Childbirth: Wait to Restart the Pill, CDC Says

Women who have just given birth should wait at least three weeks before they start using birth control pills because of the risk of serious, potentially fatal blood clots, public health officials announced las week. Women who delivery by Caesaran section or have other risk factors for blood clots — like obesity or a history of previous blood clots — should wait at least six weeks before using these medications, they said.

The new recommendations, by the Centers for Disease Control and Prevention, are more restrictive than guidelines issued last year and are similar to recommendations made in 2010 by the World Health Organization.

Women are far more likely to develop a blood clot in the weeks after delivery than non-pregnant women of reproductive age who have not just had a baby, several studies have shown. The risk declines rapidly after 21 days but does not return to normal until 42 days after delivery.

Birth control pills that include both estrogen and progestin also increase the risk of blood clots in the deep veins (venous thromboembolism). Women who are breast-feeding may want to avoid hormonal contraceptives because they can interfere with lactation, the C.D.C. said.

The guidelines were published in the C.D.C.'s Morbidity and Mortality Weekly Report on Friday, July 8, 2011.

Thyroid Function and Miscarriage

An article published in The Journal of Clinical Endocrinology and Metabolism in 2010 demonstrates an increased pregnancy loss rate in thyroid antibody negative women with a TSH level between 2.5 and 5 in the first trimester of pregnancy. The thyroid gland is an important endocrine organ involved in metabolism. Disruption of the thyroid can result in impaired reproductive function, including miscarriage.

Following are well known facts of pregnancy and thyroid function during pregnancy:

• On average 20% of all normal pregnancies end in miscarriage
  


• During pregnancy there is a 30-40% increased need for thyroid hormones due to increased placental uptake, increased thyroid binding globulin and increased blood volume
  


• Pregnant women with abnormal thyroid function experience increased rates of miscarriage, preterm deliveries, hypertension, diabetic complications, placental abruption, adverse fetal effects
  


• Women with anti-thyroid antibodies are 2 times more likely to experience a miscarriage
  

In this particular study, the authors (R. Negro, et al) studied 4123 women measuring their TSH levels during the first trimester. Findings:

1. Of the 3481 women with a TSH level of < 2.5 mIU/L the miscarriage rate was 3.6%
   


2. Of the 642 women with a TSH level of 2.5 – 5.0 mIU/L the miscarriage rate was 6.1%
   


3. If anti-thyroid antibodies are present, giving levothyroxine during pregnancy decreased the spontaneous miscarriage rate from 13.8 to 3.5%
   

Because of these findings, the authors assert that, perhaps 2.5 should be the maximum normal value of TSH during pregnancy.

References: J Clin Endocrinol Metab 2010;95:E44-48

Omega 3 Fatty Acids during Pregnancy

During pregnancy, your baby gets their food from the foods you eat and vitamins you take. Omega-3 fatty acids (omega-3s) are an important family of building blocks needed during pregnancy and breastfeeding. The two most important omega-3s are DHA and EPA. These are known and essential fatty acids as our bodies cannot manufacture them, so we have to get them from our diet.

Omega-3s are important to your health. They can lower blood pressure and reduce heart diseases and other health problems. Omega-3s also affect fetal nerves, including brain development. Consuming omega-3s during pregnancy can increase your baby's IQ and lower your their chances of developing asthma, eczema and other allergic conditions. They also may lower your risk of preterm delivery and postpartum depression.

Because of mercury contamination of our oceans, rivers, and lakes, almost all fish contain some mercury. Some fish contain too much mercury. Some fish may also have other toxins such as polychlorinated biphenyls (PCBs) and dioxin from industrial pollution. High amounts of mercury and PCBs in your body can cause impaired neurologic development of your baby, so fish with high levels of these poisons should not be eaten during pregnancy. The food and Drug Administration recommends you check local advisories on the safety of fish from local waters. Fish advisories are available from your local health department and online from state agencies.

HOWEVER, the health benefits of eating low-mercury fish during pregnancy outweigh the risks, so DO eat safe fish during pregnancy and while you are breastfeeding. Choose fish that are low in mercury. Remove skin and fat before cooking. Baking, broiling, steaming, or grilling fish lets the fat drain away and reduces PCBs in fish. Do not eat raw fish or shellfish.

Pregnant women and women who are breastfeeding should get about 1000 mg of omega-3s per day. Because omega-3s stay in the body for a few days, eating two servings of fatty fish per week can give you the 200 to 300 mg per day that you need. One serving is a 6-ounce portion of cooked fish. If you do not eat fish, or do not want to eat it every week, you can get fish oil as a pill or liquid you can swallow. Purified fish oil in pills or liquid form have all PCBs and dioxin removed. Read the label carefully to make sure there are at least 1000 mg of omega-3s. Fish oil pills can cause stomach upset, nausea and bloating; some women say they have a fishy aftertaste with burping. Freezing them before consumption often helps reduce such side effects. Cod liver oil is a good source of O3FA, however, if taken regularly can cause excess intake of the other vitamin it contains, vitamin A.

Eat at least two 6-ounce servings of omega-3 fish per week, except where indicated. Foods are listed in amounts of omega-3s from highest to lowest. During weeks when you do not eat enough fish, take fish oil supplements. Look for fish oil supplements that are purified because they are the safest.

High sources of omega-3s (about 700 mg or more per serving): Salmon, Halibut, Rainbow trout, Canned light tuna, Atlantic herring, Pollock, Whitefish

Moderate sources of omega-3s (about 150 to 699 mg per serving): Canned tuna, white albacore (limit to 1 serving per week while you are pregnant or breastfeeding), Catfish, Alaskan king crab, Flounder for sole, Shrimp, Atlantic cod, Canned blue crabmeat, Omega-3 enriched eggs

Do NOT eat the following fish while you are pregnant: Swordfish, Tilefish (also called golden bass or golden snapper), King mackerel, Shark, Tuna steaks (fresh or frozen), Marlin, Spanish mackerel, Orange roughy, Raw fish because, in general, they contain too much mercury.

How to Identify An Indigo Child

By Ezmeralda Lee, contributor to eHow

Indigo children may have possibly been around for several decades however, it was not until the 1982 book, "Understanding Your Life Through Color" by self-styled, psychic Nancy Ann Tappe, when the term was coined. New Age followers firmly believe that such children are born with a high spiritual consciousness and may even possess psychic abilities. However, psychologists and others believe that Indigo children have more conventional traits such as a higher level of empathy and creativity.

Instructions:

1. Study the child's aura, as the Indigo hue of a child's aura is the distinguishing characteristic of Indigo children. You may have a reading done of the child, if you do not possess the ability to read auras. If you sense a child is attracted to deep purples and blues, likes his room painted in these colors or prefers Indigo clothing, these are indications of an Indigo child.
2. Observe the attitude of the child starting from birth. An Indigo child has a strong, inherent sense of superiority and self-worth, often believing that she has been born to lead others or have the right and ability to do so.
3. Pay attention to how the child interacts with authority. An Indigo child will feel that he is the natural "leader of the pack." This is precisely why such a child often challenges or rebels against authoritative persons. An Indigo child will respond with a highly intelligent justification for his action or indiscipline and will also rarely feel guilty in response to disciplinary measures. As such children grow they will frequently assume positions of power and authority.
4. Notice how the child reacts to traditional systems and practice. An Indigo child has an extremely creative and active mind but will display intolerance and impatience when confronted with old traditions. At times such a child will get bored in a classroom or quickly lose patience when waiting in a queue. An Indigo child will often complain about what she perceives as an old system and will take the initiative to create better ways of organizing her room, classroom and even the world around her.
5. Watch if the child shows signs as a "loner" or displays anti-social behavior. An Indigo child often prefers to be alone and will also express her feeling of being different than everyone else. An Indigo child will find it difficult to adjust to school and extracurricular activities, unless she is able to bond with other Indigo children.
6. Listen carefully while the child communicates with you. An Indigo child knows exactly who he is and will not hesitate to talk about his psychic ability, sense to identify auras and the desire to advise or heal others. An Indigo child will also not hesitate to tell you what he needs and wishes to have, often amazing you with his blatant perception of self-identity, position in society and the world.

Tips & Warnings

• Try and empathize with the child's view of life by being a patient listener while also offering advice in a calm, soft-spoken manner.


• Do not reprimand or question the child's behavior in a harsh or overly, aggressive manner as an Indigo child is prone to acute frustration and depression.
  

Read more: How to Identify an Indigo child

Avoid Complications Associated with Cesarean Delivery

A wonderful, concise, evidence-based article by Dr. Patrick Duff was published in the December edition of Obstetrics and Gynecology entitled, "A Simple Checklist for Preventing Major Complications Associated with Cesarean Delivery".

Dr. Duff proposed the following evidence-based eight steps to significantly reduce maternal morbidity and mortality associated with cesarean delivery:

1. Clip the hair at the surgical site just before making the incision

2. Cleanse the skin with chlorhexidine solution rather than povidone-iodine solution

3. Administer broad-spectrum systemic antibiotic prophylaxis before the surgical incision rather than after the neonate's umbilical cord is clamped

4. Remove the placenta by traction on the umbilical cord rather than by manual extraction

5. Close the uterine incision in two layers rather than one

6. In women whose subcutaneous tissue is greater than 2 cm in thickness, close the layer with a running suture

7. Patients at intermediate risk for deep vein thrombosis [BMI > 30, those with gross varicose veins, those immobilized for > 4 days before surgery, those who have concurrent medical illness that predisposes to thromboembolism (e.g. sickle cell disease, sickle cell C disease, cancer, antiphospholipid syndrome, hereditary thrombophilia with no history of DVT or PE)] should receive prophylaxis postoperatively with either sequential compression devices or subcutaneous heparin

8. Patients at high risk for postoperative deep vein thrombosis (those with more than two risk factors in the moderate-risk category, those with prior DVT or PE, those who have a cesarean hysterectomy) should receive prophylaxis with both sequential compression devices and subcutaneous heparin until the patient is fully ambulatory

Referenced article: Obstet Gynecol 2010;116:1393-6

Diet Soda Linked to Preterm Labor

Danish researches have found that women who never drank carbonated beverages sweetened with artificial sweeteners compared to women who downed four or more diet (artificially sweetened) carbonated drinks a day were 78 percent more likely to deliver early than women who never drank the beverages. And those who had four or more diet, non-carbonated drinks daily were 29 percent more likely to deliver early.

Those who had one or more carbonated diet drinks a day were 38 percent more likely to deliver early.

Researchers conclusion: Daily intake of artificially sweetened soft drinks may increase the risk of preterm delivery. Further studies are needed to reject or confirm these findings.

Shelley McGuire of the American Society of Nutrition, said the findings "may be really important in terms of preventing premature births, especially those that are medically induced by a woman's health care provider."

She suggests pregnant women focus on water, juices and milk.

And in a statement, Dr. Alan R. Fleischman, medical director of the March of Dimes, said that "pregnant women should eat smart and make sure that most of their food choices are healthy ones. Artificially sweetened drinks don't make most lists of healthy foods. As the authors point out, additional research is needed to understand the impact of these beverages on pregnancy and fetal development. Until that is clear, it is prudent for pregnant women to drink these beverages in moderation. They also should discuss with their doctors their risk of preterm birth and the signs and symptoms of preterm labor. "

Resource: Thorhallur I Halldorsson, Marin Strøm, Sesilje B Petersen, and Sjurdur F Olse.Intake of artificially sweetened soft drinks and risk of preterm delivery: a prospective cohort study in 59,334 Danish pregnant women. Am J Clin Nutr 2010 92: 626-633. First published online June 30, 2010; doi:10.3945/ajcn.2009.28968

Moxibustion for Breech Presentation

Breech PresentationTreated with Acupuncture and Traditional Chinese Medicine

With Chinese Medicine, we are able to treat babies in breech presentation with an herb called moxibustion. The treatment is safe, relaxing, and highly effective. In some studies from China, success with this method in turning babies is over 90%. The British Medical Acupuncture Society cites a success rate of 84.6% after 34 weeks, and a 1991 study showed the rate of moxa-induced versions to be 75.4%.

Moxa is an herb made from the common weed mugwort (Artemisia vulgaris). When it is burned near acupuncture point Zhiyin, (Bladder 67, on the outside of each little toe) it moves the yang energy of the body, which increases fetal movement. This increased movement gives a greater chance that the breech presentation be corrected naturally.

A roll of moxa is lit and held near Bladder 67 for a few minutes on each side. This is combined with an acupuncture treatment designed to balance energy of the woman's body, allowing her to relax and her energy to flow more smoothly. We teach her how to administer the moxa (or have a friend or spouse do it for her) and send her home with a moxa pole to repeat the treatment for 5 minutes each morning and evening for 5 days. Most babies turn after three days, if not sooner.

Fainting (Syncope) During Pregnancy

What is syncope? Syncope is a brief loss of consciousness and postural change often caused by a brief decrease in blood flow to the brain.

How common is syncope (AKA "fainting" or "loss of consciousness") during pregnancy? Approximately 4.6% of women suffer from at least one episode of syncope during pregnancy. 28.2% of women interviewed reported a pre-syncopal episode including the symptoms of dizziness, lightheadedness, nausea, sweating and potentially collapsing to the floor.

What causes syncope? During pregnancy women's veins dilate in response to increased hormones from the placenta. This in turn causes a pooling effect that causes a decrease in cardiac output and a decrease in blood pressure. In susceptible individuals the vagus nerve is then stimulated causing a "paradoxical" (i.e. counter-intuitive) reaction of yet-again increased vein dilation and a slowing of the heart. In essence, in the pregnant woman's body this can occur due to the body trying to compensate for what appears to be a loss of blood. This is the cause of fainting 99% of the time.

What else can cause syncope? 1% of the time syncope can be due to more serious conditions such as heart disease, brain tumors, blood clots, seizures, abnormal heart beat, low blood sugar and other blood chemistry abnormalities.

What tests should be done? Start with a history and physical exam by a health professional. You may be asked to list the symptoms you had before the episode: palpitations, shortness of breath, chest pain, lightheadedness. Were you hydrated well? How long did the episode last? Did you injure yourself when you fell? The physical exam may include vital signs, heart and neurological exam. Some physicians may get an EKG if they believe your heart may be involved. Many times, there is no need for additional testing. In the rare instance that something more serious than a vagal response is considered, your health care provider may order blood tests, additional heart monitoring or consultations from other health professionals.

What is the prognosis for the fetus and should additional testing be done? The prognosis for the fetus is excellent. In general, no additional testing is necessary.

What general recommendations do we make to pregnant patients with a history of syncope? Get up slowly when changing positions. If you must stand for a prolonged period of time, make sure to move your legs. Remain well hydrated. Eat regular meals to maintain a steady blood sugar. Identify your syncopal triggers and avoid them. If symptoms persist, see your health care provider. The condition will most likely resolve after delivery.

Reference: Yarlagadda S, Poma PA, Green LS, Katz V. Syncope during pregnancy. Obstetrics and Gynecology. 2010; 115(2)377-80.

Restricting Food and Fluid in Labor May Not Be Helpful

Published by MedScape
Author: Laura Barclay

January 20, 2010 — Restricting food and fluid intake during labor may not be helpful or necessary for women at low risk for complications, according to the results of a systematic review reported online January 20 in the Cochrane Database of Systematic Reviews.

"Since the evidence shows no benefits or harms, there is no justification for nil by mouth policies during labour, provided women are at low risk of complications," lead author Dr. Mandisa Singata, from the East London Hospital Complex in East London, South Africa, said in a news release. "Women should be able to make their own decisions about whether they want to eat or drink during labour, or not."

The authors note that in many birth settings, fluid and food restriction during labor are common and that some women are only permitted sips of water or ice chips. These restrictions may adversely affect the experience of labor for some women.

The goal of this review was to evaluate the benefits and harms of oral fluid or food restriction during labor. The reviewers searched the Cochrane Pregnancy and Childbirth Group's Trials Register through April 2009 for randomized controlled trials and quasi-randomized controlled trials of fluid and food restriction for women in labor vs women permitted to choose what they ate and drank. Two reviewers independently evaluated the studies to see if they met selection criteria, determined risk for bias, and extracted data.

Five trials were identified, enrolling a total of 3130 women, all of whom were in active labor and at low risk of potentially requiring a general anesthetic. One study looked at complete restriction vs liberty to eat and drink as desired, 2 studies compared water only vs specific fluids and foods, and 2 studies compared water only vs carbohydrate drinks.

The meta-analysis was dominated by 1 study performed in a highly medicalized environment. No statistically significant differences were found in cesarean deliveries (average risk ratio [RR], 0.89; 95% confidence interval [CI], 0.63 - 1.25; 5 studies; n = 3103), operative vaginal births (average RR, 0.98; 95% CI, 0.88 - 1.10; 5 studies; n = 3103), Apgar scores of less than 7 at 5 minutes (average RR, 1.43; 95% CI, 0.77 - 2.68; 3 studies; n = 2574), nor in any of the other outcomes examined.

The pooled data were not sufficient to determine the incidence of Mendelson's syndrome, nor were women's views evaluated. One study did show a significant increase in cesarean deliveries for women drinking carbohydrate solutions vs water only, but the sample size was small.

"While it is important to try to prevent Mendelson's syndrome, it is very rare and not the best way to assess whether eating and drinking during labour is beneficial for the majority of patients," Dr. Singata said. "It might be better to look at ways of preventing regurgitation during anaesthesia for those patients who do require it."

Limitations of this study include domination of the meta-analysis by a single study, failure to assess women's views, and potential bias in the review process.

"Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications," the review authors conclude. "No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women’s views."

See multiple professional views regarding this new recommendation on Newsy.com

Induction for Pregnancy-Induced Hypertension and Preeclampsia After 36 Weeks Gestation

In a recent article published on line by the Lancet, there is now evidence to support induction of labor after the 36th week of pregnancy if a woman develops pregnancy-induced hypertension (PIH) or mild preeclampsia.

Study design: This multi-centered, parallel, open label, randomized study (HYPITAT) was conducted in the Netherlands. Koopman, et al recruited 756 women who presented with PIH or mild preeclampsia between the 36th and 41st weeks of pregnancy. 379 patients were expectantly monitored and 377 underwent labor induction. Another 397 women were approached to join the study and declined, but allowed their medical information to be utilized for the purposes of the study.

Question: Is it better to intervene to avoid serious complications? Which group fairs better of those women who are diagnosed after 36 weeks gestation with new-onset high blood pressure or mild pre-eclampsia: Those whose labor is induced or those who are observed?

"Serious complications" included eclampsia (seizures), HELLP syndrome, pulmonary edema, thromboembolic disease, placental abruption, severe hypertension, proteinuria or postpartum hemorrhage.

Findings: 31% of women whose labor was induced developed severe complications while 44% of those not induced developed severe complications. The findings were statistically significant.

(Relative risk 0.71, 95% CI 0.59-0.86, p<0.0001)

Implication: When a woman develops hypertension or mild preeclampsia after 36 weeks' gestation, labor induction will decrease her risk of developing severe complications by 30%.

Comment: In general, we are trying to limit labor inductions in the United States. ACOG has recently issued a Revision of Labor Induction Guidelines. However, when a woman develops hypertension or mild preeclampsia after the 36th week of pregnancy, it appears safer to induce her labor rather than await more serious complications to evolve.

Reference:
Koopmans CM, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet, 2009;374(9694):979-88