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