Labor Pain: Should I Get an Epidural?

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Pain relief during labor is a huge question that weighs on any expectant mother’s mind. No one likes pain and the mere anticipation of labor pain is a scary thought for most. I make it a point to review all pain relief options with all of my pregnant patients prior to delivery. One of the most common questions that I get is whether to get an epidural or not, and what are the risks and alternatives?

What pain relief options are available?

There are two main options available for patients who are in labor. The first is intravenous (IV) pain medications. The second is regional anesthesia usually in the form of an epidural, which is a catheter placed in your back in which medication is infused around the spinal nerves to make your belly and pelvic region numb.

Which method is the best?

Epidurals, by far, relieve labor pain most effectively. The epidural medications cause you to lose feeling in your belly and pelvic area by blocking nerve signals from the lower spinal nerves. Epidurals are very targeted and block pain directly from nerves that supply the uterus and vagina. IV pain medications, on the other hand, simply cause a decreased perception of pain and don’t necessarily target any specific organs. Their effects often wear off quicker as well.

How is an epidural placed?

An epidural block is performed by an anesthesiologist. A small area in your lower back is cleaned and made sterile. A needle is inserted into your back and a catheter is threaded over it into the epidural space (space just outside the spinal cord). Medication is then infused via the catheter, which blocks the targeted nerves. This infusion of medication is set at a constant rate but can be altered using a small pump. Since you will not be able to fully feel your bladder sensations after the epidural is placed, you will have a catheter to drain your bladder.

What are the “side effects” of an epidural?

There aren’t many major side effects of an epidural although some do exist. One possible side effect is low blood pressure. If you experience a drop in blood pressure, there is medication used to raise it to ensure good blood flow to your baby. Epidurals can also cause post-delivery headaches if spinal fluid leaks out. Rarely, a spinal hematoma, which is a blood collection around the spinal cord, can develop however the incidence of this is very rare at less than 1 in 250,000. Other minor side effects include fever, shivering, nausea, or vomiting. One last important side effect is a prolonged second stage of labor (“pushing” stage). This is due to an inability to feel the anything in the vaginal region which then makes pushing less effective. While you may push a little longer, the vast majority of women still deliver vaginally.

Will an epidural increase my chances of a C-section?

No. Studies have shown that epidurals do not increase your risk for C-section.

Is there any reason why I can’t get an epidural?

There are a few rare conditions that preclude a patient from getting an epidural. These include a low platelet count, a coagulopathy (clotting disorder), a space occupying brain lesion, or an allergy to the medications in the epidural.

What if I don’t want an epidural or pain meds? Are there any other options?

During labor, the main pain relief options are IV medications or an epidural. The only other options would be a pudendal nerve block or local anesthesia. A pudendal block is a numbing medication that is directly injected around the pudendal nerve through the vagina. This is typically performed as a mother is pushing as its effects are relatively short-lived. Local anesthesia is given as a direct injection of numbing medication into the vaginal tissue to temporarily numb the area. This is typically done after the delivery however, and only used when a vaginal tear has to be repaired.

Acessa: A New Way To Treat Uterine Fibroids

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Uterine fibroids are noncancerous tumors that originate from the muscle layer of the uterus. They are the most common tumor of the uterus and occur in up to 70% of women, however vary in incidence depending on ethnicity and family history. Uterine fibroids (also called leiomyomas) can range from a small pea size to even the size of a grapefruit or softball! As you can imagine, the larger a fibroid becomes the more problematic it can be, with pelvic pain and heavy and irregular bleeding being the most common symptoms women experience.

In the past, fibroids have been treated in various ways. Birth control pills, progesterone injections, and intrauterine devices (IUDs) have all been tried, but often with only modest success. Most often fibroids require surgery in the form of either a myomectomy or a hysterectomy. A myomectomy is the surgical removal of fibroids from the uterus. Unfortunately, even after removing them, new fibroids can still grow back. Hysterectomy is the most definitive form of surgery for fibroids, however this involves removing the entire uterus. While this surgery will eliminate any chance of fibroids returning, women often require large incisions (especially when the fibroids are large), lose their ability to have children, and also require a lengthy recovery time of up to six to eight weeks.

The good news is that a new technique called Acessa has been developed as a more minimally invasive way to treat uterine fibroids. It involves tiny incisions, good success rates, and short recovery times, all while preserving the uterus and without having to remove any native tissue or organs. Acessa is performed laparoscopically and uses radiofrequency ablation through a probe tip that is inserted through the belly and directly into the fibroid using ultrasound guidance. Once the tip is inserted into a fibroid, tiny microarrays are deployed directly into the tissue and heat is applied to destroy the fibroid from within. This procedure is performed on as many fibroids as are found by the ultrasound probe. Acessa is performed in a hospital or ambulatory surgical center under general anesthesia and usually takes around 1-2 hours. Patients are discharged the same day and typical recovery time is only around 3-7 days!

The success rates of the Acessa procedure are excellent. Clinical studies have shown that the vast majority of patients experience a significant reduction in their bothersome symptoms and an improvement in their quality of life.  In fact, in recent surveys, 98% of patients have reported overall satisfaction with the procedure and would recommend it to a friend.

If you think that you may have uterine fibroids because you suffer from either heavy or irregular periods, anemia, or pelvic pain, we encourage you to discuss this with your doctor at MacArthur OBGYN. Myomectomy or hysterectomy may still be good options for you.  However, we are now performing Acessa, a new minimally invasive way to treat your fibroids with small incisions, shorter recovery times, and preserving the uterus all at the same time!

Labor 101: When Am I in Labor and What Do I Do?

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A lot of my time in the office is spent on educating patients about their bodies and the changes that occur during pregnancy. As women get closer to their due date, many questions come up about pelvic pressure, belly pain, and contractions. Pregnancy is a time of great physical stress on a woman’s body and changes do occur that are foreign to most women. These physical changes can be unusual and even scary for some patients. There is a lot of confusion surrounding the following questions: “When exactly does my labor begin?  When will my baby be born? When should I go to the hospital? What can I do about labor pain?” We doctors are responsible for educating all patients early and often on these topics so that they feel prepared and comfortable with the labor process.

“My doctor gave me a due date. Is that when my baby is going to be born?”

Finding out a “due date” is very exciting for mothers and fathers to be. Once a due date is given, patients often mark it down on their iPhone calendar or due date app or immediately text it to family members and close friends. However, I always caution them about this and tell them that a “due date” is NOT THE EXACT DATE when the baby will be born. It’s actually a calculated date that tells us when you are exactly 40 weeks and is based on your last menstrual period and first ultrasound of your pregnancy. Your baby could come a little earlier or a little later than that date depending on when your body is ready for labor. Labor is defined as when a woman experiences regular contractions with progressive cervical dilation (opening). Dilation from 0 to 4 centimeters takes days to weeks, however dilation from 4 or 5 centimeters to 10 centimeters (when a woman is ready to push) only takes hours! For this reason, you are not considered “in labor” and not required to stay in the hospital until you have reached 4 or 5 centimeters. Consequently, you may be allowed to go home if your cervical dilation is less than 4 cm although you may be feeling contractions.

“How do I know if I am in labor?”

The natural follow up questions that patients have are “How do I know when I am 4 centimeters? Can I tell by my contractions? How do I know when to go to the hospital?” Great questions. The answer is there is no way to know for sure unless you get checked by your doctor or at the hospital. My recommendation is to time your contractions. Look at the clock to see how often your contractions are coming and for how long they have been lasting. If they are irregular, on and off, or coming every 15 to 30 minutes apart, just wait. These are Braxton-Hicks contractions (false labor). They are not associated with labor but can be uncomfortable. Once your contractions start coming every 3-5 minutes for more than 30-45 minutes then you should go to the hospital.

“Should I go to the hospital for anything else other than contractions?”

Yes. You should go to the hospital if you are experiencing leakage of fluid or vaginal bleeding. The “bag of water” is the amniotic sac. It holds the amniotic fluid that bathes the baby. The bag of water can rupture on its own at any point during labor or even prior to labor. Once the bag has ruptured there is no longer a protective layer around the baby, and infection can potentially set in. For this reason, you should go to the hospital immediately when your water “breaks”, and if you are found to be less than 4 centimeters, your labor will be induced. Regarding bleeding, it is never normal to have bleeding, however bleeding isn’t always an ominous sign. Sometimes, bleeding can occur after a cervical check in the office or just from cervical dilation during labor. However, bleeding can also be a sign of fetal distress so my recommendation is that vaginal bleeding should always be evaluated by your doctor at the hospital.

“What things can I do to relieve labor pain from contractions?”

Labor is appropriately named because having a baby is very hard work! Whether false labor, early labor, or real labor, pain from contractions can be very uncomfortable and at times, downright intense. Contractions can affect your ability to sleep, your appetite, can make you feel nauseated, or your ability to move around like normal. The first thing to remember is that contractions are a normal part of late pregnancy as you approach your due date. Don’t be scared. Being of sound mind and not panicking is key when contractions start. There are also several things that you can do to help relieve some of the pain from your contractions. First, you can perform breathing exercises in order to relax your body. Controlling your breathing and establishing a regular breathing pattern will help alleviate some of the pain and the anxiety that comes along with labor. Next, taking a warm bath can help relieve pain as immersing your belly in water will have a soothing effect. Just ensure that the water is warm and not too hot. Massages are another helpful option. Involve your significant other with this. Gentle rubbing of the lower back, shoulders, or sides can provide a lot of relief. Other things that can relieve the pain from contractions are applying warm or cool compresses to your belly, putting yourself in a low stress/quiet environment, and continuous movement to get to a comfortable position (on your right or left side, on your back, leaning against pillows to optimize back/front support).

“What about an epidural?”

Labor pain is intense, and I always feel bad for patients who are experiencing a great deal of pain. Standing at the bedside and watching an expecting mother go through labor pain is not an easy sight to see. Luckily, we now have epidurals and medications that weren’t around in the past to help us alleviate the pain you feel from contractions. An epidural is a small catheter that is placed in your back, whereby medications can be administered that will numb the areas from the top of your belly to the vaginal area to decrease the pain sensation from contractions. Epidurals are safe for the baby and are the most effective way of relieving pain from contractions. Epidurals are only given to women who are in labor (4 centimeters or more) or who have already ruptured their bag of water (regardless of cervical dilation). With an epidural, you will be much more relaxed, your baby will tolerate labor better, and you can enjoy the childbirth experience much more. As always, I leave the decision up to the patient as to if and when she wants an epidural, but I believe that epidurals are a great way to take your mind off labor pain so that you can better focus your attention to what’s really important, which is having your baby.

The Truth About Condoms

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Are Condoms still needed?

As an OBGYN, I discuss birth control and STD prevention on a regular basis, sometimes multiple times a day, and sometimes even multiple times with a single patient. Read more

Miscarriages: Tough Questions and Tough Answers

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I chose to become an OBGYN because I love delivering babies and bringing joy to expectant parents. It is by far the MOST REWARDING part of my job. Seeing the sense of pride on a new dad’s face, the joyful tears in a happy mother’s eyes, or the inquisitive look of a young big brother or sister is priceless and makes my “job” feel more like a privilege. Bringing a new life into the world is an opportunity that all of us OBGYNs keep sacred and is the main reason why many of us chose the field. But like all things in life there’s a downside to everything, and my job is no different.

Miscarriage is a topic that no one likes to discuss, myself included. It’s something that no expectant mother even wants to think about. Similarly, no athlete wants to discuss the possibility of a career ending injury, no pilot wants to talk about plane crashes, and no CEO wants to discuss the possibility of his or her company going bankrupt. Women who have miscarried are usually reluctant to discuss their experiences or share their feelings about it, which is totally understandable. It’s a private and personal matter for most that can often bring back painful memories and feelings of uneasiness. It can make women feel isolated, fearful, heartbroken, and at times, even guilty. In addition, it raises many questions like “Did I do something wrong?” “Is there something wrong with my body?” “Can I get pregnant again, and if so, when is the best time to try?” But the most important question for women and couples is “Why did this happen?” Unfortunately, the answer is one of the most challenging and elusive to provide.

Why?

Studies have shown that people are often misinformed when it comes to understanding the causes of miscarriages. In a recent survey of the general public, people were asked what they thought was the most common reason for a miscarriage. The top 7 answers were:

  1. A traumatic event
  2. Stress
  3. Lifting a heavy object
  4. An STD
  5. A previous miscarriage
  6. An IUD
  7. Woman not wanting to be pregnant

The answer to the question of “Why?” is very important for women who have experienced a miscarriage. Finding an answer or cause can lead to a sense of closure, the possibility of a solution, and a plan moving forward as most couples will want to get pregnant in the near future. The truth is that there are many causes of miscarriages none of which include the above. Various causes do include uterine or cervical anatomic problems, immunologic disorders, diabetes, thyroid disease, advanced age, smoking, alcohol, drugs, or environmental toxins. However, the vast majority of miscarriages are from chromosomal abnormalities (problems with the genetic makeup of a fetus), which cause over 50% of all miscarriages. When a genetic abnormality occurs, a woman’s body recognizes that the embryo’s genetic integrity is faulty and aborts or rejects the pregnancy. In a sense, nature is able to tell when development is abnormal and triggers a response to “start over”.

The important thing for women to understand is that while some of the above mentioned factors can be controlled such as smoking, alcohol, or environmental exposures, most of them cannot. For instance, many women are born with anatomical abnormalities or are diagnosed with chronic diseases during their childhood or adult life. Due to social reasons, some women may not be able to start a family until later in life when they are older. Because these causes cannot always be controlled, I tell my patients that they should never feel like it’s “their fault” and understand that sometimes unfortunate things just happen. I always reiterate to patients that they did nothing wrong and there was nothing that they could have done to prevent the miscarriage from happening.

Is there anything I can do?

Unfortunately, preventing a miscarriage from happening is impossible. My main advice to women who are considering conceiving is to optimize their health and body in preparation for a healthy pregnancy. These are some recommendations that I give to my patients.

  1. Eat a balanced diet that includes fruits, vegetables, meats, and carbohydrates. This will provide your body with essential nutrients, minerals, and vitamins for a healthy pregnancy.
  2. Maintain a healthy body weight. Being overweight or underweight can affect the health and the outcome of your pregnancy. It can also lead to complications later in life.
  3. Optimize your well-being if you have chronic medical diseases such as diabetes or thyroid disorders. For diabetics, your hemoglobin A1c level should be low and you should keep a daily log of your sugars and review them with your doctor. If you have a thyroid disorder, remain compliant with your thyroid medications and check with your doctor to make sure that your thyroid levels are within the normal limits.
  4. Stop bad habits. Quitting smoking and alcohol are some of the most important things you can do for a healthy pregnancy.
  5. Eliminate environmental exposures (lead, arsenic, radiation). No amount of exposure is considered “safe” especially if you have a very early pregnancy.
  6. Ensure sufficient folic acid intake. You should start taking prenatal vitamins with adequate amounts of folic acid (at least 400 micrograms daily) ideally 1 month prior to conceiving. Prenatal vitamins can be purchased over the counter at any local pharmacy or grocery store.

What now?

As vital as it is to take appropriate time for grieving and questions, most women will want to find closure and move forward. You should discuss with your doctor what the next steps are, your future plans for children, and how soon you wish to get pregnant if you so desire. You should also discuss the chances of a successful pregnancy and any interventions that may be needed for the next pregnancy. Some women may need laboratory testing or imaging procedures for some of the previously stated causes while others may not. Birth control is also an option as some women do not want to get pregnant for a certain period of time after a miscarriage. Lastly, it’s important for you to understand that while this was a tragic and disappointing time, you should not be afraid to get pregnant again. Even after a miscarriage, the vast majority of women will have no issues conceiving and will go on to have completely normal, healthy pregnancies. With my patients I strive to provide a sense of support, hope, and optimism through this process.

Air Travel During Pregnancy: Is It Safe To Fly While I’m Pregnant?

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A common question I often hear is “Can I fly while I’m pregnant?” Air travel brings a whole new set of concerns and stress to an expectant mother, and rightfully so. Nowadays air travel is much more common with most Americans traveling at least twice a year if not more often than that! With every pregnancy lasting about 9 months, it’s almost impossible to put off flying during pregnancy. Plus, you’d hate to miss a special graduation, a family member’s wedding, or Christmas with loved ones just because of pregnancy, right? This topic always brings up questions for patients but hopefully I can provide some tips that will make the answer a little more simple.

In general, occasional air travel while pregnant is considered safe for healthy, uncomplicated pregnancies. Fetal heart rate is unaffected by flying if the mother and fetus are healthy. During flight, the body adapts to accommodate the higher altitude and small changes in cabin pressure. This is seen by an increase in the mother’s heart rate and blood pressure as well as a significant decrease in aerobic capacity.

Most commercial airlines allow pregnant women to fly up to around 35 weeks. Beyond this time, they fear that you will be approaching your due date and therefore deliver on the airplane without a doctor. However, each airline is different so the best thing to do is to check with the airline regarding their individual policy. Some airlines even want you to provide documentation of gestational age for them. Check with your OB doctor as well as some doctors do not recommend flying after 32-34 weeks.

There is no optimal time to fly during pregnancy. Women should be made aware that the most common OB emergencies occur in the first and third trimesters. In addition, during the second trimester, women are usually beyond morning sickness and the risks of miscarriage that occur in the first trimester as well as avoiding the physical discomforts and demands of the third trimester at which time the uterus is largest.

While flying is considered “safe” there are some special considerations that pregnant women should take note of. Here is my list of tips/advice if you are planning on flying while pregnant.

  • First and foremost, clots can develop from prolonged periods of sitting in the same position. Long periods of sitting in one position is not healthy for anyone but especially for pregnant women. All pregnant women are in a “hypercoagulable” state or a propensity to develop clots (especially in your legs). This is dangerous as these clots in your extremities can dislodge and travel to your heart and lungs. To prevent this, you should walk the aisles and stretch your legs periodically. Taking quick, frequent bathroom breaks to prevent any blood stasis can go a long way. In addition, compression stockings or hose can be placed on your legs to prevent any pooling of blood.
  • Second, stay hydrated! The airplane cabins usually have slightly lower humidity making it easy to get dehydrated. Dehydration can lead to contractions, preterm labor, and sometimes even problems with blood circulation to your baby. Periodic sips of water will help you stay hydrated especially during longer flights.
  • Third, pregnant women should wear seatbelts continuously throughout the flight as unexpected turbulence can lead to falls and trauma to the belly, which can cause problems for the unborn baby. The seatbelt should be worn low on the hipbones below the abdomen and not directly on the pregnant belly.
  • Fourth, air travel is not recommended at any time during pregnancy for women who have complicated medical or obstetric conditions that may be exacerbated or worsened by flight. Inform your doctor anytime that you are planning on flying. He or she will let you know of any risks of flying with your specific medical condition.
  • Lastly, arrangements and planning should be made regarding your destination. Knowledge of the closest hospital and ER should be sought prior to travel. You should ensure that these facilities have the capability of managing pregnancy complications, performing C-sections, and caring for preterm or ill babies. In addition, general health insurance policies may or may not provide coverage for pregnancy-related problems if traveling overseas. You should inquire about your individual health insurance policy and assess the need for a possible supplemental plan or temporary coverage while out of the country.

Air travel during pregnancy can be a tricky and daunting task. It brings new medical issues to the forefront for both mom and baby. But with a good understanding of the risks, effective communication with your doctor, and early planning and preparation, you can ensure safe travels for both you and your baby.

Abnormal Chromosomal Screening: Will My Baby Have Down Syndrome?

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With so many technological breakthroughs recently, the field of prenatal diagnosis has undergone major advances. Over the last 30 years, detection rates for Down syndrome and other chromosomal abnormalities (Trisomy 18 and 13) have increased from a mere 60% to well over 95%. Chromosomal abnormalities were once thought of as being an issue primarily for “older” women (pregnant women over the age of 35), but now with the ability to detect these problems so accurately, ACOG (American Congress of Obstetrics and Gynecology) now recommends that ALL pregnant women who present for prenatal care at less than 20 weeks be offered some form of prenatal screening for chromosome problems such as Down syndrome.

Discussing the topic of chromosome screening with patients can cause confusion and anxiety. Many patients wonder why this testing is needed, how testing is done, at what gestational age can testing be done, and of course, the big question: WHAT HAPPENS IF MY SCREENING TEST IS ABNORMAL? These are all great questions that are difficult to explain during one quick office visit. The following questions/answers will hopefully clear up any myths or rumors that you might be hearing about chromosomal screening.

What is aneuploidy?

Aneuploidy means abnormal chromosome number (either missing or extra chromosomes). Aneuploidy results from a problem very early in pregnancy when chromosomes fail to separate properly and therefore an “extra” chromosome is obtained.  Most commonly this occurs on chromosome numbers 21 (Down syndrome), 18 (Edwards syndrome), and 13 (Patau syndrome). When a fetus has an extra chromosome at one of these positions, the outcome can have varying degrees of abnormalities. These range from learning difficulties, short stature, or distinct facial features to even more serious problems such as structural birth defects (heart, kidney, GI tract) or a baby who will be unlikely to survive after birth.

What is a screening test?

A screening test is a test that is performed to give information about a patient’s risk of having a baby with certain birth defects/chromosomal problems. It DOES NOT have the ability to diagnose a chromosomal problem. Instead, it simply indicates that a patient is at higher risk and needs more invasive testing to confirm the screening test results. The higher the detection rate, the better its ability to pick up the abnormality, and therefore the better the screening test.  Unfortunately, screening tests cannot detect 100% of all abnormalities and rarely even give false positive results.

How is a chromosomal screening test performed?

Levels of certain hormones/proteins are often abnormally high or low with certain chromosomal problems. These levels can be measured by simply analyzing a mother’s blood during specific times in pregnancy.

What specific tests are involved with chromosomal screening?

There are many different tests available to screen for aneuploidy. It’s more important that testing IS BEING DONE rather than WHICH test is being performed. With that said, different tests have different detection rates and which test you receive will depend on your doctor’s office’s resources and laboratory. At MacArthur OBGYN, you will have your blood tested on two separate occasions and an ultrasound to evaluate the neck of your baby (nuchal translucency) as babies with thicker neck measurements on ultrasound are at higher risk for having chromosome problems.

When will I be screened for chromosomal problems?

Typically, we at MacArthur OB/GYN use an “integrated” screening test. This involves combining the results of a test from 11-14 weeks with another test after 15 weeks. During your visit between 11 and 14 weeks, your blood will be drawn and an ultrasound will be done to measure the neck of your baby. These tests are combined with another blood test after 15 weeks to calculate a combined risk. The result of the test does not come back until after the second blood test is performed after 15 weeks. The combination of both of these tests (as opposed to only one test) leads to a higher detection rate and more accurate results. If for some reason a pregnant woman misses her first screening test from 11-14 weeks, but is still less than 23 weeks, a single blood test called the Penta screen can be performed to determine her risk. The Penta screen has a lower detection rate than traditional integrated screening but is still effective.

How accurate are chromosomal screening tests?

The detection rate of the integrated screening test is approximately 94-96%, while the Penta screen (the testing that occurs only in the second trimester after 15 weeks) has a detection rate of approximately 85%.

What happens if I have a positive screening test result?

If you have a positive screening test, first of all, DO NOT PANIC. You simply are deemed higher risk. It DOES NOT mean that your baby has a chromosome defect. A positive screening test will typically be followed by a referral to a Maternal-Fetal Medicine specialist (high risk pregnancy doctor), where he or she will offer the following:

  1. A targeted ultrasound to look closely at the other parts of the baby (heart, stomach, face, spine, kidneys) to see if there are any obvious birth defects that suggest chromosomal problems or other genetic syndromes.
  2. A confirmatory test to diagnose what type, if any, chromosome abnormality is present.

Confirmation of aneuploidy can be done in several different ways depending on the doctor.  Some will offer you an amniocentesis. This is a procedure in which amniotic fluid (which has fetal cells) is drawn from within the amniotic sac and sent for chromosomal analysis. Others will offer a chorionic villus sampling (CVS), in which a small sample of cells from the placenta is tested. Other testing that can be done are maternal blood tests such as the Panorama, Harmony, or Materni21 tests, which detect cell free fetal DNA in the maternal circulation. This testing involves new technology and is indicated for pregnant women over 35 years old or for women who have an abnormal standard screening test or ultrasound findings suggestive of aneuploidy. These tests are not confirmatory tests but do have detection rates up to 99% and are therefore very helpful to patients who either decline amniocentesis or where amniocentesis is not feasible.

With new technologies we now know even more about the health of babies before they are born. Improved ultrasound quality and more accurate blood testing has given us more insight into a baby’s genetic makeup, specific syndromes, or any structural problems that he or she may have. Chromosomal screening is an integral part of prenatal care and hopefully the information above has helped make it a less intimidating and confusing topic.

Folic Acid: What’s the Big Deal?

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As an obstetrician, an important part of my job is preconceptional counseling. Making sure that hopeful mothers are healthy, eating right, and avoiding harmful behaviors and substances in preparation for pregnancy is a very important duty to me as their OB doctor. Counseling women before pregnancy has even occurred is always challenging though. It’s hard for people to keep themselves healthy for something that hasn’t even happened yet. However, certain topics are so beneficial and universal to all women that they cannot be ignored. Folic acid supplementation and the prevention of neural tube defects is one such topic. So, what is folic acid and why is it so important?

Folic acid is a B vitamin that is essential for numerous bodily functions. Folic acid is crucial for production of DNA, which is the genetic code for all cells in your body. Therefore, it is important for rapid cell division and times of growth such as during infancy or pregnancy. It also plays a vital role in the formation of red blood cells which carry oxygen throughout your body and therefore prevents you from becoming anemic (low red blood cell count). Unfortunately, folic acid is not a vitamin that your own body produces so you must get it from your diet.

So, how is folic acid helpful to pregnant women specifically? Overwhelming evidence has shown that folic acid reduces your baby’s risk of neural tube defects (NTDs). What are neural tube defects? They are defects (openings) in the baby’s spine or brain that cause varying degrees of disability or even death. Normally the neural tube closes very early at approximately the fourth week of gestation. When it does not close completely or at all, a neural tube defect occurs. Because of this it is very important for women to have adequate folic acid intake prior to and during early pregnancy. In fact, taking adequate amounts of folic acid reduces the chance of NTDs by up to 70%!

Here are some common questions I often get asked by patients regarding folic acid:

How can I get enough folic acid?

There are two ways to get folic acid in your body:

  1. Take a vitamin that has folic acid in it. This is easy. Just ask your doctor to write a prescription for prenatal vitamins for you. You can also get them over the counter in grocery stores, pharmacies, and even discount stores. They are inexpensive and can be purchased without a prescription. Most bottles with 100 vitamins only cost ~$5, which is only 5 cents per vitamin! You buy them just as you would any other grocery item. Just be sure that the label says 100% of the daily value of folic acid which is 400 mcg – the recommended daily dose.
  2. Eat foods that have folic acid in them. The most common and convenient food is breakfast cereal although other foods are now fortified with folic acid as well. Fortification of cereals with folic acid occurred in 1996 and was done primarily to prevent NTDs. One bowl of cereal each morning usually provides sufficient amounts of folic acid, although with foods, you can never be completely sure that you are getting the recommended amounts because it all depends on how much you take in.

How much folic acid should I be taking?  When should I start?

With vitamins, it’s always hard to remember the recommended doses and timing because they all differ depending on who you ask. Luckily, when it comes to folic acid, all recommendations are essentially the same. You should be taking 400 mcg (micrograms) of folic acid every day starting at least 1 month prior to pregnancy and continuing it at least through the first trimester. Waiting to start folic acid until you find out you are pregnant is too late. Most women will not even know they are pregnant until 8-10 weeks after conception which is 1-2 months after the neural tube has already formed and thus too late to prevent these birth defects. In fact, almost half of all pregnancies are unplanned! For these two reasons, it is important for every woman of childbearing age to be on folic acid even if not planning to become pregnant.

Should I ever be on a higher dose of folic acid?

With all rules there are exceptions, and folic acid is no different. There are two main instances where a higher dose of folic acid is necessary. If you, your partner, or your child has had a neural tube defect you should be on a much higher dose. The recommended dose is 4 mg (milligrams) or 4000 mcg (10 times the normal dose discussed above). You will need a special prescription for this from your doctor. Taking multiple doses of prenatal or multivitamins may lead to dangerously high amounts of other vitamins in your body. Similarly, if you have a history of seizures and are on anti-epileptic medications, you should be on 4 mg of folic acid as some seizure medications can lead to an increased risk of NTDs. Again, this increased dose should be started at least 1 month prior to conception and continued at least through the first trimester.

What other foods have folic acid in them?

Lots of foods now have folic acid in them since food fortification has been in place for almost 20 years now. These include breakfast cereals, breads, rice, pasta, and other grain products. The best natural sources of folic acid are green leafy vegetables like spinach, turnip greens, and collard greens. Other foods rich in folic acid include other vegetables (broccoli, asparagus, carrots, squash), citrus fruits, seeds, nuts, peas, and beans. By eating these foods, a woman can be confident that she is getting folic acid in her everyday diet. This however should not be a replacement but rather a supplement to your daily vitamin.

What if I have trouble remembering to take a vitamin each day?

Women are busy these days, no doubt about it! Between kids, jobs, groceries, and errands, it’s hard to set aside time each day to take a vitamin. We just sometimes flat out forget as well. But just as regular exercise, adequate sleep, and healthy eating are important to your health, taking folic acid is too. Try and coordinate taking a vitamin each day with your daily routine activities (i.e. brushing your teeth, showering, putting on your makeup). Or try coordinating with someone else like your child or spouse who is also taking a daily vitamin so you can keep each other in check. Keep the bottle in sight next to your bathroom sink or on the kitchen counter so that you will be frequently reminded of it. Also, with smartphones these days, it’s easy to set a daily alarm or reminder. These are just a few ways to help you remember. Do whatever is most comfortable and convenient for you.

What if I can’t swallow pills?

Nowadays, multivitamins with folic acid come in various shapes and sizes. Many pills are chewable or in liquid form. Some even have fruity or chocolate flavors to make them more tolerable to those who have trouble with a pill’s bad taste.

Neural tube defects are the second most common class of birth defects second only to congenital heart defects in babies. However, NTDs are one of the only birth defects in which primary prevention is possible. Therefore, it is vital to make sure that all women are aware of this simple measure to prevent a birth defect that could negatively impact your baby’s life.

Gardasil (The HPV Vaccine): For Your Information

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Most of you have probably heard something about HPV (Human Papillomavirus). The importance of being well informed about the HPV virus and Gardasil cannot be understated. I encourage all my patients to be an active participant when it comes to their body, especially on topics of preventive medicine like HPV and Gardasil. The HPV/Gardasil topic touches on many important issues like adolescent/young female gynecologic care, disease prevention, and future long-term health that you as a patient can really take charge of and dictate.

HPV (Human Papillomavirus) is a common virus that is spread by skin-to-skin contact during sexual activity. Unlike other sexually transmitted infections, HPV-infected individuals are almost always without symptoms, so most who are infected don’t even know they have it! In fact, according to the CDC (Center for Disease Control and Prevention), the most common newly diagnosed sexually transmitted disease is genital HPV. Over 14 million new cases of HPV were diagnosed during the last year. To compare, the second most common newly diagnosed STD was Chlamydia with only 2.8 million new cases. In fact, newly diagnosed HPV was more common than Chlamydia, Trichomonas, Gonorrhea, Herpes, Syphilis, HIV, and Hepatitis B combined! The risk of acquiring HPV by age 50 for women is over 80%, and the most susceptible females are from ages 18-24 with infectivity rates more than 40%! In short, most women will be infected with HPV at some point in their lives.

So what’s the big deal you might ask? Well now we know that HPV is a known cause of certain cancers as well as non-cancerous conditions in both females and males. In females, these include cervical cancer, vaginal cancer, vulvar cancer, anal cancer, as well as genital warts. In males, penile cancer and genital warts have been linked to HPV. Even certain oropharyngeal cancers have been associated with the virus. The virus has the ability to actually infect body cells and change them in such a way that they transform into cancer.

Specific HPV genotypes are more dangerous than others. For example, HPV types 16 and 18 are known to cause ~70% of all cervical cancers and 50% of precancerous cervical lesions. In addition, 90% of all genital warts are linked to HPV types 6 and 11.

Luckily, a vaccine against HPV was created to combat these specific HPV genotypes. It is called Gardasil. The Gardasil vaccine is a powerful preventive tool in the fight to stop the spread of HPV. It is effective against the specific types of HPV that are known to cause majority of cervical cancer and genital warts, specifically HPV types 16, 18, 6, and 11.

Here are some important points that will hopefully answer any remaining questions you have about Gardasil.

Who can get the Gardasil vaccine?

Gardasil is a licensed, safe, and effective vaccine for all young women and men aged 9-26. Why those specific ages you might ask? Well, all of the original Gardasil trials were performed on thousands of people worldwide between these ages. Therefore, it has been approved for this age range only.

What is the recommended schedule for the vaccine?

3 injections are recommended over the course of 6 months. The first dose is given, then the second dose is given 1-2 months after. Lastly, a third dose is given 6 months after the first dose.

When is the absolute best time to get the vaccine?

The optimal time to get the vaccine is actually around 11 or 12 years old because the potential benefit is the greatest at that age. The reason for this is that the HPV vaccine works best before any sexual activity has begun. Higher antibody titers are produced in this age group too. Also remember, it IS possible to get infected during your first sexual contact.

How effective is Gardasil?

Gardasil is very effective as evidenced by its nearly 100% efficacy in prevention of primary infection from HPV types 16 and 18. In fact, a recent study by the CDC has shown a 56% decrease in the HPV strains covered by the vaccine in the first four years after the vaccine’s introduction in 2006. The vaccine is highly immunogenic and has shown maintenance of protection for at least 5 years after vaccination. It also has great immune memory with great potential benefit lasting even beyond 5 years.

What if I already have an abnormal Pap smear, genital warts, or tested positive for HPV?

Gardasil does not treat or get rid of an already established HPV infection or any cervical abnormality that has already occurred. However, even if you have been infected with the virus, you can still obtain some benefit from the vaccine. Plus, most of the time you don’t know exactly which HPV type you may have and most of the time young women tend to clear the HPV infection all by themselves anyway! So evidence of prior HPV infection does not preclude you from getting the vaccine or deriving any benefit from it.

Is Gardasil safe? Are there any side effects?

The FDA has licensed the HPV vaccine as safe. Thousands of people worldwide were tested and no major side effects were seen. Minor side effects do include pain at the injection site, headache, and nausea.

Do I still need Pap smears?

YES! You still need regularly scheduled Pap smears. Getting the Gardasil vaccine does not mean you can skip your cervical cancer screening (which should begin at age 21). Again, the vaccine does not treat pre-existing HPV infection. Plus, there are a small number of other HPV types can also cause cervical cancer that Gardasil does not cover.

What other things can I do in addition to vaccination to prevent HPV infection?

There are other ways to prevent or decrease the risk of transmission of HPV infection. First of all, protecting yourself is the most important thing and avoiding high risk behaviors is key. These include trying to limit your number of sexual partners and avoiding sex during early ages (13-18 years of age) when one is most susceptible to HPV. Using condoms whenever possible has also been shown to help prevent transmission (although not all skin-to-skin contact can be prevented by condoms).

Hopefully, this information has been helpful and informative. HPV is an incredibly prevalent disease, but we have the unique opportunity to still control its spread with the Gardasil vaccine. I encourage everyone to pass this information along to your family and friends (especially teens and their parents). Prevention of any disease involves action and self-motivation by patients, but even more importantly, it requires education and knowledge. So spread the word about Gardasil because HPV is spreading fast as well.