“Mailbag #7: What does the Fox say?” – with Dr. Nathan Fox

In this mailbag episode, Dr. Nathan Fox answers some of the top questions from our listeners. He addresses questions on placenta previa, vasovagal fainting response, subchorionic hematoma, fertility, and having a history of preeclampsia.

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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.

All right, we’re doing Mailbag number 7: What does the Fox say?

Okay, first question is from Talia, and it’s about placenta previa. Question, “Why is placenta previa more common in IVF pregnancies? After it’s diagnosed at 16 weeks, when is the next best time to check it, or how quickly will it migrate?”

All right, Talia, really good question. So again, just as a review for our listeners, a placenta previa is when the placenta is covering the cervix, right? So the placenta is where the pregnancy implants, and it can be in any part of the uterus, and occasionally it implants lower down in the uterus such that the placenta itself is covering the cervix. It’s usually not a problem. Frequently it resolves, as the uterus grows it moves away from the cervix. If it does not resolve, and it stays in front of the cervix, consequence number one is you would need a cesarean to deliver. It is not safe for the baby to deliver through the placenta to get out of the cervix. That causes hemorrhage. And consequence number two is potentially you could have bleeding during pregnancy, which can lead to other complications, or hospitalizations or whatnot. Okay, so that’s what a placenta previa is.

So it is true, Talia, as you wrote, that placenta previa is more common in IVF pregnancies. There are definitely risk factors for placenta previa. One of them is having a prior pregnancy with a placenta previa. It seems to be slightly higher if you had prior C-sections, it’s definitely higher with twins. And then, other risk factors include having an IVF pregnancy, like you mentioned. As moms get older, it’s slightly higher risk. As moms have more babies, it’s slightly higher risk. And there’s a few other things that increase the risk of placenta previa.

So the question is, why with IVF? The short answer is we don’t know. The possible reasons could be related to the IVF process itself, meaning something about the fact that the conception is happening outside the uterus, and the embryo is getting inserted into the uterus makes it more likely to implant lower in the uterus. Or maybe sometimes the hormones involved in IVF could make the uterus more, I don’t know, susceptible to the pregnancy implanting low. So that’s one possible explanation, that it’s actually the process of the IVF.

And the other possible explanation is that it’s not the process, but just women who need IVF might be more likely to have other risk factors for placenta previa. So for example, increasing age is a risk factor for previa, and it’s an increase as a risk factor for IVF.

And so, it could be a little bit of both. I saw one really interesting study where they looked at a large population, I think it was in Norway, and they did confirm that women who had IVF had a higher risk of placenta previa compared to women who didn’t have IVF. It was I think a five or six-fold increase. But what they did, which is really interesting, is they looked at women who had two pregnancies, one with IVF and one without IVF, and to see if the IVF pregnancy, so this is in the same woman, was more likely to have a placenta previa, and in fact that was true. So meaning if you have let’s say a thousand or whatever number of women who had two pregnancies, one with IVF, one with not, there was a higher chance of having a placenta previa in the IVF pregnancy. And so that is, since it’s the same woman, it would control for those other factors other than age, which they controlled for, and it still was higher.

So there’s probably something related to the population of people who get IVF, but there’s also probably something related to the process of having IVF which increases the risk of placenta previa. For that reason, if people don’t routinely get checked if there’s a placenta previa, sometimes it’s recommended to routinely do it in IVF pregnancies. Again, exactly how that’s done, you need to look closely with ultrasound. And it tends to be part of standard ultrasound assessment of the fetus because you also look at the placenta, but if for some reason that’s not being done, you’d be more likely to do it in IVF pregnancy for that reason.

And the second part of your question is about when it’s diagnosed at 16 weeks, when is the next best time to check in, and how quickly it will migrate. So I would say that for people who are diagnosed earlier in pregnancy with a placenta previa, so 16, 18, 20 weeks, the vast majority of them will not have a placenta previa by the time of delivery. And that number is somewhere north of 90%, based on some details which we’ll go into. But basically, if you’re told you have a placenta previa and your 16, 18, 20 weeks, which is commonly the first time you’d be told it, it does not mean you’re going to have it at time of delivery. How does that placenta move up the uterus? There’s different theories, but essentially the concept is as that uterus gets bigger, the placenta either rolls away from the cervix as it grows with the uterus, or it sort of preferentially grows, moving upwards, and the bottom portion of it has worse blood flow, and it sort of dies out. So those are the sort of theories, but it is true that it’s most likely to migrate.

Some of the ways we help estimate the chance it’s going to migrate is how much is it covering the cervix, right? So if it’s mostly on the, let’s say, front wall of your uterus, and just like, a sliver of the placenta happens to still be over the cervix, like covering by a few millimeters, then that’s a much higher chance, as your uterus grows, of it moving away, versus if the placenta is like, centrally located in the bottom of your uterus, smack dab on the cervix, that’s much less likely to move. There are other risk factors and whatnot, things we look for in ultrasound, or you know, certain characteristics of the pregnancy or the history that would indicate that. But overall, there’s like a 90%-plus chance it’s going to move, and based on some circumstances, we may even be more confident.

That’s whether it’s going to move. How quickly it’s going to move is based on the same factors. The more it’s overlapping the cervix, the longer it’s likely going to take to move, if it’s going to move. So it’s hard for me to say specifically, but when I see someone and I say, all right, your placenta is just barely covering the cervix, and you’re 16 weeks, there’s a really good chance that by 20 weeks it’ll either be completely out of the way, or mostly out of the way and whatnot, so it does depend on some of the details. We typically check again at around 20 weeks, because we were going to look at the baby anyways at 20 weeks. In our practice, we tend to do it about once a month. Different people do it differently. There’s those who just wait until the third trimester, and they’ll say just wait until 28 or 32 weeks, and check it then.

There are advantages and disadvantages to both of those two strategies. Strategy number one, checking more frequently, strategy number two, just waiting and checking at a certain point later. The advantage to strategy number one, and checking more frequently is you’ll know sooner when it has moved off the cervix, and the advantage to that is number one, peace of mind, and number two, and this is more practical, a lot of times we will tell women who have a placenta previa that they shouldn’t do certain things, they shouldn’t travel, they shouldn’t have sex, they shouldn’t exercise. Again, it depends on the circumstances, what exact instructions we give, but frequently there are some instructions. And so if those things are problematic, right, and they’re sort of hindering someone’s ability to live, right, not really live, but sort of live their typical lifestyle, then yeah, then you’d like to know earlier that it’s resolved so you can get back to whatever it is, to having sex, to exercising, you want to go on a trip, whatever it might be. And so that’s the advantage to checking more frequently.

The disadvantage is, all right, it’s more ultrasounds. You’ve got to come for more visits, and whether there’s a financial cost, like whatever it might be, that’s the disadvantage, is doing more ultrasounds. And so there are different strategies. Again, in our practice, we typically do it once a month, but not always. Again, it depends on some of the circumstances.

All right, Talia, good question.

The next question comes from Erin, and it’s about fainting. “Hi, learned about you from “The Toast,” welcome to all our Toasters, “and have found you to be SO great.” Capital letters for “so.” Thank you, Erin, for that. All right, “I just got married, and I’m looking forward to starting a family. However, I have vasovagal, and my triggers are anything medical in nature. I was always the person who fainted in high school, health class, biology, and during doctor’s appointments, when discussions on the human body would cause me to get “squeamish.” Therefore, you can see how I am fearful about the pregnancy process, and how much I can handle without fainting. I started listening to your podcast, thinking maybe it could be like exposure therapy, the more I familiarize myself, the more comfortable I can get. Have you ever had a patient with vasovagal fainting response or phobia of medical things? Is fainting during pregnancy bad for the baby?”

Okay, Erin, thank you for the question. There are a lot of people out there like you, you are not alone, who are vasovagal. Interestingly, I am one of those people. I’m a fainter. When I was in training, I fainted during one of my first deliveries, I fainted during one of my first C-sections, I fainted during one of my first hysterectomies, but fortunately, never since. So yes, I had some sort of exposure therapy, and got better. My family have got a long line of fainters, seeing blood or medical procedure. So it definitely happens, it’s very, very common, and yes, it’s something that absolutely can get better with exposure therapy. Frequently, pregnancy is exposure therapy for people. There’s a lot of doctor visits, blood draws, a lot of medical stuff. So it might be hard on the front end, but hopefully with more exposure could get better. There’s obviously probably other strategies to help this. I’m not…it’s not my field, but whether it’s psychiatry, psychology, whether it’s… You know, that’s not really my field, but I imagine there’s people who help people through this, and get them better at it. But yes, there is a possibility it will just get better, and yes, I’ve definitely seen this.

Whereas also a lot of people who maybe don’t have the vasovagal component, but have let’s say the anxiety component, a lot of people have anxiety over doctors visits, and that might lead to, again, just other symptoms, or heart racing, sweating, maybe their blood pressure goes up. That definitely happens, and there are sort of ways to mitigate that as well, whether it’s by some sort of, like, cognitive therapy, or whether it’s actual medication for anxiety before doctors visits, these are all possible.

Now, what’s interesting about vasovagal and pregnancy is that there are definitely women who get it, who never had it before when they’re pregnant, and that’s because of the physiology of pregnancy. So what is vasovagal? Essentially, the concept is when someone faints, the reason people faint physiologically is that there’s decreased blood flow to the brain, and then the brain sort of gets a little hazy. And that’s why before someone faints sort of they start seeing spots, they get a little dizzy, their vision starts coming in and out, they feel lightheaded, like they can say, “I feel like I’m going to faint,” and that’s because, again, it’s the brain getting decreased blood flow. It’s doing that, and then usually what happens is eventually, the brain sort of like, not totally shuts down, but sort of shuts down certain systems, and you pass out. Usually during that kind of fainting, your heart rate is slow, your blood pressure is a little bit low, and then what happens is when you’re lying down on the floor, right, there’s sort of gravity bringing blood back to your brain, and you come to, you wake up, and you’re okay, and it’s usually just, you’re out, so to speak, for just a matter of seconds, maybe up to a minute.

So one of the strategies that is employed for people who faint a lot, when you feel that pre-fainting, what we call in medicine pre-syncope, S-Y-N-C-O-P-E, that’s like the medical term for fainting, when you feel pre-syncope or pre-fainting, one of the strategies is get yourself in a physical position where your head is down, and your feet are up, like lying on the floor, and put your feet on a chair or something like that, so that gravity brings blood back to your brain. And usually it will either prevent the fainting, and you feel better, or if you did faint, it’ll make you better much, much quicker. So that’s one of the strategies.

Now, in pregnancy what’s interesting is one of the normal responses to pregnancy that the body has is blood vessels dilate. They sort of they loosen, and they dilate. And so some of the consequences of that like in your legs are you get swelling in your legs, sometimes people that have varicose veins, they get larger in pregnancy, that’s because those blood vessels sort of down in your feet are dilating, and there’s more blood pooling into them. One of the other consequences is if there’s blood pooling in your legs, in these blood vessels in your legs, when you stand up or get up from a chair, or get out of bed, there’s less blood going to your brain. Because normally, your body sort of…the blood vessels squeeze, and sort of push blood up north to your brain, and in pregnancy that’s less likely to happen. So a lot of pregnant women who never had fainting before, or syncope or pre-syncope, never had those symptoms, in pregnancy they get them a lot, and they’re usually concerned that there’s something wrong with them, that they have a new problem.

And yes, there are circumstances where it’s more concerning, or more confusing, and we, you know, double-check there’s nothing going on with their heart or whatever, but again, usually it’s just their response, their physiologic response to pregnancy. And again, the strategies are the same. Before you get up, maybe sit up, and make sure you don’t any symptoms, and if you start feeling those symptoms, sit back down, lie back down, put your feet up, all those things.

It does not appear to be dangerous to the baby, to faint. And the reason is, you know, this is about blood going to your brain, not blood going to the uterus, and when your blood pressure drops, as long as you’re able to sort of lie down and get your feet up, the blood pressure comes up pretty quickly. So as far as we know, it’s not dangerous for the baby, to have those kinds of episodes. Now, if somehow your blood pressure dropped, and you were sort of upright and couldn’t lie down, you know, that could potentially be… But that’s not what happens. Usually when you faint, you pass out, and you hit the floor.

So what I would say is the short answer to your question is it definitely happens. I’m sorry you’re going through this, it definitely happens. People can get sort of more exposure and therapy to alleviate the triggers that cause this, but physiologically, it can happen in pregnancy even if you don’t have any triggers, and you feel fine. And again, usually the thing to do is just when you feel that pre-fainting, pre-syncope, just lie down, put your feet up, and you should feel better quickly. If you’re unable to lie down, like you’re on a subway or a train or something like that, you can try to sit, and put your head down in your lap as low as you can go. The key is to do anything you can to get gravity to get blood to your brain.

Thank you, Erin.

All right, next question is from Kelly, and it’s regarding subchorionic hematoma. “Hi, Dr. Fox. As a mom to three, I love your podcast, and LOVED,” all capitals, “hearing Jackie on the pod.” All right, we’ve got another Toaster. “My questions are surrounding subchorionic hematomas. Throughout my pregnancy, from 10 weeks until birth at 29 weeks, 6 days, I had anywhere from a 6-centimeter hematoma to a 1.10 centimeters. I was always told it would go away, and that they are harmless, but that just wasn’t my case. I bled heavily every day for 19 weeks, and was terrified every single day and night. It was a constant cycle of bleeding, then contracting, contracting, then bleeding some more, both were causing the other, four hospitalizations, and one that lasted 16 days, and eventually led to my son’s birth. My questions to doctors were always left unanswered, with we aren’t sure why this happens.

Why didn’t mine go away? Is there a procedure we could have done to minimize the SCH?” That’s short for subchorionic hematoma. I joined a Facebook group of women who suffered my same pain. Any deep dive into SCH would be helpful. All this to say my baby is now two months old, adjusted, and is doing amazing. Thank you.”

Kelly, wow. Sorry you went through that. I’m really happy to hear that your baby’s doing great. That’s definitely a pretty rocky pregnancy. We did have a podcast on subchorionic hematoma, and we have done some research on subchorionic hematomas, and I will say that it’s definitely a tough topic because on the one hand, subchorionic hematomas get overblown, meaning many people who have subchorionic hematomas are told big problem, when in fact there’s no problem. And on the other side, there’s definitely people who have subchorionic hematomas that are a big problem, that are told it’s not a problem, which sounds like was the case for you. And so that is tough, as a condition.

As some background, so a subchorionic hematoma is an ultrasound finding where in pregnancy, we see a collection of blood, or we call it a blood clot, same thing, inside the uterus sort of at the edge of the placenta, or behind the placenta. And the thought is that early in pregnancy, when the placenta attaches to the uterus, there is sometimes a small sliver, a small edge of the placenta that doesn’t attach perfectly, and because of that, there’s some bleeding that happens sort of behind it, and it collects and it stays there. And these are very common early in pregnancy. In the first trimester, we see it, you know, 10% to 20% of the time, and in women with no symptoms whatsoever. Everything’s perfectly fine, we just find them on ultrasound, if you look close enough, you’re going to find them. And when we did the podcast on the topic, and the research we did on the topic, it was related to that phenomenon, someone who we just find a hematoma on ultrasound, she’s perfectly fine, the baby’s perfectly fine, she’s not bleeding, everything’s otherwise fine, and we see it, what does that mean?

And what we showed in our research, and published, and talked on the podcast is that for those women, with that kind of hematoma, it does not appear to increase the risk of anything in pregnancy. It does not increase the risk of miscarriage, it does not increase the risk of preterm birth, and this is…because that’s sort of what’s quoted. But there are also a lot of women who have subchronic hematomas, who in addition to that have bleeding, have contracting, they’re much larger, they go on later in pregnancy, during the second trimester, not the first trimester, and in those situations, yes, absolutely, they are a big problem, they’re a big deal. And for them, it would be inappropriate to say there’s nothing wrong, but they’re clearly two different populations here.

So the vast majority of people who have a subchorionic hematoma are told they have a subchorionic hematoma, and someone speaks to them about it are in the first group, where there’s nothing going on, no symptoms, everything’s fine, it’s just a finding on ultrasound. And in that group, the data shows that probably there’s nothing to worry about, you know, it should be fine, it should not increase the risk of anything. The second group is the ones who have these big hematomas like you had, and bleeding, and it’s persisting, and it’s a second trimester, and in those situations, there’s definitely studies that show there are an increased risk of all those complications of bleeding, obviously, of preterm birth, of your water breaking, of all these bad outcomes that could happen, and that ultimately you deliver preterm. Thank God your baby is well, but certainly you delivered preterm.

And so part of the problem out there is that there isn’t a distinction between the two sometimes in the counseling. Meaning sometimes when someone is in group one, and has this sort of asymptomatic, early, small hematoma, they’re told the same outcomes as group two. And they’ll say, oh, because there’s a hematoma, you have a risk of preterm birth, and fetal birth restriction, and all these horrible things that could happen to you, which probably isn’t really based on good data. And sometimes people in group two, right, who have this sort of bigger problem in the second trimester, they’ll say, oh, you know, most people with hematoma, they do perfectly fine, and really, it needs to be more precise than that. So either someone who, like, Googles, and then it’s hard to get precision, or even the doctors and midwives who counsel about it need to sort of be able to differentiate what’s going on with you specifically, your hematoma. So that would mean how far pregnant are you? How big is the hematoma? Are you bleeding or not? Are there other risk factors? And based on all of that, we try to be a little bit more precise about what the prognosis is ranging from, very, very, very, very good, to much more not good, potentially, and things we may do about it.

So that is sort of like, why the messaging is sometimes confusing. In terms of why they happen, we don’t know why they happen. We don’t know why it happens in one person versus another person, often. We don’t know why it happens to one person in one pregnancy, but not in the next pregnancy. These are things that in some people they happen over and over and over, but in most people you have it in one pregnancy, but then you don’t have it in the next pregnancy, and we don’t really understand why that is. There’s probably something related, again, to placental attachment, but how much of that is based on the actual mother, or the uterus, or genetics or whatever we don’t know, versus just luck, right? It could just be, all right, you know, 95 out of 100 times a placenta attaches fine, and randomly, five of them don’t, and those people are going to have problems. We don’t know how much of it is random, versus something sort of related to something in the mother, the uterus, or whatever it might be. So that’s an unanswered question, where we don’t really know.

In terms of is there a procedure we could do to minimize a hematoma, as far as we know, no. As far as we know, like, trying to put a needle in, and you know, suck out the blood, we don’t think it’s going to help, and it may even hurt, so that’s not something that’s typically done, so we don’t really know what to do. Ultimately, there’s sometimes treatment with progesterone that people try. Again, the data on that is pretty mixed, whether it’s helpful or not. Whether bed rest helps in these circumstances, we don’t really know, or decreased activity, or not having sex. And it’s really tough, because again, to know what treatments are going to be effective, you also have to be very specific about what population you’re using it in.

So if I looked at treatments for women with that first group, with the sort of asymptomatic first trimester hematoma, well, none of them are going to really be effective because there’s not really an issue. Versus someone with more what you had, that would be…you’d have to have a lot of people just like you, and then try treatments in that group specifically, and the studies in that are just more limited.

So again, to summarize, there’s a wide range of what a hematoma means. It can range from something that has very little consequence, to something with a lot of consequence. And what determines that range is how big is the hematoma, is there bleeding or not, are there other risk factors, and how far pregnant you are, and that’ll determine sort of what the management is and what the prognosis is. Again, I’m really happy your baby is doing well. Thanks for the question.

All right, next question is from Hannah, it’s related to fertility. “Hello, from a trying-to-conceive Toaster.” We’re getting a lot of Toaster questions. We love it. Keep them coming. “I have long feared about my fertility. There are literally notes in my chart that I have ‘undue concerns.’” Oh, that’s not nice. “I got married this summer, and am now on my fourth cycle of trying to conceive. I have a 28-day cycle, but ovulate between days 17 and 19. Is there anything you recommend to extend my luteal phase?

Additionally, when I was 23, I was diagnosed with chlamydia. I dated the biggest LOSER,” in caps, “who stole from me, and gave me the clap, lol. During this time, I had an IUD inserted as well. I’m fearful I had PID/ scarring from this, but multiple providers have told me that I would know if I ever had PID. Am I crazy? Any recommendations? Will I ever get pregnant? Thank you Dr. Fox.”

All right, Hannah, there’s a lot in there. And I’m not a fertility specialist, and I don’t claim to be one, but obviously I know something about it, so I’ll try to answer your questions as best as I can.

So in terms starting with your cycle, so you have a 28-day cycle, but ovulate between days 17 and 19, and you’re asking about anything to do about that. So just for some background, in a typical 28-day cycle, people usually ovulate 14 days before the end, so for you that would be day 14, and you’re saying you ovulate between days 17 and 19. So the first thing is I’m not aware that that itself should cause fertility issues. It would just mean that you would have to have sex and try to conceive a little bit later in the cycle, days 17 to 19, versus day 14. But if I’m wrong, and somehow getting the ovulation earlier is going to be helpful, yes, there are definitely medications one can take to sort of stimulate ovulation in general, and at a certain time. There’s Clomid, there’s Letrozole, there’s a bunch of things out there. Again, I don’t typically prescribe them in my own practice because I don’t do general gynecology or fertility, but they’re out there. Either a good general gynecologist, or certainly a fertility specialist could talk to you about that, A, do you need to have your ovulation moved earlier to day 14? And B, how to do that. And that’s possible. I don’t know if it’s necessary, but it’s certainly possible.

In terms of the fact that you’ve had four cycles and have not conceived, what I’ll tell you is fortunately, although that is distressing, it is not uncommon, and it does not mean that there’s any fertility issue whatsoever. Generally, for someone who’s young and healthy, it can take sometimes up to a year to conceive. Again, that definitely could be distressing, it can be sort of frustrating, but it does not mean there’s a problem. Typically, the numbers that I recall is that in any given cycle, the likelihood of conceiving is about 25%. So if you do the math on that, it doesn’t mean that after four you have a 100% chance of conceiving, it just means that once you do statistics, you have to work it backwards…whatever. We could do the math offline. But basically, it’s very common to go four cycles, or five cycles or whatever without conceiving. So hopefully there’s no issue whatsoever, and you’ll just conceive, and send me back a message saying, hey, I’m pregnant, great. But if there’s an issue, and it’s related to when you ovulate, again, that’s something that could be addressed if necessary, and it’s not that complicated, either by a good gynecologist or a fertility specialist.

In terms of the chlamydia you were diagnosed at age 23, yes, sorry you dated that guy who gave it to you. Fortunately, it is treatable with antibiotics, if you got that. And the question you had is whether you had PID/scarring. So PID is an acronym for pelvic inflammatory disease, and it’s basically the term we use for when someone gets an infection like chlamydia, like gonorrhea, that leads to…it ascends through the uterus, through the tubes, into the belly, into the abdomen, and you get scarring from this healed infection. And the scarring would be by your tubes, by your uterus, in the lower pelvis, and the fear from that is that the scarring would cause your tubes to sort of be either blocked or dysfunctional in some ways, so that you couldn’t get pregnant. Meaning having scarring in your tubes, having prior PID is a risk factor for infertility, specifically because it can affect the tubes which are needed for fertility.

So the question is could someone have PID, and not know about it? Well, classically no, because classically, PID, you’re pretty sick with it. You would have infection, you’d have pain, you’d have fevers, you’d be sick, and you’d need antibiotics. But from time to time, we definitely see people who have a lot of scarring by their tubes, and they don’t really recall a history of ever having that. They’re like, no, I don’t think I ever had that, and maybe they never knew that any infection. Or they got it, and it was treated, and they didn’t have all those symptoms. So I think probably you would know if you had PID, but I don’t think I would say you would definitely know. So meaning it is possible to have scarring with your tubes, without having the history of all those symptoms.

In terms of recommendations, again, the way to find out if your tubes are open is generally through a radiologic test called a HSG, hysterosalpingogram, which is basically we go to a radiologist, and they pretty much squirt some dye into the uterus, and then they take an X-ray from above, and then the dye, if the tubes are open, should spill into the tubes, and out into your belly. This is a standard test that’s done as part of a fertility workup. And so if you’re concerned that your tubes might be blocked, that would be the test to get. Again, do you need to do it after four months? You know, it’s a judgment call, right? You could on the one hand wait and see what happens, or you can do that test earlier. I’m told that test is uncomfortable to have. I’ve never had it done to me, it’s not a test I do in my office, but I’m told it’s definitely uncomfortable to have, so that’s one downside to it. But you would know, and at least answer that question.

So I think the overall arching answer to your questions, my opinion would be that hopefully, you have nothing to be worried about whatsoever. But if you did, it sounds like this is something that could be worked up either by a general gynecologist or a fertility specialist, who could hopefully get you the answers that you’re looking for, and get you pregnant either on your own, with some reassurance, or if there’s any treatments needed in a timely manner.

Good luck to you, Hannah. Thank you for the question.

Last question is from Dolly, and it’s about having a history of preeclampsia. “Hi, Dr. Fox. Toaster here.” Wow, a lot of Toasters today. Awesome. “I was wondering if you are considered high risk in your pregnancies if you had preeclampsia in your first pregnancy. I found it at around 38 weeks, and was induced. If I wanted to get pregnant again, am I considered high risk because of the chance of getting it again? It makes me very nervous. Is there anything to do to ensure I don’t get it again? I’ve heard low-dose aspirin next time, but wanted to hear what you think. Thanks so much.”

All right, Dolly, so the short answer is yes, if you’ve had a history of preeclampsia you have an increased risk of preeclampsia in subsequent pregnancies. Exactly what that risk is depends on the circumstances of your preeclampsia in the first pregnancy, how severe was it, how early was it, and do you have other risk factors for it, but it is increased. And so the general baseline risk of preeclampsia in the population is about 5%-ish, and then certain risk factors might make it 10%. Having a history of preeclampsia, we generally tell people the risk of recurrence is somewhere from 10% to 50%. It’s a pretty wide range, 10% to 50%, 5-0, but it does, again, depend on some of the circumstances.

But it is increased, so does that mean you’re a high risk pregnancy? Well, it depends. And we don’t usually label people as high risk or low risk, but it definitely is a risk factor for preeclampsia. So if one wants to consider themselves high-risk because of this, yes, or just at risk is another way of putting it. That’s another way, if you don’t want to be considered high risk. But basically, there is a risk for getting preeclampsia in the next pregnancy.

So what to do about it? There are good data that low dose aspirin, as you mentioned, lowers the risk of recurrent preeclampsia, meaning getting it again. There’s actually data that it lowers the risk of preeclampsia in probably everybody, but since the risk is higher in someone who’s had preeclampsia, it seems more valuable to take the baby aspirin, or the low-dose aspirin, in that group. One of the questions is, well, what dose? In the United States, low-dose aspirin is also called baby aspirin, and it comes pretty much everywhere in the U.S. as 81 milligrams. It’s a very specific number, 81. Why 81? It’s basically one-fourth of one aspirin. An aspirin is 325, you divide that by 4, you get 81.25, so they say it’s 81 milligrams. So that’s what it is in the U.S.

There are places around the world where you can get low-dose aspirin as 100 milligrams, as 150 milligrams, and there is some debate about exactly what is the optimal dose. In the U.S., most people are using 81 milligrams because that’s what you have, that’s what you can find. Number two, the largest studies use that dose. And so the ones that we use to tell people that it’s safe, that it does not increase the risk of any complications like bleeding was based on 81 milligrams. We’re not as certain with higher doses about the safety profile, and so most people are going to get recommended to take 81 milligrams. Now, around the world you’re gonna get recommended different doses based on what they have. Some will say 100, some 150. In the U.S. there are some people who recommend taking a higher dose, and so the way it’s typically done here, because there’s no other way to do it, is to take two baby aspirin, which would be 162 milligrams. And in our practice, I would say generally we give 81 milligrams, and there’s a few people, sort of case-by-case, who we recommend the increased dose, the 162 milligrams. That’s going to vary greatly throughout the country in terms of what dose.

But in terms of taking baby aspirin versus not taking baby aspirin, pretty much that’s the recommendation if you’ve had a history of preeclampsia, to take baby aspirin or some form of low dose aspirin in the next pregnancy.

Other things that might happen is we sometimes will do increased frequency of ultrasounds to make sure the baby’s growing well. Sometimes a history of preeclampsia in one pregnancy can have an increased risk of other things in the next pregnancy. It sort of depends on some of the circumstances. Sometimes we’ll have you check your blood pressure at home at some frequency, or have you have more frequent office visits, because you don’t always know if your blood pressure is going up. So those are some of the things that we do.

I would tell you that if your preeclampsia was at 38 weeks, and it sort of resolved quickly after delivery, and otherwise you and the baby did well, then yes, generally, your risk in the next pregnancy would be increased, but shouldn’t be crazy. It doesn’t tend to get much more worse and much more early with each pregnancy, so hopefully it would either not happen at all, or happen in a similar manner in the next pregnancy, where you can get induced and have a happy and healthy baby. Or taking the baby aspirin might lower that risk entirely. Good luck to you, thanks for the question.

All right this was Mailbag number 7. Please do keep sending in the questions. As they come in, we’re going to answer them. Have a great day.

Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast, or any other topic you would like us to address, please feel free to email us at HW@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only, and does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health, and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.


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