Fetal movement is certainly one of the more vague parameters followed at each prenatal visit and yet it is very important. Fetal movement cycles can vary in terms of intensity (fetal sleep cycles etc.) and your own perception of movement can depend on awareness as you are often busy during the day with so many things, this assessment you can often only estimate and not quantify how many times you feel the baby move in a way that brings the satisfaction and reassurance you would like. Fetal movement charting is done and this is something that will be discussed here and ultimately must be discussed with your prenatal provider.
With that being said, in many ways, as I have already stated, it is one of the more important relative measurements you can actually monitor outside of the office setting.Each visit you will notice, you are asked "is the baby moving" and though it may seem matter of fact, it is a parameter that is recorded at each visit as it can be a reflection of fetal well-being.
I almost did a study on fetal movement, as I wanted to see how to make it a more reliable and objective measurement. As I constructed the outline for the study and researched the topic, I realized it was going to be a very hard topic to reach statistical significance (regarding the number of patients one would have to include in the study) and I felt there would ultimately be little I would come up with in terms of anything new I would be able to tell women other than what is mentioned below.
As of now most sources suggest measuring fetal movement the same time each day for a defined interval of time and with a defined number of movements to be used as a cut-off. I purposely, have to avoid advising parameters to follow , as I am here to educate . Only you and your provider can determine what is considered appropriate. Surely you can look up further information on this topic but still it comes down to a discussion with your prenatal care provider. As standardized as it may seem I feel there is always a need to have the discussion with someone who knows your history and physical exam. Not only is it the absolute amount of movement but it is also relative.... often I have been told "yes the baby is moving but not like it used to" etc..
The extreme is clearly most concerning. When a women calls the prenatal nurse to report no movement for one or two days , clearly this can be a sign of a very serious problem. It is the complete lack of movement and worst scenario that we are trying to prevent by talking about being aware of this subject on a relative basis.
I apologize for this topic being unfulfilling in many ways, but it is important to talk about as decreased fetal movement (is where mother often knows best) can be a sign of a need for further testing such as an ultrasound, NST etc..
Certainly there are fetal heart tone testing devices that have been coming out and being made available to the patient though the presense of the heart tones is not the whole story. Thus, although this finding of postive heart tones is reassuring as to viability it does not test the overall well-being of the fetus.
As I mention the information I offer is for educational purposes and is not intended to diagnose, treat, prevent or cure any condition. If it helps to better understand a particular topic that is my goal.
Douglas A Penta MD
7.) Reflexes
In certain circumstances during your prenatal visit you may notice your prenatal care provider will test your reflexes to check for overactivity or hyperstimulation of the nervous system, which is significant for someone with signs of preeclampsia.
As I have previously discusssed ,preeclampsia is defined as a combination of parameters including high blood pressure, protein in the urine and swelling. The specific measurements of these parametes is what ultimately defines preeclampsia and needs to be addressed by your prenatal care provider.
What is important to know , is that preeclamsia can progress to eclampsia in certain situations and this is the reason for checking reflexes (eclampsia is distinquished from preeclampsia by the presense of seizures).
Should you be found to have hyperreflexia or brisk reflexes this is an important finding and will affect your management as it will certainly increase the level of monitoring and based on your gestational age and concern for eclampsia can impact timing of delivery.
Now you know the reason for checking reflexes at your visit. Should they be normal, then the finding will serve as a baseline as reflexes can vary among individuals . It is often hard to know when they are significant.
Though a little more advanced in terms of discussing fundamentals, is the exam of the nervous system for what is called clonus. This is when your practictitioner will push your foot up briskly to stretch your achilles tendon and check for repetitive jerking movements. This also determines if your nervous system is in a hyperactive state.
If your nervous system is found to be hyperactive , magnesium sulfate will often be used to calm down your nervous system and prevent seizure activity.
I will next discuss the symptoms you are often asked at prenatal visits which are interpreted in conjunction with your physical findings.
This is eductational material not intended to diagnose, treat., prevent or cure any condition. I truly believe the best patient is an informed patient. Often, there is not time to explain the principles I have discussed above which are not particularly complex and yet can help you feel more involved with the clinical interaction.
Douglas A Penta MD
(Each day I will add another test to this section which is part of the routine evaluation performed at your prenatal visit.)
8/21/09
Recurrent Pregnancy Loss
The topic of recurrent miscarriages and the relationship to future fertility can cause a great deal of apprehension for couples. Unfortunately , it is often seen as less of a concern to family and friends as only those going through it can know how it feels.
To begin, I have observed a great deal of guilt in patients undergoing a miscarriage. Wondering if the cause relates to something they did etc.. In fact, the majority of times it has absolutely nothing to do with what one has done whether it be athletics, emotional events etc.. Yes, there are exceptions such as significant trauma or toxic exposures (radiation etc.) but those are the rare exceptions and usually not the circumstances among couples coping with this event who are doing everything right to promote a healthy pregnancy.
It is critical to realize (and this has been easily studied and clinically proven, based on the direct genetic analysis of miscarriages) that up to one half of early 1st trimester pregnancy loses occur because something was wrong from the very start genetically . I am not referring to genetics as a result of inheritance factors or conditions such as Down's syndrome but essentially major chromosomal aberrations from the start. Thus , it truly is nature's way of taking care of such an unfortunate circumstance.
Implantation occuring in the wrong place of the uterus is yet another possibility which is sometimes assumed based on bleeding etc. but clearly hard to confirm, and this is a chance phenomenon you cannot control.
Alhough an ectopic pregnancy (extrauterine pregnancy , most often tubal) as I have written about is not considered a miscarriage it is in a sense an example of this possibilily where the pregnancy just does not attach in a favorable location for normal development.
Lastly and clearly most disturbing to gynecologists (particularly dealing with reproductive medicine) is the couple that does have recurrent miscarriages and there is no clear explanation after a full evaluation which I will discuss in my next article tomorrow. We always want answers and there are situations where this is not possible . A great deal of research continues to be done in this area.
My opening remarks stem from the fact that I have seen many women distraught and blaming themselves for something they feel they might have done wrong to cause the miscarriage, when this occurrence is very rarely related to anything they did and should not leave one feeling any guilt or blame. It is clearly appropriate to grieve and these individuals should have access to counseling. Everyone has there own approach to this but don't suppress feelings that persist and could well be based on incorrect assumptions. The important point here is to know help is available.
The next question then arises as to statistically when is this is considered to potentially be a problem and when should an evaluation be done to try and determine a cause. The general impression for years has been after there has been three consecutive miscarriages, though that is difficult to endure as a patient and clinician. I say this with the exception of pursuing aggressive procedures that may not be warranted and carry more risk than benefit. I have more often used two miscarriages in many situations, to start some of the simpler steps in the evaluation process and many clinicians do , granted the yield of finding a problem as you will see in tomorrow's article is low. Two misscarriages is still within the spectrum of unfortunate luck and not necessarily a reflection of a problem as difficult as it is to go through.
There are many variables to consider when making the decision to prusue recurrent pregnancy loss and perhaps the most important one is age as time is a significant factor and can significantly impact the work-up decision as fertility declines very gradually over the age of 30. There are truly too many variables to mention here that factor into what can impact the onset of a work up for this problem. One example ,being that a couple with prior successful pregnancies interposed by consecutive miscarriages is very different than a couple with misscarriages and never carrying a pregnancy to term. Research into immunology, hormone levels etc. in such situations are constantly being looked at.
I will complete this article as I have promised a (twitter) friend of mine by tomorrow as I am a week behind. I will be addressing statistical data and the work-up of recurrent pregnancy loss. I appologize for the time it has taken to get this information out.
It is essential for couples to know the facts as I have always said "knowledge is power" and it is disturbing when a problem such as this can impact a relationship adversely.
The only exception I can make to the routine managment of this topic (more as a public health annoucement) , is the issues surrounding abusive relationships. Trauma in a relationsip as I have alluded to in the past, is most commonly manifested during pregnancy. I mention it as it is a shame to realize what a role abuse plays in certain relationships as we have evidenced on the news in the recent past.
As always please know that I cannot diagnose , treat, prevent or cure any condition in using this means of communication, as only your doctor who knows your history and exam has the capacity to deal with this with you directly. My interest is to raise the proper information to be aware of and raise questions you may want to ask.
Douglas Penta MD
8/10/09
Endometrial Ablation
Endometrial ablation has become extremely popular over recent years as it is a more conservative approach to those who might otherwise be looking at hysterectomy to control heavy bleeding, or perhaps aggressive homonal therapy that might pose other health risks.
As with all the information I offer please understand I love to inform and educate though I cannot possibly diagnose, cure, treat or prevent a condition through this means of communication. You must always make a decision based on a thorough discussion with your primary OB/GYN physician who knows your complete history and physical examination.
Endometrial ablation when I first started learning about it and performing it in the 1990's was a huge breakthrough in the management of bleeding disorders, serving as a more conservative surgical approach to hysterectomy clearly desired by many women.
Over the years the number of techniques used to perform an endometrial ablation have increased significantly. Whatever the approach, the desired outcome is the same, to ablate (destroy) the menstrual lining (endometrrium) and thus stop the bleeding problem as all that remains is the uterine musculature (myometrium). This article is not the place to discuss the techniques used as this is a constantly changing area in terms of management within the field of gyn surgery and is very much operator dependent.
Here are my "pearls" or suggestions as you look into this very popular procedure which I receive many inquires about. This list is by no means complete but will help you think of the appropriate questions to ask your personal physician:
- Clearly there must be no desire for future fertility as the lining to carry a pregnancy is being scarred over.
- If you have an ablation ; however, the procedure should not be viewed as a sterility treatment as islands of active menstrual tissue could remain .
-The procedure has a failure rate in terms of persistent bleeding and this can relate to residual menstrual tissue after the ablation as it can be hard to be sure there has been destruction of the entire lining, deep enough, especially with conditions such as adenomyosis which I describe in the article section of this website. If bleeding persists there can also be increased cramping as the bleeding can be obstructed as a result of scarring over crypts of endometrium deep in the myometrium or uterine muscle.
- When you are past the post-operative recovery phase when bleeding may persist for a while, you must discuss with your doctor when the time is right to reevalute persistent or recurrent bleeding depending on your particular risk factors.
- One caveat to the comment above , which I have seen is that sometimes the bleeding though persistent might be much lighter and menstrual regularity returns such that the patient wishes to monitor as menses are essentially "back to normal" with regular intervals. Every situation has to be managed on an individual basis. Further evaluation is then determined based on a patient's particular medical history and the indication for ablation to begin with.
-Should bleeding persist it is not unusual to reablate or ablate using resection if the pre-operative assessment after the first ablation does not point to a more serious problem. I have taken this approach with patients and if not desired then depending on the circumstances one might choose to go to hysterectomy unless this is not an option should the patient not be an operative candidate for major surgery.
-Some of the risks of the procedure include anesthetic risk, relating to the technique chosen, the potential for uterine perforation and the usual operative risk of bleeding and infection relating to surgery in general.
-Most important, as I see it, is the experience of the operator. Although this question may not be comfortably addressed with a physician you know well or have seen for many years.I never took offense to this question as I want to treat a patient who is fully informed. I see nothing wrong with asking what technique is planned to be used, the success rate (no bleeding after the procedure) and roughly how many ablations your provider has performed. All clinicians have to learn new procedures which includes proper training and mentoring and that is something you simply want to know. When I had to learn I let my patient know this is a new procedure and the precautions taken in terms of formal training and mentoring.
-It simply comes down to trust and how confident you feel about your OB/GYN provider and the information you obtain through your personal research. As I often suggest use the American College of Obstetrics and Gynecology website to gather information to help you make an informed decision. http://acog.org. On the resource page of this website you can go directly to their patient information page. Much of the information is the same as you would receive at your doctor's offfice.
I hope this information is helpful. The endometrial ablation can be an excellent alternative to hysterectomy if all the criteria are met to insure your safety.
Douglas Penta MD
8/1/09
Diabetes Mellitus
Their are two diabetic conditions most commonly discussed: Juvenile Onset Diabetes (Type I) and Adult Onset Diabetes (AODM or Type II) . Though their causes are very different,over time they can result in similar complications.
Although there is a great deal of research to be done in this area it is exciting to see where the future is going. Efforts to support and promote research regarding diabetes mellitus is very important.
Unlike many medical conditions that are not fully understood, diabetes is understood a great deal and the goal overall is to maintain consistent, normal blood sugar levels to minimize the problems relating to long term blood sugar elevation.
What makes blood sugar management difficult is the fact that too low a blood sugar level can result in problems (seizures etc.) as well. Thus the range allowed for blood sugar control is crucial.
Juvenile diabetes is a result of the pancrease failing to produce adequate insulin and is encountered early in life with a strong genetic predisposition and the cellular level of insulin production (in the pancreatic beta cells). In addition to genetics type I is thought to have a correlation with viruses, toxins etc..
The standard approach related to replacement of one's insulin needs for type I diabetes is through shots , and insulin pumps. More recently through intensive research , pancreatic beta cell transplantation , is an area receiving a great deal of attention. At this time there is also agressive work being done on encapsulating beta cells to avoid immune system rejection/recognition.
Adult onset (AODM) contrary to Juvenile Diabetes does not have to do with insulin production but the ability of receptors to respond to insulin.
AODM can be well controlled with medications (not always insulin) and lifestyle changes which affect receptor sensitivity. Type II diabetes is very much impacted by weight gain in those who are genetically predisposed. I have seen many people able to discontinue medications for AODM simply by losing weight while under a doctor's supervision.
Finally, as an OB/GYN physician I must mention the diabetic condition I have dealt with most often during my career as it relates to pregnancy and is referred to as Gestational Diabetes. It is routinely screened for during pregnancy and is most like Type II as it is not a lack of insulin but a lack of response to insulin receptors. I have seen very large doses of insulin required to maintain normal ranges of blood sugar during pregnancy as the receptors simply are not sensitive.
Women with pregnancy-related diabetes are educated about how to maintain normal blood sugar levels and it is a task that takes a great deal of education/instruction during pregnancy as they must learn a lot about diabetic control very quickly.
A certain percentage of women who get diabietes during pregnancy (the percent quoted seems to change and is multifactorial) may be predisposed to AODM later in life and thus should be aware of this potential after their pregnancy.
Rarely the diabetes acquired during pregnancy will persist after delivery , in most cases as soon as the placenta is delivered the hormonal-related contribution to gestational diabetes ceases almost immediately.
It is always advised to get a follow up blood sugar after delivery to establish this correction has taken place as it can persist in rare cases after the pregnancy.
I hope this information was helpful. It is not intended to diagnose , treat, cure or prevent this condition . however, the more one understands the cause of a particular condition the more proactive one can be in terms of assuring detection of the condtion and management.
Douglas Penta MD
7/25/09
Menstrual Migraine Headaches
I was asked to write about menstrual migraine headaches. Though I am not a neurologist you will see from my comments and personal experiences I have had that it is truely an entity . As this website is intended to be supportive and informative it clearly cannot be used to diagnosis , treat, prevent or cure any condition as you need to have a complete history and physical exam by your personal clinician to accomplish this. I will refer you to a great government resource at the end of this article that covers this condition in more depth and can lead you to more helpful information.
Menstrual migraine headaches have been recognized as an entity in the relatively recent past as menstruation was clearly seen as a contributing factor to the onset of migraine episodes for many women. There have been countless articles written about this topic primarily by neurologists as they deal with headaches of any sort and this particular area is very intriquing as to how it shoud be managed. I frequently referred this condition to neurologists when I suspected it, as such doctors are most up to date on the diagnosis/confirmation of menstrual migraines and the treatments considered helpful to alleviate this problem.
Migraine headaches can be debilitating to the point that one has to stay in a quiet room with the lights out to tolerate the throbbing pain.The cause of migraines in general is constantly being studied and many drug companies are constantly coming out with medications that help some but not all those affected.
Migraines account for a significant impact on quality of life and absence from work.
It is interesting as I continue to learn about this problem to realize that migraines in general are actually three times more common in women than men. The causes are numerous including hormonal as discussed here, sleep deprivation, red wine, stress, etc. the list seems endless. The insult that causes migraines can have a genetic predispostition and appears to be related to perivascular inflammation in the brain causing this often referred to as "vascular" headache with or without a preceding aura which is a particular sensory change such as flashing lights, numbness, smells etc . Migraines often require substantial pain medication to stop.
I do not have a specific "pearl" for this topic other than to say that it is absolutely an entity that clearly requires the understanding and support of those around one who is suffering from this condition. I say this as it is not an objective finding (as with bleeding or an obvious injury) but instead, is based on a patient's subjective complaints which should be taken very seriously.
I refer my readers to an excellent Government-managed website to obtain more information.
http://womenshealth.gov/faq/migraine.cfm
If I have even opened the door for some to the information that is available on this topic then I feel I have done my job. Please take care.
Douglas Penta MD
7/18/09
Ectopic Pregnancy
When talking about ectopic pregnancy one is most often thinks of a pregnancy in the fallopian tube which is by far the most common. The term actually is appllied to any pregnancy that is outside the uterus and can actually involve a pregnancy implanted in the abdomin, or on the cervix, ovary etc..Though these locations are less common (than tubal pregnancies) the problem in terms of diagnosis , treatment and prognosis is very concerning regardless of location as an ectopic pregnancy can cause significant maternal morbidity and rarely but possibly mortality if left undiagnosed/untreated.
For the sake of discussion I will stick to tubal pregnancies though keep in mind what I have said.
The "Pearl" is that ectopic pregnancies account for a substantial amount of maternal morbidity and mortality compared to complications relating to "normal " intrauterine pregnancies.
As technological advances are made and awareness increases this statistics can change , though ectopic pregnancy has , without question, been the largest risk of maternal mortality. I leave this statistic subject to change as ultrasound , blood testing and awareness increases.
Years ago , I often would ask medical students/residents what the highest risk of pregnancy-related mortality was and ectopic was often not the first thing that would come to their minds , that is why I would pose the question. Thus I consider it an "OB/GYN Pearl" , the kind of information you don't forget once you are made aware of it.
The response from students , more often would relate to pregnancy complications (high blood pressure etc.) when ,in fact, the answer over the years has been ectopic pregnancy.
A pregnancy outside the uterus is often not recognized as a "maternal" pregnancy-related problem when , in fact, it is recorded as such. This is an understandable misperception as ectopics are most often symptomatic early (first trimester) .
(I have actually seen a twin abdominal pregnancy at 24 weeks (very rare!))
This information is not intended to worry women about the problem but to raise awareness of the possibility, particularly if one has a history of any prior tubal damage relating to infection, prior ectopic , endometriosis etc.. The fact is ectopics can happen to anyone regardless of history.
If you think (or know) you are pregnant and have abnormal pain (usually abdominal) or bleeding be sure to see your doctor even earlier than your first scheduled prenatal visit to confirm your pregnancy is intrauterine . Depending on the gestational age , confirmation of an intrauterine prengnancy is made by a combination of blood testing and ultimately by ultrasound.
A diagnosed, ectopic pregnancy is very treatable. If not diagnosed serious complications can arise due to rupture of the fallopian tube with intraabdominal bleeding etc.
Not a pleasant topic; however, in this day and age pregnancy with pain and abnormal bleeding needs to be evaluated immediately to confirm the pregnancy is intrauterine , at a time when we have the ability to intervene and prevent serious complications.
Often the problem can relate to a simple ovarian cyst etc. but that determination should be a diagnosis made by exclusion . Follow up ,whatever the problem, can then be arranged based on the findings.
Douglas Penta MD
7/11/08
Most Common Pelvic Cancers
When talking about the diagnosis of various cancersthe most significant factors in terms of cure , relate to it's location, the organ involved and the response to the established treatment (ie. pancreatic vs various skin cancers).
However, aside from this rather obvious fact, the rest of the prognosis largely relates to two defining characteristics of the cancer:
1.) Stage: Defined usually as I,II,III or IV is the level of spread to adjacent or distant organs essentially how advanced the cancer has become. (The reason pancreatic is seen as so aggressive is that it is adjacent to so many vital organs making access to treatment difficult and stage often advanced at diagnosis).
2.) Grade: The grade is the pathologist findings (the histology that defines the type of cancer and how aggressive it is by the cellular findings and it's known clinical behavior. The pathology is often reported as well or poorly differentiated and relates to how severely the cellular findings deviate from normal cellular structure (Level of invasion etc. also is described in a pathology report and is of prognostic significance as this can impact the staging of the disease noted above.)
The "Pearl" is that stage for stage gynecologic cancers are not as different in prognosis as one may think it is the timing of detection. Thus ovarian is often seen as the worst as it frequently presents at a more advanced stage.
Endometrial (often referred to as uterine cancer) usually gives an early warning sign of abnormal bleeding prompting evaluation and diagnosis at an early stage resulting in a good prognosis.
Cervicalcancer, if one is regular with pap smears is picked up relatively early as the pap smear prompts further evaluation (ie coposcopy) and intervention accordingly.
Ovarian, clearly is the one most women worry about and is because the symptoms are often vague , many times with only increased abdominal girth /swelling and minimal if any discomfort. Thus the diagosis is often at stage three by the time it is picked up. A great deal of attention is being given to this fact as regular pelvic exams , CA-125 blood screening, genetics and sonogrophy are constantly being looked at for optimal ways to improve early detection.
Dicuss the above issues with your provider to see what best serves your needs for screening based on your exam and your personal and family history as genetic testing is continuing to play a greater role in determining who is most at risk.
(What is presented here is intended to stimulate thought and discussion. Information is constantly changing and what I share with readers cannot be intended to diagnose, treat , cure or prevent disease. Use of this information can only be used in the context of a discussion with your primary health care provider and the results of your physical exam . )
Highlighted links are supplied by Medline Plus an excellent source of medical information. MedlinePlus directs you to information to help answer health questions. MedlinePlus brings together authoritative information from NLM, the National Institutes of Health (NIH), and other government agencies and health-related organizations. MedlinePlus also contains extensive information about drugs and supplements, an illustrated medical encyclopedia, interactive tutorials, the latest health news, and surgery videos
Douglas Penta MD
Douglas A Penta MD
7.) Reflexes
