www.medscape.com/viewarticle/755737 (free signup required to read)

Women’s Health (London England). 2012 Jan. 8 (1): 63-74.

Why do we need to wait until 39 weeks? Early term babies (between 37 and the end of the 38th week) are usually healthy, but they are at higher risk for medical problems than babies born at full term. These babies have increased risk for the following problems:

• The baby’s brain, lungs and liver may not be mature. A baby’s brain at 35 weeks is 2/3 of the size of a baby’s brain at 39 weeks.
• Admissions to the neonatal intensive care unit are increased in pre-39 week babies .
• Breathing problems occur more often. These babies may need oxygen or even a ventilator.
• Temperature control problems. They may not have enough body fat to keep warm outside the womb.
• Feeding problems. Their sucking and swallowing is not as strong and they may have trouble staying awake long enough to eat.
• Blood sugar problems. They could need an IV to help regulate their sugars.
• Jaundice.  They may not be able to clear bilirubin as well as a term infant. It can build up in their blood, tissue and fluids.
• Induction for non-medical reasons may not work. That may lead to a cesarean section which is major surgery with a longer, harder recovery and a greater risk of complications to mother and baby.

Of course inductions and cesarean sections are done before term, but it is important that they are done when the benefits outweigh the risks.

Dr Gurdian is a member of the North American Menopause Society. She recently attended the NAMS meeting in Washington D.C. We now have copies of the NAMS Menopausal Guide Book for sale in the office. This is the most complete discussion of menopause available. It is only 60 pages long and is written for patients interested in their passage through menopause.

Why use hormone replacement therapy

The results support initiation of hormone replacement around the time of menopause to treat menopausal symptoms and to prevent osteoporosis.  The duration of therapy depends on quality of life issues as well as personal risk factors for blood clots, coronary artery disease, stroke and breast cancer.  They suggest 3-5 years for combined estrogen+progesterone therapy and 7 years for estrogen alone. “The absolute risks known to date for use of hormone therapy in healthy women ages 50-59 years are low. The decision to continue hormone therapy beyond that time should be individualized based on the severity of symptoms and current benefit-risk ratio consideration.”

Why bioidentical hormones

The term bioidentical hormones is most often used to describe custom-made hormone therapy formulations..  They are compounded for an individual according to a healthcare provider’s prescription.  The term is used by proponents to convey that the hormones they use are identical to the hormones made by the human ovaries.  Custom compounding may combine several hormones (e.g. estradiol, estrone, and estriol) and the use of nonstandard routes of administration.  Some of the hormones are not government approved (estriol) or monitored and some of the compounded therapies contain nonhormonal ingredients (e.g. dyes and preservatives) that some women cannot tolerate.  Use of BHT has escalated in recent years, along with the use of salivary hormone testing, which has been proven to be inaccurate and unreliable.  There may be increased risks to the women using these products.  Custom compounded formulations, including BHT, have not been tested for efficacy or safety; product information is not consistently provided to women along with their prescription, as is required with commercially available hormone therapy; and batch standardization and purity may be uncertain.  The doing of compounded progesterone is particularly difficult to assess because the levels in serum, saliva, and tissue are markedly different.  Custom compounded drug formulations are not government approved.

The US Food and Drug Administration has ruled that some compounding pharmacies have made claims about the safety and effectiveness of BHT unsupported by clinical trial data and considered to be false and misleading.  For most women government-approved hormone therapy will provide appropriate therapy without the risks of custom preparations.

Stem cells are the building blocks of your blood and immune system, there are 3 primary sources of stem cells:  bone marrow, peripheral blood in you body and umbilical cord blood. Stem cells are the “Master Cells” that lead to the production of all the various types of cells in the body. Researchers believe that in the future stem cells may be used to repair brain damage, damage after stroke, spinal cord injury; grow blood vessels, and treat diseases such as Alzheimer’s, Parkinson’s, and diabetes.

Some data suggests that by the age of 70 a person has a 1 in 217 chance of being a candidate for stem cell therapy.  Other experts state that the likelihood of using those stem cells may be as low as 1/2700.  As research goes on there may be more uses found for stem cell therapy. 

Cells should remain viable indefinitely when properly stored. There is no expiration date on stem cells so we cannot predict the extent of their future use.

The State of Maryland mandates providing patients with information on stem cell collection.

We recommend that if you choose to save stem cells that you invest in a reputable company such as Viacord or Cord Blood Regsitry

American College of Obstetrics and Gynecology has not endorsed stem cell collection.

The web site for the American College of OB/GYN has extensive information that we cannot reproduce because of copyright laws.

At this time no insurance companies cover the cost of collecting or saving stem cells

We are happy to discuss this issue with you at an office visit.

Additional information

Umbilical Cord Banking provides information on services provided trough the Cord Blood Registry.

Viacord is also an excellent site for information on saving your baby’s cord blood.

Ultrasound or sonography is an easy, noninvasive way to see internal structures of the baby by sending a high frequency soundwave through the abdomen.  Soundwaves travel through the abdomen and bounce back off structures.  The bounce back waves return to a transducer and are seen as an image on the screen.  This sound is very high frequency and cannot be heard or felt.

There is still controversy about the value of ultrasound in pregnancy but it has become a routine part of care in the United States. 

Benefits of ultrasound:

1. Dating
2. Diagnosing early miscarriage
3. Diagnosing multiple gestations
4. Diagnosing fetal abnormalities 

Questions have been raised as to the safety of ultrasound but there have been no known adverse effects in the 30 years of use.  The 4D ultrasound, while enjoyable and entertaining, has not been shown to improve pregnancy outcome. FDA recommends against ultrasounds for keepsakes. 

When indicated for medical reasons, ultrasound is generally covered by insurance. We will schedule appointments for ultrasounds if requested, but you need to understand that insurance may refuse to cover the cost and you may be held responsible.

It is important to understand that this technology has limitations. For example, one study in Boston of over 7,000 ultrasounds identified only half of cardiac lesions. This means at least half of the heart problems were missed on ultrasound.

A normal ultrasound does not guarantee a normal baby!

One hour glucola

This is a special test to evaluate how your body metabolizes glucose during your pregnancy. Gestational diabetes affects about 5% of all pregnant women. Predisposing factors are family history, advanced maternal age, and prior medical history. Usually gestational diabetes is easily managed and it is therefore easy to prevent the complications for the baby.

About 28 weeks you will be give a glucose drink. Your blood sugar will be tested one hour after drinking the glucola.

It is important not to fast before this test. About 3 hours before you drink the glucola have a light lowfat, starchy meal such as cereal with skim milk 

Drink the entire bottle of glucola one hour before your scheduled test.  It must be consumed within 5 minutes. The blood work needs to be drawn exactly one hour after completion of the glucola. Failure to follow these instructions will require a repeat of this test.

If your one-hour test is abnormal you will need to do a 3-hour glucose tolerance test to determine if you actually have gestational diabetes.

Three hour glucose tolerance test 

The three-hour glucose tolerance test is a diagnostic test for gestational diabetes. Gestational diabetes is usually controlled by diet.  Failure to diagnose and control gestational diabetes may result in a poor outcome for your baby.

The test takes some preparation on your part.

The test is scheduled at the laboratory.  For three days prior to the test you will need to follow the enclosed diet. The night before the test do not eat, drink, chew or smoke anything after midnight.

On the morning of the test, the lab will draw a fasting blood sugar. Then you will be given glucola to drink. Blood will be drawn at 1, 2, and 3 hours after completing the glucola. Plan on eating after completing the test.   

We will call you with the results within 2-3 day if the results are abnormal.

Three Day Sample Diet for Glucose Tolerance Preparation

Breakfast:  1 cup cereal, 1 slice toast with jelly, 1 egg, 1 cup milk, 1 cup juice, 2 tsp sugar
Lunch:  Sandwich with meat and cheese or peanut butter.  Salad, banana and milk
Dinner:  Meat, 1 cup macaroni and cheese, 1 slice bread, ½ cup vegetables and 1 cup juice
AM Snack:  fruit
PM snack:  Milk and crackers
Bedtime snack:  ½ cup Jell-O and 1 cup milk

This diet includes daily:

2 cups juice
4 cups milk
1 cup vegetables
4 servings fruit
6 slices bread
1 cup cereal
1 cup potato, rice or noodles
3 tsp sugar or jelly

Additional testing

There are a number of additional tests that may be recommended for you and your baby during the course of your pregnancy.  Many of these will depend on your history, family history or your age at delivery. Often if there is a concern, you will be referred to a genetic counselor and perinatologist for testing and a consultation. We will be happy to discuss these tests with you at your visits to the office.

AFP testing/first trimester screen

These tests help identify women who are at increased risk for either Downs Syndrome, Trisomy 13, Trisomy 18, or a neural tube defect. 

Down’s Syndrome is a birth defect that occurs in about 1/800 births that is caused by a chromosomal abnormality.  About 80% of Down’s are born to women younger than 35 years of age.  These babies have abnormal physical features and mental retardation. Many have serious medical problems such as cardiac abnormalities (many of these may be corrected with surgery).

Trisomy 13 and 18 are chromosomal abnormalities that lead to death of a baby either during the pregnancy or during infancy. There is no treatment for these abnormalities.

Neural tube defects are abnormalities of the brain or spinal cord that occur about 1-2/1000 deliveries. There is a great deal of variability in how badly babies are affected. Many of these babies have mental retardation or significant limitations such as inability to control their bladder or bowels. They may need surgery, leg braces and physical therapy.

A specialist in high-risk pregnancies will perform the first trimester screen. This test involves an ultrasound where the skin at the back of the baby’s neck is measured. Those results are combined with a finger stick blood test to screen for Downs, Trisomy 13 and 18, and neural tube defects.

A followup blood test will be drawn between 15 and 20 weeks to complete the screen.

An abnormal test does not mean that your baby is abnormal; just that there is an increased risk for a problem. You will be given the opportunity to speak with a genetic counselor and a perinatologist (expert in high-risk pregnancy).  You will be offered additional testing such as amniocentesis or a more comprehensive ultrasound.

A normal test does not guarantee that your baby is normal. It will detect between 80-85% of neural defects and about 40% of Downs Syndromes. Many other sorts of problems are not detected through this testing. This test is primarily recommended for women under 35.  For women who are over 35, amniocentesis or CVS are still considered the “gold standard”.

Genetic blood tests

There are now a large number of genetic screening tests that may be run on a woman’s blood during pregnancy.  Some of them are offered routinely such as Cystic Fibrosis screens or screens for Thalassemia or sickle cell anemia. Others such as an Ashkenazi panel are recommended for women of a particular ethnic background. If results are abnormal, you will be referred to a genetic counselor and perinatologist for additional testing.

Genetic consult

If you will be over the age of 35 or have any type of family history that is genetically linked you will be offered an appointment with a genetic counselor who works with one of our referring perinatologists. Usually those visits will involve an in-depth genetic history as well as an advance ultrasound. You will be given information about potential risks for your pregnancy and the testing options that are available.

Pregnant women are considered a group that is high risk for food-borne illnesses. Therefore these guidelines should be carefully followed at all times: Clean, separate, cook, and chill.

“Clean” means thoroughly wash your hands before and after handling food, using the restroom, or changing diapers. Fresh fruit and vegetables should be rinsed under running water. Surfaces where raw food is prepared should be cleaned carefully after use. Plastic cutting boards are safer than wood since they are not porous. 

“Separate” refers to keeping raw food and cooked food from coming into contact with each other during preparation.  There should be separate work surfaces for preparing meats and fresh fruits and vegetables prior to cooking. 

“Cook” All food should be cooked thoroughly.  Undercooked meat and eggs may be dangerous.

“Chill”  Properly refrigerate perishable foods.  Do not leave them out of the refrigerator for over 2 hours. 

These 4 steps will control most food-borne illnesses.

Listeria causes listeriosis.  While the symptoms are flu-like, the onset of the disease may be greatly delayed, causing the pregnant woman to pass the disease onto her unborn child without ever actually feeling sick.  Listeria can survive in cold temperatures.  It is important to keep your refrigerator clean and be sure it is set at under 40 degrees Fahrenheit.  Do not eat blue-veined or soft cheese unless it is pasteurized.  Do not eat Pate or smoked fish from the refrigerated section of the store.  Canned is safe to use.   Do not eat raw hot dogs or drink unpasteurized milk.  Deli meat may not have been safely handled in the store so we generally recommend not using it.

Toxoplasmosis is generally associated with cats.  It may also be found in pigs, sheep, and deer.  Raw and undercooked meats from these animals are actually a more significant source of infection than cats.  Fruits and vegetables grown in soil infected with the parasite toxoplasm is also a source.  Follow the above rules for food preparation.

Fatty fish and shellfish are rich in omega-3 fatty acids; key for brain development. They also contain methyl mercury, which may harm the developing nervous system of your baby. Larger long-lived fish such as tuna, shark, swordfish, and tilefish are the most dangerous. FDA recommends limiting these fish to 3 oz or less a week. They also recommend keeping all fish to 12 ounces or less a week.

We also recommend against sushi because of bacteria and parasites, not mercury.

You may find additional updates at the FDA website. 

General rules

• A slow steady weight gain is best-about ½-1 pound a week. The first trimester you may gain more or even lose weight, depending on whether or not you have problems with nausea and vomiting.
• You do not need to restrict salt unless you have an underlying medical problem that makes it advisable that you do so.
• A substantial fluid intake is important. We recommend 64 oz a day with more if you are exercising or it is hot outside. Your urine should be a light yellow if your fluid intake is appropriate.
• Avoid alcohol. It may have a dangerous effect on your baby and is wasted calories. 
• Do not try to lose weight while pregnant. Even if significantly overweight you should still not lose weight.
• Tricks for avoiding excess weight gain:
• Weigh and measure food. Three ounces is not as big as we think it is.
• Avoid fried food and fast food.
• Fresh fruit is better than juice.
• Fresh vegetables with salsa makes a great low-calorie snack
• Skip sweets and desserts. If you plan to indulge, skip another carbohydrate to help make up for it. This should not happen routinely.
• Season with lemon juice and herbs. Avoid creamy salad dressing and sauces.
• The March of Dimes has an outstanding web page on diet in pregnancy
• How to meet your calcium needs: the recommended calcium intake in pregnancy and nursing is 1200-1500 mg a day. If you cannot tolerate dairy or need to supplement, you may use the following:  Caltrate 600, Os-Cal 500, Tums or Extra-strength Tums. If you are taking an iron supplement, do not take them with your calcium. If you have a history of kidney stones, discuss your calcium intake with your doctors.

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