Pregnancy: Ask Dr. Helain Landy

My name is Helain Landy, I’m the
head of the department of OBGYN and a practicing maternal-fetal
medicine specialist at MedStar Georgetown
University Hospital. I take care of high-risk pregnancies
in my clinical activities. I do a lot of ultrasounds
and associated procedures involving prenatal diagnosis,
and I still do some deliveries. I think pregnancy is a wonderful time,
for some patients it’s very challenging and I think it’s important for the patient
to try and enjoy what she’s going through and work with the providers to be
able to achieve that. Especially if there’re some challenges
being able to have a positive influence on the outcome. Being able to relate to the patient
as a person, as a woman, to try and give a little bit
of sensitivity to the patient really makes my day. I recently saw a patient in the office
and I took care of her 20 some-odd years ago. I delivered
her daughter prematurely after a very very high-risk pregnancy and she and I embraced and cried and all the memories of what we went
through as a team to bring her daughter to life and to
succeed as she is now graduating college, that type of experience
just will stay with me forever. I like to impart a common sense approach
to patients and patient care, even in some of the highest risk situations. I like to have a good dialog between
the patient and the caregivers so that we’re all on the same page
and we all understand what the issues are, what they risks are
and what the plan is. It’s not always so easy, but at least
so that there’s open communication. I just think that my job as an
obstetrician gynecologist has afforded me the opportunity to be
important in so many lives, to make a difference in so many lives, and I just want to say that all of
those women that I’ve taken care of through the years, have definitely
made my life fuller and made me feel like I’ve
made a difference, and I think that’s one of the most
important things for anybody going through this world, is to feel
that you’ve been able to connect and make a difference. At Georgetown we can take care of
all sorts of patients with all sorts of problems. We can take care
of patients who are completely normal and have low-risk pregnancies and we
can take care of the highest-risk patients. We have a constant availability for our
specialists in various medical specialties and surgical specialties, we can
also take care of those patients who deliver quite prematurely. Our NICU is staffed and available
24/7 to be able to take care of the sickest babies
and the smallest babies as well as those babies that have
other problems that require some surgical intervention or detailed
evaluation and care. Our obstetric providers work as a team.
We have nurse practitioners in our office, we have general obstetrician-gynecologists
who work as a team in terms of taking care of all our patients.
We have availability of maternal-fetal medicine specialists
to assist in the management and the evaluation
of high-risk patients. Our nursing staff on labor and delivery
in the maternity units care for patients at the highest level
and the most compassionate level. We pay attention to the emotional
and spiritual needs of the patients as well as the physical
and medical needs as well. We offer complete obstetric care
for patients in a very conducive setting, we have 24-hour availability for anesthesia,
whether that’s just for identification of a patient that may need a C-section
or for pain control with epidurals. We have a full-service organization
between our office which is located adjacent to the hospital
labor and delivery suite as well as our state-of-the-art
pre-natal diagnostic and ultrasound center. Before a patient is contemplating pregnancy
it’s a good idea to have a visit with her doctor
or nurse practitioner to discuss being healthy before getting pregnant.
There’re a lot of things that are important to know ahead of time.
Certainly if she is smoking or drinking, those activities should be curtailed
and if she’s on any particular medication, that may need to be changed,
it’s a good idea to discuss what’s safe and what’s not safe
during pregnancy. What’s very important is
folic acid supplementation and what’s recommended is
the folic acid supplementation at least 3 months before conception.
Folic acid deficiencies have been linked to certain
birth-defects, so eating a healthy diet which is important
may not give the right amount of folic acid that’s necessary to prevent
these birth defects. So meeting with the provider can help
identify these type of issues, vaccination issues, get some medical
issues under control, things like that. A healthy diet is important. There’s a lot
of common sense recommendations during pregnancy, so a well-balanced diet
with good amount of carbohydrates and calcium and protein, very important.
We usually recommend that women who are carrying singletons
increase their caloric intake by about 300 calories a day.
Women who are carrying twins or higher need to increase their diet even more. Early in pregnancy there may be
a lot of nausea and food aversions, so we usually recommend some bland diets,
eating more frequent meals rather than 3 large meals,
having 6 smaller meals, and especially to avoid the nausea,
a lot of people do recommend having some crackers at the bedside,
eat them before you wake up, have them there in the middle
of the night for when you do wake up. Prenatal vitamins are important to take
during pregnancy and actually to take a little before
pregnancy for the folic acid supplementation.
But most women can’t get enough of the folic acid and iron that they need
during pregnancy, so prenatal vitamins are recommended. Prenatal vitamins can be either by
prescription or over-the-counter because the formulations are virtually
the same. Fish intake has been associated with
high mercury levels and high mercury levels during pregnancy
can cause certain problems with the development of the fetal brain.
So although fish is good in terms of Omega 3
and fatty acid supplementation, it is recommended to cut out certain
fish such as tilefish and swordfish, shark and limit the intake of certain other fishes
such as salmon to about once a week. Shellfish can be eaten about twice a week.
There are very good references online through the FDA and also through the
American College of Obstetrics and Gynecology that can help guide patients who have
certain dietary restrictions or limitations. An infection of listeria in pregnancy
can cause the patient to get actually quite sick,
but has a specific effect on the developing fetus and can lead
to stillbirth and miscarriage and loss of the pregnancy.
The biggest defenders are those foods that are either processed deli meats
for instance, under-cooked hot dogs, sushi,
under-cooked raw meat and processed cheeses,
the soft cheeses such as brie, things that would not necessarily be
fully pasteurized. So those foods are recommended to be
avoided, and in terms of the meats – to be sure that they are fully cooked. Well, there are a number of things
that a pregnant woman should avoid. One of them is, especially in the 1st
trimester, to avoid hot-tubs and saunas, things that can cause her core temperature
to get up too high. Another thing that’s important for those
patients who have pet cats is to avoid changing the litter box. This
actually should stop prior to conception, especially for those cats that are outdoor
cats and go outdoor and indoor. Cats can carry toxoplasmosis,
which is an infection that if the woman is exposed to
during pregnancy, can cause certain fetal birth defects. So that is not
recommended during pregnancy. Alcohol is not recommended
during pregnancy at all. Alcohol intake has been linked
to Fetal Alcohol Syndrome which is the major cause of preventable
mental retardation among newborns. The issue is that the fetal brain is uniquely
sensitive to the effects of alcohol and we don’t know what the lower limit
of intake is safe. So it is really recommended
prior to pregnancy to avoid excessive alcohol intake and not
to drink any alcohol during pregnancy. Yes, you can drink caffeine
during pregnancy. Unless you’re drinking excessive amounts
of caffeine, it is considered to be safe. Older literature suggested an increased
risk of miscarriages and low birth weight in patients in patients that were drinking
a lot of caffeine, but that does not really
seem to be the case. One cup of coffee is probably fine
during pregnancy. Exercise is definitely recommended
during pregnancy. Having a healthy lifestyle includes
exercise and there really should not be any limitations in terms of a woman’s
desire and ability to exercise during pregnancy. Now clearly,
if it’s a high-risk pregnancy or there’s an increased risk
of complications, the woman’s doctor is going to recommend
that she refrain from exercise but moderate exercise, especially not
involving anything that could physically hurt her, put pressure on her abdomen,
would be recommended to be continued. Walking, swimming,
working on a stationary bike, all that is really recommended. Again, just like exercise, intercourse
is fine during pregnancy as long as there are no complications
and suggestions by the provider to avoid it. Later in pregnancy it can
be uncomfortable and we just recommended that patients
avoid being flat on their backs. Airplane travel is fine, up until about
the last 4-6 weeks of pregnancy. The airline personnel get a little nervous
when they see a very very visibly pregnant woman coming onto
their plane, but it is recommended because you don’t really want to end up
in an area where you go into labor and you’re not back at the home front. With any type of travel,
sitting in one position for a long time can be associated with increased risk
of blood clots developing in the legs, and so we do recommended that women
keep well hydrated, if they’re on a car ride, if they’re in
a car ride or on the train they should make sure that they get up
and walk around, move their legs, and the same thing is true
for airplane travel. The safest time to travel on an airplane
is in the 2nd trimester. Please do! Dental work is fine during pregnancy.
Even if patients need to have dental X-rays the appropriate lead shields
can be used. Women can certainly go to the dentist
and have their regular check-ups as needed. There may be some additional gum bleeding
during pregnancy, but that is fine. We usually communicate to the dentist
if any procedures are necessary regarding what antibiotics if anything
would be safe, and the use of any medication. But it is encouraged to have
healthy gums and healthy teeth. It’s probably not recommended that you
do the painting, it’s recommended that somebody else do the painting
just so that you’re not exposed to all the toxic fumes, but that goes
for any type of chemical exposure in terms of solvents or what have you.
It’s best to avoid exposure in the air to these substances, and if you need
to be in a place where there are these chemical exposures, there
should be adequate ventilation, the windows and doors should be open.
It’s okay to paint the baby’s room or have the baby’s room painted,
but it probably is not a good idea for the pregnant woman to be the only
one in the room painting the baby’s room. Yes, it is safe to dye your hair
during pregnancy. Just like any type of exposure,
we have to make sure that there’s adequate ventilation.
Although no real data exists, I do tell my patients to try and wait
until the 2nd trimester because a lot of the potential risks to
a growing fetus in terms of birth defects do occur in the 1st trimester, but it’s
certainly okay to dye your hair. Women who are of normal weight should
aim to gain about 25-35 Lbs., if they’re carrying a singleton.
Women with twins – the weight gain is going to have to be more. On average
it’s probably around 2-4 Lbs., in the 1st trimester and then
about 1 Lb. a week after that. New guidelines have really put some stricter
limitations on weight-gain partly because the amount of obesity
and diabetes in the adult community is so rampant, and a fair amount of that
may be due to pregnancy weight-gain. But we do know that healthy babies
and healthy pregnancies result from an adequate weight-gain
of the mother. Women who are starting out under-weight
should be gaining more weight. Women who are over-weight
should gain less, maybe 10-11 Lbs., and those who are morbidly obese may even be
recommended to lose a little bit of weight. Morning sickness is the term used to refer
to the combination of nausea and vomiting, usually in the 1st trimester. It doesn’t
always occur in the morning and it doesn’t always just get limited
to the 1st trimester. Some women can have significant problems
as a result of persistent nausea and vomiting during pregnancy. In most cases,
it’s self-limited and can be controlled by proper diet in terms of bland diet,
eating more frequent meals instead of 3 large meals,
having meals with snacks, and in rare cases, patients may have
to come into the hospital for some fluid resuscitation
and intravenous medication. There are some medications that can be
prescribed, if needed there are also some over-the-counter remedies that
may assist in a patient’s symptoms. Things like ginger or the wristbands that are
used for patients who have motion sickness. Morning sickness is related
to the hormones of pregnancy. We know that women who have twins,
therefore more hormones circulating, can experience worse
morning sickness, but it really… It’s not related to any specific level
of a specific substance in the body and so there’s really no good explanation.
We do know and we do tell patients that when they are feeling sick, it usually
means that things are going okay. We’re one of the few practices that
feel okay when our patients are sick … Breastfeeding is very important both
for the mother and for the baby. For the mother, it really does help
for her to lose that weight that she’s gained during pregnancy, but
for the baby there are numerous benefits: minimizing certain diseases,
the risk of illness, it helps to transmit the maternal antibodies to ward-off
certain infections that can be pretty prevalent and devastating
during the 1st year of life. So breastfeeding is really important, and at MedStar Georgetown
University Hospital we are a baby-friendly institution,
just was named this designation the only one in the district of Columbia
where we are not only supporting and encouraging patients to breastfeed, but
we have tremendous resources in this area. Patients who are encouraged to discuss
breastfeeding with their providers during the pregnancy, and to contact
the lactation consultants try and get prepared
for what breastfeeding involves. It is not necessarily an easy process,
it takes work on both the mother and the baby’s part, but it is
definitely worthwhile. High-risk pregnancy can really refer to
any pregnancy that’s complicated by pre-existing maternal issues or issues
that develop during the pregnancy, either for the mother
or for the baby. Any patient who has a pre-existing
medical condition may be considered a high-risk patient. Patients who have things
like chronic hypertension or diabetes, patients who have lupus or who have
experienced complications such as blood-clots in their legs or lungs
or somebody that has an underlying cardiac or pulmonary disease.
Those are conditions that could pose significant problems both to the mother
and to the developing baby, and so those are conditions where
pre-conception counseling is definitely recommended. Some of the
maternal medications may be important in terms of changing them or limiting them
during pregnancy, and especially in patients who have diabetes
for instance, pre-conception counseling is critical
because the higher the sugar level is at the time the patient conceives,
the higher the complication rate, including miscarriages and birth defects. Many patients with complicated medical
histories will be seen to discuss the possibility of future pregnancies. And in my many years of seeing such women
to discuss future pregnancies, it’s the minority of patients to whom we
do not recommend a future pregnancy. In most cases, patients’ medical conditions
can be controlled, managed in conjunction with their internal medicine physicians
and their specialists. But a good partnership between
the patient and her doctors is key for having a healthy outcome
for both mother and baby. Advanced maternal age is considered
patients who were over 35 by the time of delivery. One of the big
things with women who are older is that there’s an increased risk of
genetic abnormalities in the babies. This is chromosome abnormalities,
the most common of which is described as Down’s Syndrome or Trisomy 21. It is well-known that the risk of these
chromosome abnormalities increases as a woman gets older.
For instance, by the time a woman is 40,
the risk of Down’s Syndrome affecting her child could be
as high as 1 in 78. Now, women of older age also
have higher complication rates, but not so much that it would require
ongoing care specifically by a high-risk physician, and thus excluding
the patient’s general obstetrician. Women who are older have increased risk
of developing certain medical problems like hypertension or preeclampsia,
that is a hypertensive problem that develops during pregnancy.
They also have an increased risk of developing diabetes and other
problems like high cholesterol, things that may or may not be important
in terms of carrying a pregnancy. We know that older women
have a higher risk of infertility and a higher risk of miscarriage. In our practice at Georgetown, over
a third of the patients that we care for are considered advanced maternal age,
and so we work very closely as a team to provide the medical and genetic and
prenatal information that is necessary to assure a healthy outcome for
both mother and baby. We have a full-time genetic counselor
who will meet with patients to discuss their genetic risks,
we have a full access ultrasound area where we do our sonograms that involve the
prenatal screening for certain birth defects both in the 1st trimester
and in the 2nd trimester, and we have access to any of the medical
specialists that are necessary in terms of coordinating care for patients
with complicated medical issues. So advanced maternal age is something
that we are very aware of and we take care of many patients
with this condition. It does not really constitute a
reason for being considered high-risk. Pregnancies can become high-risk
with no real warning. Patients can develop diabetes
during pregnancy, patients can develop hypertensive problems
such as preeclampsia, and preeclampsia which used to be known
as toxemia is a problem that is always described as a triad
of findings including high blood-pressure, protein in the urine
and swelling in the legs. The bottom line for preeclampsia is
if it is severe a patient really needs to be delivered.
So preeclampsia is something that we pay attention to all the time.
Every obstetrician takes care of patients and is always watching
for the development of preeclampsia. There can be birth defects that develop
or become apparent on the sonogram, there can be problems with the
amniotic fluid, there could be problems with the placenta,
where the placenta is located. If the placenta is located over the cervix,
it’s called a “placenta previa” and can be a problem,
especially if it persists, can interfere with the delivery process, and also it can result in a fair
amount of bleeding and issues that would change a patient’s
pregnancy from being completely normal to high-risk. Women who have
multiples, twins, triplets or higher, are certainly considered
high-risk pregnancies. Although, again, there are many twins
that are born to very healthy women and not every twin pregnancy is
considered a high-risk pregnancy. Another reason that a pregnancy
may become high-risk is the possibility of a pre-term delivery. For
instance, if there are premature contractions or if the cervix has started
to dilate or shorten or if the woman’s water bag
breaks prematurely, those are very high-risk situations,
might require a patient to be hospitalized or if not hospitalized,
to remain at a bed rest or limited activity at home, and with
an increased risk of a premature delivery those patients should be watched
very closely.

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