The COVID pandemic has had profound impact on everyone’s life last year, and pregnant women have not been an exception.  Despite living through quarantine, masking, social distancing, development of vaccination, and sometimes even experiencing COVID firsthand, the uncertainty of how COVID may affect you or a loved one may be the most stressful experience of them all.  Unfortunately, there are still unknowns about the virus and vaccination, but today’s blog will focus on what has been learned so far.
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How dangerous is COVID for women of childbearing age? 
As of writing this blog, there have been 586,659 deaths attributed to COVID in the US.  Of those, 2.7% or 15,909 have been in the age group less than 45 years old, which would be the age group including women of childbearing age.  (https://www.cdc.gov/nchs/covid19/mortality-overview.htm)

We have demographic data for age on 26 million of the cases of COVID, and of those 26 million, 64.5% of cases occurred in those 49 years old or less.  (https://covid.cdc.gov/covid-data-tracker/#demographics)  Assuming a similar distribution among the total cases of 33,292,045, that would mean 21,473,369 cases occurred in those 49 or less.  So, 15,909 divided by 21,473,369 means that the chance of dying from COVID in this age group if infected is roughly .07%  Another study looked specifically at pregnancy (https://www.bmj.com/content/370/bmj.m3320), and it showed 339 deaths from all causes in pregnant women with known COVID of 41,664 total pregnant women with known COVID.  This worked out to 0.02%  More severe COVID in this study was associated with increased maternal BMI, medical comorbidities, hypertension, diabetes and preeclampsia.  Looking at these numbers would suggest a maternal mortality risk of 0.02-0.07% from COVID, although mothers with health conditions listed above would potentially have an increased risk.

How do COVID vaccines work?
There are 3 main types being evaluated:

1. mRNA vaccines – this is the newest type of vaccine, and it works by using material (mRNA) from the COVID virus that instructs the body’s cells to make proteins specific to the virus.  After exposure to these proteins, the body creates T and B lymphocytes to fight the virus if exposed to COVID in the future.  These include the Pfizer and Moderna vaccines.  Each requires 2 injections to obtain immunity.
2. Protein subunit vaccines – these vaccines introduce a protein from the COVID virus to prompt the body to create T lymphocytes and antibodies to fight the virus if exposed in the future.  This is similar to how the Hepatitis B vaccines work and one of the pertussis (whooping cough) vaccines.
3. Vector vaccines – these vaccines use another virus modified to contain genetic material from COVID.  Once introduced into the cell, the genetic material from COVID instructs the cells to make proteins that will induce B and T lymphocytes.  Johnson and Johnson makes a vector vaccine, and it only requires one injection to obtain immunity.  Astrazenaca also makes a vector vaccine.

(https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/how-they-work.html?s_cid=10491:how%20the%20covid%20vaccine%20works:sem.ga:p:RG:GM:gen:PTN:FY21)

Are COVID vaccines effective?
Johnson and Johnson vaccines are 66% effective at preventing COVID 19 illness in people who haven’t been exposed previously; fortunately, none of those who got COVID more than 4 weeks after vaccination were hospitalized.  (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/janssen.html) 

The Pfizer vaccine is purported to have 95% efficacy at preventing laboratory detected illness in those without evidence of previous infection.  (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Pfizer-BioNTech.html)  The Moderna vaccine is reported to be similarly effective at 94%  (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/Moderna.html) 

These numbers are a little difficult to track from an independent source as breakthrough cases (infections without hospitalization or death following vaccination) are not reported to VAERS.

Are COVID vaccines safe?
At this time, COVID vaccines have received an emergency use authorization.  This means that the FDA makes a product available to the public based on the “best available evidence,” without waiting for all of the evidence necessary for formal FDA approval.  For formal FDA approval, adequate evidence must be necessary to determine that a product is safe and effective for its intended use and can be manufactured to meet quality standards.  (https://www.fda.gov/consumers/consumer-updates/understanding-regulatory-terminology-potential-preventions-and-treatments-covid-19)

Currently, the big side effects making the news are anaphylaxis (severe allergic reaction in 2-5 per million), thrombosis with thrombocytopenia syndrome (36 of 11 million with the J&J vaccine, highest risk in women under 50), myocarditis (511 cases reported, 323 confirmed mostly with mRNA vaccination, most common in young males), and death associated with vaccination (5,343).  Now, to clarify on the last number.  These deaths have been reported to VAERS as occurring after vaccination, although at this time there isn’t a way to discern whether the vaccination was the direct cause of death.  If a causal link was shown, it would constitute a rate of 0.0017%  (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html)

Does natural immunity from COVID provide protection?
In Lombardi, Italy 1,579 patients were followed for an average of 280 days after COVID 19 infection, and of those, only 5 (0.31%) were reinfected.  Of those 5, only one was hospitalized.  (https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2780557)

Over 5 months, 1,359 caregivers at Cleveland Clinic who had previous COVID 19 infection and did not receive vaccination had no recurrent COVID infections detected.  (https://www.medrxiv.org/content/10.1101/2021.06.01.21258176v2.full)

What do the experts say?
Formal evaluation of the COVID vaccines in pregnant women with controlled studies have not yet been published, although some trials are in the works.  Because of this lack of information, the WHO suggests vaccination with mRNA vaccines only for pregnant women with either high risk of exposure, ie healthcare workers, or those with comorbidities that may increase risk of severe disease.  (https://www.who.int/news-room/feature-stories/detail/the-moderna-covid-19-mrna-1273-vaccine-what-you-need-to-know)

 ACOG suggests that all women, including pregnant and lactating women, have access to COVID 19 vaccination, as well as the most current safety information, and that they should be supported in whatever decision they make.  (https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/covid-19-vaccination-considerations-for-obstetric-gynecologic-care)

In summary, there are still a lot of unknowns regarding COVID 19 infection, vaccination and particularly how each might affect pregnancy.  We don’t yet know how long immunity from vaccination or previous infection lasts, although it looks like both may provide initial protection against COVID 19 infection or reinfection, respectively.  We will continue to await information on efficacy of the vaccine and immunity against different COVID variants.  Even though we have some idea how COVID 19 may affect a pregnant woman during her pregnancy, we don’t yet know how either infection or vaccination may affect a developing fetus in the long term, and unfortunately, by the time we do, the babies most affected will no longer be babies, and the pregnant women most affected will no longer be pregnant.  At TWHC, we will continue to monitor what data is available and provide updates as we can.  In the meantime, our goal is to provide the relevant information for each mother-to-be so that she can make the best decision for her.

Dr. Nick

If you’ve been to a doctor’s office while planning or during a pregnancy, chances are quite good folic acid (to prevent neural tube defects), DHA (to promote baby’s brain development) and iron (for prevention of anemia) have been recommended.  These relatively universal recommendations have been shown to help promote health pregnancies, and safety of these supplements have been well established.  Unfortunately, as nutritional supplements are regulated by the FDA, there is a lot of misleading information or simply limited information about most nutritional supplements.  While some of these supplements may be beneficial, others may in fact be harmful in pregnancy, even some of the “natural” ones.  Here’s a short list of some of the more commonly asked about supplements and what information is available for them.

1. Tabacum – an herbal product used for nausea/vomiting in pregnancy.  Unfortunately, this tobacco-based supplement contains nicotine and should definitely be avoided in pregnancy as it can cause harm to a baby’s brain and lungs.
2. Melatonin – this supplement has actually garnered a lot of interest in pregnancy studies, and there are some ongoing studies to assess whether it may reduce risk of preeclampsia and growth restriction in pregnancy.  However, at this time, safety data in pregnancy is relatively limited, and since Unisom with doxylamine has an extensive safety profile (and can help with nausea in pregnancy), doxylamine is would typically be advised rather than melatnonin until further safety testing can be done.
3. Kombucha – often used as a source of probiotics, this fermented food can contain alcohol as a part of the fermentation process, so kombucha should be avoided as alcohol intake in pregnancy can be associated with birth defects and intellectual/behavioral disorders.
4. CBD – although many people may be aware of the potential for marijuana and THC use in pregnancy to affect a baby’s brain development and increase the risk for a smaller or preterm baby, it may be less well-known that CBD use in pregnancy should also be avoided.  In addition to potential for liver toxicity, there is also concern for negative effects on the developing male reproductive system.
5. Astragalus – used to boost immunity, energy or even milk production postpartum, it can cause irregular heartbeat, dizziness and may be passed along to the fetus during pregnancy and lactation, so it should be avoided during and after pregnancy.
6. Red raspberry leaf- taken as a tea to reduce labor pain, nausea and miscarriage while increasing milk production, it appears to be relatively safe, although it hasn’t been proven to be effective for treating any of the above claims.
7. Nux vomica – this herbal treatment for nausea should undoubtedly be avoided in pregnancy as it contains strychnine, which can be harmful to both mom and baby.  In fact, the primary use of strychnine today is as rat poison.
8. Vitamin A – one of the trickier supplements in pregnancy.  Very low levels can potentially be associated with growth restriction, hearing loss for baby, insulin resistance for the baby later in life, and some birth defects such as microcephaly or kidney defects.  Too much is also bad – increased risk of miscarriage and heart/nervous system defects.  A typical prenatal vitamin often helps walk the line between too much/too little, although supplementing with more than 5000 IU per day should be avoided during pregnancy, and intake should not exceed more than 25000 IU per week.

Supplement use in pregnancy can be complicated, and the limited or misleading information available can make the decision of whether or not to take them very confusing.  Unfortunately, your provider may have little to add to the conversation as most of these products don’t have controlled studies available to quote, and they aren’t regulated by the FDA.  Generally, it often makes sense to err on the side of caution as even if the supplements may not have inherent risk, these products are not infrequently contaminated by other products that may not be safe in pregnancy.  The bottom line is that all supplements used in pregnancy should be reviewed with your provider so that you can make the best possible decisions regarding supplement use in your pregnancy.

​Dr. Nick

Since Marijuana has been legalized in many states, there is a general perception that it is a natural and safe drug unlike other drugs.  This perception is reflected in the number of pregnant women who use marijuana while pregnant.  In 2017, a study showed that 1 in 20 women used marijuana while pregnant.  In 2002, the number of women who used marijuana was 1 in 10.    

Now before we talk about marijuana use in pregnancy and autism, let’s review some stuff we already know about MJ use in pregnancy.  First it does cross the placenta.   THC crosses the placenta and can be found in fetal circulation at 10% of the maternal level.  Second, we also know that marijuana can bind to fetal cannabinoid receptors as early as 14 weeks of pregnancy.  Third, studies have shown that exposure to marijuana in pregnancy can disrupt normal brain development.  Children born to women who used marijuana while pregnant are more likely to have low birth weight at birth, hyperactivity, and attention, cognitive and behavioral issues.

So, a couple weeks ago a study out of Canada published in Nature showed that women who used marijuana while pregnant were 1.5 times more likely to have a child with autism. The researchers reviewed 500,000 births between 2007 and 2012 in Ontario, Canada.  They found an association between maternal cannabis use in pregnancy and the incidence of autism spectrum disorder in these children.  The incidence of autism spectrum disorder diagnosis was 4 per 1000 children who were exposed to marijuana and 2.4 among children who were not exposed to MJ in utero. 

So, while this study does not definitively prove that marijuana use during pregnancy causes autism, there does seem to be a strong association.  Based on these findings, as well as ACOG (American College of Obstetricians and Gynecologists) recommendation, we encourage our patients to avoid using marijuana during pregnancy and breastfeeding.  

​Dr. Pam

“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.
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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

We always strive for our patients to have an uncomplicated easy vaginal delivery with minimal tearing and discomfort.  However, sometimes a c-section is necessary to get both baby and mom safely through the labor and delivery process.  Some reasons for a c-section include the following: fetal distress in labor, problems with the placenta, position of the baby in the uterus, the cervix stops dilating or the baby stops moving down through the pelvis….
For many moms having their first c-section, a lot of times this is the first major surgery they have ever had.  They have lots of questions but have very little idea on the best way to get through the recovery.  Here are some tips that we hope can help you through the process.

1. Use a belly band:  So, both hospitals will provide you with a belly band if you have had a c-section; if you don’t get one right away- just ask your nurse for one.  When you are walking and moving around this will really provide you with the back and abdominal support you need to make the recovery process easier. 
2. Use a pillow when contracting your abs!  Anything that works your abdominal muscles, like coughing and laughing, can be pretty painful after a c-section.  We recommend placing a pillow on your abdomen before coughing and laughing to provide some support and help ease the discomfort your will feel when using your abdominal muscles. 
3. Make sure you stay on top of the pain!  I’ve seen lots of patients try to tough it out and not take pain medication because they did not like the way it made them feel.  For the first 3 days, it is very important to use these medications to help with the pain.  Initially we want your body to focus on healing, not on fighting pain.  Everyday will get better, and once the pain has improved, then you can decrease the amount of pain medication that you are taking.
4. Don’t compare your recovery to others.  I always hear family members talk about how they had a vaginal delivery without an epidural and toughed it out or stopped taking pain medication 1 day after the c-section.  Don’t let other people get to you.  This is not a contest.  If your family and friends are not being supportive, then you may have to consider temporarily limiting their access to you and the baby.  This time is about your recovery, not theirs!
5. Do what you can to prevent constipation before it happens!  Make sure you drink as much fluid as you can.  Usually we will provide you with a stool softener after your deliver. Recovering from a c-section and constipation can make you pretty miserable- we are there to help if you are struggling. 
6. Breastfeeding is hard, especially if you have just had a c-section!  This is a very anxiety provoking process for most new moms, especially if they had an unanticipated c-section.  Your milk probably has not come in and you are pretty sore from your c-section and your baby is not latching on- this is a pretty classic scenario.  Take a deep breath, utilize the nursing staff and lactation consultant and don’t fret- your milk probably won’t come in until the moment you’re are discharged.  Please let us know if you are struggling and need help.  If you decide breast feeding is not for you- that is ok- we are here to provide support, whatever your decision may be!

For most new moms, pregnancy is just the beginning of the baby challenge, and especially for those recovering from a cesarean section, the newborn time can seem even more daunting as you recover from surgery.  Please let others spoil you and take care of you while you are healing.  Try to take advantage of friends and family if they are available.  Utilize their help with the baby, meal planning, cleaning and whatever else they may offer and try to get some sleep!

​Dr. Pam

For many women, just “getting through” labor and delivering the baby should be the end of birth-related pain, right?  Unfortunately, that’s not always the case.  From vaginal tears to breastfeeding (yes, that can sometimes be pretty miserable, too), for some women the delivery is only the beginning of their postpartum discomfort.

​So, what can hurt so much compared to labor and delivery?  According to ACOG (the American Congress of Obstetricians and Gynecologists), somewhere between 53-79% of women experience tearing during childbirth whereas their British counterparts estimate that number to be as high as 90%.  Either way, chances are good that moms having vaginal births will have some type of laceration.  Not only can the repair process be extra uncomfortable for moms without an epidural, but suture in such a sensitive area can definitely cause some discomfort for some time after delivery.  We also know that some amount of labial swelling is also normal after delivery, and this is especially true for women who push for a long period of time.  In some cases, we can even see extra separation of the pubic bone where it stretches to accommodate a baby's head (pubic symphysis diastasis).  As for breastfeeding, pain can happen from the latch process, cracked nipples with thrush, mastitis and even the uterine contractions associated with breastfeeding.  Breastfeeding causes release of oxytocin, the same hormone used to stimulate labor, and this can result in pretty significant uterine contractions for some moms.  Lastly, moms who need cesarean delivery are expected to have pain after their surgery, too.

Is there anything to do about all this fun stuff?  During suturing of a vaginal tear, moms who have an epidural are already a little ahead of the game, although we certainly do our best to help numb the area with lidocaine for those who don’t have an epidural.  That being said, even with an amount of lidocaine injections that would be drool-inducing in the mouth, it’s quite a challenge for us to effectively numb the vagina.  Ice packs can be a big help for some of the labial swelling after delivery.  Occasional sitz baths may also be beneficial for women with tears as can stool softeners to help prevent constipation and straining in the area of a vaginal repair.  Pubic symphysis diastasis may require physical therapy or even a walker for a brief time.  With breastfeeding, moms are encouraged to take advantage of the knowledge of a lactation consultant to ensure proper latching and nipple care.  Thrush and cracked nipples often respond well to topical treatment whereas mastitis generally requires antibiotics to resolve.  Regrettably, there’s not much we can do to suppress contractions when breastfeeding.  Tylenol and Ibuprofen are also helpful for pain following a vaginal delivery, although postoperative pain from a cesarean delivery is likely to require something stronger.

For many fortunate moms, pain from labor and delivery fades soon after their baby is born; however, for others, some amount of discomfort may persist a bit longer.  Collaborating with your provider is generally the best way to ensure a satisfactory healing process, so if you are having issues, be sure to let them know.  The sooner you feel better after delivery, the more time you can focus on loving that new baby 😊

Dr. Nick