“Mailbag 29: 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 am 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 our “Mailbag Podcast number 29, What Does the Fox Say?” Our first listener, Megan [SP], sent in two questions. “Hi, Dr. Fox. Avid ‘Healthful Woman’ listener since learning about your podcast on ‘The Toast.’ Thank you for giving women such an amazing resource for pregnancy and women’s health. I found the preconception, morning sickness, and dos and don’ts episodes to be extremely helpful for me and my friends. I’m 12 weeks pregnant with my first, and I’m so grateful I learned about Diclegis and Unisom from your podcast, as I don’t think that would have been brought to me as an option. I didn’t see my OB until nine weeks, and they wouldn’t help me virtually as I was a new patient to their practice.” Oi, sorry to hear that.

“Anyways, I have two questions for you that relate to dos and don’ts in pregnancy. One, alcohol. I can see myself enjoying a glass of wine every once in a while, maybe in my second or third trimester, not feeling excited about it as I’m still feeling a little nausea in the evenings. I’m already anticipating extreme concern/pushback from people in my life, specifically my mom. When I Google ‘moderate alcohol use in pregnancy,’ only very scary warnings come up, warning against any use at all. I did listen to the episode you did with Emily about this, and trust your alignment on moderate use. My question is, where are these studies published? Are they available to us to see and read?”

All right. I will answer that, then I will go to Megan’s second question. So, in general, in terms of alcohol use in pregnancy, the issue is this. We know that high amounts of alcohol in pregnancy are absolutely not safe for the developing baby. And that’s really at any point in pregnancy, as far as we know. It’s not just a first trimester phenomenon. And so, it’s discouraged to have any alcohol in pregnancy.

Now, the question is, okay, is there a threshold? Meaning, how much alcohol causes these problems? Is there, like, a line where if you’re below that line, it’s perfectly fine, and above that line, you have risk? Or is it something where, like, one drop of alcohol will cause, like, one point on the IQ to be lower, that type of thing. And it’s very hard to know that definitively, but definitely, there are studies that have looked at moderate or low use of alcohol in pregnancy and looked at outcomes.

And each study defined it a little bit differently, but let’s say it’s about a drink a day, plus, minus. And that amount, I think a lot of people think in pregnancy would actually be a lot, but that’s sort of their threshold that sort of that or less they considered sort of moderate or low use, and above that as high use. And in those studies, when they looked at the outcomes of the children of women who drank that sort of lower amount of alcohol, they could not find any adverse effects on the children. And there’s pretty long-term follow-up on this.

And so, the best data that we have would suggest that if you do have a glass of wine here and there, it’s not dangerous. So, the issue is, okay, if that’s the best data that we have, why is there this rule that you shouldn’t have any alcohol in pregnancy? And as I said in other podcasts before, I think the reason that, you know, rule exists or that sort of recommendation exists is not because it’s known that small amounts of alcohol are dangerous. It’s because there isn’t a known benefit to having small amounts of alcohol during pregnancy.

And so, the thought is, okay, here we have something where we know that a lot of it is not good. We think that a little of it is not particularly dangerous, but it’s hard to know that 1,000%, right? It’s hard to prove, prove, prove it, but it doesn’t seem that way. So, it’s just easier to say, don’t have any alcohol at all rather than saying, yeah, it’s perfectly fine to have a couple of drinks here and there.

And I can see both sides of the coin. I can see the argument that, you know what, it’s just better to abstain completely from alcohol. And I can also see the argument that, listen, there’s no evidence that small amounts of alcohol are actually dangerous. So, why are we telling women this? And so, the way I counsel women about this when they ask me is they say, listen, the party line is no alcohol at all. And probably that’s, you know, as a strategy, the best way to go. But if someone were to have small amounts of alcohol, low amounts of drink here and there, like, the sort of amounts you’re talking about, as far as we know, it’s not dangerous to the baby, and people shouldn’t be worried that it’s going to be very dangerous to the baby.

And so, that’s sort of how I counsel them, trying to balance both sides of that argument between not having any alcohol whatsoever with trying to use the data which suggests that low amounts of alcohol are not dangerous at all.

In terms of your specific question about where are these studies, how do we find them, so, there’s a lot out there. I would say, the easiest way, in my opinion, to access them, if you go to my practice website, not the podcast website, but the practice website, which is www.mfmnyc.com, and you go along the top, there’s a tab that says resources. And in the resources, there’s a link to something called dos and don’ts in pregnancy, which is a link to an article that I wrote that’s published in what we call “The Green Journal,” which is “Obstetrics & Gynecology,” the main journal in the U.S. for OBGYNs. And there, there’s a section on a lot of things, but in my section on alcohol, which pretty much says what I’m saying now, plus, minus, there are references, and you can go…the references are listed in the back of the article. So, like, reference 11, reference 12, whatever the numbers there are, you could see in the back exactly where they are, and then you can try to go directly to the source to look at the studies themselves to see if that’s helpful.

I will say that you are correct that this is definitely a topic about which people have very strong opinions and people can be judgmental, maybe in a bad way, maybe in a good way, however you look at it. I got feedback from…I believe it was a listener. Although I guess it could have been someone who didn’t listen to the podcast, but maybe it was a patient in my practice. I don’t really know. But the feedback I got was a letter that came to my office, basically scolding me for any position about alcohol and pregnancy that was not very sternly against it. And so, they were very, very upset that I was saying what I’m saying right now, which is what the data shows and trying to sort of balance all these things. They did not like that.

I haven’t got a lot of negative feedback. I think that most people do appreciate understanding sort of where these recommendations come from, what the data shows, and so people can make some decisions for themselves, understanding sort of the background. But I get it. This is definitely a hot topic for a lot of people.

Okay. Megan’s second question, number two. “Immune system and pregnancy. Do pregnant women have a suppressed immune system? If so, how suppressed? One thing I’ve seen a lot online is that because pregnant women have a suppressed immune system, they’re more likely to get food poisoning from things like deli meat. Is there any truth to that? If it’s not already clear, I’m more relaxed and trusting, but others in my life are more skeptical, and me telling them I heard it was okay on a podcast isn’t going to sound too good. Thank you so much in advance.”

Okay. So, in terms of the second question, immune system, the short answer is yes. The immune system is diminished or lowered during pregnancy. Why does that happen? We think it happens because it’s a natural protection against a pregnant woman’s body from attacking the pregnancy. Right? So, if you think about it, a pregnancy is typically, not always, but typically 50% genetically the mother and 50% genetically other, right, the father. And so, in that situation, if you normally would put, like, an organ inside someone’s body, like a kidney or a liver, that was not a good genetic match for them, it was only 50% genetic match and 50% not, the body would go bananas and reject it. And you’d get very sick, and it would sort of kill off that organ. Fine. So, why does that not happen in every pregnancy? Why do pregnant women not attack the placenta and the baby?

And so, there’s a lot of complicated mechanisms that are put in place so that doesn’t happen. One is sort of like separating by the placenta, and another one is that the mother’s immune system is modulated during pregnancy and typically diminished. So, that’s one of the mechanisms to prevent that from happening. Okay. So, that’s a good thing.

Another positive to that happening, which is not part of your question, but just sort of as aside for women who come into pregnancy with autoimmune conditions, which are medical conditions where your body sort of incorrectly attacks itself, those frequently get better during pregnancy because the immune system is lowered. Think of, like, a volume button, it goes down. But the downside to having a decreased immune system is an increased risk of things like infections.

And so, that’s why, for example, we’re pretty vigilant about recommending a flu vaccine in pregnancy because, all right, for people who get the flu, it’s generally pretty miserable. But if you’re pregnant and you get the flu, it could be pretty dangerous because your immune system is diminished. That was sort of similar why initially with the COVID vaccine, pregnant women were sort of on the high risk group because the thought is their immune system is diminished, and therefore they’re at a higher risk of getting sick from infections. All true.

In terms of deli meat, it’s not deli meat. It’s that there’s this bug that has been in deli meat in the past called listeria. And yes, it is possible that pregnant women who ingest listeria are more likely to get infected with it, get sick with it compared to someone who’s non-pregnant. Whether that specifically means you have to avoid deli meat is debatable because listeria is not commonly in deli meat. It hasn’t been in a long time.

Listeria is something that can…and we’ve had a podcast on listeria or questions about listeria in the past. It’s something that can be found in many things from time to time. So, it’s been in lettuce, it’s been in cantaloupe, it has been in deli meat. It’s in unpasteurized dairy products. It has been in hummus, it’s been in ice cream, it’s been in a lot of things. And so, if there’s a breakout of listeria, you avoid that because, yes, when you’re pregnant, you have a higher risk of getting listeria, which could be dangerous for the mother and dangerous for the baby.

Sort of the one on the list that people always avoid is unpasteurized dairy products because that’s, like, the highest risk of getting listeria. But all those other ones, usually it’s based on what is sort of a local breakout, whether it’s happening or not happening. Deli meat is something that some people always recommend against always and others just if there’s an outbreak, and that’s sort of where people…it’s debatable what to do with deli meat. But the other things typically people eat unless there’s a breakout, and then the unpasteurized dairy, people typically do not eat when they’re pregnant.

All right. Thanks, Megan, for both questions.

Our next question is from Abigail [SP]. “Hi, Dr. Fox. Thank you for all you do, and for the super informative podcast.” Thank you, Abigail. “In my first pregnancy, I gave birth to twins after naturally going into labor at 34 weeks. And in my second pregnancy, I gave birth at 40 weeks, but it was a super fast birth. And I almost didn’t make it to the hospital. I was living across the street! I’m now in my third pregnancy, and I now live more than 25 minutes from the nearest hospital. And I’m worried I might not make it in time. I’m wondering if there’s some sort of consistency between pregnancy as to how fast labor goes, or if you have any recommendations, how to identify labor to get going to the hospital before it’s too late.”

Great question. So, Abigail, it’s not entirely predictable, but usually if someone has a fast labor, they’re going to have fast labors. Now, not always. Sometimes we’ll see a situation like yours, where the second labor was very, very fast, and then the third is not as fast. So, obviously, it’s not entirely the case, but I certainly agree that you should be on high alert that you’re going to have another fast labor. Why wouldn’t it be fast the next time? We don’t quite understand. Maybe it’s related to the size of the baby. Maybe it’s related to the uterus, how far pregnant you are, this or that. So, we’re not…you know, it’s not entirely clear, but it can go in either direction. But in general, someone has a fast labor, we sort of, like, mark that as this person had a fast labor.

So, what do you do about it? There isn’t a perfect answer for what to do about it. Living 20 minutes from the…25 minutes from the hospital is not that far. I mean, obviously, last time you lived across the street. In general, there’s a few possible strategies for what to do.

The first is, when you get to about 39 weeks, to just go in and get induced so that there’s no chance of you delivering outside of the hospital. Right? So, that’s an option for people. It’s a recognized indication for induction of labor. It’s appropriate, it’s proper. A lot of people do it for that reason. It’s going to work if you’re going to deliver at 39 weeks or later. If you were going to go into labor prior to 39 weeks, not going to work. But last time you went into labor at 40 weeks. So, maybe that’s an option for you, reduces the stress. Some people, they’re worried about literally delivering outside the hospital. Others, it’s, well, I’m pretty sure I’ll get to the hospital, but I’m worried that I’ll be so far along I won’t be able to get an epidural. I mean, there won’t be enough time for that and I don’t want to have that painful birth. And so, for either of those, that’s one strategy.

The other strategy is just sort of being hypervigilant. You know, the first contraction or the second contraction, whatever it is, or any chance your water’s broken, just, like, start heading to the hospital, call on the way. And if you have a couple of false scares, so be it. But that’s sort of another one.

The third, which is probably the least helpful, is to have someone check your cervix and try to give you a sense of what’s going to happen. But the problem is, so, let’s say you’re 37.5 weeks and we check your cervix, and it’s closed. Does that mean you’re not going to go into labor in the next week? No. Or if you’re 2 centimeters dilated or 3 centimeters dilated, like, what are you going to do about that? You’re not in labor. So, unless you’re, like, literally 6 or 7 or 8 centimeters dilated without feeling it, which happens, but it’s pretty unusual, the strategy of having your cervix checked is not likely going to do a lot more as compared to the first two strategies.

So, I would stick with the first two, which is, number one, you know, if you’re really worried about it, go into 39 weeks to be induced. And number two, either after 39 weeks, if you didn’t do that strategy or before 39 weeks, if you are planning that strategy, literally just be hypervigilant, have your bags packed. You know, don’t ever be alone with your kids where you can’t just, like, you know, run out, anything like that. Have a go plan, as I say, or a jump plan at all times for how am I going to just, like, pick up and go to the hospital immediately if I have any symptoms. Sure, you may get a false scare and end up getting sent home, but better than the alternative if you’re concerned about delivering outside of the hospital.

Next question is from Jamie [SP]. “Thank you for your informative podcast. Luckily, I happened to listen to your operative delivery episode before my recent birth. So, I was informed and confident when my OB suggested vacuum delivery. And I truly believe it helped me to avoid a C-section.” Jamie, thank you for that feedback. This is literally why we do it. I really appreciate that. So awesome.

Okay. Jamie’s question. “My placenta was sent out to pathology, and the results revealed a marginal cord insertion and high-grade fetal vascular malperfusion. It was also over the 90th percentile in size. I was tracked very closely during pregnancy, including 10 ultrasounds, and this was never detected. Luckily, I had a routine pregnancy, and no comorbid conditions, and my baby had no adverse outcomes. How common is it for this condition to go undiagnosed prior to birth? Was this more likely a problem on the fetal side or the maternal side? And is it likely to recur in future pregnancies? Do you think the size of the placenta made up for the poor perfusion?”

All right. So, Jamie, great question. In terms of… You’re referring to a condition, right, when you said, how common is it for this condition to go undiagnosed? So, I would take a step back and say that findings on placenta pathology, I wouldn’t necessarily refer to as a condition. And the reason is that, when we send the placentas to pathology…so, what does that mean? So, baby’s born, placenta comes out, and then we see this placenta. It looks like a big jellyfish. We have it sitting in a bucket. And then we have two decisions or one decision about what to do with it. Right? Unless someone’s taking it home and encapsulating it and doing all that stuff.

Okay. So, let’s assume we’re…at the hospital, we’re keeping the placenta. We have two options. One is basically goes to medical waste. They whatever, burn it, dispose of it, however they dispose of placentas, or the other option is we sent it to a pathologist. So, the pathologist is a physician whose job is pathology. They look at many different things, like biopsies, they look at organs, sometimes they do autopsies, but there are people, and what they do is they take the placenta, and they sort of slice it up, and put it on slides, and look at it under the microscope, and do all these things, and give us all these diagnoses.

And so, the question is, is that useful? Is that a useful thing to do? So, when people have organs removed from their bodies or biopsies done, the reason they’re doing that is…and sending it to pathology, is to determine what’s going on. Like, is this cancer, pre-cancer, no cancer? Or is this condition, condition A, condition B, condition C, things like that? So, with the placenta, it’s…we’re not looking for cancer, but it’s conceptually the same thing like, are there findings of the placenta that can, A, maybe explain complications that occur during pregnancy or, B, predict future pregnancy complications?

And what I would say is, in general, the science around placental pathology is confusing. And it’s confusing for many reasons. Number one, there are people who do it a lot, and are considered experts in it. And then there’s a lot of people who do it and don’t do it a lot, and do not have the same expertise in teasing out certain things. So, number one, sort of the quality of the report you get back, I would say, varies much more widely for placentas than maybe it does for other organs or other, you know, biopsies or whatnot.

Number two, frequently, if we send placentas to pathology, we’ll find things that, really, were not evident in the pregnancy, that did not manifest in the pregnancy. So, for example, for you, you had a healthy pregnancy, healthy baby, and the placenta says there was this high-grade fetal vascular malperfusion, meaning that something in the blood vessels was not perfusing the placenta properly. But as you said, the placenta was big. So, that doesn’t make a ton of sense. And number two, the baby was fine, the pregnancy was fine. So, what does that mean? And sort of how do you reconcile that, a finding on the placenta that sounds bad, but everything was perfectly fine? Is there even a problem?

And so, we really don’t know what to do with that. That’s sort of the issue. Like, does that mean you have a problem or don’t have a problem? It’s very, very complicated, and there aren’t good sort of evidence-based guidelines of what to do in that situation. There are some placental findings that are extremely profound and rare, fine. But in terms of things like that, it’s really hard to know what to do with that.

Sometimes, for example, you’ll have the opposite situation. You’ll have pregnancy, really complicated. The mother has high blood pressure, the baby has growth restriction, there’s an abruption, there’s all these things going on, and the placenta pathology comes back perfectly normal, no issues whatsoever. You’re like, well, there was clearly a problem. Like, something was going on. But the placenta didn’t show it.

And so, it’s not as sort of linear, like problem to problem to placenta. Right? So, a problem to placenta. They’re not linked as well. And so, there’s a lot of variation in when people even send the placenta to pathology to get examined. And it really…some hospitals will have, like, protocols about we’re going to do it for this condition and this condition, and we’re not going to do it for this and this. Some doctors decide themselves, some people send it all the time, some people send it none of the time, and there’s sort of everything in between.

And so, what I would say for you is that the findings that they had, a marginal cord insertion is pretty common, doesn’t usually mean much of anything. Just means the cord didn’t plunk into the middle of placenta, but it was more towards the edge, usually not a big deal. The high-grade fetal vascular malperfusion can be an issue if there was things like growth restriction, preeclampsia, other issues, small placenta. But in the setting of a large placenta in a normal baby, probably does not mean much of anything, and probably does not indicate anything for future pregnancies. And in terms of the topic in general, we’re still learning a lot about placental pathology, when it’s useful, what it can predict, and what it can’t predict.

I wish I had more for you, but that’s sort of where we are currently with placental pathology, at least in clinical practice. There are a lot of people do this, a lot who know a lot about placental pathology, but in terms of how to apply it to clinical practice, there’s still a lot that we are learning.

Next question is from Anita [SP]. “Hi, Dr. Fox. I’m a huge fan of your podcast, and often send specific episodes to friends as we navigate pregnancy and motherhood. I love that you have no ads. Thank you.” All right. Anita, thank you for that. For the record, we are okay having ads. If someone wants to sponsor the podcast, we are happy to take ads to help defray some of the costs. I think we’re actually going to have a sponsor either soon after this podcast drops or already by the time this podcast drops. So, if we have ads and you dislike them, I apologize, but we’ll try to keep them light and not too obtrusive or anything like that.

All right. “My question is,” Anita’s question is, “Is it always necessary to go to the doctor/hospital if you bleed in your first trimester? Backstory. For my first pregnancy, I had a cramp, and bled on Super Bowl Sunday.” Ooh, now, I’m curious which Super Bowl. “When I was about five weeks pregnant. Since it was Sunday, my OB sent me to the ER.” I was thinking since it was Super Bowl Sunday, the OB is like, nope, I am not available today. All right. “Since it was Sunday, my OB sent me to the ER, and I spent the whole day there. The result was a ‘threatened miscarriage’ and a $12,000 bill. That pregnancy was otherwise uneventful, and I birthed my daughter.”

“In my second pregnancy, I had bad cramping and some blood on a Tuesday night, and my doctor didn’t have openings on a Wednesday, and has a closed office Thursday and Friday. So, again, I spent the entire day in the ER and left with a diagnosis of ‘subchorionic hematoma,’ and again, a $12,000 bill. Again, normal pregnancy and healthy boy. Listening to your podcasts, I know that both bleeding and subchorionic hematomas are common and overall uneventful. So, I’m wondering, the third time around, if I bleed, can I say I don’t want to go to the ER? God forbid it’s a miscarriage. What’s the rush anyways?”

All right. Anita, great question. First is, maybe we got to change your healthcare plan so you don’t get $12,000 bills when you go to the emergency room. So, hopefully, we can do that for you because that’s quite a hefty bill to pay for going to the emergency room. All right. So, that notwithstanding, really, really interesting question.

So, first trimester bleeding in general is not a medical emergency. Meaning, the life and health of the mother is typically not threatened when there’s first trimester bleeding. And usually, for the pregnancy, while it might indicate an impending miscarriage, it often does not. And whether it does or does not, there’s usually little that we as doctors can do about it. There are exceptions to that. Meaning, there are people who can have hemorrhage during the first trimester, in which case, it can be a medical emergency. Probably pretty uncommon that we have an opportunity to intervene, but maybe sometimes.

And so, ultimately, from a medical perspective, you are correct. If someone has first trimester bleeding, often they do not need to be evaluated quickly. One of the exceptions is that you don’t yet know what’s going on with the pregnancy. So, for example, if someone has first trimester bleeding and they have never been seen in the office yet, I don’t know that they don’t have an ectopic pregnancy, which that can be an emergency for the mother. But if we already know there’s no ectopic pregnancy, meaning someone’s been to my office, had an ultrasound, we know there’s a pregnancy, we know it’s inside the uterus, whether we’ve seen a heartbeat or not seen a heartbeat yet, if they subsequently have bleeding, I know it’s not an ectopic pregnancy. But if they’ve never been seen in my office and all they have is a positive pregnancy test at home and now they’re bleeding, the concern is that they might have an ectopic pregnancy.

So, that is one reason why people might get sent to an emergency room on a Sunday if they’re having bleeding early in pregnancies because the doctor’s like, listen, I don’t know if you have an ectopic pregnancy, and that’s really something you don’t want to just sit on. And so, I need you to get evaluated. That’s one reason.

Now, what if we already know the pregnancy is inside the uterus, then what do you do? Meaning, it’s not an ectopic pregnancy. So, if we know the pregnancy is inside the uterus, it’s generally not a situation where it’s a medical emergency to go to the emergency room, but sometimes people are just really worried understandably. They’re like, I want to know, is this pregnancy still viable? Is it not? Is there a heartbeat? Is there not? Am I miscarrying? Am I not? It’s very anxiety-provoking, understandably, to have bleeding in the first trimester.

And so, what to do in the setting of first trimester bleeding logistically? Like, do I need to go to the emergency room? Do I need to go to the doctor immediately? Can I wait a few days? Depends on several factors. So, if someone’s calling me with first trimester bleeding, one of the first things I want to know is, do we know already that this is a pregnancy inside the uterus? If the answer is, no, I don’t know if the pregnancy is inside the uterus, it could be an ectopic pregnancy, I will want to see them in the very near future. Whether that means going to an emergency room or coming to my office the same day or the next day, again, depends on other symptoms, risk factors, this and this and this. But they should be seen relatively soon because there’s a possibility of an ectopic pregnancy, and that’s something you don’t want to sit on.

If I already know that there’s a pregnancy inside the uterus, and now there’s bleeding, well, again, it sort of depends on the anxiety level of the mother. And so, I’ll say to her…you know, let’s say I get this call on a Sunday morning. Generally, if I know the pregnancy is inside the uterus and she’s not bleeding heavily, I’ll generally give her the option to go in the emergency room, but usually encourage her to wait until the next day to see us in the office because it usually takes less time. Usually, you don’t get a $12,000 bill like you got. Maybe it’s a little bit easier, but sometimes it’s just too much anxiety or stress, or sometimes she’s not able to come into the office for several days. Maybe she’s going out of town. Maybe she is out of town, all these things. And so, it really has to be case by case.

But generally, if someone had bleeding where they’re not hemorrhaging, we know it’s not an ectopic pregnancy, you are correct. There’s nothing medically, typically, that we would need to do immediately. So, it’s sort of case by case. You know, when can she come in? How soon can we see her? How anxious is she? What else is going on? Also, if we don’t yet know her blood type, we need to get that within a couple of days to figure out that she needs something called a RhoGAM or not. And so, again, a lot of it depends how much we already know versus this is a brand new pregnancy.

So, for you, you’ve already had children, your blood type, I assume, is already known. If you already know that the pregnancy is inside the uterus and you have bleeding, probably you don’t need to go to an emergency room unless it’s really, really heavy. But some of that will depend on how soon the doctor can see you in the office and how much concern you have at the time.

All right. Thank you for that question. Thank you, everyone, for your questions. We’ll see you next week.

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