Courtesy of A.D.A.M

Although the cervix is supposed to hold a pregnancy until term things sometime go wrong.  Women can lose an otherwise healthy baby because of a weak or short cervix. When cervical tissue becomes weak, this condition is known as Cervical Insufficiency (CI) and affects approximately 0.1 to 2% of all pregnancies. Women who have a history of painless bleeding in the second trimester or complain of pelvic pressure followed by the delivery of a fetus most likely have CI. Also, women who have had three or more pregnancy losses in the second trimester have CI as well. Patients with these types of histories have traditionally been treated with a procedure called a cerclage. Think of a cerclage as a stitch in the cervix that keeps it closed so that the baby can continue to grow.

There are many reasons why women develop CI and include women who have a short cervix, collagen disorders, uterine abnormalities and cervical lacerations.  Some women are born with a short cervix while others acquire it because of surgical procedures such as a cone biopsy, LEEP (loop electrosurgical excision procedure) or laser ablation. Voluntary pregnancy terminations can also shorten the cervix and increase the risk for a preterm birth. The collagen disorder such as Ehlers-Danlos syndrome can so as well.

Can cervical insufficiency be diagnosed before pregnancy? Unfortunately not, however, the use of a patient’s history, physical exam and ultrasound can help tremendously. Visualization of membranes seen during a speculum exam is extremely suspicious for CI and requires a cerclage if the patient is less than 24 weeks.  Any cervical length of less than 15 mm is diagnostic of CI and requires a cerclage.

The average length of the cervix at 20 and 22 weeks is 40 mm; at 32 weeks it’s 35 mm. A woman who has a cervical length of less than 25 mm will most likely get a cerclage if she has a history of a three previous second trimester miscarriages. A woman less than 23 weeks with a cervical length of less than 25 mm might be offered a cerclage or progesterone treatment.

Part 2 of this article will discuss what happens if a woman without symptoms of preterm labor is found to have a cervical length less than 25 mm and when and where should the cerclage be removed? What lifestyle changes should be made with a cerclage?

Do you know how to anticipate the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.

The authors allege that pregnant women are in error to assume they will have a perfect baby and often request diagnostic tests and birth plans in the hopes of fulfilling this goal. Because there is a 3% risk of birth defects for all pregnant women, a 15% risk of miscarriages in addition to other potential problems such as premature births, the authors believe it is dangerous and inappropriate to make the assumption of having a “perfect” baby. They propose that physicians should make patients sign an “informed consent” documenting that it is quite possible that their baby might not, indeed be “perfect.”

One of my favorite quotes regarding obstetrics comes from Dr. George Macones who says “The risks of pregnancy and childbirth are often under appreciated.”  As physicians, we need to do a better job advising our patients that there ARE risks involved in having a baby and it was for that reason that I decided to write The Smart Mothers’ Guide to a Better Pregnancy. However I think the authors are misinformed if they think pregnant women want a perfect baby. My years of clinical experience have proven otherwise. Most pregnant women do not want a “perfect” baby. They want a healthy baby.

In my clinical practice, I offer screening tests for Down syndrome, a condition that involves an abnormal number of chromosomes resulting in a child with mild to moderate mental retardation that is sometimes associated with heart conditions. For many years, none of my patients had a positive result and then suddenly there were two in the same year. Both mothers delivered babies with Down syndrome but in their eyes, their babies were perfect. And who would disagree?

Should patients be made aware of the risks involving pregnancy? Absolutely. Should they sign an “informed consent” stating that their babies will not be “perfect,” or does that cross the line? I’d love to know your opinion.

The American Civil Liberties Union and the National Advocates for Pregnant Women celebrated a moral and legal victory last year in the case of Nelson v. Norris. In this case, Shawanna Nelson was forced to be shackled and reshackled to her bed during her final stages of labor by her correction officer. Nelson was incarcerated for credit card fraud and passing “hot checks.” Nelson sued the correction officer stated he inflicted cruel and unusual punishment by forcing her to be shackled during her labor in violation of her civil rights under the 8^th Amendment to the Constitution. Anyone who has ever witnessed the birth of a baby knows that women need movement in order to withstand painful the contractions. Sometimes they grasped someone’s hand or a bedrail or their knees in order to push or sustain the pain.

Although three judges from the 8^th Circuit Court of Appeal initially decided that Nelson could not sue the prison warden or corrections officer, that decision was ultimately reversed and is deemed “historic.” Many states have now passed a law prohibiting shackling of pregnant women, the most recent being Pennsylvania on July 2^nd of this year.

Everyone makes mistakes and some of them are costly however, no one deserves to bring life into the world shackled to a bed. Renowned medical groups such as the American Medical Association and the American Congress of Obstetricians and Gynecologists strongly advised against using restraints on women who are in labor.  Has YOUR state passed a bill prohibiting the shackling of pregnant women?

A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.

A first-time pregnant mom was understandably nervous at the beginning of her pregnancy. After a few prenatal visits, she became calm and was obviously enjoying her journey. However, as she got closer to her due date, she began to express some concerns and during her last prenatal visit, she asked me if I could tell how much her baby weighed. It’s a common question, however there are no magical answers. I informed her that the fundal height gives us reassurance that the baby is growing and an ultrasound’s estimated weight can be off by one to three pounds. She continued to look concerned and stated that a family member had just delivered a baby that weighed nine pounds and she needed a second operation because she had “torn” so badly. I silently cringed and my patient looked terrified. I asked whether her relative had been pushing for more than two hours at the time of birth and she replied that her relative had actually pushed for four. She continued to explain that she had witnessed her relative’s labor, felt something was wrong but was reluctant to voice her concerns because “the doctor knew best.”

This is the 21^st century and that mindset has to change. First, I reassured my patient that the chances of her having a complication similar to her relative were extremely remote. The definition of an arrest of labor means that a first-time mom should not push for greater than three hours and a woman who’s had children should not push no longer than two. She was now empowered with that information and had the right to challenge ANYONE if faced with that condition. While there is no magic formula for predicting an accurate birth weight, Nature does give us signs. If a woman is adequately pushing for the prescribed periods and not making progress, there is a PROBLEM that usually requires an operative solution. Fatigue, distractions and sometimes incompetence can cloud a health care provider’s judgment. If you suspect that something is wrong while you are in labor, by all means, please speak up. Nature has endowed you with a gift called instincts. Please don’t be afraid to use it.

Make no mistake, ladies, the cost of these amenities will somehow show up on your hospital bill. Elizabeth Cohen, of CNN’s show, The Empowered Patient discussed toothbrushes that cost over $100. And ironically, I ended up on her show discussing my dissatisfaction of having to pay over $800 for a $167 disposable pair of forceps during my own surgical procedure.

While it is nice to give birth in a comfortable atmosphere, the quality of care is equally important. One of my patients was pregnant with her first baby and wanted to deliver at an upscale hospital. I supported her decision because the hospital provides excellent obstetrical care and it also happens to be aesthetically beautiful. My patient worked as a manager, had a picture-perfect prenatal course and had third-party insurance. What could possibly go wrong? The lack of compassion from the admitting physician.

Although she was in the early stages of labor at 3 centimeters and extremely uncomfortable, the physician refused to admit her. His attitude was both condescending and demeaning. My patient was close to tears and her nurse was livid. When she presented to my office, it was obvious that she was uncomfortable. I offered to call the hospital and advocate on her behalf but she wanted no part of them. She requested to be delivered at a less upscale hospital where she was subsequently admitted and treated like a queen. So much for the “resort” environment.

Hospital perks might be great for marketing but they need to be accompanied with quality care and good old-fashioned courtesy.
A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.

Obstetrics has changed dramatically since I made my grand entrance in more years than I care to admit. My mother remained in the hospital for almost a week after her C. Section. Most mothers now leave in 48 to 72-hours. The gender of a baby was not known until the time of birth; now ultrasounds clear up the mystery. Men comprised the majority of the obstetrical work force. Fifty-percent of obstetricians are now women.

Mothers washed and sometimes boiled cloth diapers. Now they purchase disposables. My mom had a miscarriage with my twin and then discovered that she was still pregnant by a flat-plate- x-ray. Most mothers can now their unborn children by ultrasounds in 3-D. Diseases such as Spina Bifida and Diaphragmatic Hernias are no longer crippling because corrective surgery can be performed on a baby before birth. Women who have Rh-negative blood are no longer at risk for harming their Rh-positive babies thanks to the introduction of Rhogham. By measuring the blood flow in a fetal brain, we can now determine if they are at risk for dying if they have abnormal growth.
Despite the challenges that are inherent within our fractured healthcare system, the innovations of medicine are extremely encouraging. Cord blood from babies will help cure cancer and bring about a new specialty called Regenerative Medicine. Premature rupture of membranes might be corrected with a “medical plug” called an Amniopatch in the future. And most important, pregnant women will become empowered to recognize their high-risk conditions before they spin out of control and know where and how to obtain help.
Both patients and obstetricians now have more options. What an exciting time to practice obstetrics.

Dr. Quintero is a maverick who operates on babies-in-the womb BEFORE they are born. These procedures are collectively called fetoscopy and include the repair of conditions such as Twin-twin transfusion, Congenital Diaphramatic Hernia and Bladder Obstruction. Welcome to the 21st century. The most revolutionary procedure that has entered the obstetrical horizon is a procedure called the Amniopatch.

Preterm premature rupture of membranes (PPROM), commonly known as the “water breaking” occurs in 3 percent of all pregnancies and is the cause of 85 percent of newborn death and illness. It is also associated with 30 to 40 percent of premature births and affects approximately 150,000 births per year. PPROM that occurs between 13 to 26 weeks has a poor prognosis. In addition, PPROM occurs in 1.2 percent of patients after genetic amniocentesis and 3-5 percent after fetoscopy. However, these statistics may soon change. The Amniopatch is a procedure that can “plug” up the hole with the use of platelets and cryoprecipitate. The jury is still out regarding how and why it works but the statistics presented by Dr. Quintero are quite impressive. The procedure was developed when a patient with a twin pregnancy experienced rupture of membranes after fetal surgery. She leaked fluid for approximately three weeks until the Amniopatch was performed. Dr. Quintero explained that the membranes resealed and the patient delivered at 37-weeks via a repeat C. Section. How remarkable.

Dr. Quintero concedes that the Amniopatch is still “experimental” and requires several more medical studies before it will approved as mainstream therapy. There was also a discrepancy between the results obtained from the National Institute of Health and Dr. Quintero’s study. Presently there are three main centers that perform the procedure: The Maria Vittorio Hospital in Turin, Italy, University of Miami at Jackson Memorial Hospital and the University of Southern California.

The future treatment and elimination of PPROM is phenomenal. Let’s hope the application of this life-saving innovation will happen sooner rather than later.

For more information on the Amniopatch, please contact The Fetal Therapy Center at Jackson Memorial Hospital http://ob-gyn.med.miami.edu/x250.xml

A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.

The bond of community living that I experienced in the Marcy has never been duplicated again. Not even in my middle-class Florida neighborhood. For some, the projects were the last stop before purchasing a home. For others, it was a safe haven from extreme poverty that housed second and third generations of families in need. Contrary to popular misconceptions, project living had a code of ethics. People knew better than to cross the line.

Within the walls of those tiny two and three bedroom apartments emerged ordinary people who did extraordinary things. My sixth floor neighbor, Noble “Junie” Jackson paid the ultimate sacrifice for our freedom in Vietnam in 1967. Ditto Robert Whitley in 1968. Captain Vernon Richard of the FDNY, Engine 16, Ladder 7 left us on September 11, 2001 in a blaze at the World Trade Center. My 6th floor neighbor, Wanda Holt is a NYC elementary school principal. My third floor neighbor, Bernice Bradway, is a retired school principal and administrator of Syracuse University. Todd McCullough was an architect and alumnus of Cornell University. The Sherman brothers, Stefon and Lonnie became a dentist and ob-gyn physician. Jeff Lucas is a retired detective from NYPD. The object of my school-girl crush, Randy Hill became an artist who hung out with Andy Warhol at Studio 54 and of course, everyone knows about Sean “Jay-Z” Carter.

From the outside looking in, the Marcy may appear harsh, but from the inside looking out, it was a place where people took care of each other’s children. No one ever went hungry. Neighbors shared limited resources. Injustices were simply not tolerated. We dispelled myths, ignored societal barriers and unharnessed the potential of our human spirits. We are now spread all over the country but our hearts still remains in Brooklyn.

So on days when I am in the midst of a personal storm; when adversity reigns supreme, I recall my days in the Marcy Projects, and become inspired all over again.

Home is where the heart is. Everyone should have one.

Johnson and her partner, Blake Sinnett are the proud parents of Baby Mikaela who was born at Centerpoint Hospital in Missouri. Like most new mothers, Johnson’s first attempt to breastfeed Mikaela was clumsy. She felt something was wrong in her technique and switched breasts but not before the nurse on duty deemed Johnson to be an incompetent mother and alerted the State’s authorities. Before Johnson had a chance to bond with Mikaela, she was whisked away by the authorities and a protracted custody battle ensued.

Johnson’s battle reminds me of the ongoing struggle of Abbie Dorn, a disabled mom who is fighting for visitation rights to see her triplet sons and my own family member, who suffered from schizophrenia. She never had the opportunity to bond with her infant daughter who was placed in a foster home never to be seen for the next seventeen years at which it was too late to forge a healthy relationship. Attachment disorders are real. My relative’s daughter felt abandoned, her mother felt betrayed by a system that was allegedly supposed to help her.

I know that Johnson is capable of caring for her daughter. I’ve witnessed blind couples caring for sighted children while living in New York on numerous occasions. What is wrong with us as a society when we are quick to judge and slow to help?

Although Johnson and Sinnett have regained custody of their daughter, the battle is far from over. They will be subjected to strict scrutiny by social service agencies for the next 18 years of Mikaela’s life.
I strongly recommend that all disabled pregnant women become well-versed with the Americans with Disabilities Act and its association prior to giving birth. Having a disability is not a crime. Being discriminated against because of one is.

In light of the mortgage collapse debacle, the rules of lending have tightened. Strict scrutiny is the order of the day but the lenders have taken things too far. Dr. Elizabeth Budde, an oncologist in Washington State was pregnant with her first child and received an email that her mortgage had been approved. However, the email prompted an automatic response announcing that she was on maternity leave and her lenders subsequently rescinded her mortgage. Banks demand “guaranteed” income and do not give credence to short-term disability. Dr. Budde finally obtained her mortgage because she had enough sick and annual leave time that continued to pay her a full salary.

The federal government has vowed to protect the rights of pregnant women and is investigating lenders for possible discrimination. Are you pregnant and in the market to purchase a new home? Here are a few things that you should know:

1. The bank may ask you to purchase a home whose mortgage can be paid from one salary even in a dual-salaried household.
2. The bank will recheck your financial situation right before the loan closes. This includes calling your employer to verify your employment.
3. Your income has to be guaranteed to continue for at least three years.
4. According to the Department of Housing and Urban Development (HUD), your mortgage cannot be denied because of pregnancy or short-term disability.
5. A letter from your doctor (with a return date to work) and your employer (stating the return date and salary) should be enough to qualify your loan.
6. A lender cannot ask whether you are pregnant, but can ask if your employment or income situation will change.

If you have been denied a mortgage because your pregnancy, contact HUD immediately.