Monday, January 22, 2018

Stillbirth concerns

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. 

Interesting.

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

Small baby, big mommy

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.”)

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.

Saturday, January 6, 2018

Bizzy baby

All is good at 22 ½ weeks pregnant!  When we left for the holidays I was 20 weeks pregnant and just starting to show.  So I packed a couple of maternity pants and a few maternity tops, but mostly just roomier normal things.  And then I exploded.  I think my abs just totally gave up.  I went from looking a little chunky to very, very pregnant in what seemed like days!!  My weight gain has been strong and steady.  22 ½ weeks down and 22 ½ lbs up.  Yikes!  I’ve kept up a lower-pace workout regimen (I ran basically every other day the past two weeks), but I am voraciously hungry.  (And my husband is a total enabler—“if you’re hungry, it’s because your body wants you to eat!”)  I shudder to think how big I would be if I were not working out or if my diet were any less healthy.  (And it hasn’t exactly been super healthy the last few weeks.  I confess I have been hitting the treats hard over the holidays.)  But enough complaining about weight gain.  This is a GOOD problem to have!  And I lost it all before and I’ll be able to lose it again.  (It only took me… five years….)

The big news is that we finally told the tiny man he’s going to be a big brother.  (It was going to be impossible to put off any longer—as I mentioned, I have gotten HUGE recently.)  As expected, he was NOT super excited at first.  It went something like this:

Total silence, looking back and forth between us.  [Shock]
When he finally spoke, “no you’re not.” [Denial]
Then, “I don’t want a baby brother.” [Pain]
Then, “I thought you weren’t having another baby.”  [Anger]
Then, “Can we give him to another family?” [Bargaining]
Then, near tears.  [Depression]
Then we just let him think about it.  And (thank goodness!) he warmed up to it.  When we dropped him off at school, “this is the best day of my life” [Acceptance/hope]

Yes, he cycled through the textbook 7 stages of grief.  In about an hour.  Poor kiddo!!  We expected he would cycle through them again a few times, but so far his viewpoint has been 100% positive ever since.  He’s proudly told anyone who will listen that he’s going to be a big brother, and when I went to his class to help with their holiday party, he brought all of his friends over to me to see my at-that-point-still-just-a-little-bump tummy, telling them his baby brother was the size of a potato and was swimming around in amniotic fluid.  (Yes, I’m probably going to get some angry emails from other kindergarten parents.)  So, other than a very tense 10-15 minutes or so, it went as well as I could have possibly hoped!

What else?  Oh, this is one busy baby.  As I think I previously reported, I started feeling bubbles at 15 weeks, my hubby was feeling kicks on the outside of my tummy by 18 weeks, and I was visibly seeing big kicks on the outside of my stomach by 19 weeks.  (I’ve read that second-time moms feel movement sooner, and thin women (which I WAS when I got pregnant—notice the past tense) tend to feel kicks sooner.  And position of baby/placenta and general activity of baby all play a part in when/how often mom feels movement.  So my experience is earlier than normal, and I think earlier than with my first.)  Since then I have been feeling this baby log roll every day, multiple times a day.  He’s nuts!  I remember feeling/seeing kicks with my first little guy (and one time with my anencephaly pregnancy), but based on my memory this baby is MUCH busier than his older brother.  I mean it’s like a 24/7 dance party in there.  I actually got a little worried at one point and looked to see if there was any literature suggesting there can be TOO much movement.  What I found did not concern me, but does suggest a few things (and take these with a grain of salt)—active babies in utero might turn out to:

·       cry more
·       have a higher score on a brain maturation test 
·       have better control of body movements after birth
·       be more unadaptable and unpredictable
·       be less easily frustrated at 1 year 
·       if a boy, be more active as a toddler
·       be more independent at 2 years
·       be more likely to interact with toys or strangers at the age of 2.


I told my husband all of this and he said, “uh oh.  He’s going to be EXACTLY like his older brother.”  All I could think was, “no, this baby is MORE active!!” 

I have to confess, I am REALLY starting to believe this is going to work.  (I mean, at this point, if something happens, it’s not a miscarriage, it’s a stillbirth.  This is a real baby!)  It’s pretty scary.  And amazing.  Really, really amazing.









Monday, December 18, 2017

“When” it works

I had my “20 week” (really, 19w4d… and I think this baby is actually more like 19w1d….) appointment with the high-risk OB today.  I was a total MESS.  I kept reminding myself that at the 15 1/2w apt, the doc said she would be really surprised if we found something at the 20w appointment.  But that did not stop me from feeling absolutely ill in the hours leading up to the appointment.  (It’s amazing how much impact my mental state can have on my physical state!)

I saw a new ultrasound tech today, so of course I gave her the “do you know my history?” / “I want you to tell me if you have any concerns” speech.  She was familiar with my history, and suggested she would tell me if she was worried (but I didn’t believe her).  Baby is growing, had a heartbeat, etc.  But the ultrasound took FOREVER.  I kept asking, “is that normal” “does that look right” “do you have any concerns” “what are you looking for now” etc.  She spent a super duper long time looking at the heart, and that was freaking me out.  After about 45 mins (of her reassuring me repeatedly she did not have any concerns “yet”) she said she was done and was going to get the doctor.  For all of my “good” ultrasounds, the ultrasound techs have been like, “you can get cleaned up, I don’t think the doctor will want to see anything.”  And for all of my “bad” ones, they have asked me to stay as I am (stomach exposed) so the doctor can “take a look.”  So, of course when she said she wanted me to stay as I was so that the doctor could take a look I totally freaked.  She said, “oh it’s normal, he always likes to do a check.”  I’m like, yea right lady.  Then I pressed her, what’s he going to be looking for, do you have any concerns, etc.  She said, no concerns (not very convincingly), he’ll just want to confirm my findings and check a few things on his own.  And then she was gone for like 20 mins.  (Another bad sign.)  And when the doctor finally came in—the same one that diagnosed our omphalocele almost 2 yrs ago!—the genetic counselor was with him.  I nearly had a heart attack!  I literally said, “you guys are freaking me out!”  And the doctor said, “we’re both just so excited to give you the good news that everything looks great!”  Sweet relief!

Then the doctor did another mini ultrasound (it really is part of his practice to take a second quick look).  He said nothing looks structurally wrong at all and he would be really surprised if we had any major structural issues.  Then we talked about the potential non-structural issues that might not be diagnosable.  Both he and the geneticist said something along the lines of, you know you have had a number of pregnancies marked with structural abnormalities (the anencephaly and omphalocele ones, and likely many of your prior miscarriages).  But you have no reason to think they were also afflicted with neurological issues, although they could have been.  On a separate path you have had a completely structurally sound child who is neurologically normal.  (Actually, quite above average!)  At this point, this pregnancy appears to be on the same path as your son—structurally sound—and there is no reason to think that it would not be neurologically sound as well.   The doctor suggested that he doesn’t need to see me again, but he understands how hard this kind of pregnancy is, so if I want to come back in for another ultrasound at 28 weeks I should feel free.  I told him I would think about it.  Obviously the purpose of the 20 week ultrasound is to give you time to “make decisions” (ie terminate) if you find something really wrong.  By 28 weeks there’s nothing they can do…. Except give a freaking out mom a little more comfort… for a bit.

So that’s that.  I promised myself (and my husband) that I would stop freaking out / saying “if” this works after this appointment.  I mean, from this point on there’s nothing more I can do anyway.  And I also promised myself that I would cut some tags off of some maternity clothes!  So I’m going to do just that.  AND, we decided that this was the appointment that would be required before telling the OTHER tiny man in my life what’s going on.  Yes, you read that right, we’re telling the little man he’s getting a sibling sometime later this week.  Stand by for the report!

I am going to try to embrace the pregnancy.  After 15 weeks of “if,” it’s going to be hard to start saying (and thinking!) “when.”  I look forward to working on it.

P.S. Depending on the measurement baby looked to be measuring around 19 weeks plus a couple days or so.  So he’s continuing to measure a little behind.  (He’s been “behind” since the beginning.  I’m pretty certain I ovulated late in my cycle.)  She guessed he was weighing in at 10oz.  (Which is basically what a 19 ½ wk old should weigh.)

P.P.S. I got my final test results back—I am not a carrier for Fragile X, and my risk of being a carrier for spinal muscle atrophy is 1/834, so there is a risk that I’m a carrier, but it’s pretty small.  (The untested carrier rate for white people is 1/47, so the blood test dropped that risk because I had at least 2 SMN1 Copies.  If they had detected 2 SMN1 Copies, the chance would be 1/5600 that I’m a carrier.  https://clevelandcliniclabs.com/wp-content/uploads/2017/10/Spinal-Muscular-Atrophy-SMA-testing.pdf)

Wednesday, December 13, 2017

My lovely lady hump

All is generally good here at 18w6d.  Baby continues to have a normal heartbeat, and is rumbling around so much I haven’t been scared that there won’t be a heartbeat at my weekly appointment.  I actually felt him kick (or punch??) from the outside the other day!  All of my labs have been coming back normal.  (Although we’re still waiting on the genetic carrier results from the fragile X and spinal muscular atrophy blood tests.) 

My massive online orders of maternity clothes were finally delivered this week, and with great trepidation I started cutting off tags of a few things so I have something to wear.  (I’m planning on leaving the tags on most of the things I want to keep until after my “20 week” (really 19 ½) appointment next Monday.)  My belly is getting harder and harder to hide, and I’m running out of energy to try.  I saw a good friend the other day and told her I was pregnant, only to have her say “I was wondering….”  This is the first time the tummy has given me away!!  I think it’s going to look less like too much cheese and more like too little baby in another couple of weeks.  For now, I just look like a person with skinny arms and legs and a beer gut.  Hawt!

I’m not super stressed out about the 20 week appointment next week—the high risk OB told us after our 15 ½ week appointment that everything look great and she would be really surprised if they caught something new on the 20 week.  That being said, I am still a little nervous.  It’s particularly unfortunate that hubby can’t make this one—he has an out of town meeting.  Boo.

What’s really keeping me up at night, though, is worrying about all of the things that could be wrong that they can’t or won’t find until baby is born.  Did you know that there are more than 4,000 different kinds of birth defects, and that around 3% of babies are born with some kind of birth defect, and that up to 70% of birth defects are undiagnosed??  AND, let’s not forget that the risk of birth defects rises with recurrent miscarriages (it doubles: https://www.ncbi.nlm.nih.gov/m/pubmed/8290380/), and it increases with a history of birth defects, and it increases with age of parents (although I read that while that is definitely true for chromosomal defects, it may not be true for all defects: https://www.webmd.com/baby/news/20140203/babies-born-to-moms-over-35-may-have-lower-risk-for-certain-birth-defects#1).  So I feel like our risks are pretty much sky high.  That’s not a great feeling.

Of course, we’re under a microscope and going to an awesome clinic, so we would expect a much higher detection rate than average.  And a lot of the super common and devastating ones (anencephaly, spina bifida, trisomy 13/18/21, structural brain defects, structural heart defects, structural kidney defects, limb defects, clubfoot, etc.) either have been ruled out or should for the most part be ruled out at the appointment next week.  AND some birth defects are relatively harmless.  (In fact, I was born with an abdominal hernia—a birth defect.  After a nail-biting [for my parents] surgery when I was a month old, I’ve had no issues.)  I mean, do I want my baby to have a hernia or cleft pallet or even tracheoesophageal fistula/esophageal atresia (what my niece was born with)?  No, of course not.  But those are generally fixable and have no super long-term issues.  I continue to worry that baby will be born with something profoundly wrong.  For now, all I can do is… oh, wait, I can’t do anything.

The other night I dreamed that someone told me that if I walked on broken glass it would help my baby.  So of course I chose to walk on broken glass.  (And it wasn’t like the thick broken glass of a dish.  It was super sharp like a broken light bulb or holiday ornament.)  When I woke up, I was at the part of my dream where I was pulling out bloody two-inch shards of glass from my feet.  And then I made the mistake of googling the meaning of walking on broken glass while pregnant.  Apparently it’s a bad sign.  Whatever.  I didn’t need to search out the meaning of my dream online to know what it means—I would do just about anything for this ~6in ~8oz little fella I’ve never even met yet.  (And it might be a throwback to all of the shit I was willing to do when we were trying to have kids with fertility treatments.)

My husband has started to get on my case about continuing to say “if” this works.  WHEN he says, WHEN.  When will I feel the same way?  I’m not sure, but not now.  And probably not for a while.

P.S I wasn’t super worried about it, but it doesn’t appear that either my new low-dose aspirin habit or my long-standing swimming habit poses any risk to the little man.  (http://pubmedcentralcanada.ca/pmcc/articles/PMC4805457/; https://www.ncbi.nlm.nih.gov/pubmed/23628264)