Month: April 2020

pregnancy, Women's Health

IF MY TODDLER JUMPS ON MY PREGNANT BELLY, WILL IT HURT MY BABY?

drrupe

Being pregnant with number two (or three. . .) can be an entirely new ballgame. Each pregnancy is different, so you may be experiencing random new symptoms that vary from last time. Likely, you are also feeling much more tired than with your first baby, because now you are chasing around a toddler instead of getting some occasional rest. You are also learning to play defense with your pregnant belly, attempting to keep baby #1 from clobbering it on a regular basis. Despite your best efforts you will occasionally get bumped, pulled on, and likely even body slammed hard enough to take your breath away. This can be scary and painful to the mom, but is extremely unlikely to hurt the baby.

Your baby is protected by many layers:

Bones

Skin

Fat

Muscles

Fascia (strong connective tissue that holds muscles together)

Intestines

Uterus (super thick and strong muscles)

Any blunt force has to pass through all these insulating layers to reach the baby. But even then, the baby is further insulated by the amniotic fluid.

In the first trimester (less than 14 weeks) the uterus is still nestled deep in the pelvis, so the pelvic bones protect the baby from any belly bumps.

After  14 weeks, to injure a baby in the womb, it takes a significant amount of force. Most cases of fetal injury are due to domestic violence (gunshot wounds/stabbing) or car accidents.

What can be concerning is shearing forces, especially in the third trimester. The placenta is made to detach from the uterus after delivery, but strong shearing forces can make it pull away prematurely. Falls onto the abdomen or buttocks, car accidents or severe trauma can cause the placenta to be dislodged from the uterus in a condition called an abruption. An abruption can happen immediately after trauma or may not show up for 24 hours after an accident. Symptoms of an abruption include:  contractions, bleeding, and abdominal pain. Anytime you fall during pregnancy after 14 weeks, if it’s hard enough to to take your breath away, you should call your provider. Even if you don’t fall directly on your abdomen it is important to be monitored for signs of an abruption.

Testing for an abruption includes an ultrasound, labs to check for bleeding, and monitoring contractions and baby’s heart beat. Often we will monitor women for up to 8 hours after an accident to make sure that there is no evidence of an abruption.

Many moms often wonder if tight clothes, seat belts, a toddler sitting on her lap, intercourse or pushing on their abdomen might harm the baby. Please rest assured these activities are not going to cause any issues.

The unavoidable day to day bumping and pushing on your pregnant belly is fine. The occasional toddler hop, though painful and stressful for mom is unlikely to injure your baby.  The baby will just be sloshed around in his amniotic fluid swimming pool. If you fall or are involved in any type of auto accident, this could be a major issue. Please call your provider to determine if you need further evaluation.

pregnancy, Women's Health

8 MEDICALLY PROVEN TIPS FOR MAXIMIZING FERTILITY

drrupe

Statistically more babies are born in October than any other month of the year. Actually the entire fall is crazy busy throughout the maternity ward. That means a lot of you are likely considering getting pregnant right now. The internet is chock full of ‘hints’ on improving fertility, but it is loaded with an equal amount of anxiety-provoking misinformation as well.  So what really works and what’s merely an old wives tale? Here’s what the most recent studies say:

1. Have sex

Have sex everyday or every other day for 5 days before and 5 days after ovulation.  Ovulation usually occurs  2 weeks before your period starts. Do not have sex more than once a day, as that can lead to diluted semen.

Things that do not effect chances of conception:

  • Female orgasm
  • Sexual position
  • Female position after sex

NO, it will not help if you stand on your head afterward. Neither is there a top secret magic sexual position that improves your chances of getting pregnant.

What may effect conception: lubrication. The best lubricants for fertility are canola oil, mineral oil or Pre-Seed.

2. Don’t smoke

Smoking is the culprit for up to 13% of all cases of infertility. Either partner’s smoking can effect their ability to conceive. The effects of smoking on your reproductive system can take up to a year to be reversed. There are so many reasons to quit smoking, but here is another excellent one: it can help make you more fertile.

3. Maintain a healthy weight

A BMI between 17-27 is ideal for conception. Recent studies report >60% of the US population are overweight. In some instances, being overweight can lead to higher insulin level, which can inhibit ovulation. This is a condition know as PCOS. In other instances, overweight women will have regular cycles (meaning they are ovulating) but still be subfertile. The good news is that even a modest weight loss of 10% of body weight can improve fertility.

Being too thin can also lead to subfertility. Your body senses that you don’t have enough reserves to handle the added nutritional demands of a pregnancy, so your brain tells your ovaries to shut down, causing your periods and ovulation to cease. This is often seen in cases of eating disorders.

4. Exercise in moderation

For women with a BMI of >25, exercise was found to cause a slight improvement in fertility. However women with a BMI of <25, who exercised vigorously > 4 hours a week were found to have a slightly decreased fertility.

Much like being too thin can shut down ovulation, extreme athletes like marathon runners and dancers can go through times of no cycles (no ovulation) when training intensely.

A man’s level of exercise has not been shown to effect fertility, with the one exception.  Men who bicycle > 5 hours a week were found to have lower sperm counts.

5. Healthy diet

Is there a magic food that will make you pregnant? No. However there have been several large studies looking at the diets of women with a history of infertility who become pregnant.

The dietary recommendations based on this study:

  • Get the majority of your protein from plants
  • Eat high fat dairy food
  • Take a multivitamin with iron
  • Eat complex carbohydrates
  • Eat 5-7 servings of fruits and vegetables a day

Another smaller study has supported the Mediterranean Diet to improve fertility.

Celiac Disease (gluten sensitivity), if undiagnosed or untreated, can lead to infertility. The treatment for gluten sensitivity is to follow a gluten  free diet.

6. Limit caffeine

It is recommended to limit caffeine to less than 300 mg a day. Here’s a helpful chart to know how much Starbucks you can drink.

7. Alcohol in moderation

While a little wine might be helpful in conception (wink-wink); excess intake may inhibit fertility. Studies show that consuming >14 alcoholic drinks a week has an adverse effect on fertility in both women and men. Consuming 3-13 drinks per week had a a slight negative effect on the woman’s fertility in some studies; but none on the man’s. Three or fewer drinks a week had no effect on fertility. There is no safe amount of alcohol in pregnancy, so once the stick turns pink, then you should abstain completely.

8. Know when to see a physician

Most couples will conceive within 6 months of trying, with 85% becoming pregnant within one year. If you are less than 35 and have regular menstrual cycles (every 21-35 days), it is recommended to see a doctor if you haven’t conceived after one year of trying. If you are over 35, it’s recommended to see a doctor after 6 months of trying.  If you do not have regular cycles or if you experience severe pain with your period or intercourse, you should see a doctor right away.

There is not a magic formula for conceiving. No magic food or sexual position that guarantees quicker results. What does work best is being healthy and regular sexual activity.

Hopefully your journey to pregnancy will be a smooth. Check out this previous post on recommendations for the first trimester once you do conceive.

In the meantime, enjoy the process!

Motherhood, Women's Health

HOW I CAME TO BE AN OB/GYN

drrupe

“You must have the grossest job in the world. Why on earth would anyone want to be a Gynecologist?” my twenty something patient asked, as I was examining her ‘nether regions’.

“Well, I do enjoy helping people” I lamely replied. I was doubtful she heard me, as she had already returned back to texting at this point.

I smiled as I left the room, remembering my surprisingly similar thoughts at her age.

I wanted to be doctor for as long as I could remember. But when I started medical school, the two specialties I knew I didn’t want anything to do with were OB/GYN and Pediatrics.

There was little doubt in my mind that Family Practice was my chosen path.  I chose Oklahoma State University because of its focus on primary care. I had shadowed several FPs and truly enjoyed the continuity of care and relationships that occurred in Family Practice.

When I started my rotations as a third year student, I excitedly picked FP as my first month. The practitioner I worked with was amazingly kind and knowledgeable.  He also had a passion for teaching and I was appreciative of the time he spent instructing me. Though we saw some interesting patients, there was also a lot of mundane colds and earaches. After about 3 weeks, I started to have doubts whether this was really what I wanted to do for the rest of my life. I was a little concerned, but knew I had a few (our school required 6 months of Family Practice) more months to decide.

The next month, I did an away rotation in internal medicine with a wise internist who had been in practice for 30 years. While I didn’t love internal medicine, I did love the doctor. I soaked up every bit of wisdom about life and medicine he sent my way. He inspired me to THINK and not just memorize facts. On my last day of the rotation he sat me down and said essentially that I had done well on the rotation, but he thought my personality was the most suited for OB/GYN.

I smiled on the outside, but internally I rolled my eyes.

My first thought was, “What a sexist!” I was sure he was saying that merely because I was a woman. OB was becoming a female dominated field, and it had been commonly suggested for me to consider it. However, the last thing I could possibly be interested in was doing PAP smears all day. Yuck. Child bearing had no interest to me whatsoever. It was WAY too messy.

I composed my initial thoughts and replied, with a simple, “I don’t think so.”

“When’s your OB/GYN rotation?” he asked.

“The last one of the year.” I replied, having postponed it to the end.

“You should seriously consider moving it up earlier” he encouraged me.

I thanked him for his advice as a courtesy. Then thanked him profusely for the other things he had taught me.

On the drive home I was still fuming about his remark. However, my thoughts began to wander. His wife and all 3 of his daughters were doctors, but none OB/GYNs. There were no other sexist things he had said or done the whole month.  I respected him greatly and had trusted all the other advice he had given me. Perhaps, I should listen and at least move my rotation up to earlier in the year. After all, I wasn’t loving FP nearly as much as I thought I would.

After several frantic phone calls, I managed to set up a rotation with a local private practice doctor, in desperate need of some CME’s.  I ‘did’ very little during this month, but what I observed was life changing.  I observed his daily practice: his rapport with his patients, interesting procedures and complex diseases.  He was able to practice preventative medicine in a real way (one of my passions) and also do fascinating surgeries.  I witnessed babies born then later the same day the removal of a giant ovary full of teeth and hair from another patient. It was thrilling. On my last day of the month, I broke down in tears on the way home. I couldn’t believe my month was over. I didn’t want it to end. I had fallen in love with the crazy life of being an OB/GYN.

Then began the soul searching and prayer. How could I have a family and be an OB/GYN? As much as I loved my month of OB, the hours were harsh, and I wasn’t sure I could hack it. Was being an OB really God’s plan for me or just a selfish whim? After months of pro’s and con lists and long discussions with my husband, I finally felt a peace from God that this was the path I should take.

Finishing my last 6 months of family practice rotation only confirmed my decision.

This life is NOT easy. The hours do get crazy. Yes, there are days when I do get tired of looking a vaginas all day long. But the longer I do this job the more I love it. So here I am, 8 years into private practice reflecting on how my life is nothing like I expected it to be when I began this crazy adventure in medicine. I realize that it is amazingly better.

Thank you Dr. Bruns for telling me I should be an OB/GYN. You were right.

pregnancy, Women's Health

WHEN IS IT “SAFE” TO TELL PEOPLE YOU ARE PREGNANT

drrupe

I was at an end of the year kindergarten party this week. After consuming the usual amount of sugary snacks associated with such class parties, but before saying their dramatic goodbyes that also included full body hugs, each kindergartner circled up to say what they were looking forward to most this summer. Most announced various beach and Disney trips, but one little girl began jumping up and down and squealed, “I’m excited about summer because my mommy has a baby in her belly!” Based on the way her mom’s eyes widened and jaw dropped open in horror, I’m guessing this new baby news was not yet meant to be public knowledge.

It’s hard to know when it’s ‘safe’ to tell people you are expecting. In this age of social media, it is difficult to tell just family and close friends. Even when you try to keep it quiet, the news has a way of sneaking out like it did for my friend whose great aunt had recently joined “The Facebook” and accidentally posted her congratulations on her wall instead of a private message.

Everyone’s biggest fear is making a big public pregnancy announcement, only to have to sadly announce a loss a few weeks later. With my first pregnancy, we called all our friends and family the day we found out. We simply couldn’t contain our excitement. Sadly about a week later, we experienced a loss. It really stunk having to then tell everyone we had a miscarriage, but at least people knew why I was sad and could offer their sympathy and support, which was very helpful. With the next pregnancy I was very guarded and waited until after 12 weeks before I shared the news.

When I see a couple for their first pregnancy appointment, after we see the heart beating strongly on ultrasound and they breathe their initial sigh of relief, one of the first questions they ask is “Is it safe to tell people we are expecting?” I get a sense they feel that if I give them the blessing, all will be OK. While I can never offer a guarantee, I can offer statistics that provide some reassurance as to when it’s safe to let all their great aunts know the exciting news.

Chance of miscarriage after a normal first trimester ultrasound (maternal age <35):

  • At 5 weeks the risk of loss is 8%
  • At 6 weeks the risk of loss is 7%
  • At 8 weeks the risk of loss is 3%
  • After 12 weeks the risk of loss is < 1%

While many women choose to wait until after the first trimester to tell their news, if the baby has a normal heart beat at 8 weeks, their chance of a normal pregnancy is 97%.

Risk factor that might increase the chance of miscarriage:

  • Maternal age >40
  • History of >2 miscarriages
  • Diabetes
  • High blood pressure
  • Lupus
  • Untreated thyroid disease
  • Abnormally shaped uterus

Sadly, miscarriage is very common with up to 15% of pregnancies ending in loss. This rate can increase an additional 10- 25%  if you count “chemical pregnancies,” when a woman’s initial home test is positive only to have her cycle start a day or two late. Due to the high rate of chemical pregnancies, I encourage my patients not to rely on ultra sensitive home tests days before their period will normally start, but instead try to wait until they are at least a week late.

The decision of when to announce your pregnancy is a very personal one. I was initially horrified when I realized I was going to have to “unannounce” my first pregnancy after my loss, but eventually I was thankful I had the support of all my friends as my heart was healing. For those looking for the best time to share your news, know this: the risk of loss drops dramatically once you have seen a healthy heart beat, and then becomes extremely low after the first trimester. 

Motherhood, pregnancy

My Birth Story

drrupe

When my alarm began blaring at 5:20 am on January 21, 2004; I immediately hit the snooze button. I am normally a morning person, but the last few weeks of my pregnancy were beyond exhausting. As I reluctantly climbed in the shower I purposefully avoided the mirror. I really didn’t want to catch a glimpse of my giant whale body. I had stopped feeling like a ‘cute pregnant lady’ long ago. My feet where still swollen from the night before; I noticed my sock indention from the previous day’s work.

I was lucky. My pregnancy was healthy and had gone quite smoothly, with the exception of one small hiccup: at 32 weeks I learned that my son was breech, and he never flipped. My c-section was scheduled for 39 weeks. If I am completely honest with you, I was more afraid of a vaginal delivery than a c-section. A small part of me was slightly relieved that things would be nicely scheduled and I would never have to face all the drama of labor.

My parents had their plane tickets to Ohio. It would all happen in 2 more days.

I was in my OB/GYN residency training during my pregnancy. I worked 80 hours a week, often 12 to 14 hour days. Residency was challenging enough when you weren’t carrying around 50 pounds of extra baby weight and having to pee every 5 minutes. However this was my final day of work. Tomorrow I would take an exam, then the baby would be here on Saturday. It was surreal to know exactly when the baby would come. I couldn’t wait to meet baby Ryan (we didn’t know if it was a boy or girl, but the name was to be Ryan either way).

My last day at work was not an easy one. I was assisting with several surgeries and it was during the first case that the headache started. As the afternoon progressed, I started seeing little spots. I knew these were the sign of preeclampsia, so I stopped by labor and delivery to have my blood pressure checked. It was dangerously high. I wanted to go home and get my things, but my fellow residents insisted I stay and get blood work. “Really, I’ll be fine” I said. I had no insight. Intellectually I realized I had preeclampsia, and shouldn’t leave the hospital when my blood pressure was sky high, but it didn’t compute emotionally. It was strange. There was also an element of denial at play. This could not be happening to me.

I had seen patients act this way many times and assumed they were non-compliant. I realize now when patients have an irrational response to an emergency that it is likely denial more than ignorance. So often we spend so much time picturing and planning how our special day is supposed to happen that when things go awry, it zaps the wind from our sails and leaves us stunned in disbelief.

My doctor arrived and decided the c-section should be done immediately and a magnesium drip would be started to treat the preeclampsia and help control my blood pressure. I attempted to argue that I really didn’t need it. Magnesium was a miserable drug. She just glared at me, “Of course you are getting magnesium.” I took a deep breath and complied.

After several blubbering phone calls to friends and family, they set me up for delivery. My mom didn’t get to be there, but my husband and friends (fellow residents) were there to support me.

As they wheeled me into the cold OR, I realized I was terrified of the “unknown” despite doing hundreds of c-sections myself. As I lay strapped to the OR table, I felt vulnerable and afraid. It was so awkward to be on the other side of the knife. As the surgery got underway, though I felt more calm; comforted by the familiar sounds of the instruments and operating room banter.

2004-01-21-0003

As he was born, the entire room cheered. “It’s a boy” someone said. My husband and I were overwhelmed with joy.

2004-01-21-0006

As the doctor held him up over the blue sheet for me to see him, I remember thinking that he looked blue and they should really get him to the warmer. Myself, my husband and my friends (who we’re running various cameras) we’re all crying and cheering. It was an amazing day.

As I held him in recovery and nursed him for the first time, I remember thinking how incredibly blessed I was. I couldn’t believe how deeply I could love this sweet little boy. What an amazing gift.