In this mailbag episode, Dr. Nathan Fox answers some of the top questions from our listeners. He answers questions regarding how culture influences labor and birth, placental abruption, fetal growth restriction, Group B strep, and taking Zofran in pregnancy.
“Mailbag #6: What does the Fox say?”
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Dr. 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 number 6, What does the Dox say? All right, our first question is from Claire, and it’s regarding labor floor culture. Claire writes, “Hi Dr. Fox. Thanks so much for your thoughtful podcast. I’ve found so many of your episodes to be so incredibly helpful.
My first son was born in California, and my second was born in Switzerland, and both took place in big teaching hospitals, but were incredibly different experiences. My question is how much does culture influence medicine and birth specifically? How much do birth practices differ worldwide? Thank you.”
Well Claire, thanks for the question. The short answer is I don’t know. I don’t know how much birth practices vary worldwide, although I suspect there is a wide variation in certain practices, and less variation in others. The reason I don’t know is I have not been around the world, or seen all the labor floors, or how all hospitals practice. Obviously, I have friends and colleagues around the world, and again in certain things we do things remarkably similar, and other things it definitely varies. Obviously, there’s a major component related to resources in certain countries, or in certain towns. In certain countries with limited resources, it’s definitely going to be different compared to, let’s say, high-income countries or high-resource countries, and so there’s a huge variation in that regard. But amongst sort of places with high resources, just practices and medical practices, again, I would imagine there’s differences in some, and not in others.
As for culture, I do think it matters a lot. We’ve discussed this on the podcast before sort of in bits and pieces, but it’s a really good question to sort of go over that. And I think that culture is complicated because it’s hard to find out what is the culture. I mean, if you work somewhere, or you’ve been a patient there several times, you can definitely get a sense, potentially, what the culture is like, but it’s not something that’s readily available to you, the consumer, the patient, you know, whoever it is, you know, who do you ask what’s the culture like at a hospital? And I think that in some instances it is important.
We’ve discussed this, for example, with VBAC, right? So VBAC has numbers regarding safety, and regarding the likelihood of success and all of these things, and certainly we speak about, you know, it matters who your doctor is, who your midwife is, is it something they’re comfortable with, it is something they’re capable of doing? And then it also matters in terms of the place you’re going to deliver, the hospital for example, are they capable of responding to emergencies, have anesthesia, operating rooms, and those are sort of questions you could definitely get answered for you. But the question is what is the culture about VBAC on a labor floor, and that is a really important piece. And I frequently tell people, you know, you may be a good candidate for VBAC, and your doctor or midwife might also be in favor of it, and the hospital may have the resources for it.
But if you go to the hospital, and every single person there is sort of like, well, why would you VBAC? Why don’t you just have another C-section, and the nurses aren’t for it, and you know, the doctors who cover the labor floor when your doctor is, you know, not there aren’t for it, it’s probably not the best place to VBAC. Now, it still might be a good place to VBAC. Again, it may not. It can be overcome potentially, the culture, if, you know, you’re a good candidate, and you’re persistent, and your doctor is okay with it. Certain things can’t be overcome. Like if they’re not capable of taking care of someone with a VBAC, all right, that’s sort of a non-starter. But if it’s culture, I think these things do matter, and you know, that’s one example.
Or, for example, if you’re planning on bringing a doula with you for support, there’s definitely places that are much more open to and friendly to and encouraging of people bringing doulas, and other places that probably would be the opposite. Maybe they would snicker at you, or you know, something…I think that’s inappropriate, but again, obviously, there’s different cultures around the country and around the world. Same thing with just if you’re interested in delivering with a midwife, right? Certainly culture is going to play into part of it. Obviously, some labor floors will have midwives, and some won’t, but also, is the labor floor one where there’s a culture where the midwives and the doctors work collaboratively, and really I guess in a healthy way to take care of patients, versus is there a lot of antagonistic views, or potentially oppositional views? Which would be unfortunate, but obviously they do exist in certain places, and that’s an area of culture…
Similarly, if you’re having a labor induction, we’ve spoken about this on the podcast, the outcomes on labor induction are predicated on the idea of having patience with the labor induction. Patience not T-S, but C-E at the end, meaning to be patient and wait longer time. And so that’s an important part of the culture of the labor floor, are they comfortable with people coming in, and having longer inductions, versus saying, all right, it’s been six hours, you’re done, no more.
That’s something that is hard to get, obviously, but we’ll talk about that. I would, in order to get that information, I would say the best way is probably just to ask your doctor or midwife open-ended questions about it. You know, they’re not there to try to lie to you, so if you said to your doctor, for example, VBAC, hey, I’m trying to VBAC, what do you think about it? He’s going to say, oh, that’s great, I think you’re a good candidate, it should be this, this… And you could say, what’s the labor floor like with VBACs? And if they say to you, oh, it’s amazing, people are supportive of it, the nurses are into it, we love doing it, we do a lot of it, that sounds like a place with a pretty good culture. If they say, oh, my, God, I’m the only person there who does VBAC, and everyone’s yelling at me all day, all right, then that’s a decision to make, maybe it could be overcome, maybe it can’t. But you’ll get a sense of what the culture is like.
Similarly with inductions, you say, okay, what’s an induction like, right? That’s an open-ended question. And if you hear something to the lines of, well, you know, we start, expect it to be a long time, we have to be very patient, you know, inductions are not a bad thing if you’re patient, and we know what we’re doing, that’s an answer you want to hear. If you get a sense of, well, we start inductions, but by 4:00 they’re pressuring me to section everybody, all right, that’s not the culture, potentially, that you’re looking for. Similarly with doulas and those, you can just ask, and usually people will tell you.
I will note that when talking about culture, I’d be very careful when people start quoting or asking for cesarean rates, you know, what’s the rate of cesarean at this hospital or in this practice? And we’ve spoken about this on the podcast before. It’s not that the rates are wrong, but they can be very misleading, because you have to be comparing apples to apples. You know, a hospital that has many more let’s say high-risk patients, twins, you know, maybe there’s people with a lot of prior sections who come in, their C-section rate is going to be higher than a hospital that takes care of low-risk, nulliparous patients. And it’s not because one hospital is better at doing vaginal deliveries than the other, it’s just based on the population that comes there. So I’d be very careful about cesarean rates, because frequently they could be misleading.
Things to look for are, again, just this general idea that the place is open-minded, that they communicate well, they sort of have a philosophy of patience and teamwork. Those are things that indicate a good culture, and if you start seeing or hearing or feeling the opposite, maybe not. Again, things I care less about, interestingly, are statistics, even though I’m like a math person, I’m a stats person. If we had really perfect statistics, I think it’d be terrific, but I think what ends up happening is a lot of these statistics are misleading. Like statistics about online reviews, or patient reviews, or C-section rates, they’re generally more marketing than they are statistics. Similarly with word of mouth, again, some aspects of word of mouth are going to be helpful, if you can ask the right questions, but just someone saying, oh, I had a great birth there, it doesn’t necessarily mean they have a great culture, it just means that person had a good outcome.
Obviously, sometimes you don’t have a choice, right? Sometimes this is the hospital that’s closest, this is the hospital your doctor delivers. Try to make the best of it as you can. And this is why a lot of these questions are best asked early in prenatal care rather than at the very end, because if there’s something that’s a deal-breaker, you want to know about it as early as possible because it gives you potential options if you want to switch.
All right, next question from Molly, related to placental abruption. “Hello. Thank you for your great show, I love it. My question is about placental abruption. Could you talk about what this is, and why it happens. Background: I have had two perfectly healthy pregnancies, and babies delivered via induction at 41 and 41 weeks. At the end of my second labor, when I was around 9 to 10 centimeters but before pushing, I had a “mild” placental abruption, bleeding, baby heart rate decels, but delivered vaginally after a few urgent pushes. My placenta was sent to the lab, and the abruption was confirmed. My doctors are not concerned about an increased risk in future pregnancies or labors, but I know this can be an emergency, especially if it happens at home. Curious your thoughts on how concerned I should be if I choose to have another. Thank you.”
All right, Molly, thank you for the question. We did have a podcast recently with Andrei Rebarber about placental abruption. This question came in before that, so again, some of that or most of this was answered in the podcast. But just as a quick recap, placental abruption is when the placenta separates off the uterine wall before the baby is born, right? It’s supposed to happen after the baby’s born. And this can happen in a very small amount, some people call that mild, or it can happen more significantly, and generally the difference is how bad are the symptoms. And the symptoms are usually vaginal bleeding, because when the placenta separates off the uterine wall, there’s bleeding. That blood that should be going into the placenta is now tracking sort of along the uterus, and coming out, because the placenta is not attached.
Another symptom would be since there’s decreased oxygen going to the baby in that area that’s not getting blood flow, right, if a portion of the placenta comes off, that portion of the placenta is no longer being used to deliver oxygen to the baby, so there could be fetal heart rate decelerations. Another symptom sometimes is pain, because the bleeding can cause contractions, which can be painful. Again, not everyone has all these symptoms, but that’s another possible one. And then if it gets worse and worse, it can lead to bad outcomes, even stillbirth if it happens potentially at home, and it’s severe.
Now, the question is what is the chance of it happening again? If you have it in one pregnancy, what’s the chance in the other? And it’s hard to give a precise number because a lot of it depends on the circumstances. There are some situations where it’s probably a little bit increased, and other circumstances where it’s much more increased. It also depends on sort of what was the reason for the abruption. If someone had it because specifically, let’s say they got in a bad car crash and it caused an abruption, then probably the next pregnancy it’s much lower. Whereas if it happened because there was placental insufficiency, and she has medical conditions and it caused the placenta not to do well and then to separate, that’s more likely to recur.
So it depends on the cause, but there is a range, and probably it’s somewhere in the range of 10% to 30% of recurring. So that’s higher than it happens in the general population, but more likely than not it won’t recur. And so because of that, and that number one, variation or range in the chance it’s going to recur, number two, the fact that it depends sort of on the cause, there’s also variation in what we do about it in the next pregnancy, ranging from very little, to a lot. Now, it’s hard to get specific with you on your question, what happened to you. It sounds like you probably don’t have a huge rate of it happening again because it was mild, it happened after 41 weeks, the baby was fine, but you know, obviously, you’d want to get a little bit more precise than that. Generally, if someone has a history of an abruption either during pregnancy, during labor, or during delivery, I do recommend some form of a consultation either before your next pregnancy, or at the beginning of your next pregnancy to sort of go over all the details, all the data to try to get a sense of what is the likelihood that might recur, why, and what to do about it.
Now in terms of what to do about it, there isn’t a lot that we know that will actually prevent it from happening. Again, it depends on the cause. But what we do know is that if we think the cause was related to a problem with the placenta inherently, like some poor attachment to the uterus, that can recur in the next pregnancy, but could also manifest in different ways. It can manifest as maybe the baby not growing as well, or you getting preeclampsia. So generally, at least in our practice, we do follow women with a history of a placental abruption in a prior pregnancy, in this pregnancy, we do follow them closer. It usually just means more ultrasounds to check that the baby’s growing well, maybe more prenatal visits, again, maybe a closer check of blood pressure, depending on the circumstances.
And then, another question is whether we’re going to induce labor at a certain point, whether near the due date, like at 39 or 40 weeks, or even earlier, potentially at 37 or 38 weeks. The idea being if everything’s going fine, and it has not yet recurred, the abruption, let’s induce labor before it has a chance to recur. And obviously, that decision is based on a lot of factors that I couldn’t answer right now, but that’s sort of the thought process. So when I see someone with a history of an abruption, we try to go through all the data, why did it happen, what’s the chance that it’s going to happen again, what can we do about it potentially in the next pregnancy to monitor for it, and then the last question is, do we recommend delivering at some point in pregnancy sort of as a preventative measure, before it would happen at home, as you said.
Okay, the next question is from Shivani, and it’s about fetal growth restriction. All right, “Hello. I was diagnosed with FGR,” that’s fetal growth restriction, “and really appreciate the recent podcast on the topic. I’d appreciate a follow-up that dives into how doctors can communicate more clearly SGA, and actual restriction, and also how as a patient I should think about delivery timing, and have a productive conversation with my providers. In my case, the care team keeps mentioning SGA as an option, though my first was normal size, and neither my husband nor I are constitutionally small. Also, we are not huge either. But they also mention things like imbalanced growth in the fetus, head circumference, femur normal or large, abdominal circumference and weight,” so a lot of data in there. And so basically at the end, “What are the questions to ask a provider to understand the risk-benefit analysis?”
All right, so Shivani, you’re asking a really good question about somewhat of a complicated topic, which is fetal growth restriction, also called intrauterine growth restriction. It used to be called intrauterine growth retardation. We don’t use that terminology anymore for a lot of reasons. Number one, it just has stigma attached to it, but it’s also a little bit more complex pathophysiologically, what that means. So usually we’re using the terms FGR for fetal growth restriction, or IUGR, intrauterine growth restriction. Those are typically interchangeable.
It’s a complicated topic for many reasons. The first is that, as you mentioned, the terminology is very confusing. Just as FGR versus IUGR, there’s also something called SGA, which stands for small for gestational age, and people use that sometimes interchangeably, although it’s really not the same. The pathophysiology, meaning why the baby’s measuring small is very wide. And so there’s so much that goes into that, and frequently in these conversations, it is confusing on the receiving end. Meaning, what the hell is going on? Like, why is my baby small? Is it a problem? What are we going to do about it? All these things.
And I would say in order to get better information sort of on your end, and just understanding it, again, we did do a podcast on this, I think it was a pretty good one, but just as a review, when I see people and the baby is measuring small in ultrasound, so a few things. Number one, we are not actually weighing the baby on ultrasound. We’re not putting the baby on a scale. We’re getting measurements, and then the measurements sort of use an algorithm to estimate the fetal weight based on the measurements. We’re sort of like the guy at the carnival who looks at you and guesses your weight, like, we’re pretty good, but we’re not perfect. So number one, we could be wrong. Now, it tends to be that when the babies are measuring smaller, we are more accurate than if we think the baby is measuring very big. But again, just number one, we could be wrong.
But let’s assume we’re right. Let’s assume we’re right, and the baby is in fact measuring small. So what does that mean? It means that if you look at a hundred babies at this gestational age, and you lined them up from smallest to biggest, right, where does your baby fall in the line? If we said, all right, you’re in the 9th percentile, that means that, okay, this baby would be 9th from the smallest, or 91st from the biggest. And is that a problem? Well, usually not, right? If you take 100 third graders and line them up from smallest to biggest, the 9th smallest child doesn’t mean there’s a problem with that child, right? Some kids are big, some kids are small, and some kids are tall, some kids are short. Again, this could be true for life, or it could change over the years. The kids who were short in third grade might be tall in high school, and vice versa. And so just because the baby is measuring in a smaller percentile, that does not mean there is any problem whatsoever going on.
So sometimes, one of the ways we distinguish that is we’ll say SGA, small for gestational age, is sort of descriptive. It means the baby is measuring small, but it does not mean there’s a problem. When we say fetal growth restriction, or IUGR, the implication is that there’s actually a problem causing the baby to be small. So when we say that someone who has a baby is measuring in a lower percentile is FGR or IUGR, what we really should be saying is the baby’s measuring SGA, the baby’s measuring small for gestational age, and it might be due to fetal growth restriction, to a sort of a problem causing it, but it might also be due to absolutely nothing. So when I see people, and the baby’s measuring small, I’ll tell them, all right, the baby’s measuring small. Number one, we could be wrong. Number two, even if we’re right, the majority or whatever…again, it depends on the situation, many, if not the majority, if not the vast majority of these kids are perfectly fine, and just small. Nothing wrong with them.
But then we talk about what are the other possible reasons a baby could be small that are not perfectly fine, right? What are the possible, like, abnormal reasons? The most common reason a baby could be small, that’s not just normal, is the placenta is not working as well as it should. The placenta is what nourishes the baby, so it gives the baby food, water, oxygen, all these things, and so if the placenta is not working so well, then maybe the baby will be like “on a diet,” getting fewer calories, and might be small. So that is one possible reason, and that’s why we do all these extra ultrasounds, we look at the blood flow, we look at the movement, we look at the fluid to make sure that the baby looks healthy. And if the baby is looking healthy, and the placenta is looking healthy, it tells me that either there is no problem with the placenta whatsoever. Or that if there is a problem with the placenta, it’s pretty minor, and we don’t have to do anything, we can continue to watch and wait.
Now, if there’s other abnormal findings on the ultrasound, like the blood flow is abnormal or the fluid is low, then that tells me that, A, there probably is a problem with the placenta, and it’s a little more severe, and then we have to decide what to do about it, again which might mean come back in two days, it might mean we have to deliver the baby, it depends on the details there. And that’s usually the question that’s coming up when the baby is measuring small, do we think there’s a problem with the placenta, or do we think there’s not? Or at least it’s mild enough that we can continue? So that’s one of the first questions to ask your providers. At this moment in time, do you think the baby is small just because the baby is small? Or do you think the baby is small because there’s a problem with the placenta, and if so, how bad is it, and what are we going to do about it?
The other question is there are causes of fetal growth restriction that are much worse. They’re fortunately much more rare things like genetic problems with the baby and, anatomic problems with the baby, infections in the baby, you know , things that are fortunately rare, but can have much worse outcomes. Those are a little bit harder to know about unless it’s profound, unless you see abnormalities in the baby on ultrasound, unless the growth is way off the charts, and that’s why people talk about sometimes doing an amniocentesis to check for genetics, or other blood tests, and this… Fortunately, that’s not usually the cause. It’s rare, but it can be a possible reason, and that’s another question to ask. Say, how concerned are you that this might be something other than normal baby or a placental issue? And if the answer is, well, not that concerned, that’s good. If the answer is, yeah, I’m really concerned, then that’s a much bigger issue.
So again, it’s a complicated topic. Every case is unique, and needs to be individualized. But generally, the biggest questions are, do I think this is just a small baby who’s perfectly fine, versus a baby that is fine, but has a placenta that’s not working as well, and if so, how bad, versus the more rare, is this a bigger problem related to the baby itself, or an infection, or something like that?
All right, next question is from Chaya, related to GBS, or Group B strep. “Hi. First off, I just found this podcast through “The Toast.” All right, Chaya, welcome. We welcome all our Toasters. “And I feel like I struck gold. I love it! I have so many questions I’d love to ask, but let’s start with one. What is your opinion on Group B strep? During my last labor, I arrived to the hospital nearly ready to push. My doctor mentioned that my sac was bulging, and that if she just broke my water, then my baby would be out in minutes. But when she checked my chart and saw that I was GBS-positive, she insisted on waiting to break my waters, and instead I was put on IV antibiotics for about five hours. She then broke my waters, and my baby was out in under half hour.
Now, the part that I find strange is that the positive GBS was actually from when I was 20 weeks through a urine sample. Because I was positive then, my doctor did not retest closer to delivery. I’m now pregnant again, and was already tested through my urine at eight weeks. Why? And I’m once again positive. I’ve done some research, but I’d love to hear your take on the matter. Thank you. I’m looking forward.”
All right, Chaya, great question, Group B strep. So basically, Group B strep is a bacteria, it’s a bug that is found in a certain percentage of women, in their genital tract. So whether that’s the vagina, whether that’s the rectum, but it’s found there, and it’s not an abnormal bug to have in life. Meaning, you’re walking around, you have it, there’s no symptoms from it typically, you don’t have to treat it, you don’t have to test for it, and probably it happens in about 20% of women, meaning it’s a pretty common thing to have. And normally we would never care about it in any way whatsoever, because again, it’s not a problem. It’s not an infection, it’s just one of the bugs that some people have and some people don’t.
The reason we care in pregnancy is because if a newborn gets infected with Group B strep, it can be very dangerous for the newborn. So the question is, we know that about, again, and this is a round number, around 20% of women have Group B strep, and we know it’s not a great thing for babies, what do we do about that? Way back when, the strategy was we basically did not treat people for this because 20% of women have it, but definitely not 20% of babies get infected with Group B strep. Meaning of all the babies that pass through a mom who have Group B strep, very few of them get infected and get sick. So what we would do is if there were certain risk factors, like she had a fever, or her water was broken a long time, or she was preterm, we’d give them antibiotics, and if they’re full term and healthy, we wouldn’t give antibiotics.
Subsequent to this, this is about, I don’t know, 20, 30 years ago, they did some research and determined that in fact, a better strategy would be to test everybody at around 35, 36 weeks with a recto-vaginal culture with a Q-tip swab, send it to the lab, and find out exactly who has and who doesn’t have Group B strep, and in the ones that have it, when they come in labor, we’re going to give her antibiotics in labor to reduce the amount of Group B strep, and prevent the baby from getting Group B strep, and it was determined that this strategy, testing everybody and treating the ones who have Group B strep was better in terms of preventing Group B strep and the babies than the old strategy. So that was the upside, it was better.
The downside is now you’re giving about 20% of women antibiotics in labor. Maybe there’s some downside to that, maybe not. But basically, the strategy that’s been accepted certainly in the U.S., and I think, I don’t know, but I think in many parts of the world is we test women for Group B strep around 35, 36 weeks, and those who are positive get antibiotics in labor, those who are negative do not.
There’s a couple of exceptions to that. One of the exceptions is if someone has Group B strep in their urine earlier in pregnancy, the thought is if it gets in your urine, you must have a very high amount vaginally or rectally, so we just consider that person positive at the time of delivery, and we don’t test them at 35, 36 weeks. That’s the current strategy. So for you, that specific part of your story does make sense. Someone who has it in their urine, whether it’s at 10 weeks, 20 weeks, 30 weeks, whatever in pregnancy, we’re sort of like, they are considered Group B strep-positive at the time of delivery, and we don’t do a culture, a vaginal culture at 35, 36 weeks. So that’s why that was done. Again, even if you treat the Group B strep in the urine with antibiotics, and you don’t find it in the urine anymore, we still consider you positive for the whole pregnancy. So once positive in the urine, you’re positive for the whole pregnancy. That’s the typical sort of situation, and that’s why they did it for you.
The second issue is, okay, you come in in labor, they find out you’re Group B strep-positive, and they’re saying, oh, we need to get a certain amount of hours of antibiotics into you before the baby is born. Now, that is a little bit more of a controversial position. There are data that would tell you that the longer you are exposed to the antibiotics, the lower the chance of the baby having Group B strep. Meaning if you, let’s say, got antibiotics, and the baby was born 20 minutes later, there’s a certain percent chance of the baby’s going to get Group B strep. Versus if you come in labor, and get an hour or two of antibiotics, that chance is lower, and if it’s four hours, it’s lower, and typically, the recommendation is we’d like there to be four-plus hours of antibiotic exposure before the baby’s born.
Now, the issue with that is we don’t know for certain that if someone like you comes in we know is Group B strep-positive, you got a dose of antibiotics, is it better to intentionally wait and not break your water, and let those four hours pass, versus I would normally break your water, let’s break the water, deliver the baby, which is actually better? We don’t know, because it hasn’t really been studied in that way to know for certain. But sort of the typical stated recommendations are, well, if you can wait, you wait, and if there’s anything you would need to do urgently, don’t hesitate.
So for example, if let’s say you came and you’re in the same situation, your water bag is bulging, but they were really concerned about the baby for another reason, and wanted the baby to be born immediately, they wouldn’t sort of hold off on breaking your water because of the GBS. They would basically break your water to deliver the baby, because that’s what needs to be done, so be it. But if all things being equal, and everything’s okay, they’re like, all right, we’ll try to wait the four hours to sort of optimize potentially the Group B strep coverage for the baby, it’s a practice that’s commonly done. Again, there isn’t great data to tell you for sure that it’s the best way to go, because that would have to be studied prospectively. You’d have to take, you know, let’s say 200 women just like you, and 100 of them break their water after four to five hours like you did, and the other 100 break their water after 20 minutes, and see how the babies do. But that really hasn’t been done, so it’s hard to say for sure. But going backwards based on the data we have, that’s what’s frequently done. So I think that’s probably the reason that it happened, and it’s not that uncommon, at least in my experience.
All right, last question for today’s Mailbag. This is an anonymous listener, who did not want her name mentioned, but she asked a question about Zofran in pregnancy. Message, “I would love to hear your thoughts on taking Zofran in the first trimester for extreme nausea. Is it safe? Thank you, and love the pod.”
Okay, thank you to this listener for sending the question. Zofran is an anti-nausea medication. Zofran is the brand name, or the trade name, and sort of the generic name is ondansetron, O-N-S-A-N-S-E-T-R-O-N. Those are the same thing. And so the question is, is it safe to take in pregnancy? Now, this is a very common question because a lot of women have nausea in the first trimester, and Zofran happens to be a really, really good medication, or effective medication for nausea, so this comes up a lot.
I will tell you that the answer is, unfortunately, a little bit complicated. And part of this is because studying the safety of medications early in pregnancy is always a little complicated, because the concern, at least that comes up with Zofran, is does taking it increase the risk of birth defects in the baby, right? The fear is if the mother takes any medication in pregnancy, particularly in the first trimester, when all the organs are being formed, the baby’s organs are being formed, will that medication somehow interfere with that process, and increase the risk of birth defects? So that’s a concern.
So the best way to study that would be to take let’s say 10,000 women, randomly divide them into two groups of 5,000, give 5,000 of them Zofran at some dose, standard dose every day in the first trimester, and the other 5,000 give a placebo pill. They don’t know what they’re…you know, no one knows if they’re getting Zofran or the placebo. At least they’re not supposed to know. They might know if they have less nausea, but whatever. And then take all 10,000 babies after birth, and do, like, full MRIs, echocardiograms, everything you can do to test, count the number of birth defects in each group, and see if there’s more in the Zofran group than in the placebo group. That would be the way to do the study.
The problem is that’s not how these studies are done, because you’re never going to be able to sign 10,000 people up for a study like that. And so what ends up happening is you get these sort of series where they say, all right, we had 500 women that took Zofran, and X-percent of them had birth defects. And then we compared them to 500 women who didn’t take Zofran, and Y-percent of those babies had birth defects, and here’s the difference, and that’s the risk of birth defects from taking Zofran. But the problem with that is twofold. Number one, the people who take Zofran, they don’t take it randomly, right? So maybe it’s because, obviously, they have more nausea. Maybe there’s something about more nausea. Now as far as we know, having more nausea does not increase the risk of birth defects, but maybe there’s something about people’s response to it. Or maybe risk factors for nausea are also risk factors for birth defects. Who knows? Or maybe they’re trying other things for nausea that are not Zofran, that they’re not telling us about, or we don’t know about, or they don’t realize might be an issue, or maybe it affects…whatever, there’s a lot of things that are different.
And number two, sometimes when people take medications in pregnancy, their babies get more thoroughly examined after birth or during pregnancy, so maybe you’re picking up more birth defects that you just wouldn’t pick up, and aren’t necessarily going to be an issue after birth. Ao a classic example I give to patients is what if I have a woman who’s taking medication, and they say, oh, because of the medication, I’m going to do a very thorough evaluation of baby’s heart, and they find, like, a one or two-millimeter hole in the heart? Now, that is probably just going to close sometime after birth, and it’s not going to have any effect on this kid’s health, life, heart, anything. But we know about it, and so that baby gets listed as having a heart defect. Whereas someone who didn’t take the medication, and didn’t have that crazy, very detailed ultrasound, and we have no idea if that kid has a hole in their heart that’s one millimeter or not because you would never know about it. And so that is one of the ways these studies can be flawed.
So that’s the background. What does the data actually show? The data is mixed. The preponderance of data suggests that there is not an increased risk of birth defects for women who take Zofran. There are a few sporadic studies here and there that do suggest that, meaning if you Google it, you will definitely find a study out there that will suggest an increased risk of birth defects, particularly heart defects and I think cleft palates with Zofran, but many other studies have not confirmed those findings. And if a medication really does increase risk of birth defects, you would expect it to be found in all the studies, pretty much, because why would it happen in one group, and not in another group?
And so the overall arching review of the evidence currently at the end of 2023 suggests that Zofran does not increase the risk of birth defects. Now, with that said, obviously there could be more research coming out. It’s possible there’s always some slight risk, and that’s why we don’t typically just give medications for no reason whatsoever. So what happens is generally in pregnancy, if someone has nausea, we try things with sort of the highest safety profile, and then work our way down the list based on how severe it is. So typical first line for nausea, vomiting in pregnancy, vitamin B6 and Unisom, which is an over-the-counter sleep medication. That combination together has been studied for a very, very, very, very long time, and has been shown to be safe. Interestingly, 40 years ago, there was actually a concern that it might not be safe, but that was totally debunked, so it is safe.
And then, if those don’t work, we start moving to the next line of medications, and Zofran might be one of those. And I always tell people exactly what I said here, that the preponderance of data suggests there’s not an increased risk of birth defects, but again, it’s very hard to study this perfectly, and so really, just you have to balance the potential risks of taking the medication, which seem to be low, versus the benefit, which is going to be great if you can’t eat anything and you can’t drink anything, and you’re very, very sick. If you’re not that sick, the benefit is not as great. So it has to be a personalized, individualized conversation, but those are sort of the factors that go into it.
All right, thank you all. This was a great Mailbag. Thanks for sending in questions, keep sending the questions, and we will keep answering them. Have a great day.
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