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Prescription Medications While Pregnant

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A subject near and dear to my mom-scientist’s heart is the rapid increase and over-use of prescription medications during pregnancy. In the span of about 30 years, we’ve moved from a strong, and perhaps more medically prudent, tradition of no medication, no caffeine, no alcohol while pregnant, to 70–80% of women taking at least one prescription medication during pregnancy.

The Rise in Prescription Medications During Pregnancy

According a report by the CDC, between 1976-2008 prescription medication use during pregnancy grew at a staggering rate.

  • 60% increase in first trimester prescription medication use
  • The number of women taking >4 prescription medications while pregnant has tripled
  • The number of women taking anti-depressants while pregnant has increased significantly
  • 1 in 33 babies are born with birth defects

On average, American women are taking 2.3 medications during pregnancy and sometimes more. I cannot help but wondering when we became so unhealthy.

Prescription Opiates During Pregnancy

More recently, a study published in the Journal of the American Medical Association estimated that 13,500 babies are born every year with Neonatal Abstinence Syndrome or NAS. NAS is a polite way of describing children who are born addicted to the pain killers that were, at least originally, prescribed by physicians to their pregnant mothers. Infants who, in their first moments of life outside the womb, must endure the suffering of opiate withdrawal.

Anti-depressants During Pregnancy

A similar abstinence syndrome is observed in infants born to women taking prescribed selective serotonin uptake inhibitor (SSRI) anti-depressants. It’s called newborn behavioral syndrome, another overly benign name that describes the tremors, agitation, excessive crying, respiratory difficulties, and seizures that emerge post birth as an infant withdraws from SSRIs. This is addition to the increased risk of congenital heart malformations, Long QT syndrome and Persistent Pulmonary Hypertension, that are associated with SSRI infants.

Take Back Pregnancy

Much of this increase can be attributed to the brilliance of pharma’s mega-marketing machine, but the culpability for the consequences lay with us. Women make 80% of all family medical decisions.  We are the deciders for health. We have bought into the notion that a pill cures what ails us. Sometimes it is true. Often times is it not. It is incumbent upon us to know the difference, especially during pregnancy. Many women do not realize that:

Medications do not metabolize the same way in a pregnant versus non-pregnant woman

Most medications cross the placental barrier

Drug testing is not done on pregnant women

So we often have no idea what works, does not work and what the true risk and severity of the side effects will be until after the medication hits the market. Even then, the true risks are difficult to discern because of the glut of medical marketing that often discredits the early reports.

Marketing Prescription Medications To Physicians and Consumers

Just because a medication is prescribed by a physician or it can be purchased over-the-counter, does not make it safe. All medications have side-effects and most of those are not well-understood during pregnancy.  In the case of anti-depressants during pregnancy, study after study, after study, after study (here, here, here) has been published showing the adverse effects of these medications during pregnancy. Indeed, another two were published just recently, linking anti-depressants to pre-term birth and infant convulsions. And yet, the conventional wisdom has been, and is still, that treating depression during pregnancy pharmacologically will improve pregnancy outcome.

“Depression treatment during pregnancy is essential. If you have untreated depression, you might not have the energy to take good care of yourself. You might not seek optimal prenatal care or eat the healthy foods your baby needs to thrive. You might turn to smoking or drinking alcohol. The result could be premature birth, low birth weight or other problems for the baby — and an increased risk of postpartum depression for you, as well as difficulty bonding with the baby.”

The data have not born that out. Even the FDA , though they acknowledge the serious adverse events associated with SSRIs during pregnancy,

“FDA Drug Safety Communication: Selective serotonin reuptake inhibitor (SSRI) anti-depressant use during pregnancy and reports of a rare heart and lung condition in newborn babies.”

they recommend no changes in prescribing practices.

“At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression during pregnancy. Healthcare professionals should report any adverse events involving SSRIs to the FDA MedWatch Program.”

What Is a Girl To Do?

Learn a little chemistry, understand basic statistics, read and research every medication you take, even when you are not pregnant, but especially when you are, and most importantly, make educated choices about your health, your child’s health and the health of your family.

Photo by Joshua Hoehne on Unsplash.

This article was published originally on Hormones Matter in September of 2012. I am sad to say, the problem has only become worse.

 

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Maternal Vitamin D: Pregnancy and Beyond

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Pregnancy Vitamin D

Researching the role of vitamin D in pregnancy for this article, I unexpectedly blew inches of virtual dust from a page of medical correspondence published almost seven decades ago. With keen interest I read “Vitamin-D Requirements in Pregnancy,” published in a 1947 edition of the British Medical Journal. The author Edgar Obermer, MD asserted the necessity for English pregnant women to supplement with robust daily doses of vitamin D.

Perhaps Dr. Obermer was ahead of his time, or today we are behind in understanding the power of vitamin D. I think both are true. Nonetheless, his assertion about relatively high maternal vitamin D doses accentuates vitamin D’s importance during pregnancy. Today pregnant women typically supplement with prenatal vitamins, most of which only contain enough vitamin D to prevent rickets.

Unfortunately, taking prenatal vitamins without supplementing with extra vitamin D provides expectant mothers with a false sense of health for their babies and themselves. In this article, I address vitamin D’s role in pregnancy, recent evidence supporting the positive effect of vitamin D on expectant moms and their babies, and vitamin D supplementation guidelines for pregnant and lactating women and their infants.

A Healthy Pregnancy

Many people may not realize that vitamin D is actually a steroid hormone produced in our body. We manufacture vitamin D when we take a quality vitamin D3 supplement, expose our skin to optimal sunlight, or consume lots of wild-caught fatty fish or vitamin D3-fortified foods.

The female reproductive system comprises billions of cells. Every cell in the female reproductive system contains genetic codes as well as a receptor to receive vitamin D. Cells in the female reproductive system (including the ovaries, fallopian tubes, uterus, placenta, decidua, vagina, and breasts) are replete with vitamin D receptors.

When we have ample amounts of activated vitamin D in our cells, the vitamin D binds with its receptor to regulate genes in our reproductive system. For example, the vitamin D pathway genes affect in utero fetal development. Conversely, when the female reproductive system lacks activated vitamin D, genes essential to a smooth pregnancy and sound fetal health are not expressed.

Mom Needs Nutrients for her Health

Vitamin D is vital to a pregnant women’s health. An expectant mom with adequate vitamin D levels may enjoy a reduced risk of pregnancy complications including preeclampsia, gestational diabetes mellitus, Caesarian section, and preterm birth. However, low vitamin D blood serum levels are common in pregnant women.

The recent findings of a Canadian study published in the December 2014 edition of the journal Current Opinion in Obstetrics and Gynecology once again accentuate the importance of vitamin D to maternal health. Lead researcher Shu-Qin Wei, MD, PhD examined scientific evidence of the role of maternal vitamin D on pregnancy outcomes. Focusing on studies published between January 1, 2013 and July 1, 2014, she concluded: “Recent evidence supports that low maternal vitamin D status is associated with an increased risk of adverse pregnancy outcomes. Interventional studies demonstrate that vitamin D supplementation during pregnancy optimizes maternal and neonatal vitamin D status.”

A Seed for Healthier Babies

Vitamin D is vital to fetal bone and cell development. Medical research suggests some seeds for disease are sown before birth. Low vitamin D during pregnancy may be one of those seeds. Babies born to mothers with a vitamin D deficiency are more likely to develop a number of medical conditions including asthma; autism; soft bones (rickets, craniotabes); brain disorders; cardiovascular malformation; and type 1 diabetes mellitus.

A new study highlights the benefit of vitamin D to fetal skeletal development. Dutch researchers explored the effect of vitamin D supplementation during pregnancy and early infancy on skull formations. The scientists recommended that women in their last trimester and early infants take a daily vitamin D dose of 400 international units ((IU) albeit a small amount). The research team found that non-adherence to their recommendations for vitamin D supplementation by pregnant mums and infants is linked to an increased risk of skull deformities in babies at 2 to 4 months of age. This study was published in a November 2014 issue of the journal Maternal & Child Nutrition.

Labor, Lactation, and Early Infant Life

Vitamin D also plays a beneficial role regarding labor pain, breastfeeding, and early infant health.

Labor. The benefits of maternal vitamin D have recently been extended to decreased labor pain. In October 2014, Andrew W. Geller, MD, a physician anesthesiologist at Cedars-Sinai Medical Center in Los Angeles, presented a study about vitamin D‘s effect on labor pain to the American Society of Anesthesiologists’ annual meeting. Dr. Geller and colleagues measured the vitamin D levels of 93 pregnant women prior to delivery. All of the patients requested an epidural for pain during labor. The research team then measured the doses of pain medication required by each woman during labor. They compared the quantity of pain medicine consumed by women with higher vitamin D levels with those with lower vitamin D status. The patients with lower vitamin D levels used more pain drugs than those women who enjoyed higher vitamin D status. Dr. Geller concluded that “prevention and treatment of low vitamin D levels in pregnant women may have a significant impact on decreasing labor pain in millions of women every year.”

Lactation. Nature intended for newborns to obtain their nutrients, including vitamin D, from breast milk. Breastfeeding provides babies with the vitamins and minerals required for healthy development. That’s why it is imperative that lactating mums supplement daily with adequate vitamin D. Vitamin D supplementation guidelines are discussed in the next section of this article.

Early Life. Vitamin D is important to all stages of life including neonatal. The growth and development of an infant is associated with the vitamin D intake during pregnancy.

Recent research from the University of Southampton in the United Kingdom suggests that young children are likely to develop stronger muscles when their mums enjoyed a higher level of vitamin D during pregnancy.

The connection between vitamin D levels and muscle strength has been well-established by the scientific community. However, the Southampton study, published in the January 2014 issue of the Journal of Clinical Endocrinology and Metabolism, marks the first time that the relationship between maternal vitamin D status during pregnancy and the muscle development and strength in offspring was examined.

Led by Nicholas Harvey, PhD, the researchers measured the vitamin D levels in 678 mothers from the Southampton Women’s Survey in their later stages of pregnancy. Four years after the babies were born, the Southampton team measured their hand-grip strength and muscle mass. The researchers found that the higher the levels of vitamin D in the mother, the higher the grip strength of her child. A secondary finding addressed a lesser connection between maternal vitamin D and the child’s muscle mass. The Southampton study’s outcome suggests more far-reaching health benefits. Dr. Harvey commented,

“These associations between maternal vitamin D and offspring muscle strength may well have consequences for later health; muscle strength peaks in young adulthood before declining in older age and low grip strength in adulthood has been associated with poor health outcomes including diabetes, falls, and fractures. It is likely that the greater muscle strength observed at four years of age in children born to mothers with higher vitamin D levels will track into adulthood, and so potentially help to reduce the burden of illness associated with loss of muscle mass in old age.”

Supplementation Guidelines for Mum and her Newborn

The importance of vitamin D supplementation cannot be overstated for the health of mothers and their infants.

British nutrition expert Sara Patience, author of the new book Easy Weaning, stated, “It’s important for mums to understand that their baby will be born with the same vitamin D status as themselves, therefore, if mum is vitamin D deficient during pregnancy, baby will be too. Women, who are pregnant, or planning to become pregnant, should ensure they are vitamin D sufficient, not only to protect their own health, but also to protect the health of their baby.”

The most effective source of vitamin D3 (cholecalciferol) is an oil-based soft gel or liquid supplement. Vitamin D3 supplements (usually measured in international units) are available over-the-counter in retail and online stores. Beware of vitamin D prescriptions as most contain vitamin D2 (ergocalciferol) that is much less effective than vitamin D3.

How much vitamin D a pregnant woman (or anyone, for that matter) needs continues to be a topic of debate.

First, let’s consider Dr. Obermer’s surprising recommendation in 1947. Remarking that the subject of vitamin D supplementation in pregnancy “is a difficult and complex one,” he concludes, “In a climate like that of England every pregnant woman should be given a supplement of vitamin D in doses of not less than 10,000 i.u. per day in the first 7 months, and 20,000 i.u. during the 8th and 9th months.” (Note: England’s distance from the equator denies its residents from enjoying optimal sun light exposure during the majority of the year.)

Second, a few noted organizations recommend daily intake of vitamin D for pregnant women as follows:

  • Vitamin D Council: 4,000-6,000 IU (Upper limit: 10,000 IU)
  • Endocrine Society: 1,500-2,000 IU (Upper limit: 10,000 IU)
  • Institute of Medicine (IOM): 600 IU (Upper limit: 4,000 IU)

It is interesting (and refreshing) to note that the Vitamin D Council and the Endocrine Society’s “upper limit” recommendations almost mirror those of Dr. Obermer’s. Please note that the IOM’s Food and Nutrition Board’s controversial recommendations, announced four years ago, were largely based on nutritional requirements for bone health. Most vitamin D experts agree that the IOM’s guidelines are woefully low with regard to vitamin D and way too high concerning calcium. Moreover, the intake of magnesium and vitamin K2 (vitamin D co-factors) was not addressed by this IOM panel.

According to the Vitamin D Council, if you are lactating and taking 6,000 IU of vitamin D daily, your breast milk should have enough vitamin D for your baby. If you are taking less than 5,000 IU of vitamin D a day, you should give your baby a daily vitamin D supplement (quality vitamin D3 drops are widely available).

Daily supplementation guidelines for babies include:

  • Vitamin D Council: 1,000 IU (Upper limit: 2,000 IU)
  • Endocrine Society: 400-1,000 IU (Upper limit: 2,000 IU)
  • Institute of Medicine: 400 IU (Upper limit: 1,000-1,500 IU)

Why risk pregnancy and neonatal complications? Vitamin D supplementation is a safe, inexpensive, and effective approach to a smooth pregnancy and birth of a healthy baby.

**This article is a companion post to “Improving Male and Female Fertility with Vitamin D”.

Editor’s Note: Susan Rex Ryan is an award-winning author who is dedicated to vitamin D awareness. Her extensive collection of health articles can be found on Hormones Matter as well as on her blog at smilinsuepubs.com Follow Sue on FB “Susan Rex Ryan” and Twitter @vitD3sue.

Copyright © 2014 by Smilin Sue Publishing, LLC
All rights reserved.

This post was published previously in December 2014.

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Pregnancy Hypertension

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Chandler Marrs

Every now and again I have the great pleasure of stumbling upon a brilliant piece of research; research that shakes the very core of medical science. Sadly, this is not one of those times. No, with the research I write about here, I cannot help but wonder why? Why was this study conducted? Why was it funded? Why was it published in such a prominent journal? And perhaps most importantly, why are there 15, well-credentialed, and likely, very highly accomplished individuals, lending their names to such a weak piece of research? Did they not read the study?

Just last month, published in the esteemed The New England Journal of Medicine, whose impact factor (54) far exceeds most journals in the space by a factor of 10, published a purportedly seminal piece on pregnancy hypertension: Less-Tight versus Tight Control of Hypertension in Pregnancy. The study was a huge, presumably well-funded (through a grant from the Canadian government), multi-center, international, randomized controlled trial set to investigate the important topic how best to treat pregnancy hypertension.

Pregnancy Hypertension

Hypertension during pregnancy is a growing problem that brings with it substantial risk to maternal and fetal health. How to treat pregnancy hypertension is of critical importance but not a single anti-hypertensive medication on the market currently has been tested for safety on pregnant women. Few data exist to evaluate the risks of taking such medications on short-term maternal or fetal health and no data exist to identify long term consequences. Not even the most basic of studies, those that evaluate drug pharmacokinetics and delineate appropriate dosing have been conducted for pregnancy (or any other complex hormonal environment).

Drug disposition and metabolism are altered significantly by pregnancy when hormone concentrations, plasma volume, enzymes, binding proteins, liver and kidney function change radically. These changes impact drug dosing and safety. Without proper consideration for these variables during pregnancy, the potential for overdosing and mis-dosing is significant, increasing the possibility of evoking serious maternal and/or fetal ill-effects. Setting aside the question of whether medications should be given at all during pregnancy (I don’t think they should be), I think we can all agree that when medications are necessary, safety and efficacy data must exist prior to administration.

It is from this perspective, that I approached the current study; a long overdue investigation about the safety and efficacy of anti-hypertensive drugs during pregnancy. Boy was I disappointed. In fact, the authors state: “We did not collect information on common adverse effects of anti-hypertensive medications…”  In fairness, however, other important outcome data were collected, but the design of the study was so arbitrary that any potential insight these outcomes might have contributed, was lost.

Study Details

The current study asked whether controlling maternal blood pressure strictly within a pre-defined range of parameters provided better or worse maternal or fetal outcomes compared to a more flexible approach with a broader range of accepted blood pressure metrics. For the tight control group, the goal was to maintain diastolic blood pressure at or below 85 mm Hg. For the less tight group, diastolic pressure was to be maintained at or below 100 mm Hg. The study accepted medicated and non-medicated hypertensive women (n = 987, 56-58% were medicated from each group prior to entering the study), who were anywhere from 14 weeks of pregnancy through 33 weeks pregnancy (mean = ~23 weeks).

Once participants were enrolled into the study, decisions regarding whether to medicate (if not previously medicated), which medication to use, and at what dosages, were left to the providing obstetrician’s discretion. The study excluded women who, at the time of admission into the study, showed signs of pre-eclampsia, demonstrated high systolic blood pressure (>160 mm Hg), had pre-gestational diabetes, renal disease or were utilizing ACE inhibitors (angiotensin-enzyme-converting enzyme inhibitors). If these conditions developed subsequently, patients remained in the study.

The primary outcome variables included: pregnancy loss (miscarriage, ectopic pregnancy, elective termination, perinatal death), high level of neonatal care for greater than 48 hours, gestational age and weight at delivery and a range of neonatal complications. Secondary outcome variables, measured at a much more rigorous statistical significance level (p>.001) compared to the primary variables (p>.05) included: serious maternal complications (uncontrolled hypertension, transient ischemic attack or stroke, pulmonary edema, renal failure and transfusion), placental abruption, severe hypertension (>160 mm Hg systolic or >110 mm Hg diastolic blood pressure), pre-eclampsia or abnormal labs indicative of incipient pre-eclampsia.

Results

The reported results of this study were as follows:

  1. There were no between group differences in either maternal or fetal complications.
  2. Women in the less tightly controlled group had higher blood pressure.

So for all of the money and time spent, we learned that anti-hypertensives do, in fact, reduce blood pressure, and that how intensely one uses these medications has no statistical bearing on this particular set of outcomes. This is not to say that there were not negative outcomes. There were plenty in both groups of participants; from severe maternal hypertension, pulmonary embolism and pre-eclampsia, to serious neonatal complications and fetal death. There were simply no statistically identifiable differences in the rates of these complicatiosn between the two groups. In other words, both groups had similar rates of negative outcomes.

Flaws in Study Design

Why weren’t there any statistically relevant differences between the two groups?  The answer to this question involves study design and herein we have a number of problems. First, the participant pool was largely hypertensive and medicated before entry into the study, providing no real control group from which the assess differences between blood pressure and outcomes in unmedicated versus medicated women. Elevated blood pressure is a significant risk factor for a number of maternal complications but so too are medications. What is the risk/benefit calculus that determines when the inherent risks of medications during pregnancy are outweighed by the risks of maternal blood pressure? In other words, when should we medicate to control hypertension?  Delineating between the dangers of the blood pressure versus those of the medication would have been more telling. Admittedly, such a study would present ethical considerations and quite possibly could have only been done retrospectively. Nevertheless, without these types of data, it is impossible to discern either the safety or efficacy of any therapeutic intervention; effectively nullifying the results from the onset.

A second methodological problem is the failure to address statistically pre-existing health conditions and environmental variables that confound results. That is, we don’t know what portion of the overall negative outcomes might be attributable to pre-existing or even extraneous maternal health issues versus medication use or blood pressure control. For example, a good percentage of the women in both groups were not only medicated prior to entry into the study but were significantly overweight pre-pregnancy, smoked and/or had additional health considerations. These variables would independently impact maternal and fetal outcomes, but also, could additively or synergistically influence blood pressure and other maternal risk factors. Although the mean data for both groups were presented, no analyses that might provide a richer understanding of the relationship between blood pressure and perinatal outcomes was given.

Perhaps the most problematic aspect of this study was the failure to analyze data regarding the types and dosages of medications relative to the negative outcomes. Though the researchers collected medication data and reported some of those data in the supplementary appendices (number of women per group who took a particular type of medication absent dosages was reported), there were no analyses presented. This made it impossible to identify whether certain medications were more dangerous than others and would account for the observed negative outcomes in either group. Neither did this report tell us about the dose-response relationship relative to effective blood pressure management versus adverse reactions – a very basic calculation – nor did they tell us about the role of medication interactions in the observed negative outcomes.

What Value is This?

From the standpoint of a practicing physician, a researcher or a patient, what use is a study on medication safety and efficacy during pregnancy, if there are no analytics delineating dose-response relationships by medication(s) and risk factor?  Is one medication safer than the others? Does a particular medication work better or worse for a specific group of women? Are there anti-hypertensive medications that are more or less effective during pregnancy at managing blood pressure? Or even more basically, are the dosages we currently use correct? With such a large study group, we could have learned which medications could be used safely during pregnancy, at what dosages, and with which groups of women. It is likely that some women should absolutely not be given medications due to confounding health conditions.

To answer any of these questions would have been highly useful and added significantly to the body of scientific research on pregnancy hypertension. In its current form, however, this study adds little, if anything, to our understanding of the pregnancy hypertension, the use of medications to control hypertension during pregnancy or their potential negative side effects. All this study tells us is that blood pressure medications tend to lower blood pressure and evoke complications in some women. Well, of course they do. That is not novel. We knew that already.

There are so many missed opportunities here. Not parsing the medication, dosage data was an egregious omission; one that makes me wonder why it was funded and why it was published in such an esteemed journal. And with 15 authors attributed to this study, why did no one on the masthead push to expand the analytics beyond what was presented? Pregnancy hypertension can be deadly and there is a striking lack of research in this area. Why are we not asking the big questions?

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Maternity Care: US Versus Malaysia

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pregnancy

Undoubtedly, one of the happiest times of family life may also be one of the most stressful if a pregnant woman, in the United States, finds herself without health insurance, or with health insurance that doesn’t cover maternity care. Between, 1993-2007, the average cost of an uncomplicated cesarean section more than doubled; and the cost of an uncomplicated vaginal delivery tripled. “Looking at a sample of 9 states, researchers found that 17% to 41% of childbearing women lacked insurance before coming pregnant,” says Carol Sakala, director of programs at Childbirth Connection, a nonprofit organization that works on behalf of mothers and babies to improve the quality of maternity care in the U.S. “While 13% to 35% of the pregnant women qualified for Medicaid coverage, many either didn’t qualify or didn’t apply, finding private insurance or paying out of pocket,” Sakala says.

Let’s examine the costs, of what is considered essential care, associated with having a baby in the United States today. The average cost of prenatal care is roughly $2,000, which covers about fourteen doctors’ visits.  High risk pregnancies normally incur more tests and monitoring, which significantly increases prenatal expenditures. Add an additional $0-$300 per test, should blood work, or any other test, be deemed necessary by an OBGYN. The cost of an ultrasound or sonogram costs $100 – $1,000, with an average number of 1-3 during a low-risk pregnancy. An amniocentesis test ranges between $1,100 and $2,000, depending on the facility. The average hospital charge for an uncomplicated cesarean section is $15,800; while an uncomplicated vaginal birth runs about $9,600. A hospital stay afterward can easily increase bills to anywhere from $10,000-25,000. The price range varies widely from area to area and will depend greatly on where a mother lives.

“It’s important to be aware that these numbers reflect the amount a hospital will charge for these services, rather than the actual cost,” says Anne Elixhauser, PhD, senior research scientist at the Agency for Healthcare Research and Quality. “The actual amount of what it costs the hospital to perform the service is about 30% of what’s charged.” Add up these costs and it’s no wonder the average family in the United States has only 1.5 children. The U.S. population growth rate has stagnated for years with a large percentage of its growth stemming from immigration.

Now let’s compare the cost of modern maternity care in the US, with a country that is considered to have a more a traditional culture, such as Malaysia, Southeast Asia; a country I’ve lived in for the last 12 years. In Malaysia, it’s common for maternity care, pre- and post-, not to be covered by insurance. However, maternity costs are very affordable for the typical Malaysian family. Actually, it can be downright cheap to have a baby in Malaysia depending where a family decides to deliver. It must be affordable because Malaysia is a developing economy that is categorized as second world by the World Trade Organization, with a middle income level economy. A typical family earns $15,100 annually; compared with a typical family in the US earning $48,000 per annum. The average number of children per family is 2.6; however this seems low to me. I know many families with at least three or more children.

Nowadays, most births take place in a hospital setting; there are no freestanding birthing clinics, and midwives only practice in hospitals. Malaysia has many public, or government sponsored hospitals. If a family decides to give birth at a public hospital most of the costs are covered by the government; and if you are a government employee, it’s even better, as all the maternity costs are free. At this time the Malaysian government employs one million civil servant with about half being women. Therefore the average government employee normally has more children than those employed by the private sector.

However, the costs for a non-government employee, who chooses to give birth in a government sponsored hospital, are very low. An uncomplicated vaginal birth is $160, a cesarean is $300, and twins are $250. If forceps or vacuum are used, or a breech birth is encountered, an additional $200 is added onto the bill. Daily ward charges range from $1 for a shared room, to $25 for a private room.

Due to the fact that most insurance policies don’t include maternity care, costs vary widely in Malaysia with most hospitals offering competitive “maternity care” packages. Then there is what is called specialist, and semi-private, hospitals that specialize in maternity care. The rates at these types of hospitals are mid-range, with pricing falling between that of public and private hospitals. If a women chooses to have a private OBGYN, at a private hospital, this family would certainly fall into a wealthy income level as the fees are much higher and not be affordable for a typical Malaysian family. For example the cost of each prenatal visit may range between, $30-$100. An uncomplicated vaginal birth is, $1,300–1,600, and an uncomplicated cesarean, $4,000; plus a three to five day hospital stay, costs on average $3,000. A hospital that I know offers the following Maternity Care packages, for a normal delivery with three days and two nights stay for $5,000; and for a cesarean $13,000. Again, this is the high end of the spectrum.

In traditional cultures, like Malaysia, it is considered every woman’s natural right to bear children if they are able to, which is why giving birth is affordable.  It is expected that a woman will give birth in her lifetime, and if there is no medical reason not to, it is viewed as unusual if she doesn’t. Pregnant women are largely supported by the community they are part of, both in the work place and by their family at home. Pregnancy and child birth is an auspicious period, and both the mother and her baby are honored and celebrated in a variety of ceremonies. Birth is slowly becoming medicalized in Malaysia, but it is nowhere near to the degree it is in the US. I don’t think it ever will be like it is in the US, as the strong cultural beliefs and traditions that are firmly in place balance out the pace of the modernization of maternity care.

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Antibiotics during Pregnancy: Finally Pharmacokinetic Research

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A common refrain of mine is the lack of drug testing in women, especially pregnant women and relative to the enormous hormone changes women experience across a cycle, across pregnancy or postpartum and frankly across the lifespan. Hormonally, a 16 year old is not the same as a 45 year old. A woman’s biochemistry is not the same early in her cycle as it is late in her cycle. Nor is it the same when she is on oral contraceptives or hormone replacement therapies compared to when she is not and most especially, the pregnant woman’s biochemistry is hugely different than that of a non-pregnant woman. And yet, despite the lack of testing, lack of data, and limited understanding about how medications work relative to a woman’s hormonal state, women, pregnant and non-pregnant alike, are routinely prescribed medications for which we have a very poor understanding of the basic pharmacokinetics (how a drug travels through the body) or pharmacodynamics (what it does and how it works).

Ever so slowly, this may be changing. A group of researchers from the University Chicago, recently published a study on the Influence of Body Weight, Ethnicity, Oral Contraceptives and Pregnancy on the Pharmacokinetics of Azithromycin in Women of Childbearing Age. Though the study was small with only 53 pregnant women and 25 non-pregnant women, it represents one of the few published pharmacokinetic studies done on a drug routinely prescribed to pregnant women that evaluates hormone state.

Azithromycin: the Most Common Antibiotic Prescribed During Pregnancy

Azithromycin, more commonly known as Zithromax, Azithrocin, Z-Pack or ZMax, is the most frequently prescribed antibiotic for a range of bacterial infections of the ears, skin, throat.  It is believed to be safe during pregnancy, despite having a pregnancy category rating B (a designation given a medication that has not been tested in human pregnancy but appears to be safe in animal studies). Some research shows that Azithromycin appears to have no more adverse reactions than other antibiotics, but whether it is truly safe, whether pregnant pharmacokinetics are different than non-pregnant or how they are different had never been determined. The University of Chicago study demonstrated what many have always suspected:

  • pregnant women metabolize medications differently (more slowly) than non-pregnant women
  • oral contraceptives slow drug metabolism
  • and interestingly enough, African American women show different pharmacokinetic patterns than Caucasian, Hispanic, Pacific Islander or Asian women

Pharmacokinetics: The Basics of Drug Disposition

The disposition of a drug (how it travels through the body), is affected by a number of physiological variables including plasma volume (greater when pregnant, lower when dehydrated), protein binding (fat soluble drugs travel through the system bound and protected from metabolism-preparation for excretion- by carrier proteins), liver and kidney function (our waste removal systems). Any alteration to these variables affects how long a drug stays in the body, how much of the drug is available to exert its effects on the tissues or organs, and how effectively it is cleared from the system. Determining the disposition of the drug- the pharmacokinetics- is very important for drug dosing and ultimately, safety.  Every one of those drug disposition variables is affected by the hormone changes of pregnancy, postpartum (menstruation, menopause, oral contraceptives, HRT, etc.).

In the case of Azithromycin, pregnancy significantly slowed metabolism and clearance of the drug in pregnant Caucasian, Hispanic, Pacific Islander and Asian women, but not apparently in African American women or women not taking oral contraceptives. Translated, this means that pregnant Caucasian, Hispanic, Pacific Islander and Asian women were exposed to more drug, for a longer period of time, than were African American women. Ditto for women taking oral contraceptives versus those who were not taking oral contraceptives.

The researchers did not investigate whether hormonally-related changes in immune function interacted with the pharmacodynamics of the drug–rendered it more or less clinically effective. Nor did they evaluate whether or how other medications may have influenced drug disposition. As an aside, women in the pregnant group were taking more medications, in addition to the antibiotic in question, than the non-pregnant group.

What this research does show, however, is that hormones, or at least ‘hormone state’ affects drug disposition significantly. Additional studies are needed to determine how and if more customized dosing is required in pregnant and non-pregnant women alike.

This article was posted previously in September 2012.

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Do Cesarean Births Increase the Risk of Uterine Rupture?

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The uterus has incredible elasticity: It has the ability to grow from the size of a fist to, well, the size of a baby. In recent years, there have been numerous debates over whether women who have had previous c-sections can or should deliver vaginally with subsequent pregnancies.  The primary risk associated with a VBAC, or vaginal birth after cesarean, is uterine rupture. Though rare, at  2 per 10,000 deliveries, the American College of Obstetrics and Gynecology, issued practice guidelines requiring both the obstetrician and anesthesiologist be ‘immediately available’ during the entire delivery. This effectively eliminated the possibility of VBACs in US hospitals. As a result, VBACs have declined significantly since 1999 and the number of c-sections has increased to nearly 38% in some states.

In the UK, while the c-section rate is much lower, hovering around 23%, the question of VBACs still remain: Does the cesarean birth increase the risk for uterine rupture, and if so how much?

In March, 2012, the UK Obstetric Surveillance System (UKOSS) published a study that found 87% of women with uterine ruptures previously had cesarean deliveries. The risk of uterine rupture increased for those who had VBACS, as opposed to c-sections, (from .3 to 2.1 per 1,000 incidences). Women with two or more cesarean deliveries increased their chances of uterine rupture further, as did a shorter interval between c-sections (within 12 -24 months), labor induction using prostaglandin and/or the use of oxytocin during labor.

Though the scientists recognize that there may be some inaccuracies with the data (for example, they relied on data provided by participating hospitals, and therefore may have omitted some data), the information can still help expecting mothers start a dialogue with their doctors to prepare for future deliveries.

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A Matrifocal View of Endocrine Disruptors and Premature Birth

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Cynthia Caillagh

In the spring of 2012, the results of a long-term study on one of the most overlooked problems in the human experience was released. Born Too Soon: The Global Action Report on Preterm Birth, jointly sponsored by The March of Dimes Foundation, The Partnership for Maternal, Newborn & Child Health, Save the Children and The World Health Organization revealed an annotated selection of possible causes as well as detailed plan for actions intended to reduce premature birth and death. It also presented a dismal report card of the childbearing management and outcomes of the world’s countries; the United States ranked shamefully at 131st in preterm births.

The United States’ ranking is particularly shocking in that the primary causes of premature birth and death have supposedly been ameliorated. Since the 1990’s, lung maturity has been addressed through use of steroid injections at the first signs of labor. Nutrition has been addressed since the 1980’s through increased maternal resources (Women, Infants and Children or WIC ). Issues of ill-health, notably under/overweight, diabetes, high blood pressure, smoking, infection, age, genetics, multiple pregnancy and closely spaced pregnancy are supposedly mitigated through our mind-boggling 35% average, surgical intervention rate.

The US is unique in that its obstetrical practices include a substantial number of pregnancies are introduced by in vitro fertilization (IVF) and artificial insemination (AI) (increasingly performed in other countries, with birth occurring within the US borders). Additionally, first time moms in the US are often older and cesarean sections, either elective or for perceived complications, add to the increasing rate of prematurity in the US. These facts are presumed to explain the dismal state of maternal health and rise of premature births seen over the last decades in the US. Using these circumstances to disregard a troubling trend, however, negates the fact that this same population where premature birth is increasing, represents some of the best fed and medically attended women in the world. And yet, our premature birth rate continues to increase, along with births in which unusual defects of placenta, cord and newborn become more prominent. Why is this?

Reproductive technology and other variables not-withstanding, the largest and most rapidly developing body of evidence suggests that being born too soon is just one of the consequences of long term chemical exposures from foods, medicines and environmental contaminants. Endocrine disrupting chemicals, whether by pharmaceutical or environmental exposure, elicit subtle but recognizable damage to broad swaths of mammalian cells; damage that is complex and chronic, likely spanning multiple generations. It is damage that we are only beginning to understand.

The Power of Small, Frequent Exposures to Endocrine Disruptors

February 19, 2013 – just 9 months after Born Too Soon was published, the massive 296 page, multi-continent report on the probable effects of endocrine disrupting chemicals (EDCs) was published in joint by the World Health Organization and The United Nations Environment Programme. Though it hardly made a whimper in the common press, State of the Science of Endocrine Disrupting Chemical-2012 is a shocking narrative into the damage being done to all mammalian cells, especially and most importantly by small, frequent exposures.

In the earlier 2002 version of this report, the Global Assessment of the State-of-the-Science of Endocrine Disruptors concluded that “there is weak evidence that human health has been adversely affected by exposure to endocrine-active chemicals.”  Under then-current testing, toxicity was most frequently measured by highest tolerable dose.  Despite early works such as Silent Spring, it was not until anecdotal insight gained through the popular book Our Stolen Future: Are We Threatening Our Fertility, Intelligence and Survival? that science began to wonder if it was asking the right questions.  While it is clear that massive doses of any chemical has a level at which cellular death is inevitable, is it possible that the living cell is more impacted by low, consistent doses?

With the release of the updated State of the Science the evidence is clear and the answer is yes; human health is indeed being adversely affected by exposure to endocrine-active chemicals at remarkably low and varied levels. Further, it is clear that we have been accumulating both exposure and cellular change for many years, certainly at least as long as the earliest pesticides and hormones at the turn of the century.  Although scientists cannot agree on specifics about identification of and protection from endocrine disrupting chemicals, the global scientific chatter indicates that the State of Science is an urgent warning that most endocrinologists are taking very seriously. We are changing cellular behavior from the mitochondria (the cells furnace) outward and the consequences are profound and growing (here) and (here).

So substantive is the insight contained within State of the Science  that ACOG followed in October 2013 with its own 17-page report, Exposure to Toxic Environmental Agents, reiterating the dangers of, and potential consequences to, exposure to toxic chemicals and EDCs, including risk of infertility, miscarriage, prematurity, deformity and stillbirth. Deeming reducing pregnant women’s exposure through education “critical”, the American College of Obstetricians and Gynecologists surveyed 2500 physicians over the following months and found that fewer than one in five ask patients about toxic exposure.

Citing lack of understanding of the issues and concerns over stressing pregnant women, doctors feel that they need to focus their time on other aspects of care, but these are precisely the issues that must be addressed if maternal and fetal health are to be protected. If doctors are not willing to protect maternal health, then others must step up. I would argue that midwives must fill that role. The first step is in understanding the role of endocrine disruptors in maternal fetal health.

Endocrine Disruptors and Preterm Birth

Consider the impact endocrine disrupting substances can have on reproduction and their potential relationship to prematurity. Women are born with all the eggs they will ever have, and thus, are particularly sensitive to any assault on individual cells. We understand this from dentistry where shields are required to prevent the cumulative damage of x-rays. In contrast, we have such difficulty considering that the minute doses of any endocrine disrupting chemicals or particles might change the course of human potential; but they can and do. Here are just a few examples of endocrine disruptors affecting maternal and fetal health.

Obesogens, Chronic Disease and Prematurity

Obesogens are compounds that can alter the lipid (fat) development and metabolic balance. They are present in plastic containers including bags, BPA, air fresheners, non-stick pans, pre-packaged foods, fructose, monosodium glutamate, nicotine, DES, Estradiol, pesticides, lead. They are found in plastic and melamine dishes and cups along with urea-formaldehyde resin.

Obesogens have a very specific relationship to fat, a relationship that has grown steadily and significantly over the past 50 years. The primary mechanism appears to be the transmutation of cortisone into the active hormone cortisol in the fatty tissues. Repeated trials indicated that it promotes adipgenesis; an energy component that processes substance into triglycerol, insulin, epinephrine, glucagon and ACTH in the body. They are time sensitive:  The longer a challenge is presented (exposure) the greater the impact; the greater the artificial exposure (such as chemical and EDC), the more complex the reaction at the cellular level.

They have been found in every fat cell in the body and their presence can have very far reaching consequences in the childbearing cycle. These compounds appear to create a profound deficiency in normal ratio of sex hormones, alter lipid regulation and derange glucose metabolism. Alone or combined these changes can have a profound relationship on maternal and fetal outcomes. Some have speculated a “probable link” between these endocrine disruptor initiated changes to pregnancy-induced hypertension.

There is evidence that exposure to obesogens can be epigenetic and heritable modifications to DNA, meaning that unchecked and uncontrolled continued exposure to obesogens may permanently alter our lipid and glycogenic biology progressively, and across current and future generations.

Flame Retardants and Preterm Birth

Polybrominated diphenyl ethers (PBDEs) are compounds that are uniquely disruptive to the neurological system through changes in the receptors. Their primary use is as flame retardants and have been used in building materials, electronics, household furnishings, motor vehicles, airplanes, plastics, polyurethane foam and textiles –including children’s sleepwear since the early 1970’s. PBDEs are dangerous in all forms but particularly insidious in one of their most readily found forms, dust, as they are taken up through both breath and skin absorption and moved throughout the body.  PBDEs have a profound effect on childbearing.

  1. PBDE reduces fertility at levels found in almost every household.
  2. PBDEs are indirectly associated with premature birth, low birth weight and stillbirth through first and second generation endocrine interruption.
  3. As little as a single dose has shown to impair neurodevelopment in the preborn and delayed development in young children including Autism spectrum disorders.
  4. PBDEs disrupt hormone levels in the thyroid gland of both mother and fetus.
  5. PBDEs evoke epigenetic dysregulation.

The EPA action plains have called for the removal PBDEs from our environment for years. Despite this, detectible levels remain high within the adult population; higher still in very young children.

Glyphosate Based Herbicides: A Danger to Maternal Fetal Health

Glyphosate is a glycine based broad spectrum kill-all herbicide which is, in large part, designed to work specifically with genetically modified organism which are tolerant of it.  Early and most on-going testing of this herbicide has tested the active ingredient in isolation. Very recent testing has shown the “inert” ingredients (adjuvants) to be aggressively toxic, one ingredient of which is extremely cytotoxic.

Unlike many of the other individual endocrine disrupting chemicals reviewed in State of the Science, the glyphosate substance has been slippery to fix within research. Many of the best research papers have been either dismissed out of hand or withdrawn from publication (a behavior which is rare indeed). The financial power of the major glyphosate producer (Monsanto) is well-connected in every government and research organization.

Of the studies that have been reasonably accepted and reviewed, glyphosate/adjuvant substances have been shown to be endocrine disruptors and further studies may confirm current research indicating the greatest danger in pregnancy to be:

  1. They are capable of vertebrate cranial faults during early gestation
  2. They have exhibited cytotoxic (cell killing) capacity in human cells at levels less than half the agricultural use
  3. Because of pure glyphosate’s ability to amplify the estrogenic effect of soy, gmo soy has shown to induce human breast cancer growth
  4. In 2013, the first solid evidence as to glyphosate’s impact on gut microbiome was released. Described as the “textbook example of exogenous semiotic entropy” it is shown to reduce or destroy tryptophan, tyrosine, phenylalanine, methionine, serotonin, Alzheimer’s, Parkinson’s, autoimmune diseases.
  5. Also in 2013, Interdisciplinary Toxicology released research documentation that glyphosate is “pathway to modern diseases: celica sprue and gluten intolerance”.

Today’s report of permanent kidney damage in the farm workers of South America seems to confirm that glyphosate is not just an endocrine disrupting chemical with epigenetic and mutagenic properties. As weeds become progressively resistant to glyphosate, it would seem that the increasingly high concentrations and applications of this chemical are linked to evidence of carcinogenic damage on a large scale.

For midwifery and birth the single most remarkable statement about glyphosate’s impact in childbearing is the knowledge that glyphosate disrupts enzyme function the “cytochrome P450” enzymes regulate Vitamin D, cholesterol, sex hormones and stabilizes blood fibrinogen continuity, all important factors in healthy pregnancy. Glyphosate also causes cellular damage to the placenta, the one organ of regeneration everyone should care greatly about (here), (here),(here),(here).

The Precautionary Principle and Premature Birth

At the heart of the Born Too Soon report we are lead through the maze of what may be causing prematurity and then in State of the Science we are given an opportunity to reflect upon the cellular challenge of history; and quite possibly the single most important disturbances in our biological evolution. This is a critical moment in childbearing and one that we would do well to spend time in mindful consideration. If the research is even marginally accurate is there anything more important than understanding and putting a halt to the barrage of assaults to our mitochondria and cellular health?

Part of the global answer to this conundrum has been in place since 2005: The Precautionary Principle; “a strategy to cope with possible risks where scientific understanding is yet incomplete, such as the risks of nano technology, genetically modified organisms and systemic insecticides.” This UNESCO environmental mandate was ratified in 2005 and is part of the fundamental inquiry system outside the US. Something of a “prove its safe before you put it out there” perspective, the Precautionary Principle works antithetically to the American system of testing and releasing.

“The precautionary principle enables rapid response in the face of a possible danger to human, animal or plant health, or to protect the environment. In particular, where scientific data do not permit a complete evaluation of the risk, recourse to this principle may, for example, be used to stop distribution or order withdrawal from the market of products likely to be hazardous.”

Our work in the United States is complicated on a national level certainly as we are hindered by far too much by the politics of lobbies, big Agri-Business and Biotech companies. Evidence-based medical decision-making has been extremely slow in taking a position entirely because of the scientific corner it has boxed itself into. What then?

Born Too Soon and Midwifery: An Opportunity

Each individual world community is dealing with childbearing issues in unique ways; prematurity, birth defects and low birth weight have causal relationships that may look quite different from country to country, and yet, we are united in the truth that hunger, poverty, insufficient water, shelter and healthcare are an increasing problem worldwide.  The addition of the biochemical challenges of endocrine disrupting chemicals has turned childbearing toward a future none wants to see continue. Regardless of the promises made for more and better food through chemicals and genetic manipulation, we are watching a game-changing shift in human DNA through mitochondrial damage that is leading to more, not less, disease, disorder and childbearing loss.

Women and children are very much the canary in the coalmine of endocrinology.  If the choices we are making as a species so alter our potential for stable regeneration, we are ethically bound to not only study them without equivocation, but to soundly rebuke their presence in our world until their safety is assured.  Women are being labeled high-risk for high-blood pressure, obesity, thyroid imbalance, diabetes and reproductive challenges as consequences of the mitochondrial damage being inflicted by an indifferent industrial machine contaminating the environment with dangerous endocrine disrupting chemicals.

As midwives we are bound to stand beside women experiencing those challenges.  We have never been simply about birth. Midwifery has always been Matrifocal by definition; through our focus on the welfare of women and the communities we have stood beside in every issue.  It is time for us to remember that with or without scientific validation we are bound also by our role as teachers. We are called to educate toward sustainable behaviors, involve ourselves in community changes and focus our practices on least invasive technology, as we search for answers to the growing list of health problems within the community we serve.

Live without hesitation. Dwell not on outcome or reward. Act with full attention.

Midwives have been the guardians of the sacred in community and birth since the beginning of time. We have dared to speak the truth when none wanted to hear it; when the cost might have been our very lives. Despite the occasional feeling of loneliness, we have really never been alone in that journey and we are even less so today. There is a growing body of health practitioners asking the same questions, risking their reputations and often their livelihood in an effort to bring to light the path through the madness that is the current recklessness of science. Find resources within your area. Encourage and support their work. Comb the internet for research about hormone and endocrine disorders.  There are many online researchers that are asking good questions; endocrine research is becoming more approachable with websites like Hormones Matter. Women’s mental health is leaving the dark ages of toxic medications with a new breed of psychiatrists like Kelly Brogan, MD, providing the insight to make the shift.

There is a revolution brewing – in birth and in health – become part of it.

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Recurrent Miscarriage

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Philippa Bridge Cook

When I was pregnant for the first time, one night very early on in the pregnancy, I had a dream that my baby was going to be a little boy with blond hair and blue eyes, a little mini version of my husband. Eight years and six miscarriages later, I did give birth to a little boy, and oddly enough, the consensus is that he looks just like my husband. Those eight years before our son was born were filled with emotional highs and lows, and I still ask myself:  why did I, and so many women like me, end up with so few answers about my miscarriages?

Recurrent miscarriage, defined as more than three consecutive pregnancy losses, affects about one percent of women.  Although there are some known causes (the most common is antiphospholipid syndrome), which have effective treatments, for 50 percent of women with recurrent miscarriages, all diagnostic tests are normal and no cause can be found.  In this group of women with unexplained recurrent miscarriage, the prognosis is fairly good, as many of these women will eventually have a successful pregnancy without any treatment. However, research suggests that the group of women with unexplained recurrent miscarriages may actually be made up of two groups. In one group, the miscarriages are due to chance alone, and women in this group have an excellent chance of eventual success. In the other group, there is an underlying problem that is not identified by current clinical investigations, and this group has a much poorer prognosis.

During the time I was trying to have a baby, I saw four different doctors (three gynecologists and eventually, a reproductive endocrinologist). I had many tests, and they all seemed normal. I was a relatively healthy 28 year old. I was told that if I just kept trying, I might eventually be successful. Although that approach is understandable given the potentially good prognosis for some women, it was difficult for me to believe that it was true, and it was even more difficult to consider getting pregnant a fourth time without trying some sort of treatment. Instead of trying to get pregnant again, we decided to adopt, and my husband and I were lucky enough to adopt two newborn girls, 15 months apart.

As the girls got older, we decided to try to get pregnant again, and see if my doctors could offer any new approaches. It felt to me that if I at least tried something different, that I could have some hope for a different outcome. My doctors tried various fertility treatments with the rationale that perhaps just increasing the number of embryos would result in one that could “stick.” I never got pregnant on fertility treatment despite a seemingly good response to it.  Because I had always had painful periods that were worsening as I got older, I asked every doctor I saw about endometriosis and every time was told: “Endometriosis causes infertility. If you are getting pregnant, you don’t have endometriosis.” During that time, I had three more miscarriages.

Eventually I made my way to a reproductive endocrinologist. She agreed with my other doctors that there was no apparent reason for my miscarriages. However, by that time I had a large mass on my ovary, and I had laparoscopic surgery and was diagnosed with endometriosis. According to the scientific literature, there is insufficient evidence for a link between recurrent miscarriage and endometriosis, although it’s possible that many women with recurrent miscarriage have undiagnosed endometriosis, due to the assumption most doctors make that women with endometriosis are always infertile. My doctor did not think that my endometriosis was related to my miscarriages. However, she did decide to treat my miscarriages with a “cocktail” of medications: heparin injections, progesterone, low dose prednisone, and low dose aspirin. The rationale was that there was probably some undiagnosed problem causing the miscarriages, and the cocktail could cover a range of potential causes such as hormone imbalance, autoimmune issues, and thrombosis (which is known to be associated with recurrent pregnancy loss, through antiphospholipid syndrome).

The month after my endometriosis surgery I was pregnant again. I immediately started taking medications once I found out I was pregnant. Two days before Christmas we saw the baby’s heartbeat by ultrasound, but on Christmas morning I started bleeding. Six long weeks of watching and waiting began—I had a subchorionic hemorrhage, bleeding between the gestational sac and the uterus. Although this is not uncommon (3.1 percent of pregnancies), with my history it was worrisome, and I was on limited activity or bedrest until it resolved at 13 weeks.  I could barely believe it when my son was finally born, healthy and full-term.

My doctors said that the endometriosis surgery had nothing to do with the fact that I finally had a successful pregnancy, even though the coincidence of having success only immediately after that surgery makes me wonder. Or perhaps my success was due to one or more of the medications I took during the first trimester—the recurrent miscarriage cocktail prescribed by my doctor. Having been diagnosed with a bleeding disorder recently (see my story here), five years after that pregnancy, I now realize that the heparin and aspirin were exactly the wrong medications to give me and probably exacerbated the subchorionic bleeding. But maybe the prednisone or progesterone, or both, were helpful. Or maybe it is just that I ended up being among the percentage of women with unexplained recurrent miscarriages who will eventually succeed without any treatment.

As a scientist, I wouldn’t normally be inclined to agree to the sort of treatment I ended up receiving for my miscarriages: they were hit or miss treatments, some of which were untested for safety during pregnancy (the prednisone), and all of which had no proven efficacy from clinical trials for treating unexplained recurrent pregnancy loss. However, as a woman with six prior pregnancy losses, I probably would have tried anything I thought had a hope of helping, as long as the risk seemed minimal. More research into this area is critical, so that other women don’t have to decide whether to choose treatments with unknown side effects and effectiveness, or no treatment at all, with the emotionally devastating risk of another miscarriage. Unfortunately, such research does not seem to be a high priority for our society.

 

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