“Our First Mailbag Episode!: Your questions answered” – with Dr. Jessica Spiegelman

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 OB-GYN 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, Dr. Jessica Spiegelman, Spiegs. Jess, welcome back to the podcast. How you doing?

Dr. Spiegelman: I’m good. Thanks for having me back.

Dr. Fox: So, this is really a first for our podcast. We’re doing the mailbag or the lightning round, as you like to call. We’re just gonna go through rapid fire the topics that you, our listeners, have sent in. I thought Speigs would be great for this. This is very much like residency training at the blackboard, or whiteboard, or electronic board, or wherever they are now. Just boom, boom, boom. Just throwing questions left and right at the residents, throwing 100 miles an hour at them and seeing whether they swing and miss, or whether they hit it out of the park.

So, I did let you know, because we were talking back and forth how to do this, what the questions were. I don’t know if in the future, maybe I won’t, I’m not sure to see I…

Dr. Spiegelman: I feel like it would be more fun if I didn’t know the questions in advance. It’ll be more like residency.

Dr. Fox: That would be more like residency. But it could sometimes take a turn for the worse. I guess, this is sort of like for those who know the ’90s movie reference, this is gonna be like “Quiz Show.” So, you have the questions…

Dr. Spiegelman: I did not know that reference.

Dr. Fox: Oh, all right. You’ll have to look it up. It’s a good movie from the ’90s. So, yeah, we’re gonna be doing this. Hopefully, you guys, the listeners will be inspired by podcasts like this to send in your questions related to pregnancy, related to women’s health, related to gynecology, whatever it is. And as we compile them, we’ll just start doing these podcasts. And the more questions we get, the more of these we’ll have and get your questions answered. So, Speigs, game on.

Dr. Spiegelman: All right.

Dr. Fox: You ready?

Dr. Spiegelman: Yes.

Dr. Fox: Sixty seconds on the clock. No, no, no. There’s no clock here. So, the first question that we’re gonna talk about came in from one of our listeners. I don’t know if it’s Megan or Megan. Thank you for sending it in. And the question is, “One thing I was wondering if you could talk about is lactose intolerance in pregnancy. I’m severely lactose intolerant, and it seemed to ease off during third trimester, and has stayed away so far during breastfeeding. I can’t find any reliable resources on this phenomenon, but I’m loving it.” Honestly, I had never thought about lactose intolerance in pregnancy until that question came in.

Dr. Spiegelman: Yeah. It’s actually very interesting because I feel like the way I think about this usually is people talking about after birth, their babies having dairy intolerance and having to go off of dairy products. So, kind of in the opposite way. And I don’t know that anybody’s ever told me before that, “Oh, magically, my lactose intolerance has gotten better during pregnancy.” So, I’m very happy for Megan. That’s great news.

Dr. Fox: No, yeah. Good. Awesome. Great job. I also… Most of the time we’re talking about sort of digestion and intestinal stuff in pregnancy, most people, at least in my experience, it’s the opposite. That they’re sort of like, fine, and then in pregnancy they’re like, “Oh my God, what is going on? Like, I’m bloated, I’m constipated, I’ve diarrhea,” like you know…

Dr. Spiegelman: Can’t tolerate foods they used to tolerate.

Dr. Fox: Yeah. And not the nausea part of it, but just like they get sort of this temporary irritable bowel type thing. And which is very common in pregnancy. So, I don’t hear a lot of people saying, “I’m getting better from my intestinals.

Dr. Spiegelman: Yeah. The deception is things that are like autoimmune-mediated, which we know that the immune system is suppressed in pregnancy. And so, things that are considered autoimmune conditions do tend to get better in pregnancy, but they do tend to sometimes get worse actually postpartum. But lactose intolerance isn’t that so.

Dr. Fox: Yeah, I don’t exactly know why people get lactose intolerant, like as opposed to someone else, but it’s not autoimmune, and it’s not infectious, it’s not anatomic. It’s presumably, for whatever reason, they’re lacking an enzyme…

Dr. Spiegelman: [Crosstalk 00:03:58] genetic.

Dr. Fox: Yeah. Who knows? But, so it’s interesting. So, we did a little research and actually found that people have reported this. We found a couple of studies. There was one back from when you were just a newborn from obstetrics and gynecology in the late ’80s, where essentially, the researchers took 114 women, it looks like, who had lactose intolerance, and they were doing like proper breath tests, like the real testing for lactose intolerance, and found that almost half of them got better when they were pregnant.

Dr. Spiegelman: I like the classification that this article uses of calling people either maldigesters or digesters.

Dr. Fox: Right. So, Megan, you’ve gone from a maldigester to a digester, if you’re curious, you can just get a t-shirt, “High, I am a digester.” But they found this. And it’s a real phenomenon apparently. I don’t really understand what the mechanism might be of it. They sort of propose that there’s this like teleologic reason, this evolutionary reason that when you’re pregnant, you’re supposed to take in calcium, and all that. And okay, great.

Dr. Spiegelman: Well, pregnancy is a natural calcium depleter, like it depletes calcium from the mother’s body. So, it does make sense that there would be an evolutionary adaptation to have you absorb more of that.

Dr. Fox: Yeah. So, go figure.

Dr. Spiegelman: It’s very interesting.

Dr. Fox: And then there was a study that was repeated or similar study in…

Dr. Spiegelman: Late ’90s.

Dr. Fox: In the ’90s. And the same things, I think it was 28 women who showed up. And again, a bunch of them just did better with lactose intolerance.

Dr. Spiegelman: But they don’t mention how long it lasts. So, we do not have an answer for you on that one.

Dr. Fox: Yeah. If it’s something related, I mean, in pregnancy, the things that tend to get better during pregnancy usually worsen or get back to where they were like four to eight weeks after birth when the body comes back to normal. But I don’t know if nursing would potentially elongate that because of the calcium depletion.

Dr. Spiegelman: Yeah. If that’s really the kind of evolutionary reason for this, then it would make sense that it would last for as long as you’re breastfeeding.

Dr. Fox: Yes. So, that’s pretty cool. So, all you listeners out there who have lactose intolerance, hey…

Dr. Spiegelman: Let’s hope.

Dr. Fox: Yeah. Maybe you’ll get some sort of reprieve when you’re pregnant. And if you’re not sure, maybe try it, see what happens. Give it a whirl and see if you can have that yogurt that you never could have before.

Dr. Spiegelman: You’re gonna get a lot of angry emails now about people’s digestive issues during pregnancy.

Dr. Fox: “You told me I’m dairy. This is awful!”

Dr. Spiegelman: “Dr. Fox said I could have ice cream.”

Dr. Fox: I just said you could try. Just try. Well, it is important because just as you mentioned before, pregnancy’s a time when the mother’s calcium gets depleted, the baby’s taking it, obviously, which is a big one, and she’s diluted in terms of her blood volume, and there’s a lot more turnover. And it’s actually one of the things that most pregnant women don’t get enough of in their diet.

Dr. Spiegelman: It’s true.

Dr. Fox: I mean, yeah, the recommended amount in everybody, even if you’re not pregnant, actually is 1,000 milligrams a day, which is a lot. People don’t realize that. And the amount of a prenatal is negligible. It’s like 100, 150, because it would just be so… The calcium takes up room. So, if you had to put 1,000 in a prenatal, you’d have to, I think, eat it with a fork and a knife.

Dr. Spiegelman: It’s like those big chewy tabs that taste like caramel or whatever.

Dr. Fox: Yeah. Yeah. I mean, so, in my practice, I recommend everybody take supplemental calcium unless you happen to be a huge dairy person. Like two glasses of milk a day plus a yogurt. You’re one of those?

Dr. Spiegelman: Oh yeah. I’m a digester.

Dr. Fox: You’re a digester? So, you’re big in the dairy departments?

Dr. Spiegelman: Mm-hmm. Oh yeah.

Dr. Fox: Wow. Wow. Are you sure you’re Jewish?

Dr. Spiegelman: I know. It’s really confusing. It’s confusing. And my baby now is obsessed with cheese, and just says, “Cheese,” all the time. And I’m like, this is how we know that he’s related to me.

Dr. Fox: That’s really unbelievable. Yeah. You are the exception. I mean, I always ask my patients say, “Hey, how much calcium you had?” Like, “No.” I’m like, “Well, do you drink milk?” They’re like, “Oh, absolutely.” I’m like, “How much?” Like, “Well, I have like this tiny amount in my cereal,” I’m like, “Anything else?” Like, “No, you gotta boost it up.” So, alright, good. So, thank you Megan or Megan for that question, and we’re gonna move on.

Question number two comes from Caitlin. So, Caitlin writes, “I would love to understand more the limitations of massage during pregnancy. What are the medical risks exactly, and are the limitations different during the first versus third trimester? Also, do all the same rules around massage during pregnancy also apply to acupressure?” So, how would you hit this one, Speigs?

Dr. Spiegelman: So, I love hate this question because we get this question a lot in the office. And I feel like there isn’t a great way to answer it with a lot of science. But there is there’s some data out there about massage in pregnancy. And the sort of general things that I tell people is, most of the time, if you’re going to a reputable place and they’re marketing a prenatal massage, it is safe. If they structure these massages so that they don’t run into any of the things that we think about as risk with massage, the main risks really are positional. So, it’s not really comfortable to lie flat on your back, especially later in pregnancy. And also, can inhibit… Return blood flow to the uterus, can cause nerve issues.

So, in general, kind of like being on your side is really the best and prenatal massage does that. It positions people on their sides. And then also, the idea of deep tissue massage, and in really rare cases, if somebody happens to have like a blood clot in their leg, potentially dislodging that blood clot and having it kind of travel up to the lungs. Other things that people worry about are, and this call kind of goes into acupressure and acupuncture as well, acupressure really is, are there trigger points that can trigger labor? And I don’t know if we have great science on that. So, in general, I tell people if it’s marketed as a prenatal massage, and it’s from a place that is reputable and not kind of like someone…some guy in their basement or in a van, then it’s probably done in a way that is safe for pregnancy.

Dr. Fox: Yeah. Well, that’s a lot more than I say. I just say it’s fine. I say, “Massage? Yeah, that’s fine. That’s good. No rules.” I mean, I think that when people are concerned about massage, I think in my experience, it’s this idea that if I get a massage it’s gonna put me into labor because someone has told them that. And like the acupressure part, which I don’t really buy into so much. Someone’s like, “Well, you can’t rub the feet.” I was like, really?

Dr. Spiegelman: I don’t think the data’s there for that.

Dr. Fox: Yeah. I was like, “Really? You get a foot massage, you go into labor?” Like if it were that easy, we would’ve no problem inducing labor. I mean, it’s just, that doesn’t…

Dr. Spiegelman: You could never get a pedicure.

Dr. Fox: Yeah. So, I’m not a big proponent to that. And people’s feet hurt when they’re pregnant, they’re swollen, and they’re in pain and this, and I’m like, get a fu… Like god bless, if it’s gonna make you feel better, probably, maybe it reduces stress and anxiety and it improves outcomes. Who knows? So, I typically give people no rules. I say if you’re really the end of pregnancy, say if you’re lying flat on your back for an hour, it may be uncomfortable for you. But you’ll know that typically. I mean, it’s like when we do an ultrasound at the very end of pregnancy, you can’t do it for that long because it’s hard to lie flat on your back at the end. So, we…

Dr. Spiegelman: I think there’s a lot of fear around lying flat on your back. And I think outside of the context of massage, patients ask all the time in the office, “I try to sleep on my side, but I wake up on my back and is that okay?” I’m like, you’re sleeping.

Dr. Fox: Yeah, it’s fine.

Dr. Spiegelman: What are you supposed to do? And if that… You’re not the first person to have this problem and we don’t see a lot of problems from it. So, yeah. Your body is smart. It will be uncomfortable if you’re doing something that is bad for it.

Dr. Fox: Yeah. I think massage is great. So, I tell everyone and listen, I’m not hating on anybody who advertises prenatal massage, but it’s mostly a marketing gimmick to get you guys to come in and pay, and get a massage. It’s not that different from a regular massage other than they’re gonna sort of like take it more gentle, and talk about the baby and say, oh, we’re gonna do this. And it’s lovely and they’re great, but you could also go to a regular masseuse and say, “Hey, I’m pregnant.” Or just, they’ll see your belly and see you’re pregnant. And they should generally know what to do. Unless it’s that guy in the van or the basement who you’re apparently going to get massages from.

Dr. Spiegelman: I did not go to the guy in the van or the basement [crosstalk 00:11:52].

Dr. Fox: Sounds like someone’s gonna abduct you.

Dr. Spiegelman: It doesn’t sound safe.

Dr. Fox: Does the van have tinted windows? Hey, Spiegs, “I got candy. Come on in.”

Dr. Spiegelman: I’m very gullible like that.

Dr. Fox: That’s all that does offer you a glass of milk and you’re just coming. “I got a glass of milk. Come on in.” Wow. So, yeah. I mean, yeah, no, I’m a big fan of massage. A lot of people, it helps them with their, again, swelling in their lower extremities, low back pain, stress, neck pain, all the stuff that comes up in pregnancy legitimately. So, I think it’s awesome.

Dr. Spiegelman: Yeah, I’m a massage fan as well.

Dr. Fox: Yeah. So, I mean, specifically, there really isn’t anything different first and third trimester except in the third if it’s later you are physically larger, so it may be hard to lie on your back. First trimester, I don’t even feel it’s necessary to tell the masseuse you’re pregnant. I mean, yeah, whatever. Again, what are they… They’re not gonna do anything to you that’s gonna hurt the baby or the pregnancy. So, you’re welcome to tell them, but it’s not gonna really make a big difference. In terms of acupressure, acupuncture, there are a lot of people who get those in pregnancy. Usually, it’s for pain.

There are some people who get it at the end of pregnancy because it’s advertised as something that’s going to either put them into labor, like they want to go into labor, or it to advertise as something that’s going to potentially turn the baby from head up to head down. The data on that is very weak, but the safety data is there. It seems to be quite safe. If you wanna get acupuncture during pregnancy…

Dr. Spiegelman: Go for it.

Dr. Fox: … God bless, go for it. Go to good place that’s not doing out of his van or his basement Although, I guess, a basement would be okay if it’s a reputable basement.

Dr. Spiegelman: Yeah.

Dr. Fox: I wouldn’t do an acupuncture van. I guess. I don’t know. All right. Thank you Caitlin. The next question we have is from Toby. Hey Toby. I actually saw Toby in the office face-to-face also, so I know who Toby is. She’s delightful. So, Toby asked a real… She asked a bunch of questions, but a couple of them were really need to be full podcasts. So we’re gonna go to there. But the one she asked, which is really interesting, and we spoke about a little face-to-face in the office, here’s what she wrote. Tiktok/Instagram women’s health trends.

There are a lot of accounts, some good, some bad, some actually horrible that say a lot of different things about pregnancy and birth. Mostly, there’s a lot of doctor-bashing, boo, and an overall idea that doctors don’t have women’s best interests in mind. How are doctors and midwives responding to these accounts, and to the women in their practices who see and possibly believe some of these influencers? How do you respond when there’s something legitimate in the news/social media that is concerning patients? I just want to say off the front, I don’t have TikTok.

Dr. Spiegelman: Same.

Dr. Fox: And I actually told her that I believe TikTok is like chemical warfare. If we could go back in time and uninvent it, the world would be a better place. I actually said that like in court on a witness stand recently and the jury got a little chuckle, though I don’t know what that’s gonna do to my life. So, yeah. So, but this does happen. Obviously, there’s a lot out there and doctors’ good, doctors are bad, midwives are good, midwives are bad, doulas are good, doulas are bad, all this stuff. How do you sort of approach that world?

Dr. Spiegelman: So, I like this question for me to answer actually, because I am somebody who also doesn’t have TikTok, which maybe makes me not as an expert in this. But the reason I don’t have TikTok is because of this. So, I have a lot of feelings about it. I actually think this could be its own podcast because I could talk about it all day. And I also am somebody who, I do have Instagram, but I recently deleted it from my home screen on my phone, which has made a big quality of life difference for myself. I will just give a little plug for that.

Anyway, there are so many accounts on these social media platforms that are either claiming to promote health, or actually promoting health. And I agree, a lot of them do a decent amount of doctor-bashing and sort of make it seem like you’re supposed to believe that your healthcare team is not actually your team, and that people who really have devoted their lives and careers to women’s health are not actually women’s health advocates. And there’s a lot of danger in that. I’m not gonna say that universally, every single person who goes into OB-GYN, who goes into midwifery, birthing, these fields, 100% of them are not gonna have pure interests.

But really, it’s a very hard lifestyle and most people who choose this field do it because they care about women’s health, and because they wanna be advocates for women. So, just statistically, like most likely, your provider is on your side and wants to advocate for you. And I think there’s also a lot of money to be made in a lot of these kind of realms of your doctor doesn’t know what’s good for you, but this thing that I’m selling, it’s the new snake oil salesman, can help you with your problem. And so, I always warn people to be very wary of any accounts that are selling things because they have a big motivator, which is to make money off of people’s anxieties and fears. So, there are a lot of accounts, and I think now especially, that are trying to combat this.

There are doctors who have kind of thrown themselves into this social media world and they’re not in partnerships, they’re not making money off of it, it’s just purely to get good information out there. And so, kind of trying to figure out who those people are and those people know each other and link to each other, and a lot of them really have good information, and they are combating a lot of that misinformation.

Dr. Fox: Yeah. You’re right, this probably should be its own podcast. But again, full disclosures, I don’t have TikTok. I personally have an Instagram account that I look at if it’s once or twice a month, that’s a lot. And it’s usually just scanning through for pictures of my kids, and nieces, and nephews, and clicking the heart button. So, that’s about it for Instagram. I don’t post on Instagram. Facebook, I have, I check it sort of, not regularly, but from time to time. And I sort of see things and I rarely comment. I occasionally post something. Like when the Cubs are in the World Series, I posted a bunch of them just because it was like the greatest thing that ever happened in my life.

They’re like, from time to… I sort of like engage and disengage from Facebook. And I’m certainly not addicted to it, I don’t feel that much about it. And I do see tremendous value in social media in terms of connecting people who wouldn’t otherwise be connected, or keeping people connected in a certain way. Yes, it’s somewhat superficial, but when it’s that versus nothing… Like friends I have who don’t live near me and I don’t see them, I don’t know what their kids look like, and that’s a nice thing. But in terms of like changing the world, I don’t know. It’s, so when I look at stuff like this, it generally tends to be one of two groups. It’s either, like you said, somebody who’s probably has some vested interest in slamming that person.

So, if it’s slamming doctors, it’s gonna be someone who’s selling something else. Like whether it’s, “Oh, come to my birthing center,” or, “Come take my birthing class because these doctors are jerks,” or, “Buy this product because the medicines that these horrible doctors are pedaling is gonna kill you. So, do my whatever thing that I make in my basement out of my van and you should buy this.” Or it’s just people who had a rough experience. Either something bad happened to them or they truly had a bad experience with the doctor and then said, “This doctor wasn’t nice to me. This doctor didn’t treat me well, this doctor harmed me.” And that happens. There is a vast range of human emotions and experience in this world, and everybody is different.

And so, when two human beings interact, it could go south. And that could be because one of them has bad intentions, or it could just be that they’re not a good mix. You have the person is very anxious with the person who’s very relaxed, that can work out great or it could be a disaster. Or if you’re the person who loves jokes and tells jokes, and the person who finds jokes offensive, it’s not like one is good or bad, it just, that happens. And so, I tend to just ignore all the bad stuff. And I’ve always found that if you just, as doctors, you just do your best, you treat people nicely, you try to help them, ultimately, enough people will come to you. I think this really got escalated with the COVID vaccine that it really got ugly because people can disagree about sort of how to interpret the science and…

Or agree on the science but disagree about how that should translate to policy. Like you could disagree about exactly what does the science show the effectiveness of the vaccine was for preventing yourself from getting sick or preventing others from getting sick. And there’s diff… The science is sort of similar, but there’s always gonna be varying reports. Or you can agree on what it is but then say, “Well, therefore, should we have kids get vaccinated? Should we not have kids get vaccinated?” And argue about that, disagree about that. But it went to the next level. It’s like these doctors are trying to harm you, these doctors don’t care about you. And it’s like that’s probably a little bit overboard. I think that that was just a lot much. And I think that it was really unfortunate because things like this can drive people into really dark places, which is a problem.

Dr. Spiegelman: Yeah. And you said something earlier about kind of people who have had bad experiences on an individual level. And that’s actually the other type of account that I’ve found. Actually, the reason that I have taken a step back from Instagram is a lot of people will sort of portray their own personal experience, which I actually think is great for just kind of learning about the world and other people’s… What they’ve experienced. But will a lot of the time present what they’ve been through as hard fact from their end of one, like their study sample of one person.

When I was studying for my MFM boards, the internet algorithms started… Because I was reading things on actual medical websites about genetic conditions and all the things that you need to know to be an MFM, and my Instagram became full of all of these types of accounts of just people who have been through these experiences in their lives. And it got to be so overwhelming that I was like, I need to take a step back from this.

Dr. Fox: Yeah. That’s the other reason to get off social media because they are like inside your cerebrum. It’s horrible. Yeah. The fact that you’re like online looking at something medical and then it’s on your Instagram shows, yeah. It’s pretty creepy.

Dr. Spiegelman: It was kind of disturbing. So, I just, I had to take a step back and… But I still, I mean, I check in from time to time and a lot of my friends actually have these kind of medical account… My friends from training have these medical accounts that I think are actually very excellent where they’re trying to combat some of the misinformation that’s out there.

Dr. Fox: Yeah. It’s also like these online profiles. I don’t mean, I guess like doctor profiles. Oh they got three stars, they got five stars, someone said something nice, someone said something like that. Most of the time, people are not going and spending their time on social media or online posting a very long review unless they were very, very happy or very, very upset.

Dr. Spiegelman: Usually the second.

Dr. Fox: It’s the one star and the five star. Very few people go on and say, “Oh yeah, it’s 3.8.” Because why are they gonna take the time for that? And people tend… You need to be emotionally invested to spend the time to do something like that. And so, just I would say to the listeners and to you, Toby, although I know how you feel about it because we spoke about it. But if you’re going on and you see these accounts, everything has to be with a grain of salt. Who’s writing this? A, is it real? B, if it’s real, is it just their experience?

And ultimately, I think everyone has to just look their doctor, their midwife in the eye, and just… You get a good sense. Is this a person who cares about me? Is this a person who that’s in me? If the answer is yes, you’re probably right. If the answer is no, go see somebody else. You don’t have to be with someone who you think doesn’t care about you.

Dr. Spiegelman: No, that’s true. And then also, if you have a question about something that you saw on the internet or on social media that you are wondering about the science of, ask your doctor. Ask them to print studies for you. Like we can… We are capable of having intellectual conversations with our patients where if you have a general curiosity or a question about something you saw or heard, then just ask. And we most of the time be pretty happy to provide you with some reading materials.

Dr. Fox: Hopefully. All right. The next one is gonna be from Melissa. And Melissa asked, “Hi there. In my last pregnancy, I was diagnosed with postpartum preeclampsia. My blood pressure skyrocketed four days post C-section birth. And after a number of tests, I was confirmed. I’m now pregnant again and would like to better understand this condition, but there isn’t much literature on postpartum preeclampsia. Can you help? I’m nervous about what my future holds.” Melissa, good luck. I hope you’re doing well and the pregnancy, obviously. How would you respond to Melissa’s question about postpartum preeclampsia?

Dr. Spiegelman: So, postpartum preeclampsia is interesting because I think we still don’t entirely know if it is the same condition as preeclampsia in the antipartum period, or whether it is a slightly different condition. We always say that just to… In a sort of oversimplified way, that preeclampsia is “caused” by the placenta. There’s a lot of research going into the exact biochemical mechanisms of why preeclampsia happens. [Inaudible 00:24:53] and all of these kind of substances. But in general, we say it’s the placenta’s fault.

But postpartum preeclampsia, you don’t have a placenta anymore. So, where is that coming from, and was it a process that started before you delivered and is now manifesting in the postpartum period because of all of the fluid shifts that happen at delivery? Blood sort of rushes out of the uterus and into the rest of the body, and is the body’s vasculature capable of handling all of that fluid, and is that what causes preeclampsia, which is kind of a fluid overloaded state? And so, it’s an interesting question because we don’t totally know if it’s exactly the same entity as preeclampsia itself or if it’s slightly different. But generally, when we counsel people, we really, we sort of put it in the same basket as other types of preeclampsia.

And we say you do have a risk of recurrence, and that risk of recurrence depends on the severity of preeclampsia, whether you needed magnesium, head lab abnormalities, had HELLP syndrome. And also, the timing of when it occurred, where the earlier that preeclampsia tends to occur, the higher the risk of recurrence and potentially, at earlier gestational ages. So, if you think about it in that sort of time spectrum, then postpartum preeclampsia is as late as you can get it. And so, in a subsequent pregnancy, you may get it before delivery but we would hope it wouldn’t be a very, very early presentation of preeclampsia. And we do some of the same strategies to try and prevent it like low-dose aspirin, calcium, like we were talking about before, and that sort of thing.

Dr. Fox: Yeah. I think the reason potentially, Melissa, that you’re saying there’s not a lot about it is if you go online and all the websites that describe preeclampsia, whether medical explanatory or non-medical are gonna say the same thing. It’ll say it’s when you’re pregnant your blood pressure goes up, you get protein in your urine, you may have blood tests, you may need to be delivered early, and they give you all this stuff. But in the medical literature and preeclampsia, we include the people who had it after birth. Right? So, it’s not something that’s gonna be written in the website.

I mean, some of them might say, oh, star, by the way, this can also happen after you deliver. It’s true, everyone knows this, but it sometimes just gets forgotten that not everybody with preeclampsia presents when they’re pregnant or in labor. And many of them, it happens after birth either an hour, a day, a week, a couple of weeks. It doesn’t tend to be a month, but generally within a week or two.

Dr. Spiegelman: It could be.

Dr. Fox: Yeah, it has been reported. But generally, if it’s gonna happen, it’s gonna be within after birth, it’s gonna be within the first week or maybe the first two weeks. And so, I would say you’re actually not as alone as you would think.

Dr. Spiegelman: Yeah. It’s actually common.

Dr. Fox: This is common. Yeah. This is pretty common and it’s actually one of the reasons why there’s a lot of push now how exactly can we best monitor women after they give birth and go home because we know that this risk still exists. The things that can happen to people that are very dangerous in pregnancy don’t go away the second you deliver, you can still bleed after you go home, you can still get preeclampsia after you go home. Things can still happen. You can get blood clots after you go home. And so, how to do that exactly on everybody is not clear.

But certainly, people at high risk for preeclampsia after birth, like for example, you, you had it before or someone who has high blood pressure during pregnancy, and it sort of gets better right after they deliver. We sort of check in with them much more frequently in the first two weeks. Either they check their blood pressure at home every day, or they come back to the office in three to four days after birth. Meaning we don’t just say, “Go home and come back in six weeks,” because we know that what happened to you can happen.

And certainly, for you, I would say I’m sure that your doctors or midwives, number one, are watching you closely during this pregnancy, but they’re also gonna probably in some capacity watch you closer after you deliver. Which, of course, you’re gonna be on top of it anyways because you’re already scared about this, legitimately. But it’s one of these things that we have to check because you don’t always know if your blood pressure’s elevated. There’s no symptom from your blood pressure being high typically unless it’s crazy high.

Dr. Spiegelman: Yeah. To your point about there not being a lot of literature on this, there is a lot of literature on this but it does kind of… Sometimes, it gets masked in the just general preeclampsia literature, but there is a big focus on the fourth trimester, and this idea that just because the baby’s out doesn’t mean that you’re not physiologically pregnant anymore. And so, there’s still a lot of the complications of pregnancy that can happen in that early postpartum period. And those postpartum fluid shifts, like the things that happen at delivery with blood moving around, those are very powerful in terms of changing things like your blood pressure, and the way that your cardiovascular system handles all of that fluid is very, very important.

Dr. Fox: Yeah. Just in terms of nuts and bolts in our practice, what we do for someone, I guess, similar to you, has a history of preeclampsia after birth, and obviously, this would be changed slightly based on the rest of the details, but during pregnancy, we have you on a baby aspirin, we make sure you get enough calcium. We sort of have you start checking your blood pressures at home at some point. We do some baseline blood work just to make sure everything is sort of normalness and we do serial ultrasounds to make sure the baby’s growing okay.

And then if you don’t ever get preeclampsia during pregnancy and delivery, that’s great. And then we continue to have you check your blood pressure after you go home. I generally tell people to do it for two weeks or so. Again, based on exactly when you had it after birth, yours, it was just a few days. So, generally, about two weeks or so. But that’s what we would do in our practice again as a general sense. So, good luck. I hope it works out very, very well for you. And our last question for today’s lightning round is from Anna. So, Anna, which is a palindrome, good job. “Absolutely love this podcast.” Thank you, Anna. “It’s been instrumental in helping me get through my current pregnancy, especially as a patient of your practice. I love hearing from some of my favorite doctors.”

All right, Anna, thank you. “Yesterday’s episode on Headaches in Pregnancy”, this was a while ago, “was really helpful. Would love to hear an episode on managing ADHD in pregnancy. Thanks so much.” So, interestingly, we’re recording this, I guess, we’re in end of April and a couple of weeks we actually have a podcast on ADHD, but that’s more so in children, not in pregnancy. But what’s your experience on managing ADHD in pregnancy?

Dr. Spiegelman: So, I actually think this should be a whole podcast episode also. But it’s pretty common, ADHD in general is common. There is a lot of controversy now about whether it was kind of over-diagnosed when the population of people who are now having children were teenagers and kids. And so, there definitely are some people who don’t really have it, who think they have it. But for the most part, I think the diagnoses, at least in the people who have it carried through as adults, are pretty accurate. It’s pretty common. So, it’s something that we see a good amount of the time. Generally, as adults, most people with ADHD have kind of learned how to cope, and how to adapt their lives around the condition. Many of them are on medications to really help them and some people aren’t and are just kind of managing using lifestyle techniques.

Dr. Fox: Executive functioning.

Dr. Spiegelman: Yes, exactly. And most of them are very high-functioning adults who have jobs and clearly are building families and their lives are pretty good But the most common question is really about medication. And so, there’s a whole host of medications that people use for ADHD. Most of them are kind of safe enough if you need them. Which is sort of a general rule about medications in pregnancy, where the research on these types of medications has not really been classically on medications that are prescribed but rather medications that are taking taken illicitly. And that’s a whole different group of people, a whole different population. And so, it’s not really fair to extrapolate conclusions from those types of studies to people who are taking prescribed medications for a medical condition.

Dr. Fox: Right. I mean, just to dig in deeper on that. For example, someone says to me, “Well, I’m taking Adderall or Ritalin,” and they’re stimulants and then you find an old study unlike amphetamines from the ’70s.

Dr. Spiegelman: Yeah. It’s like about meth or cocaine.

Dr. Fox: Yeah, yeah. People on speed and they’re like, these are… I mean, they’re on a whole host of things potentially and they’re abusing them and it’s a different story. And so, the outcomes from that aren’t really applicable necessarily to the outcomes on these medications. And so, I always point like you may find some pretty scary things out there, but that’s really from those studies looking at a much different situation than what we’re talking about here.

Dr. Spiegelman: So, the things that just as like sort of when we talk about it just physiologically that we worry about with stimulant medications is vasoconstriction like blood vessels constricting and can affect the placenta, can cause things like placental abruption, it can cause sometimes the baby’s heart rate to be fast and they call it fetal tachycardia, and potentially growth restriction. These are the theoretical things that we worry about with stimulants. And so, if somebody really needs their medication to function, functioning is important.

So, I think there’s a lot of focus in pregnancy on, well, if it’s not good for the baby, I’m just gonna stop it. But the quality of life of the mother is very important during pregnancy as well. And some people really, they can’t do their jobs, they just can’t get through the day without the medications that they need. And so, if somebody has a need for being on these medications to live their lives, the general principle is you should be on the lowest effective dose of the medication. And then we watch out for some of these theoretical complications. We do ultrasounds to monitor the growth of the fetus, and we check the heart rate and things like that. And most of the time, people have good outcomes.

Dr. Fox: Yeah. I mean, the data on the more contemporary medications that are used for ADHD, the safety is pretty good. I mean, they’re not… None of these studies are perfect studies because you can’t really randomize people and this and that. And that’s true with, again, all the medications. It’s not unique to these. But the, I don’t wanna say preliminary, like they’re new, but all of the contemporary data points to them being safe. But we can never give anyone 100% guarantee on any medication that it’s gonna be totally safe. But we sort of have to work in those parameters and we sort of, like you said, there’s the medication we say, “These seem to be safe. If you need it, you should probably be taking it versus stopping it.” But that’s a really good question, Anna. All right. This was our lightning round number one.

Dr. Spiegelman: Cool.

Dr. Fox: Nice job, Speigs. Thanks for coming on. Again, for our listeners, any question you feel you want to hear us talk about, send it in. Again, unless somehow it gets canceled or we censor it, we’ll do it. We’re open. Thank you very much.

Dr. Spiegelman: Yeah. Next time I want to not know the questions in advance.

Dr. Fox: All right. That’s how we’re gonna roll. “Quiz Show.” Everyone watched the movie. All right. Take care. 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 H-E-A-L-T-H-F-U-L-W-O-M-A-N.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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