Courtesy of A.D.A.M

In Part 1, the reader learned Cervical Insufficiency is a weakness of the cervix that sometimes requires a Cerclage. However, do all women with cervical lengths less than 25 mm require a cerclage? If a “short” cervix is found by coincidence during a routine ultrasound, should a cerclage be ordered? The answers to both questions are “no.” A woman with a cervical length of less than 25 mm but greater than 15 mm is not a candidate for a cerclage if she’s had no symptoms of preterm labor or history of previous premature birth. Although twin pregnancy is a risk factor for premature birth, cerclage placement is not recommended. For reasons presently unknown, a cerclage significantly increases the risk of preterm birth in twin pregnancies.

The cervix normally begins to shorten and become thin at 32 to 34 weeks and it is not uncommon to see measurements of less than 25 mm at that time.  However women with a previous history of preterm birth should be followed by ultrasounds for cervical length measurements beginning at 15 to 16 weeks and continued every two weeks until they reach 26 to 28 weeks. If the cervical length is between 16 mm to 25 mm before 23 weeks, progesterone injections or suppositories are also suggested.

It is recommended that women with cerclages make lifestyle changes in order to prolong their pregnancy. Sexual intimacy, standing for greater than 4 hours a day, lifting greater than 20 lbs or straining, weight training exercises, impact aerobics and activities that produce pelvic pressure or discomfort should be avoided.

When should a cerclage be removed and should it only be removed when the patient has spontaneous labor? Medical studies indicate that only 11 % of women develop spontaneous labor 48 hours after a cerclage removal. Cerclage removal before the onset of labor is highly recommended to avoid bleeding, infection or a cervical tear. The average length of time of delivery after cerclage removal is 14 days, with one exception. Women who had a cerclage placed because of an ultrasound finding are 5 times more likely to deliver within 48-hours after it is removed. Does the cerlage have to be removed in a hospital setting? No according to a study cited in the American Journal of Obstetrics & Gynecology provided the patient is without symptoms of impending labor. A cerclage may be removed in an office setting.

A heightened awareness regarding cervical insufficiency can prevent undesired preterm complications. 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.

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.

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.

The anesthesiologist refused to give the patient an epidural, citing her “high-risk” status and was also rude in the process. He felt the main hospital operating room was a more appropriate arena for the delivery as opposed to the labor and delivery suite. My friend had had problems with this physician before. He would play the “dumping” game using any excuse to postpone performing a case until the next shift took over. My friend was not about to play Russian-Roulette with the patient’s baby and refused to send her home. “What should I do?” she asked in frustration. “I’m trying not to lose my composure and I’m not in the mood to fight.”

My friend needed encouragement. I reminded her that she was a brilliant physician whose calling was to heal women and save babies. I suggested that she get the hospital’s administrator and ob-gyn chairman involved to deal with the anesthesiologist directly and document on the patient’s chart why she was unable to deliver the baby. Above all, she must trust her instincts.

The high-risk specialist agreed with my friend’s assessment and wrote a note on the chart as well. My friend shared her dilemma with the nurse-in-charge who then took control of the situation and forced the hand of the anesthesiologist.

The baby was ultimately delivered and had a low APGAR score at one minute although there was nothing on the fetal tracing to suggest why. Had my friend not intervened, the baby could have possibly died.
My friend scored a moral victory with this delivery. But what will happen the next time?

In the world of obstetrics, magnesium sulfate or “mag” sulfate ranks high as an invaluable tool that has helped both obstetricians and their patients for almost 50 years. Magnesium sulfate is the first line of defense in a pregnant woman with pre-eclampsia, a condition that includes high blood pressure, swelling and protein in the urine. Magnesium sulfate is given to reduce the possibility of having a stroke or bleeding in the brain, and it is also given to delay or reduce episodes of premature contractions. Untreated or unsuccessful treatment of premature contractions can lead to premature births which accounts for 12.6 percent of all U.S. births. The advances in technology have improved the survival rate of infants who weigh less than two pounds but have also created new challenges. Low birth weight infants have a five-time greater chance of developing cerebral palsy than babies who are born full-term.

Cerebral palsy is a condition that affects body movement and muscle coordination. It usually occurs when there has been damage to the brain that has occurred before, during or after birth. 35 percent of cerebral palsy cases are caused by preterm births but all is not lost. Recent medical studies have demonstrated that mothers of preemies weighing less than 3 pounds or born before 32 weeks and were protected from developing cerebral palsy if they received magnesium sulfate. How amazing. Less is sometimes more. Back in April, I discussed how a cooling blanket can prevent brain damage to a full-term newborn with low APGAR scores and it now appears that magnesium sulfate can do the same for preemies.

As an obstetrician, I am grateful and humbled by these new developments. An “imperfect” beginning can still have a happy ending. Thank you, magnesium sulfate.

Angela is a 30-something year old African American alumnus of Syracuse University who has extensive business experience as a marketing executive for celebrities and is also married to one.  She had an uneventful pregnancy up until her late second trimester when she developed signs and symptoms that any trained obstetrician would have immediately recognized as impending pre-eclampsia. She gained five pounds a week and developed swelling. She could only sleep propped up on a pillow because she couldn’t breathe pillow. She complained of shortness of breath and difficulty walking.  All of her complaints were disregarded by her physician and staff in a condescending manner. It was only after she gained 15 pounds in one week did her physician reluctantly order lab tests based on her insistence. 

On the night of her delivery, she went to the hospital because she could not breathe. Her blood pressure was extremely high, her platelets were low and she had significant protein in the urine. Angela had a lethal variant of pre-eclampsia called the HELLP Syndrome. Against Angela’s wishes, she was forced to lie on her back for a nursing procedure and fluid seeped into her lungs. She lapsed into a coma. An emergency C. Section was performed and it was discovered that she had an enlarged heart. Her infant daughter was born in distress and there was an 80 percent chance that Angela would die. Thank God she didn’t. Angela is now on a mission to warn pregnant moms about pre-eclampsia and urges them to “trust their instincts.” I totally agree.

Arrogance and condescension have no place in a patient-physician relationship and is a sure-fire way to end up in court. I urge all pregnant women to become proactive regarding their prenatal care and above all, trust your instincts. The days of the passive patient are gone. A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.

1. Ultraviolent rays are not your friend. Wear a hat with a three-inch brim and sunglasses when sitting in the sun
2. Use a sunscreen with a minimum of 15 SPF or higher
3. Women of color should also use a sunscreen. The incidence of skin cancer has increased for all races in recent years.
4. You can swim in a chlorinated pool but check the chlorine level. The pH level of a pool should be between 7.4 to 7.6. Avoid using a public or private pool if it has been “shocked” (given extra chemicals).
5. Enjoy your barbeques but don’t eat food that has been left outside for more than 2 hours.
6. Use insect repellent to protect yourself from bugs if you go outside but use it sparingly. Mosquito bites increase the risk of developing the West Nile Virus which causes inflammation of the brain and spinal cord. Both the Center for Disease Control (CDC) and the U.S. Environmental Protection Agency (EPA) state it is safe for pregnant women to use insect repellents, specifically the longer-lasting agent DEET. For longer hours spent outside (over 3-4) use a repellent that contains at least 20% DEET. Products with more than 50% DEET does not offer additional protection and should not be used in pregnancy.
7. Use Oil of Lemon Eucalyptus or PMD as a natural pesticide if you prefer to avoid chemicals.
8. Stay well hydrated when in the sun. Drink plenty of water.
9. Don’t over exert yourself in extreme heat. The human fetus’ temperature is about 1 degree higher than its mother’s and cannot regulate its temperature. If you remain cool, so does your baby.
10. Thunderstorms increase during the summer. Have your disaster supplies ready as well as emergency numbers and a route mapped out to the hospital.

Summer is a time of enjoyment but please — play it safe.

Like millions of Americans, I have high blood pressure and am taking medication. Uncontrolled hypertension can lead to a perilous path that includes strokes, heart disease and possible death. However life style changes can improve the condition considerably and release us from the bondage of the pharmaceutical industry.

For the past two months, I’ve experienced a dry, hacking cough. When it became unbearable, I reviewed the side effects of a medicine I had been taking for over 2 years and lo and behold, I had found the culprit. I immediately contacted my cardiologist who changed my medicine. However, despite the change of medicine, the cough not only persisted but became worse. I was not only hacking and coughing, but now had wheezing. Enough was enough. I stopped taking the medicine. I checked my blood pressure and gratefully it was normal although I am acutely aware that it could “rebound” and become dangerously high. I contacted my cardiologist’s office again but was informed by his nurse that he would be away for two weeks. I described my symptoms but she stated that the medicine I was taking “shouldn’t have that type of effect.” I said it did and I was not going to take any more of it. When the nurse mentioned the medication’s category, I suddenly recalled a recent medical study that associated that type of medication with an increased risk of lung cancer. My instincts were correct. Although I trusted my cardiologist (who happens to be brilliant and a former med school colleague) I still needed to do my own research. And when my body was giving me signals that something was wrong, I was wise enough not to ignore them. As a pregnant mother, you MUST do the same. If something doesn’t “feel right” regarding your pregnancy, bring it to your provider’s attention immediately. Your persistence could very well save your life. And also the life of your baby.

1. Try to be admitted to a hospital where they have 24-hour anesthesia service to having to waiting for them to arrive from home. If there’s an emergency, an “in-house” anesthesia department will save precious time.
2. Try to deliver in a level 3 hospital has neonatology specialists in the event that you baby requires immediate specialized care after birth.
3. Make sure your information is updated properly during the change of shifts. If your fetal tracing has been lousy during the past hour or your blood pressure has been elevated, the incoming staff should be made aware.
4. Do not hesitate to ask about the whereabouts of the doctor or midwife if they are not in the hospital. By law, the admitting physician or midwife should be documenting your care by writing notes on a chart. Your physician or midwife has the ultimate responsibility for your care; not the nurse.  If you’re in a teaching hospital and being managed by resident physicians, always ask to meet their supervisor, the attending physician.
5. Ask whether you’re making progress in labor.  If you’ve been the same number of centimeters for greater than two hours, there might be a problem with your labor.

Being in labor at night should no longer be a grave concern.  When you are empowered with the proper information, the chances of encountering birth complications will be greatly reduced.

Today’s economy has proven that no one is exempt from losing a job; a home; a spouse or their dignity. If the truth be told, we are all just one paycheck away from getting the dreaded pink slip. Medicaid insurance is the government’s safety net for the working poor and has traditionally been shunned by physicians but now hospitals are following suit.

I remember when the only cancer specialists in a small Louisiana town wouldn’t provide cancer patients with chemotherapy if they had Medicaid so the patients either sought care in another town or died from benign neglect.  Perhaps it’s the memory of those cancer  patients who were denied access to care that makes me fight so hard for my patients to be delivered at a quality hospital despite the hospital’s alleged resistance. In New York City, it’s a well-known fact that a renowned teaching hospital places Medicaid pregnant patients on separate floors but at least they accept them for obstetrical care.

Complicating my dilemma is another community hospital that has had quality care issues in the past and would “love” to have my patients because their patient census is shrinking. Most of the physicians in the community no longer deliver at their institution opting to take their patients to a new competitor hospital that recently opened its doors for business.

Although I have been involved in a recent arm-wrestling match with powers-that-be to “steer” my patients in a certain direction, I ultimately leave the decision up to the patients regarding their hospital of choice. If a hospital accepts Medicaid insurance, then they have to accept Medicaid patients.

The “heart” of medicine has flat-lined. Could someone PLEASE perform CPR? STAT!