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  • About Us
    • Our Physicians
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  • Contact
  • Our Services & Treatments
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Nutritional Supplement Use in Pregnancy

4/13/2021

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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
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ADHD and Pregnancy

2/4/2020

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“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
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When should I Have My Next Baby?

4/16/2019

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I get this question a lot from my patients during their postpartum visit.  “So, I just had a baby and would like for my kids to be close in age- when is the best time to have my next baby?”
In the medical literature, this is called “birth spacing” and there have been lots of studies that have looked at ideal timing between pregnancies. 
  1. What is optimal time to wait between pregnancies?  If you are <35 and healthy, the ideal time to wait before planning your next pregnancy is 18-24 months and less than five years.  If you are over the age of 35, as fertility decreases at this age, the ideal interval may be closer to 12 months.  Remember these numbers do not apply to a miscarriage.  Most people with a first trimester loss are safe to start trying during the menstrual cycle following their loss.  However, you should consult with your doctor as they would be aware of your medical and pregnancy history and would be able to help you plan accordingly. 
  2. What are the risks of spacing a pregnancy closer than the recommended intervals?  Studies have shown that pregnancy within 6 months of a live birth increases the risk of premature birth, placental abruption, low birth weight, anemia, and congenital disorders.  Very closely spaced pregnancies often do not give mom enough time to recover from pregnancy and breastfeeding, as this can deplete your folate and iron stores, and which is why they are at higher risk of being anemic. 
  3. What are the risks of waiting too long? Long intervals between pregnancies can affect fertility and can increase the chance of developing preeclampsia.  Moms over the age of 35 have increased risks of preeclampsia, hypertension, diabetes, problems with the placenta and stillbirth.  There is also a higher chance of having a baby with a chromosomal issue.
  4. What is different if I had a c-section?  If you have had a c-section, waiting at least 6 months is preferred in order to allow the uterus to heal and decrease the chance of uterine rupture.  Most physicians also require a minimum of 6-12 months between pregnancies if you are considering a vaginal birth after cesarean (VBAC). 
Planning your family can be tough.  Even if you have the perfect plan in mind, there’s no guarantee that your body will cooperate, but by keeping the above guidelines in mind, then you can help make your pregnancy safer and more likely to result in the outcome you (and your provider) are hoping for:  healthy mom and healthy baby 😊

Dr. Pam
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Why Does Your OBGYN Get so Worked up about High Blood Pressure in Pregnancy?

11/8/2016

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From a physician standpoint, explaining the problems of high blood pressure is one of the most frustrating topics to discuss with patients. Often, a woman may not feel sick, and there is also often an element of denial, i.e. “I’m healthy, and I feel OK, so you must be confused.”  This is particularly common in those cases where high blood pressure was likely present even before pregnancy began.  So, here’s a brief overview of why your doctor cares.

First of all, what types of high blood pressure cause problems in pregnancy?  There are 3 main classes of blood pressure in pregnancy.  These are noted as a systolic blood pressure greater than or equal to 140 or a diastolic blood pressure greater than or equal to 90.  The first class is chronic hypertension.  This occurs when elevated blood pressure is present before 20 weeks of pregnancy and is generally unrelated to pregnancy.  This type of elevated blood pressure is usually before pregnancy.  Just because you don’t check your BP outside of pregnancy doesn’t mean it’s not there :)  The next two types are related to pregnancy:  gestational hypertension, which develops after 20 weeks and does not cause spillage of protein in the urine, and preeclampsia, which also occurs after 20 weeks but is associated with proteinuria.

So, what happens if I have chronic hypertension during pregnancy?  There can be actually be some lowering of chronic hypertension during the middle of pregnancy before an increase toward the end of pregnancy; however, the need for good control of your blood pressure is certainly important.  Chronic hypertension places a mother at risk for fetal growth restriction (small baby), development of preeclampsia (just because you have chronic hypertension doesn’t get you off the hook for preeclampsia), placental abruption (early separation of the placenta prior to delivery causing bleeding and risk of fetal loss if not immediately managed), and also increased risk of cesarean section.

What about gestational hypertension or preeclampsia?  These are managed similarly in their mild forms, and gestational hypertension may in fact be a mild form of preeclampsia.  With development of gestational hypertension or mild preeclampsia, this condition must be monitored closely to ensure that severe preeclampsia doesn’t develop.  In addition to the risks noted with chronic hypertension, women with preeclampsia are at risk for need for preterm delivery, maternal kidney or liver dysfunction, hemorrhage and even seizures.  With severe preeclampsia, women may even be at risk for maternal death.  After pregnancy, women with a history of preeclampsia have an increased risk for development of cardiovascular disease such as stroke, heart attack, elevated blood pressure and kidney dysfunction.  They are also at risk for having preeclampsia again in a future pregnancy.

What happens to my baby if I have preeclampsia?  Additional monitoring is required to monitor for development of severe preeclampsia.  If you do develop severe preeclampsia, then your baby will likely have to be delivered early.  Risks associated with preterm delivery may include respiratory distress, cerebral palsy, need for NICU stay, feeding issues or even loss of the baby in some cases; however, as bad as those risks sound, there may be a point in pregnancy where these risks are less than those associated with continuing the pregnancy.

How is elevated blood pressure treated in pregnancy?  You may require medication to bring down your blood pressure, lab monitoring to check for development of severe preeclampsia, monitoring to check for fetal distress or even early delivery (with or without administration of steroids and/or magnesium prior to delivery).  Magnesium may also be required to help prevent seizures associated with severe preeclampsia.

Are there risk factors for preeclampsia?  First pregnancies, history of preeclampsia in other pregnancies, personal history of chronic hypertension or kidney disease, age 40 or older, carrying more than one baby, personal history of diabetes, clotting disorder or lupus, maternal obesity and pregnancy via in vitro fertilization.

Can I prevent preeclampsia?  The best way to prevent preeclampsia is to ensure that you are as healthy as possible prior to beginning the pregnancy.  If you are obese, weight loss may help reduce your risks.  For chronic hypertension or diabetes, ensure that these are well-controlled prior to conceiving.  If you have had a history of delivery prior to 34 weeks due to preeclampsia, your doctor may start you on a daily baby aspirin.

So, even though you might not feel miserable due to your high blood pressure, it is still  very important to maintain good control in order to have the healthiest pregnancy outcome possible.  If you have any of the risk factors listed above, be sure to talk to your provider about how to minimize your risks in your current (or future) pregnancies :)

Nick
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Planning your pregnancy

3/29/2016

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Ideally, pregnancy planning should begin at least 3 months prior to conception with prenatal vitamins.  These should contain iron for prevention of anemia, folic acid (or methyl folate) for prevention of neural tube defects and DHA to help with fetal neurologic development.  Why so early, you ask?  Well, the critical time for adequate folic acid intake begins even before the first missed menses, so by the time you know you’re pregnant, your body has already begun to utilize its stores of the vitamin.  Still, my big selling point to women who aren’t a fan of taking a vitamin every day is that recent studies have shown women who take a prenatal vitamin for at least 3 months prior to conception have lower levels of nausea and vomiting during early pregnancy. Don’t want to be a “puker”? Take your prenatal vitamins.

So, you’ve been taking your prenatal vitamins for 3 months, and now you’re looking to start trying for your baby.  I’m often asked when is the best time to have intercourse in order to conceive.  For a woman with a 28 day cycle, we would expect her to ovulate between days 13 to 15, although this can vary from woman to woman.  This egg will only last between 12-24 hours, so it is critical to make sure sperm are present to fertilize the egg when ovulation occurs.  Since sperm may live up to 5 days or so within the woman’s body, beginning scheduled intercourse at least every other day (some studies say as frequently as twice a day) from 5 days prior to expected ovulation until 1 day after are the optimal times to be intimate when trying to conceive.  Ovulation can be tracked using a phone app like Glow, home ovulation kits and via basal body temperature.
​

Once pregnancy occurs, your physician will look for three criteria to confirm a successful pregnancy: 1. location within the uterus (womb), 2. presence of the fetal pole (the part that becomes the baby), and 3. the development of a heartbeat within the fetal pole.  This generally requires 7-8 weeks of pregnancy to be able to see all 3 criteria well; otherwise, testing has a higher likelihood of being inconclusive for those measurements.  After these markers have been confirmed, the real excitement can begin!  Whether a long-awaited dream come true or a happy little surprise, come celebrate your pregnancy with Teton Women’s Health Center!

Nick
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