Thursday, March 15, 2018
2 weeks!!! I had my BPP on Tuesday. All is good. Baby is moving all around, and the ultrasound again took like 5 minutes. I also had my blood re-checked. Platelets are still low, but don’t appear to be dropping very fast. So that’s good.
I also did some research on natural induction, because I don’t want to be medically induced if I go past 40 (or 41) weeks.
This article suggests that medical induction of labor increased from 9.5% in 1990 to 23.2% in 2011:
It also notes that medical induction is associated with lower birth weight and increased odds of C-section. It considered non-medical methods of induction, suggesting evidence is “sparse,” but “mixed” for sex, “tentatively positive” for nipple stimulation, and “ineffective” for castor oil (and potentially harmful). The study really focuses on who attempts natural induction (and natural pain management) versus considering what actually works. (No surprise, women who use doulas are much more likely to avoid medical reliance on either one.)
This article goes through induction methods—both “natural” and medical—and considers their effectiveness and potential negative outcomes.
As it related to “natural” methods (castor oil, acupuncture, breast stimulation, sex, “homeopathic” methods, and hypnotic relaxation), the study appeared to conclude that more research was needed. Acupuncture appeared to decrease the need for other forms of induction, as did breast stimulation. Castor oil, sex, and hypnotic relaxation did not appear to help, but women using castor oil had increased side effects (nausea). The article did not consider walking, eating dates, eating black licorice, or using evening primrose oil, other methods old wives swear by.
(This website suggests that drinking red raspberry tea, eating greasy food, or eating pineapple don’t help, and that eating spicy food or using black and blue cohosh may be harmful: http://www.birthbeyondbias.com/birthbeyondbias/2014/4/21/ways-to-naturally-induce-labor)
This is a crazy article—it suggest that rates of autism might be increased in children whose mothers were induced. https://jamanetwork.com/journals/jamapediatrics/article-abstract/1725449 Whaaa? I can’t imagine why that would be, unless there’s some association that they did not control for (like older mothers are more likely to be induced / more likely to have children with autism.)
Wednesday, March 7, 2018
A week ago I hit 30 weeks. And I also had my first biophysical profile. Well, half of it at least. I had an ultrasound that looked for a variety of things over an up-to 30 minute examination: 30 seconds of breathing, 3 big movements, 3 little movements, and a fluid measurement.
It was quite possibly the most stressful ultrasound I’ve ever had.
I went in expecting nothing but good news—this baby has been super active, and I had no reason to think that they would find something abnormal at 30 weeks that somehow was missed in all of my other ultrasounds. But then the ultrasound started and the tech said NOTHING. NOT A WORD. And in my experience, silence during an ultrasound is a bad thing. So I started freaking out. “Is everything okay?!” I asked. She was like, “I don’t see anything yet, I’m just getting started.” But I scanned the screen and was sure I saw a heartbeat. So I calmed down. For a minute. Still silence. I started getting nervous again. “Any concerns?” She was super unfriendly, “I have to count and I need silence to concentrate.” So I just sat there, fretting and stressing, until she was like, “and we’re done.”
Jeez! Talk about bad bedside manner. So I passed, I guess. She didn’t say anything about the exam. The only thing I managed to get was baby’s heartrate—142bpm.
My husband is worried that the ultrasound is going to do some harm to the baby, but the doctors do not seem concerned. From what I’ve read, though, it’s not clear that BPP actually has any value. My doctor said that if you have a normal BPP, the chances of not having a stillbirth in the next week are 99.9%. (Based on what I’ve read, that might be the same risk without a BPP.)
At least one article suggests that “There was no difference between the groups in the number of babies that died, nor in the number of babies who had low Apgar scores [between high-risk pregnancies that do a BPP and those that do not]. However, although the number of women involved was small, the BPP was associated with a significant increase in induction and caesarean section. However, the data are insufficient to reach a conclusion about the benefit or otherwise of the BPP as a test of fetal wellbeing.”
Apparently I should end up with a “score,” but she didn’t say anything:
I had another one yesterday, and it went much better. Partly because I knew what to expect, and partly because baby was going totally bananas before the appointment event started. He kept it up and the whole thing literally took three minutes—he kicked the probe off of my stomach at one point.
I asked about the score this time, and she said that if I don’t get 8/8 they go on to do additional monitoring.
After the appointment, I met with one of the doctors. She was great. She told me not to stress about my weight, noting I was “lean” before I got pregnant, that my blood pressure is really good, and saying if I exercise every day that’s great. Baby’s heartrate was in the 130s, exactly where it should be.
I’m 31 weeks in 1 day. It’s hard to believe!
Thursday, February 15, 2018
28 weeks! (I still can’t believe I’m pregnant.) And things look good!
Today I had a “growth” ultrasound. Baby looks good. He’s measuring in the 56%. (As my doctor said—pregnancy is the one time in your life you want to be average.) So that’s good, especially because he was measuring a little small (~30th%) at my 20 week appointment. And all of his measurements are consistent—so it’s not like he has a small head and big femur. So all good! They gave me a 3D picture of his little face. He’s smashed up against the uterine wall, with his umbilical cord running along the other side of his face. (It’s not wrapped around him, though, which is good.) He’s facing down, with his legs on my right side. Cozy!
When she was doing the ultrasound, it was painful when she pushed on my upper right quadrant. I told her that, and she said there was nothing medically wrong. (My placenta is along my back, and there was nothing wrong with my uterus.) I think that’s where his kicks have generally been, so I’m wondering if I might have a bruise?? Some of the kicks have been pretty strong. If this is how it’s going to be when he’s ~2lbs 10oz, what happens when he’s pushing 8lbs?!
After the ultrasound I had a check-in with the doctor. My blood pressure is good--118/74. The doctor’s office has me at 25lbs up, although I know I’m closer to 30lbs. Oh well. I had a tetanus shot today, they checked my platelets (I don’t have results yet), they checked me for syphilis (no results yet, although I’m going to be pretty pissed at my husband if I do!), and I had my gestational diabetes test (no results yet). I told her that I was trying to sleep on my left side, but that it was hard. She told me not to worry too much about it and that my body would tell me if I were doing things to cut off blood circulation.
Starting at 30 weeks, I’m going to have weekly monitoring. Every week I will have a biophysical profile. That includes an ultrasound evaluation and a non-stress test. The non-stress test involves measuring fetal heartrate, contractions, and movement. The doctors are looking at baby’s breathing, movement, muscle tone, heart rate, and amniotic fluid. The doctor told me that a normal BPP has a 99.9% chance of not having a stillbirth in the next 7 days. (The normal risk is like 99% already.)
My husband is a little worried about all the ultrasounds and their potential harm on the baby. I don’t have the energy to read about risks or potential risks of ultrasound to baby right now.
I’m still exercising (including running… although I think recently what I’ve been doing might be more accurately termed jog-walking). Mostly, though, I have just been REALLY tired. I’m getting this big bizzy baby to bed!
Wednesday, February 7, 2018
With my first birth, we used a doula, and I am so glad that we did—she was amazing! Unfortunately, she has retired. (That’s what happens when you “wait” 6+ years to have a second kiddo!) But I knew I wanted to use one again, so we started the process of looking for doulas. One woman we considered was my favorite maternity yoga instructor way back when, so we were excited when we interviewed her and loved her—hired!
She also does something cool. Like many other doulas, she partners with a number of other doulas who cover for each other in the off-chance that they can’t attend a client’s birth for one reason or another. In addition to that, though, the doulas collectively teach monthly classes so that you can get educated and meet the other doulas just in case your main doula can’t be there.
Last night, hubby and I went to our first class. The topic was “centering,” and the doula warned me that this would be less about education about the birth process and ways to make it more pleasant, and more about emotions about the birth/parenting/life process. That is NOT up hubby’s alley. He is a very level person, not someone prone to emotional swings. (I have only seen him cry two times: a few happy tears when our son was born, and then he sobbed when we got the anencephaly diagnosis.) Anyway, he was already a little leery about doing classes (“haven’t we already done this?”) but he’s nothing if not a good sport. So we met for a nice date night dinner and then went to the class.
There were 10 couples and 4 doulas. We were, by far, the oldest couple in the room. 7 of the 10 families were first-time parents, and most of the families appeared to be in their early 30s. (One woman my husband spoke to was in her mid-20s.) In addition to being the only Gen-X couple in a room full of Millennials, most of them appeared to be pretty “crunchy.” (If you hire a new-agey doula and meet up for “centering” birth classes, it suggests you might wear flannel and have a handlebar mustache!) Contrast that with my husband and me—we both came from work, and he was still wearing a suit. The first part of the class was easy (in theory): introductions, which included where you live and how you’re feeling about at that moment. When introductions started, most of the couples lived in urban areas, while we are from a suburb that has a reputation of being a bit hoity-toity. So I already felt a little out of place.
And then I started crying.
When the introductions started, people were supposed to say how they were feeling. Almost everyone said “excited!” or something along those lines. When it got to me, I was planning on saying “apprehensive,” but as I started to talk I just started bawling. I felt like a crazy person! I was the oldest soon-to-be mom there, I already had a living child, and yet I was the only one crying.
I knew I was anxious, but I had no idea how emotional I was feeling.
The evening’s exercises were, it turns out, right up my alley. They had you write down negative things you’re thinking relating to yourself, your birth, and your (future) parenting, and then they had your partner say them to you over and over. Hearing my husband call me selfish was harsh! But the point was made—why are we so hard on ourselves when we know no one else ever would judge us that way? Then we reworded them to make them positive (selfish => good at focusing on my needs too). Then our partner says the positive thing to us over and over. Then we say the bad thing to ourselves over and over. (How does it make you feel? Not great.) Then we say the nice thing over and over. (How does it make you feel? Good!) The point being, we are too hard on ourselves, and if we change our internal narrative from the negative to the positive, it can actually make us (and our tiny passengers!) go from feeling bad/stressed to good/happy.
The next exercise was for us to walk around the room, meet a stranger, and then say “who are you?” and ask no other questions. Then we had to make eye contact while they talked for a minute. It was actually really awkward/nice. I got hugs from both of my strangers.
After it was over, we wrote our “intention” for the labor/delivery/baby on a tree and wrapped it with a ribbon. Ours was “it will be okay.”
Then it was over. Woah! That was intense. The doulas loved my show of emotion—they said it gave other people in the room permission to be more “real.” I think that might be true. When the training was over, we ended up talking to a couple of the different couples. One told us that, while they were 37 weeks pregnant with their first, they had struggled for 4 years with undiagnosed endometriosis, so they definitely related to the pain of infertility. Another couple, pregnant with their second, told us they tried for over a year and were not sure it was going to happen. One of the doulas (who also gave me a hug—hugs all around!) told us that she lost one of her pregnancies when the baby was full term. Devastating. (She has 3 healthy kiddos.)
All in all, it might have been some “hippy dippy bologna,” but I really needed it!
Thursday, January 25, 2018
We like this doctor! 25 weeks pregnant today (or slightly less, depending on when I ovulated). The doctor’s office has my weight gain at 19 lbs (they didn’t start weighing me until I was already like 9 weeks pregnant…. I think my weight gain is closer to 25lbs). She seemed to think that was totally fine, and that I do not need to worry about epigenetics, and that because I was thin before I got pregnant it’s fine if I’m gaining a little more than would allegedly be ideal. Aha! Bring on the cake!!! (Kidding, a little.) Belly measuring right at 25 weeks as well.
She said it’s good to exercise and I should keep it up, and I was fine to go on two trips I have scheduled (one with my guys to Disney world and another one with my mom and grammi to New York). We talked about inducement, and she said that because I would be delivering under 40, it would be fine for me to go to my due date, although ideally I would deliver just a little ahead of it. (On it!) She said that if I were 40, they would not want me going past my due date. She also said that if I were close to my due date, we could talk about induction, and that if my cervix was already pretty open it probably wouldn’t be that bad because I’ve already had a kid. But it didn’t sound like she was going to be worried if I went up to my due date.
We also talked about baby’s movement. She said I was ahead of the curve by already doing kick counting, that it was good that baby was active (and that there’s no such thing as too much movement), and that it’s normal for baby to have periods of quiet. When I told her my concerns about cord issues, she was very understanding and said something along the lines of, “we’re watching this baby. We got this.” That made me feel good.
My next appointment is at 28 weeks for a growth ultrasound, the glucose test (to see if I have gestational diabetes), a blood test to check my platelets/hemoglobin, and I’m going to get some kind of booster shot.
Monday, January 22, 2018
When I was pregnant with my son, stillbirth barely even crossed my mind. Once I hit 20 weeks, I was like “bring on the healthy baby!” But since then, I have had 2 friends who had basically full-term stillborn children. (Both were little boys with cord accidents.) And a friend of a friend had a full-term stillbirth (and almost died) after her uterus ruptured during a VBAC.
Between our experiences with pregnancy loss after my son, and my friends’ tragic experiences, and the fact that I’m now older, stillbirth has been on my mind a fair bit. That fear that something bad might happen has been gnawing at me, so I decided to read about stillbirth more to understand it, and potentially avoid activities that could increase the risk… or at least be aware of signs that there could be a problem.
After 20 weeks, a pregnancy loss is considered a stillbirth, not a miscarriage. 24 weeks is considered the line of viability because, theoretically, half of babies born at 24 weeks would survive (many with disabilities, of course). Some studies consider 24 weeks when looking at stillbirths. The causes of stillbirths tend to vary depending on when in the pregnancy they occur, with stillbirths earlier in pregnancy looking a lot more like late-term miscarriages.
Stillbirths are surprisingly common. 1 in 160 pregnancies ends in stillbirth in the US.
This article suggests that the cause for a stillbirth can be probably found about 60% of the time, and possibly or probably found around 75% of the time. (And this article talks about a system for determining causes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3832680/) Almost a third of stillbirths in their review occurred between 20 and 24 weeks, and 50% occurred before 28 weeks. In their review, the authors found the most common causes were obstetric conditions (29.3%), placental abnormalities (23.6%), fetal genetic/structural abnormalities (13.7%), infection (12.9%), umbilical cord abnormalities (10.4%), hypertensive disorders (9.2%), and other maternal medical conditions (7.8%).
Obstetric complications included abruption (7.4%), complications of multiple gestation (6.1%), and preterm labor, preterm premature rupture of membranes, and cervical insufficiency, often in combination with chorioamnionitis (15.0%). When the baby died during labor (intrapartum stillbirth), it was always categorized as an obstetric complication. Placental abnormalities included uteroplacental insufficiency (4.7%) and maternal vascular disorders (7.6%). (Evidence of placental insufficiency can include fetal growth impairment, oligohydramnios [low amniotic fluid], and preeclampsia.) Placental disorders and hypertensive disorders were more likely with later pregnancy losses, with cord issues occurring more frequency in the latest pregnancy losses. The researchers considered it a cord issue when there was vasa previa, cord entrapment, or evidence of occlusion and fetal hypoxia, prolapse, or stricture with thrombi. They did not include nuchal cord alone to be a probable cause of death because they occur in around ¼ of uncomplicated pregnancies. But the researchers noted that nuchal cords can be harmful, and noted cord issues generally can be, potentially, preventable. They also noted that, after 24 weeks, causes of stillbirth like preterm labor, cervical insufficiency, preterm premature rupture of membranes, chorioamnionitis, and abruption could, instead, lead to preterm birth if the baby could be delivered via C-section.
This article goes through some of the risk factors for stillbirth: increased maternal BMI, advanced maternal age (boo!), smoking (or exposure to smoke), a fetus below the 10th percentile for gestational age (nearly half of stillbirths are below the 10th percentile in weight), mother’s health issues (which account for 10% of stillbirths) such as diabetes (including gestational diabetes), hypertension (4-9% of all stillbirths), hypothyroidism (1% of stillbirths), lupus, and multiple gestation.
It also goes through causes, finding about 6-10% of pregnancies complicated with preeclampsia end in stillbirth. About 3-7% of pregnancies with lupus end in stillbirth. 9.5% of women with recurrent stillbirth have antiphospholipid syndrome. 10-20% of stillbirths are from genetic abnormalities, with anencephaly being one of the more common anomalies leading to stillbirth. Chromosomal abnormalities cause 6-13% of stillbirths, with trisomy 21, 18, and 13 being the most common. With respect to uterine complications, premature rupture of membranes causes about 0.8% of stillbirths, with better outcomes the further into the pregnancy. Chorioamnionitis, the inflammation of the uterus, accounts for 22.6–36.9% of total stillbirths. Cervical incompetence can also cause stillbirth, although a cervical cerclage (which also carries risks) can help. 7.3% of stillbirths involve multiple births. Placental abruption causes 1-4% of stillbirths, and can be caused by trauma, prior cesarean section, hypertensive disorders, parity, maternal age, smoking, and gestational age.
Okay, here’s another one on risk factors. It suggests that the overall stillbirth rate was 4.2/1000 (when only including singleton pregnancies and those without genetic abnormalities), but only 2.4 in pregnancies without fetal growth restriction. Fetal growth restriction (birth weight below 10%), maternal obesity, and smoking accounted for over ½ of the stillbirths. The authors also suggest that only around 15% of stillbirths are unexplained.
The authors focused on “normally formed singletons” (i.e. no twin pregnancies, and no pregnancies with genetic abnormalities) to consider risk factors. They also defined stillbirth as pregnancy loss after the 24th week. In their study, ½ of all stillbirths occurred after 34 weeks.
They had a chart with the stillbirth rate depending on the maternal trait. Younger (under 20) had the highest rates, with older and young (20-24 and 35 and up) the second highest rates. The rates were lowest for moms 30-34. The rates were highest with 0 parity (the number of times a woman has carried a child to a viable age is parity, so parity 0 means never having a child) as well as parity of 3 or more. The lowest was for women 1 parity (like me!).
As we already knew, stillbirth rate increases when mom is heavier. The stillbirth rate was the same for BMI under 24.9, increased super slightly for BME up to 29.9 (although not much, causing the authors to note that even slightly overweight women had lower risks than those who were much heavier) and then rose with BMI above that, the heavier the higher the stillbirth rate.
It also appears that economic insecurity increased stillbirth risk. This study was done in the UK, and found that UK/European women had (much) lower stillbirth rates than those from other countries. Working moms had slightly higher rates (although that could relate to things beyond work, like financial condition). Stillbirth rates were higher if “partner” was not working (again, probably relates to financial condition). They rated an “index of multiple deprivation” and found the most deprived people had the highest rates of stillbirth.
With respect to maternal history, rates were higher with mental health problems, pre-existing hypertension, and cardiac disease. They were MUCH higher in women with pre-existing diabetes (3.7 v. 13.8). And they were much higher with a woman with a previous stillbirth (3.4 v. 11.1).
With respect to pregnancy related factors, smokers had a higher risk than non-smokers (5.8 v. 3.2, although smokers with children without fetal growth restriction was close to the non-smoking mothers) and women who took folic acid has slightly lower risk (3.5 v. 4.7). Alcohol consumption did not have a risk—women who drank had a rate of 3.3 v 3.8 for non-drinkers—yes, the rate for stillbirth was LOWER for drinkers than abstainers. (I highly suspect that this does not show alcohol consumption is good for pregnancy. It might be an economic indicator, as I have seen other studies that suggest very moderate alcohol intake is associated with better child outcomes. That’s likely not because alcohol is GOOD for the pregnancy, just that the women who make the reasonable decision to very occasionally imbibe are, on average, better educated. Take me, for example. Since I got pregnant I have had a few drinks since 12 weeks—a glass of sangria with my family around Thanksgiving, a glass of sparkling wine with friends at a celebratory dinner, and a glass of sangria with friends at a Christmas celebration. And I’ve had maybe a few sips of my husband’s wine or beer over the course of the past 4 months. That has probably added up, grand total, to less than six glasses. Would I call myself a non-drinker? No. Although I certainly don’t think I’m doing anything to harm baby. See more below about alcohol consumption and stillbirth risk.) Likewise “late-booking” an appointment (after 13 weeks) increased the rate of a stillbirth (4.5 v. 3.6). This, too, is likely an economic indicator (or at least an indication of a woman who has not been taking the same care in her early pregnancy).
With respect to pregnancy complications, gestational diabetes increased the risk (4.5 v. 3.7), pregnancy induced hypertension increased the risk a little (3.9 v. 3.7), pre-eclampsia increased the risk a lot (10.3 v. 3.6), and antepartum hemorrhage—bleeding after 24 weeks—increased the risk a lot (3.3 v. 8.7).
With respect to the baby, boys were more likely to be stillborn than girls (4.4 v. 3.9). (This study says the same thing—saying the stillbirth risk for boys is about 10% higher than with girls https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0220-4 and noting a cause might be “Y chromosome-linked genes are transcribed at the two-cell stage and, in animal models, male embryos have faster development and higher metabolic rates than females, potentially leaving the male fetus more vulnerable to a range of stressors, including endocrine fluctuations, oxidative stress, and nutritional compromise. Recent experimental work in animal models has demonstrated that gene expression in the murine placenta is adaptive and shaped by diet, with placental growth in males being more susceptible to nutritional compromise than that of females”.) Babies in the 10th weight percent were much, much more likely to be stillborn (16.7 v. 2.4 for those in 10-90 and 2.6 for those greater than 90). Fetal growth restriction was also, unsurprisingly, associated with an increased stillbirth rate (2.4 for no growth restriction versus 9.7 for growth restriction detected before birth, and 19.8 for growth restriction not detected until after stillbirth).
The authors found, as I suspected, that women who lived in the most “deprived” areas had an increased risk for stillbirth, as well as those whose partners did not work or who were ethnic or racial minorities.
The authors found that, “Contrary to a systematic review, we found no significant increase in risk of stillbirth with older maternal age. This may be because we excluded congenital anomalies from our cohort, which are known to be increased in older mothers. This is consistent with a recent report which found that the association between stillbirth and maternal age disappears when congenital anomalies are excluded.”
That makes me feel better and worse at the same time. On one hand, I am a (much) older mother, so I do not want to have an increased risk. On the other hand, I’m still worried that there is some congenital abnormality we just don’t know about. Of course, it would be far less devastating to lose a pregnancy to stillbirth if it was because of something like an undiagnosed and un-survivable defect than to lose an otherwise healthy baby. Maybe.
The authors concluded that fetal growth restriction was the single largest risk factor for stillbirth, and that stillbirth is potentially avoidable if those babies are delivered early. That makes me glad I’m having a growth ultrasound at 28 weeks.
Okay, this article is completely crazy—the authors suggest that higher outdoor temperatures increase the risk of stillbirth. Looking at spring/summer stillbirth risks in Quebec Canada (where the temperature fluctuates and women might not be used to heat), “Odds of term stillbirth for temperature 28 °C the day before death were 1.16 times greater relative to 20 °C”.
This article suggests that up to 8% of “unexplained” stillbirths might actually be because of genetic heart defects, which can also cause sudden infant death syndrome.
Going back to the theme of behaviors that might prevent stillbirth, this article suggests that sleeping on your left side might reduce the risk of stillbirth. It found “women who slept on their back or on their right side on the previous night (before stillbirth or interview) were more likely to experience a late stillbirth compared with women who slept on their left side (adjusted odds ratio for back sleeping 2.54…, and for right side sleeping 1.74 …).” The article noted that “The absolute risk of late stillbirth for women who went to sleep on their left was 1.96/1000 and was 3.93/1000 for women who did not go to sleep on their left.” In other words, “Compared with women who went to sleep on the left side, women who went to sleep in any other position had a doubled risk of late stillbirth”. The authors suggest that this position provides the best position for “Cardiac output and fetal oxygen saturation.”
Strangely, it also found that “Women who got up to go to the toilet once or less on the last night were more likely to experience a late stillbirth compared with women who got up more frequently (adjusted odds ratio 2.28 (1.40 to 3.71)).” And “Women who regularly slept during the day in the previous month were also more likely to experience a late stillbirth than those who did not (2.04 (1.26 to 3.27)).” In other words, it’s best to sleep on your left, and at least to try to go to sleep on your left. It’s also better to go to the bathroom more often (?) and it’s better not to sleep during the day. I should note, the authors only considered singleton births of healthy babies (no birth defects). The authors also found, as we’ve previously discussed, that “Women with late stillbirth were more likely to be obese, socioeconomically deprived, to smoke, and be of high parity compared with controls.”
I read this theory—that sleeping on your left side is best—and I’ve been trying to do it every night. It’s horrible. I generally like to sleep on my stomach (a no-go now) or on my back. As far as sides go, I much prefer my right side. But every single night, I try to go to be on my left side. And every single night, I wake up (at least 2-3 times) on my back or right side… because I HATE sleeping on my left side. I can’t explain it. I just don’t like it. I never do it. But I’m going to keep trying.
Okay, I think I previously mentioned that one of my Drs. suggested they might want me to deliver at 39 weeks to decrease the risk of stillbirth? Well, obviously I had to read about that! This article notes that there was a “Rule” that restricts elective delivery before 39 weeks 0 days. It notes that as early-term deliveries decrease, the rate of stillbirth generally increases. Well, to that I just have to say no duh. Of course if you deliver all babies at 39 weeks (not what they’re saying, but making a point), you would decrease the stillbirth rate because you would avoid all stillbirths that would otherwise have happened from 39 weeks to delivery. The question is not whether delivering at 39 weeks decreases the stillbirth rate, it’s what are the risks to the babies delivered early and do those risks outweigh, or not, decreasing the stillbirth risk. If we delivered all babies at 24 weeks, the stillbirth rate would drop a ton, and yet no one is suggesting that’s a good idea. In the author’s defense, I’m not sure they’re taking on the idea that it’s not desirable generally to be delivering at 39 weeks 0 days, just that they think Drs. should have more authority in making the decision unburdened from a “Rule.”
Because I have had 2 friends have basically full-term stillbirths of otherwise healthy babies due to umbilical cord accidents, and because those have been touted as potentially preventable (I’ll have to do another post on kick-counting later), I wanted to read more about them.
This article suggests that a fetus with a heartrate of 90 bpm for 1 minute on a non-stress test should potentially be delivered. It also says the 18-20 week ultrasound should look at the umbilical cord, its characteristics, and its placental and fetal attachment. (Um, isn’t it always attached to the fetus at the belly button?!) Specifically, they want to look for these possible umbilical cord abnormalities:
• Abnormal insertion
• Vasa previa
• Abnormal composition
• Cysts, hematomas and masses
• Umbilical cord thrombosis
• Coiling, collapse, knotting and prolapse
It also notes that “Hiccups occurring daily after 28 weeks, and greater than 4 times per day requires fetal evaluation” because it can relate to a potential cord issue.
The article also notes that stillbirth due to cord issues often occurs between 2 and 4am, and may relate to hormonal issues.
Okay, I know I previously represented that stillbirth rate found to be a little lower with women who drink versus women who do not, but I do not want to suggest that drinking is a good idea. This article looked into this exact issue:
It noted that drinking 1 or more drinks a day is associated with reduced birth weight and fetal growth restriction, heavy drinking is found to be associated with malformations, mental retardation, and behavioral and psychosocial problems in childhood and adolescence. The researchers asked mothers how many drinks they had a week, and mothers could answer <1, 1–2, 3–4, 5–9, 10–14, 15–19, 20–29, 30–39, and ≥40 drinks/week. Because there were so few women in the higher categories (thank goodness!) they grouped the women into four groups: <1, 1–2, 3–4, and ≥5 drinks/week. The vast majority of women (68%) were in the <1 group. 23% were in the 1-2 group, 7% were in the 3-4 group, and the remainder (2%) were in the higher groups. (For the groups of 15 drinks/week and above, it was less than 0.4% of the group). Of those groups, the stillbirth rate was 4.2/1,000 for the <1 drink per week group, 5.1 for the 1-2 drinks per week group, 5.6 for the 3-4 group, 10.6 for the 5-9 group (although there were not actually a thousand women in this group, so I extrapolated), and 32.5 for the 10-14 group (same). The sample sizes were so small for the higher drinking groups that there were no stillbirths in that group. (Which is not to say that drinking that much is okay, obviously.) The article also tracked infant deaths: 5/1,000 for the <1 drink per week group, 4.1 for the 1-2 group, 4.5 for the 3-4 group, and 6.4 for the 5-9 group (although there were not actually a thousand women in this group, so I extrapolated). There was only one infant death in the higher drinking groups (again, the sample sizes were small), representing a 62.5/1,000 infant death rate. So, the stillbirth rates were lowest in the <1 drink/week group, but still relatively low in the less than 4 drinks/week groups. The numbers went up dramatically in the 5+ drinks/week group. Infant death rates, on the other hand, were actually pretty steady until the highest drinking groups, but there were very few women in those groups.
The researchers calculated a stillbirth “risk ratio” for each group, and compared that to other “risky” things. <1 drink/wk = risk ratio of 1. 1-2 = risk ratio of 1.23. 3-4 = risk ratio of 1.35. ≥5 = risk ratio of 2.96. Smoking is still worse. 0 cigarettes/day = risk ratio 1. 1-9 = 1.51. ≥10 = 2.23. (The infant death risk ratio was also worse with smokers.) Caffeine intake had the lowest risk ratio for women who had 200-399mg/day, and the highest risk ratio for women above 400mg/day. (Strangely, for infant death it was the opposite.) For a maternal age of 25-29, the risk ratio was 1. <25 is .87 and ≥30 is 1.06. (Note that’s different than what I read above, which suggested that once chromosomal abnormalities were pulled out there was not an increased risk for stillbirth in older moms. And for infant death it was the opposite.) BMI risk ratio was 1 for 18.5-24. It was 1.47 for <18.5, 1.22 for 25-29, and 2.82 for ≥30. (Once again showing the risk of stillbirth increases with increasing maternal age. The results were similar for infant death.) Women who were single actually had lower risk of stillbirth than those who were married/cohabitating. (But for infant death the result was opposite.) Students had a lower stillbirth risk ratio than women who were employed, who had a lower rate than women who were not employed. (Also different than what I read above. Infant death risk was similar.) The more education mom had, the lower the risk of stillbirth (but, strangely, that did not hold for infant death). For parity, they only did 0 (first pregnancy to viability) or ≥1. Stillbirth risk (and infant death risk) was lower with ≥1. Preterm delivery was, unsurprisingly, a risk factor for stillbirth. (No preterm birth = risk ratio of 1, yes = 21.72. Risk was also higher for infant death.) Same for birth weight. (<2,500g [~5.5lbs] = 29.29 v. ≥2,500g = 1.) Risk was also higher for infant death.
The authors concluded that the risk of stillbirth increased with increasing alcohol categories, and women who drank ≥5 drinks / week had almost 3x the risk of women who drank <1 drink/week. The cause was mainly due to fetoplacental dysfunction. They noted previous studies had inconsistent results. The authors also suggested that underreporting of alcohol use was a risk. They also noted that their data did not allow them to distinguish between women who totally abstained and those who drank less than 1 drink a week. But they were not concerned about it, because “In a recent study, when we focused on low-to-moderate intake, we found that a very large group of women (5–44 percent) who reported being total abstainers on the questionnaire actually reported consuming small amounts of alcohol (>0 but <1 drink/week) in interviews or diaries, and vice versa”. In other words, women who report not drinking might actually drink a teeny bit.
Okay, so I’ve read a fair bit about stillbirth, risks, etc. What are my takeaways?
· Babies measuring less than the 10th % for weight are at a much, much higher risk for stillbirth.
· Don’t smoke, don’t drink (much), try not to be obese or too thin.
· Diabetes is a bitch. Preeclampsia is a bitch. Lupus and antiphospholipid syndrome? Also bitches. In general, mom’s health issues pose a risk to babies.
· Twin pregnancies are riskier.
· Women with bleeding are more likely to have a stillbirth.
· Boys are 10% more likely to be stillborn.
· The jury is still out on how much of an increased risk there is for increased maternal age, particularly when birth defects are not taken into account.
· Stillbirth risks are higher for first time moms and women who have a lot of kids.
· The 18-20 week ultrasound should include a review of the umbilical cord.
· After 28 weeks, go to the hospital if your fetus has the hiccups more than 4 times a day.
· Keep cool at the end of your pregnancy!
· Sleep on your left side, or at least try to. Avoid sleeping on your back.
Honestly, reading about all of the different causes / risk factors of stillbirth made me feel much better. I feel like my risk of stillbirth isn’t actually all that high, and I have some things I am going to do (or try to do) to make my risk even lower.
Monday, January 8, 2018
I had an appointment with my regular OB today, because I did not see them for my 20 week appointment. (I went to the high-risk OB.) I found a few things troubling.
(1) Baby’s small. I’ve been saying this whole time that baby’s been measuring behind, and it did not really concern me because that was how it was from the beginning, and hubby and I think I ovulated a few days later than they are measuring. Today my OB told me that my measurements from the high-risk OB showed baby measuring in the 30th %. (Apparently they use a variety of measurements to come up with that estimate, including some leg measurement, head measurement, etc.) I was like, “oh, that’s no problem, we’re probably a few days behind.” But then she said, “yea, even though your due date is May 10, they measured as though it were May 13, and you’re STILL in the 30th percentile.” Yuck! But is that even bad? I mean, it’s not like 30% is small. (I understand they get worried when baby is measuring below the 10th % or when baby’s growth falls behind.) The high-risk OB didn’t even mention it, so maybe I have no reason at all to be concerned. After the OB told me that, though, she suggested I could have another ultrasound at 28 weeks to check growth (the same offer the high-risk OB made), so I decided to take that appointment after all. Let’s make sure this little man is not too little. I can always change my mind.
(2) I am gaining too much weight. I mean, I knew that, but a (big) part of me thought, I’m so healthy—I exercise and (generally, outside of the holidays) eat well—and my husband and I have never had any problems with weight (and we have a skinny little kid!) so NBD if I put on 5-10lbs more than the “ideal.” I mean, if I can brag for a minute, my husband and I looked like fitness models before I got pregnant! (And he still does.) But Dr. said the concern is not just mom having to lose an extra 5-10lbs after baby—some studies suggest that if mom gains too much weight it puts her baby at risk for obesity in later life. UGH. Then she showed me my weight gain chart and the basically vertical weight line (ie it shot up) from Thanksgiving to now. She was like, “that’s the holidays. You do not want to keep gaining like that. Eat cheese or peanut butter. Avoid carbs.” But I love carbs!!
Now, she admitted that many women with obese children are obese themselves, and that can have a genetic / environmental component (obviously). But there is concern that when mom gains too much weight—even if she is otherwise generally healthy or in a healthy environment—that can set the kid up to be fat.
My doctor then measured me and said my tummy was measuring at 24 weeks pregnant—so AHEAD of where I should be. Small baby, big tummy. Dammit!
I decided to read a little more about this. It does appear that there is real concern that if mom gains too much weight it can impact baby’s weight later in life and increase the risk of obesity:
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001521 (“The results showed that the amount of weight each mother gained in pregnancy predicted her children's BMI and the likelihood of her children being overweight or obese. For every additional kg the mother gained during pregnancy, the children's BMI increased by 0.022. The children of mothers who put on the most weight had a BMI that was on average 0.43 higher than the children whose mothers had put on the least weight…. This study shows that mothers who gain excessive weight during pregnancy increase the risk of their child becoming obese. This appears to be partly due to a direct effect on the developing baby.”). This figure shows what appears to be a direct correlation between weight gained and child’s BMI: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001521
http://ajcn.nutrition.org/content/early/2017/09/06/ajcn.117.158683.abstract (“maternal weight across the childbearing period increases the risk of obesity in offspring during childhood, but high prepregnancy BMI has a stronger influence than either gestational weight gain or postpartum weight retention.”)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001295/ (“Mean (SD) gestational weight gain was 31.5 (11.2) pounds and offspring BMI z-score (BMI standardized for age and sex) was 0.15 (1.0) units; 6.5% of adolescents were obese (BMI greater than or equal to the 95th percentile). Gestational gain was linearly associated with adolescent adiposity: compared with 20–24 pounds, gain less than 10 pounds was associated with child BMI z-score 0.25 units lower (95% confidence interval [CI]: −0.47, −0.04), and gain greater than or equal to 45 pounds with BMI z-score 0.18 units higher (95% CI: 0.11, 0.25). Compared with women with adequate gain according to 1990 Institute of Medicine guidelines, women with excessive gain had children with higher BMI z-scores (0.14 units, 95% CI: 0.09, 0.18) and risk of obesity (odds ratio 1.42, 95% CI: 1.19, 1.70).”)
https://www.nature.com/articles/0803582 (“We found that high weight gain during pregnancy (⩾16 kg [35lbs]) was significantly associated with higher risk of overweight in Portuguese children.”)
http://onlinelibrary.wiley.com/doi/10.1111/ijpo.12163/full (“The results of this study suggest that ‘overnutrition’ in pregnancy independently affects child body composition throughout child development, particularly in non-Hispanic White respondents.”)
Even asthma is a risk, potentially due to “proinflammatory mechanisms”!
http://pediatrics.aappublications.org/content/pediatrics/early/2014/07/16/peds.2014-0439.full.pdf (“[Maternal obesity in pregnancy] and high [gestational weight gain – more than 42lbs] are associated with an elevated risk of childhood asthma; this finding may be particularly significant for mothers without asthma history. Prospective randomized trials of maternal weight management are needed.”)
I truly thought that discouraging too much weight gain during pregnancy (within reason) was just mom body shaming. I had NO IDEA that it might actually hurt baby!!! I gained around 35-40lbs with my first and he’s a healthy skinny little thing. I started this pregnancy very thin (BMI 19.1) and about 10 lbs lighter than I was with him, so I assumed I would gain more. I wasn’t super worried about weight gain but now I’m freaking out a little bit. My question, of course, is if I am not supposed to gain too much weight when pregnant, WHY AM I SO HUNGRY???
More cheese, less donuts I guess.
[Before we go any further, yes what you’re reading is that I am both worried my baby is currently too small and that he will end up being too big.]
(3) I might need an early induction. This one potentially threw me for the biggest loop. At the end of the appointment she made some comment about inducing labor at 39 weeks. I was like, “what now?” Then she told me that older (now defined as 35 and up) mothers are at an increased risk for stillbirth later in their pregnancies, and maybe their placentas may deteriorate faster than younger mothers. (This risk of stillbirth issue is why my OB’s office was not going to let me go past 42 weeks with my son back when I was a youthful 33.) She then said that to avoid this they recommend induction at 39 weeks. She also said that induction when you’re already dilated with an open cervix is very different than if you’re tight as a drum, which is NOT FUN. UGH!
Just the other day my hubs and I were talking about my delivery (the first time we’ve discussed it) and he was like, “maybe home birth?” I said, “nah, I’m more comfortable in a hospital.” Now it sounds like I might not even have a choice. BOOOOOOO.
Here’s an amazing article on the subject: https://evidencebasedbirth.com/advanced-maternal-age/
I have to think more about this. Damn my old age.