Placenta Previa 

After I finished my shift at The Valley Hospital as the "Doc in Box" I did my rounds and went home. My shift ended at 7 am. I signed out and handed the phone over to the next on call Obstetrician, and came home around 8:30 AM or so. Then I tried to get some sleep. I did some reading, and finally did fall asleep. 

Later in the morning I got a phone call. 

I have a full term pregnant patient who has a suspected placenta previa. What does that mean? 

A human embryo is created about day 14 of a 28 day cycle. This is called ovulation. Once the egg pops out of the ovary on day 14, the sperm will start looking for it. If there are sperm there, they will all swim to the egg. The egg is surrounded by a protective covering called the zona pellucida. One sperm by itself is unlikely to get through the zona. Instead, about a hundred sperm need to be there. But usually only one sperm will penetrate the egg membrane. This process is called fertilization.  The egg once fertilized becomes an embryo and starts floating down the Fallopian tube. A week after fertilization, about day 21 of a normal 28 day cycle, the embryo will float (or be propelled by tubal peristalsis) into the uterus. By day 21 the uterine wall is covered with a sticky secretion that is ready for the embryo to come along.  The embryo floats around until it comes into contact with the uterine wall. Once it does, it sticks on, and starts to burrow into the uterine wall. This will frequently cause a day 23 spot of blood called an implantation bleeding. Any women who is trying to get pregnant should welcome the day 23 spot of blood. It is really great news. The problem with implantation is that it can happen almost anywhere. Ideally it can happen in the fundus, or body, of the uterus. Sometimes the embryo implants in the fallopian tube. This is called an ectopic pregnancy and may be a life threatening emergency. Sometimes the embryo is just a few millimeters short of making it into the uterine cavity. This is an even worse spot called a cornual ectopic. This means the implantation is in the "corner" of the uterus, in the part of the fallopian tube that is within the muscle of the uterus. Nowadays, some ectopics can be treated with cancer chemotherapy, and therefore avoid surgery. Obviously there are risks with chemotherapy as well. And sometimes the ectopic can take forever to dissolve. But is is there as an option. 

But for a placenta previa, the implantation occurs very low in the uterus. It is then very near the cervical opening. When this happens the placenta grows very low. The placenta itself grows over the cervical opening. Since the baby needs to come out the cervical opening, and the placenta is in the way, there will be a life threatening hemorrhage when the women goes into labor. The baby will not survive losing the placenta's function while still inside the mother. When the placenta disconnects from the mother, there will be a hemorrhage, and the baby will suffocate from lack of oxygen. 

There are many different types of previa. If the baby implants in the cervix, instead of in the uterus, it is called a cervical ectopic. This is a bad event that needs to be managed quite urgently. 

If the placenta only edges up to the cervix, it will be called a marginal previa. This can go either way. If the placenta is low, but not up to the cervix, it will be called a low placenta. These women can try for a vaginal birth if they want, but they are subject to abnormal bleeding. If they bleed a lot in labor, then a C-Section might be safer. 

My patient today was told she had a previa early on in the pregnancy. We watched  the baby and the placenta very carefully for many months. The placenta seemed to move away from the cervix a bit as the uterus grew up to full term size. This is not unusual. Many previas resolve themselves as the pregnancy grows. We had at first scheduled her C-Section, but then unscheduled it because the placenta appeared to be in a better spot. 

As a pregnancy grows, the uterus grows with the baby. The uterus and the baby grow about a centimeter a week. The placenta, if it is stuck sufficiently to the uterine wall, can move up with the uterine growth. But, on the other hand, the placenta and the baby are growing. The placenta, if it is stuck near the cervix but continues to grow, it can grow back over the cervix. This can make a marginal previa worse, so that it can become a total previa again. 

So, it is best to follow the previa clinically. Analyze its growth pattern. Follow it with the sonogram. Try to make predictions about what might happen with time. Don't examine it with the hands, because that may cause severe bleeding. Only examine it with the sonogram. And if there is a lot of bleeding, then deliver the baby by C-Section. The delivery can be elective at term, or at any time if there is a lot of labor contractions or bleeding. 

But today, she was 39 weeks and waiting for labor, when she started having a bloody show. The bloody show was normal, and a good sign that labor might be beginning. But then she broke her water, and the water gushed out and was very bloody. She called and I advised her to go to the hospital. At the hospital she kept on bleeding and ultimately passed a softball sized clot. Obviously this is risky for both the baby and the mom, so I advised a Cesarean after all. She couldn't keep bleeding to that extent and expect a happy outcome. So we did it. And everybody is fine now. At the C-Section we did find that the previa was close to or over the cervix, so labor would have continued to be very risky, and the bleeding would have gotten much worse with time. 

She didn't get her vaginal birth. But she did get a healthy baby at 39 weeks. Everybody is fine. Maybe the next baby can be a vaginal birth if she wants to try for it, and there is no previa. We will have the discussion about the benefits and the risks of a VBAC. VBAC means vaginal birth after Cesarean Section. 

Thank you all for reading today's blog. I appreciate all of the readers from around the world. 

Sincerely, 

John Marcus MD Ob/Gyn FACOG

89 North Maple Ave

Ridgewood, NJ, 07450 

201-447-0077 

Preconceptional Counselling

Hello Everybody. Thanks for coming.  I really appreciate all of you reading my blog. This blog has expanded much faster than I imagined. I now have readers from about 10 different countries all over the world.

Today was a busy Obstetrics day in my office. Since we have just finished a long weekend, a lot of the pregnant patients came to the office today, to catch up from yesterdays holiday. So my office hours were filled up with pregnant patients, and had just a few gyn patients in for checkups.

After my office hours, I've delivered two babies, and I assisted at one more. The babies are beautiful and healthy. One baby was a Cesarean Section.

I am now taking my shift in the hospital. Our hospital, The Valley Hospital in Ridgewood, New Jersey, has elected to always have an Obstetrician present on the unit. We stay here to cover the unit for emergencies. There are about 14 of us Ob's that share that particular duty. I am one of them. I am on duty now. We call ourselves the Doc In Box. The hospital's official title for us is the "Valley On Call Obstetrician". The official title is too hard to say over and over, so we just shorten it to Doc In Box. As in "am I Doc in Box tonight?"  We take 12 hour shifts, or two in a row for 24 hours. When here, we consult with the nurses whenever they ask, we assist in complicated deliveries, we examine laboring patients whenever we are asked, and we occasionally save lives of new moms and babies. Particularly we save lives when there is a placental abruption. We can try to get some sleep in between the calls. Some of us try to get some of our boards done. We all need to get about 30 hours of boards work done every year, to maintain our board certification.

But I promised I would write about preparing a women for pregnancy, so that someday, she can herself be here in labor and having a baby. What does a women need to do in order to be safe for the pregnancy, for optimal chances of health?

Sometimes a woman will make an appointment for a "preconceptional consult". Other times, a woman will be in for her annual checkup and in the course of that checkup I will determine that she is trying to get pregnant, or will be soon. Either way, we have to help her prepare for the pregnancy. This is what we should do:

First , we will review her history to determine if there are any health issues that need to be addressed. All medical issues in the past will need to be analyzed to make sure that whatever the problem was, it will be optimally managed. For instance, one in twenty people have a misbehaving thyroid gland. It could be either hyper- or hypo-thyroid.  These women will need their thyroid gland examined and her TSH checked to make sure it is optimal. A properly adjusted thyroid hormone will make it easier to get pregnant, and will keep the baby safe and growing well. Another example is if she has high blood pressure, we will need to change her pill to one that is safe for the fetus, and get her BP under good control. Virtually all medical problems in the past will need an analysis. Many young women will have no medical problems in the past, so this part will be easy for them. Many people have multiple mild issues. Everything is on the table here. More examples: Seasonal allergies, with or without allergic asthma. Yeast infections. Urine infections. Back pains. Sciatica. Palpitations. And on and on.

Second , she will need a complete checkup and an exam to make sure nothing obvious is wrong.

Then, I will ask her to get a dental checkup and cleaning. Proper dental care is important for the pregnancy. believe it or not, gingivitis is a cause for preterm labor. In fact, any infection anywhere in the body is bad for the pregnancy. Infections can spread into the baby. But even if it doesn't get into the baby, it can still release toxic substances that make the uterus and the placenta irritable and threaten preterm labor.

Then, we will discuss the diet. Special dietary needs will need to be discussed. Many women are vegetarian, or even vegan. It is possible to keep the baby healthy as a vegan, but we will need to make sure she is getting proper proteins from the veggies. Right about now, I will discuss the "fish rules". There are five fish that women should not eat in pregnancy. Many times I will write this down for women, because it hard to remember everything from this visit. So I will take notes for the women, and make sure that she gets this note when she leaves the office. The 5 fish that women cannot eat are: shark, swordfish, tilefish, monkfish, and tuna. They cannot eat these fish because they are all too high in mercury. Then, I will explain that salmon has no mercury and is therefore the best fish for pregnant women. Salmon also has very high DHA, which is an essential fatty acid and is great for the babies brain development. I blogged about salmon before in one of my prior posts. All of the whitefish varieties are healthy. This will include cod, flounder, tilapia, sea bass, etc. And shellfish is good, too. Unfortunately, some women still have the mistaken opinion that all fish is bad for pregnancy. Many times it takes a lot of discussion to explain to women why that opinion is incorrect.  Fish is so good for the baby that this discussion is worth having, if I can convince the women to actually eat it.

I will usually explain that hamburgers that are under cooked red or over cooked black are not good for her or her baby. Hamburgers and cheeseburgers must be medium only. Black burgers have toxic burned black material on them. This is the food equivalent to smoking. Red hamburgers are infectious with E.Coli and Salmonella. Eggs must be cooked through with no runny yolks.

If she has ethnic food requirements, I will try to address those requirements here.

All cheeses and juices must be pasteurized.

Now is a good time to discuss recreational habits, and exercise. All high impact exercise will have to be toned down to low impact only. Running is ok, but elliptical is just a bit safer because it is low impact on the baby and placenta. Skydiving, bungee jumping, and motorcycle racing are examples of activities that will have to stop. Any illegal or recreational drugs should stop before pregnancy. Alcoholic drinks should stop while pregnant, although a few glasses of wine near the end of the pregnancy will not likely hurt anyone.

I will explain to women that heat can damage fetuses. How can a women get overheated? Most commonly, it is hot tubs. Hot tubs are forbidden to pregnant women, or even women that might be pregnant. Incidentally, hot tubs damage sperm as well. A fever higher of 101F or so is dangerous to the baby. A fever can be reduced with a dose of acetaminophen and a cool shower. There are other ways to get overheated. Examples are: hot days outside, such as at Disney World, hot exercise, hot sex for a long time, hot waterbeds, hot baths, saunas, etc. So we will try to keep a woman's body cool during her pregnancy.

I might ask a woman to buy a pregnancy book. "What to Expect When Your Expecting" is a famous and good book.

Finally, I will ask a woman to call me anytime there is a question or a problem. Keeping the phone lines open can help keep the pregnancy safe.

I will ask a woman to call whenever there is a medical problem in pregnancy.

I will try to explain to women that the phrase "you can't take anything because you are pregnant" is commonly said, and frequently well intentioned,  but is actually a very dangerous notion. It is dangerous because it means that a woman will be tempted to ignore her medical needs. Since the baby and the mother are one, it is not possible to allow a pregnant woman to get sick, and have the baby better off by ignoring the illness. All medical illnesses need to be managed properly to keep the baby safe. All medical issues have pregnancy safe alternative management options.

All of the above is a 15-20 minutes or so discussion. I will many times keep notes as I go, and give her a copy of these notes. Because of the time required, this discussion is best done on a separate visit from a checkup or a problem visit. Women will commonly request preconceptional counselling at the time of a checkup. If there is time on the schedule, I might do this at a checkup. But sometimes, there is just not enough time. I may have to ask a woman to come back to have this discussion. Other times, I may convert the visit to a preconceptional consult, and delay the checkup or whatever reason she is there.

Remember, this is not medical advise. Please see your doctor for medical advise. This is just general information. 

Thank you for reading.

Sincerely,

John Marcus MD FACOG PC
Ridgewood, NJ, 07450
201-447-0077

Good Deeds Come Back 10 Fold 

Welcome back to my Blog everybody. It is Saturday night, on Memorial day weekend. There will be parades tomorrow, on Sunday. Many of the firemen will parade around town on their fire trucks, blowing off their sirens. There's going to be barbecues and backyard parties. Memorial day is also the unofficial beginning of Summer. Lucky for me I have this weekend off. It is nice to have some time off. I can take time off call because I have a cross coverage arrangement with Dr. Fred Rezvani. When he takes time off, I cover him, and when I take time off, he covers me. On average, that works out to about two weekends a month off duty, and the same for him. This means that I am on duty for almost two weeks straight. These work hours, which are common in the medical practice of Obstetrics, are a continuing source of controversy  in Obstetrics and Gynecology around the world.

My covering doctor, Fred Rezvani,  is a good doctor. And he is a good friend to me. Our practices are similar. We are both solo Ob/Gyns. Both Fred and I were once Chairman of the Department of Obstetrics and Gynecology at our hospital, The Valley Hospital in Ridgewood, New Jersey.

Before Fred and I worked out this present coverage arrangement, we were both on call all the time, 24/7. I like this practice style because I really wanted to "be there" for my patients. I felt that if my patients trusted me with something as important as their health and their lives, then the least I could do was to honor them  by being there when they needed me. Fred and I worked all the time, 24/7. This 24/7 practice made taking time off for vacations difficult. On duty means getting calls and taking care of patients. On duty usually means that we can still get at least some sleep, but most nights there will be at least a phone call from a nurse or a patient.

Eventually, though, reality forced us to realize that nobody can work 24/7 forever. It is just too hard. And it is unhealthy to work so many hours. Sleep deprivation is unhealthy.

So now, Fred and I have this weekend coverage arrangement. And it is really great.

Back when I was picking a career, I knew the work hours were long. All the Ob's knew this in med school. Nevertheless, many people still pick this career and this specialty. For the people who have the stamina to make it through the stress, it really is a fantastic job.

I make my living by battling the forces of nature that cause mayhem in women. I fight against pain, misery, discomfort, dysfunction, disease, depression, infertility, and all of those awful things. And I try to help create a state of health and happiness. I feel that I am really good at my job, and despite the long hours, I really like my job.

A mentor once told me that a good deed comes back 10 fold. So, I try to do good deeds, by doing a good job. And I do feel that these good deeds reflect back on me.

So the long hours are worth it, no doubt about it.

Sure, sometimes it is hard to get out of bed, if I am sleep deprived. But once I am up and moving, I can be totally awake and on the job when I need to be.

I haven't decided on my next post yet. Maybe, how to prepare a woman for a pregnancy?

Disclaimer: none of this is medical advise. This is just general information. Please see your doctor for medical advise. 

Thanks for reading. Please share it around.

Sincerely,

John W Marcus MD FACOG
Ridgewood, NJ, 07450
201-447-0077

Post edited on 5/28 at 1 am. I tightened up some poor pronoun references.

Urinary Incontinence and Prolapse

Today in my office I gave Kegel instructions about 20 times. Admittedly, it was a busy day, but there was nothing unusual about that number.

What is the problem? The problem is that about a billion dollars a year are spent on adult diapers in USA alone. And there are about 16 billion dollars a year spent on incontinence, it's control, and it's correction. Most of the incontinence is urinary, but some is fecal as well.

And, much more important than the money spent, is the awful discomfort of being incontinent. Women are unnecessarily filled with shame. They feel like they cannot go outside the home. They cannot go on trips. They are mortified when or if they might wet their pants. They are mortified when the have to buy giant pads, or even worse, adult diapers. And they are ashamed and discomforted with the thought of having sex.

The solution to getting diapers discretely is easy. Just buy them online, maybe from Amazon. No one will have to face the clerk. The clerk that fills the order will be very far away. And someone might get a very good deal. Although, they will have to be forevermore targeted by Amazon with adult diaper ads. Most likely even I will be targeted just because I wrote this blog.

What do Kegel instructions have to do with it?

There is a giant muscle that exists in women and men that elevates the structures in the pelvis, and keeps everything from falling out of the bottom of the pelvis. This muscle has a bunch of different names. Doctors like to call it the Levator Ani, and the bulbocavernosus muscle, along with some smaller muscles with different names. We can just call the whole thing the pelvic floor. This pelvic floor muscle acts like a sling under the pelvis. But it has some other very important functions. It also wraps around the external urine carrying tube. In both women and men this tube is called the urethra. In men, it extends through the penis. In women it is very short, and goes from the bladder, just under the pubic bone, and ends externally anterior to the vagina, and about 2 cm below the clitoris. So, this muscle wraps around the urethra, vagina, and rectum. And, when it is tight, it closes these openings tightly. And when it is tight, it blocks the flow of urine, it holds the vagina together, it keeps fecal material inside the rectum until it is time to defecate, and keeps the structures near the vagina from falling out the vaginal opening. When this muscle is loose, the urine leaks. The uterus falls into or out of the vagina. The rectum falls out of the vagina. The bladder falls out of the vagina. Even the intestines call fall out. These problems are called incontinence, uterine prolapse or procidentia, rectal prolapse, cystocele, and enterocele, respectively.

Most women do not ever exercise this muscle. I might have a menopausal women patient who runs marathons, and is fitter than any 20 year old, who never exercises this muscle. This is not uncommon at all.

Most women are told to exercise this muscle when they are pregnant. It is fine to do this, but the real problem begins later, when they are older. The muscle atrophies from lack of use, and these problems I noted above begin to show up.

This is where I come in. During a regular checkup, I will many times ask the patient to do a Kegel. Many times they are reluctant because they aren't sure they are doing the right muscle. With coaching, almost all women are able to contract the right muscle. It is the same muscle that can be used to stop a urine flow if the doorbell rings, or the phone rings, or the baby screams for attention. If the women can close off the urine mid flow, then she has the right muscle. Some women do not have the option of shutting off the flow, because they don't know how. With encouragement, I can teach them how. I don't advise women to routinely stop the urine flow, because that can lead to some urinary retention or infections. But it is fine to do this as a test of learning once in awhile.

In my experience, some women have such a strong muscle that they can break fingers. Some women have such a tight muscle that they cannot release it. This, if symptomatic, is called vaginismus. Vaginismus, if bad, can make exams impossible, and even sex impossible. Vaginismus is curable with proper stretching exercises, sometimes muscle relaxers, and sometimes pain meds.

But many more women have such a weak muscle that there is no detectable contraction despite full effort and coaching. These women are at high risk for incontinence and prolapse symptoms.

The good news is that I have seen women who could not hold a drop of urine completely cure themselves with exercises. I can remember patients who were so sure that they could not repair the prolapse that they opted for a surgical repair. I would try to delay them to give them a chance at exercises. Many times, after a few weeks there is improvement, and after a few months there is a complete cure. These women are dry again. And they are very happy. And they do not have surgical risks.

There are things called "Pessaries" that can go into the vagina to hold up the other structures. Pessaries are great because they are simple, mostly free of side effects and risks, and assist the Kegel exercises to repair the prolapse. Pessaries can cure the problem with enough time and exercise. Although, many older women keep them forever. And they are happy because it gives nice support and does not hurt, and has no surgical risks.

The surgeries do work, that is for sure. They are not completely reliable, in that there is an unfortunate failure rate, and an even higher recurrence rate. There are hundreds of surgeries described to tighten the bladder  control, fix the fallen uterus and enterocele, and fix the fallen rectum. Which surgery is done is mostly up to the surgeon you pick. The urologists will frequently pick a mesh implant repair. I am not a huge fan of the mesh due to some of the mesh problems that have occurred. Although it is ok when it is done properly, and the success rate is high. I have my favorite types of surgery because I have had good results.

Most of these prolapse surgeries are done through the vagina, because that is where the problem is. There are abdominal approaches. They do not have a higher success rate than the vaginal procedures, and add a lot of surgery to the technique. So, with some exceptions, I prefer the vaginal route to repair. That makes me an old fashioned Gynecologist. Because the newer Gyne's usually prefer meshes, implants, and sometimes abdominal and even robotic repairs. Those procedures are all technically demanding, higher risk operations.

So, to get back to the original point, Kegel exercises really do work. There is solid scientific evidence to this claim that it works. Kegel exercises can prevent and or repair a fallen pelvic floor. You just have to keep doing it enough. It can save a huge amount of problems later.  I encourage all of my patients to do it. I can teach them.

Sometimes a little bit of estrogen in the vagina can help strengthen these tissues as well, and complement the Kegel efforts.

Comments are appreciated.

Thank you sincerely,

John W Marcus MD FACOG
Ridgewood, NJ, 07450

201-447-0077

Article updated on 5/28 at 1 AM to tighten up the prose, and to change pronouns to nouns.