and minority women were under-represented.

Following MacEachern’s presentation, one delegate asked whether the fertility of the women’s partners may have contributed to fertility failure rates.

The “downfall” of this study, and of a CDC general population study, is that they don’t determine whether the male or female contributed to the infertility, she said.

Good News for Patients

Commenting on the study for Medscape Medical News, session co-chair, Kelly Knupp, MD, Pediatric Neurology and Epilepsy Program, Children’s Hospital Colorado, said the results are “good news” for patients.

“The fear of many teenage girls with epilepsy is that they can’t have babies.”

The higher infertility rate among women with epilepsy uncovered by the study is something “we worry about in terms of what that means in a bigger population and something [physicians] have to be cognizant of.”

However, as information in the database is self-reported, “we have to be a little cautious because it doesn’t represent the entire population,” she said.

Women who regularly consume soft drinks may be reducing their chances of getting pregnant

Posted by

0


Women who regularly consume soft drinks may be reducing their chances of getting pregnant, according to new research.

A study of 524 patients found a link between artificial sweeteners, such as those used in “diet” sodas, and lower fertility rates, while use of sugar in soft drinks and added to coffee was associated with poorer quality of eggs and embryos.

A woman drinking (stock)

One of Britain’s leading fertility experts last night described the findings as “highly significant”, and warned women not to underestimate the effects of food additives on their likelihood of conception.

Other scientists, however, have said the lower pregnancy rates may have been driven by obesity, which is already a known negative factor, rather than the sugar or its synthetic equivalent per se.

Artificial sweeteners, such as saccharin and sucralose, are chemical substances that many people choose over sugar because they are low-calorie or calorie-free.

In the study, which will be presented today at the American Society for Reproductive Medicine congress in Salt Lake City, a batch of women who were undergoing IVF treatment were interviewed by nutritionists about the foods they consumed, as well soft and hot drinks.

 The finding, showed that reduced rates of pregnancy was most closely associated with consumption of soft drinks made with artificial sweeteners, as well as coffee with added artificial sweeteners.

Meanwhile the use of sugar in soft drinks and coffee was associated with a poorer quality of egg, which can be a factor in likelihood of getting pregnant.

Unsweetened coffee, however, had no effect on egg quality or pregnancy chances, said the researchers from the Federal University of Sao Paulo.

Professor Adam Balen, Chairman of the British Fertility Society, said: “This is a very interesting study that suggests the false promise of artificial sweeteners that are found in soft drinks and added to drinks, such as coffee, may have a significant effect on the quality and fertility of woman’s eggs and this may further impact on the chances of conception.

“These findings are highly significant to our population.

“There should be more scrutiny of food additives and better information available to the public and, in particular, those wishing to conceive.”

However, a spokesman for the British Dietetic Association said the study made no effort to distinguish the effect on fertility outcomes of the bodyweight of the women in the trail from the impact of artificial sweeteners and sugar in their diets.

Professor Sir Colin Berry, Emeritus Professor of Pathology at Queen Mary University London, also cautioned about drawing inferences on wider reproductive outcomes from the experience of IVF patients.

How a Transgender Woman Could Get Pregnant

Posted by

1


The uncharted territory of uterus transplants is sparking patients’ interest, but surgeons and endocrinologists remain wary.

When Mats Brännström first dreamed of performing uterus transplants, he envisioned helping women who were born without the organ or had to have hysterectomies. He wanted to give them a chance at birthing their own children, especially in countries like his native Sweden where surrogacy is illegal.

He auditioned the procedure in female rodents. Then he moved on to sheep and baboons. Two years ago, in a medical first, he managed to help a human womb–transplant patient deliver her own baby boy. In other patients, four more babies followed.

But his monumental feats have had an unintended effect: igniting hopes among some transwomen (those whose birth certificates read “male” but who identify as female) that they might one day carry their own children.

Cecile Unger, a specialist in female pelvic medicine at Cleveland Clinic, says several of the roughly 40 male-to-female transgender patients she saw in the past year have asked her about uterine transplants. One patient, she says, asked if she should wait to have her sex reassignment surgery until she could have a uterine transplant at the same time. (Unger’s advice was no.) Marci Bowers, a gynecological surgeon in northern California at Mills–Peninsula Medical Center, says that a handful of her male-to-female patients—“fewer than 5 percent”— ask about transplants. Boston Medical Center endocrinologist Joshua Safer says he, too, has fielded such requests among a small number of his transgender patients. With each patient, the subsequent conversations were an exercise in tamping down expectations.

To date there are no hard answers about whether such a fantastical-sounding procedure could enable a transwoman to carry a child. The operation has not been explored in animal trials, let alone in humans. Yet with six planned uterine transplant clinical trials among natal female patients across the U.S. and Europe reproductive researchers are hoping to become more comfortable with the surgery in the coming years. A string of successes could set a precedent that—along with patient interest—may crack open the door for other applications, including helping transwomen. “A lot of this work [in women] is intended to go down that road but no one is talking about that,” says Mark Sauer, a professor of obstetrics and gynecology at Columbia University.

Such a future is hard to imagine, at least in the near term. The surgery is still very experimental, even among natal women. Just over a dozen uterus transplants have been performed so far—with mixed results. One day after the first U.S. attempt, for example, the 26-year-old Cleveland Clinic patient had to have the transplanted organ removed due to complications. And only the Brännström group’s procedures have led to babies. More efforts are expected in the United States: Cleveland Clinic, Baylor University Medical Center, Brigham and Women’s Hospital, and the University of Nebraska Medical Center are all registered to perform small pilot trials with female patients who are hoping to carry their own children.

A RISKY PROSPECT

The trouble is that uterine transplants are extremely complex and resource-intensive, requiring dozens of health personnel and careful coordination. First a uterus and its accompanying veins and arteries must be removed from a donor, either a living volunteer or a cadaver. Then the organ must be quickly implanted and must function correctly—ultimately producing menstruation in its recipient. If the patient does not have further complications, a year later a doctor may then implant an embryo created via in vitro fertilization. The resulting baby would have to be born through cesarean section—as a safety precaution to limit stress on the transplanted organ, and because the patient cannot feel labor contractions (nerves are not transplanted with the uterus). Following the transplant and throughout the pregnancy the patient has to take powerful antirejection drugs that come with the risk of problematic side effects.

The dynamic process of pregnancy also requires much more than simply having a womb to host a fetus, so the hurdles would be even greater for a transwoman. To support a fetus through pregnancy a transgender recipient would also need the right hormonal milieu and the vasculature to feed the uterus, along with a vagina. For individuals who are willing to take these extreme steps, reproductive specialists say such a breakthrough could be theoretically possible—just not easy.

Here is how it could work: First, a patient would likely need castration surgery and high doses of exogenous hormones because high levels of male sex hormones, called androgens, could threaten pregnancy. (Although hormone treatments can be powerful, patients would likely need to be castrated because the therapy might not be enough to maintain the pregnancy among patients with testes.) The patient would also need surgery to create a “neovagina” that would be connected to the transplant uterus, to shed menses and give doctors access to the uterus for follow-up care.

A small number of surgeons already have experience creating artificial vaginas and connecting them to uterine transplants. Most of Brännström’s transplant patients have been women with a condition called Rokitansky syndrome, and as a result they lack the upper part of the vagina and had to have a neovagina surgically made—typically by extending the lower vagina. Separately, surgeons that specialize in working with transwomen also often create neovaginas after castration, using skin from the penis and the scrotum.

BIOLOGICAL CONNECTION

Even if the hormonal and anatomical challenges are overcome, for someone who was born producing sperm instead of eggs there would be one more hurdle: Before castration that person’s sperm must be collected and combined with a donor’s or partner’s egg to make an embryo via in vitro fertilization, and that embryo would have to be frozen until the transplant patient is ready. If the embryo is successfully implanted, the transwoman would then naturally produce the placenta required to sustain the pregnancy and begin to lactate in preparation for breast-feeding, Cleveland Clinic’s Unger says.

Experts disagree about what would be the biggest barrier to pulling off these theoretical transplants and pregnancies. Giuliano Testa, a transplant surgeon at Baylor University Medical Center who will soon be directing uterine transplant surgeries among natal women, says the hormones would likely prove the biggest obstacle. “It would really be a feat of unknown proportions,” Testa says. “I would never do this.” But he concedes the transplants are not out of the question. “At the end of the day it is two arteries and two veins that are connected with fine surgical techniques.”

Unger—who is not involved in Cleveland Clinic’s uterine transplant team trial—worries about a consistent and ample blood flow to the fetus. Bowers, who is transgender herself, says she is concerned about dangers to the fetus from a potentially unstable biological environment and unforeseen risks for the mother-to-be. “I respect reproduction and I don’t think we will ever see this in my lifetime in a transgender woman,” she says. “That’s what I tell my patients.”

Costs and ethics also pose significant barriers. Many transgender patients have already been saving for years to pay for male-to-female genital surgery— which can cost around $24,000 without insurance coverage—so a uterine transplant could be out of financial reach, Unger says. And some doctors working on the frontlines with transgender patients have expressed concerns about the ethics involved in the risks. Sauer, the gynecologist from Columbia, says that with options including surrogacy and adoption available in many locations, an experimental surgery to help patients give birth—not save their lives—seems like a huge risk. Safer, medical director for the Center of Transgender Medicine and Surgery at Boston Medical Center, agrees. “If you are going to die without a transplant, of course you take [antirejection] drugs. But this is not the case here,” he says. “This is not life and death.”

The American Society for Reproductive Medicine’s Ethics Committee is already discussing how uterine transplants could be prioritized, says Sauer, who is a member of that panel. Yet there is no discussion yet about how transgender candidates would be included in the mix. Additionally, it is unclear how demand for a uterus would be weighed by a hospital or an organization like the United Network for Organ Sharing.

Yet interest in uterine transplants is growing: Brännström, the Swedish surgeon who led the prior transplant work among women, says his inbox is now inundated with messages from less-traditional patients. “I get e-mails from all over the world on this, sometimes from gay males with one partner that would like to carry a child,” he says. Brännström does not plan to perform such procedures himself—instead he wants to focus on women who were born without a uterus or lost it due to cancer or another illness. The next natural step for those interested in assisting transgender or male patients, however, would likely be tackling this procedure among women with a rare condition called androgen insensitivity syndrome, he says. A person with AIS appears largely female, but has no uterus and is genetically male.

Amid these complex discussions there is one bright spot, the relative ease of finding the organs. Already one group has proved rich in willing donors: people who are transitioning from female to male and have also decided to have their uteruses removed. Unger says among her female-to-male patients, “one in three” have asked if they could donate the organs. Because there is no protocol set up to deal with these offers (Cleveland Clinic’s trial uses cadaver uteruses), they are currently turned down. Such potential donors may seem ideal because they are not pursuing a hysterectomy due to disease. But a major catch is the medical risk they face: A standard hysterectomy takes between a half-hour and an hour, but preparing a uterus and its associated blood vessels for transplant would keep such patients under the knife for as long as 10 or 11 hours. Clearly, the ethics of such donations would have to be studied extensively, Unger says. Like uterine transplants for transgender patients, this is all uncharted territory.

The Effect Of Cannabis On Pregnant Women & Newborns

Posted by

0


It’s almost too taboo to discuss: pregnant women & marijuana. It’s a dirty little secret for women, particularly during the harrowing first trimester, who turn to cannabis for relief from nausea and stress.

Pregnant women in Jamaica use marijuana regularly to relieve nausea, as well as to relieve stress and depression, often in the form of a tea or tonic.

In the late 1960s, grad student Melanie Dreher was chosen by her professors to perform an ethnographic study on marijuana use in Jamaica to observe and document its usage and its consequences among pregnant women.

the-effect-of-cannabis-on-pregnant-women-newborns

Dreher studied 24 Jamaican infants exposed to marijuana prenatally and 20 infants that were not exposed. Her work evolved into the book Women and Cannabis: Medicine, Science and Sociology, part of which included her field studies.

Most North American studies have shown marijuana use can cause birth defects and developmental problems. Those studies did not isolate marijuana use, however, lumping cannabis with more destructive substances ranging from alcohol and tobacco to meth and heroin.

In Jamaica, Dreher found a culture that policed its own ganja intake and considers its use spiritual. For the herb’s impact when used during pregnancy, she handed over reports utilizing the Brazelton Scale, the highly recognized neonatal behavioral assessment that evaluates behavior.

The profile identifies the baby’s strengths, adaptive responses and possible vulnerabilities. The researchers continued to evaluate the children from the study up to 5 years old. The results showed no negative impact on the children, on the contrary they seemed to excel.

Plenty of people did not like that answer, particularly her funders, the National Institute on Drug Abuse. They did not continue to flip the bill for the study and did not readily release its results.

“March of Dimes was supportive,” Dreher says. “But it was clear that NIDA was not interested in continuing to fund a study that didn’t produce negative results. I was told not to resubmit. We missed an opportunity to follow the study through adolescence and through adulthood.”

Now dean of nursing at Rush University with degrees in nursing, anthropology and philosophy, plus a Ph.D. in anthropology from Columbia University, Dreher did not have experience with marijuana before she shipped off for Jamaica.

She understands that medical professionals shy from doing anything that might damage any support of their professionalism, despite marijuana’s proven medicinal effects, particularly for pregnant women.

Dr. Melanie Dreher’s study isn’t the first time Jamaican ganja smoking was subjected to a scientific study. One of the most exhausting studies is Ganja in Jamaica—A Medical Anthropological Study of Chronic Marijuana Use by Vera Rubin and Lambros Comitas, published in 1975. Unfortunately for the National Institute of Mental Health’s Center for Studies of Narcotic and Drug Abuse, the medical anthropological study concluded:

Despite its illegality, ganja use is pervasive, and duration and frequency are very high; it is smoked over a longer period in heavier quantities with greater THC potency than in the U.S. without deleterious social or psychological consequences [our emphasis].

Pot Smoking Pregnant Moms Likely Use Other Drugs

Posted by

0


A quarter of mothers and their newborns who tested positive for marijuana use had evidence of other illegal drugs, according to a small retrospective study of mother/newborn pairs.

Based on data collected from an urban non-profit teaching hospital, 26.1% of mother/newborn pairs tested positive for tetrahydrocanabis (THC) in urine-meconium screenings, 11.6% tested positive for opioids, followed by amphetamines (10.8%) and cocaine (6.5%), reported Shirley Chen, MD, of Creighton University in Omaha, and Edith P Allen, MD, of St. Joseph’s Hospital and Medical Center and Phoenix Children’s Hospital in Phoenix.

Of the 491 mother newborn/pairs testing positive for marijuana, only 22.4% picked up marijuana use in both mother and newborn. More than three-quarters (77.6%) of these tests came back positive for one party only, though it was more common in newborns compared with mothers (42.4% versus 35.2%), they stated in a poster presentation at theAmerican Academy of Pediatrics (AAP) annual meeting.

While not involved with the study, Sharon Levy, MD, MPH, director of adolescent substance abuse program and assistant professor of pediatrics at Children’s Hospital in Boston, said she thought the latter data was the most interesting “nugget of information” from the results.

“Fetal samples were much more likely to be positive for marijuana than maternal samples, underscoring that fat soluble THC crosses the placenta and is concentrated in the fetus,” she told MedPage Today via email. “When mothers use marijuana, their fetuses are actually getting a higher dose than they are themselves.”

The authors also screened mothers and newborns separately, and found that the most common illicit substance in THC-positive newborns was amphetamines (8.8%), while the most common among THC-positive mothers was opioids (16.3%). Levy added that these results showed that by collecting both maternal and newborn samples, the authors were able to get more information about drug exposure.

Urine and meconium tests were used to screen drug exposure in infants and a large majority (78.6%) of infants only had positive meconium tests to identify THC exposure. The authors noted that there was no exposure in newborns that urine picked up and meconium did not.

Co-author Allen told MedPage Today that even though mothers are usually open to saying they use marijuana, the meconium of the baby might be the most important piece of information to tell about the history of drug use in the mom.

The retrospective study was done using data from 2006 to 2010. The authors examined data from an urban teaching hospital that averaged 5,000 births a year. About 10% of the sample tested positive for THC/marijuana use.

Screenings for both mothers and newborns were done per Arizona state’s guidelines. Criteria for drug screening included history of previous or current substance use by the mother, noncompliance with prenatal care, symptoms of withdrawal in the mother and signs of neonatal abstinence syndrome, low birth weight, and other adverse outcomes, such as necrotizing enterocolitis.

Mark Hudak, MD, of the University of Florida at Jacksonville and former member of the AAP committee on drugs, told MedPage Today that examining past marijuana use was a new point of view in light of the legalization of medical marijuana in some states.

“Arizona is one of those states that has made a change allowing medical use of marijuana, and I think that was the genesis of going back and looking at their population,” he said. “I think the message they were trying to convey is if you have a mother or baby where you find marijuana, you have to think about other substances and whether those substances may contribute to newborn issues.”

One obvious potential issue would be whether or not to allow a mother testing positive for drugs to breastfeed, and Allen said that was something to be aware of, particularly in states where marijuana is legal for medical or recreational purposes.

“I think it’s our responsibility as pediatricians to really be more objective and more cautious about the decisions that we take about the care of those babies,” she said. “We have to be careful about when we allow this baby to breastfeed if there is a problem with other drug consumption during pregnancy by the mother.”

Hudak said that clinicians need to be aware of the situation and to make sure there is good follow-up on the babies. He added that the pediatrics field is currently working through the conflicting recommendations about breastfeeding in mothers with substance abuse.

“Whether breastfeeding is a good thing or maybe contraindicated in some of these mothers [is] another topic under very active debate,” he concluded. “I don’t think that issue is settled yet.”

Light Drinking While Pregnant Is Probably Safe

Posted by

0


So why are women being told otherwise?

pregnant women should not drink at all.
Physician-approved activities only, please.

Women received a familiar directive from the American Academy of Pediatrics on Monday: Don’t drink while pregnant. Not even a little bit. Ever. At all. That’s the message of a new survey to be published in the journal Pediatrics. The message from the paper’s lead author, University of Texas Health Science Center professor of pediatrics Janet Williams, as paraphrased by theGuardian: “[T]here is no known ‘safe’ level of alcohol consumption.”

Those words seem definitive, but they also suggest a more complex truth. The interdiction on light drinking while pregnant is about known unknowns: whether there’s a totally safe level of consumption and what that level might be. It’s not a statement about something that we do know: that alcohol, even the occasional glass of wine, is definitively harmful to a developing fetus.

Roughly 1 in 10 American women drink while pregnant, with college-educated, professional women more likely to do so than other groups. Binge drinking—usually defined as having more than four drinks in a sitting—has long been known to carry a risk of fetal alcohol spectrum disorders, including learning and emotional disabilities as well as physical abnormalities. But many new studies suggest that light drinking is just fine. A series of five papers published by Danish researchers in 2012 found no differences between the 5-year-old children of mothers who had up to eight drinks a week (never bingeing on any single occasion) and those who abstained. Writing forSlate in 2013, economist Emily Oster, author of Expecting Better, highlighted a few other studies, including one that found no behavioral differences in 14-year-olds whose mothers had had up to a drink a day, and one that found the same for test performance and intellectual ability.

These new studies don’t constitute enough information to tell us where, exactly, to draw the line, which could explain why doctors set it at zero. In her much-sharedCosmopolitan piece “Why I Drank While I Was Pregnant,” writer Michelle Ruiz hypothesized that, in our litigious society, OB-GYNs don’t want to be responsible for telling women that the occasional glass of Pinot is fine, even if that’s what they privately believe. It’s also true, as Williams argued in the Guardian, that “we don’t have sensitive enough methods” to detect every minor abnormality that could stem from alcohol use. Since researchers don’t know for sure what they could be missing, she said, “I think it’s a leap in faith to say it’s safe, it’s completely safe.”

The same logic has sometimes been applied to women who take psychiatric drugs. Expecting mothers with histories of bipolar disorder and depression are often advised to stop taking their medications, sometimes with disastrous consequences for their mental health, even though the studies disagree on the risk the drugs pose.

In the case of alcohol, it’s worth pondering why the U.S. medical establishment’s response to uncertainty has been a blanket assertion that no one should drink while pregnant. Other countries seem more comfortable leaving the decision in women’s hands. The most oft-cited example is the United Kingdom, where the Royal College of Obstetricians and Gynecologists has called abstinence the safest option but openly acknowledged that “[s]mall amounts of alcohol during pregnancy have not been shown to be harmful.”

The group National Advocates for Pregnant Women has documented hundreds of cases where women were unconstitutionally arrested for “endangering” their unborn cargo. Some of these women had used illegal drugs, but others were detained for contemplating ending a pregnancy, contemplating self-harm while pregnant, or even, in one case, for accidentally falling down the stairs. Across the country, attacks on pregnant women are increasingly prosecuted according to the rights of the fetus. Drinking while pregnant is a subtler issue—but it seems to give rise to the same set of biases. In her Slate piece, Oster noted that—of all the conventional wisdoms around pregnancy that she addressed in her book—her writing on drinking “garnered the loudest reaction, much of it outrage.”

Some of the arguments levied at Oster, she wrote, were “philosophical”:

People ask, “Why take the risk?” since there is no benefit to the baby. But this ignores the fact that we are always making choices that could carry some risk and have no benefit to the baby. Driving in a car carries some risk to your baby, and your fetus does not benefit from that vacation you took. Or they ask, “Is it so hard to give up drinking for nine months?” The answer is, of course, no, but because you might enjoy the occasional beer, it seems worth at least asking the question about the risks.

It’s not fair to ask women to forego driving, working, and eating junk food because they’re pregnant. Likewise, it’s not necessarily constructive for the American Academy of Pediatrics to simply deliver its two-dimensional decree. Better to give women the complex, contradictory information and trust them to make their own decisions.

Pregnant in the OR: Potential Hazards

Posted by

0


Regardless of your position, occupational hazards exist when working in the operating room. Normally these things aren’t given too much thought, but when my choices suddenly affected another developing life, it caused me to pause and contemplate these hazards on a deeper level. Unfortunately, studies on pregnant healthcare workers (and other occupations) are difficult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting:

Anesthetic Gases. While every effort is made to avoid elective surgery during pregnancy, even pregnant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic levels that would be passively inhaled in an occupational capacity should theoretically be safe as well. That being said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a period of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status.

Methylmethacrylate. MMA is a common ingredient in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. Studies, which have mainly occurred in animal models, reveal mixed results in terms of impact on fetal development. As a pregnant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. In one human study, MMA was not found above a 0.5 ppm level in breast milk of surgeons who utilized vacuum mixing devices. At our institution, the use of these devices is mixed amongst surgery personnel, but local suction can also be easily employed. If I am in a joint room and my patient is stable, I elect to step into the adjacent substerile core (which has a window to the operating room) for a few brief minutes while the mixing occurs. However, I did have a recent case where the patient was very unstable and I could not leave the room or easily turn the case over to another provider temporarily. After that experience, the scheduler changed me to a different OR.

Radiation. Discussed briefly in my previous Pregnant in the OR post, radiation is commonly used during OR procedures such as orthopedic repairs, gastrointestinal explorations, interventional pain management, interventional radiology, angiography, line placement… I could go on. For radiation, potential harmful effects are directly related to the dose of exposure. The CDC website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. As with general anesthesia, pregnant women themselves must occasionally undergo irradiative procedures, but care is always taken to balance risks with benefits. In addition, protective shielding goes a long way to reduce exposure. Even in an occupational capacity we wear protective lead garments during periods of radiation. Wearing these and standing at least 6 feet away from the beam will decrease the exposure by more than 99%. However, the garments must encircle the body and not just cover the front of the body in apron form. This is especially important for anesthesiologists, who often turn their backs to the OR table to gather drugs or supplies, etc. And during my pregnancy, I have actively avoided assignments that involve continuous use of fluoroscopy (such as cath lab, GI lab, and interventional vascular or radiology).

Infection. It goes without saying that universal precautions need to be followed by everyone, but there are wider implications and possible sequelae if a pregnant woman contracts an infectious disease while working in the OR. Discussing the details of this would be beyond the scope of this article, but the gist is that potentially teratogenic effects of certain microbes and their treatments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection.

Stress. This is the most difficult “hazard” to avoid. Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage. It must also be mentioned, especially for trainees, that the financial burden of NOT working during pregnancy can cause significant stress in itself. Some women might choose to take a lighter load or less frequent call shifts during pregnancy, if possible.

I have mitigated many of these hazards during my pregnancy by notifying the schedulers early of my status, so that they could avoid giving me assignments with increased exposure as much as possible. In terms of stress, my job has no call duties, so long and tiring hours have usually not been an issue. Not everyone can be as lucky, but vigilance to self-care postcall and adequate hydration during call can help.

For readers who have been pregnant during hospital or OR duties, did you encounter any other hazards at work? What were your experiences trying to avoid them? Share your thoughts with us here!