(pic: http://www.camelliawomenshealth.com/Prenatal-Care)

The importance of prenatal visits can never be underemphasized. It is a must that all pregnant mothers, regardless of social and economic strata, should receive adequate prenatal care for a successful outcome of the pregnancy.

I was once called to attend to a baby who was born premature at 36 weeks via emergency cesarean section due to uncontrolled maternal hypertension. The baby was having uncontrolled seizure despite the fact that the baby was already seen by a neurologist and on anti-convulsant. I requested some laboratory tests and results revealed that he has low sodium levels (hyponatremia) at a level that can trigger seizures.

Going back to the mother’s prenatal course, she didnt know she was pregnant then because of irregular menstrual cycle. There was a certain period when she noticed that she was having bipedal edema (swelling of both lower extremities). She was self-medicating with furosemide, to no avail. She consulted a nephrologist who noted that she too was having elevated blood pressure. Unknown to both of them, she was pregnant and this was not at all investigated. The mother too was a bit plump and she never noted abdominal enlargement until few days prior to delivery when the abdomen was already large enough to disregard. Furosemide was continued. Abdominal ultrasound revealed a singleton pregnancy. Because of the uncontrolled blood pressure, baby had to be delivered thus.

The mother’s prolonged intake of furosemide, a loop diuretic, lead her to have electrolyte imbalance, particularly sodium. This was reflected to the baby who also had low sodium levels at a level that could trigger seizure. Had she known she was pregnant, and had she been receiving prenatal care, this could have not happened to her baby. The effect of the seizure to the baby’s brain is another story.

 

Giving Birth in the Cordillera Mountains

It has been two years since I started attending the Regional Neonatal and Maternal Death Review in our region, the Cordilleras. I had been invited to be a panelist and as such, it is my duty to critique why such happened, and what should have been the intervention, and what could have been the possible problem that really transpired for such a death. But this forum is not only me and my fellow panelists giving our “expert opinions.” Rather, I in particular had so much learnings and realizations that makes the scenario surrounding each death very painful to accept and embrace as a health care provider. These are some of the few things I came to realize…

GEOGRAPHY

One of the problems identified in our region is the geography. Because of the mountainous terrain of Cordilleras, one pregnant woman would need to hike 45 minutes, some 1 or 2 hours from their house just to reach the road or access a vehicle that will bring them to the nearest barangay health station (BHS), or rural health unit (RHU). Imagine a pregnant woman in labor, walking this distance in between contractions, you would expect a longer time to access the road. Likewise, because of this terrain, some areas are infested with the rebels (New People’s Army) that deters them to go the the nearest health facility, no matter what stage or phase of health emergency they are already in. So if the mother is having post-partum bleeding, they will wait till sunrise before the go to the nearest BHS. And if the midwife at the RHU or BHS would not be able to address the problem, they will have to transfer the patient to the nearest district hospital, which might again take them a while to look for a vehicle that will transport them there.

Another problem that the geography poses is the lack of telecommunication network’s signal. While the nurses, barangay health workers may have mobile phones that would facilitate referral to their superiors for proper advise while patients are being transported to higher centers, the lack of communication signal deters such and thus are only addressed when the midwives or the receiving doctor in the district hospital sees the patient

LACK OF HEALTH CARE PROVIDERS

Another deterrence to full delivery of health care to every household in the rural is the lack of midwives. While there may be barangay health workers (lay people who are not necessarily midwives who can be first line to check on ailing residents), it is the midwives who supervise them and who will ultimately decide whether she can manage the scenario or refer the patient to higher institution. In one municipality alone in Ifugao with 18 barangays, they only have 5 midwives. ONLY 5 midwives. Again, consider the distances of each house, their distance from the BHS or RHU or district hospital. And they usually access these houses on foot. Midwives need to track women who are pregnant, follow them up at the RHU, refer them to higher centers if the pregnancy is high-risk, deliver their babies if unable to reach a birthing facility, follow them up to make sure the mother-baby dyad is in perfect condition, submit monthly report to their municipal health officers.

During the past administration, nurses (nurse deployment program, NDP) and doctors (doctors to the barrios, DTTB) were hired to augment this vacuum of labor force. The nurses were deployed to each barangay or two, to help and facilitate the work of the midwives. Definitely being novice in the community and public health, there are flaws and misgivings, that given more time and experience, these will eventually be addressed. Nevertheless, there was a noted decrease in the number of maternal and neonatal deaths because they were monitored.

Unfortunately, starting next year, these contractual employees will no longer have their contracts renewed, making again the workload of our midwives double, maybe triple or quadruple when the NDPs are gone. Thus a rise again in the number of maternal and neonatal deaths will not be a surprise.

LACK OF SKILLS

We the panelists are specialists and subspecialists. We talk of interventions appropriate to our settings, which is way far up compared to the birthing facilities that the NDPs, midwives and MHOs work at. For one our NDPs, who are mostly first time on the job, still lack clinical acumen to detect subtle signs of disorder in the newborn, or signs of high risk pregnancy. Thus they only become alerted when the severe complications have set in, and thus intervention would be late already. Recognition of these subtle signs and early referral would definitely make a significant difference in these conditions.

Not all midwives are skilled in performing episiotomy. Not a single midwife in the region is even skilled in performing full course of neonatal resuscitation. Even doctors at district hospitals are not specialists to correctly treat these problematic parturients and/or their babies.

CULTURE

One thing that I commonly noticed is the influence of the matriarch of the family or clan. Usually, especially in a place where the house of the parturient is far from the nearest birthing facility, a birth plan is laid out. They assign which (of the limited vehicle) will be used to transport in case she goes on labor. And after birth, how soon they will be visited by the midwive or NDP. In other instances however, the matriarch interferes and alter already the planned contingency. A first-time mother ought not to contradict what their “experienced” seniors dictate upon them. While our health workers are campaigning and encouraging health facility deliveries, some “experienced” matrons insists that their daughters deliver at home, with them helping out. Only then will they call for help when they encounter a major problem. One classic example was when a woman on her third pregnancy delivered at home, assisted by the family members. It took them several minutes attempting to deliver the placenta. And because the placenta was adherent to the uterine wall, as they were tagging the former, the uterus inverted. Only then was the midwife called. And because there was no “birth plan” it took them several hours before the parturient was brought to the hospital. There was massive hemorrhage, with the source not identified, that eventually lead to hemorrhagic shock and her death. Such useless loss of lives would have been prevented had it not been for the “usual practice” that these elder people enforced.

 

Many of these problems presented are often preventable but it takes interplay of so many factors to prevent one maternal or newborn death. Our region as a long long way to go…

 

In The Nick Of Time

(photo: http://www.moondragon.org)

A first time mother was well into the third trimester of her pregnancy. She never got sick, currently with no pregnancy-induced illness like hypertension or diabetes. She was regular on her prenatal visits, compliant. Unremarkable.

During the wee hours in the morning, she began to feel some abdominal cramps. She thought it was hunger pangs, so she had something eaten. However, after few minutes, in contrast to the relief she was expecting, the abdominal cramps continued, intermittently.

She then went to consult her OB-Gyne and have the problem assessed. On internal exam, her cervix was already 1.5 cm dilated. Her abdominal contractions were intermittent. What was unusual was that she was screaming as if in in severe pain, which was incongruent to the degree of the abdominal contraction she was experiencing. She was thus advised admission.

Upon arrival at the emergency room, it was noted that the abdomen was a little harder than the usual premature contractions, with her screaming still as if in severe pain. A tracing taken from the abdomen to assess the contractions of the uterus and heart beat of the baby (cardiotocography, CTG) showed abnormal uterine contractions and variable fetal heart rate pattern. Quick thinking by the OB-Gyne lead to the consideration of impending abruptio placenta (premature detachment of placenta from the uterine wall).

Normally, the baby gets delivered first, before placenta separates from the uterus. When the placenta prematurely detaches from the uterine wall, ahead of the delivery of the baby, this can lead to exsanguination (massive hemorrhage). On the maternal part, she can have anemia, or worse, hypovolemic shock, due to the blood loss. On the fetal side, since the placenta (which serves as the baby’s siphon for blood from the mother, delivering nutrients and oxygen supply to the baby) prematurely detached, baby can also have hypovolemia, anemia and shock. And since baby gets deprived of oxygen, baby is in a similar situation to that who is drowning or strangulated, resulting to asphyxia, and worse, death. It is then crucial that this condition (abruptio placenta) be diagnosed and managed very early on to prevent the occurrence of such adverse effects on both the mother and the baby.

Mother had to undergo emergency cesarean section. While the obstetrician was doing her job, I went to peek on the complete blood count of the mother. It showed that the mother was already having anemia. This means that she was losing significant amount of blood. (This could then explain why the uterus was unusually hard, and her unusual screaming, characteristic of one in severe pain.) On opening up of the uterus, there was a huge blood clot between the uterine wall and placenta, with about 30-40% of the placenta detached from the uterus.

When baby came out one minute after opening of the uterus, baby had difficulty of initiating his first breaths. I had to stimulate and provide bag-mask ventilation until baby began to cry. We did uninterrupted skin-to-skin contact for that chance to acquire maternal bacterial flora that will eventually help protect baby from infections. As soon as baby began to grunt (which began at about 10 minutes after skin-to-skin), we took him to the NICU for care.

When the result of the complete blood count of the baby came in, it showed that per 100 of white blood cells (WBC), 45 of which were nucleated red blood cells (NRBC). RBCs are produced in the bone marrow. While still undergoing development, the immature forms are still nucleated. Once they mature and before they are released to the peripheral circulation, the nucleus is extruded. This now allows the RBC to be pliable in the peripheral circulation, with an increased carrying capacity for oxygen. If however, in cases where baby becomes deprived of oxygen such as in massive bleeding as was the case for this baby, immature RBCs, the nucleated ones, are then thrown out into the peripheral circulation, in an attempt to increase the oxygen-carrying capacity of the RBCs — to protect the brain, heart and adrenal glands from the devastating effect of hypoxemia and hypoxia.

The urgency of the cesarean delivery has just saved the mother from massive hemorrhage and the baby from being asphyxiated. A few minutes of delay perhaps would have resulted otherwise… In the nick of time.

IMAGINE this happening to a mother, who is living in a far-flung area, with no access to obstetrics care; where hospital is 2-days travel away; where there are no barangay health workers that can be called, or even if there are, but no nearby health care facilities… would we have saved the mother? the baby? How many perinatal deaths would have to occur before the reproductive law be enacted? Do we need to have a national dumping site of dead mothers and babies (similar to that of the “Killing Fields” of Cambodia), which our leaders will personally inspect, or perhaps do a skull count, before they believe there is a need for the immediate enactment of the reproductive law? Well, one senator wanted to have maternal death certificates as an evidence before he could believe high perinatal mortality is happening.

 

Foul: SC SQAOs RH LAW

(photo courtesy of http://www.pogsinc.org)

UN resident representative described the Philippines as the “worst performer” in Asia as far as achievement of Millenium Development Goals (MDG) are concerned. This, as far as lowering of child mortality, decreasing maternal morbidity and mortality as well as HIV prevention are concerned.

These three are included in the Responsible Parenthood and Reproductive Law that was already signed, implementing rules and regulations signed as well, but put on hold by the “status quo ante order” issued by the Supreme Court on March 19, 2013.

This law went through hurdles for about 16 years before being finally passed by the 15th Congress. It aims to empower people by making them a responsible parent. By this, it will allow parents to determine the number of their offspring they can responsibly have – those that they can feed, vaccinate, send to school and be a responsible citizens of the country. This can be achieved through sexuality education, which will be taught while the children are young, and employment of safe and acceptable contraceptive methods, depending on the couple’s choice, heightened HIV education and awareness especially to population at risk.

Recently, there was a scandal about an adolescent college student who claimed her life after, bottom line, cannot afford to pay her tuition. They are 4 siblings and yet the father cannot afford her tuition fee. And how does this relate to the RH Law? I am not saying the father is irresponsible. BUT, had he considered that he could only afford to rear one or two children, providing all their needs, then his daughter wouldn’t have suffered this problem at such a young and tender age. He could still have his brilliant daughter this very minute with him.

I am the eldest of 4 children. My parents used pills and condoms. We don’t own a house and we had been renting up to this date. When I was about to enter the school of medicine, the 4 of us were already simultaneously going to college. With my father’s income, he couldn’t afford to send us altogether. He talked to me that he cannot afford my tuition. If he would, my other siblings wont be able to enrol. I on the other hand has graduated from college already, so perhaps I could already work and save up for my tuition. I was heartbroken as my aspiration of being a physician was imperiled. I won’t be graduating with my batch mates. I felt it was so unfair for me. I was selfish as I didn’t want to trash my dreams to happen at the right time that I want it to, and without considering my other siblings’ welfare too. But my selfishness was my motivation and determination to find myself a scholarship that can fuel my ambition. My youngest sister as well was able to secure a scholarship for her. So basically, my father was only supporting two of my other siblings as far as tuition and miscellaneous fees are concerned. It was very very difficult time. Sometimes we have to make do with our meager allowance. But one thing I salute my parents for was that we were never delayed in paying our tuition. My parents didn’t want as much as possible for us to be delayed from graduating. They didn’t want as much as possible for us to be working scholars in order for us to afford college. As much as possible, they wanted to shoulder the entire burden of sending us to college as it is their obligation to do so. They believed it was was their duty and responsibility. My parents admitted that they won’t be able to give us land, house or any property for inheritance but our education that will help us build our own future. Now, if my parents who practiced family planning were still hard up to give us good and quality education, how much more for those who had not?

I am aware of that it will be a long time before the concrete effects of RH Law will be experienced by our fellowmen. But delaying it or even preventing it from being implemented, considering our country’s situation right now, is a violation of our rights to access to reproductive health care. We need an immediate tangible effect such as in the following case.

Small for Gestational Infant

A mother conceived, she was hypertensive even at the early stages of her pregnancy. After reaching 20 weeks, her blood pressure all the more shoot up. Even with medical care from a private obstetrician, still the blood pressure wasn’t adequately controlled. At 36 weeks, she came to the hospital in active labor. The baby’s heart beat was erratic and had to be delivered immediately, or else we will lose the baby.

The baby came out without spontaneous breath and crying, and the heart beat was very slow. He had to be resuscitated, a tube was inserted into his trachea to assist him breathing. He was small for his age of 36 weeks, with respect to his weight, length and head circumference (an indirect indicator of brain growth). This only means that the baby was chronically “undernourished” inside the mother’s uterus that’s why all of his anthropometric measurements were below normal.

Adequate blood glucose and oxygen supply from the placenta to the baby is necessary for optimum brain and body growth. Normal or good glucose level stimulates the production of more insulin-like growth factor 2, which is responsible for increasing the number of neurons and oligodendrocytes, and increasing the communications between neurons through dendrites and axon. An increased communication between these two parts of neurons leads to faster transmission of signals. Bottom line, intelligent kid. The opposite, “bobo.” I am not saying this is always the case but the risk, a very high risk at that, to being one is undeniably there.

So this baby already suffered an injury biochemically and physiologically inside the womb, even if he was born alive. So it’s true no mother died in this case. It’s true, no baby died in this case. But the impact of the chronic uncontrolled hypertension to the baby’s brain, IS permanent, and may be debilitating. This thing is still happening among our pregnant mothers, even if they are under the care of able obstetricians. But what about those who have no access to obstetricians? And mind you, this is just one aspect of issues surrounding a pregnant woman. There are more other pressing equally important concerns.

One anti-RH bill argues that there is no more need for RH law as there is already an existing Magna Carta Law for Women. Let me throw back the question to you. With the MCW in place, how come, we still have this high incidence of maternal morbidity and death? With the MCW in place, how come we are not achieving the millenium development goals? And what about HIV which is not included in the MCW, neonates? With the SQAO against implementation of the RH Law, aren’t we not endangering further our poor constituents? Is it right to issue this SQAO at this time?

 

Flu Vaccination and Pregnancy 2

PREGNANT MOM’S FLU LINKED TO HIGHER RISK OF AUTISM

Expectant moms may have one more reason to get a flu shot.

According to the latest research on flu vaccination during pregnancy, following current recommendations for influenza shots may help to lower rates of autism.

In research published in the journal Pediatrics, scientists studied the rates of developmental disorders like autism among nearly 97,000 children born in Denmark between 1997 and 2003. The children’s mothers answered questions about infections they might have had during pregnancy — colds, sinus infections and urinary tract infections, among others. They also reported whether they’d suffered from the flu or had fevers that lasted more than seven days before they gave birth.

When the researchers compared the mothers’ answers to the registry of developmental disorders, they found that moms who fought the flu while expecting had children with double the risk of being diagnosed with autism before their third birthday. Mothers who endured flu-based fevers for seven days or more had triple the likelihood of having kids with autism, and those mothers also had a 60% greater chance of having a child diagnosed with developmental difficulties falling into the more expansive category of autism spectrum disorders (ASD). In addition, moms who used antibiotics while pregnant had children with a small increased risk of autism. Infections and antibiotic use can also contribute to low birth weight babies, another risk factor for developmental abnormalities; in a 2011 study, researchers concluded that premature babies who weigh less than 4.5 pounds are five times as likely to be diagnosed with an ASD.

Influenza seemed to be the only infection linked to a higher risk of autism among these mothers’ children; other common infections such as colds and sinus infections during pregnancy did not seem to increase autism among their offspring. While it’s not clear why influenza is so potentially harmful to early development, experts suspect that the fevers associated with flu might be largely responsible, since previous studies show that periods of high fever during pregnancy are associated with birth defects. So bringing down rising body temperatures while expecting is a must, they say, to avoid potentially detrimental effects on a still-growing baby.

Still, as worrisome as the results sound — after all, avoiding the flu isn’t entirely in a mom-to-be’s control — Coleen Boyle, director of the National Center on Birth Defects and Developmental Disabilities (one of whose members contributed to the study) says that the research is “exploratory. (bold and italics mine)”

Adds Dr. Marshalyn Yeargin-Allsopp, chief of the center’s developmental disabilities branch: “It’s important to note that most women experiencing flu, fever or taking antibiotics during pregnancy did not have children with autism spectrum disorders.”

The results however, emphasize the importance of protecting against influenza, particularly for pregnant women, and the researchers urge expectant moms to get vaccinated to protect both themselves and their babies. Throughout gestation and even after birth, for the first six months of life, babies depend on mom for any immunity against bacteria and viruses like influenza. So a flu shot can give an infant a head start in fending off infections from a virus that’s hard to avoid. “It’s flu season and pregnant women should get vaccinated immediately,” says Boyle. Good advice, it seems, for many reasons.

Read more: http://healthland.time.com/2012/11/12/pregnant-moms-flu-linked-to-higher-risk-of-autism-among-children/#ixzz2LUdciEWP

 

Ooops!

I was once called for a referral. A few days old preterm baby having seizures that occurred within the first few hours of life. Baby was having seizures despite the anti-convulsant that was already given. The baby was already referred to a neurologist before I stepped into the picture. Baby was worked up and his electrolytes showed low sodium (112). (The normal level is 135 – 145; if the value is lower than 135, that’s considered hyponatremia. If value is less than 125, baby can have seizure that will not be controlled by anticonvulsant until the problem is corrected). In this case, it seems the most likely cause of seizure was identified. Thus, the immediate thing for me to do was to correct this abnormality and hope that it will eventually stop the seizures.

So after 48 hours, the sodium level was already raised to near normal. The good thing was, seizure already stopped. So I guess the baby’s urgent problem was resolved.

The question that bothered us was, why did the baby have severe hyponatremia? It is a rule of thumb that the electrolyte picture of a baby within 48hrs from birth generally reflects that of the mother. Unless that baby also has a congenital abnormality such as in cases of congenital adrenal hyperplasia (CAH). The baby in this case did not have physical signs highly suggestive of CAH, and the newborn screening eventually was normal, so this as the cause was easily ruled out. So, this made me then thought of the mother’s electrolyte status.

I interviewed the mother when she visited her baby at the NICU. I asked her if she was on prolonged intravenous fluid administration, if she was taking medications. She revealed she was on prolonged furosemide “maintenance.” This was given by an internist she consulted. BINGO! Seems I nailed the culprit with mere few questions. So I went on further with my interview. I asked why was she on prolonged furosemide intake. She said, she consulted the internist because she had edema (swelling) of both her lower legs. I further asked, “at what months of pregnancy did she notice the onset of edema, of hypertension. She did not know she was pregnant then when she had that consultation. Then my next question was, “is your menstrual cycle irregular?” And she replied YES! I was then flabbergasted and felt sorry for the mother, most especially for the baby. Why?

Let me reconstruct the story for a clearer understanding. Here was a woman with irregular menstrual cycle. She became pregnant but was not able to realize it because of her irregular schedule. Then later in the pregnancy, she developed edema of both lower extremities. She consulted an internist because of the latter, who also incidentally discovered she was hypertensive. The internist did not know the patient was pregnant; he did not do pregnancy test nor abdominal ultrasound. Pregnancy was remote from his consideration, thus he did not do these tesst… even if the woman was already showing signs of PREECLAMPSIA. So he gave furosemide. But since the edema was unresolving, she kept on taking the drugs. Few days ago, she was having abdominal pain. She saw another doctor, an OB-Gyn, who requested for an ultrasound. HALLELUJAH of all hallelujahs, she was indeed PREGNANT. And since her blood pressure remained uncontrolled, she was scheduled for emergency CS delivery. Since she was on prolonged furosemide intake, aside from it removing water from the body, furosemide also eliminates electrolytes like sodium and potassium. Since she was already hyponatremic, so was also the baby whose blood supply comes from the mother via the placenta.

The rest of the baby’s course in the neonatal ICU was unremarkable thus I signed out from the service after making sure baby was ready for discharge.

 

When One of the Twins Die In Utero

Did you always think that when a mother conceives twins, triplets, quadruplets or more, all of the fetus will be born alive? As morbid as it maybe, some fetus/fetuses die prematurely even before being born. Some may die within the first, 2nd or 3rd trimester (3 months). And their death can bring about complication/s not only to the mother, but to the remaining twin as well.

The effect of the fetal death to the surviving twin may vary according to the timing of the death. In a data published 1994, loss of one twin at the first trimester does not impair the development of the surviving fetus. (Some are completely resorbed in a condition termed as “vanishing twin syndrome.”) In the second trimester however, this is associated with increased risk for the survivor as reflected by a high incidence of growth retardation, premature labor and perinatal mortality.

An observation of twin pregnancies where single fetal death occurred after 20 weeks of gestation, the mothers were known to have preeclampsia which may also prompt babies to be delivered prematurely. The surviving twin aside from being delivered prematurely, they are also observed to be with intrauterine growth restriction. This could be an effect of the death of the other twin, or that and the effect of preeclampsia wherein the blood flow to the fetus may become diminished. This in turn causes diminished delivery of oxygen and nutrients to the baby thus. Head MRI and ultrasound of these survivors revealed some neurologic injury. Fortunately, in these mothers, there was no detected abnormality on coagulation profile.

A similar observational study was also done among twin pregnancies where a single fetal death occurred after 20 weeks of gestation. The study showed that the main cause of the fetal death was twin-to-twin transfusion syndrome. The survivors were also delivered prematurely and later also died after birth because of the same cause. (TTTS is due to abnormal communication between the blood vessels supplying the placenta of both, leading to shunting of more blood to the other twin while deprivation of the other one. One may die immediately while still in utero, while the other may survive or end up hydropic; or both may survive with severe physical discrepancy — see my other blogs on hydrops fetalis). 

Another in depth observation was done among twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation. Chorionicity of the twin pregnancies was noted (see illustration below on the types of twin pregnancy according to chorionicity).

(Image courtesy of  http://www.health.sa.gov.au/ppg/Default.aspx?PageContentMode=1&tabid=75)

Often times, the surviving twin was delivered prematurely, and that baby ended up with intrauterine growth restriction. The mother on the other hand had preeclampsia and gestational diabetes, both of which may also lead to the growth restriction of the surviving twin. In cases of monochorionic pregnancies, again twin-to-twin transfusion syndrome afflicted the babies. Some of the twin eventually died as well in utero (before being delivered), while others after birth. Also, ultrasound of the baby’s head should cerebral anomalies in some.

Even if one of the twins survive after the death of the other, and gets delivered, it is not reassuring that he will live and be discharged as well baby as his outcome may be compromised by the complications of premature birth, or presence of neurologic injury.

References:

1. Prömpeler HJ, Madjar H, Klosa W, du Bois A, Zahradnik HP, Schillinger H, Breckwoldt M. Twin pregnancies with single fetal death. Acta Obstet Gynecol Scand. 1994 Mar;73(3):205-8.

2. Axt R, Mink D, Hendrik J, Ertan K, von Blohn M, Schmidt W. Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.J Perinat Med. 1999;27(3):221-7.

3. Aslan H, Gul A, Cebeci A, Polat I, Ceylan Y. The outcome of twin pregnancies complicated by single fetal death after 20 weeks of gestation. Twin Res. 2004 Feb;7(1):1-4.

4. Chelli D, Methni A, Boudaya F, Marzouki Y, Zouaoui B, Jabnoun S, Sfar E, Chennoufi MB, Chelli H. Twin pregnancy with single fetal death: etiology, management and outcome. J Gynecol Obstet Biol Reprod (Paris). 2009 Nov;38(7):580-7. Epub 2009 Oct 14.

 

Does Physical Abuse To Pregnant Mother Affect The Baby?

Did you know that physical violence to a pregnant woman can cause intrauterine growth restriction (retardation)? Strange as it may sound, yes, physical abuse of a pregnant woman can indeed to several perinatal complications. Worse the fetus may be dead by the time he is born.

This was the topic during the first day of the convention I attended, though I failed to catch the first part of the talk. What struck me was the slide showing a strong association between violence towards pregnant woman and adverse outcome of the baby.

With that, I searched for any articles online, any study on physical violence and its adverse effect among pregnant women. I found a study conducted in Canada, but it is a large scale one involving 4750 study population. Independent variable (cause) studied was the physical abuse, which may have occurred even as early as before pregnancy. The dependent variables (outcome/effect) were presence of antenatal (before birth) hemorrhages, intrauterine growth retardation, and perinatal death (death between 20 weeks of pregnancy until 7 days after delivery). The study has shown that there is higher risk for occurrence of antenatal hemorrhage, intrauterine growth retardation and perinatal death among abused pregnant women.

(Reference: Patricia A. Janssen, PhD,a,c,d Victoria L. Holt, PhD,a Nancy K. Sugg, MD, MPH,b Irvin Emanuel, MD,a Cathy M, Critchlow, PhD,a and Angela D Henderson, PhDd/  Intimate partner violence and adverse pregnancy outcomes: A population-based study. Am J Obstet Gynecol 2003;188:1341-7.)

The speaker in the lecture explained why physical abuse restricts the growth of the fetus. Abuse causes the woman to be stressed. During stress, there is a release of stress hormones and substances, including epinephrine (otherwise known as adrenaline). This causes an rise on the resistive index at the level of the umbilical vessels.

(http://www.fetal.com/IUGR/treatment.html)

During ultrasonography, the sonologist can focus on the umbilical cord and obtain the resistance index on the blood flow that goes to the baby. (Resistance index is almost similar also to the resistance along an electric wire; the higher the resistance, the lesser the output in the end). If the resistance index is increasing, it means to say that blood flow through the umbilical cord going to the baby is decreasing. Because of lack of blood supply, the baby receives less nutrition and oxygen– the basic baby’s requirement for rapid growth in utero. As a result, baby ends up smaller than expected for his age of gestation.

The chronic the stress of the mother is, the worse the fetal outcome. And as I have previously stated, worst case scenario may end up in fetal death, not from the physical trauma but from the reversal of blood flow to the fetus due to very high resistance index.

(Will include the lecturer’s name later when I get hold of my program).

 

The Myths of Breakthrough Ovulation & It’s Purported Abortion

A woman posted a meme on twitter talking about “breakthrough ovulation” and how these eggs fertilized after breakthrough ovulation gets killed by contraceptive pills. I asked her to explain scientifically how does the killing happen, but I never got a reply. My guess was she really did not know what she was talking about and thus the answer (because she just want to instill fear among her readers). How responsible tweet that was huh?

Breakthrough ovulation can happen, especially when the female taking pills is not compliant and does not follow instructions well. According to Dr. Dennis Higginbotham, “failure rates for pregnancy with BCP’s (birth control pills) can be 1% to 5% depending on the particular pill and on the patient compliance. Skipping pills is the usual cause for failure, but ovulation (and pregnancy) can occur even when the pill is taken properly.” (highlight is mine; Reference: https://www.healthtap.com/#topics/breakthrough-ovulation-on-birth-control). Following his statement, it would show that the pills are 95-99% effective in suppressing ovulation.

Pill are composed of synthetic estrogen and/or synthetic progesterone. Some pills are plain progesterone, while some are combined estrogen and progesterone. The hormonal contents of birth control pills are minute as compared to the volume released by the ovary. It mimics the hormone’s action by causing ovary to stop ovulating, thins out the uterine wall, thickens the cervical secretions, all for the purpose of preventing pregnancy.

What are the circumstances surrounding ovulation? When a woman ovulates, there is a high estrogen level in her blood, there is the surge of luteinizing hormone. These two events are important to trigger the eruption of the ovum from the ovary. What are the sequela of elevated levels of estrogen? In the uterus per se, it causes thickening of the walls, increase in blood vessels, as if preparing for a possible pregnancy. That’s what estrogen does to the uterine lining. So, what will happen in cases of breakthrough ovulation, and this egg becomes fertilized? It has a rich uterine lining for implantation. This is contrary to the claim of misinformed anti-reproductive health bill measure that because the woman is taking pills, the uterus is thin and cervical mucus is thick disallowing pregnancy to happen. This is false! Estrogen and progesterone are endocrine hormones. This means that it is secreted by a certain organ, but its effect is transmitted to other organs sensitive to it via the bloodstream. In contrast, paracrine hormones/substances are substances which exert effect to nearby organs by diffusion but not via bloodstream. So in breakthrough ovulation, where the egg gets fertilized, PREGNANCY will take place, NOT ABORTION. As Dr. Higginbotham mentioned, there is 1-5% failure rate.

During the woman’s menstrual cycle, estrogen hormone predominate during the 1st 2 weeks (day 0-14). This hormone prepares the uterus and other reproductive organs for the forthcoming “pregnancy,” assuming that the egg gets fertilized upon its release – uterine lining thickens, there is increase in blood vessels, glycogen, etc. Everything happens in a concerted fashion for the anticipated pregnancy. By around day 14 of the menstrual cycle, the luteinizing hormone surges (released by the pituitary gland) and then triggers the release of the ovum.

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Beautiful series of pictures taken by accident by the team of Jacquez Donnez as they were preparing the woman for partial hysterectomy. (source: http://login.totalweblite.com/design/1120/index.asp?pageid=34422&AccId=4049)

Image courtesy of http://www.britannica.com/EBchecked/media/99761/The-steps-of-ovulation-beginning-with-a-dormant-primordial-follicle

Image courtesy of http://ib-biology2010-12.wikispaces.com/Human+Reproduction

When the ovum is released, the follicle is converted into corpus luteum. Estrogen level now declines dramatically. The corpus luteum now releases progesterone to sustain the ovum. If the ovum gets fertilized, there is rapid proliferation of cells until the fertilized ovum will transform into blastocyst. This happens until about 13 days from fertilization. Up to this point, the corpus luteum provides progesterone for this developing embryo.

By around 13th day post-fertilization, the blastocyst implants. It may cause a minor bleeding in some women (post-implantation bleeding) while others may not. The outer layer of the blastocyst now imbeds itself into the rich vascular uterine wall and forms the placenta. Once implanted, the placenta now assumes the role of producing progesterone for nine months until the baby’s birth, as the corpus luteum has already involuted. This predominance of progesterone over estrogen during the period of pregnancy inhibits the ovary to release ovum for nine months as well.

This effect of progesterone predominance during pregnancy is mimicked by intake of contraceptive pills.  When the woman takes in hormonal pills, the progesterone becomes elevated thereby inhibiting the ovary to release an ovum, the uterine lining not prepared for pregnancy and the cervical mucus viscid, unfriendly to sperm that might swim up to the fallopian tube. Hence pregnancy will become unlikely.

Now it makes me wonder why these anti-rh bill supporters keep on saying that contraceptive pills are abortifacient. How can abortion happen when no ovum is released? And when there is no ovum released, what is there to fertilize? As of now, majority are in acceptance of the fact that fertilization is when human life begins. In cases of breakthrough ovulation which they repeatedly claim, again, if there is ovulation, then the uterus and the cervix is also prepared for a pending pregnancy because the effect of estrogen that lead to ovulation is also echoed in other parts of the female reproductive organ and not on the ovary alone. It does not happen that estrogen causes ovulation, but uterus remains thin and cervical mucus remains viscid. Estrogen and progesterone effects contradicting at the same time? No, dear anti-rh bill supporters, estrogen effect is endocrine. Again, read the meaning of endocrine as I have mentioned above. And if you insist on this premise that an ovum is released but the uterus and cervix is unprepared for a pregnancy, leading to the abortion of that fertilized ovum, then you should be one who is menstruating while pregnant because you think that estrogen and progesterone effects can happen at the same time. I wonder what subspecies of homo sapiens you are, perhaps Homo sapiens mutatis?

 

When Intestines Go Out Of The Abdominal Cavity (Gastroschisis)

(Image courtesy of: http://www.dfwareamoms.com/forums/showthread.php?t=53861)

GASTROSCHISIS is a condition where there is a defect at the anterior abdominal wall (usually towards the right of the umbilical cord insertion), leading to the evisceration of the intestinal segments or abdominal contents as seen in the picture above. Because of this, the intestines is now exposed to the amniotic fluid where the baby floats. (Amniotic fluid is made up mostly of the fetus’ urine, thus may contain chemicals that can be irritating to the intestines but not to the baby’s skin). This exposure triggers the intestines to react to the amniotic fluid, causing inflammatory response, thickening of the intestinal walls than their regular diameter when not exposed to amniotic fluid. If an operation is attempted immediately at birth, it would be impossible to put back all those intestines into the abdominal cavity at once hence a silo bag is placed to contain the intestines outside of the abdominal cavity. Slowly the intestinal contents in the silo bag is pushed (in days or weekly basis) until the abdominal cavity is able to contain everything, thus the wound is now closed.

Intestines contained in a silo bag. (Image courtesy of http://bestpractice.bmj.com/best-practice/monograph/883/resources/image/bp/3.html)

AMNIO-INFUSION

The abdominal wall is sterilized. Then under ultrasound guidance, a needle is poked into the amniotic cavity. Amniotic fluid is then aspirated, and then an equal amount of normal saline solution is replaced back. This is then repeated until the return flow becomes clear in color. This is being done in order to refreshen the amniotic fluid that might irritate and cause inflammation of the intestines that has eviscerated outside the abdominal cavity (as you recall that the amniotic fluid is mainly composed of the fetus’s urine). If the intestines become inflamed, the abdominal cavity might not be able to contain everything when replaced all at once during a corrective operation.

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I was lucky again to have witnessed a case of a baby with gastroschisis, diagnosed prenatally via an ultrasound, and who underwent the above procedure. The perinatologist did serial amnio-infusion treatment on the baby (of course, while mom still pregnant with him) until the time that delivery was already inevitable. During one of the amnio-infusion treatment, I was a witness and assisting the perinatologist. The postnatal outcome was marvelous!

During delivery, we did a double set-up at the operating room. At one room was the cesarean section for the delivery of the baby. At the other room was the team of the pediatric surgeon waiting. We, the neonatology team was in between. A sterile plastic container was readily available. When the baby was out of the mother’s uterus, we the neonatology team attended to the baby immediately. We were so lucky that baby was vigorous upon delivery so there was no need to help him breath. Immediately while my colleague was wiping baby dry off the amniotic fluid, I was inserting a line and my other colleague was putting the baby’s legs, intestines and his lower trunk into the sterile plastic. This is to avoid losing much fluid from the abdominal cavity and contaminating the intestines and abdominal cavity. Then we immediately brought baby to the other operating room where the pediatric surgeon was waiting.

Primary closure (all intestines brought inside the abdominal cavity at once) was done on baby. This was easily possible because the intestines weren’t that much inflamed, thanks to the amnio-infusion, thus the abdominal cavity was able to accommodate them all. I wasn’t sure though if all layers of the abdomen were co-aptated and sutured all together, or just the skin and the subcutaneous layer, my bad not to have remembered.

The baby was able to tolerate feeding immediately. Because of this, the baby did not stay long in the hospital, went home in less than two weeks if I was not mistaken. I guess this is another benefit of amnio-infusion – avoid prolonged hospitalization and thus hospital acquired infections. I wish to do this again, now that I am in private practice.