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 number 28: What Does the Fox Say?” First question is from Nona [SP]. “Hi, Dr. Fox. I’ve been listening to the pod since 2022 when I got pregnant with my first child. I’m about to have my second. With my first pregnancy, I developed preeclampsia with mild features during delivery. I did weekly labs to check for preeclampsia starting around week 34 because of protein in my urine. The preeclampsia went away and stayed away postpartum. Now, in my second pregnancy, I was diagnosed with gestational diabetes at 29 weeks. I’m worried because I’ve read that people with gestational diabetes are at higher risk for preeclampsia. What’s the magnitude of that risk? How much have you seen this happen in your own practice? What kinds of contingency plans might be necessary for labor and delivery?”
All right. Nona, if you’ve already delivered by the time I read this, congratulations. Please write back. Let us know how everything went. But in terms of your question… So, yes, having gestational diabetes is associated with an increased risk of preeclampsia. I specifically use the word associated, which means that the two are related, but it’s not entirely clear that A causes B, meaning it’s not entirely clear that gestational diabetes causes you to have preeclampsia. And what’s the difference?
So, the first, when we say things are just associated, there could be overlapping risk factors. For example, women who carry twins are at increased risk for gestational diabetes, and they’re at increased risk for preeclampsia. But the thought is not that A causes B, gestational diabetes A causes preeclampsia B, but rather C, which is having twins, causes A and causes B. Right? Puts you at risk for both. And so, there are definitely risk factors for both preeclampsia and gestational diabetes that overlap. I don’t know what your risk factors are, but things like advanced maternal age is associated with both. Mother’s body weight is associated with both. Family history is associated with both. Twins is associated with both. Right? So, there are certain things that can…and there’s obviously risk factors we don’t understand that would be associated with both.
And so, even though someone has gestational diabetes and they might be at increased risk for preeclampsia, it’s not clear that A causes B. It might to some degree. There’s some data that if you take women with gestational diabetes and you treat them, the risk of preeclampsia goes down a little. So, that would indicate some level of causation, but it’s not entirely worked out.
But either way, for you, what I would say is the fact that you had preeclampsia in your first pregnancy is way more of a risk factor for getting preeclampsia again than is whether you have gestational diabetes or not. Meaning, whether you do or don’t have gestational diabetes in your second pregnancy is almost irrelevant in terms of your risk of getting it again. Right? The risk of getting preeclampsia again when you get in your first pregnancy is somewhere in the range of 20%, 30%, 40%, sort of based on how severe it was, how early was this or that. So, let’s say 25% just for a rough number.
So, your risk of getting preeclampsia is 25% give or take because you had in your first pregnancy. Having gestational diabetes maybe bumps your risk by a couple percent compared to baseline. So, it’s not really the risk factor for you. So, what do you do for someone who’s at increased risk for preeclampsia? Like, we can talk about contingency plans.
Well, there’s different ways to do it. You know, one is to just have your blood pressure checked frequently. Either that means coming to the office and having it done, or what I frequently do is have people pick up a blood pressure cuff and do their blood pressures at home about once a day starting in the third trimester. Because when your blood pressure goes up a little bit, you have mild hypertension. Usually, there’s no symptoms with that. So, you wouldn’t know your blood pressure is high unless you checked it. So, you can either come to the office and we’ll check it or you can check it at home, which is usually more convenient for people, and they can do it more frequently.
The other thing we do in the next pregnancy is we usually put people on baby aspirin. It lowers the risk of getting preeclampsia. I also usually recommend calcium unless women are already getting enough in their diet, which is a thousand milligrams a day. Most people don’t get that in their diet. So, probably they need it anyways. And there’s some data that lowers the risk of preeclampsia. And then you just watch for it. And then you either hopefully don’t get it, in which case, pregnancy proceeds as it would have and you make a decision about when exactly to deliver. Either wait to go into labor on your own or induce labor at some point. Or if you do get preeclampsia, hopefully, it’s diagnosed early and it’s mild, and you can deliver before it gets severe and causes any issues, sort of like what you had for your first pregnancy. Okay. Good question.
Next question from Noemi [SP]. “Do I need a cerclage, or would I say, did I need a cerclage? Hi, Dr. Fox. Firstly, I want to thank you for the amazing information you provide on your podcast. I discovered you initially from Jackie Oshry’s birth story, but I’ve become an avid listener. I have an interesting OB history because I’ve had three healthy pregnancies and babies, and I’m now 19 weeks pregnant with my fourth. Thank God. With my oldest, my water spontaneously broke at 37 weeks, and then I basically had an hour-long contraction and a very stressful car ride, and delivered in triage of the hospital one hour later.” All right.
“When I was pregnant with my second, I was anxious about delivering at home. So, I went in for a cervical check at 37 weeks, and was 6 centimeters dilated, and ended up delivering an hour later. With my last pregnancy, it’s number three, I had some cervical shorting after 30 weeks and had steroid injections, and then was 8 centimeters dilated at a 35-week routine visit, and was sent straight to delivery. My baby was in the NICU for two days, but ultimately came home with me.”
“My doctor this pregnancy, number four, said that I should have a cerclage placed because the painless dilation started occurring earlier with each pregnancy, I guess. And he called that cervical insufficiency. I had the cerclage placed at 14 weeks with no complications. After listening to your previous podcasts, specifically the one with Dr. Rebarber, I have been questioning this. Technically, my cervix has been fine, and even shortening at 32 weeks isn’t really considered cervical insufficiency. Do you think I made the wrong call having the cerclage placed? Do you think it’s likely to help in my scenario? Thank you for the helpful information always.”
All right. Noemi, that is indeed an interesting history, and it is in fact a difficult question to know the answer to. I would say, according to strict textbook definitions, as you said, you do not have cervical insufficiency. You did not have painless dilation in the second trimester. You did not have a lot of preterm births. And so, therefore, you would not be a textbook candidate for a cerclage for what we call a history indicated cerclage, which is just placing it from the outset of pregnancy. Because, again, you had three pregnancies, no cerclages, two of them went full term, and one of them was 35 plus weeks. And had you not gone to the doctor, it’s unclear when you would have actually delivered if it would have been two days later or maybe a week or two later. So, it could have been close to term. So, someone like you with that history would not technically have cervical insufficiency, and you would not normally place a cerclage.
However, it is also highly unusual to have what you had. Right? For your first baby to be born that quickly, to be dilated 6 centimeters at 37 weeks for your second pregnancy, and be dilated 8 centimeters at 35 weeks for your third pregnancy. So, that’s unusual as well. What do you do in that situation? Sort of the phrase we use in medicine all the time is not everybody reads the textbook, meaning you didn’t read the textbook. So, you’re not textbook A and you’re not textbook B. You’re somewhere in between. You don’t have classical cervical insufficiency, but you also…something’s going on. Right? You don’t have something that’s “typical” or normal or whatever it is.
And so, what do you do about it? And there isn’t one perfect answer for that. And it’s ultimately a conversation. You could be more aggressive, so to speak, like your doctor was and saying, listen, there’s something going on with your cervix. I’m worried about this maybe getting worse, and maybe in your next pregnancy, you’re going to be 8 centimeters at 28 weeks, and maybe you’ll deliver much earlier. And I’m worried about that. And let’s do a cerclage. If we do it at 14 weeks, it’s relatively uncomplicated. It is likely to work, and probably you’re not going to be, you know, six, seven, eight centimeters until they take out the cerclage. Fine. That’s a reasonable way to think about it. I don’t know if it’s the best or not the best. There’s really no way to know that for sure, but it’s a reasonable way.
Another way on the sort of opposite end of the spectrum, the least aggressive would be to say, listen, you don’t “have anything wrong with you.” All right. Your cervix is open as you get closer to term. That’s unusual. But at the end of the day, you’re having full-term or close to full-term babies, and they’re healthy. Why are we messing with this? Why are we doing surgery on you? Let’s not do anything. You’re good to go.
There is an option in the middle maybe to do cervical checks in the second trimester, usually a cervical length by ultrasound. And if your cervix gets short in the second trimester, either put you on progesterone or give you a cerclage at that time. That’s sort of in the middle that if there’s an issue, look for issues in the second trimester. If they’re there, place a cerclage. If not, no. Which of the three options is best? There’s no way to know for sure because you would have to take, you know, 400 women just like you and randomly decide, all right, these 200 get a cerclage and these 200 don’t, and see what happens in those groups. And that’s impossible to do because every situation is unique. Every person is unique. How are you going to find 400 people just like you? It’s really not a study that can be done.
So, it’s one of these things where it’s a conversation about the various options from, you know, least aggressive to most aggressive, and somewhere in between, and coming up with a plan that you’re comfortable with, your doctor’s comfortable with and going from there. Again, I don’t think it’s unreasonable that they placed a cerclage. I’m not sure if that’s what I would have recommended. I’m usually more in the middle, the sort of the middle option, baby bear, so to speak. And that’s probably what I would have done, but I don’t…I’m not at all disparaging the decision that was made. It could have been the right thing for you. There’s really no way to know for sure what would have happened. If you didn’t get the cerclage, what would have happened with this pregnancy? Ultimately, if everything goes fine and you deliver full-term, at worst, you didn’t need it. And at best, it helped you deliver a full-term baby.
Okay. Next question is from Hava [SP]. “Hi, Dr. Fox. As a birth nerd and mom of three and pregnant, I love your show. Thank you so much for everything you do to keep women informed. I’m currently pregnant and living in Israel. At my first anatomy scan at 16 weeks, the doctor found a cystic mass in the baby’s abdomen. We’re having a follow-up at the end of the month to try and determine the type of cyst that it is. For now, all we know is that it is 2 centimeters by 1.5 centimeter by 1 centimeter. It’s not an ovarian cyst, and all the other organs look normal at the time of the scan. I’m having a little bit of trouble understanding exactly what is going on since there isn’t that much information available via Dr. Google.” I’m shameful that Dr. Google can answer this. “How often do you see these kinds of cysts in your practice, and what do you usually counsel your patients? Thanks so much.”
So, in terms of how often do we see this, I would say, from time to time. Right? It’s not that common to see a cyst in the fetal abdomen, but it’s not crazy. Like, we do see them. And for our listeners, a cyst is basically a fluid-filled structure, like a little circle of fluid inside the baby’s belly. So, we do see them from time to time. The first thing we do think of, like you said, is an ovarian cyst. I’m guessing that, since you wrote in capital letters, not an ovarian cyst, I can guess that you’re having a boy. So, there’s no ovaries on there. I don’t know that, but that’s usually the only way we know for sure it’s not an ovarian cyst because you can’t usually see the fetal ovaries on ultrasound because they’re so small. You usually will just see if there’s a cyst in the ovary. Okay.
So, one of the things that could be is an ovarian cyst. It really could be, in theory, anything. You can have cysts that come off the kidneys, cysts that come off the ureters, cysts that come off the bladder, cysts that come off the intestines, cysts that just sit in the belly, what’s called the mesenteric cyst. And the way I counsel people is we try to find out what it is, either by ultrasound, sometimes an MRI. But ultimately, what’s more important is not so much what it is, but whether it’s affecting the baby otherwise. So, small cysts that are not growing tend not to impact the pregnancy, not to impact the baby, not to impact the baby’s health, and then can be dealt with after delivery either by doing nothing or occasionally getting removed surgically. Whereas, if there’s a cyst that’s getting bigger and bigger over the course of pregnancy, that’s obviously a bigger issue, and may need to be addressed. Sometimes they can even be drained. It’s very unusual. Typically, the cysts, they do not get bigger and bigger.
But what I would say is we’ll try to figure out what it is. Typically, it’s not something to worry about. Most of them are benign. Most of them are fine. Most of these babies are perfectly fine. And the key is to just watch serially over the course of pregnancy on the size of the cyst and the location of the cyst, and whether it’s impacting any other organs. And typically, small cysts that are not getting bigger will not impact anything. If the cyst is getting bigger and bigger, to make sure it’s not impacting the baby in any other way and then go from there. And then, usually, it’s dealt with after birth.
Okay. Next question is from Leia [SP]. “Hi, Dr. Fox. Absolutely love your podcast. I’m hoping that you can include this on your next “Mailbag” podcast. Well, Leia, here you go. I have some questions about pelvic floor prolapse, specifically bladder prolapse. I recently delivered my third baby, and at my six-week checkup was diagnosed with in between grade one and grade two bladder prolapse. I’ve been working with a pelvic floor PT, and my pain is starting to improve. But she mentioned that, anatomically, things will not go back to how they were previously. My question is mainly for the possibility of future pregnancies. If I were to attempt to get pregnant again, would I be able to deliver vaginally without making the prolapse worse? Would a C-section help prevent any further damage, or is another pregnancy regardless of type of delivery risky and increasing the grade of prolapse? Is there anything else that would be important for someone struggling with prolapse to understand or ask their pelvic PT about?”
Leia, great question. Very common issue. Many women after pregnancy or after delivery, particularly vaginal deliveries, can have some form of pelvic floor prolapse, whether that’s the bladder, whether that’s the rectum. I mean, there’s all these different sort of types and grades of prolapse, but it is definitely more common if you have babies, and it’s more common if you deliver them vaginally. And so, there’s a lot that goes into what to do. Right? So, obviously, if you have it, you want to try to make your symptoms better. You want to try to treat it, and you’re doing the right thing, pelvic floor PT, and there’s all these things to do.
The ultimate treatment for pelvic floor prolapse, if it does not improve with pelvic floor physical therapy, is surgery. Right? And so, whether someone needs surgery for it or not is based on how bad it is, how much it bothers them. Right? For some people, the prolapse bothers them terribly, and for other people, it doesn’t bother them at all. If it doesn’t bother you, it’s not dangerous. And so, you don’t need surgery for it. But if it bothers you, then yeah, people have surgery for it. And so, that’s sort of an individualized decision about who needs surgery.
The issue is, if you’re going to have surgery ever, typically, you’re going to wait until you’re done having children because if you have surgery and then you have another child, particularly if you deliver vaginally, it may sort of reverse whatever you fixed with surgery. You may have to have surgery again. So, typically, people…again, unless there’s extreme situations…I’m not a urogynecologist. I don’t do these surgeries. But typically, women who are going to have surgery for this wait until they’re done having children. So, okay. So, you’re sort of between point A and point B. Point A is you have children, you have some amount of bladder prolapse. And point B is when you are done having children and you may or may not need/want surgery. And so, what do you do in between?
And so, it is not an easy answer because, yes, getting pregnant alone could make it a little bit worse, and having a vaginal delivery could make it a little bit worse. And so, there’s a lot of ways to think about that. For some people, they’re like, listen, if I am exactly how I am right now, I don’t need surgery. But if I get pregnant again and I deliver vaginally, I may get to the point that I do need surgery. So, either I don’t want to get pregnant again, or if I get pregnant again, I want to have a C-section to not make it worse. But then you’re sort of having surgery, C-section, to prevent surgery, which isn’t exactly logical. Although, again, it’s not wrong. It’s sort of your…you have to sort of play this out. Whereas, others would say, all right, I definitely don’t want to stop having kids. I want to have more kids. So, I’m going to get pregnant. I’m going to deliver them. I hope that the bladder doesn’t get worse. But either way, when I’m done having kids, I’m going to have surgery.
And so, there isn’t…there’s a lot of ways to navigate this. And it’s based on exactly how bad it is, whether you think you’re going to end up having or needing surgery afterwards. You know, how many more kids do you want to have, for example? And then with those pregnancies, you know, how much does a C-section bother me versus, you know, the recovery from a vaginal delivery? And you have to sort of put all of that into a blender and come up with an individualized plan for you that works for you in your circumstance.
And so, what I’d say is there isn’t one way to do this. For some people, it’s I’m not having more kids. For other people, it’s I’m having more kids, but I’m having a C-section. For other people, it’s I’m having kids, I’m delivering them vaginally, and then when it’s all said and done, I’ll have surgery if I need to have surgery, and just have that. And all of those are reasonable. It’s just an issue of which works best for you, your plans for your family, your bladder, your feelings about surgery, you know, and all that.
I think it might be valuable, if you’re not quite sure, to speak first to your OBGYN, not just the pelvic floor PT, but second, maybe get a consultation with a urogynecologist, who is basically a gynecologist who does extra training on things exactly like this, who can give you a sense of what they think you have, whether it’s going to get worse or not, what kind of surgery they think might be needed down the road. So, you can see, is that…do I view that as, like, a really big surgery or not such a big surgery? And sort of start having those conversations to figure out what is the best plan for you.
I will tell you that the situation you’re in is very common. Many, many, many, many, many women have this, and think about this, and have to come up with a plan for this. And so, you’re definitely not alone. And this is something that you spoke to your OBGYN or your gynecologist. This is a conversation they would be able to have readily because they probably have it all the time. All right. Great, great question. Great topic.
Next question is from Molly [SP]. “Hi, Dr. Fox. I recently read that there is a greater use of instruments, forceps or vacuum, in delivery with an epidural. I’m curious if this has been true in your experience or research. My son was delivered with a vacuum, and I did in fact receive an epidural. Pregnant with my second and weighing my options. Thanks so much.”
Okay. So, Molly, great question. In terms of my experience, well, it’s a little bit tough because where I practice and deliver — and this has been true for my whole career — more than 90% of women in labor are getting epidurals. And so, it’s hard to sort of know, like, to tease out, is it more likely to have forceps or vacuum with an epidural versus not when the vast majority of the people I’m delivering have epidurals? And so, in my experience, not really a difference.
I will say, it is difficult to do forceps on someone without an epidural because it could be quite painful. A vacuum is a little bit easier. I personally am a fan of forceps over vacuum. But if I had someone without an epidural, I would be personally more hesitant to do forceps or vacuum because I’d be worried about the pain, right, because it’d be more painful. Now, if they absolutely needed it, right, the heart rate’s dropping, the baby’s…I’m going to have to deliver the baby, obviously, we’ll figure it out. We’ll do what we need to do and try to do it as painless as possible. But, you know, it’s not really going to be a great comparison in my practice.
Now, there are data out there, a lot of data, that one of the consequences of having an epidural is an increased use of forceps and vacuum. So, in some countries where, let’s say, women…fewer women have epidurals, or maybe when the studies were done, fewer women have epidurals, it was noted that getting an epidural did increase the risk of forceps or vacuum. And the question is, why? And so, one of it could be something related to the epidural’s effect on labor or on pushing or on physiology that maybe women with an epidural, their labor doesn’t progress as well, or they’re not able to push as effectively, and therefore, there’s a consequence that they’re more likely to have forceps or vacuum.
I would say, it’s obviously possible, though the data on labor has really been debunked. Meaning, if you have an epidural, the labor is not really different. I think there are some women who, with pushing, it’s a little bit harder for them with an epidural. But nowadays, I think that everyone recognizes that maybe it’ll take a few more minutes for sort of them to “get the hang” of pushing because they don’t have all the sensation feedback as someone without an epidural. But once someone sort of gets the hang of pushing and knows what they’re doing, the pushing is actually very similar with or without an epidural. So, maybe that’s a part of it, but not much.
I think probably my guess is that with the older studies when they did it, probably once the women got an epidural, the…these studies were mostly done, like, in the UK. They weren’t really done in the U.S. When the women got an epidural, it was probably just easier for the doctors or midwives to say, hey, you’re so comfortable. I can just do this and do forceps or vacuum. And so, that’s probably the reason that there was an increased rate, that it was just easier to do those operative deliveries because the woman wasn’t in so much pain. And so, they sort of said, oh, like, I’m more likely to do it because it’s…there’s less stopping me from doing it. I’m not saying it in a nefarious way. I’m just saying, like, it was…like, became one of the options available to them much more readily when someone had an epidural than before. And that’s my best guess.
Nowadays, I don’t think it’s as relevant just in terms of how people are trained now. People aren’t really doing forceps or vacuum unless there’s really a reason to do it. And that would be the case whether you do or don’t have an epidural. I would say, without an epidural, forceps are going to be more painful as compared to a vacuum. So, maybe that’s a difference. But I think it’s probably not so much a difference now. And that’s more of a thing of the past. And so, you’ll see it in the studies, but I would say those studies are generally older, and probably not as relevant for today.
All right. Thank you all for sending in questions, and we’ll see you all next week.
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