Mother's Exercise decreases Fetal Macrosomia

Exercise during pregnancy is beneficial for mom. But, does it have an effect on baby, too?

Fetal macrosomia is defined as a baby weighing greater than 4000 to 4500 grams (approximately nine pounds). Fetal macrosomia contributes to increased maternal risks including increased perineal lacerations, cesarean delivery and postpartum hemorrhage. Fetal macrosomia contributes to fetal risks such as shoulder dystocia (which can result in temporary or permanent injury), other birth trauma, low Apgar scores and obesity.

In the October, 2009 edition of Obstetrics and Gynecology a large, Norwegian, prospective pregnancy cohort study included outcomes of 36,869 singleton pregnancies lasting at least 37 weeks. 10.9% of the babies were macrosomic at the time of birth. Regular exercise (at least 3 times per week) during pregnancy significantly decreased the likelihood of a woman delivering a macrosomic fetus. Regular exercise before pregnancy had no effect on the rate of delivering a newborn with excessive birth weight if the exercise did not continue during pregnancy.

The exercise most likely to be associated with a normal birth weight included walking, running, dancing and low-impact aerobics. Women who participated in swimming during pregnancy were more likely to give birth to a newborn with an excessive birth weight.

Conclusion: Regular exercise during pregnancy at least 3 days per week reduces the odds of giving birth to newborns with excessive birth weight by 23-28%.

Reference:
Owe KM, Nystad W, Bo K. Association between regular exercise and excessive newborn birth weight. Obstetrics and Gynecology 2009;114(4)770-776.

Home Birth Gone Awry

This is an excellent MedScape article that discusses the potential perils of home birth but offers a balanced discussion about improving the care for women who opt for a home birth in the United States. Important clarifications about the different midwifery certifications is reviewed - they are not one size fits all. As medical costs continue to climb in the United States, and home birth is 1/3 as expensive as hospital delivery, consideration should be given to European systems that deliver safe and less expensive care for pregnant women. Women who opt for home deliveries, almost without exception, are seeking more autonomy surrounding the delivery of their baby.

It is time for the medical community to have meaningful discussions with women about their desires for childbirth. It is time to better educate women about the potential risks associated with childbirth - whether within a controlled medical environment or at home. This, of course, assumes that the medico-legal environment surrounding childbirth be reexamined, as well.

Read: Home Birth Gone Awry

H1N1 2009 Influenza Virus Infection during Pregnancy

The H1N1 virus, otherwise known as the swine flu virus, was first identified in April, 2009. While pregnant women have always been more affected by the influenza virus, the H1N1 virus has hit them particularly hard. The CDC states that pregnant women infected with H1N1 are four times more likely to be hospitalized with their illness than the general population. A study recently published in the Lancet Medical Journal states that 13% of all the deaths reportedly caused by this virulent influenzae virus in the Untied States between April 15 and June 16 of 2009 have been in pregnant women. This is an alarming number as only 1% of the population is pregnant at any given time - therefore, pregnant women are over-represented in the portion of individuals who develop severe disease.

Excess influenza-related deaths in pregnant women have been reported during prior pandemics between 1918-1919 and 1957-1958. The possible effects of influenza virus during pregnancy include increased risk of miscarriage, preterm labor and delivery, maternal and fetal death. The CDC has put out certain guidelines in anticipation of

• Pregnant women with suspected or confirmed influenza infection need prompt treatment with antiviral medication - best if within the first 48 hours.
• Pregnant women are at increased risk of severe complications if they become infected with the influenza virus.
• Pregnant women, regardless of health status, are more severely impacted by the H1N1 virus.
• Pregnant women who become infected with the H1N1 influenza virus are more likely to be hospitalized if infected than non-pregnant patients.

Typical influenza (H1N1) symptoms include: body aches, cough, fever, runny nose, headache, fatigue, vomiting, diarrhea. Women who present with symptoms of influenzae should be quarantined in a separate waiting room while awaiting their appointment.

Women who are ill with a flu-like illness should be treated promptly; they should receive treatment while awaiting test results. Please, do not hesitate to contact your health care provider if you think you may be infected by the influenzae virus.

As reported by staff writers of the Washington Post on July 10, 2009. 100 million vaccinations should be available by mid-October; another 20 million later in the season. Those first in line for the vaccine will be school-aged children. Next up will be pregnant women, adults with chronic illnesses, younger children and health-care workers. An additional $350 million dollars of aid has been dispersed by the Obama administration to stem the tide of another pandemic.

The CDC reported July 2, 2009 that number of swine flu cases in the United States reached nearly 34,000 and number of deaths rose 34% to 170. The United States has reported nearly one-half of all the world's reported cases.


References:
1. Jamieson DJ, et al. H1N1 2009 influenza virus infection during pregnancy in the USA.
www.thelancet.com Published online July 29, 2009 DOI:10.1016/S0140-6736(09)61304-0
2. Students 1st in Line for Flu Vaccine by David Brown and Spenser S. Hsu, Washington Post
3. How to take care of an ill person with the swine (H1N1) flu.

Images:
H1N1 virus posted by News.Yahoo.com
H1N1 virus posted by Stanford.edu

Postpartum Depression Linked to Poor Sleep

How well are you able to sleep when your baby sleeps? This is the single most important question to ask yourself if you think you may be depressed. If your answer is "not well" or "I can't" you may be suffering from postpartum depression.

Approximately 13% of women giving birth in the United States will suffer from postpartum depression (PPD). Postpartum depression is defined in the United States as a depressive episode that occurs from the time a woman gives birth until six months postpartum. European countries expand this definition to include a depressive episode within the first twelve months postpartum.

A recent study published in SLEEP explored the relationship between poor sleep and postpartum depression. All 4191 women who delivered at Stavanger University Hospital in Stavanger, Norway from October, 2005 through September, 2006 were mailed questionnaires seven weeks after giving birth. Approximately 70 percent responded. 57.7% were experiencing sleep difficulties at the time while 16.5% were suffering from postpartum depression. Those who suffered from sleep problems, especially during the daytime hours, were more likely to be diagnosed with postnatal depression than the 40% who did not.

This is important information as it alerts the medical community to look for depression in new mothers who are experiencing sleep difficulties. Afterall, symptoms of fatigue from sleep deprivation such as decreased energy, impaired memory and tearfulness are not all that different from symptoms of depression.

Symptoms of depression include:

• Feeling very sad, anxious or irritable
• Frequent crying
• Not feeling up to doing normal daily tasks
• Not feeling hungry, or eating when not hungry
• Not wanting to care of yourself (bathing, getting dressed, doing your hair)
• Trouble sleeping when your tired, or sleeping too much
• Things don't seem fun or interesting anymore
• Trouble concentrating
• Feelings of guilt
• Feeling of hopelessness
• Difficulty making decisions
• Worrying too much about the baby or not caring about the baby
• Fear of harming or being alone with your baby
• Thoughts of harming yourself or suicide

If you think you may be suffering from postpartum depression, please seek the help of a medical professional. If you think a loved one is suffering from postpartum depression, please encourage her to contact the provider who cared for her during her pregnancy and/or her primary care provider. Postpartum depression resources are listed below.

Help lines

1. Postpartum Depression Helpline available 24/7

1-800-PPD-MOMS (1-800-773-6667)

2. Postpartum Support International

1-800-944-4PPD (1-800-944-4773)

Online Postpartum Depression Resources

1. Healty New Moms

2. The World Health Organization

3. American Psychiatric Association

4. The National Women's Health Information Center

Article Reference:

Dorheim SK, Bodevic GT, Eberhard-Gran M, Bjorvatn B. Sleep and depression in postpartum women: A population-based study. SLEEP 2009;32(7):847-855

IOM Issues New Recommendations for Weight Gain During Pregnancy

May 28, 2009 — The Institute of Medicine and the National Research Council today released a report recommending new guidelines for weight gain during pregnancy. The report updates guidelines that were last set in 1990 and takes into account changing US demographics, particularly the increase in the numbers of women of childbearing age who are overweight and obese.

The new guidelines are available on the Institute of Medicine's Web site.

"The earlier guidelines recommended weight gain that would be optimal for the baby. These new guidelines take into account the well-being of the mother as well. This is a fundamental and important change," Kathleen M. Rasmussen, ScD, professor of nutrition at Cornell University and chair of the guidelines committee, said at a press briefing where the new recommendations were announced.

The 2009 guidelines also differ from those issued 2 decades ago in 2 other ways. They are based on World Health Organization cutoff points for body mass index (BMI) categories, unlike the earlier guidelines, which were based on weight categories taken from the Metropolitan Life Insurance tables. They also recommend a more narrow range of weight gain for obese women.

The recommended weight gain for each category of prepregnancy BMI is as follows:

• Underweight (<>2); total weight gain range: 28 to 40 pounds
• Normal weight (18.5 - 24.9 kg/m²); total weight gain range: 25 to 35 pounds
• Overweight (25.0 - 29.9 kg/m²); total weight gain range: 15 to 25 pounds
• Obese (≥ 30.0 kg/m²); total weight gain range: 11 to 20 pounds

"Women who gain within these guidelines will do better than if they gain outside of them. We have good evidence for this," said Dr. Rasmussen.

Read IOM press release

Calculate your Body Mass Index (BMI)

Early Predictors of Successful Pregnancy

May, 2009

Successful pregnancy can be predicted with up to 94% accuracy between days 33 and 36 using transvaginal ultrasound to detect 3 markers, according to new findings presented by Dr. Soyoung Bae at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting in Chicago, Illinois.

The predictors include ultrasound findings between 33 and 36 days after conception in otherwise healthy women:

• gestational sac at least 12 mm in diameter
• yolk sac with a diameter of 2 to 6 mm
• presence of fetal cardiac activity

Dr. Bae said. "These markers were associated with favorable pregnancy outcome even in the poor prognostic subgroups of women of advanced maternal age and those with recurrent pregnancy loss."

Read entire article

Diabetes May Double Risk of Perinatal Depression

Pregnant women and new mothers that have diabetes, whether the diabetes was discovered during pregnancy or before, are twice as likely to experience depression than women who do not have diabetes (Kozhimannil, 2009).

The authors reviewed the medical records of 11,024 low-income women who delivered in New Jersey between 2004-2006. 657 women had diabetes. 15% of those with diabetes had or developed depression, whereas only 8% of women without diabetes had or developed depression.

Perinatal depression (i.e. depression "around" the time of giving birth) is under-diagnosed and, therefore, inadequately treated. Clinicians, family members and expecting and new mothers should be aware of this risk and pay particular attention to evolving mental health issues - especially in women with diabetes.

Read article abstract HERE.

Reference:
Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression. JAMA 2009 Feb 25;301(8):842-7

USPSTF Recommends Folic Acid Supplements for Women of Child-Bearing Age

By Laurie Barclay, MD

May 12, 2009 — New observational evidence supports previous evidence from a randomized controlled trial that folic acid–containing supplements lower the risk for pregnancies affected by neural tube defects, according to a US Preventive Services Task Force (USPSTF) statement and review of evidence reported in the May 5 issue of the Annals of Internal Medicine. The review suggests that the previously noted association of folic acid use with twin gestation may be confounded by fertility interventions.

Based on the evidence, the USPSTF has issued a grade A recommendation that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 - 800 µg) of folic acid.

Regarding benefits of this preventive measure, the USPSTF found convincing evidence that taking supplements containing 0.4 to 0.8 mg (400 - 800 µg) of folic acid during the periconceptional period lowers the risk for neural tube defects....

Read complete article.

Effect of Food Intake During Labor

There is an ongoing international debate about food consumption during labor. The current rationale for women fasting during labor is to protect them from pulmonary aspiration should general anesthesia be needed for an emergency cesarean delivery. Other concerns include increased cesarean rate (Scheeper, 2002) or prolongation of labor (Tranmer, 2005) should women be allowed to eat while laboring.

On March 24, 2009 the British Medical Journal published a well-done randomized controlled trial (O'Sullivan, 2009) of over 2000 women suggests we should revisit current practices of not allowing women to eat while in labor.

Historical perpective:
1946: CL Mendelson published a paper in The American Journal of Obstetrics and Gynecology (1946) entitled: The aspiration of stomach contents into the lungs during obstetric anesthesia. Mendelson described acid pulmonary aspiration and an increase in maternal death due to choking if women consumed solid food while in labor and needed a cesarean delivery.

2007: The American Society of Anesthesiologists published obstetric guidelines stating that "the oral intake of solids during labor increases maternal complications....solid foods should be avoided in laboring patients and that the oral intake of modest amounts of clear liquids (e.g. water, clear tea, black coffee and sports drinks) may be allowed for uncomplicated laboring patients."

Recent advances in intrapartum care (e.g. increased use of epidural anesthesia, antacids and better training of obstetric anesthetists) have caused a dramatic decline in pulmonary aspiration.

Some countries now challenge the practice of mandatory fasting for all laboring women - more so in Europe than in the United States.


O'Sullivan study:

• This study was performed in a London hospital between June 2001 and April 2006.
• 2426 women were randomized to eating vs. water-only group.
• All women were experiencing their first delivery.
• Primary outcome was the rate of spontaneous vaginal delivery.
• Secondary maternal outcomes included the duration of labor, use of IV oxytocin, use of inhaled or epidural analgesia.
• Secondary neonatal outcomes included fetal weight, Apgar scores and admission the the neonatal intensive care unit.
• Women in the eating group were advised to consume a low fat, low residue diet at will during labor. Suggested foods included fruits and vegetables, breads, soup, low fat yogurt, fruit juices and sports drinks.

Results:

• No difference in vaginal delivery vs. cesarean delivery rate between the two groups (30% cesarean delivery rate in both groups).
• No difference in length of labor.
• No difference in Apgar scores or admission to the neonatal ICU.
• No cases of aspiration pneumonia (However, because aspiration is so rare, a much larger study would have been needed to see one case.)
• One maternal death occurred in the water-only group due to a brain hemorrhage.

Interpretation:

• Feeding in labor does not increase or decrease risk of cesarean delivery.
• Feeding in labor does not shorten or lengthen labor.
• Obstetrical and neonatal outcomes are not altered based upon whether women are allowed to eat during labor.
• Some clinicians may decide, in low risk laboring women, that the consumption of a light diet could be left to the woman's discretion.

Side note:
The UK Confidential Enquiries into Maternal and Child Health reviewed 2,113, 831 deliveries between 2003-2005. Six anesthesia-related deaths occurred, none of which was associated with pulmonary aspiration. Similar findings were reported by the Australian Anesthesia Incident Monitoring Study. This supports the statement that aspiration pneumonia is exceedingly rare.

References:

1. O'Sullivan G, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:b784

2. American Society of Anesthesiologist’s Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia. Anesthesiology 2007;106:843-63.

3. Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

4. Scheepers HCJ, Thans MCJ, de Jong PA, Essed GG, Le Cessie S, Kanhai HH. A double-blinded randomised, placebo controlled study on the influence of carbohydrate solution intake during labor. Br J Obstet Gynecol 2002;109:178-81.

5. Tranmer JE, Hodnett ED, Hannah ME, Stevens BJ. The effect of unrestricted oral carbohydrate intake on labor progress. J Obstet Gynecol Neonatal Nurs 2005;34:319-28.

6. Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003-2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH, 2007.

Fibroids and Infertility

Q: Do fibroids cause infertility?

Fibroids are common benign tumors of the uterus. They occur predominantly in premenopausal women, and their growth appears to be hormone (estradiol, progesterone) dependent. They may grow towards the uterine cavity (submucosal) or towards the abdominal cavity (subserosal), or they may be located within the uterine wall (intramural). Fibroids may be asymptomatic or could be associated with a variety of complaints. Symptoms, such as irregular bleeding, pelvic pressure, urinary frequency, constipation, and pain, are associated with size, number, and location of the fibroids.

It has long been suspected that fibroids that distort the uterine cavity (submucosal or intramural) are associated with infertility and miscarriages. The association between fibroids and reproductive failure (infertility, pregnancy loss) has been studied by several groups. However, the majority of these studies have been too small to yield meaningful results. In addition, few studies have addressed the benefits of treatment in a well-designed manner. To further complicate the issue, several treatment options -- medical, surgical, radiologic -- are available, but their effects would need to be assessed separately.

New Research: A Meta-Analysis

This combined analysis is based on the results of 23 studiesthat evaluated fibroids and their effect on reproductive success. The results suggest that fibroids, in general, regardless of location, were associated with a 15% reduction in pregnancy rates, a 30% reduction in live birth rates, and a 67% increase in miscarriage rates when compared with controls without fibroids. The effect was especially pronounced when submucous fibroids were analyzed (64% reduction in pregnancy rates, 69% reduction in live birth rates, and 67% increase in miscarriage rate). The effect of intramural fibroids was significant but less pronounced (22% decrease in live birth rates, 89% increase in miscarriage rates). Subserosal fibroids did not affect pregnancy rates or pregnancy outcome. The analysis did not demonstrate a consistent effect on pregnancy rates and outcomes.

Myomectomy (surgical removal of fibroids) was associated with improved pregnancy outcome when submucosal myomas were evaluated. The pregnancy rate was significantly higher after myomectomy when compared with women with fibroids left in place. On the basis of a small number of cases, the removal of intramural fibroids was not associated with improved pregnancy outcome. More studies of better quality are needed to assess the benefits of removing intramural and subserosal fibroids.

Pritts EA, Parker WH, Olive DL. Fertil Steril 2009;91:1215-1223.
Epub 2008 Mar 12.