The grocery shelves are empty and most of us have been to at least 3 different places just to find toilet paper.  Many of my new moms can’t even find formula for their babies.  Is there a shortage?  No, but there is a manufactured shortage fueled by hysteria.  At this point, one might wonder what is more dangerous the coronavirus (COVID 19), or the fear and anxiety that has been generated by the media?

1. So, let’s compare COVID 19 to the flu for a second.  Which is more likely to kill you? The answer is the flu.  As of March 7, 2020, 38 million people in the U.S. have been affected by the flu.  Somewhere around 390,000 have been hospitalized, and somewhere around 23,000 people have died.  In fact, the hospitalization rate for influenza in children 0-4 and adults 18-49 is the highest ever, even higher than H1N1.  To date, Covid 19 has affected nearly 50,000 people in the US and about 650 people have died.  The mortality (or death) rate from the seasonal flu is typically around 0.1%.  The mortality rate for Covid 19 currently stands at a little over 1% in the US.  What this means is if you get COVID 19, you are more likely to die than if you get the flu; however, you are far more likely to get the flu than COVID 19.  So, statistically, at this point, you are far more likely based on probability to die from influenza than you are from COVID 19.  Despite these numbers and the big push for a coronavirus vaccine, only around 40% of the population is amenable to the influenza vaccine that could potentially save more lives.
2. That being said, I am definitely not telling you to ignore the current recommendations of social distancing or taking appropriate sanitary precautions and following guidelines set by the governments.  Even though up to 20% or more of those infected may have no symptoms, coronavirus is still a very serious illness for those who become ill.  Who does this virus affect?  Those most at risk of death are the elderly, especially those with chronic disease.  The mortality rate for those over age 65 with chronic diseases is 16%.  By following these precautions, we are decreasing exposure and the chance that this age group will contract a disease that is way more deadly for them than a healthy 20-year-old (the chance of a healthy person younger than 55 dying from coronavirus is <1%; for those 85 or older, it could be anywhere from 10-27%).  As for pregnant women, the good news is that coronavirus does not appear to cross the placenta to the baby, but just like for the flu, pregnant women are at a slightly higher risk for severe respiratory symptoms because their immune system is a bit compromised in order to prevent rejection of their growing baby.
3. One of the biggest concerns for many is a comparison of our healthcare with Italy-they don’t have enough ICU beds, ventilators or even enough space to bury the dead.  Fortunately, there are a lot of differences between Italy and the US.  In Italy, 25% of its population is over the age of 65 (thank you Mediterranean diet!).  In the US, only 16% of the population is over the age of 65.  The number of critical care beds per 100,000 people in the US is 34.7.  The number of critical care beds per 100,000 people in Italy is 12.5.  So, not only is there a disparity in patient population, but it is also present in the healthcare infrastructure that is contributing to the higher mortality rate that we are seeing in Italy compared to the US.  These factors contribute to a mortality rate in Italy is currently at 9%!  This does not mean that we should be falsely reassured, though.  The U.S. population is 5 times higher than Italy, and this is going to be a huge strain on our health care system.  Covid 19 has also shown that we may benefit from reassessing our production/supply chains for medical devices/pharmaceuticals as we find decreased availability of medical supplies and medications for sick patients and healthcare providers. 
4. There will be lots of lessons to learn from COVID 19.  This will test our preparedness in adversity, and it will teach us how to be better equipped for large-scale health crises in the future.  Importantly, though, we cannot lose our humanity and touch with reality.  Stocking enough toilet paper for 1 year is not going to make you immune to COVID 19, and in fact, it may help facilitate its spread.  If the rest of us have to go to three different stores to find a roll of toilet paper, it increases our exposure to others.  This could negate the effects of social distancing that we have been practicing for the past week.  All those hours of being cooped up in the house and driving each other crazy, and the only benefit will be a really clean bum 😉 

Dr. Pam

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Image via Pexels

Let’s face it: Nobody wants to wake up on Monday morning and start a new work week. However, the Sunday Scaries
— that feeling of anxiety at the midpoint of the weekend — can make Monday that much worse. And by stressing out, you can lose the joy of half your weekend. Here are a few resources that can help you prepare for the week ahead.
 
Your Home, Your Sanctuary
 
Your overall attitude is partly determined by how you feel when you’re spending time at home. Here’s how to make your space a sanctuary.
 
57 Inspiring DIY Fire Pit Ideas and Plans to Make S’mores with Your Family
8 Must-See Features for the Ultimate Spa Bathroom Makeover
5 Tips to Create a Relaxing Bedroom
Room-by-Room Stress Reducers for Your Home
 
Feed the Senses
 
Sight, sound, touch, and taste also make a difference in how we perceive stressors.
 
The 10 Most Relaxing Songs in the World, According to Science, Ranked
21 of the Most Comforting TV Shows to Watch When You're Stressed
9 Foods That Calm Anxiety (and 3 That Make It Worse)
Reduce Stress Using the 5 Senses
 
Exercise Does a Body (and Mind) Good
 
Exercise really is nature’s medicine. Whether you want to walk or spend the weekend trekking the backcountry, the more you move, the better you’ll feel.
 
Can Exercise Help Treat Anxiety?
The Pacer Blog: Walking, Health, and Fitness
10 of the Best Weekend Backpacking Trips in the US
33 Ways to Increase Dopamine to Boost Your Productivity
 
Monday does not have to be a terrible “four-letter word.” The above links are full of great information to help you get your entire family mentally prepared to enjoy the weekend, and then tackle the week ahead.

Elena Stewart

As a definite meat-eater married to a definite vegetarian, we have certainly discussed the health aspects of eating meat (or not).  Now that there’s a new spin on typically meat-based dishes, we’ve had a chance to rehash some of those discussions, and after doing some research, here’s what we’ve found.

First of all, what’s this “fake” meat made of?  Meat alternatives generally start with a plant-based protein such as soy, pea, wheat or potatoes.  Mushrooms can also be a foundation of synthetic meats.  The “blood” that comes out after a big bite of your rare burger is produced either from beet juice or leghemoglobin, the plant version of the protein that makes your red blood cells red.  Given the variety of sources of plant-based “meats,” be sure to check the ingredients for any triggers of food allergies.  Also, as there are a number of oils and other preservatives, sometimes there can be some GI sensitivities as well, so it’s probably best to see how your body responds before downing a meat substitute breakfast sandwich followed by a plant-based burger for lunch and some faux fried-chicken for dinner.

Is it really healthy?  One of the most common misconceptions about a meat-free diet is that it’s inherently healthy.  A cinnamon roll for breakfast, cheese pizza for lunch, and fries with a milk shake for dinner is technically vegetarian, but it’s not healthy.  Unfortunately for many meat substitutes, while base ingredients like pea protein can be very healthy, the amount of salt and additives you have to add to convince my taste buds that I’m devouring a juicy hamburger renders most of the health benefits a moot point.  The caloric content is roughly equivalent, the few grams of fat you save are replaced by carbs, and you’ve increased the salt content by about 25%.  You do end up with less cholesterol and a little more fiber, but you’ve lost a few grams of protein.  You may also lose out on some of the benefits of eating meat to begin with, which are vitamin B12 and iron (these micronutrients are often deficient in vegetarians).  Lastly, we don’t really have any studies regarding the longterm health effects of meat substitutes and the additives needed to make them taste like meat.

So, there’s not really any benefits?  From a health standpoint, a greasy burger or fried chicken (real or fake) isn’t going to be the foundation of anyone’s healthy diet, but there are a few advantages of fake “meat.”  First, there’s no need to inject antibiotics or hormones to make an animal grow faster and increase food production.  Also, to be fair, there is noticeably less impact on the environment to grow vegetables than animals for food.

What’s a person to do then?  From a health standpoint, we do note increased health benefits from a plant-based diet, although that’s probably not one based entirely on meat substitutes, at least with how these are produced now.  As for real meats, less processed is generally preferred, and free range, antibiotic-free and hormone-free are going to be the best options with regards to health.  When it comes to choosing some of the healthiest meat of all, wild game is another strong contender.  These animals tend to have the leanest meat as they are inherently free range, and it also guarantees avoidance of hormones and antibiotics while having the added advantage of increasing exercise for the hunter.

In the end, whether eating real meat or fake, moderation is going to be key, and be sure to keep an eye on the ingredients in those foods, especially synthetic ones.  Cooking for yourself will give you even more control over your food ingredients, and to maximize your health benefits, try making the foundation of your meals unprocessed vegetables and fruits.  It turns out that when your mom made you eat your vegetables before you could go play, she knew what she was talking about after all 😊

Dr. Nick

What causes varicose veins in pregnancy?  During pregnancy your blood volume increases.  However, because the large pregnant uterus places pressure on the inferior vena cava (the large vein that brings blood back to the heart), the rate at which blood flows back from your legs to your pelvis decreases.  This puts an enormous strain on your veins.  This pressure in addition to hormones such as progesterone which can dilate veins causes blood to pool in the veins which stretches the vein walls and can cause veins to swell twist and bulge.  

Where do they show up?  Varicose veins are large swollen dilated vessels that show up in the lower half of your body.  They are most common in your legs but can show up in the vulva or rectum (aka hemorrhoids in the rectal area).  When they swell above the surface of the skin, the have this lumpy purple unsightly appearance and can affect 10 to 20% of pregnant women. 

Are they dangerous?  While varicose veins are pretty ugly in appearance, they are usually harmless and will recede after pregnancy.  That being said, look out for development of ulcers or marked difference in the swelling in one leg compared to the other as these could indicate more concerning issues such as venous insufficiency or deep vein thrombosis.  Either of these conditions would require more urgent evaluation.

What can I do to minimize varicose veins when I am pregnant?  Not all women get varicose veins when they are pregnant.  However, if you have had varicose veins in a previous pregnancy, the likelihood of getting them with a subsequent pregnancy is high.  Also, this can be genetic.  So, if your mother had bad varicose veins, the likelihood that you will develop them is higher. 

​What can I do about varicose veins and prevent their appearance from getting worse? 

1. Exercise: Moving is key.  Even if it’s just walking and not more intense exercise than a slow stroll- it is important to stay active. Exercise is important for maintaining good circulation. 
2. Keep the blood flowing.  Whenever sitting, try to keep your legs elevated- helps that blood get back to the heart. 
3. Compression: using compression socks or support hose will help counteract the downward pressure of your pregnant belly and give the circulation in your lower extremities that extra push upwards. 
4. If you have hemorrhoids (varicose veins essentially around the rectum), try to do what you can to minimize constipation and the need to strain.  Fluid and fiber intake are key.  Add stool softeners and fiber supplements if necessary. 
5. Try to stick to the weight gain recommendations for pregnancy.  For women with a normal bmi, the weight gain recommendation is 25-35 pounds.  Extra weight gain increases the demands on your circulatory system. 

For most women, the appearance of varicose veins improves significantly after delivery.  However, if yours are persistent there are different aesthetic procedures available to decrease their appearance.  Wait until you have had all your babies before pursuing one of these options.  Talk to your provider about what’s out there to help!!!

​Dr. Pam

Graphic created by USA Vein Clinics

One of the biggest international headlines of the year has been the outbreak of coronavirus in China, and its potential spread around the globe.  Here in Idaho, that seems pretty far away, but with the connectedness provided by international travel, are we really that isolated?  It turns out, cases have been reported as close as Washington state, right next door.  While there are many things we don’t yet about this disease, here is an overview of the information we have so far:

What is a coronavirus, and where does it come from?  These include a large number of viruses common in animals but that in some cases may spread to humans.  For instance, SARS was a coronavirus thought to have originated in civet cats (a nocturnal Asian mammal).  There is some speculation that this new Coronavirus (COVID-19) may have originated in bats in Wuhan, China at the live food market.  In answer to your next question, yep, some people may eat bats. 

How does it spread?  If this disease was only limited to those with a culinary affinity for flying mammals, then it would have likely remained relatively isolated; however, COVID-19 appears to have developed the ability to spread from person to person.  This transmission appears to mostly occur via spread of respiratory droplets affecting those within up to 6 feet of the infected individual, so please cover your mouth when you cough.  Transmission may also occur through fomites (things people touch with their dirty hands), though, so be sure to wash your hands regularly.  In fact, this latter form of spread has become enough of a problem in China that they may be considering destroying currency (money) in circulation and printing new yuan (bills).

What else can be done to limit the spread of coronavirus?  In addition to handwashing and good hygiene, the government is limiting travel to and from affected areas.  Recent travelers and those with confirmed cases are also being held in quarantine as affected individuals may not show symptoms for up to 2 weeks.  While putting your life on hold for a couple of weeks of mandatory isolation may sound aggressive, it’s certainly not as intense as the North Korean government’s reported execution of an official who broke quarantine by going to a public bath after returning from China.

What hasn’t worked to limit transimission of coronavirus?  Use of surgical masks on a day-to-day basis hasn’t been proven to reduce infection frequency except in health care workers regularly exposed to the virus.  Also, despite the name, there is no association of the virus with Corona beer.

Well, just how big of a problem is the coronavirus?  At this point, over 70,000 people have been reported infected, and a little under 2,000 have died, or approximately 2.5% of those infected.  2.5% mortality would place it as somewhere more deadly than the flu, which kills only 0.1% or so of those infected, but much less lethal than Ebola, of which some outbreaks are fatal in 90% of infected individuals.  That being said, the actual death rate may be either higher (many of the 70,000 infected individuals are still sick and may still die) or lower (many mild cases may be present and not ever diagnosed).  Even so, 2.5% mortality would be “nothing to sneeze at” if the number of infected individuals becomes high enough.  For instance, the flu typically infects 3 million people in the US each year, and a similar number of coronavirus cases would cause the death of 75,000 people.

So, what is the take home message from all of this?  At this point, we haven’t seen any cases of coronavirus in this state yet, but that could change in the future.  Continue to use good health hygiene, limit your and your family’s exposure to sick individuals, and continue to keep an eye on the news for updates.

Dr. Nick

“I have ADHD and take Adderall.  I just found out I’m pregnant.  Now what?”

ADHD, or attention-deficit/hyperactivity disorder has become one of the most commonly diagnosed neurodevelopmental disorders of childhood, and the number of people on medication for ADHD has increased dramatically.  According to the CDC, 6.1 million (9.4%) of children between the ages of 2 through 17 have been diagnosed with ADHD.  Two thirds of these children are taking medication.  4% of adults have been diagnosed with ADHD and this number has increased steadily over the last couple of years.  Currently the number of women with ADHD on medications is small.  About 1 in 100 women took ADHD medication during pregnancy.  This number will likely increase dramatically as so many more adults carry the diagnosis. 

Medications taken for ADHD include the following: Adderall, Concerta, Vyvanse, Ritalin, Focalin, Dexedrine, Metadate to name a few.  These medications are stimulants and can be short acting, intermediate or long acting.  The side effects of these medications include loss of appetite, weight loss, sleep problems, tics, heart palpitations, or worsening of anxiety or depression. 

Is my baby at higher risk of birth defects if I take medication for ADHD?  The answer to this is, unfortunately, yes.  ADHD medication in early pregnancy may be related to the following birth defects: gastroschisis (a condition where the baby’s intestine develop outside the baby’s body), omphalocele (a condition where the intestine of other abdominal organs are outside of the body), and transverse limb deficiency (where all or part of an arm/hand or leg/foot don’t develop).  A study performed by the CDC found that women who took ADHD medicine during early pregnancy were at a higher risk of having a baby with certain birth defects compared to women who did not take ADHD medication. Since the overall risk of birth defects is very low, data from this study was based on small numbers and so the literature on ADHD medication during pregnancy is very limited. 

In addition to this, there is an increased risk of low birth weight, prematurity, preeclampsia and increased morbidity because of increased placental vasoconstriction (when the blood vessels contract and don’t deliver blood effectively).  There can also be symptoms neonatal withdrawal. 

So, what should I do?  Unfortunately, we don’t have a great reservoir of information on the topic because the data is limited.  The data is even further limited to determining long term behavioral and learning effects to children who were exposed to stimulants in utero.  For these reasons, we encourage women with mild to moderate ADHD symptoms to consider discontinuing medication and switch to behavioral therapy while pregnant or even before conceiving if possible. 

For patients with severe ADHD, this decision would likely be made on a case by case basis in conjunction with their psychiatrist.  If you are pregnant or trying to conceive and currently taking medication for ADHD, please have a detailed discussion with your provider prior to continuing (or discontinuing) the medication while pregnant or attempting pregnancy.
 
Dr. Pam

One question that I hear a lot from women either looking to conceive or at first pregnancy visits is “how will my weight affect my pregnancy?”  As weight can very often be a sensitive topic, it can be a tough topic for your provider to discuss with a patient.  That being said, weight has been proven to play a role not only in a women’s ability to become pregnant, but also her ability to have a healthy pregnancy and carry it to term.  Below are some of the most significant ways that BMI (and yes, I understand that for a select few BMI may not be perfectly accurate, but it’s what we’ve got) can affect pregnancy.
​
Starting with getting pregnant, obesity (a BMI over 30) is often related to increased adipose (fat) tissue, and this adipose tissue actually makes its own hormones that can disrupt ovulation.  If no egg is released, then pregnancy can’t happen.  Even with successful ovulation and pregnancy, the risk of miscarriage increases by 3%, and there is also an increased chance of birth defects such as neural tube defects (problems with the spine) as well as heart defects.  This can be associated with either a problem with chromosomes (genetic material) in the egg or during the development and growth of the pregnancy.

Unfortunately, there are also increased chances of maternal health issues during pregnancy with higher BMI.  For preeclampsia (blood pressure issues in pregnancy that may cause seizure/stroke, kidney/liver damage, or even death), the single greatest risk factor is obesity, which is present in about 1/3 of cases.  In fact, women with a BMI >30 are 3 times more likely to develop preeclampsia than those women who begin pregnancy with a BMI in the normal range.  Why do we care?  Blood pressure issues in pregnancy are the most common cause of maternal death in most developed countries, like the U.S.

Blood sugar issues are another problem that is more common in obese women during pregnancy.  Gestational (pregnancy-related) diabetes risk increases as maternal BMI increases.  While only about 2.5% of women with a normal BMI develop gestational diabetes, this increases to about 5% with a pre-pregnancy BMI of 30 and to more than 10% for a BMI >35.  While it’s certainly not enjoyable to watch one’s diet before pregnancy, having to prick a finger to check blood sugar and taking or injecting medicine during pregnancy would definitely be less fun.

Even delivering the baby can be tougher for obese moms.  Labor tends to last longer, the chances of needing a cesarean section are higher, and babies tend to be bigger.  For moms with a starting BMI >30, the chances of delivering an 8 lb 13 oz baby is as high as 15%, and the chances of having a baby weigh nearly 10 lbs or more is about 4%.  In comparison, mothers with a normal BMI have less than a 10% chance and about a 1% chance, respectively.  The issues with larger babies are that they often have to stay in the hospital longer as they can have trouble with their blood sugar or they can potentially get hurt if they get stuck during the delivery.  In fact, baby size alone increases the odds of needing a cesarean section to deliver the baby.

Of course, not all obese mothers have poor pregnancy outcomes, and not all normal weight mothers have good pregnancy outcomes.  Also, we’d definitely not advise intentional weight loss during pregnancy.  Still, working to attain a healthy weight prior to conceiving and monitoring weight gain during pregnancy do decrease the risk of pregnancy complications, and that happy, health pregnancy is what it’s all about 😊

Dr. Nick

CBD Oil seems to be the hot new product that cures all sorts of ailments: anxiety, depression, nausea, seizures, inflammation, and insomnia just to name just a few.  CBD oil is available in sorts of different products: gums, candies, lotions, hair products, capsules, vape oil.   At prenatal visits, I get asked all the time- Is it safe to use CBD oil products for my nausea while I’m pregnant?

1. So, let’s start with what is CBD oil?  CBD oil is made by extracting cannabidiol from the flowers and buds from Marijuana or hemp plants and then diluting it with a neutral edible oil.  It does not have an intoxicating effect because it does not contain THC which is what causes the “high” when you smoke marijuana. 
2. Is there any medicinal use for Cannabidiol?  The FDA has only approved the medication Epidiolex to treat a rare form of childhood epilepsy.   Of the research done with cannabidiol, this is the only indication where the evidence suggests there may be some efficacy for treatment with cannabidiol.  For all its other purported benefits, there is not enough evidence for the FDA to recommend it as a treatment modality.  Also, whenever any product seems to be the panacea for so many different symptoms, there is always a concern about it being the new snake oil. 
3. Is CBD oil safe to use during pregnancy?  So unfortunately like most things, there are not enough studies for us to be able to say with certainty that CBD oil is safe in pregnancy.  However, several studies have found that there is an increased risk of preterm birth, small for gestational age babies, placental abruption, and increased admission to the Neonatal Intensive care unit for moms who used marijuana while pregnant.  Long term neurologic studies in children whose mothers used marijuana while pregnant do show increased risk of attention and behavioral problems, impaired visual acuity, verbal reasoning and comprehension and short-term memory issues.  For these reasons the American Academy of Pediatrics, the American College of Obstetrics and Gynecology and the US Surgeon General all warn pregnant women not to smoke marijuana or use any of its byproducts.

So, at this point, the FDA hasn’t found CBD oil to be an effective treatment for pregnancy-related nausea, and the medical community is concerned about the safety of cannabinoid-based products as they may be related to negative pregnancy outcomes.  Also, while we are aware that the THC in marijuana is responsible for the “high,” there haven’t been any studies to determine which part of cannabis plants is dangerous in pregnancy.  Given the lack of proven efficacy and also the potential danger of these products, the safest course of action would be to avoid them in pregnancy until the FDA and the medical community suggest doing otherwise.

​Dr. Pam