Category Archives: Popular OBGYN Topics

Getting the RSV Vaccine by Dr Supriya Mishra

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We recommend RSV Vaccine for pregnancy 32-36 weeks between September and January.

 

We recommend the Pfizer RSV vaccine if you are 32 to 36 weeks pregnant from September to January. The vaccine creates antibodies that pass to your fetus. This means the baby will have some antibodies to protect them from RSV for the first 6 months after birth. 

RSV, or respiratory syncytial virus, is a virus that spreads in the fall and winter. RSV can be dangerous for babies and young children. It is the leading cause of hospitalization among infants in the United States.

There are multiple RSV vaccines approved by the U.S. Food and Drug Administration (FDA). The only RSV vaccine approved by the FDA for use in pregnancy is the one made by Pfizer. It is called Abrysvo. 

You can get the Pfizer RSV vaccine at the same time as other vaccines recommended during pregnancy. Common side effects of the RSV vaccine include arm pain, headache, muscle pain, and nausea, similar to other vaccine side effects. Side effects are normal and not a cause for concern.

The RSV vaccine is one of two new options for protecting babies during RSV season. There is also an option to give babies an injection called Nirsevimab. Nirsevimab contains lab-made antibodies that protect against RSV. It is not a vaccine. Please talk to your pediatrician to see if this is an option at their office for your newborn. 

You can get the Pfizer RSV vaccine at the same time as other vaccines recommended during pregnancy. 

In most cases, you should choose between the RSV vaccine during pregnancy and Nirsevimab after birth. The goal is to protect your baby from RSV, either with antibodies made during pregnancy or with antibodies given directly to your baby after birth. 

We can help you decide between these two options. You may want to consider the following:

The RSV vaccine gives your baby protection right after birth. If you get the RSV vaccine, there is one less injection for your baby to get after birth. Nirsevimab may provide your baby with longer-lasting protection but confirm with your pediatrician, this will be an option for your baby at their office. It may be hard to get Nirsevimab this fall and winter.

• • • 

List of pharmacies our pregnant patients have received their vaccines without issue:

  1. Walmart in Germantown
  2. Costco in Gaithersburg 

Get Your Flu Shot!

  • 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

Headaches during Pregnancy

More than 40 million people suffer from headaches. Headaches interfere with leisure activities, mood, concentration and daily function. The National Headache Foundation suggests that understanding the type and triggers of a headache can not only guide potential treatment options but also help people make lifestyle changes and efforts to try to  prevent them. 

Headaches during pregnancy can be common in each of the 3 trimesters.  The causes are multiple and need to be evaluated carefully as the causes are varied.  The most common headaches include tension, cluster or migraines. Common triggers include exertion, foods, stress, hunger, anxiety, dehydration, neck strain and poor sleep habits.  Other causes of headaches include medication side effects, changes in hormones and underlying medical conditions such as high blood pressure or hypertension.  

First trimester is often a time of altered eating due to hormonal changes which accompany food aversions, heightened sense of smell, nausea and vomiting. It is important for pregnant ladies to avoid long periods of fasting and to limit the risk of dehydration. Pregnant woman who abruptly stop caffeinated beverages may experience headaches as well.  In second trimester, higher levels progesterone, a normal female hormone, can lead to an increase in headaches and are typically self -resolving as the pregnancy progresses.  Viral illness, seasonal allergies sinus congestion, tooth pain, infections and other medical problems may also lead to a headache.

Stretching, reduced computer time, eyeglasses, sunglasses, sleep, rest, massage and exercise all may improve quality of life and lower frequency of head pain.

Acetominophen is the generic name for Tylenol which is both safe and effective as first line treatment for both pain and fever in pregnancy. The maximum amount that adults can take is 4000mg or 4gm orally in divided doses in a hour period. For example:  325mg tabs, taking 2 by mouth with water every 6 hours.

Water alternatives include products such as Gatorade, Propel, Powerade, lemonade, carbonation, decaffeinated tea, shakes, popcicles, smoothies, sugar water, ginger, lemon and lime additives to water may help increase fluid intake so headaches resolve and IV fluids in the acute care setting is not required.

Home remedies are appropriate to try initially; however, if not improved please be sure to seek advice and /or evaluation from your primary care provider or obstetrical medical team.  The first consideration in third trimester of pregnancy is hypertension or high blood pressure.  Pre- eclampsia is more common in the first pregnancy. Prenatal visits are more often in the third trimester so that if problems occur close follow up and early intervention is possible.

You are advised to call our office at 301 468-4900 for headaches or if not feeling well so that blood pressure and symptoms can be evaluated promptly.

-Dr. Jennifer Jagoe

Travel during Pregnancy

Expecting a baby is an exciting and special time. Women feel energized and empowered when they observe miraculous body changes. The body knows exactly what to do and healthy personal choices help support this amazing natural process. Travel is sometimes considered a way to celebrate, however safety and comfort needs can be prioritized if you plan to travel during pregnancy.

The American College of Obstetrics and Gynecology (ACOG) suggests the best time to travel is between 14-28 weeks. Cruise lines and airplanes caution about having pregnant ladies aboard. Traveling can sometimes cause problems. Be careful about standing too long waiting in line as you may feel faint. If you do feel so, sitting down and having a cold sweet drink can help. Try to avoid carrying too much weight. Travel to other countries later in third trimester can lead to hospitalization or delivery far from home. Seatbelts, of course, are always advised. Long car trips can become complicated when women need to frequently make trips to the bathroom. Water intake requirements increase to approximately a gallon of water a day, preferably from bottles. Once you arrive, try to avoid doing too much physical activity right away. Your skin may be more sensitive to the sun, so wearing a large hat and putting on sunscreen can help. Anticipating hunger and the need for frequent snacks and healthy meals is essential so planning ahead is important. Travel is not always easy. Preparing ahead of time with food, water bottles, sensible footwear and thoughtful creative ideas are required, appropriate and fun.

American popular culture shows us professional athletes competing while pregnant such as the LPGA star golfing at top level tournament in third trimester and the performing artists at the Super Bowl halftime show demonstrate how a woman with an enlarging abdomen and a healthy fetus can gracefully do just about anything. However, sometimes activity modification to prevent a fall, accident or injury in pregnancy is not only medically recommended to optimize outcome but also may be more comfortable. Being able to anticipate common discomforts and to minimize potential complications in pregnancy needs to be carefully considered and is something to discuss with both family and the health care team. If you have an urgent question, you are able to reach us by calling our office even while away from home.

-Dr. Jennifer Jagoe

Sterilization by Laparoscopy BISALP

Let’s talk about permanent sterilization or getting a “BISALP”

There has been a lot of discussion lately on social media platforms regarding this. On Reddit/Facebook/Instagram there are many threads on “getting your tubes tied.” I would like to share my support and present reliable information regarding this on our website as well for you. 

I have placed my name on a list of physicians who are willing to perform sterilization procedures on women despite the number of babies they’ve had or their marital status. As always done in my practice, I will counsel you on all the options of contraception including the risks/benefits of female sterilization. We can discuss the option of vasectomy for your partner and where I would recommend to go for this outpatient procedure. We can discuss the option of placing a LARC contraceptive to help with heavy periods while also completing permanent sterilization if desired. 

If after our discussion about even the risk of regret and the usual risks of laparoscopic surgery etc, you would still like to have surgery, then I am happy to walk you through that process. I operate at Adventist Shady Grove Hospital. 

Please call and speak to my office staff if you would like to come in for a consult. You may bring a friend/family member to the consult for support if you choose. 

Here is a thorough FAQ list about permanent sterilization for men and women:

https://www.acog.org/womens-health/faqs/sterilization-for-women-and-men?utm_source=higher-logic&utm_medium=email&utm_content=july-6&utm_campaign=acog2022-digest&fbclid=IwAR3lwGhKSDHz-JhSAvtGIuUVKGr_2vQBbxPgNU3ImL3DEnyH2wVckubQznM

-Dr. Mishra

We Recommend You get Vaccinated!

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We recently have received communications from the Maryland Department of Health and from the American College of Obstetricians and Gynecologists regarding whether pregnant women should become vaccinated:

ACOG stated that “pregnant patients with COVID-19 are at increased risk of more severe illness compared with non pregnant peers.”
“These data indicate an increased risk of ICU admission, need for mechanical ventilation and ventilatory support (ECMO), and death reported in pregnant women with symptomatic COVID-19 infection, when compared with symptomatic non-pregnant women.” “ACOG recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination.”

Considering the relative safety of the vaccine compared with the much greater short-term and unknown long term risks of the virus, we recommend you do what we did, Get Vaccinated!

We are working to be able to provide the vaccine in our office. Until that is available, we recommend you get the vaccine as it becomes available wherever you can.

Fetal Movement Counting

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Myths about Fetal Movement Counting

Counting your baby’s movements in pregnancy is important and worth doing. But education about how to do it right is not widely available. In this post we will discuss myths about fetal movement counting.

Myth 1: Kick counts reassure. The standard advice given to pregnant women is to check in on your baby and call if there are less than 10 kicks per hour.  This is not bad advice but research shows that while most moms will pass that test there is no data on which percentage can perceive decrease movement and still pass. For example, if you normally feel 50 movements in an hour, sensing only 10 represents a significant drop. So if you are worried about a concerning change in fetal movement, please give us a call.

Myth 2: Fetuses slow down at the end of pregnancy. A 2019 study looking at fetal movement showed that fetal movement does not decrease in frequency or strength at the end of pregnancy.  It found that only 6% of patients noticed decreased fetal strength and 14% noticed decreased frequency of movements at term. Furthermore, 59% noticed an increase in strength and 39% noticed an increase in frequency of movements. 

Myth 3: Patients should try juice, ice water or food before evaluation. Common advice when patients notice a decrease in movement is to recommend having a sweet cold drink before calling to report a potential problem. Studies about this have not shown improved reactivity when testing is done. When a patient calls with decreased fetal movement, advice should be to come and be evaluated, not have cold liquids or a sugary meal, as it is not supported by research.

Myth 4: An increase in fetal movement is not of concern. An increase of fetal movement can sometimes occur before a stillbirth. A single episode of excessively vigorous activity which is often described as frantic or crazy is associated with an odds ratio for stillbirth of 4.3. In a study, 30% of cases reported it, compared with only 7% of controls (BMC Pregnancy Childb 2012 10.1186/1471). In our practice,  we manage mothers who call with this concern the same way as a report of decreased fetal activity, and bring in the mom for immediate evaluation.

Myth 5: Patients all know that a concerning change in fetal activity is a risk factor for stillbirth. Decreased fetal movement has been associated with an increased risk of stillbirth. However patients often do not know about this. OB physicians are sometimes reluctant to discuss this issue due to fear of anxiety it can provoke. Most patients are very appreciative of receiving this information and feel reassured that help is available if needed.

Conclusion: When I think about the patients I cared for who have had a stillborn baby, I recall that they often come in for evaluation of a different complaint, such as a labor check or a routine prenatal visit. When asked about it, they will sometimes say they last felt fetal movement several days before. This does not need to happen. Protocols have shown that when patients have received education about fetal activity, they will call sooner to report a potential problem. Not all stillbirths can be prevented, but being more aware of changes in your baby’s activity can be successful at minimizing your risk.

Covid-19 Update

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You Can Make a Difference!

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.

COVID-19, an OBGYN Perspective

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COVID-19 was first recognized in Wuhan China. It started in December 2019 with one case and by the end of two months it had grown to over 70,000 cases. As of early March it has been diagnosed in over 100,000 people and has killed 3300. Currently it is most prevalent in China, South Korea, Iran, Italy, France, Germany and the US, which is ranked 7th in the amount of cases.

Patients who get sick with COVID-19 have cough and fever, sometimes with muscle aches or chills. In the more severe cases patients can have viral pneumonia. In the worse cases patients develop a syndrome called ARDS which is a pulmonary syndrome and is similar to that seen with a different virus called SARS which was prevalent in 2002.

Some patients’ symptoms can also be GI symptoms such as nausea, vomiting or diarrhea. In China approximately 80% of those infected developed mild symptoms and did not require any medical intervention. About 15% required hospitalization and 5% required critical care.

The overall mortality rate of the disease is difficult to calculate because of the different ways it is being diagnosed around the world. We find severe cases first so there is probably an over-representation of those cases and the mortality rate is probably lower than current estimates. The more that we do diagnosis, the more we diagnose mild cases. In South Korea with the greater availability of testing, the mortality rate was found to be 0.6%, which is probably more accurate than the numbers from China. The risks are substantially higher in people who are older than 70. At present, it does not appear that pregnancy increases your risk.

The virus has a 1 to 14 day incubation period, with the average incubation of about 5 days. The virus is spread by respiratory droplet with close contact, usually within 6 feet. In China as many as 20% of cases have no symptoms which makes it more challenging to identify it and contain it.

In China they took major interventions to contain the virus such as closing cities, canceling mass gatherings, closing of travel routes, closing of businesses, closing schools and confining people to homes.

The US has moved to increase capacity for testing to make tests available for any patient with symptoms who needs it. The government is proceeding with making drive through testing centers available in all communities. Local government and hospitals are gearing up to make testing and treatment available in our community.

Our practice plans to stay open and continue to see our OBGYN patients. To help us help you, please do not come to our office if you have symptoms of this infection, such as fever, chills, cough, muscle aches, or recent exposure to someone who did. Feel free to reschedule your non-emergent gynecology visit. 

 If you want to be tested for the virus, Montgomery County has a hotline to find out where to go: 240-777-1755. You can also find out up to date information about the virus at the COVID-19 Johns Hopkins site.  If you have further questions about whether or not you should come in for your visit, please call our office before coming in.

Thanks!

Are Hormones for Menopause Safe?

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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!