Category Archives: Obstetrics

Covid-19 OBGYN Update

Stop the Spread of Germs (COVID-19)

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
    2. Stay home except for medical care
    3. Limit contact with others in your home
    4. Practice good hygiene with frequent had washing, cleaning common surfaces, and covering your cough or sneeze with your elbow, not your hands
    5. Manage symptoms at home with over the counter medications for fever and cough. Currently Nsaids such as ibuprofen are not recommended.
    6. Get plenty of rest
    7. 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.
    2. Only the ER entrance should be used from 8pm to 5am.
    3. Visitors will be screened for flu like symptoms and will not be permitted to enter if positive.
    4. Visitors who have traveled internationally will not be permitted to enter.
    5. No visitors under age 18 unless they are a parent of a child in the hospital.
    6. Hospital Tours and Childbirth classes are suspended. We recommend as a substitute online classes such as 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!

 

Introducing Dr. Jennifer Jagoe!

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We are very pleased to announce that our practice has grown. As you can see in the picture, we now have four doctors in our practice!

Dr. Jennifer Jagoe, pictured on the left in the above image,  has joined our practice. She has a strong background in Obstetrics and Gynecology. She served as an OBGYN physician at the Naval Medical Center San Diego, the Naval Hospital Guam, the Naval Hospital Bremerton, Washington, the Madigan Army Medical Center, Tacoma, Washington, and the Walter Reed National Military Medical Center in Bethesda, MD.

She recently worked as an Assistant Clinical Professor of Obstetrics and Gynecology at the University of Maryland School of Medicine. Her work included being a preceptor for medical students, being a member of the Perinatal Advisory Council, and a member of the Maryland Patient Safety Center.

We are very fortunate to have her joining our group!

Dr. Jagoe is available to see patients at our Rockville office on Tuesday, Thursdays and Fridays, and at our Germantown office on Mondays and Wednesdays.

Pregnancy Dos and Don’ts

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Pregnancy is a great time, an exciting time, but it’s also a time of endless questions. Women have access through social media, television, print media, Internet searches, and their friends to much information about pregnancy, but sometimes it can be confusing or wrong. There are many questions about all facets of life including eating, drinking, sleeping, working, travel, exercise and having sex.  We are often asked these questions by our patients, and in the recent issue of our professional publication, Obstetrics and Gynecology (April 2018, p713), Dr. Fox wrote a nice summary about current, science-based recommendations regarding these topics. I’m going to summarize them for you in this article.

Prenatal Vitamins

Prenatal vitamins are designed to meet the needs of pregnant women. However, except for folic acid, iron and Vitamin D, it’s unknown if taking them makes a difference in outcome. For women with well-balanced nutritious diets, they are probably not required. Folic acid deficiency is associated with fetal birth defects, so women who don’t have it in their diet should be on 400-800 micrograms a day. Women who have had a history of a previous pregnancy complicated with a neural tube defect should be on 4,000 micrograms a day. Iron supplementation is advised to increase the mother’s blood count to avoid becoming anemic at birth.  It is more needed if the mother’s blood count is low to begin with. Vitamin D deficiency is associated with pregnancy problems including pre-eclampsia and premature birth. While testing for Vitamin D levels is not routinely recommended, taking Vitamin D (usually 200-600 IUs) daily is. Calcium supplementation has been shown to decrease high blood pressure in pregnancy. Women should be sure to consume through diet or supplements at least 1,000 mg of calcium per day. Some prenatal vitamins don’t have that much.

Nutrition and Weight Gain

Pregnant women should eat a healthy, well-balanced diet and usually should increase their calorie intake in the second and third trimesters by only a small amount, about 350-450 calories per day. A good nutrition resource is a website run by the U.S. Department of Agriculture at www.chooosemyplate.gov. Women with higher pre-pregnancy weight should not gain as much as women with normal or low weight.

Alcohol

High alcohol intake in pregnancy has been associated with fetal malformations. Studies in Denmark and Australia have found no association between a low level of maternal drinking (less than one drink per day) and developmental cognitive abilities in children. However, the threshold for safe drinking is not known, and it can’t be concluded that a small amount of drinking is safe. All major health organizations recommend abstaining from alcohol completely during pregnancy.

Artificial Sweeteners

There is no evidence that aspartame (NutraSweet), sucralose (Splenda), acesulfame potassium (Sunett), stevioside (Stevia) or saccharin (Sweet N Low) cause birth defects.

Caffeine

Most studies in humans show that low to moderate caffeine use is not associated with any adverse outcomes. Some animal studies suggest that high caffeine intake (greater than 10 cups per day) slightly increases the risk of miscarriage.

Fish

Eating fish conveys both benefits and potential risks. Benefits are that studies have shown eating fish in pregnancy resulted in improved neurodevelopment in children, and also lowered the risk of premature birth. However, fish is also a potential source of mercury exposure and mercury can cause harm. Therefore pregnant women should try to consume 2 to 3 portions weekly of fish that are high in long chain polyunsaturated fatty acids and low in mercury, such as anchovies, Atlantic herring, Atlantic mackerel, mussels, oysters, farmed and wild salmon, sardines, snapper, and trout. Other safe fish which have less fatty acids include shrimp, pollock, tilapia, cod and catfish. Women should avoid fish with higher mercury content such as king mackerel, shark, swordfish, marlin, and tilefish. For women who do not consume 2 to 3 servings of fish a week, there is no clear evidence that supplementation with omega-3 fatty acids improves outcome in children, but they are unlikely to be harmful.

Most health organizations advise women to avoid raw fish in pregnancy. However, the fish that typically makes up sushi (tuna, salmon, yellow tail, snapper, flounder) rarely carries parasites. Therefore, the risk of infection from eating well-prepared sushi in a clean and reputable establishment is not significant.

Other Foods to Avoid

Food restrictions in pregnancy are designed to minimize exposure to harmful infections such as toxoplasmosis and Listeria.  To lower the risk of toxoplasmosis, avoid eating raw and undercooked meat, and wash all fruits and vegetables before eating them. To lower the risk of Listeria, avoid unpasteurized dairy products, raw sprouts, unwashed vegetables, and unheated deli meats. While Listeria outbreaks were linked to deli meats in the 1990s, recently outbreaks were caused by ice cream, cantaloupes, hummus, and unpasteurized dairy products, so it’s difficult to make a list of safe foods without becoming overly restrictive.

Smoking and Nicotine

Smoking in pregnancy is harmful to both maternal health and to fetal health, causing many possible pregnancy complications. Although some of the adverse effects of smoking are due to nicotine, nicotine products designed to aid in smoking cessation are acceptable as part of a smoking cessation program, since nicotine in gum or a patch would reduce exposure to other toxins in cigarettes and in second hand smoke.  Other interventions such as bupropion and varenicline are thought to be effective and safe, but data is limited. Electronic nicotine delivery systems such as electronic cigarettes and vaporizers deliver high amounts of nicotine and could potentially be harmful, but less is known about them.

Marijuana

Marijuana is the most common illicit substance used in pregnancy. Current evidence shows that marijuana use in pregnancy is not associated with premature birth, low birth weight, or an increased risk of birth defects. Doses of it are not regulated and could vary significantly. Current recommendations are to avoid marijuana in pregnancy due to concerns about fetal neurodevelopment.

Exercise and Bedrest

Women with normal pregnancies should engage in regular aerobic and strength conditioning exercise. It is prudent to avoid exercise with a higher risk of injury such as contact sports, downhill skiing, and horseback riding. Women should try to moderately exercise 20-30 minutes four to five times a week. Moderate exercise is at the level at which women can still talk while exercising.

Bedrest, or activity restriction, is associated with several risks and has not been shown to be beneficial in pregnancy. Activity restriction has not been shown to be beneficial for women with high blood pressure, premature rupture of membranes, fetal growth restriction, or placenta previa.

Avoiding Injury in the Car

Pregnant women should continue to use three-point seatbelts in pregnancy. The lap belt should be placed across the hips and below the uterus. While airbags can also reduce the risk of injury, deployment of an airbag itself can also cause injury. It’s unclear if they are beneficial or harmful.

Oral Health

Oral health and routine dental procedures should continue as scheduled during pregnancy, including cleanings, extraction, root canal and fillings. X-rays can be done if the abdomen and thyroid are shielded.

Hot Tubs and Swimming

Hot tubs have the potential to increase body temperature, which is considered a risk for miscarriage and birth defects. It is thought to be more potentially harmful if it is done within the first 4 weeks from the last menstrual period, or if it is done more often.

Swimming pools are typically maintained below normal body temperature, and their use is not associated with harmful outcomes.

Insect Repellents

Topical insect repellants can be used in pregnancy because they are not associated with adverse fetal effects. As a result of the risk of mosquito-borne illnesses including Zika virus, their use in high risk areas is recommended.

Hair Dyes

Most studies on exposure to hair dye relate to the profession of cosmetology, and studies are mixed as to whether or not there is increased risk of pregnancy loss in that setting. Data on safety is limited, but for an individual pregnant woman, exposure to hair dye results in minimal systemic absorption, so hair dyes are presumed safe in pregnancy.

Travel

Airline travel is considered safe in pregnancy, but it is prudent to take precautions to lower the risk of a blood clot by periodic walking.  Pregnant women may go through security metal detectors. The radiation exposure from the newer backscatter units is also safe. In regard to travel destinations, women should be aware of the potential infection exposures (including Zika virus) as well as the availability of medical care at their destination. As the length of the pregnancy advances, the risk of travel increases, but there is no exact gestational age at which women cannot travel. In our office, it’s our policy to not allow distant travel in the last two months.

Sexual Intercourse

Sex and orgasm are not associated with an increased risk of pregnancy complications or premature birth. For women with vaginal bleeding or ruptured membranes, the risks of bleeding or infection may increase. Although there is little data to support it, most authorities recommend avoiding sexual intercourse after 20 weeks of pregnancy if a placenta previa is present.

Sleeping Position

Women are frequently advised to sleep on their sides, especially the left side. Several retrospective studies (limited by recall bias) have shown an increased risk of stillbirth when sleeping flat on one’s back. Considering the limitations of these studies as well as not knowing more about the benefits of side sleeping, it’s unclear if side sleeping conveys a benefit, how much it reduces risk and when. We recommend not sleeping flat on your back in the last 2 months of pregnancy. Sleeping on your side or on your back being tilted up by additional pillows should be safe.

Should I have a birth plan?

by Bailey K. Cannon, MD

We get this question a lot. You may have heard about birth plans from your friends, the internet, or even the hospital. What is a birth plan? It is a document that states your wishes for delivery. That sounds like a nice idea but when it comes to labor and delivery the only person who is in charge is the baby. Have you ever planned a family vacation and you have the great plan of how things will go, what restaurants you’ll eat at, and the sights you will see? Then only to find the roads are under construction, the restaurant you really want is closed, and the parks are closed for maintenance. You may still have had a great time but feel a little let down because “not every went as planned.” The same is true with birth and plans for it.

In our office we do not encourage birth plans. Our ONLY plan is for a healthy mom and a healthy baby. Additionally, a vaginal delivery is also always our first wish for you. We certainly care about your preferences and will discuss any ideas you may have. You are welcome to bring any music, scents, clothes, etc. that you would like. Additionally, during labor if there is a choice: we will always give you that choice. Such as: Would you like an epidural or not? That choice is 100% up to you – we are happy either way. We may use our medical education and training to suggest an intervention that we feel will help you, but as long as it is safe – you are welcome to decline. If ever you or the baby are in danger we will immediately make a medical decision and we hope you will agree.

While we do not encourage birth plans, should you desire a birth plan we will be happy to review it in the office and discuss what is reasonable or what things may be unsafe. There are many unsafe recommendations on the internet. We have included a birth plan from the March of Dimes that we think is a good choice in birth plans.

Our only plan for you is a healthy baby and healthy mom. We look forward to achieving this goal together.

Click on the following to see a sample birth plan: