What Does it Really Mean if Your Pregnancy is High Risk?

good afternoon welcome to from belly too baby I’m here with Dr. Ebony Carter a maternal fetal medicine specialist at Washington University of Barnes Jewish Hospital and today were at Missouri Baptist where they wear all kinds of hats but wear a white coats as the case may be Tell us a little bit about yourself and your background and what your medical practices oh great so I joined the faculty here at Wash U in September has a maternal fetal medicine specialist did my fellowship here and prior to that I was in Boston for three years and decided I wanted to transfer taking care of more high-risk patients so that’s what brought me to St Louis we’ve seen a lot of babies a lot of moms that’s great I know a lot of answers which I’m really excited about and just to give any of you who are joining for the first time a little background my name is Abby I work at st. Louis Children’s Hospital I am pregnant with my first child 19 weeks right now and going through this as a first-time parent just like anybody else the only major advantage i have and i will say it as a pretty major advantage because i just thought of another question even ask you after we’re done is that i have access to all of these in these doctors and clinicians so i don’t have to google all of my questions I just pick up the phone and call someone so it’s a little unfair for me to have that advantage and not share it which is a good thing for everyone to do I mean we are what every four episodes and doctors say please turn off the google it’s just a little scary um and my husband tells me the same thing on a regular basis because when i’m home and i pull it out it just it doesn’t do much more than scare oh well and people tend to share their scary stories they don’t share like the happy wonderful moments and so I think Google’s a little bit biased. we talked about this a little bit last week to see when I find that also kind of among women in general the things to remember and I say that those memorable moments in general you remember the highs you remember the lows and so if someone had a horribly negative experience associated with something you say oh my gosh I have a pain in my sides well it’s just not conflicted whether they called round like a missing home in those situations but for that one person it was something much more dramatic and so you blow it out in your mind from chat boards do not help so today is we’re talking about you know things getting a little bit too we’re talking about high-risk pregnancies which you say high risk and immediately I think all of us go just breath a little bit first of all can you demystified us a little bit what does high-risk mean it doesn’t mean that you’re an older mom does it mean that you come into pregnancy with a health risk to begin with what does it cover so what are the things I love about my job is I have two patients I have mom and baby and either mom or baby can bring high risk to the table so let’s start with mom mom might have a condition that she brings into the pregnancy that’s a she has diabetes or she has high blood pressure and having those things and pregnancy means that potentially you’re a higher risk of having some complications with the pregnancy sometimes it sucks that you came into pregnancy with so let’s say that early on heaven forbid you’re diagnosed with cancer or some really scary issue that could make you high risk and then on the other hand that baby could make the pregnancy high-risk so let’s say that we find out early on is there’s some structural issue with the baby maybe there’s a problem with the baby’s heart or the baby’s kidneys or maybe a little bit later on the baby’s not growing quite as well as you want the baby to grow so those are some of the issues that can make the pregnancy overall high risk and next week we’re going to be talking a lot about that 20 week ultrasound that the midpoint that I think a lot of us go into with the expectation that will just get a fun picture but it’s a whole lot more than that and I know that at the women an instant Center on the main campus Washington University of orange juice and completion table at Children’s Hospital we tend to get a lot of patients I understand after that 20 week ultrasound backing up even smarter though does high risk in that first of all let’s talk about age of mom and I should say I’m asking these questions as oblivious as anybody else and so you have questions please don’t hesitate to chime in and ask them as well but just what it was it cause it was such a horrible term a geriatric pregnancy i think it was in a coma answers really or a ma there’s a technical definition of advanced maternal age is over the age of 35 we really don’t start to get more concerned until a mom is 40 over the age of 40 really the stillbirth risk is a bit higher and that’s one of the major concerns that we have and if we get older you tend to have more conditions like diabetes and hypertension so 35 is kind of technically where the cutoff is where we start to be more concerned about things like Down syndrome and let’s be clear as a person over the age of 35 right it’s not like a 35-year risk of down syndrome skyrocket this is continual thing that keeps kind of moving and 35 tends to be the age at which wich your risk of downs is similar to the risk associated the amniocentesis

and that’s kind of why it’s the match voyage where we start to worry and screen more for it so so yes a number of things can make a person high risk but backing up even more before this 20 week ultrasound and the first trimester let’s talk about how do we reduce the risk associated with pregnancy and I think one of the most important things that all of us can do is a preconception visit now granted only fifty percent of the pregnancies the United States are planned then my definition is if you’re not actively trying to prevent a pregnancy you’re planning one IPO second factory of that exact same phrase as well and then exaggeration intended to go into the obstetrician and sometimes you know that you have some hires condition and since you don’t so I think it’s a really good thing before you have a pregnancy to figure out you know what are the risk what is what am i dealing with and what are the things that I can try to prevent and take care of before I get that’s so interesting when you say that I do remember now it was an appointment probably six months before I got married I said to my doctor or something about you know we’ll probably have kids in the next year or so a little bit no would be less though but they she said it changed the conversation entirely there were a lot more questions there were a lot more brochures that were handed to me just based on things that you can screen for in advance right and it’s incredible the amount of technology and information that is out there and that you can learn beforehand do you find that that at any point is you know we hear that information is powered you find that there’s too much information that we take in or do most people self select to the point that you get just enough to form a good picture um I think that most people self select to get a good picture I definitely feel like in the age of the Internet it’s a little bit more scary and out there but I think that’s good for patients to do due diligence and as physicians we are here right so I would much rather a person come in and have a conversation with me then be terrified at home alone going to global to try to answer these questions every single woman every single pregnancy is different but are there any tips that you commonly tell people and I think it’s we’ve heard a lot of them in pastor’s house but anything that you would tell women to put yourself an optimal health before deciding if you are in the position where you’re deciding that you want to have children that you can do to really make sure everything’s yes that’s where and I think a lot of that starts kind of a depth great conception level so one of the things is to get prenatal screams done so there’s certain vaccinations that are really good to have when you’re pregnant that you can’t get when you’re pregnant because they’re live acts seems so all of that so that’s low line through text even hit here before you’re pregnant I’m the other thing is a prenatal vitamin so the reason we really care about prenatal vitamins a large part is because they have folic acid folic acid has been proven to reduce the risk of having a neural tube defect so then the spinal cord doesn’t completely the way we wanted to and you can have something like spina bifida right very tragic for a kid but if you take folic acid that that risk is significantly reduced but that’s what all of that is happening before most people even know they’re pregnant so it’s important to start taking that several months before you get pregnant so those are the kind of issues that you can easily deal with and then other things are optimizing medical conditions as much as possible so diabetes hypertension obesity trying to handle all of those and then women to have autoimmune disease and so let’s say a person has lupus for all sort of colitis autoimmune conditions tend to be much better handled in pregnancy if you have been symptom-free and the year preceding pregnancy so I think a lot of us think I worked at any medication but illusion anything that could harm this little person who I love more than life and we shoot ourselves in the foot they’re not taking our medication so healthy mommy equals healthy baby and certainly there are some medications that are absolutely no dose of pregnancy but it’s good to have that conversation initially and not just take yourself off of all of your medications because if your diseases out of control then you haven’t really done much to help yourself for the baby and it’s so interesting that you bring that up because we’ve had this conversation in our household about how you know I’m nervous even though I have been told by so many clinicians you can take clear it’s not going to hurt you allergy meds are fine you do have that weird a sense of but what if and I have to remind myself continuously the thing that I’ve seen at the hospital and our punishment have treated we put women who are pregnant through chemo who are diagnosed with cancer move so it is incredible the things that your body can do and can manage outside and still take care of a baby right and it’s all about kind of managing risks and benefits so if a mom has cancer that’s life-threatening and so you’re willing to take a higher risk with chemotherapy in that situation because if mom doesn’t survive that baby it’s not going to five and then there are people who have called me and you know kind of want to take all of these meditations and the underlying condition isn’t so serious and a place probably not worth the risk

in that situation but that’s what we’re here for is to help people balance those risks and benefits and make the best possible decision for the growing family and do you work with you work not only on the hospital for syphilis but you work with outside hospitals as well so we have a lot of obviously not all women are able to be in a place where there are the acute medical centers I mean I grew up in a teeny tiny town and we have a great community hospital but it still doesn’t have the resources available so are you able to communicate with those outside hospitals in order to maximize care for a mom definitely so we travel we have several sites in the st. Louis area we also travel to several sites in southern Illinois and we have telemedicine so that people who can’t physically get here we actually have a nice room at Children’s and so we can talk to each other on this screen at communicating not all that different from this which is the main thing that you’re able to do that but it really just helps to have that conversation going and it’s if mom needs to be transported at some point to a major facility you guys are able to work that out well all of our patients who come here who live far away we give them a little pin that have our transport number and say we will come get you whether it’s by ambulance helicopter plane you know give this to the provider where you are and we will come wherever you are and pick you up essentially so it’s a great service and I think we should probably talk a little bit if there’s no questions at this point like how do we manage patients in a high-risk setting and I think there’s several models so let’s say that you’re 12 weeks there’s some condition is making your pregnancy high-risk that your obstetrician doesn’t feel totally comfortable with and they say COC maternal fetal medicine which is what I do and it doesn’t necessarily mean that you have to leave your home position your bond too and you want to be with so there are a number of models one is that you come one time and we talk about what’s going on we make a list of recommendations and communicate that back home to your doctor and hopefully he’d never have to see us again right and that’s the end of it but if something arises and make things a little more complicated the relationship is there it’s established and we are always available to you there’s a hybrid model where the doctor at home says you know what this is a higher level of care than I can throw back provided I could be four basic obstetric care but you manage her sickle cell or whatever else was going on and so patients are seen at home and they come see us every four weeks or so and we work together with the doctor to manage it and then sometimes things are so complex just come on over you do everything and manage their gear and deliver the patient here ok so I thought this was so funny when you mentioned me sometimes it’s a one-time only because it was in a meeting with one of your colleagues dr bebington who is a fetal surgeon and he was talking about this I think people forget that oftentimes we give great news and there are times when you are referred to us and we’re able to look at something and say oh this is something we can totally handle or this is this is something we need to watch but you don’t need to worry so I do want to throw that out there as well that i previously always associated maternal-fetal as being that’s the last place in the world you want to go but it’s the same note that but it says am tired there is a real opportunity there to just understand what the situation is low event I’ve had that situation earlier today I saw a patient whose last baby have lots of issues lots of complications and understandably she’s terrified with this pregnancy and saw her doctor yesterday and they said the same things to her that she remembers hearing when things went poorly in that last pregnancy and so she came and was in tears and so upset and it was wonderful to be able to do the ultrasound here to do a high level ultrasound look at this baby and give her that reassurance that you know nothing of medicine ever one hundred percent but to the extent that I could I could say you know the things that happen last I am things are not happening right every call signs point to the fact that this baby is doing really well so I don’t we can do that all the time but it was nice to kind of just give that sense of relief so tell us who’s been traumatized by her last pregnancy and I think that brings up a really good point in a question that I had earlier is if you have one high-risk pregnancy does it automatically means that your next one is going to be high-risk where that’s going to be treat their tyreq it does not so it depends on what the issue was in the preceding pregnancy so let’s say that the baby had issues with Brooks right so certainly you’re a higher risk for the next baby to have gross because what what’s the underlying issue that caused the problem in the first place but not necessarily and that’s really just a call to us to say take close attention right like follow it closely but it doesn’t mean that you’re going to have that same as you can versus a mom who has a chronic lifelong condition then yeah that’s probably going to be an issue with every pregnancy you have so it’s really a on a case-by-case basis okay and of course it always starts at that visit ear your primary OB GYN and they will then refer out as needed or do they if you ever have fusion to start with you yes we have some patients who just sell for further like yes I’m yours ok so we think that usually the patients come from their primary obstetrician we

see both ok and talking about the baby at supper or we had a point where we can discuss the 20-week ultrasound what you learn from that day thing certainly conversation Hank so that is such although yeah I we can talk about the 20-week ultrasound you want to talk about the genetic testing before that and sure we’ve talked a little bit about in the past that I’d love your take because that is something that I think it’s a lot of women really struggle with it myself included i had a really hard time deciding what to do and what not to do just because i’ve said this before on this program I’m 34 years old from not quite to that 35 mark where everything is a insurance is going to cover it regardless of may as well go ahead with it the same time there’s that do I really want to know I mean what it is I know do I automatically have to make a certain decision I think the best way to think about any testing including genetic testing is what’s what I do with this information how would I handle it and how that it changed my behavior so we offer every single mom genetic counseling genetic testing in the first trimester and I use Down syndrome because most of us know what that is but there’s other things that we can test for as well and usually that testing happens somewhere around 11 to 13 weeks of pregnancy and we offer different things based on what the risk of the mom is right so some people will be offered a first look and that consists of an ultrasound babies without and have a thing unfold behind their neck and then there’s also blood work cuz it goes along with it because there are certain chemicals that are higher or lower in the blood of a mom sharing a baby sit down and you put that together and you get mom to risk so we might come back and say to you the baby shirts godowns is one in 10,000 great that’s pretty well and nothing else to do what if we came back insist the risk is one and three that’s a lot more concerning we probably should do a little bit more testing and so how do you know if you wanted that in the first place I think there’s three groups of parents group one would say if the baby had a release of your issue I would think about having an abortion and that group should get the test and groups who would say I wouldn’t have an abortion but I would want to know so i could emotionally prepare to take care of a child that was going to have some special needs and that group should definitely get the text and group three would say when have an abortion I don’t need to emotionally prepare even if I got the test and it was positive I would say I don’t want to add me open pieces thanks but no thanks where we sent to me Galindo belly and take some loose from the baby to send it off for more definitive testing so if you don’t need to know to mostly prepare and you’re not going to go to meö to pieces anyway don’t get the text there’s no reason to do it I remember having a patient back when I was a general as Tonetta risk of downs that was one in 74 and she was terrified and I kept saying the chances are 73 and 74 that the baby’s just fine and that was of no comfort but she didn’t want to meö subpoena so she spent her entire pregnancy terrified there was something wrong with her child and so in that situation all we did was provoked anxiety right so if you’re not going to do anything with the information say thanks but no thanks for the testing that’s really very succinct advice and I think we have a question we have a lot of questions okay and all of a sudden like Trina is saying that she’s 36 years old and she had a gastric sleeve so with those two factors which she qualified high risk right out of the gate as she became pregnant yes so I think that it’s certainly worthwhile first of all get a preconception consultation who’s the number one and then number two I think this worthwhile to have a consultation with the maternal fetal medicine physician if if everything that’s well controlled it’s possible that you can go right back to your obstetrician we like to check that a number of labs to make sure there’s no nutritional deficiencies another thing to be concerned about if there’s any type of gastric bypass surgery is screening for diabetes is important pregnancies so I always say pregnancy is life’s ultimate stress test right and push your body through a lot and it exposes some of the things that you’re more likely to have happens down the road like diabetes and so certainly anyone who had gastric bypass is going to be at higher risk of having diabetes of pregnancy but the test that we use doesn’t work so well for people with gastric bypass is this discussing little sugar drinks that people often can’t handle and complications can arise from that so there are some other little special things that we do with pregnancy for a woman with that history and so I think a minimum of a one-time consultation of maternal fetal medicine is warranted preferably before pregnancy okay schlee says that in her first pregnancy she had a placental abruption is she automatically high-risk in the second so um I would say you’re mostly at risk for having another eruption and the question is what was the underlying thing that caught that eruption so let’s back up for all of the other viewers and say what is an eruption in the first place I think most of us know the afterbirth right normally you have the baby and then the afterbirth which is the placenta and that helps the baby get nourishment comes afterwards so it’s my hand with the uterus and this is so pleasant to attach to it simin I’m the baby great

the issue with an eruption is that the placenta starts to separate prematurely while the baby is still inside and you can have bleeding in that area that sometimes stays in the uterus so you don’t even see it and sometimes mom starts bleeding and when about fifty percent of that placenta has separated babies can get stressed out and it can be a portable emergency I mean even as bad as like resulting in like the baby dying man’s how you know so usually at the clinical diagnosis and so blood is an irritant to the uterus so when that starts to happen a lot of times people start zooming out contractions really quick to use like very uncomfortable painful so if it’s not concealed and the blood is coming out you’re having vaginal bleeding and the things that can kind of precipitate that are I think that probably the number one thing is a really high blood pressure so women who have preeclampsia and high blood pressure at higher risk of having that happen so sorry I was all the way around to now get back to the question there’s certainly an increased risk of a brush in happening again if that abrupt should happen because of preeclampsia or because of blood pressure issues those are certainly things that we can try to address so things like a baby aspirins have been shown to reduce the risk of preeclampsia for moms if blood pressure with an issue we can try with other medications to control the blood pressure so I’m seeking a very broad term like of course this individualize to each patient but the answer is yes there’s a risk of abruption happening again but I think learning from the lesson from the last pregnancy and optimizing health as much as possible means that the chances of having pregnancy without eruption potentially are a lot better unless you’ve optimized health and just to interject I know there’s going to be so many specific questions especially given the topic that we’re addressing today we are able to answer the doctor Carter’s able to answer in very general terms but always always always and we start out in the fourth every woman every pregnancy is different so talk to your doctor and I know I sound like a broken record I would say go see your obstetrician before getting pregnant again to talk about what were the specific circumstances surrounding that eruption and how do we try to minimize the risk of that again okay the climber issued more questions go ahead so melissa has a question she is a triple transplant patient hot dog yes and she’s thinking about getting pregnant is she automatically high-risk and have you ever worked with a woman who have had a transplant yes we actually are several patients that our practice math with that transplant the best of situation where I’d say certainly before even they think about pregnancy with one is the maternal fetal medicine physician and we i should say now that part of the reason why I love working at watch you and love working with Barnes is we don’t work in a silo right this is definitely an interdisciplinary effort where the obstetrician should be speaking you know very closely with like the transplant physicians the medicine physicians to really make a good plan and because so my people come to us pre pregnancy and we’re like you’re great go for it did pregnant and sometimes we say you know what I’m worried about how some of these other organs are functioning we’ve gone through alive and the risk potentially outweigh the benefits and maybe we should think about other things in pregnancy like a surrogate or some other options so you know it’s very different it’s on a case-by-case basis sometimes transplant patients are good to go and we’re ready and then sometimes you say I’m really really worried about you know your health status so kind of depends entry fee have a question she says if you had a pulmonary embolism does that automatically make you high risk yeah that was a very freudian system I can you know Simon pulmonary embolus pulmonary embolism is a clot that often starts in the leg and then can dislodge and travel to the lungs and it’s potentially life-threatening when it happens and there are lots of things that can make a woman higher risk for sometimes it’s like something genetic and your form is just being a higher risk for class happening sometimes it’s provoked so let’s say that you were in a bad car accident and you were in a cast and you are in bed for a long time and you’re you know kind of lack of mobility or let’s say you took a plane to taiwan and you were sitting in that plane secret right so there’s different things that can cause it and so for any woman who’s had a clot you want to look first of all with underlying reason that you have to clot and in pregnancy pregnancies also a risk factor for having a five right so it’s a higher risk condition and but thank god there’s really nice medications that reduce the risk of having clocks that we can use in pregnancy so once again it’s one of those kind of a case-by-case basis in terms of what you need to be on anticoagulation during the pregnancy we can do two different doses one is trying to prevent it into lower dose and then we can do a higher dose of saying you’re a really high risk right we need to do a

little bit more in this situation and that high risk associated with pregnancy for clotting isn’t just when you’re pregnant it actually extends to six to twelve weeks after you have the baby so it actually continues after after childbirth it is so fascinating and I think we’ll explore more of that is this whole series unfolds but how much of pregnancy does continue beyond delivery it doesn’t stop as soon as they move out by any stretch and we’ve heard from many people that six to 12 weeks later you’re still seeing adapter and still seeing a lot of the the issues that are associated or could be associated apartments in writing so are we good with questions right now if I have any more please keep texting or heard me messaging us in the or typing them into the comments section if we miss them it’s not that we’re ignoring you sometimes they just keep flying in quickly and we don’t see them so ask it again don’t hesitate so I think that brings us or at least we were at some point talking about that 20 week ultrasound and I am so amazed at how long they take because I think everybody or at least obliviously you kind of go into them and think I’m just going in and this is my first shot take a look at my baby but that’s not all you’re doing you’re taking a darn good look at that baby what all are you looking for an act so I think the patient’s thanks for looking at gender which yeah we definitely do that but that is like one percent of that anatomy scan so we’re going to go from head to toe we’re looking at the baby’s brain and making sure that all of the anatomy looks normal in the brain we’re taking a really good look at the heart and making sure that all the connections there there are the way that they’re supposed to be and the belly is and kidneys and then all the limb measurements in making sure they’re right so there are different levels of ultrasounds I’d say a woman who is coming into the pregnancy high-risk because of a genetic condition or let’s say mom have heart problem herself you want to try to get that ultrasound at a center that is used to seeing families or structural issues in the baby right a very high volume center that’s doing lots of them because all ultrasounds are not created equal so yeah we’re looking at a lot of anatomy and I say the average anatomy scan probably takes more than order of 45 minutes mmhmm yeah okay and once you’ve had that and what information are you able to take away from their consent really mean aside from the testing that you’re able to do prior to that that really gives you an indication of any additional care that baby might need so what what do you see sometimes that would indicate this mom needs to go for more or testing or whatever so sometimes we see that there’s a tissue was one of the organ systems lips say that on the heart views I’m just not completely satisfied that it means everything that I wanted to see we might refer that mom onto a fetal echocardiogram which is you know an ultrasound of the heart I’m the baby’s heart and we do that at Children’s and we have a phenomenal team there and that’s kind of all you know like sonographer to just really focus on that and they can get a better view than even we can in high-risk obstetrics so Lily the anatomy scan is kind of a flag to say you know you know everything looks great and we can go on in this is a routine pregnancy or we need to look at this a little bit more carefully the other nice thing about an Anatomy scan is we can hook moms into the care that they might need for their baby so let’s say that there is a hard tissue and that baby is going to mean surgeries and other issues and we have a field care center here and a dedicated feel care nurse who really is the guardian angel for those patients right she’s amazing I seen her with one patient after another and I totally have to interrupt you in sync Sarah’s Grace’s because I you part with a family and outcomes aren’t always perfect and exactly what you want and we’ve seen a couple of situations and going back to the genetic testing and deciding what you’re going to do I’ve seen here with the families of children with an ice no I’m asked the question and I think every episode the trisomies that are not down syndrome they’re they’re doing variances 13 and 18 that are almost are they always are almost always good always almost always fatal and there are a number of family to make that discovery and then determine that what they want to do is plan what time they will have with their baby and she helped facilitate a great deal of that make sure that baby that amount that are able two days maybe or that you know make sure videos pictures and the in the prints and everything which is so incredible so I think that that’s something that when you talk about the fetal care centers a lot of people aren’t necessarily aware of is that it’s there to help get baby healthy but also to help empower families decisions and make sure that regardless of how you want to spend that time with that maybe that those wishes are honored right and the fact that there’s going to be several pediatricians and moth in this baby’s care and so wouldn’t it be great to know your baby’s dream team before that baby’s here and so that’s part of

the peel care center is making sure that all of those connections are made so that when this little one arrives we have a great plan in place and a great set of people to be clear up this little one and I know I’m a grown adult but there is one of the fetal care physicians I have asked her to adopt me a few times I’ve been a serial child for her but will actually meet her in a couple of weeks when we talk about the fetal echo in those kinds of things but the additional testing that comes after baby is born but I’m sorry I completely interrupted you but so there there things that you can go on the field care center for and then what else do you learn from that ultrasound about baby unless we get a first chance to see the baby’s growth so let’s say that a person didn’t want any genetic testing of first trimester right and then you see a few things that suggest that we’re at higher risk may be having a chromosomal disorder you could revisit that then and say lots of some things that make us a little bit concerned about this do you want to get an ambulance pieces are we interested in looking into this further or if there’s already some growth issues that early on that might trigger more testing in terms of could there be an infectious reason why this may be as small because there would be a genetic reason so I feel like part of obstetric care really is minimizing risk we talked about risk a whole lot and the anatomy scan is a nice time to be able to pick up things and then make sure that we’re trying to optimize outcomes for the rest of the pregnancy and it really is remarkable and we’ll see the pictures next week how much you can tell from a tiny little black-and-white image and even just a amount of detail that you’re able to gather pretty phenomenal well and I have to sing our sonographer prices so it’s not rid of the people who actually do the ultrasound and they are a highly skilled competent group of individuals who catch nearly everything so we’re really really lucky to have that team here and for the vast majority of women I think it’s important to note that that 20 week ultrasound went in they do kind of nervous I’m very very scared which is so funny because a lot of my friends really why are you scared is so exciting and it is exciting but I think whenever you see be all of the web you get a little bit more nervous but the vast majority you send out they were without a single right when I was a general obstetrician I used to say my favorite part of prenatal care is the anatomy scan where you can see ten little fingers and ten little toes and you know if you don’t take anyone to any other part of your prenatal care take someone with you to be Anatomy can because usually it’s a time of great joy and getting to see your baby and every now and then it’s not and it’s good to have someone from love shoes and cares about you it could be another set of ears to hear what’s happening either with you I think that is actually a point we didn’t talk about addressing but it’s really important and we don’t want to take for granted in any situation we see women who in a number of different capacities coming into parenthood some who have a partner some who do not what is your advice whenever you’re talking about going through pregnancy and it’s nine months it can be hard how do you build a support team if you don’t have one that’s just automatically in place do you give your patients advice on that ever well actually I do group prenatal care for our patients with diabetes for we have groups of about six women who all have type 2 diabetes or diabetes a pregnancy and they get their care together and one of the activities that we do in our groups is a support map right and it’s a middle of the max a little circle and it’s mommy and baby and write because usually it’s just going to be you and then the next circle is who can be instantly available to you right and sometimes people will say the father of the baby or a parent or grandparent or whatever and then the next level out is who’s going to be available to you but not instantly but within a couple of hours they can get there and we have some patients who feel like they have absolutely no one right but by the time we go through that map and then the next one is like who can you call and they can be with you within a day and that’s us right like we fit sweet fit in that category I’m just about people realize that there are lots of resources that are around for our feudal care patients sara is going to be in one of those inner circles of the map but we really are here to support mom through the pregnancy and after the baby arrives new talking about Sara we would offer the other day with a family that had lost a child and they were doing some things at the hospital over several months after they had lost him to honor his memory and she was having a really hard time coming back into the hospital which naturally you would and she just took this woman by the head and sister on the forehead and I thought that it was such a thing that I mom would do that I had as a boy I think that is so amazing that she was very clearly a connected part of her fair team and seen her hold hands of women any there delivery where dad within the room but he was very distracted and so Sarah was there holding montanez during the c section which ones which was amazing and mom was perfectly happy and she was nervous but she was very happy to have both sources of support there’s no and another thing to think about and if it’s

possible is a doula so you know if you want to have your child birth experience and don’t have a person who can be with you and doulas are also wonderful support people and resources to have available oh can you have a doula in a hospital I think that’s something i know that i didn’t know beforehand i thought that that was something that was reserved only for birth centers or something but that’s a decision that you will support within are more than welcome alright did we have I thought finger look at a question attic or so Marella asks if you would recommend pregnancy to someone who has had systemic scleroderma but does not yet have organ involvement very specific questions very specific than i would say come see us for a consultation so for some maternal fetal medicine physician somewhere for a consultation beforehand i think at that point really all of the records need for review from the outside place and let me put a plug in for that too so when you go for a consultation for any position and come with no records just a waste of time the person is going to say give the records and come back and see me then because you’re basing your recommendations on nothing so I think it’s always good to have all of your records if you can have them with you in addition to have sending them ahead of time that’s great so we’re really not wasting their time and giving you the best possible recommendation because for that patient I would want to for through all of those old medical records and kind of see exactly what we were dealing with and on the patient’s side what would that look like would they go into their current doctor’s office and ask for everything to be copied what they just have to be sent to your office so usually you’re defined a release of information form saying permission for my medical records to be released and then definitions office will send it to us and I can’t tell you how many times things get lost in translation I actually think it’s much more efficient to go get them physically yourself send them yourself and then have your own copy so when you get there like oh my deceiving the computer system it’s like here I’ve had this happen before and I can tell you if you have a hard copy in your hands it’s awfully reassuring because you can walk I mean computers are great animal drone alien or human all right now do we have any other questions right now all right so the other thing we talked about our sometimes most of the time you know before the 20-week ultrasound but I don’t have to people who have gone into the 20-week thinking they were pregnant with one child coming out with more than one so if you have multiple does that automatically make a pregnancy hai Ram um yes and no so if you have twins specifically die guys win for each one has their own placenta and that really can be managed by a general obstetrician in those situations if you have twins that are sharing this with cinta or they’re sharing the amniotic sac bizarre in that’s a higher-risk pregnancy and should really be followed by a maternal fetal medicine physician and for twins in general you have to pay closer attention to grow through those kinds of things so I guess the answer is depends ok and then with after you know what happens patients I totally lost my train sonic totally honest up took my question that but and then our base are multiple pregnancies followed more carefully or more routinely do you see patients more often we tend to do more ultrasounds amor non-stress test so one of the things that we think about what iris got this vetrix especially you know the way that we handle some initiative it arises at 20 for me it’s totally different than the way we handled exactly the same issue with 37 weeks and why is that the question I’m always asking as a physician is where is this a leader is it doing better inside mommy where they’re going to do better in our attention period or out in the hospital and at 24 weeks to answer is almost always keep that baby inside mom and the closer you get to 37 weeks which we consider full term the less foolishness you’re willing to put up with from a fetus right the threshold is much you know lower to say no we need to deliver at this point so and now I lost my train of thought in terms of like I’ve been on a tirade when I only make someone make sense of you seeing a doctor more often and how do you fit a 37 so you know if we’re worried about the risk of stillbirth or really concerning how come like that there are tests that we can do that reassure us that hey babies okay so let’s talk about ways that we reassure ourselves that our pregnancy is going well from from the mom status late movement is really important to moms moms will say how does kid with select I’m sick of it I’m like there’s no such thing as too much movement we love movement movement is a kid’s way of saying hey mom I’m doing okay in here it’s what a kid’s not moving that you have to be worried about it so you know you talk to the general obstetrician about counts and other things to reassure yourself in terms of how the baby is moving the other thing we can do our non-stress test and that’s where you kind of sit in a lazy boys and there’s two monitors on the belly one is looking at contractions the other ones looking at the baby’s heart rate and a happy healthy baby their heart rate looks like a sawtooth pattern kind of this thing and every now and then it has an

acceleration of upgrade and so when a kid does that it’s saying I’m doing okay and things are looking good so that’s another reassuring factor the middle of the last main thing we use is something called a biophysical profile so that’s an ultrasound where we look at the baby and there’s different domains of a kid you know moving and kind of flexing practicing the breathing movements inside looking at how the fluid looks and if the baby gets all the points on that that makes us feel great so any mom that were worried that her risk of stillbirth is higher than other moms we will do that testing then we start to do it more later on right because at one for weeks even if it’s not looking great I don’t want to live I do at 37 weeks oh we’re going to deliver it something is not looking great so we have all kinds of tools in our toolbox to reassure ourselves that this pregnancy is going well that it’s safe to stay inside and do you tell moms ever she’s trust or not trust their instinct when it comes to how much they’re feeling the baby move or anything like that is there ever any harm i should say in calling the doctor and saying I’m a little nervous at the Saturday night I would always rather a mom err on the side of calling us because we talk about it down so you know babies have sleep and wake cycles just like we do so some moms will say like my baby is up all night but I don’t really feel them too much during the day and so pay attention to what those patterns are and when the baby is breaking the pattern and not moving in your stairs you do kick counts right like drink some juice so you know the sugar control wakes the baby up and then start counting and you know there’s different parameters for what people say that general generally within an hour you should feel ten movements from my baby if you sit into your kik constant pay attention out like right now probably not paying attention right we’re talking to doing other things so really you want to like sit down and focus on nothing but bad and if you’re maybe doesn’t indicate cows and I’m talking more like 28 weeks now like you know my babies don’t do this as well that’s when you call it the doctor like Luke what’s important and it’s interesting and I feel like jenny is totally the man behind the curtain here do you mind if I ask you a question really for experience because that happened to you right that it was lack of movement can you talk a little bit about it yeah so is 26 weeks and six days and he stops moving and so I called it was like four p.m. in the afternoon they got me in for a 9am appointment and it was an umbilical cord accident and they said have we waited one day to call he would have died so and we should know you delivered a howl howl I exactly 27 weeks and years two pounds and he is seven jackals and exactly and healthy skin perfect yes yes lots of time in NICU night happy ending yeah yeah I’m Eric yeah man but obviously worth we’re calling on that and you know to the gut instinct I will say people say I don’t want to go into the house when they tell me it was nothing or I don’t want to go in and think I’m in labor they tell me it’s nothing my big thing is I don’t want to be a bother I don’t want to and I know they’re there people with bigger problems I’m like be a bother great so I would always rather have a patient who comes in and gets evaluated and we’re like everything looks great and you get sent home than to be at home terrified that something is wrong because when people come in with still works I can’t tell you how many times story is you know I had it felt the baby move in three days right lateness and when I hear that before I even put the ultrasound on I am terrified the decks of silver so I think part of it is about nutrition needs a good education teaching people about kicks Houston to be aware of movement and then for patients it’s always err on the side of calling it is better to get that reassurance than to be scared alone and don’t let Google to tell you it is ok my husband google that afternoon and he said well I read online and it said around 27 weeks the baby grows really fast there’s not as much room if you won’t feel it as much like almost in a call because of google yes oh well this is dr. Holloway like that cuz if you’re like scary message again the color is so Superman sir oh but is there a point at which you would start following a patient between let’s say twenty one pic so you gotten past that 20 big ol just not everything works right and I pick 21 totally out of this guy but that and then delivery is there a point at which a maternal fetal medicine would come into the picture or usually have you identified by that point patients that are that are going to be more high-risk so in a low-risk patient normally they’re seen every four weeks by their primary doctor and then the closer you get to term it becomes every three weeks every two weeks and finally at 37 weeks it’s every week for patients who are seeing us there’s usually something else that’s going on that we’re going to follow them more closely and so for many of our high-risk patients you will do another bro stand right because growth is another indication of a kiss and I’ll do it pretty well and when a kid starts to get stressed out we go down this predictable path of events and limits the early events on that path that goes not so great as broke so we pay a lot of

attention to it so you know we might do a growth span between 24 28 weeks just to kind of see where we are and if the growth isn’t great then that’s when we start to do some of these other tests that I already talked about like the non-stress test in the biophysical profile but it’s totally different for every patient and kind of a case by T space we have some some general guidelines like these we do certain things for diabetes different things for hypertension but a lot of its individual life ok and this is going back to a point you’re discussing previously about whenever you look at maybe and determine whether they would do better in mom or outside and I want to point out that and only seen that the timer to you can speak far more intelligently toward it but when you’re talking about combine that with multiple pregnancies the answers sometimes different for each child so how is it done to become a team effort to decide at what point you are minimizing risk to both babies so it can get very difficult and ethically complex when you’re dealing with multiple pregnancies because you’re worried about mom tells right so you have you know certain positions like preeclampsia which is characterized by high blood pressure and mom a lot of times moms enough protein in the urine and the risk to mama seizure and stroke and the risk the baby is not growing well and kind of going on vessel past you know trying to prevent still burns in that situation let’s say that a mom is valueless preeclampsia at 26 weeks what is it mom’s best interest delivery that’s secure she should be done with this pregnancy but a 26-week earth super sentence and we would rather not meet this little one at 26 weeks and so if we can keep mom well enough we’re going to try to push the envelope a little bit further to get the baby time realizing that this is not best interest right um so I feel like we are often balancing the you know the risks for mom and baby and then when you have twins or triplets or quad right it becomes even more difficult so and we had a situation recently where we had a lady who had you know several babies inside and one of them had a heart defect and wasn’t growing so well and what do you do do you deliver all of the babies because the little one has this heart defect and is not growing and isn’t doing well or if you’re having that baby eventually pass away to try to get the other babies as much time as possible those are heart wrenching decisions and when it’s a clear evidence based black/white decision I state as a patient that was my recommendation and this is why in that situation I couldn’t really tell them this is what you should do because it’s a really personal decision all I can do is kind of give all of the information possible so that family can make the best possible position for them and these are days when I am grateful as there are other people to look at those situations because I cannot fathom having to be the person who says in and I know you’ve got so much education behind the decisions that you make but that is when you get into those gray areas it’s become really tenuous than I think unnerving and there are lots of them because when i did my residency which is not 10 years ago 24 weeks so kind of the period when a baby to live independent a mom and we we step firm and back to that 24 weeks and now with medical advances it’s creeping back so now maybe it’s 23 weeks and maybe for some babies play two weeks and change and how do you make the decision that what about what to do when you’re in that period where maybe the baby it was our unsub wences are two and we’ll talk a little bit and I believe it’s been probably seven weeks we’re going to be in our newborn ICU talking to some of the neonatologist about what they see it is something about that 2627 week mark but yes you can technology is incredible and we can save these babies very early now and we can give people a lot of resources but it is still there are so many decisions that come with that about the consequences that you’re going public down the road and I think that’s what we have trouble counseling patients with on the labor floor right because you hear you know if you want everything done for your baby yes of course right because of no brainer but what does that mean so you have a baby that’s living on the edge of viability and it’s not going to live so very on potentially and have you send that time you spend that time rocking that child so that at the time that they have they feel loved and warm or abuse in that time doing check depression simply breathing tubes down and right and it’s really hard and then you know I don’t have an answer for it but I think it i’m looking forward to that session in six weeks so then some of our and nearly all intensive care unit colleagues can share the exciting that’s the part that’s really hard for parents to understand when they’re at those early gestation all ages you ever counseled people to make many of these decisions before they get for that point that you’re going to have a baby early here are the things

you should consider or a really is it and I don’t know if it and I hope never to know but do you make those decisions in advance have your baby look at your maybe and say I know I said x y&z but I want you to pull every plum you’ve got and fix this so the vast majority of the time we don’t have that luxury just kind of happening in real time and you’re making the best decision you can for some families that know that their child is going to be born with the condition that’s not compatible with life or life for very long then we also have a palliative care service at Children’s that is really good with helping families figure out like we know we’re not going to have very much time how do you want to use the time that we have with our child and those are those services are remarkable and they are available in number of places and hopefully no one there the things you want to know exist but never one have to access so we will talk and like I send a couple of weeks to the newborn medicine folks and it’s very interesting to share their perspective and had the fortune of talking to many of them over the years about what they see and how they counsel families and really does I think more than anything and we talked about this earlier about how you remember the hive and you remember the loans and I think the lows really stand out more but we have usually everything right in the middle people forget out the middle in the middle it’s usually thing okay I mean this it isn’t perfect but it’s a lot of times great and then the successor is that we clear pretty remarkable oh and one of the things that we do with the team approaches we counsel together so whenever possible which is over ninety percent of the time as the maternal fetal medicine physician and our neonatologist you know the baby doctors we will go in and talk to moms together so that we are all on the same page everybody’s doing the same information we kind of give the pregnancy perspective and they help provide this is what we can potentially do when the baby gets here and I think that makes the picture it’s not perfect right you never know until you’ve lived in those shoes what it’s going to be like but we try to get patients as much information possible from both teams together and it will be so fantastic I know we’ve talked a little about people influence having the frustration and we drive through it every day on kingshighway about the amount of construction that’s been ongoing in the last few years and it’s to a great end a significant part of what’s being for together right now is this women in penn center which will engage all right about everything you see there’s there’s a balcony that connects to a defensive end opening a walkway of bridge walkway that connects two of the building and that connects mouth and baby and so very soon you’ll be on the same floor with a lot of those more medicines in the medicine specialists and maternal fetal medicine and over you and it’ll be a lot easier to have those conversations and make everything relatable which we’re looking forward to yeah and we’re also looking forward to this beautiful new facility where people others will be able to deliver babies and before we let you go and it’s so funny because I started them stuff like I can’t imagine we’ll go past 30 minutes I have no idea how long we’ve been talking but I know it is more than 30 minutes of doing any questions they have for development and the two very specific question okay so Laura said that she’s on blood thinner blood blood center inspection injections because of an unknown cause PE four years ago my baby’s measuring in seven 70th percentile at 17 weeks do you recommend stopping blood thinners I all ready to tell you the answer the question should i go by can remind to taste okay so i would say mistake if they were prescribed someone felt that you needed them and you know one other thing is we talked about before we’re on camera second opinions so I am never offended when a patient gets a second opinion and no physician ever should be so if there’s ever something that’s happening with the care where it’s like I’m not sure about this I’m not comfortable or even if it’s like I totally trust my doctor but I just want to make sure that another person agrees with then go for it I think that we all need to take ownership of our care and advocate for ourselves and so you know in terms of the probably on lovenox most likely it’s either go back to the doctor and kind of say can you explain to me exactly why I’m on this or go get a second opinion to make sure that it’s indicated to be on it so I’m not going to say come up with what the doctor prescribed but we’ll be happy to see you in consultation and did you say there was one more time yep so Mindy says that are asked would you recommend trying again after three highly complicated pregnancies and deliveries and one most recent silver 227 week due to undiagnosed MTHFR revealed in the autopsy okay so first of all I’m really sorry and it’s a heartbreaking decision but I say that’s a situation where it’s good to come back kind of like once your heart is healing from like all of the emotional trauma and the grease of that loss to figure out you know what was the underlying thing that happened what are the chances that will happen again or

not happen again and am I willing to take that risk so I think that that’s a really good kind of preconception consultation to go through and the other thing I will say is sometimes just with the drama stuff you feel like you’re the only person who’s ever been through something so horrific right losing your child is something that nobody should ever have to go through and we also have wonderful services and support groups to help moms who have been through similar situations because we’re the regional referral center and people come here from everywhere unfortunately we have our unfair share of moms who have been through similar situations I say number one you’re not alone that there are services and support services to help and once you’re ready I’d say it’s worth bout to have another conversation with a high risk position talk about what can we do to try to prevent these things where could she or another woman in a similar situation go to get access to the support groups and services so i will say that our MFM versus Molly Hanson and Laura 7th house are phenomenal and I basically always ask them hey a lot of clothes and I’m going to say I don’t that i can say i’m trying to rake the back of my brain i know that i have the the website in there along with the phone number but i think that there have been a lot of services mentioned in this that will go back and need to include in the comments so that people have direct access to those and also the place where they can call to get in touch with your one of your colleagues as well in that brings up another thing and I keep feeling we’re going to go for hours here because one of us is spiraling into another but the idea of we talked a little bit about community hospitals and second opinions before once your pregnancy is determined to be high risk do you need to be looking at the facility where you’re going to deliver your baby and what do you need to be taking into consideration so I think the general answer is yes usually the primary obstetrician is maybe pretty good at saying you’re totally fine delivered here we can handle this or you really need to deliver some place like bars or go to st. Louis and in general you think about two things so what is mom and what our mom’s medical needs and can mom needs to be met and community and like I said here we practice with the team approach though it’s not just that I’m so great and so comes into barnes-jewish hospital to deliver right it’s because we have a dedicated cardiologist who is really interested in pregnancy and cardiac disease and I have her on my cell phone on speed dial right is that we have hematologist and we have all of these specialists who helped us to manage these patients so nothing against community hospital I think that what we what we have to provide are these just wealth of resources in this depth of physician to be kind of our super specialized so for mom I say where are your consultants like and do they have a cardiologist you feel comfortable with you if you had cardiomyopathy in your last pregnancy and then for the baby usually it’s a hard and fast rule in terms of how many weeks a baby isn’t in that community hospital deal with it so most places are not going to feel comfortable dealing with a baby for in less than thirty four weeks or if the baby has a congenital defect that maybe probably needs to be born some place like this that’s for the most part where there’s a neonatal intensive care unit so definitely a worthwhile conversation we have some patients who are seeing that literally because they need to deliver at barnes right there’s nothing else to it they just need to deliver here so they’re there any other considerations that you need to take into account with a high-risk delivery does it automatically imply c-section no actually the opposite so our goalie most always is to get mama vaginal delivery yes so there are there are some situations where we need to do a c-section but typically we try to do them for extension indications just like any other woman just because the recovery in general is going to be much better after a vaginal delivery so my hope is for high-risk patients and all patients been a vaginal delivery there are some exceptions to that rule but the exception not the rule statistics are there and then as far as the delivery itself is concerned I know that there are some situations whether you’re talking about multiples or a very early delivery where you can we’ve seen pictures or been you have been in delivery rooms where there are a lot of people and a lot of folks who are dedicated to taking care of baby taking care of mom and taking care of that transition ours are those teams available anywhere or will your OB direct you accordingly if you need to be in a place where there’s a lot of books focusing on your care though oki probably well-directed yes it didn’t we have big birthday parties and not infrequently but i will say even with the big birthday parties i feel like the time when you deliver a child is this

sacred really special time and so even when it’s not normal because it’s high-risk we try to make sure that mom has a nice birth experience and so for all of the people who were watching if I was a mom who was pregnant about to have a baby it was high risk this is what I would put on my birth plan not to 10 page birth plan it’s a real simple birth plan right which is when my baby is born as the baby comes out and looks good so ziggurat like breathing that blew it was a baby on my chest right the guy have been waiting 10 months to meet this little person I left them right here and and get the caveat if the baby is in distress please take them right take them into pediatricians those the baby’s okay I want the baby right here and if the baby is doing ok I would love for my support person husband you know other parent whatever to cut the umbilical cord sometimes it’s not possible right like some of the baby comes out and the babies stress and we are just trying to take care of that child but I say even when things are high-risk we still try to give moms that nice experience and so I say advocate for yourself lament your nurse and physician billing those are things are important to you that they are it is really good advice do we have any other questions given you the points that you think we need to cover here all right I love and you ended on the first plane because toward the end of April we are going to be talking in detail about those and I love that you brought up the 10 pages versus one page I can’t wait to see we have an OB and a labor delivery nurse who are going to be there to talk about that with us so it’ll be so fun to hear from them what they’ve seen over the years and wants to recommend and I know the templates out there do get a little bit modeling I don’t know I didn’t even know there was an option absolutely i think operating in good faith like you choose your team and you have good faith of these people have my best interest at heart right they’re not trying to harm me they’re trying to take care of me and when they’re pushing back a little bit as probably cuz they’re worried about the safety of me or my child I feel like it’s sad that sometimes there’s an antagonistic relationship and I can speak for all of my colleagues when I say unless we disagree with what the patient’s plan is but it’s usually coming from a genuine point of concern then something is not going to go right here so I think it’s nice and there’s that trust and there’s the relationship and I think everything’s closed much better everybody wants the same outcome great we all want a happy mom at healthy mom and a happy healthy baby okay Jeremy partners thank you so much for making time to talk to us today for as long as you get like a way to limit this o’clock or make no long since been going well then again it may take us up a little bit but we will in the next day or two certainly by Monday have links in the comments if not before to a number of the resources that we talked about today so thank you so much for joining us we’ll see you next week to talk about ultrasound thank you you