COVID19 Vaccine Considerations for Pregnant or Breastfeeding Women

Many of our patients have been asking about the safety and effectiveness of the COVID19 vaccine in pregnancy and breastfeeding.  Vaccination is the best way to reduce the risks of COVID-19 infection and COVID-related complications for both you and your baby.  Now that the vaccine has been out since December 2020, we have a lot more information about the vaccine for pregnant and breastfeeding women.

Both the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommend that pregnant and breastfeeding people be vaccinated against COVID19.  The Society for Maternal-Fetal Medicine has issued a statement with some guidance to women who are currently pregnant, planning pregnancy, or breastfeeding who are considering the COVID19 vaccine.  Click here to read the article.

Although pregnant or lactating women were not included in the COVID19 vaccine clinical trials, at this time more than 177,000 pregnant people have been vaccinated and no unexpected pregnancy or fetal problems have occurred.  There have been no reports of any increased risk of pregnancy loss, growth problems, or birth defects.

We know that about 1 to 3 in 1,000 pregnant women with COVID19 will develop severe illness.  Compared to those who aren’t pregnant, pregnant women infected by COVID19 with symptoms are 3 times more likely to need ICU care, 2 to 3 times more likely to need advanced life support, and have a 70% increased risk of death.  According to a September 29, 2021 urgent health advisory from the Centers for Disease Control (CDC), there have been more than 125,000 confirmed cases of COVID19 in pregnant people including more than 22,000 hospitalizations and 161 deaths.  To reduce these risk, the COVID19 vaccine is recommended.  See the full CDC health advisory here.  

With the rising COVID-19 cases in New Hampshire, we unfortunately have seen some of the sad outcomes that can occur with COVID-19 in pregnancy.  We get calls daily from unvaccinated pregnant women who recently tested positive for COVID-19, asking us how they can prevent complications from COVID-19.  Unfortunately, there really isn’t anything that can be done once someone has COVID-19 other than monitor symptoms and treat a fever.  The best way to prevent complications from COVID-19 is vaccination.

We strongly recommend that our pregnant and breastfeeding patients get the COVID19 vaccinationPregnancy is not an indication for a COVID19 vaccine waiver.  

If you have questions about the vaccine, please talk to your provider at your next visit.

COVID Vaccine Boosters – Do I need one?

The short answer is YES.  As of November 29th, 2021, the U.S. Centers for Disease Control and Prevention (CDC) recommends that everyone ages 18 and older should get a booster dose.  

If you received Pfizer-BioNTech or Moderna vaccines: You should get a booster at least 6 months after completing your primary COVID-19 vaccination series.
If you received the Janssen (J&J) vaccine: You should get a booster 2 months after completing your primary COVID-19 vaccination.

Which booster should you get?
You may choose which COVID-19 vaccine you receive as a booster shot.  Some people may prefer the vaccine type that they originally received, and others may prefer to get a different booster.  CDC’s recommendations now allow for this type of mix and max dosing for booster shots.

For any adults 18 years old or older who completed their primary Pfizer-BioNTech or Moderna vaccine series at least 6 months ago OR received the Janssen (J&J) vaccine at least 2 months ago, a booster dose of the COVID-19 vaccine is recommened.

Where can I get a booster?  Although we are not giving COVID19 boosters at Bedford Commons OBGYN, if you are eligible for a booster dose, you can schedule an appointment at any retail pharmacy or can inquire about an additional dose through your primary care provider office.  Find a vaccine location by clicking here: https://www.vaccines.gov/.  If you haven’t gotten a flu shot this year, consider getting the flu vaccination along with your COVID19 booster.  Both can be given on the same day.

What about boosters in pregnancy?  We strongly recommend that our pregnant patients receive the COVID-19 vaccine and also strongly recommend the COVID-19 booster for our pregnant patients who qualify.  For more information about the COVID19 vaccine and pregnancy, click here.

What is a DO?

Throughout my training and career, this question has certainly come up more than once. Now, more than ever, with the topic of DO physicians making news and headlines (all press is good press, right? Not necessarily…) are we presented with the opportunity to educate and share exactly what “DOing” is.

DO stands for Doctor of Osteopathic Medicine whereas MD stands for Doctor of Medicine.  Like MDs, Doctors of Osteopathic Medicine are fully licensed physicians who can practice in all areas and specialties of medicine.  We practice evidence-based medicine, using the latest science and technology.  During our medical school training, like MD students, the first two years are centered around classroom learning, and the last two gaining clinical experience in various specialties during clinical rotations.

Many DOs sit for the same licensing exams as MDs (USMLE) during medical school in addition to their osteopathic licensing exams (COMLEX).  The field has grown 300% (wow!) in the last three decades, currently making up 11% of the physician population.  In addition, 42% of actively practicing DOs are female!

In many circumstances, patients may not even notice a difference between their DO or MD physicians.  Where DOs differ is the underlying philosophy that is incorporated in our medical school training.

The hallmark of Osteopathy emphasizes a “whole person” approach (a person is a unit of “body, mind and spirit”).  We are trained that the person and body is whole and interconnected, and each body system affects the other.  DOs have an additional 200 hours on top of general medical school curriculum that focuses on Osteopathic Manipulative Treatment (OMT).  OMT is a hands-on approach, where we learn in depth musculoskeletal exam and treatment of musculoskeletal dysfunction, which may be related to visceral (other body systems/organs) or somatic (musculoskeletal) causes.  While not every DO uses OMT in their day to day practice, this inherent philosophy of treating the person as a whole is how osteopaths are trained to approach each and every patient.  Many of my MD colleagues approach their patients with a similar view due to their compassionate personality, but this philosophy is not part a focus their medical school curriculum.

One of the best parts of being a DO, like all differences, is being able to bring a different perspective to the table.  I am proud of my training and where it has led me (here at BCOG!)!

Flu Vaccine – coming to Bedford Commons OBGYN October 1, 2020!

“Ouch, that hurt!  Why did you do that?!?” — that’s what my 5 year old daughter yelled at the nurse giving her the flu vaccine last year.

In the midst of the current COVID-19 pandemic, it’s easy to forget the flu season is just around the corner.  Or maybe you haven’t forgotten because you have seen signs advertising the flu vaccine at many national pharmacy chains.  I think I saw my first flu vaccine advertisement at the end of July, more than 2 months before the onset of the flu season!

The Center for Disease Control (CDC) recommends the flu vaccine every year for everyone 6 months of age and older.  It is especially important this year given the overlap of symptoms caused by COVID-19 and the flu.  Getting your flu vaccine is one of the best ways to protect against the flu.  Although the flu vaccine is currently available at many pharmacies, the CDC recommends waiting until late September to get vaccinated because getting the vaccine too early may cause reduced protection against the flu later in the flu season.

As we have been so focused on COVID-19, I think it is important to remember that last year, more than 410,000 Americans were hospitalized due to the flu and more than 24,000 people died from the flu.  Although wearing a mask can help prevent the flu, the best way to protect yourself is to get the vaccine.

At Bedford Commons OB-GYN, we will begin to offer the flu vaccine to our pregnant patients starting October 1, 2020.  We recommend the vaccine for all of our patients but due to a limited supply, we are only able to offer the vaccine in our office to our obstetric patients.  For our non-obstetric patients, we would recommend heading to your primary care or a local pharmacy to get vaccinated.

Click here for more information from the CDC about this year’s flu vaccine.

 

Trial of Labor after Cesarean (TOLAC)

So you had a cesarean for your first delivery and now you are pregnant again.  One of the major questions you will make with your OB is what type of delivery, vaginal birth after cesarean (VBAC) or repeat cesarean, is most reasonable.  How do you make that decision? If we had crystal ball it would be so easy, but we don’t, so let’s look at all the factors that influence the decision.

Risks to consider

After a cesarean there is a scar on the uterus. That area is just a little weaker than the rest of the uterus.  As the uterus grows and stretches this area gets thinned out and even weaker.  Labor contractions put even more stress on the scar.  All this increases the risk that the scar can break open, or what we term “uterine rupture”.  If the scar ruptures, the blood flow to the baby can be compromised and sometimes cause permanent neurologic problems for the baby, or even death.  The risk of these are extremely low.  Only half of a percent of women laboring after a previous cesarean will have rupture.  Of those that rupture approximately 3 percent (and remember this is 3% of 0.5% total ruptures) will have complications or fetal death.  Because this number is so low, it is reasonable to consider a trial of labor in appropriate patients.

So what makes a patient appropriate?

Things your provider is considering when they are counseling you about a TOLAC include the reason for your cesarean, baby’s weight as well as your height and weight, whether or not have you had a vaginal delivery, and your ethnicity.  All of these can affect the potential success of a TOLAC.  There are online calculators that will give you the chance of a successful vaginal delivery.  Additionally we factor in how many more pregnancies you are considering. The final factor is what do YOU want.  Sometimes in your gut you know how you want to deliver. Realize there is no wrong or right.  Your provider will always guide you away from a overly risky option.

Recovery

Many women fear the recovery with another baby at home.  Surprisingly most women do really well after a repeat cesarean.  Certainly if you labored last time, then had a c-section while you were both mentally and physically exhausted, the recovery of a repeat may seem easier even if you have other children at home.

It’s a big decision and no gut instinct, physician or VBAC calculator can always predict a successful vaginal delivery, all of these tools will guide you into a decision that makes you and you provider are comfortable.  End of the day the goal is a healthy baby and a healthy mom!!

Hormone Replacement Therapy (HRT) – Is it for me?

What’s in your hormone therapy? (The facts about bioidentical hormones)

As your gynecologists, we know you are interested in bioidentical hormones.  We can prescribe such hormones and we are interested in talking to you about your menopausal symptoms.

Prior to 2002, HRT (hormone replacement therapy) was widely prescribed to treat menopausal symptoms and was once prescribed for prevention.  The WHI, or Women’s Health Initiative, was started to study HRT’s effectiveness in lowering the risk of heart disease and other medical conditions in women ages 50-79.  In 2002, the Women’s Health Initiative study was paused because of the increased risk of breast cancer, heart attack, stroke and blood clots seen in women on estrogen and progesterone.  In turn, there was an abrupt decrease in prescriptions for HRT.

Since then, women’s health providers have been able to make better sense of this data and can have a meaningful discussion with our patients about the many benefits of HRT as well as the risks.

There are many women who benefit from HRT and there are many forms of HRT.  Over the last few years I have seen more and more women come to their annual or for a consultation other than for menopausal symptoms, after having seen another provider to obtain compounded bioidentical HRT.

A bioidentical treatment is a plant derived compound that is chemically similar or structurally identical to those produced by the body.  There are bioidentical hormones approved by the FDA.  I get it that my patients are not excited to use hormones that are sourced from the urine of pregnant horses found in a commonly prescribed form of estrogen.  There are options for bioidentical micronized estrogen and progesterone that are monitored by the FDA.

As the compounded forms of hormone therapy are not regulated, a patient is ultimately unaware of the purity, potency or quality of the product used.  I also see many women having their hormone levels checked which is not necessary.  Let me discuss each issue further.

Many compounded hormones use combinations of the 3 types of estrogen produced by our bodies: estriol, estradiol and estrone.  Estriol is the weakest of the estrogens and is often used in the highest amount in compounded hormones.  However, estriol is less bioactive so to get the improvement in symptoms, there is the risk of overdosing on this estrogen.   Estradiol is more bioactive, is bioidentical, and is included in the options approved by the FDA.  Such options have doses that are stable and well-studied.  High doses of any estrogen can lead to the risk of cancer of the uterus and blood clots. For women with a uterus on estrogen in doses high enough to treat hot flashes, progesterone is needed to protect a woman from the risk of cancer of the uterus.  Compounded progesterone that comes from certain wild yams may not be bioavailable, so a woman may not be receiving the protection the uterus needs.

As far as hormone testing, steroid hormones do not meet the criteria for requiring individualized testing.  Steroid hormones have a large range of levels that lead to a desired effect.  These hormones are not directly eliminated by the kidneys in our urine and they are metabolized by our GI tract.  There are no known therapeutic and toxic concentrations base on large studies of blood levels.  Furthermore, checking salivary levels do not provide a representation of blood levels.  Salivary levels depend on a patient’s diet, time of day and the specific estrogen being tested. When I prescribe HRT, I do not check hormone levels.

When a patient needs HRT I discuss the FDA approved options that make sense for her individualized history.  I prescribe the lowest dose that provides benefit.

Thanks for your time and I encourage you to talk to your provider if you are interested in learning more about HRT.

Pregnancy Loss and Miscarriage

Miscarriage is sadly incredibly common, occurring in approximately 10% of all pregnancies in the first trimester. It most often occurs due to an abnormal number of chromosomes in the developing embryo. In healthy women, there is little that can be done to prevent miscarriage from happening.

Symptoms of pregnancy loss

At the start of a miscarriage, many women will have bleeding and cramping, however, some women have no symptoms at all, and the miscarriage will be diagnosed on an ultrasound exam.

Treatment options

Miscarriages can be treated in three ways.

One is to wait for the pregnancy tissue to pass on its own. While this has the benefit of not having any medical intervention, it can take up to four to eight weeks to occur, so many women prefer not to have the uncertainty of waiting that long.

The second option is to take a medication called misoprostol that causes the uterus to contract and expel the pregnancy tissue. This usually happens within 24 hours of taking the medication, but can take up to several days. The medication can be repeated if it does not work after the first dose. This is effective 70-90% of the time.  Management with medication has the advantage of being able to control the timing of miscarrying while still being able to be in the comfort of your own home, however, there is typically a several hour window of time that is very uncomfortable with heavy bleeding and cramping.

The third option is to have the pregnancy tissue removed surgically through a procedure called a dilation and curettage (D&C). This allows for the most control of timing and least amount of pain, however, does mean receiving anesthesia and undergoing a surgical procedure.

Follow-up

After a miscarriage, you will be seen in the office to confirm that all the pregnancy tissue has been passed and to discuss any questions you might have about the process. Your bleeding will typically taper down and eventually stop after one to two weeks. Your periods will typically resume four to six weeks later.

Planning for another pregnancy

Many women who are trying to get pregnant wonder when they can begin trying again after a miscarriage. While women used to be advised to wait a couple cycles before trying, newer data shows that there is no advantage to waiting and that there may be some advantage to attempting in the first three months after a miscarriage. The bottom line: when you feel physically and emotionally ready to try again, it is safe to do so

Prenatal Vitamins Made Simple – What should you be looking for?

A balanced diet is the best way to get the vitamins and minerals you need for a healthy pregnancy.  However, it is easy to fall short on key nutrients during a pregnancy.  A prenatal vitamin can fill in the gaps.

Here are a few key rules to consider when thinking about prenatal vitamins:

Rule #1: Start the prenatal vitamin before you try to conceive.

Many pregnancies are unexpected some it’s reasonable to consider taking a prenatal vitamin daily even if you aren’t actively trying for pregnancy.  Important events are happening in an early pregnancy before a woman even misses her period and knows she is pregnant.

Rule #2: Find a prenatal vitamin that is cost effective.

It will need to be taken for a year or more as it is also recommended to continue a vitamin while breastfeeding.  Prescription prenatal vitamins are no better than over the counter prenatal vitamins.

Rule #3: Make sure your prenatal vitamin has these critical components:

  1. Iron, 27 mg. In the United States approximately 20% of pregnant women are iron deficient. During pregnancy, the body needs to make extra blood to support the health of the mother and fetus. It takes iron to make this extra blood.  Iron is also needed for fetal brain development.  Although gummy prenatal vitamins tend to be easier to tolerate, they do not contain iron.  A separate iron supplement would be needed if you are using gummy prenatal vitamins.
  2. Folic Acid, at least 400 micrograms.  Low folic acid levels are directly linked to neural tube defects or spina bifida.  The adequate amount of folic acid needs to be present from conception which is why prenatal vitamins should be started before a woman knows she is pregnant.  It can be challenging to consistently get the adequate amount of folic acid in the food we eat.
  3. Iodine, 150 mcg . Many prenatal vitamins do not contain iodine. Iodine is needed for normal maternal and fetal thyroid function as well as fetal brain and central nervous system development.
  4. Other important ingredients in your prenatal vitamin that are important for fetal bone, central nervous system and overall growth include:
    • Calcium 1,000 mg
    • Choline 450 mg
    • Vitamin D 600 IU
    • Vitamin A 770 mcg
    • Vitamin C 85 mg
    • Vitamin B6
    • Vitamin B12 2.6mcg
    • Zinc
    • DHA: 200 mg There’s evidence indicating that omega-3 fatty acids (particularly DHA)–a fat found in some types of fish–may play an important role in the development of your baby’s brain and nervous system.

There are many medical conditions where the amounts recommended above would need to be adjusted.  For example, taking the prenatal vitamin depends on adequate absorption through your gastrointestinal tract.  If you have certain gastrointestinal conditions or have had gastric bypass surgery, speak with your ob/gyn.  In general, a preconception counseling visit is always a wonderful idea to discuss any woman’s history and unique needs.