“Mailbag 25: What does the Fox say” – With Dr. Nathan 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 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, everyone. Welcome to Mailbag 25: What Does the Fox Say? Our first question is from Anastasia, and it’s on choroid plexus cysts. “Hi. My 20-week anatomy scan showed that my baby has bilateral choroid plexus cysts. His genetic tests in the first trimester all came back negative, and the rest of the anatomy scan was normal. My nurse practitioner explained that although he has these little cysts, since there were no other ‘soft indicators,’ that the cysts are likely to resolve by the time he is born. She was very thorough in talking to me about it, and put it in order for a third trimester scan. She also warned me not to Google it when I get home. Well, I Googled it. And now, I’m freaking out. What if the cysts are still there at the third scan? What if he’s born with them? Have there been any findings in babies that had cysts resolved and now could have impacted them? Could the genetic test have missed something? Is he in fact at risk? Thank you, Dr. Fox.”

All right, Anastasia, good question. Short answer is, no, don’t worry. Okay. Here’s the long answer. So, basically, choroid plexus cysts are little cysts, which are fluid-filled pockets that we see in the structure in the choroid plexus. So, the choroid plexus is in the baby or the fetus’s brain. It’s supposed to be there. The choroid plexus makes a spinal fluid and sort of secretes it into the system of channels and tunnels and whatnot in the baby’s brain. And so, that’s all supposed to be there. That’s all normal. Sometimes when we look at this choroid plexus, it looks like a spongy material. And every now and then, within it, we see little pockets of fluid, and those are cysts.

In terms of the cysts themselves, they’re not dangerous to the baby. They’re not a brain problem. They don’t hurt the brain. They don’t affect development. Nothing like that. So, actually, in fact, while it’s fine to get a follow-up scan in the third trimester, you don’t even really need to because they don’t need to be followed up because whether they stay or whether they go away is not relevant to the health of the baby. It’s not something that needs to be followed up after birth. Right. They’re totally fine to have.

The concern with choroid plexus cysts is really an older one. Back in the day, when there was really no or very minimal genetic screening, seeing choroid plexus cysts increased the risk slightly of the baby having something called trisomy 18, which is a very, very severe genetic condition. Now, most babies who have choroid plexus cysts…not just most. The vast majority of babies who have choroid plexus cysts do not have trisomy 18. They’re perfectly fine. But sort of when there was a time when there was no genetic screening, there was no nuchal, there was no NIPT, and people just sort of showed up for 20-week ultrasound, if you saw choroid plexus cysts, we’d have to decide, all right, do I need to do, like, an amniocentesis to check for trisomy 18, or do I not need to do it?

Even back then, if the baby otherwise looked normal, the chance of trisomy 18 was exceedingly low, and we usually didn’t worry too much about it, but it was a conversation. But nowadays, when there’s genetic screening and people have all this sort of pre-screening before their 20-week ultrasound, if the baby looks fine and we see these choroid plexus cysts, basically, we ignore them. Meaning, the chance that the baby would have trisomy 18 is so minimal that we don’t even, like, drop that. So, when you Google it, it can be very terrifying because sometimes you’ll find a website that will say, oh, it’s linked with trisomy 18. And while that’s not false, it’s really out of context. And so, nowadays, it’s not really the same thing.

So, if I see someone who at 20 weeks, just like you, everything’s been normal, screening’s been normal, baby looks fine, and I see these choroid plexus cysts, it’s actually a debate of whether we should even tell people about it because, since it has no consequence whatsoever, by telling people, you may just be scaring them unnecessarily. So, different people fall on that line differently. Some talk about it, some don’t talk about it, but either way, it’s not anything to be concerned about. All is well. Not a problem.

Okay. Next question is from Megan [SP] or Megan. Sorry if I don’t know which way to pronounce it. And it’s about placing an IUD at the time of caesarean. “Hi. I plan to use a Mirena IUD for contraception after the birth of my second child. I plan to have a repeat C-section. On the postpartum episode with Melka — love her!” Thank you for that. “You mentioned that it’s possible to place an IUD during a C-section, but not always the best. Can you give a little more detail as to why? Because I never dilated with my first child’s birth, the placement at eight weeks postpartum was pretty painful, and I’d like to have it placed during the surgery if possible. Thanks so much for a great podcast. It always makes the Monday morning drive to work more enjoyable.” Thank you for that.

So, it is possible to place an IUD at the time of C-section. Basically, uterus is open, you put the IUD in, you close the uterus. And so, it seems pretty straightforward. And there are definitely places that do that. And it’s doable. In our practice, we don’t do it. And the main reason we don’t do it is that there is a relatively high rate of it being expulsed, meaning, coming out of the uterus, or finding that it’s malpositioned because after, you know, the uterus has to squeeze down and heal, that the IUD might be in the wrong position. And also there are some logistical issues with getting an IUD and having paid for the IUD, and who pays for it, is it the hospital, insurance? There’s some hoops to jump through, which is annoying, but that’s just reality, that it’s not the simplest thing in the world to have a device placed because someone has to figure out who’s going to pay for that device, and how does that get done? Fine.

But putting that aside, just on the medical side, we prefer not to do it at the time of C-section, but there are definitely people who do, knowing that there’s a risk that it’s going to be expelled or malpositioned, and you’ll have to go through removing it and replacing it. So, there isn’t a perfect answer to this. Again, there are definitely people who do it. And it’s possible that when you have your C-section, if it’s not with us, that your doctor would be able to do it. But know that there is a rate afterwards that will have to be redone. I hope that answers your question. Good luck with the upcoming C-section.

All right. Next question is from Lily, and it’s on third trimester bleeding. “Dear Dr. Fox, I’m grateful beyond words to you and your whole practice. I had my daughter three years ago, delivered by the wonderful Dr. Shlansky.” Agreed. Thank you for that. “After many months of anxiety due to a single umbilical artery that was only eased by your team and your podcast episodes. Since then, we moved to Barcelona. Knowing I’d have to carry on with my second pregnancy under different care was a tough decision. And the healthcare system has been nothing but amazing here. But now, I find myself in a puzzling situation involving a complication, and wanted to hear your thoughts.”

“At 32 weeks, a few days ago, I landed at the ER with a gush of bleeding. And while I felt no contractions, the monitoring revealed that I was having them regularly, 2 in 10 minutes for a while. Baby was doing great, and nothing was visible in the ultrasound. Now, the bleeding has stopped and so did the contractions. But they gave me shots for the baby’s lungs just in case. And I’m staying under observation a bit longer. What could have caused this? I had hematomas earlier with this pregnancy at 16 weeks, but then the hematoma or its prior spot was visible. Could this mean I was in preterm labor that resolved itself? Could this mean preterm labor is in the cards? Could it be a partial placental abruption? Scary. Will I need to be on bed rest for the rest of pregnancy? I hope not because I have a delightful three-year-old at home. Once again, thanks for all the thoughtful care. I truly miss my visits on Madison Avenue.”

Thank you so much, Lily, for the question. I hope you guys are doing great in Barcelona. We miss you as well. In terms of your question or questions, there’s a bunch there, ultimately, to sort of, like, trim it down, you had bleeding and contractions at 32 weeks. Okay. So, someone comes at 32 weeks, which is preterm in the third trimester, and had bleeding and contractions. What could it be?

So, there’s a bunch of options, but probably the two most common would be either just some form of either preterm labor or possible preterm labor, where there’s contractions. Again, why that would happen is sort of unclear. It could be for risk factors, not risk factors, but whatever. You have some form of either preterm labor or close to preterm labor, preterm contractions. And definitely, there are people who, when they have preterm labor or preterm contractions, can have bleeding associated with it as a sort of result. And usually, that’s…we think, that when the cervix shortens or dilates, sometimes the cervix will bleed a little bit. So, that’s one possibility.

Another possibility, which is sort of the other one that’s on the common end when that happens is that it’s sort of the opposite sequence. At first, you have bleeding and it causes contractions. That’s usually from what you described as a partial placental abruption. And so, what a placental abruption is, is when the placenta starts to separate while you’re still pregnant. Right? So, normally, in the course of events, placenta is attached to the uterus. At some point, you go into labor. You deliver the baby. Baby’s out. We clamp and cut the cord. And then sometime thereafter, 1 minute, 2 minutes, 5 minutes, 10 minutes, whatever, the placenta starts to shear off the uterus. Then there’s some bleeding from that. Then the placenta plops out. The uterus squeezes down. The bleeding stops. Fine.

But sometimes, the placenta starts to shear off the uterus while you are pregnant. And if it happens a little bit, you will usually have a little bit of bleeding that may or may not continue. If it happens a lot, like if half of the placenta separates, there’s usually a tremendous amount of bleeding. And that is something that can happen, and it happens to many different degrees. Some people have a small amount of bleeding, some people have moderate, some people have heavy, usually based on how much of the placenta is separating. But when there’s bleeding that’s in the uterus, it’s an irritant to the uterus, and it causes contractions.

So, for you, the two most common possibilities is either you had contractions or labor, which caused a little bit of bleeding probably from the cervix, or you had a partial placental separation that caused bleeding, which then caused contractions. It’s often hard to distinguish the two, at least initially. Ultrasound usually does not see anything when you have a placental abruption. You don’t usually see the placenta separated, and you don’t usually see a big blood clot behind the placenta. Although you could, but usually not.

Some of the other possibilities, something called the placenta previa, but that, usually if you’re bleeding and you’re 32 weeks from previa. If you’ve had prenatal care, usually people already know they have a previa. So, for you, presumably, you didn’t have one or don’t have one. And so, they know this. And there’s other sort of rare causes, but those are the main ones. And so, for you, I’m not exactly sure which one of the two it is or was. It could be either. They gave you the shots of the steroids just in case either the baby was born spontaneously, meaning, went to labor and the baby delivered, or if they needed to deliver the baby. Sometimes there’s an abruption. If it’s severe, the safest thing is to deliver. So, they did that to help mature the baby’s lungs.

But otherwise, in terms of what happens afterwards, well, it depends. I mean, these things can play out in many different ways. For some people, they’ll get an episode like this, the contractions stop, the bleeding stops. Everything is fine. And then there’s really no reason…you know, we monitor, but there’s really no reason to do anything, just sort of watch and wait. For some people, there’s on and off bleeding or contractions, and they have to be watched a little bit closer. We’re not big proponents of bed rest for either of those conditions. It doesn’t seem to work. I mean, obviously, there’s some common sense involved in not going too crazy with your activities, but it’s not like if you rest in bed, the contractions won’t come back. It doesn’t really work like that. So, I don’t know exactly how it’s going to play out, but it could be many different ways, and you just have to monitor for that. All right. Best of luck.

Next question is from Madeline. It’s a short question, but a very good one. “Can you explain the difference between Cervidil and Pitocin for induction?” All right. So, for induction of labor, where we’re taking someone who’s not in labor, and trying to put them into labor…and we have podcasts on induction, on elective induction, and all of these things. And so, the reason why we do that, fine, we’ll leave it for the other podcast. But in terms of the actual process, how do we do it?

So, there’s many ways we can induce labor, but typically the two things that have to happen is, number one, the cervix, which is the bottom part of labor, we want it to become what’s called favorable, which is, instead of being, like, long and closed and firm, we’d rather it be soft and short and a little bit dilated. And then, number two, we want to give…we want the uterus to be contracting. And then also the third part, which is in a medication is we usually want to break the water.

So, the types of medications we use are based on which of these things we’re doing. So, for example, if someone has a long and closed cervix, and we want it to be open, one of the options we can do is put a balloon through the cervix. So, we do that and that’s part of our induction episode. You slip, like, a catheter through the cervix, inflate a balloon, put it on tension. As the balloon comes out, the cervix opens. Sometimes it causes some contractions as well, but usually it’s just to get the cervix open, and then we can break the water.

In terms of the medications, there’s really two big categories. One of them is Pitocin or oxytocin, and the other one is Cervidil or Cytotec misoprostol. These are all what’s called prostaglandins. So, what’s the difference between them? So, Pitocin or oxytocin is given intravenously, and it mimics the hormone that’s secreted by the brain in labor, which is also called oxytocin. And what it does predominantly is causes the uterus to contract. So, you give oxytocin or Pitocin when you want there to be contractions, when there aren’t, or if you want there to be more contractions. So, if we’re inducing someone’s labor, either to start or some point in the middle of the process if the uterus isn’t contracting, we’ll start the Pitocin or oxytocin in order to get the uterus contracting.

Now, the prostaglandins, which is a different form of medication, one of them is something called Cervidil, one of them is something called Cytotec or misoprostol. Those can be given vaginally. For one of them, for the Cytotec, you can also give it orally as a pill. But basically, what they do is predominantly they act on the cervix to make it shorter, softer, and a little bit more dilated. They will also stimulate the uterus to contract, but not as much as Pitocin. And so, what usually happens in the course of events is there’s sort of phase one and phase two. Phase one is working on the cervix with either the Foley balloon or Cervidil or misoprostol/Cytotec, or some combination of them. Some people use the balloon plus Cervidil or something like that. And that’s sort of phase one to work on the cervix.

And then phase two is to start Pitocin to get the uterus contracting, and also to break the water. Now, exactly how you time that will…different people do it differently. There’s a lot of different strategies. It’s not clear that one’s better than another. But typically, that’s how it’s going to be. You’re going to have that combination of them. And that’s usually how it’s done to induce labor. Now, some people, when we’re starting the induction, their cervix is already short, soft, dilated. Like, if someone’s coming in for induction and their cervix is already 3 centimeters dilated, let’s say, and they’re not in labor, there’s really not much need to use Cervidil or Cytotec or the balloon because the cervix is already, like, there. It’s already what we call favorable. So, someone like that will probably only get Pitocin to induce labor.

Also, there are some people who, let’s say, get Cervidil or Cytotec, and then that puts them into labor, and then they might not need Pitocin. So, people don’t always get both, but frequently, they do. They get first the Cervidil or the Cytotec, and then later, the Pitocin. Hope that answers your question.

All right. Our last question is from an anonymous listener, and it’s about family history of pregnancy complications. “Hi, Dr. Fox. I’m a toaster and love your podcast. Welcome, toasters. My husband and I are planning to start a family soon, and I’m thinking about my family history. My mom’s four pregnancies and births were uneventful and smooth. My aunt, however, had a weak cervix and has two children who were born early, even with the cerclage, and have disabilities. My sister had preeclampsia and gestational diabetes in her pregnancy, and delivered early via emergency C-section when her baby had stopped growing and had other complications. I’m wondering how worried I should be about having complications on my own. Is your experience in pregnancy and delivery closely tied to genetics?” Great question.

So, we’ve definitely addressed this on other podcasts before in different contexts. But the short answer is we don’t exactly know. Meaning, there’s probably some component of family history in terms of people’s risks of pregnancy complications. It makes sense that there’s some genetic component to this. So, for example, the risk of preterm labor, or the risk of preeclampsia, or the risk of gestational diabetes, or maybe the chance of a C-section. And you can sort of map out why that might be from sort of a plausibility standpoint, meaning…for example, let’s say someone’s mother had a bunch of C-sections and thought, well, maybe her pelvis is a little more narrow and her daughter is more likely to have a narrow pelvis because her mother has a narrow pelvis. So, maybe that means she has an increased risk of C-section. Fine. Or maybe something like there is some genetic predisposition to responding to placental hormones such that you get gestational diabetes or preeclampsia. And that’s something that can be passed on to a child. Fine. It all makes sense, and it’s plausible.

The issue is it’s not precise enough that we can really, A, map it out, B, understand what are the genetic causes, and C, give you, like, a percent prediction. Like, it’d be very hard for me to say, well, the baseline risk of a C-section is 20%, but since your mother had four C-sections, your risk is now 50%. Like, it doesn’t work like that. And so, a lot of it is just…it’s like one piece of the puzzle. It’s part of the gestalt. And so, when I’m taking someone’s history, right, so, that involves what medical problems do you have? Have you ever been in the hospital? What surgeries have you had? What medications do you take? You know, going through the gynecologic history. Do you exercise? Do you smoke? You know, all those things that we go through, and we go to family history.

Obviously, we ask about, do you have a family history of cancer? Do you have a family history of diabetes? But I also ask, what were your mother’s pregnancies like? Do you have sisters? Do they have children? What were their pregnancies like? And I sort of use it as part of the puzzle. And it’s different for each person exactly how it’s going to play into their risk profile and what I might do about it.

Probably, for your history, I wouldn’t think you’d be at a very high risk for having something that happened to your aunt or cousins. That seems a little bit more removed. If it didn’t happen to your mother, again, hard to say for sure, but that’d be my guess. But having a sister who had preeclampsia, gestational diabetes, and having an issue with maybe the growth, maybe that is something. And so, does that mean you need to be followed a little more closely than someone else? Maybe. Do we know that for sure? No. Is there a big downside in following you a little bit more closely for things like how the baby’s growing in preeclampsia? Not particularly. And so, you also have to balance. If I’m going to be monitoring more closely, is that with tests that are invasive, expensive, complicated, painful, things like that? Or is it pretty simple stuff that, like, not such a big deal for you to undergo, like an extra ultrasound or something like that?

And so, all of this sort of gets thrown into the hopper. And we come up with a plan that’s individualized based on your own risk factors, what exactly happened to your family and to whom. And different people have different levels of anxiety as well. Some people say, well, I’m not really worried about this, and I really prefer to have less testing. And I’ll be like, all right, since we don’t know that you need it, I’m okay erring on the side a little bit of less testing versus someone who says, listen, I’m really worried about this, and it’s really going to bother me, and I’d rather have more testing. Fine. We can err on that side. Like, these things are not…they’re not black and white, and they shouldn’t be black and white. They really have to be individualized and tailored to each person for their own situation, their own history, and their own concerns.

If you’re not really sure how to address it, I think it’s…this is a really good opportunity for you to maybe have an appointment with your OB or maybe an MFM or something either before you get pregnant or maybe very early in pregnancy to say, “Hey. What do you think about this,” and go over all this and come up with a plan just so you know that there’s something that we’re doing that’s sort of satisfying your concerns and the potential increased risk, if it’s real, for what happened in your family.

It’s possible that with more research and with more understanding of various genetic markers related to pregnancy, related to outcomes, we will be able to map this out a little bit better. Like, for example, maybe we’ll find a gene that increases the risk of preeclampsia and then we’ll be able to find, all right, your mother has it. You don’t have it. Your sister does have it. Something like that, right? But until that happens, we just sort of have to go with our gut.

It’s not much different from sort of the podcast we had, we dropped several weeks or a couple months ago on cancer genetics, right? So, prior to understanding genetics of cancer, we just sort of knew that if there’s a family history of cancer, you know, you have to be screened a little bit more. Exactly how much? It depends on who it happened to, how much, and this or that. We have, like, a sense, but not really as much precision, but with the understanding and the discovery of various cancer genes, that’s getting a little bit more precise. And so, maybe we’ll move that way in pregnancy as well and sort of discover and understand some of the genetics of this a little bit better. But until then, we’re really just going with our gut and sort of a gestalt, I would say, of what someone’s risk is.

All right. Great stuff this week. We’ll see you all next 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 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.