Mailbag 32: “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 32nd “Mailbag” podcast, “What Does the Fox Say?” Our first question is from Sarah [SP]. “Thank you for your fantastic and informative podcast. I always learn so much.” Thanks, Sarah. “I’m currently 22 weeks pregnant and recently had my anatomy scan. Thankfully, most of the results came back clear. However, my doctor noted two specific findings that I hope you can provide some additional context on, as I’m feeling quite anxious. First, my baby’s growth is in the seventh percentile. My doctor mentioned this would require frequent monitoring to measure the growth. After doing some research online, I am naturally quite worried about this finding. Second, one of my baby’s kidneys has mild pyelectasis. While my doctor said he would monitor it, and assured me I shouldn’t worry, my anxious nature is making it difficult to feel at ease. This is not my first pregnancy, and I did not have these issues with my other children. Do you have any additional information regarding these conditions, and is this something I should be concerned about? Thank you for your time and expertise.”

Okay. Thank you, Sarah, for the question. Based on the time you sent this in and the time I’m recording this, probably you already had all the testing, and probably you already had your baby, and I hope all is well. In terms of your question, so, two separate issues. There’s a chance they’re related, though likely not. The first is in terms of the baby’s size. So, we definitely have had podcasts on fetal growth restriction, and it’s come up in a bunch of other podcasts. But essentially, when the baby’s measuring a little bit smaller than one would expect…right? So, you know, if you’re using percentiles, usually, we’ll say that it’s between 10 and 90, it’s normal, under 10 is on the small side, over 90 is on the big side.

I will put a caveat there that, in the second trimester, like at 22 weeks, the percentiles can be a little wonky. Meaning, you could have a baby that’s in the seventh percentile like yours, but you could be 22 weeks, and the baby could be measuring 21 weeks and 5 days, which is basically the same thing, and get a smaller percentile.

So, when I’m speaking to someone about the baby’s growth in their earlier in pregnancy, I not only look at the percentile, but sort of look at how is the baby measuring size-wise compared to how it’s supposed to be. And sometimes you’ll see it’s not quite as concerning as it looks. But let’s take it on the face, and let’s say the baby’s actually measuring a little bit small.

Most babies who are measuring a little bit small, whether in the second trimester or the third trimester, are fine. They’re fine. You’re fine. The placenta is fine. Everybody’s fine. It’s just some babies are big, some babies are small, some babies are average. Okay. And if that’s the case and we know that’s the case, there’s really nothing at all to be worried about. The reason there’s potential for concern is because we don’t know for certain that babies who are measuring in the seventh percentile in the second trimester are just small. There could be reasons why the baby should be bigger, but there’s sort of a problem that’s causing the baby to be small.

And the big buckets are that something is off with the placenta. Meaning, the baby’s fine and you’re fine, but the placenta that’s connecting you and the baby, and providing nutrients and everything to the baby is not working so well, and that’s causing the baby to be small. So, that’d be one potential sort of abnormal reason why the baby would be measuring small. And the second is that there’s a problem, so to speak, with the baby itself or himself or herself, whether that’s a genetic issue or some sort of infection or something like that.

Now, fortunately, issues with the placenta and issues with the baby in the second trimester tend to be unusual. They tend to be rare. And if those are the cause, usually, there’s other things going on. So, for example, if the baby’s in the seventh percentile, and there’s also low fluid, and maybe they do blood flow studies and they’re abnormal, that’s much more concerning for a placental problem than if everything else looks perfectly fine.

Similarly, if the baby’s in the seventh percentile and the baby looks perfect head to toe, and all the genetic screening you’ve done is normal, the chance that there’s a genetic problem or an infectious problem is much, much, much lower. And we tend not to worry about it. Whereas, if there was other things going on, it would be more concerning. And based on how concerned we are, we may recommend frequent follow-up ultrasounds to make sure the baby’s growing, and check the blood flow and the fluid if there’s a concern over the placenta. Or if there’s a concern over something with the baby directly, maybe we can consider an amniocentesis to check for the chromosomes. And these are decisions that have to be made obviously based on the specifics.

And so, again, as that alone, a baby in the seventh percentile, 22 weeks, I would tell you that the majority, not just 51%, but the overwhelming majority are fine and end up being fine, and ends up being no issues whatsoever. Every now and again, we find a placental problem, which could be mild, could be moderate, could be severe sort of, and that will play out based on how severe it is. And every now and again, rarely, but every now and again, there’s actually an issue with the baby, but typically in that circumstance, there’s other things we find besides the baby just being in the seventh percentile.

So, what happens practically if that’s all that we see is, we say, hey, why don’t you come back in two or three weeks or four weeks or whatever it is, and we’ll check again and see how the baby’s grown. And then maybe the percentile will bump up and it’ll be the 20th, nothing to worry about. Maybe it’ll stay around the seventh, but everything still looks fine and we’ll keep following. Maybe it drops, in which case, we’ll do some more tests and then figure out is it…are we concerned now, are we not concerned? And all those. Okay.

Now, the second thing you mentioned is that the baby had some mild pyelectasis, which for our listeners is just like a little bit of extra fluid within the baby’s kidney, either one of them or both of them. There’s always fluid inside the kidneys. The kidneys make urine and they store urine, and they drain out of these tubes called the ureters, and we sort of measure how much is in the kidney. And typically, it’s under a certain amount. At 22 weeks, most of us will say the measurement is under 4 millimeters. That’s what we typically use in the U.S. And if it’s over that, we say it’s mildly dilated. That itself, typically, if there’s a little bit of extra fluid, typically, it’s nothing. We’ve mentioned this on prior podcasts. Usually, the baby’s fine. Usually, there’s nothing to do about it and so forth.

Now, the question for you is, is having that sort of in addition to the baby measuring small, does it make it more concerning that your baby has a genetic abnormality? I said earlier that if the baby’s small and the baby looks perfect, we’re not concerned about a genetic abnormality. So, does this finding sort of take you out of the my baby looks perfect category and put you into another one? And I would say, based on how most of us think about it, no. Pyelectasis does not tend to be associated with genetic abnormalities when it’s mild and it’s this. You know, again, a lot of this depends on the details and the rest of the ultrasound. I would say, if someone wanted to be more aggressive with these two findings together, they would do an amniocentesis to check, you know, all the genetics of the baby. If you want to be a little less aggressive, you can just see how each of these play out. Does the pyelectasis get worse? Is it more than one kidney? Does the growth restriction get worse, or do all these things sort of stay the same or better? And then maybe you choose not to do an amnio.

But pyelectasis alone, we don’t usually nowadays worry too much about genetic abnormalities. Usually, it’s other findings on ultrasound, like a heart abnormality, or a brain abnormality, or a spine abnormality, or certain other things that would be more concerning. So, what I would say is, hard for me to say just on the information you have. Statistically, most of the time when you have a baby that’s in the seventh percentile with mild pyelectasis at 22 weeks, everything’s going to be okay. I would agree to have close follow-up. I would do the same thing, probably bring you back in two or three or whatever weeks and look again. Sometimes if someone was on the fence of whether to do an amni or not, this might push them over the edge. Some people want to do it anyways, but it’s not something that is sort of screaming to me there’s a problem. And so, usually, most people would just choose to follow up in a few weeks, and see how it goes from there. And then if either of those conditions gets much worse, then maybe readdress it, but if they stay about the same or improve, then you just keep following.

Okay. Next question, which is from an anonymous listener. Buckle up, everyone. This is a long question, but it’s a great one. So, I’m going to read the whole thing. All right.

“Hey, Dr. Fox. Found your podcast because of “The Toast,” and so glad I did because you and the information you share are simply AMAZING.” In all caps, by the way. “And you explain things so clearly, honestly, and with neutral opinions, which I love and appreciate. I find you do a great job of breaking the fear hysteria for me with your facts and experience.” All right. Anonymous listener, thank you for that compliment. All right. “I’m 30 weeks pregnant. I’m 31 years old, normal pregnancy, healthy, very active, and would love your deeper explanation on Braxton Hicks. I noticed them at 18 to 20 weeks. And at 22 weeks, actually noticed them come on more often after a weekend of ‘too much,’ too much working out, too heavy lifting weights, busy days, also having sex. (Sorry).” I don’t know why you’re sorry. It’s perfectly fine for this podcast for you to have sex.

“I went in, my cervix was fully closed, baby’s heart rate was doing great, and therefore, was good to go home and truly take it easy. Phew. After going in and resting, they became painful and more frequent for three days, no bleeding. And in hindsight, I should have gone back in, but didn’t know to. Yikes. God bless. They went down in intensity and now are no longer painful. Since that episode, I’ve reduced my activity intensity quite a bit, but I do though still have them daily. Maybe once an hour during the day, two to three hours in the evenings when I work out, when I walk, if I move too quickly, pick up too much weight, I’ll get them, but they’re no longer painful.”

“My OB is amazing, and is now keeping a close eye on me. She mentioned that if I get four per hour, to call, then come in and be monitored. I will ask her this at my next appointment as I love and trust her, but wanted to write in because maybe other women, too, are experiencing the same scenario. And I just love your long and clear explanations, too.”

All right. Here are the questions. “Why do Braxton Hicks happen? And what does it mean to have an active uterus? Sounds like I have one. Next, does having Braxton Hicks have any connection to people who are more fit, less fit, or lifestyle? Is there any connection to stronger, more painful labor contractions or going into labor early if you have Braxton Hicks? What do they do when you go to the hospital for them and monitor you? If you have four an hour, what are they looking for? And I know the risk is that you may go into preterm labor. How do I know if this is happening, and why would it happen? Thanks so much, Dr. Fox.”

This is like…there was a great movie from the 80s, “Back to School,” with Rodney Dangerfield, where he had to go back to college and he had to take an oral exam. And the professor who was like the bad guy in the movie, said to him, “I have one question with 27 parts.” So, here we go.

Basically, let’s start from the beginning. So, Braxton Hicks…and just for the record, Braxton Hicks are called that because they’re named after a physician. I thought at first it was two physicians, one Dr. Braxton and one Dr. Hicks, who came up with it together, but no. In fact, it was one person, Dr. John Braxton Hicks. He’s the one in the 19th century who coined this phrase. Basically, what are they?

Braxton Hicks, what I tell people, are contractions that are not labor. And why they’re called Braxton Hicks is only, I guess, out of respect for the person who coined them first. But you can call them Braxton Hicks, you can call them false labor, you can call them contractions, you can call them warmup contractions. You can call them anything you want, but it’s basically contractions that are not labor.

So, the uterus, which houses the baby, when one goes into labor, the uterus will start to contract painfully, regularly, frequently, and will cause the cervix to shorten, then open to what we call efface and dilate. So, our definition of labor is uterine contractions, painful, regular, frequent uterine contractions that cause the cervix to change, shorten, and open. That’s labor. Okay.

So, there are people prior to labor who will have changes in their cervix. It’ll shorten, it’ll open a little, but they’re not in labor. They’re not contracting regularly, painfully. And there are people who have regular painful contractions, and their cervix does not change. Both of those people are not in labor, and those contractions are either Braxton Hicks or false labor, a lot of it is semantics. Now, there are definitely people even before that will have irregular, usually not painful, and not frequent, uterine contractions. And we call those Braxton Hicks. Some people get a lot of them. Some people get none of them or feel none of them. If you put someone on a contraction monitor, most pregnant women, you’ll find a contraction every now and again, even if they don’t feel it.

But basically, they’re very common. They are completely benign. Meaning, they’re not harmful to the mother. They’re not harmful to the baby. They can be sometimes annoying for people, particularly if they’re concerned, if they matter or not. And they tend to become more common as you have more pregnancies. Meaning, on average, most people in the first pregnancy have very few of them and then…or, you know, they have less. And then as you have more babies, you have your second baby, you have more, your third, you have more, and that’s all very common. And they tend to start earlier in pregnancy as you have more pregnancy. So, someone in the first pregnancy, it’s unusual for them to have Braxton Hicks in the second trimester and early third trimester. Sometimes they do, and usually it’s every now and again. But if you have someone who’s on their third or fourth baby, they will frequently have them. So, that’s what they are.

What does it mean to have an active uterus? Just some people have it more than others. Why that is, we don’t really know. Is it more common in people who are fit or less fit, or lifestyle? I don’t think it’s more…as far as I know, it’s not more common in people who are more fit versus less fit or exercise more or less. It is known that people, after you exercise, you can get them. After you have sex, you can get them. So, I guess people who exercise more or have sex more will have them more, but only because it happens after that. But it’s not like they will then have them more three weeks later. It’s just at the time or right afterwards, it’s more common to have.

And is there a connection to going into labor early if you have Braxton Hicks? Basically, no, as far as we know. If they’re sort of irregular, not frequent, not particularly painful, people do not seem to be at an increased risk for going into labor. If we’re not really sure, like, hey, are these important, are these not important, and we want to bring someone in to get monitored, that could be done in many different ways, whether in the hospital, the office, one of which is to put someone on a contraction monitor and see how often this thing is really happening. And if they’re happening every 2 minutes, that’s a lot different than they’re having every 15 to 20 minutes.

Why four an hour is the cutoff? It’s a round number. There’s nothing magical about four an hour versus five an hour versus six an hour, three an hour. Generally, none of those are particularly concerning, but that’s sort of when we’re like, all right, maybe we should see what’s going on. So, one way is to do the contraction monitor. Another way is to examine the cervix. So, if the cervix is long and it’s closed, we know that it’s not changing. It’s not dilating. It’s not effacing. So, you’re not in labor. Sometimes we’ll do an ultrasound cervical length because that can sort of identify maybe changes in the cervix before you would feel that on exam. Sometimes we’ll do a test called a fetal fibronectin test, which can also indicate is this sort of more likely to turn into preterm labor or not.

In terms of how do you know if it’s going to turn into something important or not, sometimes you don’t. But generally, what I tell people is, if they’re not that frequent, they’re irregular, they come and they go, you could sleep through them, it does not tend to be something that is or will turn into preterm labor. Again, every person is specific, and there’s exceptions, and based on what’s going on. So, take this with a grain of salt and still ask your doctor about you specifically. But in general, for most people, if those are true, they don’t tend to be anything and don’t tend to be concerning. And some people just have them more than others.

All right. Thank you, my anonymous listener friend, for that wonderful question and series of questions. Thank you to Dr. John Braxton Hicks for coining the phrase in the 19th century.

Next question is from Rachel [SP]. “Hi. I’ve been told to completely avoid crunches and core exercises because it can cause diastasis recti in pregnancy and postpartum, and cause more harm than good. I just listened to your podcast on exercise, and you mentioned that it’s a myth that core work will hurt the baby. But how does it impact the mother’s body when it comes to abdominal wall and pelvic floor? Thank you.”

So, great question. I had two people ask me this question last week, just coincidentally in my own practice. So, in terms of core, abdominal crunches, whatever it is that’s working your abs, it is true it does not hurt the baby. Fine. The reason you’re hearing this… Because some people definitely say that. There is this thought that if you do core work in pregnancy, it’s going to increase the chance of getting the condition you mentioned called diastasis recti, which is basically when your rectus muscles separate from each other.

Now, a lot of pregnant women get that during pregnancy or notice it postpartum. It’s definitely annoying. Some people, it bothers them enough that they get it fixed surgically, but it can happen to anyone. Interestingly, we don’t really know, but there’s a big debate out there whether doing core work during pregnancy increases the chance that’s going to happen, meaning it’s bad, or decreases the chance that’s going to happen, meaning it’s good, or none of the above.

And I don’t think…as far as I know, unless someone wants to write in and show me a study that refutes what I’m saying, which is possible, I don’t think anyone’s done a study that’s proven it one way or another, meaning that doing core work makes it more likely or less likely or none of the above for your rectus muscles to separate when you’re pregnant. If I had a guess, I would guess that it decreases the chance because you are strengthening your muscles and whatnot. And that just seems to be like how it would work. There’s also other good reasons to work your core in pregnancy. It helps for back pain. It helps for after birth. In terms of things like the pelvic floor, well, it depends exactly what you’re doing, but typically, most core work is going to be good for your pelvic floor and not bad for your pelvic floor.

And so, I typically tell people, if you like doing it, if it feels good, if it’s helping you in any way whatsoever, I say it’s fine to keep doing. But I always say that nobody knows the answer of whether it increases or decreases or does nothing to the risk of getting your rectus muscles separating. And my personal opinion, my guess, based on no science, but just based on my logic is that it’s probably overall good rather than bad.

Next question is from Sarah [SP]. “Dear Dr. Fox, thank you firstly for your excellent podcasts and all the information you provide. I’m writing to you from the UK.” Hey, Sarah. Greetings from across the pond. “I’m currently 32 weeks pregnant, and have been told my baby is above the 90th percentile for head circumference and abdominal circumference. I was reading The Lancet Big Baby Trial.” Good job dropping a study here, Sarah. “And wanted to ask what the practice is in the U.S. for LGA or large-for-gestational-age babies, and whether you could possibly do a podcast about it. Thank you once again for everything you do.”

All right. So, when we’re doing ultrasounds and we’re measuring the baby, earlier in this podcast, we spoke about if the baby’s “too small,” and now, we’re talking about when the baby’s measuring “too big.” So, when babies are above the 90th percentile, either overall or sometimes the abdominal circumference, or you were mentioning the head circumference, there’s a concern. Right? And this is late towards the end of pregnancy towards delivery. There’s a concern of two things. One, that having a larger baby will increase the chance of a C-section, because the baby “won’t fit.” And number two, there’s a concern that if the baby delivers vaginally and not by C-section, there’s an increased risk of a condition called shoulder dystocia, where the baby’s head comes out, and then the body and the shoulders sort of get stuck, which can be dangerous to the baby. It could be dangerous to the mother, but it’s mostly the concern is for the baby. Okay. So, that’s sort of the concern.

And then there was this great sort of debate about what to do if the baby’s measuring on the big side. Option A is just do a C-section. Option B is to wait, let labor happen on its own. A natural labor is “a better labor,” and let it happen. And option C is, hey, why don’t we induce early so the baby doesn’t stay inside and continue to get big and increase these risks. And based on the exact circumstances and how big is the baby and the mother’s history and her pelvis and how far pregnant she is, there may be a reason to choose the first, the second versus the third.

But the study that Sarah referenced from The Lancet was where they were trying to compare option two to option three. Meaning, you have someone who has a baby that’s being measured larger. And is it better to wait and let them go into labor on their own, sort of use the force of natural labor and that’s going to be better versus, hey, let’s induce early so the baby’s a little bit smaller? And in that study, they showed better outcomes in the women who were induced, meaning lower risk of C-section and complications. And so, that sort of cemented that as a reasonable option.

One of the interesting things is, if I recall in that study… I’m doing this from memory, I didn’t look it up, just FYI. If I recall from that study in the women who got induced, they got induced early, like 37 or 38 weeks. In the U.S., it’s unusual to induce under 39 weeks. And the only time we might do it in the setting of a larger baby is if there’s other things going on or maybe she has diabetes. And because in the U.S., there’s a big push not to deliver babies under 39 weeks, unless there’s a really good reason.

And so, what ends up happening in the U.S. is the same three options tend to be on the table, C-section, wait for labor, or induce. But the timing of the induction tends to be, for most places, 39 weeks rather than how they did in the study at 37 and 38 weeks. Again, there’s exceptions to all of this. I don’t know if in the UK they’re inducing people 37 and 38 weeks for larger babies or if they’re also doing 39. But in the U.S., it’s usually 39, I would say, unless there are exceptions. So, that’s the answer to your question of how we do it in the U.S. Thank you.

All right. Next question is from Elizabeth [SP]. “Hi, Dr. Fox. Toaster here. I started listening when you had Jackie on a few years ago, and your podcast has been invaluable during my two pregnancies.” Thank you, Elizabeth. “My question is, how far in advance does what you eat affect the one-hour and the three-hour glucose test? I’m specifically curious about the day before and the week leading up to it. I failed my one-hour glucose test in my first pregnancy by three points. And I’m wondering if it’s because I had the test taken two days after my baby shower where I was indulging in sweets way more than normal. Thankfully, I passed my three-hour test, three out of the four numbers.”

“Unfortunately, I just failed my one-hour glucose test again in my second pregnancy. I now need to take the three-hour test. Did eating too many sweets over the holidays possibly affect my results? In preparation for my upcoming three-hour test, is there any evidence that doing a low-carb or a high-carb diet leading up to it can impact the results? I’d love to be more informed about how much of the glucose screening results are diet-related versus hormone-related for my placenta. Thanks for your amazing and informative podcast.”

All right. Great question. So, I will get into the specifics. But in general, what you eat prior is not really going to affect the test. Meaning, when we do screening for diabetes in pregnancy, what we’re trying to do is figure out how a pregnant woman’s body responds to a boatload of sugar. It’s not a test of how much sugar have I eaten in the past one, two, three days, one, two, three months, one, two, three years. Right? There are other tests that can be done to look for that. There’s something called the hemoglobin A1c, which sort of checks your sugar levels over the past three months, but that’s not really going to pick up something like gestational diabetes. That’s more for real diabetes.

So, for gestational diabetes, you’re trying to find out how your body responds to sugar. So, what we do typically in the U.S. is everyone has a one-hour test, which one hour is sort of the time we wait, which means you come in, you have this drink of sugar, it’s 50 grams of glucose. And then an hour later, we draw your blood, and we see what your blood glucose is. Typically, your body within that hour is going to be able to process the glucose, you know, get it out of your bloodstream and below a certain number. And so, if that happens, you know that your body processes sugar well. This is the one-hour test we’re talking about.

It’s not a fasting test. Meaning, even though some people tell patients to come and fast before that test, that’s not how it’s intended to be. It’s intended to be done any time of the day, any way you want, just have the big glucose, and an hour later, your blood glucose should be below a certain number. I frequently would tell people not to eat or drink for an hour beforehand, just so there isn’t a boatload of sugar in their stomach when they take it, only because maybe they’ll get a false positive from that. We don’t even know if that’s true, but fine. But it’s not something where it’ll be impacted by what you ate the night before, the day before, two days before, three days before.

So, in terms of the first part of your question, the fact that you did not pass the one-hour test had nothing to do with your baby shower two days before. Okay. And if you go back and look at people who sort of in the months preceding their one-hour test ate a lot of sugar versus didn’t eat a lot of sugar, it should not affect the results of the test.

Now, the three-hour test is a little bit different. That’s the definitive test, the one that actually tells you if you do or don’t have gestational diabetes. The one-hour test, if you pass it, you’re done. If you “fail” it, it does not mean you have gestational diabetes. It means you have to move on to sort of phase two, which is the more annoying and longer test, the three-hour test. And why is it called the three-hour test? Because it takes three hours. And in that test, you do come in fasting. Then we draw your blood while you’re fasting before you have any sugar whatsoever. Then we give you a boatload of sugar, 100 grams, and then we draw your blood one hour, two hour, and three hours afterwards. So, there’s four needle sticks. One is checking your blood glucose while you’re fasting. Then you take a lot of sugar, and then you do one hour, two hour, three hours.

That also is not typically impacted by what you had the days preceding. And when we give instructions to people about that, if we’re thorough, we actually tell them the opposite. We don’t tell them stay off of sugar for the time before it so that you can pass. We tell them to eat a normal or even a high-carb diet because we want to be sure that their body’s sort of used to carbs and has carbs in their system. Because if you stayed off of carbs, we’re concerned that maybe if we give you a boatload, your body will go a little bit haywire. Maybe it’s the opposite of what you’re thinking.

So, there’s no studying for the three-hour test. There’s no prep for it. I tell people just eat normally. And if they typically don’t eat any carbs, maybe have some carbs in the few days before so we can get a real accurate assessment of how their body responds to carbs in a normal circumstance. Again, that test is done fasting. It’s done that way for a couple of reasons. But the biggest reason is we like to get that value, what is your fasting blood glucose. Because that tends to be the most predictive and most important for gestational diabetes. And so, to get a fasting blood glucose, you have to come in fasting.

All right. Great questions, everybody. Thank you so much. 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.

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