Happy Go Lucky

In thinking about Michelle Duggar’s most recent birth — baby Josie was born at 25 weeks gestation and is considered a “micro-premie” — I wonder if this has changed or will change their outlook on things. I hope nobody thinks I’m being snide — I’ve certainly seen plenty of people say things like, “It serves them right, having so many kids” or “maybe they’ll stop having kids, finally — I’m certainly not doing that! But I do wonder if their attitude has changed.

It’s easy to think that pregnancy and birth and babies are all easy, all “sunshine and rainbows” when that’s all you’ve experienced. That’s not exactly the case with Michelle Duggar — she’s had now 4 C-sections (if I’m remembering correctly) — the latest one an emergency, with the two previous ones due to the baby being in a sideways position or “transverse lie”, and I’m not sure about the first one but maybe something to do with one of her sets of twins. But aside from this last pregnancy, for the most part her pregnancies seem to be, well, just plain normal.

Among stories I’ve read, shows I’ve seen on TV, friends I know in real life, plus other people that I “know” via the computer, I know that ease of pregnancy is not something many women can take for granted. Some people struggle with infertility. Some women suffer multiple miscarriages. Many women have fetal demises or stillbirths. Many women have severe problems during pregnancy that threaten their health and their baby’s life. Some have had it all.

Recently, I had a miscarriage, but up until that point, I pretty much took it for granted that not only could I easily get pregnant, but that I also would have a problem-free pregnancy and a relatively easy birth. My sister had three miscarriages before she had her first baby; I know that had I miscarried my first pregnancy, that I would have feared that I had the same problem that my sister had. As it was, it has been easy for me to have a basically positive attitude about pregnancy and birth. I still have that attitude, but think it might have been different for me, had I miscarried to start with. Since I had two easy pregnancies, it’s easy for me to say, “That’s what’s ‘normal’ for me, and what is likely to happen.” But others can’t.

Prior to this latest Duggar’s birth, perhaps some time after the Duggars announced the most recent pregnancy, somebody commented on a blog, criticizing the Duggars for having so many children, basically saying they were “asking for trouble” with Michelle having so many pregnancies. This commenter said something about having had severe problems with her two pregnancies, and she opted to be sterilized and enjoy her two children, rather than face a third pregnancy with the potential for something else to go wrong.

The problem is, what happened with Michelle Duggar’s 17th pregnancy (19th baby — she’s had two sets of twins), could have happened with her 1st, or at any other time during her life. Certain problems are more prevalent or more common with older moms, but eclampsia and gall-bladder attacks are not exclusive to “elderly great-grand-multips”. Plus, she had had 16 basically problem-free pregnancies, at the time of that person’s writing, so there was really no basis for her to think that the current pregnancy would be any different. But, of course, this woman was writing from her own perspective — being that of a woman who had had two problematic pregnancies, and could probably scarcely conceive of anyone not having problems.

While I’m not planning on getting pregnant any time in the near future, I do think that I will eventually have another baby or two. And I will probably be a bit more nervous about a miscarriage until I get past the time I miscarried before. Your experiences shape you, for better or for worse. I’m still pretty “happy go lucky” when it comes to pregnancy, but having had a negative experience, I “know” in a different way, I know by experience, that a miscarriage is quite possible, so why shouldn’t it happen to me?

And I wonder if the Duggars, since they have now been “once bitten,” might now be “twice shy”? It’s no skin off my nose, whatever they do, whether that’s get sterilized, intentionally get pregnant as soon as she ovulates again, or anything in between. But I think it would take some very special people not to have some fears and misgivings after this experience.

Pre-eclampsia and Parental Sexual Relationship

That’s an interesting idea. It’s known that a woman’s first pregnancy has a higher likelihood of her ending up with pre-eclampsia than in subsequent pregnancies; there is also a higher likelihood of women who are artificially inseminated (meaning, donor sperm, not her husband/boyfriend’s) ending up with pre-eclampsia than women who conceive naturally. So, researchers looked at how long the father and mother slept together, and found that women who have a short sexual relationship with the baby’s father prior to the onset of pregnancy have a higher likelihood of pre-eclampsia — possibly due to repeated exposure to sperm somehow altering or desensitizing the uterus to the “foreign” presence of the baby (with half of the genetic material being maternal, but the other half being paternal, and being contained, in one way or another, in the other sperm that didn’t make it to an egg). Here’s a link to the study’s abstract, and here’s the link to a blog talking about it [the blog links to a website that you can read the full article (not the study itself, but about the study), if you register (which is free)].

One potential confounding problem, is that women who get pregnant by a man without having been in a long-term sexual relationship with him (for the purposes of this study, it’s 6 months or less), may be at higher risk for pre-eclampsia due to other factors — not having the study, I don’t know for sure if they tried to control for all known risk factors for pre-eclampsia; and even if they did, there may be unknown risk factors for it — some underlying health issues, for instance, that may predispose to pre-eclampsia, that may also more likely to be in women who are not in a long-term, stable relationship. Married women have a lower risk for many pregnancy problems, such as preterm birth and infant mortality, so perhaps this is similar.

Also, I wonder if repeated exposure to sperm during pregnancy plays any role in pre-eclampsia. Take, for instance, a couple who gets pregnant soon after their marriage; and they were either not sexually active prior to marriage, or did not give into temptation much prior to it. They’re probably going to (and I speak from personal experience here!), “make up for lost time,” in their early months (unless she is overcome with nausea or something due to the pregnancy), and she may very well have as much, ahem, exposure to his sperm in a short time as others may have over a longer relationship. One couple may have sex only once a week (like, only after Friday-night dates) — or she could get pregnant from a one-night stand; while others may make love every day. I wonder if that was likewise taken into account — it’s one thing to say, “We started sleeping together three months ago,” and it’s another to document X number of encounters in that span of 3, 6, or 12 months. [They mention “total number of semen exposures” in the abstract, when speaking of SGA (small for gestational age) babies, but again, without the study, I don’t know if they wrote down every woman’s history, or if they took an average, or what.] Some men turn tail and run when the woman tells him she’s pregnant, so there might be a difference between a married couple getting pregnant a month or two into their sexual relationship and continuing it through pregnancy, and a similar couple getting pregnant a month or two into their sexual relationship and not continuing the relationship (for whatever reason). I wonder if there would be a large enough population of women becoming pregnant by artificial insemination to participate in a trial like this — the study arms could be women in long-term sexual relationships prior to pregnancy (in other words, they have multiple exposures to the semen of the father of the baby), women in short-term sexual relationships prior to pregnancy (perhaps separated by whether the relationship continues during pregnancy or not), women in long-term sexual relationships prior to pregnancy, but not with the father of the baby (artificial insemination by another man due to partner’s low sperm count), and women with no heterosexual relationships at the time of pregnancy (artificial insemination as a single woman or a lesbian).

However, even women in long-term relationships can and do end up with pre-eclampsia, so even if being in a stable marriage reduces your risk of pre-eclampsia, it does not totally prevent it.

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Pollution and Prematurity

Since September is National Infant Mortality Awareness Month, and since 67% of infant deaths in the first year occur in babies born prematurely, if we can lower the premature birth rate, we can lower infant mortality.

In June of this year, a new study was released, which showed a higher rate of preeclampsia and preterm birth among women who lived within 2 miles of the busy Southern California interstate system. Here’s the full study.

Background: Preeclampsia is a major pregnancy complication leading to substantial maternal and perinatal morbidity, mortality, and preterm birth. Increasing evidence suggests air pollution adversely affects pregnancy outcomes. Yet, few studies have examined how local traffic generated emissions affect preeclampsia in addition to preterm birth.
Objectives: Examine effects of residential exposure to local traffic-generated air pollution on
preeclampsia and preterm delivery.
Methods: We identified 81,186 singleton birth records from four hospitals (1997-2006) in Los
Angeles and Orange Counties, California. We used a line-source dispersion model (CALINE4)
to estimate individual exposure to local traffic-generated NOx and PM2.5 across the entire
pregnancy. We used logistic regression to estimate effects of air pollution exposures on
preeclampsia, preterm delivery (PTD, gestational age <37 weeks), moderate preterm delivery
(MPTD, gestational age <35 weeks), and very preterm delivery (VPTD, gestational age <30
Results: We observed elevated risks for preeclampsia and preterm birth from maternal exposure to local traffic-generated NOx and PM2.5. The risk of preeclampsia increased 33% (odds ratio (OR) =1.33, 95% confidence interval (CI): 1.18–1.49) and 42% (OR=1.42, 95% CI: 1.26–1.59) for the highest NOx and PM2.5 exposure quartiles, respectively. The risk of VPTD increased 128% (OR=2.28, 95% CI: 2.15–2.42) and 81% (OR=1.81, 95% CI: 1.71–1.92) for women in the highest NOx and PM2.5 exposure quartiles, respectively.
Conclusion: Exposure to local traffic-generated air pollution during pregnancy increases the
risk of preeclampsia and preterm birth in Southern Californian women. These results provide
further evidence that air pollution is associated with adverse reproductive outcomes.

What can be done about this? Not really sure. Move? Try to avoid the freeways, and use the car’s air conditioning system so the air goes through the filter (the researchers’ suggestion). Have a lot of plants in your house, if you live close to a high-traffic or high-emissions area? Perhaps get a personal air purifier?

It’s interesting that only about 60 years ago, doctors “knew” that the placenta acted as a barrier to protect the fetus (which it does… partially), so they gave drugs to mothers under the assumption that the baby could not be hurt. The nausea drug Thalidomide vividly proved them wrong (images of babies born after their mothers took Thalidomide here). Now, doctors are rightly concerned about the air we breathe.

Taking Blood Pressure

Well-Rounded Mama has been having a series of posts concerning “women of size” (particularly pregnant women) and blood pressure. Extremely informative. I did not realize there were several sizes of sphygmomanometers, nor that it makes a difference to have the right size cuff for your arm. But if your arm is larger than “normal” you may very well need a larger cuff in order to get a correct reading on your blood pressure. If the cuff used is too small, it will register your blood pressure as being too high (one woman included a story of being literally an hour away from having an emergency pre-labor C-section for her BP being way too high, when it was discovered that it was the fault of the too-small cuff — her BP was actually normal); if the cuff is too large, it may register a too-high blood pressure as being normal or even low. How many people — of all sizes, both men and women, pregnant and not — are taking blood pressure medicine when their blood pressure is actually normal, or are actually suffering from hypertension when they think their BP is normal? How many skinny-armed pregnant women are told their blood pressure is normal when they are really in danger of eclampsia? How many full-figured pregnant women are told their blood pressure is dangerously high and they need a C-section before they cause harm to their babies or themselves, when their blood pressure is actually normal (or at least not dangerously high)? How many women gain weight during pregnancy, and may need to have an adjustment in blood-pressure cuff size, but don’t get it, so they are risked out of midwifery care and into the care of a high-risk OB, when their blood pressure was actually normal all along — just their arms got larger but the BP cuff didn’t?

Anyway, here are the articles she’s written so far:

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First Sign of Preeclampsia?

A blog post I read about a month ago had this link, which said that “a stable or rising hemoglobin/hematocrit when the blood volume was beginning to contract” was the first sign of preeclampsia. Because I understood that maternal blood volume increased throughout pregnancy, I asked the site owner about this, and she responded,

The article was talking about the earliest signs of pre-eclampsia and the clinical sypmtoms of a contracted blood volume. When a woman is NOT experiencing the beginnings of pre-eclampsia, her blood volume increases with extra fluid, but it takes several weeks for the hemoglobin/hematocrit to catch up to the amount of fluid in the blood volume. Therefore, when running a blood test for hemoglobin/hematocrit, they appear to drop. If that doesn’t happen, that’s a sign that the blood volume is not expanding it’s fluid content. This is considered to be a warning sign that all is not well.

Interesting. It goes on to talk about maternal diet and fluid intake, to help the body fight preeclampsia. I’ve not heard that before, and wondered what everybody thought of it. I don’t know what this midwife is basing her diagnosis on, although she’s written midwifery textbooks, so I assume that she goes into that in greater detail in those. I assume that obstetricians do not generally believe this, but I wonder if they even have ever heard of it.

I can easily see that OBs would dismiss it out of hand, but I wonder if there have ever been studies undertaken that would disprove this. It is easy to say, “Nope! Won’t work!” And much harder to show that it does or does not work. Just like there have been studies that supposedly show that the Brewer Diet does not work, when you look at the actual studies done, they don’t take pregnant women on the Standard American Diet and put them up against a similar group of pregnant women on the Brewer Diet and see how they fare. Instead, what I’ve seen is that they’ll take one element of the Brewer diet (for instance, high protein, or vitamin C, or whatever part they choose to look at that day), and give one group of women the S.A.D. and the other group of women the S.A.D. with extra protein, vitamin C, or whatever, and then with much fanfare say, “See! It doesn’t work! Extra protein doesn’t keep pregnant women from getting preeclampsia.” Well, maybe protein powder doesn’t work, but natural protein (in the form of whole foods, and in conjunction with the other beneficial nutrients found in whole foods such as beans and broccoli) does work. But they don’t check that. They check artificial foods. And I daresay that adding extra protein on top of a nutrient-deficient diet (of french fries and hot dogs) probably wouldn’t keep anyone from getting any disease or ailment; but perhaps extra protein on top of a nutritious diet might. But we don’t know that, because they don’t check it. (If anyone knows of a study which does actually look at the foods consumed, and not just the types of food [proteins or carbs or whatever, as if all protein were identical] or quantity of food [calories consumed or pounds gained], please let me know. I’m anxious to see it!]

Oral Hygiene, Preeclampsia, Preterm Birth

I’d previously read that gingivitis is associated with higher rates of preeclampsia, but that it was not known if it was a “cause and effect” or just an association. If gingivitis causes preeclampsia, then better oral hygiene might prevent some cases of preeclampsia; but if it’s just an association — that women who are predisposed to either gingivitis or preeclampsia, or just are in poorer health or have an underlying health condition — then combatting gingivitis would do nothing.

In that vein, I was intrigued when I read this article, which said that bacteria has been found in the amniotic fluid of women who have given birth prematurely. One possible pathway given was that a kind of bacteria normally found in the mouth (and harmless there) may make its way into the bloodstream, and from there through the placenta into the baby’s amniotic fluid. This might weaken the amniotic sac, or perhaps cause some sort of uterine infection or fetal infection, or something that would account for the preterm birth. This is a new discovery, because this bacteria does not respond to traditional culturing, but instead requires examining DNA.

I wonder if preeclampsia might also be a manifestation of some sort of infection, perhaps transmitted through the weakened areas of the mouth when gingivitis occurs — the puffy and bleeding gums just seem like wide-open places for bacteria to cross into the blood-stream.

As an aside, I had two heart surgeries as a young child, and am supposed to take antibiotics for life whenever I have dental work done. It’s to prevent this sort of thing from happening — nasty oral bacteria (that may do nothing worse than cause bad breath, plaque or cavities when kept in the mouth) upon entering the bloodstream move to the weakest point, which for heart patients would typically be the heart. Southern humorist Lewis Grizzard eventually lost his life because of this — after four heart surgeries. In a pregnant woman, the baby may be “the weakest point” which is attacked, or at least may be the area with the least defenses. Antibiotics are given with the hope and assumption that if the dental patient’s mouth is pricked or otherwise open and/or bleeding, and oral bacteria enter the bloodstream, that the prescription antibiotics will prevent these bacteria from setting up a heart infection.

When I was pregnant the first time, I didn’t know about the gingivitis-preeclampsia risk, much less this newly released bacteria-preterm birth link. But I did know about the possibility that always exists (no matter how small) for oral bacteria to enter the bloodstream through an open sore in the mouth. I assume the risk is much greater when, say, the pick that cleans your teeth and may have untold numbers of bacteria on it jabs into the gum and more or less “injects” the bacteria below the surface. However, when my gums bled during pregnancy — which is not uncommon — I was concerned and wondered what to do about it. Sometime in the past, I had read that gingivitis might be caused by a lack of vitamin C, or at least, that taking vitamin C would stop it. You’re not supposed to take large amounts of vitamin C while pregnant because the baby might develop scurvy (although I think this is mostly talking about large doses around the time of birth, causing the baby to develop scurvy after birth when he’s withdrawn from the maternal vitamin C; and I’ve read one doctor who prescribes large doses of vitamin C, and his protocol for dealing with this is to give the baby vitamin C as well, and then gradually wean him off of it), so do your own research before doing anything! So I took a couple of grams of vitamin C for a few days, in addition to whatever was in my prenatal vitamin, whenever my gums started bleeding, and usually within a day it would stop. I only had to do this a few times during pregnancy.

This seriously bugs me

While working on a totally unrelated post, I came across this study which shows that DES daughters (women exposed to DES while they were fetuses) have a higher risk of preeclampsia. This is in addition to the higher risk of and incidence of reproductive tract problems, infertility, ectopic pregnancy, preterm birth, vaginal cancer, breast cancer, etc. Since I apparently am also a DES daughter, I’m taking this very personally.

A brief synopsis, in case you don’t want to read all of the previous DES posts: I have a cockscomb cervix, which as far as I can tell is only ever attributable to DES exposure. I must be either a DES daughter or granddaughter. I was born in 1977, six years after the FDA issued a warning against prescribing DES to pregnant women, because they finally figured out after 40 years of using it, that not only was DES not helpful (for preventing miscarriage, supposedly), but it caused some babies exposed to DES in utero to develop vaginal cancer in childhood or adolescence. (It makes me wonder what else is being pushed onto the masses with no possible way to know of any long-term damage, and when we’re going to finally find out that the “cure” is worse than the disease.) So, I’m too young to be a DES daughter… yet my cervix tells a different story. My mom took prenatal vitamins with me, but no drugs. DES used to be formulated into PNVs. The other possibility is that I am 3rd-generation, which means that my mom is actually the DES daughter, and my grandmother took it when she was pregnant over 60 years ago. The only problem with that scenario is that my grandparents were dirt poor, and at that time, DES was exhorbitantly expensive — I forget the exact number one lady remembered, but it was more than her rent or mortgage at the time. Also, my grandmother never experienced a miscarriage or a threatened miscarriage, which would have been the main reason for it to have been prescribed then. (It wasn’t until the 50s that DES was really pushed for “healthy babies” instead of supposedly reducing miscarriage rates.) It’s unlikely that they could have afforded it; and my mom said something like my grandmother didn’t want to be pregnant, so wouldn’t have taken drugs to avoid a miscarriage anyway.

My oldest sister had a septate uterus, my other sister was recently treated for precancerous spots on her cervix (dysplasia) — both of these are more likely in DES daughters. Did my mom take DES with all of us? Or was she a DES daughter, and passed on some problems to us? My mom’s sister had one pregnancy, and had such a horrible case of toxemia (as it was called then) that her doctors told her never to get pregnant again. My cousin was born early (I’m thinking a month or so early) after my aunt went into seizures unexpectedly. My cousin had such horrible “female problems” that she got a hysterectomy in her mid-20s, because she couldn’t handle the symptoms any more. She experiences bouts of depression related to that, and not being able to have any more children, and now wishing she’d tried alternative therapies. Is it common to have so many gynecological problems in one family? My mom’s and my sisters’ and my pregnancies and labors were all uneventful, as far as that goes… well, except for my oldest sister’s three miscarriages prior to her uterine surgery. And she went on progesterone, in case it was hormonal, not structural.

Ok, enough of following rabbit trails. Back to preeclampsia.

When I first started researching DES, the thought struck me, that with all the people who were exposed to DES, that could seriously change some statistics, if DES caused problems. Since DES was in PNVs, how many women took them without realizing it? How many children (now adults) were really affected? The most common estimate is 5-10 million people. If half that number is female, then 2.5-5 million women were affected by it. Supposedly, those women are past the age of childbearing for the most part, so it shouldn’t be a problem any more, right? Well, what if it affects the DES daughter’s offspring? From what I can tell, one small study concluded that there was little difference between exposed and non-exposed granddaughters. But I don’t like the sample size of it — I think it’s just too small.

This is, I think, an important point: if being exposed to DES increases all of these problems, then DES exposure ought to be considered as a separate factor, when looking at women with these problems, or looking at the mass of women as a homogeneous group. If being exposed to DES in utero doubles the risk of developing preeclampsia, then that needs to be considered in trials that look into preeclampsia, and whether or not certain factors are involved in the development or continuation of the disease. One problem is, most people probably wouldn’t know if they or their mothers were exposed to DES or not. Really, the only way to tell would be to look at the mother’s or grandmother’s prenatal records, and see if DES was prescribed. But, come on, who has access to 60-year-old doctor’s records? I doubt if doctors or hospitals even keep them longer than 20 years, unless required by law.

Was I or my mother ever exposed to DES in utero? I suppose I’ll never know for sure. But one thing is for sure — it really bugs me that it was even done. A whole generation, or two, or three is now saddled with the sad effects of this legacy. Over-eager, over-active, over-zealous doctors who thought they knew everything, and thought they could improve on nature by giving women extra hormones, simply because they could. The dosages of these hormones was mind-boggling. And it caused a lot of men and women to have reproductive tract problems. And it increased their risk of cancer. It took from 1938 until 1971 for scientists to actually figure out that DES caused these problems. What will we find out about tomorrow?