As you may have noticed, it has been a while since I have posted on this blog. Rest assured, I have a ton of great content in the works.
But what has been keeping me too busy to post and up at night? Well, Baby #3 for starters. (Now 8 months! How time flies… or with a new baby, how it passes in slow motion and sudden leaps.)
And in my stolen moments (read:naps) I have been writing content for a company called BloomLife. BloomLife makes a contraction tracker, just like those used in a hospital but for at home use. It syncs with your phone and lets you know if you are experiencing contractions, how strong they are, and how long they last.
Baby #3 and her big sister. None of us were quite ready to wake up the morning this picture was taken. Yet there we were, up.
Many of my posts for Bloom will be of interest to my readers, so I wanted to share them with you here. Hop on over and check them out!
Prenatal Genetic Testing and Screening. My take on the new kid on the prenatal genetic screening block, Non-Invasive Prenatal Testing (NIPT) and why it needs to be offered to all women, not just women over 35.
Stalled Labor. My first labor was going gangbusters until I arrived at the hospital, where it swiftly ground to a halt. This is a common birthing experience. At the time, I blamed the slowdown on stress, but another unexpected culprit may have been to blame: those glaring florescent hospital lights. Here’s more on how humans evolved to labor at night, and why laboring women would be wise to dim those darn lights!
Exercise during pregnancy. Should you avoid starting a new exercise program while pregnant? Do you need to keep your heart rate below 140? Will lifting weights prompt preterm labor? Contrary to what you may have heard, the answer to all of these questions is an emphatic NO. I discuss the all these exercise myths here, and talk about the latest research and recommendations on exercise for pregnant women.
Natural Remedies for Group B Strep. Anywhere from quarter to a third of pregnant women test positive for Group B Strep (GBS) in their third trimester. In the U.S., this means receiving IV antibiotics during labor, to prevent early-onset Group B Strep, a serious but rare infection that occurs when a newborn contracts GBS during birth. But nobody wants to receive antibiotics if they can avoid it, especially during birth, when mom needs to pass her microbiome–a diverse collection of healthy bacteria and other microbes–to her baby. So, is there anything you can do to avoid testing positive? I talk about the research on vinegar rinses, yogurt squatting, and probiotics here.
It’s been awhile since I’ve posted on this blog, so I wanted to give my readers a bit of an update on what I’ve been up to these past couple of months.
Mostly I’ve been away because of some good news: I’m expecting our third child, a girl, coming sometime in October!
For most women, the first trimester is brutal. About a week or two after you find out you’re pregnant (two lines!), you start to feel exhausted, queasy, and like you might throw up at any moment.
You are not alone. Somewhere between 70-80% of pregnant women experience nausea during their first trimester. About half of women also experience vomiting.
Nausea tends to worsen with each subsequent pregnancy, and become more likely to persist into the second trimester. Your race and ethnic background also matter: White women are more prone to nausea than Black and Asian women, and Black women are more likely to have nausea that starts after the first trimester.
While morning sickness is awful, it does come with a significant silver lining: Nausea tends to signals a healthy pregnancy. Women with nausea have a much lower risk of miscarrying and–as is less widely known–a lower chance of preterm labor.
Morning Sickness and Risk of Miscarriage
For those experiencing nausea, the risk of miscarriage is not just a tiny bit lower, but a huge whopping amount lower than that of women with no nausea.
Woman with nausea have only a third of the chances of a miscarriage as other women. The effect is even stronger among women of “advanced maternal age”–that is, over 35: They have only about a fifth the odds of a miscarriage as other women over 35 with no nausea.
Despite these large effects, if you do not have any nausea, do not panic. A lack of morning sickness does not necessarily imply an impending miscarriage. A lucky 20-30% of pregnant women never experience any morning sickness but give birth to perfectly healthy babies.
Timing also matters: Before 7 weeks, a lack of nausea does not predict miscarriage risk.
Name Calling: Nausea and Vomiting of the Pregnancy (NVP) Versus Morning Sickness
Before we dig into the details, let’s get our terminology straight: Although nausea and vomiting during pregnancy are often referred to as “morning sickness”, most medical professionals prefer the term nausea and vomiting of the pregnancy (NVP). “Morning” sickness, they feel, is misleading.
As many first-time mums-to-be discover to their dismay, nausea often lasts all day long, not just in the morning, . In fact, in one study, less than 2% of women with “morning sickness” had nausea and vomiting only in the morning. Other studies have put the percentage of morning-only suffers at 14%.
The Onset of NVP and Miscarriage Risk
On average, women start to experience NVP 39-40 days after their last menstrual period, around the middle of the 5th week of pregnancy (counting from a woman’s last menstrual period), Symptoms typically begin to ease by around 12 weeks and usually disappear completely by 20 weeks.
That said, 39 days is only the average day of symptom onset. For an unlucky 10% of women, NVP begins much earlier, before they even miss their period. For the 70-80% women who will experience any morning sickness, though, that all day queasy, on-a-winding-road-with-a-bad-hangover feeling will have started by the end of your 8th week of pregnancy, or 7 weeks after conception.
So it’s only in 9th week of pregnancy that a lack of morning sickness predicts higher chances of a miscarriage, according to a prospective study that tracked symptoms of 2407 pregnant women from early in their first trimester.
When a women’s nausea begins does not matter. Women who had nausea starting at 4 weeks or at 7 weeks have about the same low chances of a miscarriage. Similarly, the end of nausea does not appear to make much of a difference. By 12 weeks, the risk of women without nausea drops back down to that of women with nausea.
What Exactly Is Morning Sickness and Why Does It Predict Miscarriage?
So we know that NVP is strongly related to the chances of a healthy, successful pregnancy. But why?
NVP is one of pregnancy’s great mysteries. We don’t know why it occurs. We don’t even know what hormones or other biological changes causes NVP. And we don’t know whether NVP serves a a specific adaptive purpose, as some evolutionary theorists have proposed, or whether it is just an unpleasant side effect of hormonal shifts during early pregnancy.
Rapid rises in hormones like estrogen, progesterone, and human chorionic gonadotropin (HCG) are the prime suspects. So far, though, the evidence for their role is only circumstantial.
Consider HCG, the hormone with the most evidence for a role in NVP. HCG levels in a woman’s blood rises rapidly during the early weeks of pregnancy, doubling every 2 to 3 days. Its concentration peaks sometime between 8-10 weeks of pregnancy.
HCG’s rise corresponds when NVP symptoms are usually at their worst. Conditions which cause high HCG levels like Down’s Syndrome, molar pregnancies, and twin pregnancies are often linked with severe NVP.
That said, HCG levels do not reliably distinguish women with and without NVP, and no one understands why, at a biological level, HCG would induce nausea.
Another potential suspect is pregnant women’s bloodhound-like sense of smell. In a small study of 9 women who had congenital anosmia–they were born with without the ability to smell–only 1 of the 9 suffered from NVP during pregnancy, a rate substantially lower than the usual 4 out 5.
Despite our poor understanding what causes nausea biologically, few researchers believe that a lack of symptoms causes miscarriage.
Why not? For one, treating NVP does not lead to worse pregnancy outcomes. If anything, the opposite is true: Women who take anti-nausea medications have better outcomes, on average, than women who do not take anti-nausea medications–not because treatment itself improves outcomes, but because severe NVP severe usually indicates a healthy placenta.
The Bottom Line
For everyone discretely ducking out of meetings to quietly vomit in the ladies room, there is light at the end of the tunnel. And knowing that your sickness likely means that your pregnancy may provide some comfort. I always clung to that fact as I was clinging to the toilet bowl after dinner.
But please do not think I am trying to minimize the dreadfulness of nearly non-stop nausea.
Nausea and vomiting are more than a simple inconvenience. Women with NVP, even those with so-called “mild” NVP accompanied by little or no vomiting, commonly report decreased productivity at work, taking sick time, strained relationships with their partners, and heightened anxiety and depression.
For around 1 in 100 pregnant women, NVP is life-threatening. Women with especially severe NVP, a condition known as hyperemesis gravidarum, suffer from such severe nausea that they cannot keep food or water down, and require hospitalization. In the U.S. each year, around 50,000 women are hospitalized for severe NVP.
If you are vomiting several times a day or unable to keep fluids down, seek medical help right away. Early treatment may help prevent NVP from becoming dangerously severe.
Three years ago, sitting with my 15-month-old son and my husband during a long layover, on our way back home from Norway, I felt a sudden gush of warm blood.
So much for my miracle pregnancy, I thought. I was only six weeks along and certain I was miscarrying.
Our return trip was already off to a poor start. United Airlines had cancelled our original flight from Newark home to San Francisco. Then, to rub salt in the wound, they refused to refund our first-class tickets.
We never fly first class, but had made an exception for this trip. We were travelling overseas with my 15-month old son and facing a 9-hour jet lag. The chance of sleeping on route, we decided, was worth the extra cash. We had bought our tickets a year in advance to lower the cost.
But United, being United, told us wewould have to request a refund, and then maybe theywould grant it. And–perhaps just for kicks–they refused to let us access the first-class lounge while in Newark, because our replacement tickets were now in Economy.
My husband–who nevers argues with anyone behind a counter and hates it when I do–spent half an hour arguing with their “customer service” that they should give us passes to the first class lounge. After all, we had paid for first-class tickets even if we no longer had them. But no dice.
So there we were, exhausted and enraged. I had not slept in over 24 hours. My son, sick for the last 3 days with a high fever, had nursed continuously the entire flight from Oslo to Newark. And then I started bleeding.
At that point, I contemplated tweeting, “United, you ate my baby,” but decided against publicly sharing my pregnancy or what I assumed was an impending miscarriage.
The pregnancy had been a surprise, but a welcome one. We had taken over a year to conceive my son. This time we had not been trying. I was still breastfeeding, and my cycles had only resumed a month earlier. We were planning to wait a few more months and then start trying for #2, expecting that it could easily be another 6 to 12 months before we conceived.
The bleeding tapered off by the next morning. I had no pain or cramping, so little fear of an ectopic pregnancy. And I still felt pregnant: nauseated, tired, and lightheaded.
I called my OB, but they could not fit me in for another 5 weeks. Until then, they told me, just sit tight. Oh, and assume that I was still pregnant, because a miscarriage would have caused several days of heavy bleeding.
I found another OB.
My new OB ran tests. My HCG levels were normal, but my progesterone was low, perhaps because of the nearly constant breastfeeding, the lack of sleep, and the stress. She could not say for sure. She prescribed progesterone supplements for the rest of my first trimester.
Progesterone helps build up and maintain the uterine lining for implantation of the fertilized egg. High levels of progesterone are required to sustain an early pregnancy. But taking progesterone supplements during the first trimester to prevent a miscarriage is controversial.
Over half of miscarriages result from chromosomal abnormalities, and no amount of progesterone will save these pregnancies. A 2013 review of randomized trials, however, found that while progesterone supplements did not alter the risk of miscarriage for pregnant women as a whole, they did significantly lower the chances of miscarriages for women with 3 or more prior miscarriages.
And for women like me, with a threatened miscarriage (defined as any bleeding within the first 20 weeks of pregnancy), who have more than double the normal odds of a miscarriage*, progesterone supplements appear to cut the risk of miscarriage in half, and oral progesterone, as opposed to suppositories, may be especially effective.
So, although I will never know for sure, my OB may have saved my pregnancy.
A Subchorionic Hematoma
At that initial visit, she also performed an ultrasound. The fetal heartbeat was loud and clear, fast and reassuring, racing along like a rabbit’s. When I heard my baby’s heartbeat, I fully exhaled for the first time in days.
Less reassuringly, the ultrasound revealed a subchorionic hematoma–a blood clot next to the placenta and the cause of my bleeding.
Pregnancies with a subchorionic hematoma are considered high risk. They have a higher risk of miscarriage (17.6% versus 8.9%), stillbirth (1.9% versus 0.9%), and placental abruption (3.6% versus 0.7%). They have a slightly higher risk of preterm delivery (13% versus 10%) and for the waters breaking before labor starts (tv-style labor).
The risk varies by the location of the hematoma. Pregnancies with recurrent bleeding or with hematomas located between the placenta and the uterine wall (retroplacental hematomas) have a higher risk of miscarriage and other pregnancy complications like placenta abruption. Because of the risk of placental abruption, bleeding in the second and third trimesters require immediate medical attention.
As worrisome as these statistics sound, most subchorionic hematomas resolve on their own, as mine eventually did. By 11 weeks, we could no longer see the hematoma on an ultrasound. And thankfully, rest of my pregnancy was uneventful. I gave birth to healthy baby girl, who in a few months will turn 3.
Do you have a story of bleeding in early pregnancy? Was a cause detected, and how did things turn out?
Footnote
*About 20% of women experience bleeding during early pregnancy. Figuring out their chances of a miscarriage is far from simple.
One commonly cited statistic states that roughly 50% of these women eventually miscarry. Some digging reveals that this claim derives from a 1981 obstetrics textbook rather than recent research. (Lots of researchers cite papers that cite papers that cite this textbook, and I am willing to bet that none of them have read the original research behind this claim.)
If bleeding starts after detection of a normal fetal heartbeat, most prospective studies find a much lower rate of miscarriage, of 3.4-5.5%.
References
Haas DM, Ramsey PS. Progestogen for preventing miscarriage. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD003511. DOI: 10.1002/14651858.CD003511.pub3.
Stand at our neighborhood playground for a few minutes and you are almost sure to hear remarks like these:
“My child started walking at 8 months.”
“My two-year-old is speaking in full sentences.”
“My son was potty trained at 18 months.”
Some of these remarks have been made to me. And some, I am ashamed to admit, have been made by me. But no longer. I refuse to take part in these conversations any longer.
Why? Because they always make someone feel bad. Someone’s child always ends up on the downside of the comparison.
And that sucks.
Of course, intellectually we all know that our children are not going to be the best at everything. And for a while, I was mentally stuck there: Why was I letting these kinds of conversations make me feel bad? Surely, I know my kids were wonderful. Surely, I love them for who they are and not for what they accomplish.
But, then, I realized I was asking the wrong question.
Here’s the right question: Does talking about our children’s accomplishments lend itself to good conversation?
My goal in writing that post was not to nurse some long-standing grudge against breastfeeding advocates. Nor was it an attempt to justify my own parenting choices: I breastfed both my children for well over a year.
(And yes, as some readers have inquired, I know just how wonderful breastfeeding can be. How breastfeeding your baby can be calming and joyful, even magical. But whether I found breastfeeding magical or a chore–or, in actuality, both–has nothing to do with whether it lowers the risk of asthma, or heart disease, or anything else.)
In response to my post, someone shared this comment on Facebook:
“Anyone who thinks this [my post] a solid piece of work needs to read my latest book, Milk Matters: infant feeding and immune disorder. No one has to prove that breastfeeding (the evolutionary and physiological norm that provides free stem cell transplants) makes a positive difference. Those who assume, claim or promote artificial feeding as safe or adequate need to prove that deviating from such basic physiological norms is safe, that there are no short or long term harms from doing so. …”
I am sharing this comment not because I find it particularly compelling, but because I think it nicely illustrates the problem with arguments made by many breastfeeding advocates: They start with the assumption that breast is best. And then, inevitably, they fail to scrutinize the evidence, no matter how flimsy, that supports that assumption.
And the evidence is flimsy indeed. Most of the alleged benefits of breastfeeding are found only in observational studies, which are widely acknowledged as biased. On average, breastfeeding mothers have a higher levels of education, higher incomes, and live in safer neighborhoods than formula-feeding mothers, granting their children an early leg up in life. Separating the effects of breastfeeding from these other advantages is next to impossible.
How do we know that these observational studies are biased? Primarily because we do not find the same benefits in better-designed studies–sibling comparison studies and the PROBIT randomized controlled trial. The only clear-cut benefit seen in these studies is a lower risk of severe vomiting and diarrhea during infancy. (For a detailed summary, see my earlier post).
To be fair, breastfeeding advocates are right, in a way. Breastmilk does contains numerous hormonal, antimicrobial, immunological, and nutritional factors not found in formula. This is why breastmilk helps protect against vomiting and diarrhea during infancy.
Before the advent of clean water, sanitation, and modern medicine, breastfeeding was frequently life-saving. In countries where access to these resources remains limited, it still is. There’s no bigger possible benefit than survival.
But these beneficial properties do not imply that breastmilk has any long-term benefits for the panoply of modern ailments: allergies, asthma, obesity, type 2 diabetes, and cardiovascular disease. We cannot claim such long-term benefits without sound empirical evidence. And that is entirely lacking.
If the American Academy of Pediatrics, and others were to say, “We recommend breastfeeding because it reduces the risk of severe diarrhea and vomiting during infancy, and because breastmilk contains unique immune, hormonal, and nutritional factors not found in formula, the long-term benefits of which are unknown,” I would have no problem with their claims.
But instead, they have chosen to present poor quality evidence as fact. Playing fast and loose with the evidence in this way undermines their credibility. Worse, it violates the trust that women have placed in them.
Finding the right caregiver for your baby has to be one of the most stressful experiences as a new parent.
To make the prospect a little less daunting, I’d like to share some tips I sent to a friend back when she first started looking for a nanny.
1. Start looking for a nanny at most 1-2 months before you need her to start. Most nannies are looking to start work immediately or within a few weeks of starting their search. Unless you are willing to pay someone to hold them, or know someone who has a great nanny and is planning to let them go because of a move, finances, and so on., I would wait until close to the time you need them to start.
2. Parenting groups and word of mouth are the best ways to find nannies. Local parenting listservs are a great place to find excellent caregivers, because people who love their nannies will often help them find their next position.
When reading through posts about potential nannies, you should prioritize those that are posted by employers, as opposed to the nanny herself, and those that are genuinely glowing.
Trying to conceive? Here’s how to identify your peak fertile days, why you and your partner should avoid alcohol, and why it’s best to skip the lube.
Back when my husband and I decided to try for a baby, I remember feeling so impatient. I basically wanted a baby right then. Today. That instant. The inevitable nine months seemed too long to wait, let alone the time it would take for us to conceive.
I am sure I am not alone in this sentiment.
So, if you too are feeling impatient to become pregnant, here are some science-based tips to help maximize your chances.
Kudos to people who can wait until the birth to find out if they are having a boy or girl. The feminist in me feels guilty about this, but I never wanted to wait that long. Pretty much the second I learned I was pregnant, I started trying to figure out if it was a boy or or girl.
The good news for people like me: ultrasounds can now detect a baby’s gender as early as 12-13 weeks gestation.
Genetic testing through CVS remains the most accurate way to determine fetal sex in the first trimester. But since this test carries a slight risk of miscarriage, many of us choose not to have it performed. (New blood-based tests that rely on cell free DNA can detect your baby’s gender as early as 9 weeks, without increasing the risk of miscarriage, but these are only about 95% accurate in the first trimester).
Until recently, forging genetic testing meant we had to wait until the second trimester screening to learn our baby genders, sometime around 18 to 20 weeks gestation. By that time, the penis, testes, and labial folds are clearly visible on an ultrasound.
The latest research, however, suggests we can learn the gender months earlier, during the ultrasound for the first trimester screen, which is performed sometime between 11 weeks 0 days to 13 weeks 6 days of gestation. The key is scheduling your scan towards the end that window.
Male and female fetuses look pretty similar throughout most of the first trimester. The genitalia are just starting to develop from their root, the “genital tubercle,” which slowly develops into either a penis or clitoris. This genital tubercle is same size in boys and girls until around 14 weeks gestation, when the penis begins to elongate.
A sonographer therefore has to rely on more subtle clues to determine gender in the first trimester. The angle of the genital tubercle is one important clue. By 12-13 weeks gestation, the angle of the penis begins to point up, towards the baby’s head, while the clitoris remains flat or points slightly down.
The ultrasound images below illustrate this. A male fetus is shown on the left, a female fetus on the right. The angle of the genital tubercle is noted with faint white lines.
From Efrat et al. 1999
In small study of 172 pregnancies, sonographers were able to accurately detect fetal gender using this angle from about 12 weeks on. Before then, sonographers correctly identified only 70% of fetuses. They were most prone to misclassify the boys: roughly half of the male fetuses were misclassified as girls. So at 11 weeks, when the sonographers guessed that a fetus was a boy, they were usually correct. But when they guessed it was a girl, they were often wrong.
But by 12 weeks this method’s accuracy shot up to 98%. By 13 weeks, there were no more misidentifications; 100% of their classifications were correct. In a follow-up study of 656 pregnancies, sonographers were again perfectly accurate by 13 weeks.
At this point in pregnancy, using the angle of the genital tubercle is more accurate than trying to detect the labia or testes, the method commonly used to determine gender in the second trimester. Classification by the latter method was only about 75% accurate until 14 weeks.
(Incidentally, several websites, like this post at CafeMom and this one at About Health, claim that fetal gender can be detected with nearly 100% accuracy at the 6-8 week ultrasound using “Ramzi’s Method”. I tracked these claims down. All of them appear to derive a paper written by Dr. Saad Ramzi Ismail, which was posted to obgyn.net last year (and has since been removed). In it, Dr Ismail claims that the placenta is almost always on the left side for girls and on the right side for boys. While her paper is formatted and reads like a legitimate scientific article, it was never published in an actual scientific journal. Moreover, it seems extremely unlikely that, if we could determine gender by something as simple as the location of the placenta, we would already know this and use this method all the time. So, as far as I can tell, “Ramzi’s method” is pure junk science.)
The Bottom Line
If you want to learn your baby’s gender, schedule your first trimester scan for 13 weeks gestation. The methods used to detect gender at this fetal age are pretty new, so some sonographers may be hesitant to give your their best guess. But don’t let this deter you. Ask! They are very likely to get it right.
Additional Reading
Like this post? You may also like my take on fetal sex tests based on cell free DNA. With a simple blood draw, these tests can determine fetal sex as early as 9 weeks.
References
Efrat Z. Akinfenwa O.O, and Nicolaides K. H. (1999). First-trimester determination of fetal gender by ultrasound. Ultrasound Obstet Gynecol 13:305–307.
Efrat Z., Perri T., Ramati E., Tugendreich D., and Meizner I. (2006). Fetal gender assignment by first-trimester ultrasound. Ultrasound Obstet Gynecol.27(6):619-21.
Emerson D.S., Felker R.E., and Brown DL. (1989). The sagittal sign. An early second trimester sonographic indicator of fetal gender. J Ultrasound Med. Jun;8(6):293-7.
