“Mailbag #16: What does the Fox say?” – with Dr. Nathan Fox

Welcome back to the Healthful Woman Podcast! In this mailbag episode, Dr. Fox answers your questions regarding whether or not C-section is a high outcome for most velamentous cord insertion cases, the accuracy of initial ultrasound dating, the development of preeclampsia during pregnancy, and more!

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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. Welcome to our Mailbag podcast, number 16, What Does the Fox Say? Let’s get right into it.

Our first question is from Shelby. “Hi, Dr. Fox. We just had our 20-week scan and velamentous cord insertion was found during the ultrasound. Everything I’m reading online points to a C-section being a high outcome for most velamentous cord insertion cases. Would love your expert opinion on it if that is the case, from what you know. Thank you.” Good question, Shelby. I’m going to disagree with the Google on this one, and I don’t think that velamentous cord insertion significantly increases the risk of C-section. Okay, so that’s the short answer to your question, but let’s back up. So what is velamentous cord insertion? Essentially, when you’re pregnant, the baby inside has a umbilical cord that starts at its belly button and goes to the placenta, which is attached to the uterus. And that’s essentially the lifeline for the baby. The placenta attaches to the uterus. Nutrients, oxygen, fluids come through there, through the umbilical cord into the baby, and then baby’s waste products through the cord back to the placenta. Fine. Whenever we look on ultrasound and everything, we look at how the umbilical cord inserts into the baby, right? We call that the umbilical cord insertion, and there’s certain issues that could happen with that. And we also look at how the umbilical cord inserts into the placenta, and we call that the placental cord insertion. And usually, the cord sort of plunks right into the middle of the placenta, think the middle of a bullseye. And that is the typical or near the middle of the bullseye, and that’s fine.

There is a situation where instead of going into the middle, it inserts more towards the periphery of the placenta and different definitions for that, but we usually call that a marginal cord insertion, which is its own topic, whether it does or does not have significance, and that’s debatable. Then there’s a situation where the cord, if you think about it, basically, let’s say, misses the placenta and inserts not into the bulk of the placenta, but a little bit off to the side into the membranes, into like the clear saran wrap type of thing, and inserts there. And then the blood vessels from the cord travel in those membranes, and then they go into the placenta. So the cord and the placenta, the blood vessels are connected, meaning there is connection to the blood flow and there’s nutrients going back and forth, but instead of the cord going directly into the placenta, there’s like a space between the placenta and the cord where there’s just as clear saran wrap membranes and the blood vessels going in both directions, and we call that a velamentous cord insertion.

So does it matter? If you look at studies that have evaluated pregnancies with velamentous cord insertion, there are some increased risks in those pregnancies compared to pregnancies where there’s not a velamentous cord insertion. And some of those risks might be related to just physically that there’s these blood vessels that are exposed, so to speak, meaning they’re not within the cord, they’re not within the placenta, they’re sort of traveling between the two. And it also could just be that any placenta and cord that’s built, let’s say differently, is also a placenta that’s at risk for not functioning perfectly. And so when we see someone with a velamentous cord insertion on ultrasound, what I tell them is that for most people, there will be no impact whatsoever. You wouldn’t know you had this, there’d be no impact on the baby, no impact on the mother, no impact on your labor, no impact on anything. That’s what happened for most people.

But there is a slightly higher risk of certain complications in pregnancy. Exactly how much higher depends potentially on the person, on the circumstances. Things like fetal growth restriction, is the baby going to grow very well? And again, that’s probably more related to velamentous cord might be a sign that there’s something off with the placenta to begin with. It’s not so much that the nutrients can’t flow through those blood vessels, but that’s one thing we look for. And then there’s also this potential that in labor, right, since those blood vessels are not protected in the cord and not sort of within the placenta, there’s a concern that in labor they can easily get compressed. And when that happens in labor, the baby’s heart rate drops and that could lead to an increased risk of a C-section. But I would say it’s not the majority, it’s just slightly higher than somebody else. So when we see this, I tell people when you’re in labor it’s possible that you have a higher chance of the baby’s heart rate dropping with contractions and you will need a C-section, but I would not tell them it’s more likely than not or probable or anything like that.

There is one other situation where velamentous cord is potentially an issue and that’s if coincidentally that area where the blood vessels are traveling between the cord and placenta also overlies the cervix, it just happens to be in that location, that would be something called the vasa previa where the blood vessels are going right over the cervix which has its own set of risks. We’ve done other podcasts on that. But assuming those blood vessels, and if you had a vasa previa, you would definitely need a C-section. But assuming the blood vessels don’t cross over the cervix and all you have, so to speak, is a typical velamentous cord insertion, what I would say is there’s some risks. Most of the time it means nothing, we just watch a little bit closer and there probably is a slightly higher risk of a C-section, but I would not say that it’s most people will need a C-section because of it. Once the baby is born and the placenta is out, it has no effect on anybody, baby, mother. This is just an issue for during the pregnancy, the placenta.

Okay, question number two from Amy. “How accurate is the initial ultrasound dating? For context, I went into my appointment thinking I was eight weeks pregnant and the ultrasound showed that I’m actually seven weeks. My periods were irregular, but I do know the exact date of conception. Thank you. Love the pod.” All right, Amy. Thanks for the love. So in terms of your question, ultrasound dating is pretty accurate. And let’s get some background. So essentially when we “date” pregnancies, what are we doing? We’re essentially trying to say how far along is a pregnancy where you could either think of that as counting from conception, like how far are we from conception or how close are we towards the due date?

And so the way we think about pregnancy is a pregnancy on average is 38 weeks from the date of conception until the due date. Now, the due date obviously does not mean it is the date you will deliver, but that’s sort of like the average, so we call it the due date. And so you would think that pregnancy would be 38 weeks long because it’s 38 weeks from conception to the due date. However, to confuse matters, we don’t start counting from the day of conception. We start counting from the first day of the last period, which in most people is two weeks before conception. That’s why we say pregnancy is 40 weeks. Again, with week zero being when you have the first day of your period, which is actually two weeks before you conceive. So yes, it makes no sense whatsoever, but that’s how we count. And so we say pregnancy is 40 weeks with the first day zero being the first day of your period and 40 weeks being your due date.

Now again, that assumes that everyone’s going to ovulate and conceive on day 14 or two weeks into it, making a 38-week pregnancy. Now obviously not everybody does. And so when we see someone who’s pregnant and we ask them, “What is the first day of your last period?” and they give us a date and we either use a wheel or a computer or electronic medical record or whatever it is, comes up and says, this is your due date. That is assuming someone ovulated and conceived around day 14. But obviously that does not happen for everybody. For example, somebody with irregular or long or short cycles, then they typically ovulate on a day that’s different from day 14. It could be later, it could be earlier based on that. So that’s something we take into account.

Now ultrasound, when we look at ultrasound, particularly early in pregnancy and we measure the size of, we call them an embryo typically in the first semester, the size of the embryo, the sizes of embryos do not vary that much. Meaning if you take babies that are born, right, full term, nine months, 40 weeks, their birth weights in normal healthy babies are going to vary significantly from 6-plus pounds to 10 pounds, something like that. So there’s a wide range of what normal weights would be. But if you’re in the, at seven weeks pregnant, the size of embryos are almost always exactly the same. You don’t see a wide range in how big an embryo is at seven weeks. So if we see someone early in pregnancy and we measure an embryo that’s seven-week size, that is pretty accurate that you are probably what we call seven weeks pregnant. Again, five weeks from conception, what we call seven weeks pregnant.

Okay, so what do you do if someone from the first day of their last period is supposed to be eight weeks, but on ultrasound, the embryo is measuring seven weeks? What do we do? Do we pick eight weeks? Do we pick seven weeks? Now, the practical implication of this is not huge because no matter what we say, right, the baby was conceived at a certain time and the due date is a certain time and the baby has no idea what we’re calling the due date. So it’s going to come when it’s going to come. I could tell someone their due date is three years from now, the baby is not going to wait three years. So it’s not really impacting when someone’s going to deliver. It just impacts our expectations in pregnancy, meaning when someone’s 20 weeks, we expect the baby to be 20-week size and it’s measuring 19-week size, then we might say, well, this could be a problem. It can not be a problem. But if you’re actually 19 weeks, well, it’s certainly not a problem. So some of the implications are just like, how do we interpret the size of the baby moving forward and when to do certain tests in pregnancy, things like that.

But again, so how do we pick a due date? And essentially, the way we do it is unless someone had IVF, when we know the exact second, right, there was conception and everything, we generally the default is to use the first day of the last period unless the ultrasound gives convincing evidence otherwise. For those of you who are football fans, it’s almost like the replay rules. There has to be clear and convincing evidence to change the ruling on the field. So the ruling on the field, right, the default is the last menstrual period. And if the ultrasound is clear and convincing that it should be otherwise, we’ll use the ultrasound. And exactly what that means depends. The earlier in pregnancy you are, the smaller that is. So typically, if it’s more than a week in the first trimester difference, more than a week difference will change the due date. Some people, if it’s very early in pregnancy, if it’s more than five days, we’ll change it. And there’s sort of different criteria we use. But if someone is eight weeks by their period, measuring seven weeks by ultrasound, definitely we’re considering changing the due date. And particularly, if someone has irregular periods, we would do that.

Now, if you were 100% certain when you conceived and it lined up with eight weeks versus seven, then we would sort of figure that out. But that’s essentially the principles that we use. So I can’t give you your answer, like what your due date should be. But in general, we would use the last day of the last menstrual period, the first day of the last period, then do an ultrasound. If the ultrasound is sort of consistent with that, we’ll keep the day from the period. If the ultrasound is way off from that, then what determines way off is sort of a table we use based on how far pregnant you are. We will then go to the ultrasound. And then obviously, if there’s certain other factors, like if you know when you conceived or something like that, we’ll take that into account as well. All right. Good stuff.

Next question is from Gabrielle. “Dr. Fox, thank you so much for your podcast. The information you provide is extremely helpful and I’m a huge fan.” All right. Thank you for that intro. “I’m hoping that you may be able to answer a question I have about fetal growth restriction and preeclampsia. During my first pregnancy, my daughter was measuring around the 50th percentile until 37 weeks when she dropped to the 10th percentile. I was diagnosed with fetal growth restriction and monitored closely until I was induced at 39 weeks. After my daughter was delivered, on the small side, but otherwise healthy, I developed postpartum preeclampsia. My typically low blood pressure reached 175 over 96.” For our listeners, that’s high. “And I was administered magnesium. I understand that fetal growth restriction and preeclampsia are both tied to issues with the placenta. As I am preparing for a second pregnancy, I’m wondering whether if my daughter had been delivered at 37 weeks when potential fetal growth issues were first detected, that would have decreased my risk for developing preeclampsia or severe preeclampsia. Thank you for the podcast. I appreciate all your insights.”

All right. So there’s a lot to unpack there and we’re not going to be able to do a thorough review of all fetal growth restriction and all preeclampsia in this answer. But again, as a general review, fetal growth restriction, for our listeners, is when we suspect that the baby is smaller, the fetus is smaller than we would anticipate at that gestational age, most of the time babies are measuring small. They’re just measuring small, meaning some babies are big, some babies are small. Usually does not mean much of anything, but occasionally it can mean that there’s actually something wrong with the placenta. It’s not functioning perfectly and a baby who’s supposed to be bigger is smaller because he or she is not getting all the nutrients through the placenta that they should be because the placenta has some dysfunction. It’s not functioning perfectly. So that’s the concern or one of the concerns with fetal growth restriction. And for that reason that the placenta might not be functioning perfectly, we follow closely, we do more ultrasounds and potentially deliver early, all those things.

Now, preeclampsia is typically a condition of the placenta, meaning it’s how the body responds to the placenta. And, Gabrielle, you are correct that frequently people who have fetal growth restriction, particularly if it’s a problem with the placenta, will also have some form of preeclampsia and vice versa. People with preeclampsia will often have fetal growth restriction. And that is because a placenta that’s not functioning well, well, the placenta has to do a lot of things. So one of the things a placenta does is nourish the baby. So if a placenta is not functioning well, the baby may get fewer calories and therefore be small. Placenta also, right, it secretes hormones and other factors into the body that will affect the mother’s physiology. And placentas that are not as healthy are more likely to send things into her circulation that will cause high blood pressure, preeclampsia and whatnot. So they typically go together. Other things that go along with that could be something like placental abruption where the placenta separates early. And in the worst case scenario, like if it’s totally left untreated, it can lead to stillbirth. And so that’s the concerns we have with a placenta. So yes, they frequently go hand in hand.

So your question was, okay, we have someone with suspected fetal growth restriction. If you could go back in time and instead of delivering at 39 weeks, deliver at 37 weeks, would you have been less likely to develop that preeclampsia after birth? The short answer is possibly, but we don’t know. Right? It’s very hard to say for sure, because again, you were delivered and then you develop preeclampsia. So it’s not clear if had you delivered earlier, somehow the placenta would have secreted different factors or less factors and you would have not gotten preeclampsia. There are some data that the earlier you deliver, the less likely you are in general to get preeclampsia, which makes sense. But we don’t know for certain that delivering at 37 weeks would lead to less preeclampsia or less severe preeclampsia. It’s possible, but we’re not certain. But on the other hand, it’s also very hard to make that call because at 37 weeks, we’re not confident necessarily that the problem is with the placenta. It’s not 100% the case. And so therefore you’re like, well, do I deliver someone at 37 weeks, which is not terrible, but a little bit early, or do I wait? And that’s also a balance because what if there’s nothing wrong with the placenta, then we really shouldn’t be delivering. So all of these things are trying to balance all the risks of delivering early versus all the benefits of delivering early.

On the flip side, all the risks of waiting versus all the benefits of waiting. And it is possible that one of the benefits of delivering earlier is a slightly lower risk of preeclampsia, but it’s hard for us to quantify that and to know for sure how much are we lowering that risk. And so I don’t know what would happen if you would deliver two weeks earlier. It is possible. Now, I can tell you that when you’re talking about your next pregnancy, if I have someone who has a history of fetal growth restriction and postpartum preeclampsia, meaning a placental issue, and then the next pregnancy, I see one of those things happening again. Obviously, I’m much more likely to think it’s a placental problem than to think it’s something else because it’s already happened before. And so that is something that in your next pregnancy, it’s possible that under the same circumstances they might recommend delivering a little bit earlier than 39 weeks just because now you have the additional history of what happened to you in the first pregnancy, whereas in your first pregnancy, you obviously don’t have any history of that. So I hope that answers your question, even though I gave you mostly an I don’t know, but I hope that gives you some context for why it’s not such an easy question to answer.

Okay, next question is from Alexandra. All right, Alexandra, here’s what she asks. “I gave birth at 36 weeks, 3 days due to severe preeclampsia and HELLP syndrome. I’ve always wanted more than one kid, but after my experience, it makes me nervous for a second. My induction lasted 36 hours, magnesium, pitocin, Foley balloon and all. I ended up having a C-section. I want to know when HELLP syndrome presents itself, why do doctors push to still try to have a vaginal birth? Why not do a C-section right away to avoid platelets dropping even further? What is the research on subsequent pregnancies after severe preeclampsia and HELLP? Is it recommended for next pregnancy to have a scheduled C-section?

Okay, so this is some connection to the last question in terms of overlying topics, but definitely a different aspect of it. So Alexandra, you had severe preeclampsia and HELLP syndrome. For our listeners, HELLP, H-E-L-L-P is an acronym, which stands for hemolysis, that’s the H, elevated liver enzymes, that’s the E-L, and then low platelets, that’s the L-P. So it’s three things. It’s hemolysis, elevated liver enzymes, low platelets. Essentially, HELLP is a syndrome where there are three or at least three very abnormal blood tests in someone with preeclampsia. Hemolysis is basically your blood cells being broken down inside of your body and there’s certain blood tests or a smear that someone looks at into the microscope that could diagnose it. Elevated liver enzymes is when there, again, there’s blood tests where we check your liver enzymes and they can be elevated and low platelets, as you mentioned, seem to happened to you, is that your platelet count will become low, which has its own secondary issue of potentially increasing your risk of bleeding.

So HELLP is something that happens in a small subset of women with preeclampsia, meaning most women with preeclampsia will not have HELLP syndrome on top of it. But there’s definitely those that do. There’s actually, interestingly, a few people who get HELLP syndrome without the elevated blood pressure. We call that atypical HELLP. So meaning it’s like we know that preeclampsia, but they don’t have the classic feature of preeclampsia, which is elevated blood pressure. But either way, when someone has HELLP, it is a severe form of preeclampsia. It is dangerous to you, to the mother. It can be dangerous to the baby. Typically, we are recommending delivery, almost any gestational age, when it happens. And sometimes rarely we can hold off for a little bit of time. But basically, if you have it, particularly if you’re close to your due date, you’re going to get delivered.

And so your question is, well, how should we deliver? Should we induce labor, which we know can take a long time, as it did with you, or should we just recommend a C-section? Now, normally, when we are faced with someone who needs to be delivered, and we’re deciding whether they should be induced or have a C-section, in most circumstances, when you weigh everything, most people are going to choose to have an induction of labor. Because even though it’s going to take a fair amount of time, there is a significant chance of a vaginal delivery. Based on the circumstances, it might be 50, it might be 70, it might be 80, it might be 90, whatever percent chance there is of a successful vaginal delivery. And there isn’t much of a downside compared to doing a C-section, other than it could be a long labor, it could be frustrating, it could take more time. You know, there’s always some risk to an induction, but there’s also risk to a C-section and whatnot. But what you’re asking, Alexandra, astutely, is, well, okay, that’s normal. But in someone with a medical situation or something like severe preeclampsia with HELLP syndrome, isn’t it possible that by waiting all that time, 12 to 24 hours, let’s say, the condition could worsen over that time period and you wish you could go back in time and deliver earlier?

And what I’ll tell you is that is a really, really good question where we really, really don’t know the answer. And the reason we don’t know the answer is you don’t know how it’s going to play out necessarily. Meaning, if someone has HELLP syndrome, yes, we are concerned that if we wait, they’re going to worsen with time. That is a concern. But we’re also concerned that if we operate on them, it can be more complicated because especially if they have low platelets, it can be a concern related to their risk of bleeding and complications from surgery and a harder recovery. And on top of the fact that they’re sick from this preeclampsia and HELLP syndrome, they also have to recover from a C-section. And so they’re less likely to get out of bed, more likely maybe to get blood clots, harder to give them blood thinners because they have low platelets. So it’s sort of one of these things where it’s not a great situation to be in either way because you’d prefer not to induce the labor and waste such a long time, but you’d also prefer not to operate on someone with HELLP syndrome. And so it’s really an individualized decision based on how sick is the person, how rapidly are they deteriorating versus how stable they are, how likely is it that they’re going to end up with a vaginal delivery and taking each case individually and trying to figure out is it better to try to induce and take the risk that it won’t work and you’ll end up with a C-section, you’ll end up with both waiting a long time and having a C-section versus if you induce, you can end up having a vaginal delivery without a C-section and that’s good, obviously.

And so what I would say is in general, to answer your question, why don’t we recommend C-section in everyone? It’s because the best option is to deliver vaginally and if there’s someone who we think is a very low chance of delivering vaginally or we think that they are decompensating so quickly that we can’t safely wait, then yes, we would recommend a C-section, but I would say most people, they’re stable enough that there’s an option to try to deliver vaginally, particularly if their chance of success is reasonable. Nothing from your question tells me that your chance of success was unreasonable. Obviously it could not work for anyone, but unless there was some factor that would make it very unlikely to deliver vaginally, I do think it’s generally reasonable to do the induction. Now, what to do in your next pregnancy obviously depends. Depends if you do or don’t get preeclampsia again, if you do or don’t get HELLP syndrome again, what’s going on, how far are you? It’s sort of the same calculus, but in someone who’s had a prior induction that “failed” and ended up with the C-section, your odds of it working are slightly lower and there’s an additional potential complication of a uterine rupture, which is small. So again, it depends on the circumstances. It’s not like you can’t be induced, but it does have some additional risks and if you’re very sick again with HELLP, they might say, all right, in this situation on balance, we’re going to recommend a C-section. Again, it depends on the exact circumstances, but I think hopefully that answers your question. All right.

Our last question for today is from Michelle. All right. “I just finished reading ‘The Unexpected.’ Thanks to Dr. Fox and to Emily Oster for this book.” Thank you, Michelle. “I delivered via C-section at 30.1 weeks due to severe preeclampsia. This was my first pregnancy and I’ve been struggling with the decision over whether to try for a second pregnancy. So this book was written for me. It is mentioned in the book that someone in my situation should be tested for antiphospholipid antibody syndrome. I’ve already had blood work done that suggests this. I go for repeat blood work later. Can you explain more about this condition, both in the context of future pregnancies, but also if I decide not to get pregnant again? Thank you.”

All right, Michelle. So antiphospholipid antibody syndrome, sometimes just called antiphospholipid syndrome. Sometimes we use an acronym APAS. Sometimes people use APS, APLS. There’s a lot of sort of terminology for this. But basically antiphospholipid syndrome is an autoimmune condition. Autoimmune conditions are ones where for reasons we don’t quite understand, the body starts to believe that things that are in the body that are supposed to be there are foreign and they start attacking it. Right? So we have this immune system in our body where things, if they get in our body that aren’t supposed to be there, like bacteria, like viruses, like a transplanted organ, whatever it is, our body’s going to recognize that and say, “Hey, that’s not me. And I’m going to attack it.” And it’s very, very good if you get bacteria in your body or viruses. If you have to get an organ transplanted, it’s not great. And so we give medicines to modulate that so you don’t attack the organ. But there are a whole host of conditions we call autoimmune conditions where, for whatever reason, sort of short circuits and starts saying, “All right, this blood cell line no longer recognizes itself. I’m going to attack it,” or this organ. “I’m going to start attacking it or this joint. I’m going to start attacking it.”

And an antiphospholipid antibody syndrome, it’s essentially something that’s found on the inside of blood vessels that the body starts to attack. And the way it manifests in people who are not pregnant are a lot of varied conditions related to blood pressure, sorry, to blood vessels. It could be things like blood clots, right? So having a thrombosis or a blood clot either in a vein or an artery, it can sometimes lead to stroke. It can sometimes lead to other medical problems. It can sometimes affect people’s blood tests. There’s a lot of things that can do to people who are not pregnant. Now in pregnancy, having antiphospholipid syndrome has been associated with several complications of pregnancy, things like multiple miscarriages, things like stillbirth. And one of the things it’s also related to is early onset preeclampsia or fetal growth restriction, meaning if someone has, like you had it 30 weeks, severe preeclampsia, that is unusual even for people who get preeclampsia, right? So people who get preeclampsia at ballpark, you know, 5% of the population, let’s say. But getting preeclampsia for most people is a mild form at the end of pregnancy. But to have both a severe form like you had and early, like under 34 weeks, is unusual amongst the unusual. And so the thought is either you’re just terrifically unlucky or potentially you actually have an underlying condition that led to the early onset severe preeclampsia.

The most famous one is antiphospholipid syndrome. So people who end up with early onset severe preeclampsia or early onset severe growth restriction, both of which are, again, assuming it’s from severe placental issues, we test them for antiphospholipid syndrome. The testing for it is basically a bunch of blood tests. And then since these, and they’re testing for the antibodies, these antiphospholipid antibodies, and since these blood tests can sometimes be transient, meaning they come and they go and it’s not having the syndrome, we do generally recommend testing them. And if they’re positive, abnormal, repeat them several months later. So it sounds like you’re in that in between period from your first set and your second set. If it’s confirmed and you truly have antiphospholipids for several months in your body, and you have this early onset history of an early onset severe preeclampsia, then yes, you would have the diagnosis of antiphospholipid antibody syndrome.

In terms of your next pregnancy, that’s bad news and that’s good news. The bad news is you have the syndrome and you’re at risk for a lot of these complications. The good news is now that we know about it, the treatment for it is relatively straightforward. It’s taking baby aspirin and a blood thinner, something like Lovinox or heparin. And for people who take the blood thinner and the baby aspirin, the likelihood of the complication happening again is much, much lower. Is it zero? No, it’s not zero, but it’s much, much lower. It tends to work. So for people of antiphospholipid antibody syndrome and history of, like you had, severe early onset preeclampsia, usually they don’t get it again if they’re treated. So that’s the good news.

Now, if you don’t get pregnant again or during the times in your life you’re not pregnant again, yes, having antiphospholipid antibody syndrome can impact your health in general. And so what I typically recommend is anyone who has this diagnosis be followed either by a hematologist or a primary care doctor who is familiar with antiphospholipid syndrome, but somebody who knows about this and knows that you have it because there are certain things that they may or may not recommend, like maybe taking a baby aspirin every day. Or maybe if you have surgery in the future, the surgeon needs to know that and maybe you need blood thinners before or after the surgery or potentially it affects what birth control we want you to have or not have, you know, things with hormones. So there are implications for your health moving forward. And generally, it makes sense if you have this diagnosis to follow with someone regularly who knows about it. Again, it doesn’t have to be a hematologist, but typically they’re hematologists who specialize in sometimes they can be rheumatologists. And there’s different people who know a lot about antiphospholipid syndrome, so I don’t want to say it has to be one specialty specifically. They tend to be hematologists, sometimes rheumatologists, sometimes very astute primary care doctors or internal medicine doctors. All right.

So yeah, a bunch of questions today related to preeclampsia, but not all of them. Thank you to our wonderful listeners for sending in questions, to Shelby, to Amy, to Gabrielle, to Alexandra, and to Michelle. And hope you all have a wonderful week.

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 healthful.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day. The information discussed in Healthful Woman is intended for educational uses only and does not replace medical care from your physician. Healthful Woman is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.