“First Trimester Bleeding and Subchorionic Hematomas” – with Dr. Mackenzie Naert

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy and wellness. 

 

All right, we’re here again with Dr. Mackenzie Naert who was with us before to talk about her transition from medical school to residency and what that’s like Mackenzie is an OB-GYN resident in Boston at the Brigham. And she’s a graduate of Mount Sinai Medical School, we did research together, she’s one of my favorite humans. And I’m really excited that you’re back to talk about the topic of sub-chorionic hematomas, and vaginal bleeding in the first trimester of pregnancy. Mackenzie, welcome back. 

 

Dr. Naert: Yeah, thank you. Thanks for having me again. 

 

Dr. Fox: Let’s just jump right into it. Because from the last podcast, everyone already knows who you are, and everyone thinks you’re, amazing and super nice. And if you didn’t hear that podcast, go listen to it. And you’ll be convinced. So let’s just start, how did you get interested in studying this particular topic? 

 

Dr. Naert: Yeah. So when I was sort of trying to think about what I wanted to spend my dedicated year of research doing, I knew that I wanted to do something that was going to feel really clinically important. And when I say clinically important, I mean, both in terms of patients and patients having questions and wanting answers, and providing good data for them. And then also from the provider side, I wanted to be answering your question that physicians, OB-GYNs and NFMs found themselves often encountering. And so when I started meeting with Dr. Fox, him and I were talking about different research ideas, and I also took the time to speak with a lot of other physicians in his practice, of which there are many awesome people who I miss a lot and one of Dr. Fox’s colleagues, Dr. Naxy, had done a little bit of research looking at outcomes of sub-chorionic hematoma in twins. And in doing that research, she really realized that there’s not a lot of great data out there about outcomes of singleton pregnancy, so one baby pregnancies with sub-chorionic hematoma. 

 

So I did some initial research myself and spoke to other doctors and, sort of determined that, wow, this is a really important clinical question. Because a lot of women are diagnosed with subchorionic hematomas during the first trimester, and occasionally even the second trimester of pregnancy. And there’s just not a lot of data out there. And the data that is out there has a lot of significant limitations in terms of what type of patients were included in the studies and what variables were controlled for. And because of that, it was very difficult to counsel patients with sub-chronic hematoma on the outcomes. So from all of that preliminary research, I sort of decided Dr. Fox and I sort of figured out that this would be a good thing for me to spend my research here studying. 

 

Dr. Fox: That’s fantastic. So I love that you picked this topic, I was also super interested in it. So what I wanted to do is I wanted for you and I to take a step back and just talk about sort of the clinical situation. So what are we talking about, what’s happening? What are we worried about, what are patients worried about? And sort of what, you know, and then go into, okay, what did we study and what did we find? So, just to take a step back, what exactly is a subchorionic hematoma? Because that’s a lot of a lot of big words there. 

 

Dr. Naert: To sort of break it down a hematoma just generally means a collection of blood. So you can have hematomas in many other parts of the body. A lot of people have heard of, like a subdural hematoma or an epidural hematoma. And these are collections of blood around the brain. So a subchorionic hematoma is referring to the chorion, which is one of the layers of the fetal membranes surrounding the pregnancy. So a subchorionic hematoma sub meaning under is therefore a collection of blood under the chorion so it is something that can be visualized on first trimester ultrasound. And I think, most of the time that is how patients first hear about a subchorionic hematoma is, they’re getting a routine first trimester ultrasound or potentially an ultrasound because they were having some vaginal bleeding. And the ultrasonographer, or the physician tells them that they see a subchorionic hematoma. 

 

Dr. Fox: Right. So when we tell patients there’s a subchorionic hematoma, people sometimes say different things like patients come to my office and say, “Oh, I had a blood clot or I had a collection,” it’s all really the same thing. I mean, the placenta attaches to the uterus, and generally it’s flush up against the uterus and all the blood flow just goes into the uterus, like through the uterine wall and into the placenta. But occasionally, if let’s say the edge of it separates off a tiny bit, there’s gonna get some blood that doesn’t actually get into the placenta but sort of hangs out there in that space. That new space between the uterus and the placenta. And if we see it on ultrasound, it’s pretty easy to see. And we call it a subchorionic hematoma. And most people who have it, they have no symptoms. They feel fine, their pregnancy is fine. The baby’s there, there’s a heartbeat. And we just, we say, all right, the baby’s the size, the heart rates, this, everything looks good, and you have a hematoma. And we sort of measure it in centimeters, it’s two centimeters by three centimeters by whatever. Okay, so that’s one scenario that someone just walks in and have an ultrasound and we happen to find it, incidentally. And how is that different from let’s say, someone who comes in with bleeding? Because it may be due to the same cause with the placenta separating a little bit so and how is that usually described or thought about? 

 

Dr. Naert: Exactly. So when someone comes into the office with bleeding during the first trimester, or often we’ll have these patients call in and sometimes overnight, or during the day, or they’ll come into labor and delivery chairs and say, “Hey, like, I’m a little bit concerned, because I’m having some bleeding.” And I think, the important thing for patients to know is that bleeding in the first trimester happens, it can be in up to one fourth of women of pregnancies. And I think there’s a lot of different causes for that bleeding. And I, of course, completely understand when patients feel concerned and alarmed, because they don’t expect to have bleeding once they’re pregnant. But I think, the first thing that’s important to know is that there are so many different things that can cause the bleeding and that a lot of them are not serious and will resolve on their own. So it’s not something to initially be overly concerned about. 

 

Dr. Fox: One of the other reason that freaks people out is the synonym for first trimester bleeding is threatened abortion, which is like two scary words put together. And so it’s like… 

 

Dr. Naert: Totally. 

 

Dr. Fox: …they feel like, “I have a threatened abortion? That sounds horrible.” And all it means it’s like it’s the term that was given to people who have bleeding and you don’t know what’s gonna happen. And I agree, it’s very common, fourth, third. Some significant percentage of women will have bleeding in the first trimester. And the vast majority, nothing happens. They don’t miscarry. Everything, it just goes away, and they’re fine. And the reason it sort of gets mixed together with this subchorionic hematoma, the reason these we’re doing this podcast together, why they sort of get intertwined is, they’re both very common, right? It is common for women to have bleeding, it is common to find a hematoma. It’s common to have them together, or you can have one without the other. But the thought is that there’s is an over lapping mechanism, this idea of like the placenta separating a tiny amount, right? The placenta separated a huge amount, like someone would miscarry because you can’t have a pregnancy if there’s no placenta attached. But if it just a little tiny bit separates, sometimes that collects as blood that doesn’t go anywhere, and that’s a hematoma. And sometimes it tracks out the cervix, the uterus and that bleeding. 

 

And so the thought is, if someone has one of these, maybe they’re at a much higher risk of miscarriage, because if the placenta separates a little bit a tiny bit, maybe it’s gonna separate more, and they’ll miscarry. And again, so we frequently see them together, and there’s a lot of overlap. And it’s part of the reason that the research is complex. Because if you look at a study on hematomas, well, how many of them had bleeding at the same time? Or how big are the hematomas? Or did they have other risk factors for miscarriage? Or why were they getting an ultrasound sometimes higher risk patients get ultrasounds and lower risk patients don’t and so you would only find the hematoma on someone who’s already at higher risk. And there was so much about that. So when clinically, when we would see patients who had either of these, you know, we’ll go over what we did. But one of the things is, it’s very hard to sort of tell them, what is the likelihood that this is gonna be fine, versus the likelihood that it’s not gonna be fine, other than sort of our gut or intuition. 

 

Because if you look at the studies, they’re all over the place. I mean, there’s just there was data everywhere on these hematomas, for example. And so it was a really good reason to do this study to try to tease that all out. And one of the reasons we’re able to do it is because we have a lot of women who come through our practice, and pretty much all of them get an ultrasound early, like 100% of them. So we weren’t picking the highest risk women to get ultrasounds, we did it for everybody. So we really had good data on the front end, sort of who had hematoma and who didn’t. That was a big thing. And I mean, listen, you went through, how many years of data did you go through? Let’s see, it was three years, right? 

 

Dr. Naert: Yeah. 

 

Dr. Fox: Yeah. And we were talking and it was over. I think it was 2000, 3000, 2400. 

 

Dr. Naert: Twenty-four hundred yeah. 

 

Dr. Fox: Yes, it was big numbers. So that’s great. Now, what do we do clinically if someone comes in, let’s say they have bleeding like you said, someone calls and it’s bleeding or they come to the office for bleeding. What is it that you worry about other maybe than they could be miscarried? 

 

Dr. Naert: When I see a patient with first trimester bleeding, there’s sort of a couple different buckets that I try to sort of think about the causes. So the first bucket that I think about is sort of non-obstetric causes. So it’s important to think about how during pregnancy, the cervix just bleeds a lot more easily. It has a lot of blood vessels that are developing in the area. And so people can have spotting or even light bleeding after things like sexual intercourse, or a pap smear, or a pelvic exam, things that might not normally cause this patient bleeding, but because they’re pregnant, and their cervix is very vascular, they might have some bleeding. So I think when I’m evaluating a patient with first trimester bleeding, I’ll often do a speculum exam. And depending on other symptoms, I might do additional things to try and look at the cervix and see if sometimes the cervix has a color on it, and that could be the cause of the bleeding, sometimes you can tell that the cervix is just really inflamed, and the patient might have cervicitis, or they might have, vaginal discharge and itching and other symptoms that would make me think that this patient has vaginitis. And then that might be the cause of their bleed. And so I like to sort of think about those causes and sort of trying to eliminate those things as causes of bleeding before I think about obstetric causes and things that are more directly related to the pregnancy. 

 

Dr. Fox: So that’s your first bucket. What’s bucket number two? 

 

Dr. Naert: That’s my first bucket. So then bucket number two is obstetric causes. And I think, this is when what people are really worrying about when they have vaginal bleeding during early pregnancy, because people are worried about pregnancy loss, but you can have vaginal bleeding and a viable intrauterine pregnancy that isn’t associated with pregnancy loss. For example, one of the things that we think about is implantation bleeding. And one to two weeks after fertilization when the fertilized egg is implanting into the lining of the uterus, it’s totally normal and healthy and physiologic to have some bleeding at that time. So that’s one of the things that I’m thinking about. 

 

Dr. Fox: And when you said you specifically use the term intrauterine pregnancies, why did you use that specific word? 

 

Dr. Naert: When a woman takes a new urine pregnancy test at home, and have the plus or the correct line on the stick indicating a pregnancy, what we’re testing for is a hormone called Beta hCG. And that hormone can be because the woman has a pregnancy inside the uterus. So we call it an intrauterine pregnancy. But it can also be from an ectopic pregnancy, which is a pregnancy that occurs outside of the uterus, most commonly in the fallopian tubes. And so if a woman is coming into the office, or coming into triage, and has this positive pregnancy test at home, and they haven’t had an ultrasound yet, you know, we don’t know yet at that point if this is gonna be a viable and treat pregnancy, or if this is going to be an ectopic pregnancy outside of the uterus. 

 

Dr. Fox: Right. And I think that that’s such an important point. And it really, it seems so vast and so complex of what the options are, but it actually ends up being relatively straightforward. Someone calls me with bleeding. I agree that the first thought is, well, is this from the pregnancies, is it not from the pregnancy? And the way we know that usually is by the exam, sometimes based on the story, they tell me like, why are they having bleeding? What happened before but usually the exam, and then they need an ultrasound, right? Because if the pregnancy is in the uterus, we know it’s not an ectopic pregnancy. So that’s off. And then if I see a pregnancy in the uterus, and everything looks fine, then generally the outcomes are very good. So if someone calls me says, “I’m pregnant, and I’m having bleeding.” The first thing I wanna make sure is that you have an ultrasound. And we’ll do that. Make sure it’s in the uterus and see how the pregnancy looks. And we’ll do an exam. And after that, generally, you’ll know pretty much what’s going on and be able to give either very reassuring news, say, “Hey, there’s a pregnancy in the uterus, everything’s the right size, the heartbeat is good. 

 

And because of that, your risk of miscarriage is very low, it tends to be under 10%, under 5%, based on exactly how far pregnant she is,” or unfortunately it is a miscarriage, or it is an ectopic pregnancy, something that’s, what we were hoping it wasn’t or none of the above. It’s a fine pregnancy, but she has bleeding for some other reason, like you said either the cervix. And so it’s not a very complex evaluation, the only time it gets complex is when we can’t figure out if the pregnancy is viable or not. And this is when they have to come back and repeat a blood test to repeat an ultrasound. We’re just not sure what’s going on. But usually it’s pretty straightforward. And the only other thing we have to think about is we look at our blood type and this is sort of like a unique thing to pregnancy where if her blood types anything negative like A-negative B-negative we have to give her something called RhoGAM that’s its own podcast, but that’s something we need to know. And that’s really it. It’s pretty straightforward except the details of the ultrasounds how far pregnancy? What if there’s a hematoma, what if there’s not a hematoma and how much bleeding? Meaning heavy versus light. And that’s sort of how we do it clinically. Is that how they do it in Boston? Am I missing anything? 

 

Dr. Naert: Yeah, sounds great. 

 

Dr. Fox: There a little smart in Boston, you Harvard people. 

 

Dr. Naert: Oh, God. 

 

Dr. Fox: Do you guys have any new fancy ways of evaluating people? 

 

Dr. Naert: Unfortunately, not no. 

 

Dr. Fox: And again, it’s really, fortunately, most people are not gonna miscarry. If the ultrasound looks normal, and by most I mean the vast majority, once you see an embryo with a heartbeat, inside the uterus, unless there’s something that looks really off on ultrasound, the likelihood of miscarriages is some low number, right? There’s sort of some details that affect that number, which is one of Mackenzie’s other research projects. 

 

Dr. Naert: I was just gonna say our study. Yeah, our study just got accepted to be published. Dr. Hawkes and I looked at a lot of different factors that impact a woman’s risk of miscarriage and created a little table where you can plug in a patient’s age and number of prior miscarriages and get an estimated risk of pregnancy loss, like you said, it’s very low. 

 

Dr. Fox: Yeah, it’s lower than people think it is. Like when women have bleeding, they usually think game over, like that’s it, and they’re terrified and they call in, even on the phone, we say, “Listen, it’s most likely fine. Come on in, we’ll take a look.” And if they’ve already had an ultrasound, where we know it’s an intrauterine pregnancy with a heartbeat, you could sort of be more reassuring them, but even if they have it, will say, “Come in, we’ll take a look.” And if the ultrasounds normal, and everything’s seems to be sort of in line with what it should be by size and by heartbeat, then really, the likelihood is pretty low that she’s gonna miscarry. And obviously, some women go on to miscarry, I mean, women who miscarry will start with bleeding. But the most women who bleed do not go on to miscarry. And the other thing which is in terms of what do we do about it, the problem is usually the reason women miscarriage because there’s something abnormal with the pregnancy with the genetics of it. 

 

So there really isn’t much we can do that’s gonna prevent miscarriage, if she’s having bleeding. Usually, it’s sort of like it’s gonna be what it’s gonna be. And that’s some people find that very horrifying that they have no control over it. Some people find it very comforting that they have no…they can’t screw it up. Like it’s gonna happen. It’s not gonna happen. But that’s the reality of it. We really were just observing, we have little control. I mean, people have tried progesterone, which with very limited success, if or some would say no success, that arrest doesn’t work. There’s really nothing that helps or hurts and that circumstance, you just have to wait and see how it plays out. 

 

Dr. Naert: Yeah, exactly. 

 

Dr. Fox: So let’s go into your study. You said you looked at the women who had the early ultrasounds is about 2500 women, and how did you set that study up? What were you trying to compare? By the way, I know the answer to this question. I’m just asking for the listeners, right? Because I was involved. 

 

Dr. Naert: Oh, yeah, [inaudible 00:18:16]. So we did a couple of different studies with subchorionic hematoma. But our first study was really looking at the association between the hematomas and pregnancy loss and singleton pregnancies. And so we looked at all of the patients over a three year period, so it was a little bit over 2400 women and gathered a bunch of data on our pregnancies. So we got a bunch of, information about the patient’s including their demographics, as well as other important information about the pregnancy and about the outcomes of the pregnancy. And then in women with sub- chorionic hematomas. We also got information about the hematoma because we, in addition to wanting to know are the hematoma associated with a risk of pregnancy loss. We were also wondering, if so, are there certain characteristics of the hematomas, such as size, volume, the associated presence of rational bleeding, or the association of additional hematomas that we’re going to be associated with pregnancy loss. So in our sample, there were about 450 women so close to 20%, with subchorionic hematomas. And so we basically compared the outcomes of the pregnancies with hematomas to the pregnancies without hematomas. 

 

Dr. Fox: And what do we find? 

 

Dr. Naert: So we found some good news from patients with subchorionic hematomas, and we found that after controlling for all of the variables that there was no significantly increased risk of pregnancy lost in women with hematomas. And even beyond that, we found that looking at the hematomas all of the different ways that I described before, including by volume, by largest diameters, by presence of bleeding, by presence of additional hematoma, there were no characteristics associated with pregnancy loss. In simple terms, we took almost 500 hematomas, and looked at them every way that we could think of. And none of these ways had an increased risk of pregnancy loss, which is super reassuring. 

 

Dr. Fox: We only included women where the embryo had a heartbeat, which is important, because that sort of changes the numbers because if there’s no heartbeat, it may already be a miscarriage before that happens. But, for basically, for women who come in in the first trimester of an ultrasound, and you find the hematoma, what we found was the likelihood of a miscarriage was 7.5%. And if they didn’t have a hematoma, it was 4.9%. So that seems like, it’s a little bit higher. But number one, both those numbers are small. So that’s good, right? It’s under 10% for everybody. But what ends up happening interestingly, is it seemed to be most related to how far pregnant they were meaning hematomas are more likely to be seen earlier in pregnancy, because that’s when they are and they tend to go away with time. But if you’re early in pregnancy, you’re also more likely to miscarry than if you’re later meaning because the longer you go on pregnancy, without miscarrying, the lower your chance of miscarriage. And because you sort of made it that far, it’s like a sort of like the TV show “Survivor,” like you’ve made it to the next week, and so it’s literally like that. 

 

Dr. Naert: Exactly. 

 

Dr. Fox: So, meaning, for example, the women we saw who were six weeks, the chance of miscarriage was 12%. But by the time they got to, you know, let’s say 11 weeks, it’s only 2%, which makes sense. And so it seems to me that the reason that hematomas had a slightly higher risk of miscarriage was because they were only seeing earlier it wasn’t really because of the hematoma. And that was interesting because again, older studies it was they weren’t as big they didn’t have as many numbers like as many women with hematomas to try to sort this out and in some of the studies made it seem like you’ve had a hematoma, your risk of miscarriage was much higher and we did not find that and it’s very reassuring. I see women in ultrasound now and I see it, everything looks fine. And I see the hematoma I tell them, “Don’t worry about it, like, your chance of miscarriage is low, and it’s not higher than if you didn’t have the hematoma, which is really great.” And that’s an important thing. And then what was the follow up study because there’s also some thought that maybe it affects outcomes later in pregnancy not related to a miscarriage, things like preeclampsia, or how the baby’s gonna grow preterm birth. 

 

Dr. Naert: Second study, we sort of took the research one step further, and we were looking at outcomes later in pregnancy. So we looked at the gestational age of delivery, thinking about risk of preterm birth. We also looked at birth weight, and specifically birth weight less than the 10th percentile for gestational age, also known as intrauterine growth restriction. And then we also looked at conditions that are associated with the placenta such as placenta abruption, as well as gestational hypertension and preeclampsia. And, once again, we found what is really, reassuring news for patient because we found that there was no increased risk of these adverse outcomes later on in pregnancy from having a first trimester subchorionic hematoma. 

 

Dr. Fox: This was great to find this out. I mean, I remember when we first looked at the results, how excited I was that it came out, because you don’t know how it’s… you don’t really know how it’s gonna play out, you may have, your sort of gut of what it’s gonna be just from taking care of these women and sort of seeing it, happen, but to really collect all the data and look at it and analyze it. It was really exciting. And there’s a reason that these got published. I mean, both of these studies got published in obstetrics and gynecology, which is what we in the business call the Green journal, because the journal itself is green. But that’s like the American Journal for OB-GYN that is the one that’s in the U.S. the biggest one. And here you are, you’re a medical student, and you’re the first author on these two big studies on this topic. Do you have people like, saying, “Oh, my God, wait, you wrote this study? I just looked this up.” Does that happen to in residency, like are people starstruck by you? 

 

Dr. Naert: Yeah, I wouldn’t say starstruck. But I have found it really cool when I’ve been, in a patient encounter and heard another doctor, counsel patient about subchorionic hematomas and share these results. And, I don’t know if anyone’s ever like, made the connection with “Oh, that’s that girl, crying over there in the hallway.” 

 

Dr. Fox: That’s the intern crying in the hallway. 

 

Dr. Naert: Yeah, but in my mind, I’m smiling. I’m like, oh, that’s kind of cool. And I think, there’s definitely a bias in research against publishing what are considered negative studies. So studies that, find there’s no connection between two things or in our case, no association between subchorionic hematomas and adverse outcomes. And there’s been a big movement against this because it’s as important to publish negative studies as it is once with positive findings, so I think it’s really awesome that we were able to get this research published in the Green journal has such a wide readership. Despite the findings, I think that is really important. 

 

Dr. Fox: With research there are two elements to it that to accomplish it to achieve it. The first is sort of that cerebral part to think about, what is the question? How are we gonna design the study? How are we gonna setup the statistics? How are we gonna write it, interpret, that part that you sort of do that, but there’s a ton of roll up your sleeves, elbow grease type of work that goes into this. And what you had to do was crazy. I mean, you basically had to go through 3000 charts, this wasn’t just some database that existed and you just sort of like, press the button on the Excel spreadsheet, and you got all your answers, you had to build it from scratch, which is crazy. And that’s one of the reasons these things don’t get done is because in order to get a good database with the right variables, sort of formatted in a way that you want with the correct information that’s not just pulled out of a computer, I mean, you actually have to look and make sure it’s verified that it’s correct. It’s a ton of work. I mean, that’s why I took close to a year. I mean, you were like twice as fascinated with thoughts you did in six months, but you know, it’s a ton of work. But that’s the reason these studies are not as common, they’re hard to do. 

 

And I think that when people read this, they’re like, “Wow, you went through 3000 charts, you got all this data on every single patient, and then you can get really good, reliable statistics.” And it’s amazing, listen, I am so proud of you. And I’m so proud that we work together on these. And I use this all the time when I’m counseling patients, because I see this literally every day of the week, either someone was bleeding or someone has a hematoma. And I show them the studies, and I’ll say, I’ll tell them who you are. And I tell them to call you and I give them your cell phone number. And say, she’s at Boston now… 

 

Dr. Naert: That’s why I’ve been getting all those spam calls. 

 

Dr. Fox: …yeah, she’s in Boston now. Does it feel strange that you’re an intern, but you’ve published these I mean, I’ll call them landmark just because why not? I can it’s my podcast, the studies. How does that make you feel? 

 

Dr. Naert: I just feel really lucky to have been able to work on a project and having to be published in the Green journal. But more important, yet we have been clinically significant in a way that, can impact patients on a day-to-day basis. I think, during pregnancy, there’s so many things to be worried about, and if I help patients have one less thing to be worried about. And I feel pretty good about that. 

 

Dr. Fox: That’s great. I mean, yeah, listen, I totally agree. And just to review for our listeners, first trimester bleeding, common, subchorionic hematomas, common, common for them to happen together or alone, most of the time, everything is gonna be fine either way, really, it’s just an evaluation to make sure the ultrasound looks good. If the pregnancy looks fine, the heartbeat is good. The likelihood of a miscarriage is very, very low. It’s not zero, but it’s never zero. Even if everything looks perfect, and everything is going perfect. It’s not zero. But fortunately, it’s very low. If someone does, unfortunately, ultimately go on to miscarry. It’s not because they didn’t do anything, or because they did something, it’s generally just a problem with the pregnancy from the beginning. But again, moving into that process, most people will not miscarry, when they have these symptoms, or these ultrasound findings. 

 

And that was sort of our experience, and the research that you did and took the time from medical school, and had to show up in my office every day and deal with all the terrible jokes, and all the stuff that goes on our office really is valuable, because people are gonna quote the study for a very long time, because I don’t know if anyone’s gonna have the wherewithal to go through 3000 charts again, because I feel like why should I? Someone already did that. I wanna do that again. And I think that that’s amazing. And I really look forward to the projects you’re gonna continue to do as you move forward in your career and what other types of clinical questions you could help answer for the rest of us so we can, you know, take better care of our patients. 

 

Dr. Naert: Oh, yeah. Thank you. 

 

Dr. Fox: Mackenzie, well, I’m gonna follow your career closely. 

 

Dr. Naert: Please do stay in touch. 

 

Dr. Fox: I will. Thank you so much for coming on. Thanks for taking the time. I know that probably is the only free hour you have in the entire week. So thanks for spending it with me and hopefully, yeah, hopefully when you cure COVID we can see each other in person. 

 

Dr. Naert: That would be amazing. 

 

Dr. Fox: Thank you for listening to “The Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topics you would like us to address please feel free to email @hwhealthfulwoman.com. Have a great day. 

 

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