by Sarah Obican, MD, MotherToBaby President

Though I wish I didn’t remember the day well, I do. I was a maternal fetal medicine fellow in NYC and I was sitting with my two beautiful co-fellows. When I say my co-fellows were beautiful, I mean that inside and out. We were an odd pairing of three musketeers. Young, bright, professional women, training to take care of women with high-risk pregnancies… and all three of us were pregnant. It was completely unplanned and highly unusual for all three of us to conceive, all within a few short weeks of each other. But there we were one day, sitting at our desks, talking about our individual research projects and occasionally interjecting in each other’s conversations with excitement about our future babies. I loved my two colleagues so much, and I was so excited to imagine that we would follow each other’s careers and see our children grow up, all similar in age.

In the middle of this conversation, something made me just get up and say to them “I’ll be right back!” I still don’t know what made me do it. I had a feeling hard to describe, but it made me walk over to our ultrasound unit and ask my sonographer colleague to please do an ultrasound.

I was on the examining table within minutes. But her silence after she put the probe down on my ultrasound gooped-up belly felt like an eternity. Another sonographer came into the room. I knew. That’s when the world went dark.

Now, I am physician and I cannot explain this. For a few moments, quite literally, the bright NYC day, the room, the people in the room, went completely dark. I couldn’t see. I didn’t lose consciousness, but I couldn’t see.  In my career, I sadly had to care for countless women who went through a miscarriage and in that darkness, I wondered if they had experienced the same. A few moments later I was back in the ultrasound room, now with an overcoming wave of sadness which made me wish I was in the numbing darkness again.

The American College of Obstetricians and Gynecologists estimates that 26% of all pregnancies end in a miscarriage and a significant proportion of those are in already clinically recognized pregnancies (when the pregnant woman already knows she is pregnant).

Miscarriage vs. Abortion

The words miscarriage and abortion are often used interchangeably. For example, a missed abortion in the world of obstetrics means that pregnancy stopped naturally and that there is no heartbeat or if early enough in the pregnancy, that there is no continuation of fetal growth or development. These pregnancies can pass naturally with bleeding or can be aided by a physician by giving medication of performing a procedure. During this time, there is a lot in terms of discussion of possible contributing factors including abnormal genetics and counseling on recurrence for the next pregnancy. It’s a tough, sensitive time for patients. I know it from both sides.

Ectopic Pregnancy

Sometimes desired pregnancies present themselves as ectopic pregnancies. An ectopic pregnancy is when an already fertilized egg implants and begins to grow outside of the uterus in an area that cannot adequately support the pregnancy. Most of the ectopic pregnancies (>90%) occur in the fallopian tube, but no matter where the pregnancy implants, it can be life threatening for the pregnant woman. This is because the location in which the ectopic pregnancy has implanted cannot grow, expand and adequately support the pregnancy nutritionally and can result in the structure rupturing and causing internal bleeding. While all miscarriages can feel devastating, an ectopic pregnancy is an emergency that requires immediate treatment by a physician. Depending on the size and development of the ectopic pregnancy and the patient’s symptoms, the ectopic pregnancy can be treated with medication or by surgery. This too gives a great sense of loss for patients because often these pregnancies were highly desired.

It is important to note that being treated for a miscarriage or an ectopic pregnancy either by the use of medications or surgery is not considered a termination. As a high-risk obstetrician, I know that providing great medical care for a miscarriage, an ectopic pregnancy or providing access to desired abortion care is essential for the pregnant woman’s health and safety.

Shedding Light on the Darkness

With my personal journey of years of infertility and in vitro fertilizations, there are not many positives from that sunny day in NYC. However, that personal darkness shed light on all of what my patients in similar situations had to go through. I talk about my history openly, if asked. When appropriate, I share with my patients about my loss and about infertility. I am reminded by my patients that we have to speak more about these human experiences. To normalize them, to not feel alone.  As for the experience of that day, I am thankful for that knowledge and when I have to be the first to tell my patient that she just had a pregnancy loss, I get close to her and I hope that my words, my actions and my demeanor show them what I am thinking inside…. I see you and I’ve got you.

References/Resources

https://www.acog.org/advocacy/abortion-is-essential

https://www.acog.org/advocacy/facts-are-important/understanding-ectopic-pregnancy

https://www.ncbi.nlm.nih.gov/books/NBK532992/#:~:text=The%20American%20College%20of%20Obstetricians%20and%20Gynecologists%20%28ACOG%29,early%20pregnancy%20loss%20occurs%20in%20the%20first%20trimester

The year of the pandemic has not been easy. It has left most doctors and essential workers drained from the added stress. But I just got off a telehealth visit (sadly, a part of my new normal) with my long-standing patient and I am so excited! My patient (and myself) has struggled to lose weight for most of her life, but considering some of her chronic medical conditions, she was so motivated to lose weight prior to her pregnancy. I am so ecstatic because I love my patient! My patient, beautiful inside and out, has just made some lifestyle changes that will make her pregnancy that much safer for her and her baby.

Obesity and Its Impact during Pregnancy

Based on a large US survey, close to 60% of women are either overweight or obese. Unfortunately, obesity increases risks for both mom and baby during pregnancy. In early pregnancy, obese women have an increased risk of miscarriage and later in pregnancy an increased risk of stillbirth. There is also an increased risk of birth defects, most notably defects of the spinal cord, heart, face and limbs. Additionally, detecting these anomalies poses a greater challenge. Accounting for how ultrasound scientifically works, it is difficult for ultrasound detection of fetal abnormalities in obese women.  The higher the body mass index of a patient, the lower the anomaly detection rate. Compared to non-obese women, obese women also have higher risks of heart complications, diabetes in pregnancy, sleep apnea, blood pressure disorders such as preeclampsia and heart dysfunction. Our obese patients need to be closely monitored for possible complications throughout pregnancy.

At time of delivery, studies and clinical practice tell us that obese women have an increased risk of a cesarean section. After their delivery, they are more apt to struggle with an infection of the womb or infection of the cesarean incision.

Prepping Before Pregnancy

January is Birth Defects Prevention Month and this year’s theme is “5 Tips for Birth Defects Prevention,” which includes the following tip: Before you get pregnant, try to maintain a healthy weight.

Due to all the potential complications, the best time to address obesity is before becoming pregnant. This is where mom-to-be may need the greatest support in helping to optimize health and the health of baby. Weight loss is the one thing we can do to help change our health. I often tell my patients that we cannot change our genetics, our family or personal medical history, but we can make lifestyle changes that can make a lasting difference in our baby’s health and ours. Achieving optimal weight, or even just starting to work toward it, can be achieved through so many avenues such as nutrition and exercise, help with medication, or even surgery. The many approaches should be personally customized to mom-to-be.

During pregnancy, we recommend less weight gain for our overweight patients. Overweight and obese patients should gain between 15-25 lb (6.8-11.3 kg) and 11-20 lb (5.0-9.1 kg) respectively. Increased testing and monitoring in pregnancy is often recommended. A healthy diet in protein, fats and carbohydrates as well as exercise should be discussed with your doctor. What works for me may not work for some of my patients and that is important to know – Each of us are beautifully individual!