miscarriage
Have a Miscarriage? No Explanations Needed!
February 21st, 2011Few things can make my blood boil like racism, sexism and discrimination against women. So when I read that Georgia Republican Representative Bobby Franklin has proposed a bill to the Georgia legislature, HB1, that would require women who miscarry to have to prove that the miscarriage is a spontaneous, natural occurrence I was seething mad.
In my experience, most women who miscarry wanted the child that was lost and had been doing their utmost to have a healthy successful pregnancy. Unfortunately, not all pregnancies are viable. Nature in her infinite wisdom (far superior to this Georgia representative’s!) has created mechanisms within a woman’s body to dispose of non-viable pregnancies. We call them miscarriages.
I have been through 2 miscarriages myself so this is an issue that is near and dear to my heart. Despite the fact that I had my miscarriages in 2001 and in 2004, I can still remember them vividly. The first began with severe cramping and back pain followed by copious blood flow for days while I was traveling on business. If I was a Georgia resident, would I be charged with felony homicide because I deigned to travel while pregnant? That was my very first pregnancy, the first of 4, and one that I really wanted. I was devastated that it had resulted in miscarriage and was depressed for months as I subsequently endured a fertility work up and surgery to remove uterine fibroids.
The second miscarriage (my third pregnancy) occurred between my children. Again, my husband and I decided we wanted to add to our family and I became pregnant. Every thing seemed just fine. I felt good, much better than I had while pregnant with my daughter, and was really looking forward to another little one. When I went in for what I thought would be my first prenatal visit at 9 weeks, my OB could not find a heart beat. Additionally, the embryonic sac looked empty and she suspected that I had miscarried. Actually, she said that it looked like I had a blighted ovum, that the fertilization process had not occurred properly and no fetus was developing. Again, I was devastated. To make matters worse I had to call my husband, who was traveling on business in Japan, and tell him that our child was gone.
My OB thought that my body would expel “the products of conception” ( my baby) but it did not. I carried the remains of “my child” around for a week. When my husband returned home, a final ultrasound confirmed the diagnosis and my OB recommended that we remove the fetal tissue. I opted to take misoprostol to induce uterine contractions and expel the fetal tissue at home rather than go to the hospital for a D&C. Suffice it to say that the misoprostol worked and about 12 hours after taking it, I scooped the remains of “my child” out of my commode and put it into a container to be analyzed in a pathology lab. Then my husband and I sat on the side of our bed while I cried uncontrollably.
Even now, many years later, I have a lump in my throat and tears in my eyes as I remember these events. I could not have endured an interrogation as to my behavior and possible contribution to the demise of my children when these events took place. Yet, this is exactly what Rep. Franklin is proposing. Rep. Franklin, a republican, who opposes big government, health care reform and has agreed with his chums that medical decisions need to be made between patients and their doctors in opposition to many of the proposed mandates in “Obamacare”, feels that it is okay to completely invade the privacy (in direct violation to HIPAA) and grief of a woman and her partner to protect the rights of an unborn child. What about the rights of the woman? This woman is very likely one of his constituents. This woman may have (although I now hope not) voted to put him in office! Yet if this same woman has a miscarriage and cannot prove that it was through no fault of her own, Rep. Franklin is proposing that this woman face criminal charges-essentially punishing her for what is very likely a force of nature.
This is nothing more than another assault on women’s reproductive rights and another attempt to regulate how and when women have children and what they do with their bodies. How can Republicans and others concerned about the size of government propose another government entity to “police” what women are doing with their bodies? By their own admission, government is already too big and we can’t fiscally support the programs that are already in place. And if Rep. Franklin is so concerned about all of his constituents and the citizens of Georgia, why isn’t the same concern shown for women when they are raped (Here again they have to prove that they did not in some way provoke the attack!), when they are battered (often while pregnant) or when they are otherwise left without means or protections? Where is his outrage and indignation for these women, these citizens of Georgia?
The bottom line is that a woman’s reproductive health is between her and her health care provider and what goes on with her body is her business, no one else’s, and it should stay that way! Keep your nose out of our uteri, Rep. Franklin! No Explanations needed!
Resources to Help Mamas on Bedrest & Beyond Quit Smoking
November 18th, 2010Today, November 18, 2010, marks the 35th anniversary of the American Cancer Society’s Great American Smokeout. It is a well known fact that smoking is the number one preventable/modifiable risk factor to heart disease and stroke as well as to many cancers. However, smoking is also very detrimental to pregnant women and their babies. The National Partnership to Help Pregnant Smokers Quit estimates that between 12 and 20% of pregnant women continue to smoke during their pregnancies.
According to the March of Dimes, Smoking during pregnancy can have the following consequences:
- Ectopic (tubal) pregnancy
- Vaginal Bleeding
- Placental Abruption (separation from the uterine wall)
- Placental Previa (The Placenta covering the entrance to the birth canal)
- Still Birth
- Premature Rupture of Membranes
- Preterm labor
The US Centers for Disease Control and Prevention report that 5-7% of infant deaths and 23-34% of infant deaths due to SIDS could have been prevented if the mother had not smoked during her pregnancy.
Babies born to mothers who smoke are at increased risk of:
- Birth Defects
- Low Birth Weight
- Prematurity
- Intrauterine Growth Retardation
Premature infants and low birth weight infants are at increased risk of having life long health problems such as asthma, colic and obesity. They also face numerous developmental problems such as Cerebral Palsy, metal retardation and learning disabilities. In a study published in the July 2010 edition of the American Journal of Preventive Medicine, researchers reported that if all women quit smoking during pregnancy, health care costs in the United States could be reduced by about $232 million a year and there would be improved overall health for mothers and babies.
People often ask, “With all the information available about the dangers of smoking, why would any woman smoke-especially while she is pregnant?” While this is a fair question, many people including many pregnant smokers don’t understand that smoking is a very serious addiction and addictions are very hard to break. What is interesting about smoking and addictions in general is that not everyone who smokes is addicted. We’ve all heard stories about people who one day decided to quit smoking and simply never picked up another cigarette. However, this is the exception rather than the norm. Most smokers have quite a bit of difficulty and need assistance to quit smoking.
Smoking cessation is even more difficult during pregnancy. Many people who decide to try to quite smoking will use nicotine replacements such as patches and gum. The efficacy and safety of these products is not established in the pregnant woman, so in order to avoid harm to the developing baby, they are not recommended for use during pregnancy. The same holds true for the various prescription medications used to help smokers quit. In the November 2010 issue of Obstetrics and Gynecology, a special review committee issued Opinion 471: Smoking Cessation During Pregnancy (Obstetrics & Gynecology: November 2010 – Volume 116 – Issue 5 – ppg 1241-1244), the review panel noted that medications such a buproprion, a common antidepressant and Varenicline, a drug that acts on brain nicotine receptors, are commonly prescribed for smoking cessation in non-pregnant patients. However, while neither medication has been shown to increase fetal anomalies or other adverse pregnancy side effects, they both have been linked to increased psychotic behaviors including suicide, so neither are recommended for use in the pregnant population. The panel found little or no evidence that meditation, hypnosis and acupuncture as effective strategies for smoking cessation, and although these techniques are often used successfully by smokers who wish to quit, no one has been able to that they are effective and safe in the pregnant population.
So what’s left? What is a pregnant smoker to do if she wishes to quit smoking? We already know that quitting greatly benefits mother and baby and that according to the ACOG review panel, the greatest benefits occur if a pregnant woman is able to quit smoking prior to the 15th week of pregnancy. But if a pregnant woman can’t use nicotine aids nor the available prescription medications, and if alternative therapies are supposedly ineffective, what is a pregnant mama to do?
The ACOG review panel recommends that obstetricians develop and carry out specific protocols in which they ask at each prenatal visit if a woman smokes or if she is exposed to second and/or third hand smoke. They find that OB intervention has a strong bearing on whether or not a pregnant woman quits smoking.The initial screen should be at the first prenatal appointment and the OB should have information readily available about the dangers of smoking during pregnancy and resources and referral sources for quitting (If the OB is unable to provide effective guidance and support for smoking cessation within his or her office). One of the best resources is The National Partnership to Help Pregnant Smokers Quit. The ACOG review panel also recommends that clinicians adopt The 5A’s, an office based smoking intervention designed to be used by trained practitioners. The 5A’s include:
The 5A’s of smoking cessation are as follows:
- ASK the patient about smoking status at the first prenatal visit, and continue to ask at subsequent visits. If the patient stopped smoking before or after she learned she was pregnant, the clinician should reinforce her decision to quit, congratulate her on success in quitting, and encourage her to stay smoke-free. If she is still smoking, the clinician should document this in her medical record and proceed with the remaining A’s.
- ADVISE the patient who smokes to stop, while offering information about the risks of continued smoking to the woman and her baby.
- ASSESS the patient’s motivation to attempt smoking cessation. At subsequent prenatal care visits, the clinician should offer quitting advice, evaluation, and motivational assistance.
- ASSIST the patient who wants to quit by offering pregnancy-specific, self-help smoking cessation materials, including a direct referral to the smoker’s quit line (1-800-QUIT NOW).
- ARRANGE follow-up visits to monitor the progress of the patient’s attempt to quit smoking.
Smoking is a very difficult habit to break. Pregnant women who smoke are faced with additional challenges because many smoking cessation aids should not be used during pregnancy. If you are a mama on bed rest and want help quitting smoking, talk to your obstetrician. Also, try the resources listed in this blog and in the resource section of our website. If you still need help, contact us directly at info@mamasonbedrest.com.
Image courtesy of The Ultimate Quite Smoking Guide-Smoking During pregnancy.
Incompetent Cervix, Now What?
October 5th, 2009One of the most common indications for the bed rest prescription is incompetent cervix. What is an incompetent cervix and what does it mean for the pregnancy if a woman has this diagnosis?
Simply put, an incompetent pregnancy is one that is unable to remain closed for a full term pregnancy. Abnormally weak, an incompetent cervix will gradually widen (dilate) and shrink (efface) typically during the second trimester of pregnancy as the uterus enlarges and becomes heavier. Undiagnosed, incompetent cervix often leads premature labor and/or miscarriage.
There are several causes for incompetent cervix. These include:
- Congenital abnormalities
- Hormonal changes such as occur during pregnancy
- prior cervical surgery (such as conization)
- Trauma during another procedure (such as during dilation for D&C) or a prior traumatic delivery
- In Utero Exposure to DES (Diethylstilbestrol)
- No obvious reason
Unfortunately for many women, the first indication that they have an incompetent cervix is when preterm labor or a miscarriage occurs. With subsequent pregnancies these ladies may opt to have a cerclage, a surgical procedure during which the cervix is stitched closed, performed between about 14-16 weeks gestation. Depending on the woman’s situation, she may then be prescribed bed rest for the remainder of her pregnancy.
For some women, the incompetent cervix is not initially detected, but becomes suspect if a women has 3 consecutive pregnancy losses in the second trimester. Pregnancy loss due to incompetent cervix occurs in about 20-25% of all second trimester pregnancy losses. An incompetent cervix can be detected via manual examination or by ultrasound.
Once an incompetent cervix is diagnosed, what then? For those ladies in whom there is no anatomic abnormality, the cerclage will typically suffice. If the cervix is too dilated (more then 4 cm) or if there are complications with the fetus (intrauterine fetal demise, premature rupture of membranes (rupture of the amniotic sac) then a cerclage cannot be performed and the pregnancy will be lost. But of the cervix is less than 3 cm dilated and the fetus is not in any danger, then the cerclage can be placed and the mother closely monitored for the rest of her pregnancy. The success rate for cerclage is quite good, especially if done early in the pregnancy. Roughly 80-90% of pregnant women with incompetent cervices will deliver healthy babies.
The decision to put a woman with an incompetent cervix on prescribed bed rest is controversial and the decision is typically made on a case by case basis. Because some women experience significant contractions in addition to the incompetent cervix, bed rest is used in conjunction with the cerclage and medication to stop the contractions and to prolong pregnancy. For other women, the need for bed rest is not so clear. Many obstetricians fearing pregnancy loss will put women with an incompetent cervix, even if they have a cerclage, on bed rest. Medical Research does not support that this is always necessary.
A test has been developed that is able to predict whether or not a woman is going into preterm labor within the subsequent 2weeks. The fetal fibronectin test checks for the presence of fetal fibronectin, a pregnancy protein found in the cervical plug, in the vagina. If fetal fibronectin is found in the vagina, it means that the cervical plug has somehow been disturbed and a woman may in fact be at risk for preterm labor. If no fetal fibronectin is found, there is a 99% or greater chance that the pregnancy is proceeding and there is no current risk for preterm labor.
The fetal fibronectin test has significant indications for high risk obstetrics. Women at risk of preterm labor may now be tested using the fetal fibronectin test and may avoid prescribed bed rest. Some women may in fact still need to be on modified bed rest, but with the fetal fibronectin test, the current number of 700,000 American women who are prescribed bed rest annually may be reduced.
In my next post I’ll look more closely at the fetal fibronectin test.
