“Polyhydramnios: Deep Water!” – with Dr. Jen Lam-Rachlin

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and 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. Jennifer Lam-Rachlin. Jen, welcome back to the podcast. How goes it?

Dr. Lam-Rachlin: I’m doing well. Thank you. Thank you for having me back.

Dr. Fox: It’s my pleasure. Sorry, we’re not in person, but it’s not a COVID thing, it’s just a scheduling thing.

Dr. Lam-Rachlin: Yeah.

Dr. Fox: Yeah. So, such as the world of our lives with scheduling. But it’s good to have you on. And this is a topic that I know that you and I see a lot of in our day-to-day work. And I think that it causes a tremendous amount of stress, and usually unwarranted, either people, you know, they go on the Google or they come in with the concerns or maybe someone else told them it was a huge problem. And that is polyhydramnios or high fluid. How many times a day or a week would you say you have this conversation?

Dr. Lam-Rachlin: I mean, at least once a day, right, new diagnosis. And then at least once or twice a day for people who are coming back for follow-up. So, it’s very frequent.

Dr. Fox: Yeah. I’ll say the same. If you’re in a busy ultrasound unit, seeing pregnant women, I mean, definitely once a day, if not more. I don’t know if people find that reassuring or not reassuring, but it is common. It happens a lot. Statistically, it’s like 1% to 2% of pregnancies and people think that’s rare, but that’s not. That’s actually pretty common in the world of pregnancy, 1% to 2%. How do you explain to people, like, what it is? And what are we talking about here, polyhydramnios?

Dr. Lam-Rachlin: Kind of simplistically, we see your extra amniotic fluid from the quote norm that we serve, right? And for the most part, it’s a benign finding, it doesn’t really much [inaudible 00:01:58] you know, in any adverse event. But there’s certain things that we think about when we see excess fluid, and then we do the evaluation for it at that time. And generally, things are normal, and just a follow-up more detail-wise. And usually, I would talk about exactly what that means, right? Like, you know, what is normal fluid? What is abnormal fluid? How do we measure?

Dr. Fox: Right. And I think that part of the hard part is, you know, as the baby swims in amniotic fluid and, you know, we try to measure it, but it’s hard because we can’t really get in there and get a volume, you know, to say there are three liters or whatever fluid in there. There are people who have tried to do that and, you know, estimate and quantify, but it’s pretty complex to do that and frequently involves having to, like, stick a needle in someone to do that. So, we don’t do that.

And so we’re just doing an ultrasound and, you know, sometimes her belly might seem a little bit bigger than expected, sometimes not. And when we do an ultrasound, and we measure the fluid, it’s a bell-shaped curve, right? So, there’s varying amounts of fluid that we call normal. And if someone is, like, above that or below that, we call that abnormal, but we know that just like most bell-shaped curves, people on the outer ends are usually fine. It’s just their whatever. For whatever reason, they have more fluid or less fluid or they’re taller or they’re shorter and it’s not usually pathologic, but it’s usually just whatever. This is the number that they have and it doesn’t mean anything.

And the other reasons [inaudible 00:03:24] is because the fluid level changes all the time. I mean, from day to day, from week to week, probably from minute to minute, you can measure it. Yeah, you can measure the fluid four times in a row and get different numbers because, you know, ultrasound is limited. We can’t, again, get the volume. The baby moves and suddenly a big pocket of fluid is now filled with a, you know, butt, there’s no fluid in that spot. And so that is something that, I think, frustrates a lot of people and they can’t get such…and we give them a number, but they feel like it’s a little bit less scientific than maybe some other things we measure.

Dr. Lam-Rachlin: Right. I agree with that. I mean, even from within the same scan, we can definitely get different measurements or they’re all usually around the same ballpark. It’s not gonna be, like, tremendously different, but the ballpark number could be just above the cut-off or just below the cut-off or right around the cut-off. But that’s one of the reasons why we have patients come back, right, routinely, like, once a week to see if there’s any traumatic changes in terms of that number.

Dr. Fox: Right. And also it’s interesting because, you know, we’ll talk about the ways we measure the fluid, but one of the ways sort of the traditional way, and it’s completely legitimate, is literally just eyeball it, and have someone who has experience, a sonography doctor say, “That’s a lot. That’s normal. That’s not enough.” Right? Just one of the three. You have a lot, you know, like, small, medium, large, right? And that actually is… That’s true. You get some that just eyeball it and say, “I don’t care what the number is. That looks high. Or I don’t care what the number is. That looks normal.” And there is validity to that kind of assessment if the person…if it’s someone who does ultrasound all the time, you get a good sense of that. We tend to give numbers. People like numbers, but that is… The reason it’s valid is because, again, since these numbers don’t mean so much, you know, point to point, it’s really just the overall gestalt. Is this a lot of fluid? Is it normal? Or if it’s a lot, is it really a lot, like, a tremendous or just a little bit more? And that’s how we sort of break it down. So, how do we measure fluid technically, like, to give a number? What are the two ways that we do it?

Dr. Lam-Rachlin: So, two ways are either traditionally or historically we use an AFI, which is arbitrarily separating the belly into four quadrants, and then measuring the deepest pocket within each of the quadrants. And if the sum total is 24 centimeters or higher, it’s considered polyhydramnios. It’s gonna be considered excess fluid. Another way of measuring fluid amount is just going by the deepest pocket that you get. And if that’s, you know, higher than eight centimeters, that’s considered polyhydramnios or excess fluid. And I think varying practices will use either way of assessing fluid amount.

Dr. Fox: Right. And so some people like the amniotic fluid index, which is sort of measuring before, some, like, the deepest pocket, and sometimes you get into situation where one of them is abnormal and the other one is normal. And then what do you do? Okay. And where does the amniotic fluid come from? So, once we’re measuring it and we’re talking about, people are like, “Well, why… What is that stuff?”

Dr. Lam-Rachlin: Why do we care?

Dr. Fox: Yeah. Why would we care? What is it?

Dr. Lam-Rachlin: Generally, what I tell patients is mostly baby’s urine, right? So, as the baby goes through cycles of peeing and swallowing, peeing and swallowing. So, most of what we measure in terms of [inaudible 00:06:22] fluid is coming from the urine of the baby with, like, a small amount of the rest coming from either placenta or lungs, but the vast majority is urine.

Dr. Fox: Yeah. I think people are sometimes surprised to learn that babies live in a pool of their own pee.

Dr. Lam-Rachlin: In Urine.

Dr. Fox: And not only they live in their…

Dr. Lam-Rachlin: And drink it.

Dr. Fox: Yeah, they drink it. Meaning, the babies don’t get…they don’t get hydrated by drinking their own pee. Right? In fact, they get hydrated through the umbilical cord through the belly button, but they do swallow it, the pee, and it’s actually helpful to them because it gets in their lungs, it helps their lungs actually like expand and mature and we see the fluid in the stomach. And there is a cycling, some people find that gross, but that’s how it is, that’s what the babies…that’s what they live in.

The reason we go over that with people is when there’s high fluid, some of the possible causes of it could be related to that cycle. So, like if the baby is either peeing more or potentially swallowing less, there would be high fluid. And so we sort of…that’s part of the reason we go into that explanation, so what’s going through in our heads. So, if we see high fluid, what do we do? How do we assess what’s going on and what else is there so we can figure out is this something that’s important or not?

Dr. Lam-Rachlin: Yeah. So, generally, we would check on the size of the baby. And the reason for that it kind of tells us, you know, if the baby is measuring large, a larger baby can make more urine just like a larger adult makes more urine, that maybe that’s an explanation for polyhydramnios. Or when we think about larger babies and excess fluid, we think of potentially diabetes or gestational diabetes and we wanna make sure that the patient has had screening for that or being tested for that.

Otherwise, if the baby is very, very small and we find polyhydramnios very early on, then that might point towards a more of a pathology that’s innately with a baby like genetics and stuff like that. But those are rare. The other assessments that we look for is just general movement, right? Like, if we are worried about maybe the baby is not moving well or not swallowing as well, then the assessment of movement will help. So, the baby is vigorous and doing all the movements that we want and not showing signs of distress. That’s very reassuring. And then things that we also look for would be to see fluid go all the way down to the stomach because that tells us that there’s not a big blockage or obstruction for that normal digestion of that amniotic fluid.

Dr. Fox: When I’m meeting with people either who were diagnosing it on that, you know, during that ultrasound of fluids higher they had it before, sort of the assumption going into it is that the vast majority of babies with high fluid, everything’s fine, right? Baby is fine, mom is fine, everything is good, nothing is gonna happen. And so we’re looking for things or not seeing things that would indicate otherwise. So, for example, we wanna make sure, all right, the number one cause of this is nothing. Baby is fine. Everyone is good. Okay. So, another cause, like you said, another common one might be gestational diabetes or real diabetes. And so we make sure, “Did you have a screen for it? Was it normal? Or if you are a diabetic, how are your finger sticks? Like, are they normal? Okay.”

So other than those two, right, it’s baby is fine and diabetes, there are other conditions, like you said, that are much worse but much more rare. And so for example, if we’re worried that the baby has some sort of, like, disorder that they can’t swallow, yeah, those babies there’s neuromuscular disorders or babies don’t swallow, but they also don’t move. Right? So, if I see high fluid and the baby just, like, floating around in there not moving at all, yeah, that’s pretty scary. But if the baby is bouncing around and swimming laps back and forth and, you know, doing kick turns at the fundus, then that’s not gonna be the cause. Similarly, if the baby looks normal and had normal genetic testing and it’s not presenting it too late in pregnancy, the chance that it’s a genetic disorder is very low. And if I see the stomach filled with fluid, the chance that there’s some blockage, like, the baby is trying to swallow, but can’t, you know, it’s very, very low. And so when we see all those things reassuring, we say, “All right. Statistically, overwhelming likelihood is nothing is going on and you’re fine.” And then why would we bring them back? If we do an evaluation and we think everything looks okay, what is your reason we might wanna follow it serially?

Dr. Lam-Rachlin: Yeah. You wanna see whether it’s stable or resolves, right? Resolves, maybe just that one-time thing, whatever, we just caught the baby in the cycle and just peeing and haven’t quite solved everything and back yet. Or is it stable? It’s poly still, but it’s really consistently in the same ballpark. Or if the fluid level has dramatically increased, right? So, even at the initial assessment knowing that most of the time these are idiopathic and there’s nothing necessarily wrong. If we do see a dramatic increase week by week, then maybe there is something going on that we’re not able to pick up at least ultrasonographically or when we might pick up at future ultrasounds.

Dr. Fox: Yeah. I mean, if the fluid is going up and up and up every single time, there’s definitely a higher level of concern that’s there’s like a blockage or something like that. And unfortunately, we aren’t really good at seeing those before birth, meaning, you know, ultimately, the way to find out there’s a blockage is after the baby is born, you feed the baby, and if the food goes down, there’s no blockage. Kind of old school, but it works. It’s more and more likely for fluids going up and up and up.

But again, that’s really the exception. Most people will come in and get a diagnosis of high fluid. It stays around the same number, like, if, you know, 24 is a cut off and let’s say we diagnose in the 27, you know, a week later might be 29, then it’s 25, then it’s 30, then it’s 25 again. It sort of does that, kind of bounces around. But if it went from 25 to 30 to 40 to 50 to 55, yeah, we’re really worried that there’s something more going on, but fortunately, that is the exception.

And also we like to see the fetal movements week to week because, again, if we’re some concern that potentially there’s some, you know, thing going on, if the baby keeps moving every week and we see the baby moving every week and the mom feels them moving every day, then that’s highly unlikely and it’s less concerning for us. What do moms feel when they have high fluid?

Dr. Lam-Rachlin: Physically you mean or when tell them that?

Dr. Fox: Yeah. Yeah. Oh, no, I don’t mean emotionally. Yeah. Yeah.

Dr. Lam-Rachlin: Physically, I mean, they might feel totally normal or, like, they don’t have to feel anything. If they do feel something they might feel like they are, like, physically a little bit bigger than where they should be because of just the added size of the fluids to the belly for the uterus. They might feel more contractions. They might have contractions earlier. They might go into labor earlier. But I would say I think most patients will probably feel nothing out of the ordinary. If anything, they just feel a bit bigger.

Dr. Fox: Yeah. Most people are surprised to learn that the fluid is high because they usually feel fine. And what’s interesting and also actually nice about the high fluid is since there’s more fluid, the baby does have more room to bounce around. And so typically, they really get that reassurance of, “Oh, I feel my baby moving all the time.” Right? Whereas someone with a fluid is a bit lower as the baby is getting bigger, those movements get more subtle and now that we freaked them out and we’re worried about the baby’s movements, it’s nice that at least they get that feedback every day that, “Oh, yeah, this baby is, you know, just swimming laps and doing great.”

That is helpful, fortunately, because if someone has low fluid and we have other concerns, they often don’t feel the baby move as much because there’s no room in there. They have a hard time, you know, punching and kicking because they’re just, you know, more crowded. So, that’s interesting, you know, that they have that.

Now, you know, when we think about high fluid, you know, we’ve talked about our concerns of the cause of the high fluid, right? So, we get… We wanna make sure it’s not genetic, we wanna make sure it’s not an atomic problem or something neuromuscular. But what about the effects of high fluid? Right? What are we concerned about that might happen because there’s high fluid for whatever reason?

Dr. Lam-Rachlin: Obviously, it depends on the amount that we get and also gestational age. But let’s say we see the high fluid and she’s preterm, it is expanding the uterus, right? So, uterus is just a muscle. And when a muscle is expanded, it can contract. So, we’re worried that she might go into preterm labor or just rupture them and, you know, break their water or rupture their membranes earlier or at term, again, that occurs. That’s not necessarily that scary, but sometimes the head is not fully engaged because it’s floating around in a big bag of water. And sometimes when the membrane is ruptured, the umbilical cord can slip between the baby’s head and the cervix, and that’s called a cord prolapse. But again, those are rare. That’s not like the most frequent thing that occurs.

Dr. Fox: Yeah. And is there ever a time when we try to drain the fluid out of the uterus?

Dr. Lam-Rachlin: Pre-term-wise if there’s just a significant elevation to the point where it’s affecting mom’s physical symptoms, right? So, with the excess fluid, they cannot…it doesn’t allow her diaphragm to really expand as well, so they might have more difficulty breathing. And in those cases, I mean, we would do what we call an amnioreduction, which is reducing some of that amniotic fluid just so that we can give the mom some symptomatic relief.

Dr. Fox: Yeah. I mean, that’s pretty rare. I mean, like I said, we have this conversation about high fluid every day and I would say maybe once or twice a year, maybe. Where we’re doing the amnioreduction to get rid of some of that fluid. It’s pretty unusual to do that, but, again, it’s mostly just for maternal symptoms in that sense because sometimes if it’s really bad, you know, if the number is like 40 or 50, sometimes it can be pretty uncomfortable and that would be something. And I think it’s also really important, you know, when we talk about polyhydramnios and people listen to this, it’s… And you mentioned this before, but it’s really critical, when is it diagnosed? Right? Because the vast majority are diagnosed at the end of pregnancy, you know, past 32 weeks, past 34 weeks, past 36 weeks, somewhere there and where it’s almost always nothing. It’s a lot different if we see it at 20 weeks. And why is that?

Dr. Lam-Rachlin: If we see it earlier, that kind of raises the suspicion that there is something going on with the baby, say, something going on and so it’s either structurally or genetically, right? So, we think of genetic abnormalities or structural abnormalities on the baby, versus, you know, the later half of their trimester it’s so common to see it. It’s so commonly idiopathic and generally not associated with these concerns.

Dr. Fox: Yeah. When I see someone at 34 weeks of high fluid, they may be worried initially, but the conversation is usually very reassuring. “This is very common. Everything is gonna be okay. Typically nothing happens. We’ll follow you, you know, yada, yada.” Whereas if I’m having this conversation at 20 weeks, it’s a lot more serious because we don’t usually see high fluid at 20 weeks. And if we do see it, like if it’s slightly above normal, fine, and that’s probably just, you know, bell-shaped curve type of stuff. But if it’s markedly elevated at 20 weeks, we are highly suspicious that there’s an actual problem here whether it’s genetic, and so we usually will recommend an amniocentesis to look for genetic diagnoses or, you know, further imaging and echocardiogram and infectious studies, like, all the other things that could possibly do it early. But again, fortunately, that’s pretty unusual. That’s not a conversation we have every day, the 20-week polyhedron [SP]. It’s very rare, but it is a lot more scarce. So, the vast majority of people who have this and are listening to this who know someone with high fluid, usually it was towards the end of pregnancy and it really wasn’t that much.

And what about with delivery? So, number one, we’ll start with the simplest. Does having high fluid means someone needs a C-section?

Dr. Lam-Rachlin: No. So, that’s not an automatic C-section.

Dr. Fox: Right.

Dr. Lam-Rachlin: Obviously, there’s other reasons why they could have a C-section, but just high fluid, no.

Dr. Fox: Right. And also once they’re in labor and their water breaks, no more high fluid, right? So, that problem solved. I mean, they wanna warn the people on the floor below you that there could be flooding, but there’s sometimes a lot of fluid in that water breaks, so don’t… If you have high fluid, word to the wise, don’t wear expensive shoes just in case the water just…

Dr. Lam-Rachlin: And find a towel.

Dr. Fox: Yeah. So, okay. So, it does not require a C-section. What about the timing of delivery? Do we deliver people earlier than we normally would because of high fluid?

Dr. Lam-Rachlin: I mean, not extraordinarily early. I mean, most of the time these are mild cases and we don’t…and as I said, it’s idiopathic, but in general, as a practice, we would say don’t go past the due date. So, you might be thinking of an induction around the due date time period. It’s very rare that we would recommend any earlier than 39 weeks for just polyhydramnios unless it’s a severe case.

Dr. Fox: Yeah. I mean, if you look at, you know, some of the studies or some of the Google, you’ll find that there’s an increased risk of stillbirth if someone has the high fluid. And it’s hard to understand why that would be. I mean, it makes sense if, you know, they go into labor and, like you said, there’s a cord prolapse, the cord drops. So, that would be a reason to maybe, you know, bring someone in in a controlled setting, induce the labor.

Okay. If there’s some cause of the high fluid that’s dangerous to the baby, then, you know, it’s not the high fluid causing the problem, but you know, the problem causing the high fluid and increased risk of stillbirth. Okay. But why someone with sort of idiopathic, you know, a little bit above the line, high fluid would have an increased risk of stillbirth. We don’t really know. But since it’s sort of out there, usually a lot of people are like, “Okay. Let’s just… The baby looks fine at 39-plus weeks. Let’s just, you know, get out of dodge and deuce.” It is a recommendation we make, but it’s probably one of the softer ones in terms of, you know, knowledge, why we make that recommendation.

Dr. Lam-Rachlin: Even with, like, the increased risk of the stillbirth, the absolute risk is still quite low, it’s still less than 1%. So,it’s not like when we diagnose poly, oh, we should, you know, induce that 37 weeks just for poly. I mean, that’s the reason why we kind of let, you know, pregnancy go. Most people hopefully will just deliver and go into labor beforehand, and if not, then a good time period would be, you know, due date in terms of induction.

Dr. Fox: Right. With super, like, really high fluid, you know, we sort of grade it as mild, moderate, and severe, but, like, whatever. When it’s really, really high, we’ll often recommend delivery earlier just because we’re really worried that if their water breaks at home, you know, bad things might happen, that the baby might not be head-first anymore, you know, there’s like a hand presenting with the cord can come out or when her water breaks since the uterus gets, like, decompressed from such a big size to a smaller size so quickly, maybe the placenta will shear off and she’ll have what’s called an abruption and start bleeding.

And so we get more concerned when the number is, like, you know, mid to high 30s or 40s or something. And usually, in that situation, we’re gonna bring them in a little bit earlier. But the sort of the bread and butter, so to speak, you know, polyhydramnios where it’s like 24 to 35. I agree. We usually… We do it 39 to 40 weeks, but even if we didn’t, probably everything would be okay when they just went into labor on their own.

When you have this initial conversation, how much do you go into? Because I’m just curious. Do you just sort of say, “All right, it looks okay. Come back in a week.” or do you go into everything including delivery in the first time? Or how do you make that decision?

Dr. Lam-Rachlin: I try to give most of the information. Again, as you said, most of the time this happens in the second half of the third trimester, it’s usually mild. And we all know that that’s probably idiopathic, right, because that’s the vast majority of time. So, I don’t scare them with, like, so many scary scenarios, but we do talk about, you know, what…if this persists, right, like, what it could mean. If it gets worse, what it could mean. And then if it stays like this, you know, from a delivery standpoint, like, generally recommend delivery, maybe by due date or something like that. So, try to, you know, talk about all these potentials without getting too scary, unless I am concerned. I’m concerned that it might be a scary talk.

Dr. Fox: Yeah. I mean, I agree. Again, if it’s early in pregnancy or when I see them, the fluid is crazy high, or I see other abnormalities or the baby is not moving, all right, that’s a scary talk, obviously, because there’s a higher chance that it’s a big deal.

But in this sort of typical scenario where mom is fine, everyone is feeling okay, baby looks fine. Just the number, the measurement we’re getting is above the bar like a little bit higher. I’m usually telling the same. I’m saying, “Listen, this is almost always nothing. If you don’t have gestational diabetes, it’s probably absolutely nothing. You’re gonna be perfectly fine. But since it sort of like raises a warning flag, we’re gonna follow you a little bit closer, we’ll see every week, we’ll check the fluid, make sure it’s not getting higher, make sure the baby is moving, make sure the baby is growing well, and which is normally gonna happen.” And as long as the fluid is not getting crazy high, we’re just gonna wait and just watch closely and wait and deliver, like you said, somewhere by the due date, give or take.

And I think most people are pretty fine with that. I mean, maybe a little bit annoying to come in every week for an ultrasound. And you could get away with not doing that, obviously, because most of the time it’s nothing, but I think it’s important just to get that ongoing reassurance that when we’re telling them that’s probably fine, I’d like to be able to, you know, verify that week to week and not just, you know, go with the numbers and say, “All right. It’s still fine. Fluid is so mild. Baby is moving good. Come back in a week.” And I think that most people appreciate that. Some people get annoyed with it, obviously, but that’s the reason we’re doing it. It’s just we can go by the numbers and just say, you know, “Ninety-plus percent of time it’s gonna be fine, but we’d like to, you know, tighten that up a little bit.” And not just make that recommendation once and, you know, be on your way to delivery.

Dr. Lam-Rachlin: Right. I agree.

Dr. Fox: And is this something that happens in future pregnancies if they had it once?

Dr. Lam-Rachlin: I’ve seen it occur and recur in future pregnancies, but it doesn’t have to. So, meaning that, you know, I don’t think that once you have poly, that means that all future pregnancies you’ll have polyhydramnios for random reasons. But interestingly, we’ve seen some patients back and they’re like, “Oh, yeah, my last pregnancy I had the same thing.”

Dr. Fox: Yeah.

Dr. Lam-Rachlin: And they just see that that’s where they fall in terms of the bell-shaped curve.

Dr. Fox: When I joined the practice, the first patient I had… And I always call her my first patient because, you know, when I start, you know, “Who the hell wants to see me? Right? I’m the new guy. So, my schedule is wide open.” You know, [inaudible 00:24:30] they’re packed, you know, they’re three deep, people waiting to see them. And there I am sitting twiddling my thumbs and this, you know, nice young woman, pregnant, first baby, she’s like, “I’ll see him.” And I see her and she’s there because she has pretty high fluid. It was like in the mid-30s. It wasn’t like a little bit. But everything looked fine. Nothing was really changing. We’re really sure. And she would come in twice a week basically. And I was seeing her twice a week for like two months. So, we became pretty close.

And then her next pregnancy, same thing. And it was really fascinating. And her kids are fine. No one ever figured out why it was. They don’t have any kidney issues and they’re perfectly healthy and everything is great, but I don’t know. Whatever it is. Maybe there is some, like, genetic predisposition to making more urine when you’re a fetus. That’s not pathologic, but whatever. Or maybe it’s just the way the uterus, you know, stretches is different in people. We don’t really know. It’s interesting. But there are some people who it happens every pregnancy, they’re like, “Oh, my God. Again? Really? This? You guys? You again?”

Dr. Lam-Rachlin: And they know the drill.

Dr. Fox: They know the drill. Beautiful. All right. Jen, high fluid, polyhydramnios, a long word for not such a complicated situation usually. It’s a good word to freak people out. “You have polyhydramnios.” Yeah. When you bring…

Dr. Lam-Rachlin: It’s a good [inaudible 00:25:43]

Dr. Fox: Yeah. When you bring up the Latin, it never sounds good. Beautiful. Thanks for coming on, Jen. I appreciate it.

Dr. Lam-Rachlin: No problem. Anytime.

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

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