• Pregnant and postpartum women are at higher risk for severe illness and complications from influenza than women who are not pregnant because of changes in the immune system, heart, and lungs during pregnancy…. Influenza vaccination can be administered at any time during pregnancy, before and during the influenza season. Women who are or will be pregnant during influenza season should receive inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV).
• Flu shots have been given to millions of pregnant women over several decades with a good safety record.
• Pregnant women should get a flu shot; NOT the live attenuated vaccine (LAIV or nasal spray).
• Postpartum women, even if they are breastfeeding, can receive either type of vaccine.
• There is a lot of evidence to show that flu shots can be safely given to women during pregnancy. CDC and ACIP recommend that pregnant women get vaccinated during any trimester of their pregnancy.
• Pregnant women should receive a seasonal flu shot.
  • Influenza is more likely to cause severe illness in pregnant and postpartum women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza.
  • Vaccination has been shown to reduce the risk of flu-associated acute respiratory infection in pregnant women by about one-half.
  • Getting a flu shot can reduce a pregnant woman’s risk of being hospitalized with flu by an average of 40 percent.
  • Pregnant women who get a flu shot are also helping to protect their babies from flu illness for the first several months after their birth, when they are too young to get vaccinated.

-Dr. Jennifer Jagoe, courtesy of CDC

In Montgomery County, Maryland we are heading into an expected surge in infections with the Covid-19 virus. We are trying to make everyone safer by following these precautions:

1. If you are having symptoms such as fever, cough, shortness of breath:
   1. Call your primary care physician
   1. Stay home except for medical care
   1. Limit contact with others in your home
   1. Practice good hygiene with frequent had washing, cleaning common surfaces, and covering your cough or sneeze with your elbow, not your hands
   1. Manage symptoms at home with over the counter medications for fever and cough. Currently Nsaids such as ibuprofen are not recommended.
   1. Get plenty of rest
   1. Stay well hydrated
2. If you are sick, keep in touch with your doctor. Most cases of Covid-19 are mild and do not require a trip to the ER or hospital. If your symptoms worsen to high fever an difficulty breathing, call your doctor or health facility before you go there. This can help them to prepare for your visit.
3. If you are in Labor, Shady Grove Adventist Hospital remains open, but there are changes in procedures:
   1. In order to minimize exposure, only ONE visitor will be allowed in Labor and Delivery.
   1. Only the ER entrance should be used from 8pm to 5am.
   1. Visitors will be screened for flu like symptoms and will not be permitted to enter if positive.
   1. Visitors who have traveled internationally will not be permitted to enter.
   1. No visitors under age 18 unless they are a parent of a child in the hospital.
   1. Hospital Tours and Childbirth classes are suspended. We recommend as a substitute online classes such as www.mybirthly.com
4. Our office remains open, but we have suspended routine gyn visits. We continue to encourage prenatal visits as long as you have no symptoms of the virus. If you have questions about whether or not to come, please call us first. 
5. Unfortunately, we also must limit visitors to our office. We request that you do not bring visitors to our office including husbands, partners and children until this crisis has passed unless they need to be present for translation.

I recently attended the American Congress of Obstetricians and Gynecologists Annual Clinical Meeting and heard an excellent talk from one of George Washington University’s Professors, James Simon MD. The talk was inspirational! He spoke about a very important topic, “The Status of Hormone Replacement Therapy.”

By way of background, in the past many women were treated for symptoms of menopause with hormones, but in 2002 a report came out, called the “Women’s Health Initiative,” which changed everything by painting a very negative picture about the harm that hormones could cause. As a result, many women, all over the world, were scared into stopping hormones, and some of that fear persists to this day, despite much evidence to the contrary. Years later we have gradually discovered that the study was deeply flawed.

Dr Simon described this as an example of a  “Zombie Idea,” an idea that should have been killed by evidence, but refuses to die! This actually is similar to the current situation involving fear of vaccines, which was originally based on a fraudulent and discredited study, but still lingers on despite overwhelming evidence of vaccine safety.

Similarly, the WHI Study from 2002 was also flawed and following its recommendations has caused harm.

We now know about the “timing hypothesis” that the safety of starting hormone replacement therapy depends on when it is started in relation to menopause. Studies show a much decreased risk of complications such as stroke or heart attack if the woman starts treatment within 10 years of menopause.

Transdermal patches as a way of receiving hormones appear to decrease the risk even further, according to an extensive French study.

Re-analysis of the old WHI data shows no effect of hormones on causing breast cancer.

A Finnish nationwide study showed a decreased chance of death from breast cancer if hormone therapy with either estrogen or estrogen with progesterone was used.

To make it even more definite, a review of 17 studies looking at the risk of recurrence of breast cancer in women who had previous breast cancer, showed that 16 of the 17 studies had either no change or a reduction in recurrence of cancer if they were on hormone therapy.

Another review showed women lived longer if they received hormones starting at age 50-59. This looked at death from all causes, death from cancer, and death from stroke or heart attack.

The risk of Alzheimer’s disease or dementia was decreased by use of hormones.

How do hormones compare with other medications? Surprisingly, recent  studies found an increased risk of breast cancer from taking statins, which are often prescribed for high cholesterol levels. Medicines prescribed for improvement of bone density such as Pioglitazone showed an increased risk of breast cancer of 88 per 10,000.

Surprisingly, analysis showed one of the most dangerous medications causing breast cancer is Vitamin D, which caused 70 per 10,000 additional cases of breast cancer.

What was the aftermath of stopping hormonal therapy based on the WHI report when it came out in 2002? A study in 2009 showed a significantly increased number of bone fractures. Another study in 2011 shows more hip fractures in women who stopped hormonal therapy compared with those who continued it.

Was there an increased risk of death from stopping estrogen therapy? A study in 2013 showed over a 10 year span, starting in 2002, a minimum of 18,000 and as many as 91,000 US women died prematurely because of the avoidance of estrogen therapy.

The conclusions are that hormone therapy risks are rare, and even more rare when started in women who are less than 60 years old and/or within 10 years of beginning menopause. Starting it at a younger age does decrease the risk and increase the benefit.

The degree of risk, when it does occur, is similar to that of many commonly used medications or vitamin supplements. Hormone therapy significantly reduced the risk of bone fractures and is the most effective treatment for reducing the worst symptoms of menopause including hot flashes and atrophy of the vulva and vagina. If you have any symptoms of menopause, talk with us about being treated for it!

Becoming pregnant can be fun, happy, exciting, or sometimes unplanned. Knowing how it happens is very useful information to make it easier to achieve when desired, and to be avoided if that is the goal.

 
The average menstrual cycle lasts for 28 days and can range from 21 to 35 days. In an average cycle ovulation occurs on day 14. Signs may include a cramp in the lower abdomen or back, breast tenderness, increase in a clear vaginal discharge, or an increase in sexual desire.

 
For pregnancy to happen, sperm must be present in the fallopian tubes and meet with an egg. When a man climaxes during sex millions of sperm go into the vagina and some can make their way through the cervical mucus and into the uterus and from there into the fallopian tubes. Sperm can live inside a woman’s body for 3 days or more, but an egg’s life is much shorter, only 1 day. So pregnancy can occur if an egg is already present when you have sex, or if you ovulate within a day or two after you have sex. This means that your fertility time is limited. You are fertile from 3-5 days before ovulation to 1 day after ovulation. Trying to time intercourse so that you have sex just before ovulation seems to be a good way of thinking about it. There is also a new theory that ovulation is not just a random event. Research has discovered a special protein in semen that can actually cause ovulation.

 
Knowing when you are fertile can be a challenge. There are different methods to predict it. For planning purposes, there are phone apps that can be helpful such as Fertility Friend or My Days. These apps calculate your expected next period and make predictions based upon it. The predictions are less accurate if your cycles are less regular. You can also go to the drug store and purchase an ovulation predictor test kit such as Ovutime or Ovutest. These urine tests indicate when the hormone LH becomes present. When LH rises in your circulation it causes ovulation and this hormone can be detected in your urine. When the ovulation test turns positive, this means you should have intercourse that day and the next day for best results. You may also notice changes in your cervical mucus where it becomes increased in amount and more clear and watery in quality. To promote pregnancy you should time intercourse to be daily or every other day when good quality cervical mucus is present. It should not be less often than every other day or more frequent than once a day for the best fertility results. You can also track your temperature with a special thermometer to measure your basal body temperature. Your temperature rises after you ovulate and stays up by a small amount for 2 weeks. This method is not that useful in that by the time you discover you have ovulated, it’s already too late for timing of sex.

 
You can start trying for pregnancy soon after you stop using a birth control method, but not too soon. If you are using the pill or a similar hormonal birth control method, it is a good idea to wait at least a month or two to allow your body to return to normal. If you get pregnant in the first cycle after stopping the pill you will have double the chance of having twins. While that may sound exciting, having one baby at a time is a much safer way to go, and much more manageable for taking care of children later on. We recommend stopping the birth control method, waiting 1-2 months before trying for pregnancy, and being on vitamins that contain iron, folic acid and DHA. In a given cycle the chance of success is only 20%, and it is normal to take months for pregnancy to happen. Do not be discouraged if it does not happen right away. With normal fertility you will become pregnant within 1 year, and 85% of couples will be successful in having this happen. 15% of couples will take longer than a year (that is called infertility), but only 1% of couples are unable to conceive. If you are trying for pregnancy and it seems to be taking too long, don’t worry about it. Sometimes you can be trying too hard for pregnancy. Increasing your anxiety about it is not helpful for fertility. Relaxing and having a good time is usually the best recipe for success.

 
First signs of pregnancy include feeling very tired, feeling nauseous, having breast tenderness, and your period being late. If you think you may be pregnant, doing a home test is helpful. If positive, these tests are usually reliable. If a test is negative it may be accurate or not. Sometimes the level of pregnancy hormone is elevated by too little to be detected by the urine method. If you really need to know (for example when a tubal pregnancy is suspected), then a blood test is much more reliable to detect an early pregnancy. Blood tests and ultrasound are also very helpful if you are bleeding and concerned about a possible miscarriage.

 

 

When you have a positive test, call us to make an appointment to come in and confirm your pregnancy. If you are at least six weeks and one day from the first day of your last period, we should be able to see the fetus and its heart beat by ultrasound. Once we see the fetal heartbeat the chance of successfully having a baby goes up to 85%! Then you are on your way to having a new life in your family. Good luck!

 
This article is partially based on information in ACOG’s book, Your Pregnancy and Childbirth, Month to Month.