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Folic Acid’s Role in Preventing Neural Tube Defects

Thursday, February 27th, 2014

Neural tube defects (NTDs) are common birth defects that present an elevated risk of serious disability and infant mortality. NTDs include spina bifida, anencephaly, and encephalocele, and occur in about 1 out of every 1000 US births. Many of these pregnancies are either terminated or spontaneously lost, resulting in about 2,500 babies born with NTDs each year.

Spina bifida occurs when the vertebra do not form properly around part of the spinal cord. The disease can be mild, with no symptoms, or it can be debilitating, affecting every aspect of a child’s life. People with a very mild form may never even know they have it until some other problem prompts a back x-ray. In more serious cases, fluid can leak out of the spine and push against the skin, forming a bulge, or spinal nerves can push out of the spinal canal and sustain damage. This can cause problems with walking, coordination, and bladder and bowel control.

Anencephaly is a birth defect in which an infant is born without parts of the brain and skull. Most babies with anencephaly die shortly after birth. Encephalocele is a rare NTD that also affects the brain. In encephalocele, the brain and the membranes that surround it protrude through an opening in the skull. This defect is often linked to nervous system problems, such as uncoordinated movement, vision problems, seizures, and developmental delays.

Folic Acid Key to Prevention

Studies such as this one show that folic acid is instrumental in preventing neural tube defects. Folic acid is a synthetic compound used to fortify foods and supplements. The term “folate” means any compound containing the same vitamin properties of folic acid, and includes both folic acid and the natural compounds found in many foods.

Folic acid is water-soluble and has no known toxicity. (However, certain vitamins found in many multivitamin supplements are toxic at high doses, so do not continue a vitamin regimen that your doctor has not approved when you are considering becoming or are pregnant.) Women of childbearing age should be getting 0.4 mg of folic acid each day. Folic acid is highly bioavailable and one of the important ingredients in prenatal vitamins, a key reason why you should be taking them if you are pregnant or thinking of becoming pregnant.

You can also up your intake by eating plenty of leafy green vegetables, citrus fruits, and whole grain breads, pastas, and other foods enriched with folic acid. And plant foods, in particular, contains many compounds that are essential for your health and which you can’t get from a pill, so don’t let your vitamin supplement be a substitute for a healthy diet. The bottom line is that when it comes to optimal prenatal nutrition, both prenatal vitamins and a healthy, balanced diet are essential.

– Yvonne S. Thornton, M. D., M. P. H.

How to Handle Mastitis when Breastfeeding

Thursday, January 23rd, 2014

Mastitis is, simply put, an inflammation of the breast. It can occur without apparent cause, but it often occurs during breastfeeding. In fact, about ten percent of breastfeeding women experience mastitis. Mastitis can be particularly problematic in women who wish to continue breastfeeding, because it is often painful and women suffering from mastitis are very likely to wean their infants during this time.

Mastitis is caused by infection by bacteria that enter the breast through the nipple; the cracked and sore nipples common in breastfeeding women make perfect pathways for the bacteria to get in through. Most commonly occurring during the first six months of breastfeeding, it can add to the already-considerable burden of caring for an infant and increase the mother’s fatigue and stress. It often leads to the cessation of breastfeeding, but breastfeeding with mastitis is safe, and it is usually cleared up easily with medication.

Symptoms and Treatment of Mastitis

Usually the first thing a woman with mastitis notices is a painful area in one of her breasts. The area may also be warm and red. She may also experience body aches, chills, and fever. Swollen and painful lymph nodes, flu-like symptoms, and a faster than normal heart rate are signs that the infection is getting worse.

Mastitis is usually easily diagnosed by observation of the symptoms; specific tests are not typically needed. If you have symptoms of mastitis, don’t hesitate to see your doctor; an antibiotic will usually cure it relatively quickly. It is safe to breastfeed while taking antibiotics, so feel free to continue to do so, unless your doctor directs you otherwise. During treatment, help your body heal and yourself feel better by resting more, drinking plenty of fluids, and using warm or cold compresses on the painful area. You can also take acetaminophen or ibuprofen for pain. If you think you have mastitis, get medical attention promptly; delaying treatment can lead to complications which can be harder to treat.

Breastfeeding (or Not) with Mastitis

If you are determined to continue breastfeeding, you can do so safely with mastitis. Make sure to empty the affected breast completely each time you breastfeed in order to prevent a dwindling milk supply. If it is too painful to breastfeed much on the affected side, use a breast pump to completely empty the breast on a regular basis.

However, for some women, mastitis presents either too difficult a situation in which to continue to breastfeed, or a good opportunity for weaning for those who were planning it soon anyway. Caring for an infant is extremely challenging, and formula presents a perfectly nutritious and healthy option for feeding your baby. I know that most women feel like they “should” breastfeed, but in fact, millions of completely healthy and well-adjusted people were never breastfed.

Don’t worry about “bonding,” either. Feeding your baby should be a time to interact closely with him or her, but it’s the physical contact and the attention that matter, not whether the milk being fed is coming from a breast or from a bottle.

For more information on this topic and others, see my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

Is It Safe to Get the Flu Shot During Pregnancy?

Monday, January 13th, 2014

If you are pregnant, chances are that you are questioning everything that goes into your body, and for good reason. It’s your job during pregnancy to nurture and protect your baby from a wide range of potential dangers. During the winter months, you may be wondering whether the flu vaccine is among those dangers.

It’s not. The fact is that it is completely safe for pregnant women to get the flu vaccine. In fact, getting vaccinated against the flu could make a big difference in your baby’s health; it could even be the difference between life and death. The CDC (Centers for Disease Control and Prevention), the American Academy of Pediatrics, the ACOG (American Congress of Obstetricians and Gynecologists), the American College of Nurse-Midwives, and numerous others all strongly recommend that pregnant women get flu shots.

Getting the flu while pregnant can cause serious complications. Pneumonia is one major concern. Pneumonia is potentially life-threatening and could be a risk factor for preterm labor. In addition, there is evidence that when you get the flu shot during pregnancy, your baby may continue to benefit from this protection after birth. Also, if you avoid catching the flu yourself postpartum, then your baby is less likely to be exposed to it at all. And protecting your newborn from the flu is important, because the flu is particularly dangerous for young babies, who can’t be vaccinated themselves before they are six months old. (Therefore, not only you but other family members as well should get flu shots.)

The flu vaccine may have no side effects at all, or you may notice mild side effects such as mild pain, tenderness, or redness at the site of the shot. Some people notice muscle aches, nausea, fever, or headaches after the shot, but these generally only last a day or two. Allergic reactions are extremely rare.

Anyone considering the flu shot, including pregnant women, should tell their doctors or anyone who is administering the shot if they have severe allergies to eggs or anything else that may be present in the shot. It is important to note that pregnant women should receive the flu shot, and not the nasal spray, which contains live flu virus.

Pregnant women can get flu shots at any point in their pregnancy. Getting vaccinated as early as possible to avoid being unprotected when flu season begins is best. However, if you have avoided getting the vaccine because you were concerned about safety during pregnancy, go ahead and get one even if it is later in the season. Flu season can last well into the spring, so even women getting vaccinated later on can still benefit.

Lately there has been some concern among people getting vaccinated about thimerosal, a preservative used in some flu shots. However, the CDC has uncovered no evidence that thimerosal presents any risk whatsoever. Besides, the benefits of getting a flu shot far outweigh even any theoretical risk. If you are worried, though, don’t let it stop you from getting a flu shot; ask your doctor about thimerosal-free vaccine. If it isn’t available in your area, go for the regular flu shot, and don’t worry – it’s much safer than not getting one at all.

– Yvonne S. Thornton, M. D., M. P. H.

Thyroid Problems and Pregnancy

Monday, January 6th, 2014

The thyroid gland is one that most people never give much thought to – until it causes problems. The gland itself is about two inches long and shaped like a butterfly. It sits in the front area of the neck just below the larynx with one lobe on each side of the windpipe. Along with the other components of the endocrine system, the thyroid’s job is to produce hormones. It can also store these hormones and release them into the bloodstream.

The hormones produced by the thyroid are very important, as they affect metabolism, weight, breathing, nervous system functions, muscle strength, body temperature, and menstrual cycles. If the thyroid produces too much or too little hormone, nearly every organ in the body can be affected. Hypothyroidism is underactivity of the thyroid; overactivity is called hyperthyroidism. Because the thyroid affects the menstrual cycle, a woman with a thyroid disorder may find it more difficult to get pregnant.

If a pregnant woman has a thyroid problem, there are special considerations to keep in mind. A woman with thyroid disease can certainly have a healthy, normal pregnancy and baby if she talks about this problem with her doctor, educates herself on the ways in which the thyroid is affected by pregnancy, stays up to date on her thyroid function testing, and takes the proper medications on the proper schedule.

How Is the Thyroid Affected by Pregnancy?

The thyroid gland is basically responsible for controlling our body’s metabolism.  It is regulated by a hormone known as thyroid-stimulating hormone or TSH, which is secreted by the pituitary gland. Pregnancy causes the production of many hormones, one of which is human chorionic gonadotropin (hCG).  In early pregnancy, the growing placenta makes human chorionic gonadotropin (hCG).  HCG increases the production of progesterone, which is crucial for the growing fetus and without it may increase the risk for miscarriage. What does hCG and TSH have in common?  Well, they are two different hormones;  one (hCG) plays an integral role in maintaining pregnancy while the other (TSH) regulates the thyroid gland.  However, hCG can mimic TSH , causing the thyroid gland to become hyperstimulated.  It turns out that the molecular structure of both of these “different” hormones are very similar. 

Both are composed of two different protein subunits. One of those protein subunits is called “alpha” and the other “beta.” The alpha subunits of hCG and TSH are identical but the beta subunits are different; but not by much.  The beta subunits of hCG and TSH are about 40 percent identical.  Given that mechanism, very high concentrations of hCG can actually stimulate the thyroid gland sending it a message to become hyperactive. In other words, hCG can sometimes act like TSH, which is the reason an elevated thyroid function test in the first trimester (which may be interpreted as an overactive thyroid), should be repeated in the second trimester when the levels of hCG have stabilized.

The fetal thyroid becomes active at 12 weeks. Until then, it depends on the mother’s supply for brain and nervous system development.

The thyroid also becomes slightly enlarged during pregnancy, but not enough to be viewed as abnormal during a physical exam. If a thyroid is noticeably enlarged, this could be a sign of thyroid disease. But again, thyroid problems are tricky to diagnose during pregnancy, because the thyroid hormones levels are higher than normal and also because fatigue and other symptoms of thyroid disease are often similar to normal pregnancy symptoms.  That is why subspecialists, like myself, known as maternal-fetal medicine specialists, may need to be called upon by the midwife or obstetrician when caring for a pregnant woman with suspected thyroid dysfunction.

How Is Pregnancy Affected by Thyroid Problems?

Depending on whether you are dealing with hyper- or hypothyroidism, uncontrolled thyroid disorders in pregnancy can cause a number of health risks to mother and baby, including congestive heart failure, thyroid storm, neurologic deficits in the fetus, miscarriage, fetal growth restriction or neonatal Graves disease (hyperactive thyroid function in the newborn).   Thyroid disease has an autoimmune component and other autoimmune diseases also need to be ruled out.  Antibodies (TSI—thyroid stimulating immunoglobulins) from a hyperactive, hyperthyroid patient can cross the placenta and cause fetal goiter.

For these reasons it is extremely important that a woman with a thyroid disorder optimize her health by eating a balanced diet with iodized salt, taking a prenatal multivitamin that contains iodine (which the thyroid uses to make hormones), and taking the appropriate medication to control symptoms and regulate hormone production.  Up to 10% of postpartum patients develop new-onset of Graves disease or autoimmune thyroid dysfunction.  In my practice, patients who were six weeks postpartum all underwent thyroid function testing.  It is not the standard, but, after diagnosing several patients with thyroid dysfunction, I did not want to miss an abnormally functioning thyroid gland in any of my postpartum patients.  Thyroid conditions often require lifelong monitoring, but with the right medical attention, are easily controlled.

 – Yvonne S. Thornton, M. D., M. P. H.

What about Postpartum Depression?

Thursday, January 2nd, 2014

Regardless of how much you have looked forward to the birth of your baby or how happy you are about it, having a baby is extremely stressful. A range of emotional reactions are expected and normal, including sadness, “baby blues,” or some depression. However, if you find yourself with feelings of depression that don’t go away within a few weeks, you could have a condition called postpartum depression. This is a serious condition that requires that you see your doctor as soon as possible to discuss treatment and support options so that you are healthy and able to take optimal care of your new baby as well as yourself.

The baby blues are common and mild, and may include symptoms such as sadness, moodiness, irritability, and trouble sleeping. These symptoms appear within a few days of giving birth and improve within a couple of weeks. Postpartum depression, on the other hand, is more serious and the symptoms are more severe and last longer.

Symptoms such as a lack of interest in your baby, worrying that you might hurt your baby, lack of interest in personal hygiene, lack of motivation or energy, feeling worthless or guilty, or thoughts of death or suicide are examples of the types of symptoms that should alert you to the fact that you may be dealing with something beyond normal baby blues.

What Causes Postpartum Depression?

It is not well understood why postpartum depression affects some new mothers and not others. However, there are a number of causes and risk factors that may contribute. Changes in hormone levels after childbirth, physical pain, insecurity about your changed body, exhaustion, and the stress of taking care of a new baby can all play a role in the development of postpartum depression.

In addition, it is known that some women are more likely to get postpartum depression, such as those who have a history of depression, a history of severe PMS symptoms, medical complications with the pregnancy or delivery, and a lack of support from friends and family. In fact, this study shows the important role that peer support plays in preventing and lessening postpartum depression.

How to Treat Postpartum Depression

To start feeling better, it is very important to take care of yourself. Making sure you get enough sleep, which may sound impossible when you have a new baby, but being exhausted will worsen your depression. I was told from a wise mother of several children, “When your baby sleeps, you sleep.”  No vacuuming, washing clothes or paying bills. Enlist help if at all possible so that you can get enough rest. And when awake, do not spend every waking minute caring for your new baby, your other kids, or your house – take breaks from mommy duty to pamper yourself.  That may be easier said than done when you have a maternal sense of danger if your baby is not within your sight every minute.  Even taking a shower may be difficult for some new mothers.  Single mothers have the most difficult time of balancing their lifestyle with the arrival of a newborn.  Instead of meeting a friend for coffee, ask that friend if she (or he) can come over to spell you from the rigors of motherhood for a few hours.  And, when she’s there, take a long, hot bath and do whatever simple things you enjoy to recharge and relax.   It DOES “take a village” to raise a good kid without exhausting yourself trying to do it alone.

You can also get closer to feeling like yourself by eating a healthy diet, getting plenty of mood-enhancing sunshine, and easing back into a regular exercise routine. A 30-minute walk each day is a good way to start, and your baby will probably love it, too.

Finally, make sure and take advantage of the help and support others offer – or be proactive about asking for it. Stay in touch with your friends; make plans with them and do not let yourself become isolated. Talking about your feelings can help, too.

As stated in my blog back in 2010, “Everyone feels sad some of the time. It’s normal to have a bad day. But if your bad day stretches into weeks, for your own sake and the sake of your baby, you need to get help. If you don’t have a therapist, ask your ob-gyn for a referral if you experience feelings of hopelessness, sadness or despair. Don’t suffer needlessly. Help is available.”

Talk therapy, hormone therapy, and medications such as antidepressants can all be highly effective in relieving postpartum depression.

– Yvonne S. Thornton, M. D., M. P. H.

Everything Old is New Again when it comes to Morning Sickness

Thursday, December 19th, 2013

Back in the 60s, and 70s, when I was a medical student, resident and perinatal Fellow, the drug of choice of morning sickness was Bendectin.  Bendectin, Bendectin, Bendectin.  It was prescribed like jellybeans to pregnant women in their first trimester to treat nausea and vomiting of pregnancy (morning sickness). It worked!!  I don’t think I would have gotten through my certification Boards without Bendectin when I was eight weeks pregnant with my daughter.

Then, all of a sudden, its was unceremoniously removed from the market and was unobtainable in 1983.  Why? Because the original manufacturer, Merrell Dow, could not continue to defend the lawsuits brought against the drug for supposedly causing birth defects.   After numerous horrific episodes of birth defects due to Thalidomide (which was not FDA approved in this country), women were quicker to blame medications taken during pregnancy for complications and birth defects.  Unfortunately, attorneys set their sights on Bendectin, which became the “whipping boy” for medications taken during early pregnancy and soon the mounting lawsuits (which were unfounded) resulted in its removal from the market.  In other words, this very effective medication was removed totally based on fear.

However, those of us who knew that the ingredients were just an antihistamine (doxylamine) and Vitamin B6 (pyridoxine), continued to direct our patients to the over-the-counter combination of Unisom and Vitamin B6.  In 2004, the American College of Obstetricians and Gynecologists sanctioned this jerry-rigged, improvised approach to “homemade” Bendectin as a first-line treatment for nausea and vomiting of pregnancy (morning sickness).

Well, thirty years later, a “new” drug, under a new manufacturer, called Diclegis (the brand name for doxylamine succinate and pyridoxine hydrochloride) was approved by the FDA earlier this year for use in pregnant women for the treatment of nausea and vomiting.  The drug is exactly the same as Bendectin.  However, this time, it has been categorized as Class A by the FDA, which means that there is no evidence that the drug causes birth defects in the human fetus.  With this FDA category of Class A, hopefully, it will reduce the threat of lawsuits.

As you are probably aware if you are or have been pregnant, so-called “morning” sickness can actually strike at any time of day, even lasting all day long in some cases. There are simple self-care strategies to try that are effective in many cases: avoiding fatty foods, eating smaller, more frequent meals, and avoiding smells that seem to trigger nausea. However, more often than not, these measures are not enough. Diclegis offers a welcome solution for many women.

Studies have shown Diclegis to be effective and safe. 261 women who had been pregnant for anywhere from seven to 14 weeks, were all 18 years old or older, and were all experiencing nausea or vomiting, were evaluated. In the study, there was more of a decrease in nausea and vomiting seen in women who took Diclegis than in women who took a placebo. The drug was also found to be completely safe for the fetus.

Women whose doctors prescribe Diclegis can expect to take two pills at night to start with. If this does not improve symptoms, the dose can be increased to a total of four pills per day (one in the morning, one in the afternoon, and two at night). Drowsiness is among the possible side effects (because of the antihistamine), so women who take the drug should not drive. If you have questions about Diclegis or need further information on morning sickness, see my book, Inside Information for Women, and talk to your doctor. He or she can help you decide if Diclegis is the right choice for you.

Pregnant women who suffer from morning sickness may be worried that their babies aren’t getting enough nutrition, but in most cases, there is no cause for concern. The caloric needs of a fetus are tiny, especially in the first trimester, when the majority of morning sickness occurs. Occasionally a woman develops hyperemesis gravidarum, which is a very severe form of morning sickness in which she may not even be able to keep water down and may need to be hospitalized. Diclegis has not been tested on women with this form of severe nausea and vomiting.

– Yvonne S. Thornton, M. D., M. P. H.

Obsessive-Compulsive Disorder and Pregnancy

Monday, December 9th, 2013

Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by unwanted, recurring thoughts or fears (obsessions) and the behaviors a person develops to try and stop the fears from coming true (compulsions). People with OCD get into cycles of obsessive thoughts which are followed by compulsive behaviors. The compulsive behavior brings temporary relief from the anxiety, but only temporary. Soon the obsession and its accompanying anxiety return, and the cycle starts all over.

For example, a person might repeatedly wash his or her hands, clean the house, or check things such as locks or light switches. Sufferers are aware that there is no need for the behavior, but they are unable to stop themselves from repeating it. OCD can be very time-consuming and cause more anxiety or stress, rather than reliving it. In severe cases, it can stop people from leading normal lives.

Pregnancy and OCD have a relationship that is not yet well understood. Sometimes, a woman experiences OCD for the first time during pregnancy or following childbirth. Also, some women who have existing OCD may find that their symptoms worsen during pregnancy or in the weeks or months following childbirth. Still other women find that their symptoms improve during pregnancy.

OCD and depression are commonly found together; new mothers with OCD may be more likely to experience postpartum depression, or they may experience postpartum depression that is more severe. Among the general population, OCD is thought to affect about one in 100 people; about twice that number are affected during pregnancy and after childbirth. 

How Do You Know if You Have OCD?

Worries and fears are normal and common among pregnant women or new mothers. Such thoughts and fears usually do not signal OCD. However, OCD could be a concern if the anxiety is overwhelming or if it leads to needless and repetitive behaviors.

Fears that the baby is in some kind of danger are common among pregnant women with OCD. A woman may be afraid that she will somehow harm her baby herself, and therefore develop compulsions to try to protect her baby. For example, she may stop eating certain foods she believes may harm her unborn baby, even if her doctor says they are safe to eat. Or, after the baby is born, the new mother may compulsively check on the sleeping baby. She may constantly clean areas the baby has contact with, or she may even avoid spending time with her baby.

Why Is OCD More Common During Pregnancy?

The reason for this is not fully understood. Often, the reason for OCD cannot be pinpointed, even when pregnancy is not a factor. In some cases, it could be that new mothers feel the added pressure of the extra responsibility having a new baby places on them. Or, it may be that a mother suppresses negative emotions because she is “supposed” to be experiencing a joyful event. It is also possible that changes in brain chemistry play a role, or that hormonal fluctuations have an effect.

If you think you may have OCD, ask your doctor about it. He or she can refer you to someone who is trained to help people with OCD. Talking to someone who understands what you are going through is usually very helpful.

– Yvonne S. Thornton, M. D., M. P. H.

Pregnant Women and Work Concerns

Monday, November 25th, 2013

In 2012, women account for 47 percent of the salaried labor force in the United States ( It’s only natural that concerns would arise regarding pregnant women and working. Today, many pregnant women plan to work throughout their pregnancies – probably too many. Pregnancy alone places an extraordinary amount of stress on a woman’s body, and it is extremely important to get enough rest. The decision to stop working can be a tough one, financially, emotionally, and socially, but it may be essential to protecting maternal health and the health of the baby.

If a woman cannot stop working or chooses to work despite the risks, she should be aware of safety precautions that must be taken in order to minimize the risks involved. Even if she sits at a desk all day, she must remember to get up and move around regularly, drink plenty of water, and eat a healthy diet – those office fast-food runs aren’t going to cut it. If she stands for an extended time as a supermarket cashier, hairstylist, bank teller, etc, the pregnancy may be at risk for preterm delivery.  Therefore, she must walk around or sit down every hour or so.  Getting enough iron, calcium and protein may help somewhat with fatigue, but women should realize that fatigue is their bodies’ way of telling them to rest, so that’s what they should do.

Pregnant women should take steps to stay as comfortable as possible, including making sure the chairs they sit in are supportive, that they are not standing for prolonged periods of time, and that they are not doing excessive bending or lifting. Heavy lifting and twisting while lifting should be avoided altogether. Exposure to harmful substances should also be avoided.

A pregnant woman who works should seriously consider ways to cut back on activities in other areas of her life. For example, shopping online can create more time for rest. Or, if possible, hiring a service to clean the house or do yard work or enlisting the help of other family members is a good idea. She should also do everything in her power to get enough sleep, including going to bed early and lying on her side with pillows between her knees and under her belly for maximum comfort and to prevent swelling in her feet.

It will also be important to keep stress under control. Pregnant women should do what they can to reduce workplace stress. For example, making to-do lists and prioritizing tasks can help them take the work day one task at a time as well as identify tasks that can be delegated to someone else. Taking a few minutes alone to practice some relaxation techniques several times a day can keep stress at a minimum, as can having someone to talk to about frustrations.

The bottom line is that women should discuss their jobs with their health care providers to determine whether they need to make other arrangements for the duration of the pregnancy. A woman who is at risk for preterm birth should not work, period – she should be focused on resting with her feet up and drinking plenty of water. Although pregnancy is a normal physiologic process, the workplace may be unkind to a pregnant woman and if that is the case, a pregnant woman should seriously consider giving up her job, if at all possible, or at least cutting way back on her hours.

– Yvonne S. Thornton, M. D., M. P. H.

Options for Labor Pain Management

Thursday, November 14th, 2013

No two women experience labor pain exactly the same way, but one thing is certain: if you go through labor, you will experience pain. The size of your baby, his or her position, and the strength of your contractions all affect the severity and location of your pain; your stress level, including whether you are afraid and how prepared you are mentally and physically for labor, will also have an effect. For these reasons, knowing what to expect and what your options are before you ever have your first contraction is vital. Education and preparedness can allow you to make informed decisions unpressured by the immediacy of pain that you are unprepared to handle.

Lamaze Still the Best Overall Option

Your best bet, all things considered, is a labor and delivery free of drugs of any kind. Lamaze training doesn’t seem to be as en vogue as it once was, but it remains the safest option and, when learned properly, is highly effective. It does not block the sensation of pain entirely, but instead, teaches you techniques for coping with the pain calmly by focusing your attention on your breathing and on some focal point outside of your body. Many women have been pleasantly surprised to find out how effective Lamaze actually is. Perhaps its biggest benefit is its complete lack of potentially harmful side effects – something that cannot be said about drugs used in labor pain management (or any drug, for that matter).

Epidurals Effective But (Somewhat) Risky

Despite the fact that Lamaze costs nothing, is free of risk, and is effective, many women understandably prefer a pain relief method they perceive to be better: the epidural. Epidurals have become so common that these days, almost every pregnant woman plans on having one. Epidurals offer the distinct advantage of blocking pain sensations entirely (some pressure is still felt but it isn’t painful) while leaving Mom wide awake and ready to greet her new baby.

Which sounds great, except for one tiny detail: epidurals are not completely harmless. For starters, they are extremely expensive, although that isn’t much of a deterrent for most women when an insurance company is footing the bill. The much more important issue is that the drug used in epidurals crosses the placenta and can slow the fetal heart rate, sometimes necessitating Cesarean deliveries that would otherwise not have been necessary. There are also potential risks to the mother, including the possibility of needing to be put on a respirator if the epidural blocks more sensation than it is meant to, and other risks such as headache and low blood pressure.

My personal assessment, after delivering 5,542 babies and being an obstetrician for over 40 years, is that prolonged use of epidural anesthesia is associated with the development of autism in childhood.  This is just a theory, based on anecdotal observations; but, I have found that the babies born to mothers who are attended by midwives, who don’t use epidural anesthesia,  are less likely to be diagnosed with autism compared to children who have been exposed for many hours to the drugs used in administering epidural during labor.  It sounds preposterous, but remember where you read it first.

This is not to say that I am against any woman ever having an epidural. But women need to be informed of the risks and provided with the opportunity to learn completely safe alternative pain management techniques, such as Lamaze. If an epidural is chosen, it should not be administered too early in labor – not before the cervix is dilated to at least five centimeters. In addition, the epidural should be stopped once the cervix is dilated ten centimeters and the mother is ready to push; otherwise, she will not be able to push effectively. For more information on this topic, as well as my theory on epidurals and autism, see my book, Inside Information for Women.

– Yvonne S. Thornton, M. D., M. P. H.

X-Rays and Pregnancy

Monday, November 4th, 2013

Many people are concerned about the effects of radiation from X-rays, such as those used for medical diagnoses. Some people become so worried about this that they refuse even important diagnostic X-rays that they need.

The small amount of radiation emitted by X-rays is actually no more dangerous than naturally occurring radiation, such as that from the sun or when you are flying in an airplane at high altitudes.

Low-energy ultraviolet (UV) rays, visible light, infrared rays, microwaves, and radio waves are all forms of non-ionizing radiation.  Ionizing radiation, on the other hand, is generated through nuclear reactions and can alter chemical bonds. Exposure to ionizing radiation causes damage to living tissue, and can result in mutation, radiation sickness, cancer, and death.

Just remember that diagnostic radiation is measured in millirads, while the concern about harming the fetus or embryo is in rads, specifically more than 5 rads.   That means there is 1000 times less radiation in the average diagnostic chest X-ray and one would need to have a thousand chest X-rays in order to reach one rad.   The National Institute of Child Health and Human Development says that a small amount of X-rays are safe even during pregnancy.  Because the fetus is inside the mother, it does benefit from some measure of protection from the effects of radiation. Pregnant women should, however, make sure that they tell their dentists or other doctors or technicians performing X-rays that they are pregnant so that proper precautions can be taken.   But, receiving an X-ray at a dentist’s office or at the hospital is NOT the same as being exposed to the amount of radiation emitted from Chernobyl or Hiroshima.  People exaggerate the harm of these medical diagnostic X-rays to the detriment of the mother because she may be denied appropriate imaging studies in order to diagnose a medical condition that, in and of itself, may worsen without the knowledge gained from the diagnostic X-ray.

With most decisions you make during the course of your pregnancy, you will want to weigh the risks against the benefits of any particular action and choose the option that is best for you and your baby.  According to the American College of Radiology, “no single diagnostic procedure results in a radiation dose significant enough to threaten the well-being of the developing embryo or fetus.” This statement was made over 20 years ago and it still rings true today.  So, why all the hysteria?  Ignorance and fear of possible lawsuits.  It’s important to remember that with X-rays, often not getting the X-ray will be the more harmful choice. X-rays have been shown to be quite safe, and even if you are still worried about the radiation exposure, keep in mind that your undiagnosed infection, condition, or injury may turn out to be much more harmful and may lead to death.

It is true that there is an abundance of misinformation and dysinformation surrounding the topic of X-rays during pregnancy. With that said, it is a good idea to limit X-rays to those that are imperative. Routine dental X-rays, for example, should wait until after your baby is born, while  X-rays of the lung to rule out tuberculosis or to investigate a troublesome symptom should not be delayed. Remember that X-rays save lives in many cases because of the information they provide for your doctor about your condition.

To reiterate, the fact is that diagnostic X-rays pose no threat to your unborn baby. Especially in the case of one-time X-rays that do not involve the lower pelvis, such as those that image the chest, arms, or legs.  Serial or cumulative X-rays and CT scans are another concern and should be limited during the course of the pregnancy.  MRI’s are not ionizing radiation, but rather powerful magnets which temporarily alter the energy state.

What if you had an X-ray before you knew you were pregnant? Don’t worry. The chance that it caused any harm is infinitesimal.  At that very early stage of pregnancy, the body invokes the “all or nothing” principle.  Either there is no harm at all or the body rejects the abnormal embryo, resulting in a miscarriage (spontaneous abortion).  If you are concerned about X-rays you had early in your pregnancy before you were aware the pregnancy existed, a discussion with your doctor should allay your fears.   Now that you know you are pregnant, be sure your doctor knows it when he or she orders X-rays for any condition. This is important for any treatment a doctor orders such as prescriptions and certain medical procedures as well as X-rays.

Occasionally, a woman may have X-rays to diagnose a mysterious “illness” that turns out to be pregnancy. Fifty percent of all pregnancies are unintended.  Therefore, if you are sexually active, you may be pregnant and you need to discuss that with your doctor before moving on to other diagnostic tests or treatments.

Finally, if your doctor wants you to have X-rays, inform him or her of any other X-rays you may have had in the recent past or before you were pregnant, so that they might be able to look at them instead of ordering new X-rays. This can help you avoid unnecessary X-rays, but again, if you do need X-rays, remember that refusing them is likely to be more detrimental to your health and that of your baby as compared to having an X-ray which could save your life by diagnosing or ruling out the problem.

– Yvonne S. Thornton, M. D., M. P. H.