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 OBGYN 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.
Hey, welcome to our mailbag podcast #23: What does the Fox say?
First question from Kara: “Hello, Dr. Fox. I am a toaster and was introduced to your podcast by your wonderful episode with Jackie. I’m planning to have a baby and was told to start taking a prenatal. The information out there is all different and confusing for what specific vitamins you should have included. What would you recommend focusing on? Are there specific brands? Also, what are your thoughts on CoQ10 to boost egg viability?”
All right, Kara, so the short answer to your question is it doesn’t really matter what prenatal you take in terms of brands. The vitamins that we have data for that you want to be on early in pregnancy is really just folic acid or folate. So, what is typically recommended is if you’re trying to conceive, to start taking any prenatal vitamin with folic acid prior to conception just so that it is pretty clear that you’re on it when you get pregnant. Not everyone knows when they get pregnant. Most likely if you started it the second you got pregnant, that’d be fine too. But usually recommend just starting in advance.
Prenatal vitamins will typically have 400 micrograms, which is 0.4 milligrams or more of folic acid in them. You’ll have that. Sometimes they’ll have double, like 800, sometimes they’ll have 1,000. But that’s what’s typically in there. The rest of the vitamins that are in the prenatal are usually not markedly different from what’s in any standard multivitamin and different prenatals market for different reasons. Some because they want to have smaller pills, some because they want to have more of this, more of that. But ultimately in terms of like health, it really shouldn’t matter which one you take prior to getting pregnant or early in pregnancy. And in fact, for a lot of women, the prenatal makes them nauseous. It’s usually a bigger pill because they put a lot of vitamins in there. And so for those women, usually we’ll tell them just, you know, stop taking the prenatal and just take the folic acid as well.
In terms of other vitamins, well, you know, it depends how you look at it. If you have a well-balanced diet with good healthy foods, maybe you don’t need any other vitamins or supplements. But since we’re not always clear who’s eating what or able to eat what, usually we’ll recommend some form of a prenatal early in pregnancy just to make sure you get them. In my practice, what I typically will tell people is take any prenatal that’s out there, you know, whether you want one that’s smaller, that’s bigger, that’s chewable, whatever it is, fine. If you can’t tolerate a prenatal, you don’t like the prenatal, just make sure to get the folic acid. Then on top of that, I usually do recommend people take calcium as a supplement because most people don’t get enough calcium in their diet. The recommended daily amount is 1,000 milligrams a day. That’s like three to four servings of dairy. So, most people don’t get that in their diet. And so if someone does, that’s fine. But if they don’t, usually I’ll tell them to pick up calcium. And most prenatals will not put 1,000 milligrams of calcium in the prenatal because otherwise the prenatal will be the size of a golf ball. No one would have it. Fine.
So, either a prenatal or folic acid, number one. Number two, make sure either through diet or through supplements get enough calcium. And then also similarly, whether it’s beneficial to take, like, a fish oil supplement or not. I ask people if they eat fish, if they eat it, you know, twice a week. For instance, I allow people to eat sushi during pregnancy. That’s sometimes the way people get fish. So, if people eat fish two to three times a week, that should be fine. If not, then usually I’ll tell them to either get a prenatal with fish oil or pick up a fish oil supplement.
Your question about CoQ10. So, CoQ10 is a supplement that a lot of people take. It has antioxidant properties. The thought is that maybe it will improve fertility or maybe it’ll improve early pregnancy and lower the rate of losses. What I would say is a lot of people take it. A lot of people recommend it. The data on it is very unclear whether it actually does what it’s supposed to do. So, I think that a lot of the people who recommended or people take it, it’s sort of faith-based that like, “Hey, maybe this will help.” So, I don’t routinely tell people they need to take it, but I do have a lot of people who come into pregnancy taking it, and it is safe, and it’s fine. Maybe it’s helpful. Maybe it’s not. We’re just not really sure at this point.
Okay, next question from Tamar: “Hi, Dr. Fox. First off, I want to thank you for reassuring me during my first pregnancy. You had read one of my scans,” oh, how nice, “and reassured me that my baby simply just have my body type, LOL. I put the pieces together who you were after seeing you on the toast.” All right, we got a couple of toasters going on here today. “Anyways, I am hoping to get pregnant with number two sometime soon and trying to avoid having another 4-pound 3-ounce baby. How soon in my journey/early pregnancy should I be avoiding caffeine? In my head, I blame my coffee and diet coke for the previous IUGR.”
All right, first of all, Tamar, thanks for reaching out. Glad it worked out. Glad you have the connection of who I am between all the various parts of your life pregnancy and toast-related. So, first thing is your coffee and diet coke did not cause you to have a 4-pound 3-ounce baby as opposed to a 6-pound 3-ounce baby. That is not even amongst sort of the concerns with caffeine. That’s really not a big one. Generally with caffeine, the concern is early in pregnancy… Concern. It’s not necessarily true, but the concern is that maybe if you take a lot of it early pregnancy, it’ll increase the risk of miscarriage.
Number one, that data is very, very weak. Number two, if there’s an association with caffeine and miscarriage, it’s very high doses of caffeine. It’s not the typical human consumption of having a coffee or a diet coke or a Snapple or whatever it might be. And so for people who have normal human consumption of caffeine, that tends to be fine in pregnancy as far as we know. We don’t tell people they have to stop caffeine entirely. I mean, if I run into someone that says, “Yeah, I’ve eight cappuccinos a day,” fine. Maybe that person should cut back. But pretty much that’s unusual. The amounts of caffeine that most people have in a typical day is not associated with miscarriage.
There’s some theory that maybe it could decrease blood flow to the placenta, which would then decrease growth in the baby. I would say it’s really speculative. It’s not really proven. Again, normal human consumption shouldn’t do that. There’s so many other reasons to have small babies, both normal and sort of normal reasons like baby is supposed to be small versus something with the placenta or whatever. And caffeine is way, way, way down on the list.
So, in terms of your question, while you’re trying to conceive, I think you can have normal amounts of caffeine. Early in pregnancy, I think you can have normal amounts of caffeine. If you, Tamar, happen to be someone who has 10 cappuccinos a day, maybe we should talk about that. Maybe cut back a little bit. But if you’re sort of like everybody else, you know, has their iced coffee in the morning and maybe a diet coke in the afternoon, I think you should be fine. And it should have no impact whatsoever on your pregnancy, ideally. Okay, good luck.
Next question from Sierra: “Hi, Dr. Fox. I’ve been a listener since I conceived in April. Now my husband is too when we drive to see his in-laws in Long Island. We’re big fans. A small part of me wanted a twin pregnancy so I could come to your practice.” Oh, Sierra, that’s very, very sweet. By the way, you don’t need to have twins to come to our practice. Everyone’s welcome. Okay, that was my little commercial. “In my 20-week anatomy scan, the doctor saw a choroid plexus cyst on the ultrasound. He said he was noting it in my chart. It would very likely go away and he would do another ultrasound in two months. He said he was very unconcerned about it. Can you talk about what causes these? Why or why they wouldn’t go away? What harm it could cause when someone would want to do an amnio? My NIPT and nuchal were both normal. I’m 31. It’s my first pregnancy. Thank you.”
All right, Sierra, good question. So, a choroid plexus cyst is a finding that we see on ultra during pregnancy. Typically, we’re going to see them when we do the anatomy ultrasound at 20 weeks, so you can find them at any point in pregnancy if you happen to look. They’re located in the baby’s brain in an area called the choroid plexus. And the choroid plexus is a part of the brain that is located inside what we call a ventricle. And essentially the choroid plexus makes fluid like spinal fluid and it dumps it into the ventricle. And then there’s like a whole plumbing system in the brain and down the spine. Fine. So, we always see the choroid plexus in pregnancy and we see the ventricles. And sometimes when we look in the choroid plexus, which sort of in an ultrasound looks like a grayish spongy material, we’ll sometimes see inside of that a black circle of fluid, which we call a cyst in the choroid plexus, hence choroid plexus cyst or CPC.
So, we do see them probably in a couple percent of pregnancies. The overwhelming majority of the time, it means absolutely nothing. Nothing for you, nothing for the baby, nothing for the pregnancy, nothing after delivery. It does not require follow-up. It goes away. It doesn’t go away. It does not make a difference. It is what we call a benign finding. The reason choroid plexus cysts have gotten in the past some notoriety is way back when when we didn’t do any genetic screening, really other than an ultrasound and then maybe or maybe not an amnio, choroid plexus cyst was associated with babies with a specific genetic condition, trisomy 18. And so babies with trisomy 18 would frequently have choroid plexus cysts. However, babies with choroid plexus cysts did not usually have trisomy 18. And so this is like when I was training, you know, way back when, if we did an ultrasound and saw a baby with a choroid plexus cyst, what we would say is, “All right, the likelihood this baby has trisomy 18 might be slightly higher. So, let’s just look really closely.” And babies with trisomy 18 typically have many, many more findings on ultrasound than just a choroid plexus cyst. They usually have lots of things in the heart and the other parts of the brain and the hands. So, if the baby looked totally normal otherwise and all we saw was a choroid plexus cyst, what I would generally tell people is you don’t have to worry about this. You’re fine. And then we wouldn’t need to follow it up or anything like that.
Nowadays it’s even more so because nowadays when we do the nuchal ultrasound, the NIPT and all these things that say that the risk of trisomy 18 is exceedingly low, when we see the choroid plexus cyst, it basically does not move the needle for trisomy 18 in any significant way because of all those other tests are such a better test to look for trisomy 18. So, nowadays what typically happens with a choroid plexus cyst in places that do good ultrasound and do genetic screening is essentially we ignore it. Whether we even tell the patient about it is sort of debatable. Some say we should tell them and then tell them not to worry, and others would say, “Why would you tell someone something and then tell them not to worry? Maybe you just shouldn’t tell them at all. Just call it normal finding. There’s merits to both arguments. I’m not taking a position here on either one.” Bbut essentially it’s considered a benign normal finding. We do not follow them up or do not need to follow them up because there’s no significance of them in terms of the baby’s brain itself. It’s not an abnormality of the brain. It doesn’t cause any problems in the brain. Again, it either goes away or doesn’t go away, but doesn’t matter in either direction. It really has no impact whatsoever on the baby himself or herself. And so it’s really not an issue. So, I would agree with your doctor who was unconcerned about it. I probably wouldn’t have even needed to do an ultrasound to follow it up. And typically we don’t use this as reason alone to recommend an amnio. Anyone who wants an amnio is welcome to have one. Obviously, whether the baby has a CPC or doesn’t, but this is not a finding that nowadays increases our suspicion at all.
Okay, next question from Jane: “Hi, Dr. Fox. Love the pod. Found you through The Toast.” Big theme today on The Toast. “I ended up with two kidney infections during my pregnancy. Both times I was admitted to the hospital and the second time I was septic”. Oh, that’s not good. What’s the likelihood this happens again in the future pregnancy? Is this more likely because of the way my organs shifted due to a growing baby? For reference, I don’t frequently get UTIs and both times I had no symptoms until having a fever.”
All right, Jane, I’m sorry you got the kidney infections. I’m really sorry you got septic. I’m glad you’re well now. So, kidney infections are more common in pregnancy than non-pregnant. So, there are people who have no infections in their life, kidney infections, bladder infections, who do get them in pregnancy. Some people do have them when they’re not pregnant as well. And basically, the reason that is, when you’re pregnant, some of the mechanisms that your body uses to fight against kidney infections are somewhat reduced. So, what does that mean?
So, normally, women do not have bacteria in their bladder at all. So, normally if you do a urine culture on someone, you send a urine sample, which is basically urine from the bladder. You put it, you culture it. There’s normally no bacteria. Fine. Occasionally, you’ll find a small amount of bacteria in the bladder, which is not typically thought to be a problem at all. And then occasionally you’ll find a higher level of bacteria in the bladder, which is called asymptomatic bacteriuria, which means you don’t have any symptoms. You feel fine. You don’t have signs of a urine infection, but there’s bacteria in your bladder. When you’re not pregnant, that’s not typically treated because it’s not, sort of, a symptomatic infection. When we treat this… Again, non-pregnant. People who are non-pregnant, who have a bladder infection, have symptoms, right? They have to pee all the time. It burns when they pee. When they pee, they don’t feel like they finished, and it’s very irritating. It’s very painful. And we do treat those because, number one, we want them to feel better. But, number two, there’s always a small risk, if you don’t treat it, that that bacteria will travel backwards up the ureters, which connect the kidneys and the bladder, up the ureters, all the way up into your sort of upper back to where your kidneys are, and then infect the kidneys, which is a much more significant infection because then it gets into your bloodstream and you’re very sick and you get high fevers. People with urine infections in their bladder don’t tend to have fevers. They could, but they don’t tend to have fevers. They just tend to be irritated. They don’t tend to be as sick, but they tend to be very irritated. When it gets into your kidneys, you’re sick, right? It’s like having a pneumonia. It’s in your body. You’re very, very sick.
So, someone has an infection and they’re not pregnant, we typically treat because of their symptoms. Yes, it reduces the risk of it going to the kidneys, but that’s pretty uncommon in general. And if they don’t have symptoms, we don’t typically treat. In pregnancy, what happens is the valves that sort of keep the urine in the bladder and prevent them from traveling up backwards into your kidneys. When you’re pregnant, they get a little bit sort of softer and weaker. And so there’s a higher chance of urine going backwards from your bladder back up into your kidneys. Some of that is a hormonal change and some of that is a physical change. So, this risk increases even early in pregnancy when your uterus is small, and it gets worse in pregnancy as your uterus is bigger.
And so because of that, a few things. Number one, because of that, if women have a significant amount of bacteria in their bladder when they’re pregnant, even if they don’t have symptoms, we do typically treat them in pregnancy with antibiotics because we’re worried that that bacteria, even though it’s not causing any symptoms in the bladder, it could travel back up into the kidneys and cause an infection in pregnancy. So, that’s number one. Number two is that, yes, it is more common for women to get infections in their kidneys. So, you had it once, you had it a second time. And what we typically do with anyone who has a history of an infection in their kidney, we usually in the next pregnancy, either give them an antibiotic, like once a day, every day the entire pregnancy, as what we call prophylaxis, to prevent that from happening again. Or we do very frequent urine cultures in the next pregnancy, like once a month, just to maker sure there’s no asymptomatic bacteria inside the bladder.
So, in terms of your question, it is maybe not… When you said, “What’s the likelihood of it happening again in future pregnancy,” the answer is much higher than somebody else.” Is it because your organs shifted?” Somewhat yes, but also just hormonal. And so in your next pregnancy, I would typically recommend either taking an antibiotic every So, that doesn’t happen again, or you would need urine cultures very frequently to test for asymptomatic bacteria in your bladder so that could be treated promptly so you don’t get it again.
All right. Next question, Madison: “Hi, Dr. Fox. What is your opinion on horseback riding while pregnant? Obviously there is an inherent risk of accidents happening, but assuming the riding stays safe, any risk for mom and baby associated with riding? I’m pregnant with my third baby. Prior to pregnancy, I was riding multiple times a week. I was advised to stop my very light riding, only walking.” I assume that’s the horse that’s walking. “I’m 20 weeks. Thoughts on this? I’m not sure if this is just because the risk of accident or there’s another reason I’m unaware of.”
So, Madison, you’re correct. The issue with horseback riding is not related to the horseback riding itself. It’s not exposure to horses. It’s not sitting on a saddle. It’s not sort of the movement. It’s not sort of the bouncing up and down. It’s really just the concern with horseback riding that one might get thrown from the horse. One might get, I don’t know, kicked in the head. Obviously, these are not usual things to happen for people who are horseback ride, particularly people who do it often and do it well. Way back when horses were mode of transportation, you know, 150 plus years ago, I imagine that pregnant women rode horses all the time. So, ultimately, it’s just an issue of how far do you want to go to prevent risk.
For most people, horseback riding is not a part of their regular routine. It’s leisure activity. And so for most pregnant women, if we tell them, you know, no horseback riding while you’re pregnant, they’ll be okay with that. And that’s fine. If someone, let’s say, does it professionally or somebody, let’s say that is their mode of transportation or for whatever reason, that’s it and they’re highly confident they’re not going to get injured while doing it, then no, there’s no risk to actually doing it, though it’s obviously hard to predict these things. And that’s true with most of the activities that we tell people not to do when they’re pregnant.
Skiing is another classic example I get asked about. And people are like, “Can I ski when I’m pregnant?” Well, there’s nothing dangerous about skiing when you’re pregnant. The danger is if you fall and break your leg or if someone runs you over or, you know, something like that. That’s the concern with skiing. And so those are… Obviously someone who’s a good skier and does it a lot, those chances are low but it’s very hard to make those chances zero. And so sort of an issue is, is it worth it to go skiing? Understanding there’s a risk of getting injured. And when you get injured when you’re pregnant, it’s a bigger deal. It’s harder to heal. Those things you can and can’t do, it’s just much more complicated. So, it’s similar paradigm for horseback riding in pregnancy.
All right. Malka has two questions. Malka, I’m going to answer both your questions. Here we go. First question: “Hi, Dr. Fox. Major fan. Thank you for the high-quality content that you release every week.” If you flatter me, I’ll answer both your questions. Two questions. Number one: “I’m currently 28 weeks pregnant with baby number 3. Do you recommend pregnant women take the RSV vaccine? Is there anything to consider? Any downsides? What is the best time to take it?”
All right. So, the RSV vaccine is one of the newer vaccines that came out. So, we’re now in 2025. I believe it was two seasons ago, if I am correct, in the winter of 2023 to 2024. Essentially it’s one of the vaccines that we give to moms while they’re pregnant, not for them but for the baby. So, when the baby is born, he or she would have a lower risk of getting RSV after birth. Now RSV is a significant infection in newborns. It is common. It spreads. It can cause significant issues in terms of things like hospitalizations and even death. Fortunately rarely but it’s not off the table. It can be a very, very significant infection for newborns.
The treatment if babies get it is mostly supportive. And so it’s really, really great if we can prevent it. And there seem to be two ways that we can… Other than, you know, preventing it by not being around sick people in the winter but basically in terms of preventing it medically, the two ways that we have is you can either do a vaccine of the mother. The other option is after the baby is born, they can give the baby’s antibodies to RSV sort of after birth as a preventative measure.
In terms of the vaccine, as far as we know, all the data is that it is safe for the mother and for the baby, number one. Number two, it does work, meaning if the mom got the RSV vaccine, the baby is less likely to get RSV, less likely to be admitted to the hospital for RSV. It doesn’t make your risk zero, but it reduces the risk significantly. And so it is recommended that pregnant women get the RSV vaccine.
Now it’s only given for moms who are going to deliver during the winter months. So, RSV vaccine, for example, is not really given in the summer for babies who are going to be born in the summer because RSV is not really prevalent in the summer. It’s really meant for babies born in the winter. This is in contrast to the Tdap vaccine, which is another vaccine that we give to prevent an infection in the newborn. That’s the P in Tdap, pertussis, which is whooping cough. Since that’s a year round virus, it’s worse in the winter, but it is year round. That’s a vaccine that we also give year round to pregnant women, but RSV is specifically given in the winter. So, if you’re going to deliver winter time, RSV vaccine is recommended.
As far as we know in the studies, we haven’t really seen any downsides. One of the studies suggested… Again, there was what’s called a signal, which means that maybe there’s a red light, that there was an increased risk of preterm birth amongst women who got the vaccine. But that seems not to be borne out in further studies. And so for that reason, we give it more towards the latter part of pregnancy just in case that we’re real. We don’t give it earlier. We give it sort of latter, but it does not seem to be an issue and we are not discouraging people. I mean, we are encouraging people to get the RSV vaccine in the winter season. And so that’s the best time to take is in the winter. Best time in pregnancy is sort of… It’s given generally, like, 32 to 36 weeks towards the end of pregnancy.
Okay, Malka, your second question: “My first two kids were 10 pounds 9 ounces. Is there any good evidence to induce early if the baby’s measuring big in fear of shoulder dystocia, etc.? I have no gestational diabetes or any other complications. Both my births were very quick and smooth. Forty-one-week inductions, no tearing. I’m 5’8″, not a tiny petite person.”
All right. So, this is a really, really good question. It does come up. When we’re suspecting that babies are going to be large, right, and we do that either by feel, by the mother saying, “I think this baby’s big,” by ultrasound, none of these are perfectly accurate. But let’s say we think that the baby’s going to be large. So, most large babies are born as you had uncomplicated, baby’s healthy, mother’s healthy. Everyone does fine. But as the babies get bigger at birth, right, from 9 to 9 and a half to 10 to 10 and a half, 11 pounds, so forth, there are risks that go up as the baby gets bigger, both to the mother and to the baby. For the baby, the risk that we get concerned of is what you mentioned, a risk of shoulder dystocia where the baby’s… That’s a complication where after the baby’s head is delivered, the shoulder doesn’t really fit. The baby’s shoulders don’t fit. And that can be a minor issue. It could be a major issue. It can sometimes cause injuries to the baby. Sometimes it could be permanent. So, that’s something we certainly would prefer to avoid. It’s not always avoidable, but that’s something we prefer to avoid, obviously. And that is one of the major risks to the baby. To the mother, bigger babies, higher risks of bigger tears, higher risk of needing a C-section, higher risk of blood loss and whatnot.
So, the question is, what do you do if you think a baby’s measuring big? And there’s really three options as broad categories. Option number one is don’t do anything. Wait, mom will go into labor. Do what you would normally do. Most of the times it’s going to work out. But obviously, as the babies get bigger, you are taking certain risks, and those percentages go up as the baby gets bigger. That’s option number one. Option number two is you go the opposite direction. You say, “Hey, this baby’s measuring big. Let’s just schedule a C-section.” So, you avoid the risks of the baby getting injured because of sort of the head coming out and not the shoulder. The mother avoids the risk of, like, a big tear, complicated delivery, whatnot. On the downside, you have to have a C-section, right? It’s an automatic surgery, but that’s sort of the other end of the spectrum option. And then the one sort of in the middle, I would say is, well, maybe we should induce labor earlier so that the baby is smaller. And those are the three options.
And the question of which of the three is the right option to choose, right? Letting things go as they are, doing a C-section, inducing earlier. It’s hard to give a definitive answer because it depends a lot on the specifics of the circumstance. Who is the mother? What is her birth before? What is the exact estimate of this baby? Does she have gestational diabetes? What are the specific measurements of the baby? So, there’s a lot of factors that go into it, but I will say that this is definitely a discussion that we have with people when we think the babies are starting to measure bigger. Again, to go over what is the best of those three options for this woman, this baby, this pregnancy, exactly what to do.
So, there is evidence about inducing early. To answer your question, there is evidence about inducing earlier and there’s, you know, some upsides, some downsides. It really depends on the circumstances. I would say the best evidence available is that overall inducing, let’s say, 39 weeks versus waiting to go to 41 weeks does lower the risk of having a shoulder dystocia, which makes sense because the baby will be smaller if you’re at 39 weeks compared to waiting 2 more weeks. There used to be a fear that it would increase the risk of a C-section by inducing, but that does not seem to be true. So, I would say there is evidence to support that strategy of inducing at 39 weeks. Is it necessary in everyone? Well, it depends on the circumstances is what I would say.
All right, Malka, thanks for your two questions. Thank you, everyone, for sending in your questions. Please continue to send them and we will keep doing the mailbag podcast. Have a great day.
Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.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. It 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.
