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.
Hi, everyone. Welcome to our mailbag podcast #22: What does the Fox say?
Our first question is from Simi. As a side note, Simi is a longtime listener of the podcast and a friend. Thank you for sending in your question. All right, here’s Simi’s question: “At what point in pregnancy does gestational diabetes generally kick in and is it possible for it to go undetected? Is it possible for it to kick in later than 28 weeks and what would the symptoms be? Looking forward to hearing from you.”
All right, great question, Simi. So, as a little background, and you can check out our podcast on gestational diabetes, essentially gestational diabetes is when the hormones of the placenta affect the metabolism of the pregnant woman such that her sugars, her blood sugar is elevated more than we would like it to be. It’s not the same thing as like diabetes, the disease, but there’s a lot of obviously overlap and it has the name gestational diabetes. You know, we test for it in pretty much all pregnancies or we screen for it and then to have it, we treat it so forth. You can go to that podcast.
So, generally, the time that we screen for gestational diabetes is between 24 and 28 weeks. So, why do we pick 24 to 28 weeks? Well, the reason we pick it now is because that’s when all the data is from and all the studies on this were from people screened 24 to 28 weeks. So, that’s what we know about. But the reason that is, is generally in order for gestational diabetes to manifest, the pregnancy hormones have to be a certain amount, right? You have to be far enough into your pregnancy for it to manifest. So, meaning if we screened everybody, let’s say, at 12 weeks very early, a lot of people would test normal, but then later in pregnancy at like 24, 26, 28 weeks would test positive. So, we don’t screen everybody at 12 weeks. We screen everyone at 24 to 28 weeks.
Now there’s a few questions about that. What about someone who has it earlier? What about someone has it later? So, in terms of people who have it earlier, and there are some people that we screen earlier in pregnancy, generally people who are at higher risk for developing gestational diabetes, either because they have certain risk factors or because they had it in a prior pregnancy or whatever it might be. And people who we screen early, let’s say at 10, 12, 14 weeks who screen positive, they could have a case of gestational diabetes that is manifesting earlier than 24 weeks, like you asked, Simi, or it could be that in fact they have some form of real diabetes or borderline diabetes that they came into pregnancy with, but most people who are young, healthy women don’t get tested regularly for diabetes when they’re not pregnant.
And so if we test someone early, it’s, number one, to see might they have something coming into pregnancy and, number two, to see if they have a very early manifestation of it and that can happen. So, yes, you can come into pregnancy with no issues with your sugar and you can develop gestational diabetes earlier than 24 weeks. And so certain high-risk patients, we will screen them for it earlier.
Okay. Now, in terms of later, that’s a really interesting question and there’s a lot of debate on this, meaning you can screen someone at 32 or 34 weeks for gestational diabetes, and there are people who would test normal at 24 to 28 weeks but then test positive for gestational diabetes at 32 or 34 weeks. But the question is, number one, is that really gestational diabetes? And number two, what do we do about it? So, in terms of question number one, the reason we don’t know for sure is it really gestational diabetes is because the cutoffs that we developed for sort of saying, “This test is normal versus abnormal. This finger stick is normal versus abnormal. This result on your GCT or GTT is normal or abnormal,” was taken or developed in women who are 24 to 28 weeks. So, it’s possible that maybe we need different cutoffs when you’re 32 or 34 weeks. And we don’t really have great data to know that. So, when someone tests normal between 24 and 28 weeks, and then for whatever reason, someone decides to test them again at 32 or 34 weeks, let’s say, and it tests abnormal, the first thing we think about is we’re not really sure. Does this really mean they have gestational diabetes or might it be sort of more normal for them? And we don’t really know. And the second question is, “Well, okay, now that we see this, if we started to intervene with diet, with insulin, whatever it is, is that going to have an impact on the baby?” meaning it’s already done. And ultimately, after 28 weeks, the way we do it is case by case, whether we choose to actually screen somebody, if and when we do that and how we interpret the results and what we do about it.
So, going back to your question, we don’t know if gestational diabetes will kick in after 28 weeks, whether that’s a real thing or not a real thing and what to do about it. But it can kick in earlier than 24 weeks. And so in high-risk patients and exactly what makes someone high risk for that depends on the circumstances but things like having history of gestational diabetes, maybe a strong family history. Sometimes if they have like PCOS or other medical conditions, we might screen them early. But it can kick in early and so we do screen some people for it earlier. But even if you screen someone early and they pass, we do always repeat the test at 24 to 28 weeks. All right. Great question.
Our next question is from Samantha: “Hello. For my second pregnancy, I had a very normal spontaneous labor at 40 weeks and 6 days. It only lasts about six hours and pushed twice. Around five days postpartum, I started spiking fevers. And two days after that, I was hospitalized for endometritis. I spent two nights in the hospital and a number of heavy antibiotics until the fevers were under control. I didn’t have any of the risk factors such as prolonged labor or C-section. I did have two membrane sweeps and a number of cervical checks prior to going into labor. I’m interested if the multiple sweeps or cervical checks could increase your risk of developing the infection postpartum or if there’s any other reason I might have developed the infection. Would love it if you go to some detail about endometritis as I really got zero answers. Thanks so much.”
All right, Samantha. Sorry you got zero answers. Hopefully we can help. So, as background, endometritis is an infection of the uterus, specifically the inner lining of the uterus, the endometrium. In this context, it’s related to delivery. And it’s something that can happen after any birth, whether vaginal or C-section. You are correct in your question that some of the risk factors for endometritis include having a C-section, meaning the risk is higher if you have a C-section than a vaginal delivery. And if you have longer labors, the risk is higher because there’s a higher chance of bacteria coming up from the vagina into the uterus and causing an infection.
So, in terms of your specific question, whether membrane sweeps and cervical checks increase the risk, as far as we know, membrane sweeps, which is what’s done while you’re pregnant, usually in the office as a way to try to stimulate labor where your water is not broken, the membranes are intact. As far as we know, that does not significantly increase the risk of endometritis later and after delivery. In terms of cervical checks and labor, that’s a really fascinating question. The thought traditionally in obstetrics is that the more cervical checks you have in labor, the higher the risk of infection. And the thought process behind that is, okay, even though we use a clean sterile glove when we do exams, by nature, if you’re going to take anything, whether it’s an instrument or whether it’s fingers, and you’re going to insert it in the vagina and then insert that through the cervix into the uterus to sort of feel how far dilated the cervix is, the thought is that there’s always an opportunity to push more bacteria, not from the outside world, but the bacteria that live in the vagina and push those up into the uterus and cause or increase the risk of an infection. So, that was always the teaching.
However, it’s actually very difficult to know if it’s really the cervical checks themselves versus people who have more cervical checks tend to also have longer labors, right? So, it is known to be a risk factor that if you have longer labors, you have an increased risk of an infection. And it’s known that if you have more cervical checks, it increases the risk of infection. But those two are related. Longer labors and more cervical checks both happen together because the longer you’re in labor, the more times you get your cervix checked. So, is it the cervical check? Is it the longer labor? Is it each of them independently? It’s not entirely clear. In labor, we tend to still not do more cervical checks than are necessary just in case it increases the risk of infection, but it’s also not entirely predictable. I mean, you can have people with very, very long labors who don’t get infections and you can have people with short labors like you had who do get an infection. So, there’s certainly other factors that come into play. Some of it’s probably just luck. Some of it might be the specific bugs that live in one’s vagina, which you have no control over, obviously. And there’s definitely factors that are probably there that we don’t understand.
I will say that what happened to you is a little bit unusual. It’s unusual to have an uncomplicated deliver and then develop endometritis five days later. Most often when people get it, it happens in labor and then it just takes some time for it to go away. So, I don’t know exactly why you got it specifically, but based on the fact that it happened five days later, I would suspect it had nothing to do with the cervical checks or the membrane sweeps to answer your specific question.
All right. Our next question is from Danielle: “Hi, Dr. Fox. I love your podcast and have been listening long before I even became pregnant.” Thank you, Danielle. “I’m currently nine weeks and today I met with a midwife from my OB/GYN practice to discuss first-trimester genetic screening options. We reviewed carrier screening, which my partner and I have already done, the cfDNA/NIPT and the nuchal translucency ultrasound. I went into the appointment planning to ask for both the cell-free DNA and the nuchal scan, as this is the standard I’ve heard from my mom, friends and family members, and I’d prefer to have more information than less. However, the midwife ultimately made me feel like getting both would be silly and extraneous, stating that NT scans are outdated and she has never ordered one. I understand that cell-free DNA testing is more accurate, but I can’t help but feel like it would also be useful to have a doctor examine the baby’s physical characteristics to roll anything maybe not tested through cell-free DNA. My question, is there any real merit to doing the NT scan in addition to the more accurate blood tests? Does the NT scan ever catch something that the blood test would not? If I do not push to do the NT scan, I would not have another ultrasound until my anatomy scan. And my concern is finding something that could have been detected sooner. Thank you so much. And let me know if you have an episode on this.”
So, that is a really terrific question. I will tell you that this is a question that is ongoing and there’s a lot of debate about it. In fact, I once gave a lecture on this… Actually, twice I gave a lecture on this specific question, and the audience was…first time was sonographers, and the second time was maternal-fetal medicine specialists. And so this is a hot topic.
And so in terms of the background, so when we’re doing the aneuploidy screening, which is genetic screening for certain conditions in the fetus, in the baby, there are sort of currently two different screens that can be done. And as you said, you could do one, you could do both, you do neither. Fine. So, one test is the cell-free DNA, also called the NIPT, which is basically a blood test. We’ve definitely done podcasts on this where essentially it’s a very, very accurate screen. We do a blood test from the mother, and it’ll say whether the baby’s at high risk or very low risk for certain genetic conditions. This is also the blood test that can tell you you’re having a boy or girl. And it’s very, very, very accurate. And it’s a blood test. And that can be done in the first trimester, usually around 9, 10, 11, 12 weeks or later.
The other test, which is a nuchal ultrasound, is an ultrasound that’s done around 12 weeks. So, also the ends of the first trimester. And it can also give a lot of information about risk of Down syndrome, risk of genetic conditions, but obviously since it’s an ultrasound, it can give you some other information. And so what ultimately happens is we have two tests that are both good in screening for genetic conditions. I think in terms of pure test characteristics, your midwife was correct that if you had to choose one versus the other and your goal was, “I want to look at the risk of genetic conditions, specifically Down syndrome,” the blood test performs better than the ultrasound, meaning in terms of if it comes back normal, the chance the baby’s normal, if it comes back abnormal, the chance the baby’s abnormal. Those are sort of higher percentages with the blood tests than the ultrasound.
And so, okay, so you have two tests. Does that mean you should only do the blood tests and not the ultrasound? Some people will say yes, that you should only do the blood tests and not the ultrasound, which is I guess what your midwife believes. In our practice, we do both basically for the reasons that you stated. So, while there’s a lot of overlap in what they screen for, let’s say for Down syndrome, the blood tests will give you some information that the ultrasound won’t. So, for example, some other genetic conditions, whether it’s a boy or girl, for example, things like that, because you can’t do that in ultrasound reliably at 12 weeks. So, the blood test has some additional information, the ultrasound doesn’t. And the ultrasound has some additional information that the blood test doesn’t. So, for example, well, if you haven’t had an ultrasound before to make sure the pregnancy dating is correct, to make sure it’s, you know, singleton versus twins, to make sure, you know, there’s certain conditions that you can find at 12 weeks that you buy ultrasound, you know, two arms, two legs, has the sort of the brain structure developed normally, at least in sort of the most simplistic way, right? Is there anencephaly versus not, which is a very bad brain condition. And so there’s certain things you can tell in the ultrasound that you can’t tell from the blood tests.
And so, you know, ultimately, each practice decides what they do, each patient decides what they do based on what they want, right? Some people want as much information as possible like you said you do. And so for you, I would say it’s totally reasonable to do both. There sometimes are insurance issues that some carriers will say, “Well, if you had an NIPT, we’re not paying for the ultrasound.” But, okay, that’s maybe an issue to put on the side. But from a pure medical perspective, it’s totally reasonable to do both. I would disagree with your midwife that it’s silly to do the ultrasound or, I don’t know, that she’s never ordered one. Again, I don’t know the exact circumstances of her practice. But in our practice, we do offer both. Most of our patients do accept both, and that’s been working well for us. There are other places that only do one or the other. I think, again, it’s all reasonable. But ultimately, I do think that you should be a part of that decision if it’s something that you want. All right. Great, great question.
All right. Our next question is from Sarah: “Thanks for your awesome podcast.” Thanks, Sarah, “I look forward to Mondays. I absolutely love listening to your podcast. You always have the most incredible speakers and I’m always learning new things.” Wow. All right. “I have a weird question for your mailbag podcast. Is there a way to conceive a boy or a girl? I Googled it so many times. I’m just wondering if any information I came across is true. Do you know of any tricks?”
So, Sarah, that’s not a weird question. We get asked that all the time. It’s a very common question. The short answer to your question is no, there is no way to conceive specifically a boy or specifically a girl that’s reliable aside from doing IVF and picking an embryo that’s one or the other and putting in that embryo. That’s really the only way that’s reliable. And there are people who have very strong reasons why they want one or the other. Some of them are medical reasons like there’s genetic conditions that will present an only boys or only girls that they carry and they want to make sure that that’s not a case or, for example, they have, I don’t know, three or four kids and they’re all the same sex and they want one of the other. And so they decide to do that. And that’s definitely done.
In terms of all the things you’ll typically read about online, like various positions, various times of the month, you know, all these things, they’re not reliable. I tell people sort of jokingly but actually mathematically true that they all work about 50% of the time. And so it’s not really something that’s reliable. There is something that used to be done more frequently that’s done much less now by much fewer people, something called sperm sorting, where basically the theory is that the sperm that carry the X chromosome are going to be heavier than the sperm that carry the Y chromosome, because X chromosomes are bigger than Y chromosomes. And so if you put, like, a semen sample in a centrifuge and you spin it, the heavier sperm will go to one side, the lighter to the other. And so that is a way to maybe select a sperm that are more likely to have an X chromosome versus a Y chromosome. And there’s different quoted success rates for that generally quoted as better than 50%, meaning that will improve your odds. It’s not 100%. So, it’s some number between 50% and 100%. Not a lot of places do that nowadays, but those that do will usually tell you what their success rates are. But in terms of the other stuff you read online, no, not reliable. 50/50 unless you do IVF. All right. Good question.
Our next listener, Katherine, has two questions. I’m going to answer both of them. Katherine, question number one: “Dr. Fox, I just finished reading ‘The Unexpected’ and I started listening to the podcast.” All right. The reason I’m answering both your questions, Katherine, is because you did a plug for the book. Good job. All right. First question: “Is there research on generational recurrence of complications in pregnancy? For example, if a mother had preeclampsia giving birth to her daughter, does this increase the daughter’s risk? Are there any epigenetic…” good word, “…or other signals regarding pregnancy that are passed on to offspring?” So, that was question number one.
So, Katherine, that is a very high level advanced question. I love that you asked it. Great job. The short answer to this is yes but we don’t quite understand it, meaning there are definitely pregnancy complications that run in families, either from mother to daughter, let’s say, or maybe you’ll see in siblings and sisters. So, for example, preeclampsia is slightly more likely to happen, preterm birth, gestational diabetes, and some of those we can explain and sort out through various things. For example, one of the simpler ones is let’s say a mother had a bunch of preterm births or C-sections, and she had a uterine abnormality, right? She had a bicornuate uterus or something like that, which I think we discussed on a prior mailbag podcast. Those things do tend to recur more commonly in their offspring. So, a mother with an abnormal uterus is more likely to have a daughter with an abnormal uterus herself. So, if the daughter also has an abnormal uterus, she will also have an increased risk of C-section and preterm birth. So, that sort of explains the family connection in a way that we can sort of see and track and understand.
But your question was related to epigenetic or other signals. And for our listeners who don’t understand that, it’s complicated genetics where the idea of epigenetics is sort of like a level above genetics. What is that? So, okay, genetics is very… I think people get that if sort of a parent has a certain gene, a certain defect in a gene, a certain variation in the gene, and they pass that gene, that different or abnormal gene onto their offspring, their offspring will have the same risks or the same condition or whatever it is. So, that’s sort of pretty well-understood conceptually. What epigenetics is, is there’s no abnormalities in the gene but somehow the mother having preeclampsia in pregnancy sort of takes the baby inside the uterus, that baby’s genetic makeup, and turns on and turns off certain genes that were always there, meaning the baby’s born with the same normal, so to speak, genetic makeup, but there’s something that’s got like a switch that got flipped on to turn on a gene that’s going to make that baby more likely to get preeclampsia when she’s pregnant. And there might be is the short answer, but it’s definitely not mapped out at this time.
Is it true for all conditions, some conditions? There’s definitely some theories about epigenetics, not related to exactly the same thing, but for example, for babies who are, let’s say, growth-restricted in utero that they’re getting undernourished and they’re sort of very small in utero, there is this concept or theory that they have an epigenetic chain so that when they grow older, they have the opposite. They sort of like keep food in their system, which is why some people believe that babies who are born growth-restricted might have an increased risk of hypertension as they grow up or maybe obesity as they grow up because something about their genes were modified in a way when they were sort of in utero.
So, this is a really fascinating topic, epigenetics in general, and this idea of things running in families. But as far as we understand it currently, it’s hard to map it out. It’s hard to give specific percentages. When I’m meeting a new patient, I will typically ask her, do you have any sisters? Have they had any children? Have they had any complications of pregnancy? And I make note of them. Tell me about your mother’s pregnancies. Did she have complications in pregnancy? You know, did she have preterm birth? Did she have preeclampsia? And I sort of take a look and you sort of get a feel if there’s something that runs in a family or not. What exactly you do about in this pregnancy, it depends on the exact circumstances because it’s hard to say specifically what the increased risk might be if there is. But it’s definitely something I make note of. And hopefully with more time and research, we will be able to map this out further.
All right, Katherine, since you asked a great question, number one, and you plug the book, you get question number two answered. All right, here’s question number two: “Have you dealt with patients with tokophobia?” I’m going to spell that T-O-K-O P-H-O-B-I-A. “How do you help them through preconception, pregnancy, labor, postpartum? How would your reproductive psychiatrist colleagues handle this to have a handle on the prevalence and causes and if it can be successfully treated?”
So, I have to admit, Katherine, I had to look up what tokophobia was, and it’s the fear of childbirth. So, I definitely know of people who have fear of childbirth, and I’ve seen and taken care of many women who have fear of childbirth. I just didn’t know it was called tokophobia. We’re all learning here. So, this is great. In terms of your question, yes, absolutely positively I see patients who have a fear of childbirth. Now, I guess everyone probably has a little bit of fear of childbirth, especially if it’s their first baby, and there’s a lot of unexpected, and there’s a lot of things they don’t know about. And, you know, okay, I think when it goes from, let’s say, sort of “typical anxieties, fears” about childbirth versus like a condition is what really impacts your day to day life, meaning is it so prevalent the fear, that it’s hard to function. That’s usually… Again, I’m not psychiatrist, but usually in psychiatry when things like anxiety or depression, when do they go from just being like moods like, “Hey, I’m a little anxious, or I’m feeling a little down,” to this is a anxiety disorder. This is a depressive disorder. There are a lot of criteria, but the simplest way to think about it, I think, again, in my… This is my non-expert opinion in psychiatry, the simplest way to think about it is really when it transitions from just being like a feeling or a mood or, you know, some thoughts to, “This is affecting my life. I can’t function. I can’t interact with other people. I can’t work. I can’t get out of bed. I can’t eat.” Whatever part of your life it’s affecting, if it affects your life in that way significantly, that’s when it sort of becomes something.
So, in terms of people have… Let’s call it a severe fear of childbirth. Yes, it does happen. I don’t know the exact prevalence. Certainly in my practice, I might have a higher rate of it because we deal with higher risk pregnancies. So, maybe there’s more fears. Again, I’m just guessing that’s a possibility. And I think that, yes, this is something that would be helped by professional mental health care, whether it’s a psychiatrist, whether it’s a psychologist, whether it’s a therapist, whether it’s all the above, some of the above. Sometimes medication, sometimes not just like I would think any let’s call it an anxiety disorder. I think that anyone who has any form of anxiety that’s significantly affecting them, there’s a very good chance they would be helped by professional mental health, right? And so that could involve therapy. It could involve some sort of cognitive behavioral therapy. It could involve medication, obviously. And I’ve definitely had patients who have used some of the above, all the above to address this.
Yes, there are probably people who have it to the point that they don’t get pregnant and I wouldn’t see them. So, that’s not people that I would typically be seeing. But in terms of those that I do see who are pregnant, in my experience… Your question was, “Can it be successfully treated?” So, it depends on what you mean by success. Does it mean that if they get treated, they’re going to no longer have any anxiety over childbirth? No, I think that’s probably unrealistic as a goal. Can we get it to the point… By we, I mean with a team, including psychiatrists, psychologists, whoever might be, can we get to the point where they’re functioning and able to get through their pregnancy relatively unscathed and get through the birth? Yes, absolutely. I think that is something that can be treated. Again, if your goal of success is sort of getting from point A to point B as opposed to removing all anxieties forever, which is pretty unrealistic. Great questions, Katherine.
All right. Thank you, everyone, for sending in your questions. Please continue to send in questions. We’ll see you all next week.
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