Women & Wellness - Insights by Vandna Jerath, MD

Perinatal Depression - The Antidepressant Treatment Dilemma

Optima Womens Healthcare Blog — Tue, 17 Jan 2012 06:32:33 GMT

Vandna Jerath, MD

Depression disrupts daily life and affects thoughts, feelings, behavior, and relationships that have a significant impact on mental, emotional, social, professional, and physical well-being. Women are twice as likely as men to have depression. Clinical depression is common among reproductive age women 25-45 and the leading cause of disability in women in the U.S. This can account for $30-50 billion in lost productivity or medical costs.

Perinatal depression refers to depression that occurs during pregnancy and postpartum up to one year after delivery. 14%-23% of women experience depression during pregnancy and 5%-25% of women will have postpartum depression. It is essential that perinatal depression be treated as it can lead to sporadic prenatal care, inadequate nutrition, poor fetal growth, preterm delivery, preeclampsia, low birth weight, self-medication with tobacco, alcohol, or drugs, increased risk of postpartum depression, inability to care for self or child, lack of mother-infant bonding, and in extreme cases may lead to suicide or infanticide. Studies have shown that untreated maternal depression negatively affects an infant’s cognitive, neurologic, and motor skill development and can also impact older children’s mental health and behavior.

Symptoms of depression include:

Sadness
Trouble sleeping - Insomnia or increased sleeping
Feelings of guilt, worthlessness, or hopelessness
Lack of motivation or interest
Decreased energy
Changes in appetite with weight loss or gain
Difficulty concentrating
Psychomotor retardation or agitation
Thoughts of death or suicide
Anxiety, worry, and fear
Physical manifestations of body aches, digestive problems, fatigue, or sexual dysfunction

Treatment options for depression in pregnancy include:

Therapy
- Psychotherapy
- Cognitive Behavioral Therapy
- Support Groups
- Family, friends, church, community
- Antidepressants
  - Tricyclic Antidepressant (TCA)
    - Elavil (amitriptyline)
    - Pamelor (nortriptyline)
    - Tofranil (imipramine)
    - Sinequan (doxepin)
  - Selective Serotonin Reuptake Inhibitor (SSRI)
    - Prozac (fluoxetine)
    - Zoloft (sertraline)
    - Paxil (paroxetine)
    - Celexa (citalopram)
    - Lexapro (escitalopram)
  - Monamine Oxidase Inhibitor (MAO)
    - Nardil (phenelazine)
    - Parnate (tranylcypromine)
  - Alternatives
    - Wellbutrin (bupropion) – also good for smoking cessation
    - Effexor (venlafaxine) - SNRI
    - Cymbalta (Duloxetine) - SNRI
- Alternative Therapy (still being studied/investigated)
  - Exercise – yoga
  - Massage
  - Light therapy
  - Acupuncture
  - Omega 3
  - Calcium
  - Herbs
    - St John’s Wart (very little known about the effect on the fetus)
  - Electroconvulsive Therapy (ECT) – safe in pregnancy
  - Transcranial magnetic stimulation

As many as 1 in 4 pregnant women may suffer from depression, and about 1 in 8 receives treatment with antidepressants. If a pregnant woman was previously on antidepressants then it is not advisable to stop abruptly as she may experience nausea, vomiting, fatigue, anxiety, and irritability. Additionally, a 2006 study in Journal of American Medical Association (JAMA) found that 68% of women who discontinued their antidepressants in pregnancy experienced a relapse of their depression.

Many antidepressants and drugs have been used for many years without any obvious signs of serious risk to the baby. There are some potential concerns, side effects, and risks associated with the anti-depressant medications. However, studies have had small sample sizes, conflicting data, and lack of consistency with findings.

MAOIs are not typically recommended as they can limit fetal growth and aggravate maternal high blood pressure. There appears to be a small potential risk of fetal malformation with antidepressants, but not higher than the average overall risk of malformations in the general pregnancy population which is 1-3%. Previously, there were concerns for limb defects with TCAs, but these results have not been reproduced in future studies. TCAs are considered safe, but blood levels may need to be monitored during treatment. SSRIs may be associated with low birth weight, preterm birth, and miscarriage. Of all the SSRIs, Paxil is a category D and not recommended in pregnancy due to initial studies showing possible cardiac defects of the fetus when taken in the first trimester of pregnancy. 15-30% of babies whose mothers took SSRIs late in pregnancy may experience withdrawal symptoms with irritability, jittery behavior, weak crying, hypoglycemia, seizures, temperature instability, and tachypnea. These symptoms typically resolve within two weeks. The remaining SSRIs are considered safe, but there have been some inconsistent findings of cardiac septal defects (“holes in the heart”) which typically occur in less than 1% of babies and resolve spontaneously without treatment, omphaloceles, and neural tube defects. There have been no studies showing any neurobehavioral , IQ, or language problems. There has inconsistently been an increased relative risk of persistent pulmonary hypertension of the newborn (PPHN).

PPHN is a condition which causes an elevation in the pressure of the pulmonary artery causing a patent ductus arteriosis and right to left shunting of blood through the heart which results in hypoxia (lack of oxygen) to the baby and results in respiratory distress. Most cases are treatable and 10% of cases can be fatal. Risk factors for PPHN can include meconium aspiration, maternal obesity, smoking, diabetes, or maternal use of non-steroidal anti-inflammatory drugs (NSAIDs). It can normally occur in 1-2/1000 infants. Based upon 6 studies from the past 15 years, for those pregnant women taking SSRI medication there can be no association to a 6-fold increased risk of PPHN. Most recently a study published in British Medical Journal (BMJ) on January 12, 2012 reveals that SSRI treatment in pregnancy may double the risk of PPHN as their findings from 1.6 million infants revealed an incidence of 3/1000 rather than the normal 1.2/1000. Although, the risk may be two-fold in this study, it is still clearly extremely low.

The FDA recently made a safety announcement regarding SSRI and PPHN on December 14, 2011:

FDA has reviewed the additional new study results and has concluded that, given

the conflicting results from different studies, it is premature to reach any conclusion

about a possible link between SSRI use in pregnancy and PPHN . . . At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression

during pregnancy.

The FDA had not evaluated the recent BMJ study which was published a few weeks later. However, it is unlikely the findings would have changed their recommendation as it was another conflicting result.

This poses the question as to whether it is worse to have depression during pregnancy or take medication for it? As outlined at the beginning of this discussion, untreated depression in pregnancy can lead to multiple maternal, obstetrical, and neonatal problems. As for the antidepressant options, no drug is 100% safe, but most are considered safe and effective for treatment and may be necessary depending upon the severity of maternal depression. Additionally, in some cases the duration of treatment can be targeted to not start until after embryogenesis is complete at 8-10 weeks and discontinued in the third trimester before delivery to reduce risks of withdrawal and PPHN. However, if there is severe maternal depression this would not be advisable as it increases the risk of postpartum depression.

Postpartum blues encompasses mood symptoms such as crying, anxiety, trouble sleeping, feeling sad or doubt, and being overwhelmed that may occur immediately postpartum, but subside within two weeks without treatment. 70-80% of women will have some “baby blues”. Postpartum depression is depression and anxiety symptoms that occur anytime postpartum up to 1 year after delivery and interfere with daily functioning. The condition may occur from an imbalance or adjustment of hormones, body changes, lack of sleep, feeling overwhelmed as a mother, lack of support or socialization, loss of freedom/identity, genetic predisposition, and breastfeeding problems. The same treatment options can be used during the postpartum period and most antidepressants are considered safe during breastfeeding. Antidepressant exposure through the breast milk is significantly less than transplacental exposure and is not associated with significant risks to full-term and healthy infants.

The risks and benefits of taking an antidepressant during pregnancy must be weighed carefully. Ultimately, it is best to treat each patient individually, case by case to determine the best course of action and treatment. Whenever possible, multidisciplinary management involving the obstetrician, mental health clinician, primary care provider, and pediatrician is helpful to facilitate and coordinate care. It is essential that we screen and treat perinatal depression and stabilize maternal mental health for the overall well-being of mom and baby.

optimawomenshealthcare.com

Breast Awareness and Early Cancer Detection

Optima Womens Healthcare Blog — Sun, 04 Dec 2011 18:32:46 GMT

By Monique Fox, MD

Don’t Forget To Do Your Monthly And Yearly Clinical Breast Exam
In Addition to Your Yearly Mammogram

So many of my patients casually mention to me that they do not do their monthly breast exam because they get a yearly mammogram and think that they are covered. While yearly screening with mammography is the only test shown to decrease mortality, the combination of a yearly screening mammogram , monthly self breast exam and yearly clinical breast exam is the best combination for early detection of cancer.

Breast Cancer Detection

Breast screening that included both a clinical exam and a mammogram was 95% effective at detecting breast cancer.
Screening using mammography alone was 89% effective at detecting breast cancer.
20% of breast cancers are found by the patient’s physician on clinical exams.
10% of breast cancers are found by the patients on monthly self breast exams .

Clinical Breast Exam

A clinical breast exam (CBE) is an exam of your breasts by a health expert such as a doctor, nurse practitioner, nurse, or physician assistant.
For this exam, you undress from the waist up.
The examiner will first look at your breasts for changes in size or shape. Then, using the pads of the fingers, she or he will gently feel your breasts for lumps. The area under both arms will also be checked.
This is a good time to learn how to do breast self-exam if you don't already know how.

Breast Awareness and Breast Self-Exam

Women should be aware of how their breasts normally look and feel and report any changes to a doctor right away. Finding a change does not mean that you have cancer.
By being aware of how your own breasts look and feel, you are likely to notice any changes that might take place. You can also choose to use a step-by-step approach to checking your breasts on a set schedule. The best time to do breast self-examination (BSE) is when your breasts are not tender or swollen. If you find any changes, see a doctor right away.
Women with breast implants can also do BSE. It may help to have the surgeon help you feel the edges of the implant so that you know where they are. It may be that the implants push out the breast tissue and actually make it easier to examine.

Commonly Accepted Recommendations For Early Breast Cancer Detection

Women age 40 and older should have a screening mammogram every year.
Women with increased risk factors should start regular mammography before the age of 40.
Between the ages of 20 and 39, women should have a clinical breast examination by a health professional every 3 years. After age 40, women should have a breast exam by a health professional every year.
Women age 20 or older should perform a breast self-examination (BSE) every month. By doing the exam regularly, you get to know how your breasts normally feel and you can more readily detect any signs or symptoms.

*Remember: No one knows your body like you do, and you have the best chance of spotting changes early on!

Dr. Monique Fox is a breast radiologist at The Trio Breast Center at Parker Adventist Hospital. For more information visit parkerhospital.org/mammogram.

Important Facts About The Flu And Flu Shot In Pregnancy

Optima Womens Healthcare Blog — Mon, 17 Oct 2011 00:51:57 GMT

By Vandna Jerath, MD

Pregnant women are more prone to severe illness and pregnancy complications from the flu.
Physiologic changes and an altered immune system in pregnancy make pregnant women high-risk candidates for the flu.
In pregnancy, the flu can cause dehydration, pneumonia, acute respiratory distress syndrome (ARDS), miscarriage, preterm labor, or preterm delivery and birth.
In 2009, pregnant women accounted for only 1% of the population, but 6% of H1N1 related deaths.
ACOG (American College of Obstetricians and Gynecologists) recommends that ALL pregnant women receive the flu shot.
Influenza vaccination is the best way to prevent the flu – it can reduce your risk of catching the flu by 70-90% and decrease your risk of hospitalization or death by 50-80%.
Vaccination during pregnancy protects both the mother and her infant (up to 6 months of age).
Influenza vaccine is SAFE as it has been given to millions of pregnant women and has not demonstrated harm to women or their infants.
The flu shot can be given to pregnant women in ANY trimester.
Pregnant women should receive the inactivated vaccine (killed virus) or flu shot, but NOT the nasal spray vaccine (live attenuated virus) which is contraindicated.
Postpartum women – especially within two weeks after pregnancy or pregnancy loss – should also receive the flu vaccine and may receive either the shot or nasal spray.
Women who are breastfeeding are encouraged to receive either type of vaccine and can pass antibodies via the breast milk to their infants that may provide passive immunity. This is one of the best ways to protect infants under 6 months of age, who are too young to be vaccinated.
If preferred, a thimerosal free version of the flu shot is available.
Women with an egg allergy or who are actively ill with a fever should not get the flu shot.
Influenza vaccination is an essential part of prenatal care and recommended for all pregnant, breastfeeding, or postpartum women.
Please talk to your doctor about getting your flu shot.

www.optimawomenshealthcare.com

PMS: A Woman's Monthly Madness

Optima Womens Healthcare Blog — Tue, 14 Jun 2011 03:15:26 GMT

Vandna Jerath, MD

Dr. Jerath will be discussing this topic live on Denver Channel 7News on June 14, 2011 at 6:30am.

Premenstrual Syndrome (PMS) is defined by the American College of Obstetricians and Gynecologists (ACOG) as “the cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predictable relationship to the menses.” Typically, PMS is a syndrome with physical, emotional and/or psychological manifestations. Symptoms occur after ovulation and are most significant 5-7 days before the menses and subside within 4 days after the onset of menses.

PMS can affect women of any reproductive age, but is most common between age 25-45. 75 - 85% of women will have at least one symptom or some form of PMS. Many women will find their symptoms tolerable, but 20-30% will have clinically significant PMS with moderate to severe symptoms that have an adverse affect on their life. 3-5% of women will have debilitating PMS with a disruption of daily, social, and work activities and a significant impairment of their lifestyle. These women have a severe variant known as PMDD – Premenstrual Dysphoric Disorder.

Risk factors and the cause of PMS or PMDD are still unknown and research continues, but symptoms are thought to occur due to an imbalance or alteration of cyclic physiologic hormones and brain chemicals known as neurotransmitters, particularly an insufficient amount of serotonin.

Symptoms include an affective or mood component and/or a somatic or physical component:

Emotional/Mood Symptoms

Crying
Angry outbursts or mood swings
Depressed mood
Anxiety
Irritability
Social withdrawal
Poor concentration

Physical Symptoms

Breast tenderness
Bloating
Constipation
Weight gain
Swelling
Acne
Headache
Fatigue
Sleep disturbances – insomnia or hypersomnia
Appetite changes/food cravings

PMS can mimic several medical conditions including hypothyroidism, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, migraines, and depression/mood disorders. The best way to diagnose PMS is to keep a comprehensive menstrual diary outlining symptoms for 2-3 cycles. If symptoms typically occur after ovulation, before menses, and resolve after menses, they are consistent with PMS. A variety of menstrual diaries can be found on the internet or most smart phones will have a useful app for charting.

There is no “cure” for PMS, but there are multiple options to reduce PMS symptoms. Treatment regimens include lifestyle modifications, alternative therapies, and medications:

Lifestyle Modifications

Stress reduction and support
Relaxation
Aerobic exercise – release endorphins which improve mood
Healthy diet –
- Smaller and frequent meals
- Reduce sugar and fat intake
- Increase complex carbohydrates (whole grains, fruits, vegetables)
- Calcium rich foods
- B vitamins – thiamine and riboflavin (spinach, fortified cereal, dried beans, red meat)
Reduction in caffeine, salt, and alcohol
Quit smoking

Alternative/Natural Therapies

Vitamins
- Calcium - 1200 mg daily
- B6 – 50-100mg daily (doses over 100mg can cause peripheral neuropathy)
- Magnesium – 400mg daily
- Vit E – 400 IU daily
Herbs – not FDA approved or regulated and may react with other prescription medications; may still require further investigation
- Chasteberry
- Gingko Biloba
- Black Cohosh
- Raspberry Leaf
- St John’s Wart (may reduce efficacy of OCPs)
- Kava Kava
- Primrose Oil – not particularly helpful
Massage Therapy
Yoga
Acupuncture
Psychotherapy – cognitive behavioral therapy
Light therapy – being researched

Medications

Analgesics or NSAIDs
- Ibuprofen (Motrin, Advil)
- Naproxen (Aleve, Anaprox)
- Mefenamic Acid (Ponstel)
Oral Contraceptives (OCP’s)
- Drosperinone (Yaz, Yasmin, Safryl, BeYaz, Ocella)
Diuretics
- Spironolactone (Aldactone)
Ovarian Suppression
- Danacrine (Danazol)
- GnRH analogs – gonadotropin releasing hormone (Lupron) – cannot be given for more than 6 months and may lead to menopausal symptoms and osteoporosis
Antidepressants /Anxiolytics
- SSRI – selective serotonin reuptake inhibitors
  - Fluoxetine (Prozac, Sarafem)
  - Paroxetine (Paxil)
  - Sertraline (Zoloft)
  - Citalopram (Celexa)
  - Venlafaxine (Effexor)
  - Duloxetine (Cymbalta)
  - Benzodiazepine
    - Alprazolam (Xanax) – increased risk for addiction
Other
- PH80 – pherine intranasal spray in clinical trials now
- Bilateral Salpingoopherectomy – removal of ovaries, extreme measure

PMS is definitely a woman’s monthly madness and many women live in silent suffering. But, with proper recognition, communication, and understanding between the patient and doctor, there are many options that can improve quality of life.

www.optimawomenshealthcare.com

Dr. Vandna Jerath on Parker Adventist Hospital TV - Q&A Regarding Preparing and Planning Pregnancy

Optima Womens Healthcare Blog — Tue, 15 Mar 2011 07:17:00 GMT

Do's and Don'ts During Pregnancy

Optima Womens Healthcare Blog — Tue, 14 Dec 2010 19:55:00 GMT

By Vandna Jerath, MD

THINGS TO DO:

Be excited: Relax and enjoy the pregnancy. Share your experience with your friends and family.
Make an appointment with an Ob/Gyn: An appointment between 6-10 weeks from your last menstrual period is ideal.
Take prenatal vitamins: These should include at least 400 mcg of folic acid to help prevent fetal brain and spine abnormalities.
Consider DHA or Omega-3 fatty acids: These can be good for fetal brain development.
Know your genetic history: It is important to share details with your doctor.
Rest more: Sleep an extra hour every night and alternate activities with rest breaks.
Get regular exercise: 30 minutes a day is ideal. You may maintain previous exercise routines, but do not start a new vigorous activity. Maintain a manageable heart rate. Walking, swimming, and prenatal yoga are great activities.
Wear seat belts: Seat belts should be worn low, under your tummy, and across your hipbone.
Take care of your teeth: Gently brush and floss daily. See your dentist regularly. It is common to have bleeding gums during pregnancy. This can be decreased by rinsing with warm salt water.
Get educated: Find out as much as you can about pregnancy, labor and delivery, breastfeeding, infant and child care, and parenting. Hospitals offer courses, libraries have books and videos, and many websites can be helpful resources.
Eat healthy: Maintain a healthy and balanced diet. Good nutrition will be helpful throughout your pregnancy.
Drink fluids: Water is ideal to stay hydrated, but drink at least 8-10 glasses of water, juice, or milk daily.
Limit Morning Sickness: Eat small frequent meals 6-8 times a day. Try Tums, ginger, or vitamin B6 to decrease nausea.
Sex: Continue lovemaking if it is comfortable for you and you are not experiencing signs of preterm labor, bleeding, or cramping.
Get your flu shot: It is safe and recommended for all pregnant women in any trimester.

THINGS TO AVOID:

Medications: Limit or avoid all medications unless discussed with your doctor.
Herbs: Although some herbs are safe in pregnancy, check with your doctor before taking any.
Toxic fumes and chemicals: Use paint and chemicals in well ventilated areas and wear gloves when using chemicals.
Too much exercise: Avoid heavy lifting, contact sports, and unusual activities without proper preparation. Eliminate high risk activities such as snow/water skiing, snowboarding, and scuba diving.
Hot tubs: Water should not exceed 100 degrees Fahrenheit.
Xrays: If necessary, be sure to wear an abdominal shield.
Caffeine: Eliminate or reduce to one small cup a day as it can cause miscarriage and other problems.
Alcohol: Causes birth defects and there is no safe level so it is best to avoid entirely.
Smoking: Direct and second hand smoke may cause complications in pregnancy, labor and delivery. It can be a primary cause of preterm labor and birth. Wean off any tobacco.
Recreational Drugs: Avoid all illicit substances as they cause birth defects and pregnancy complications.
Douching: Douching can destroy the “good” bacteria in you vagina and allow “bad” bacteria to overgrow into an infection.
Cat litter boxes: Cat feces can carry a disease that can be harmful to your baby.
Raw meat, fish, lunch meats, eggs, and soft cheeses: Limit fish to two servings per week, cook all meats and eggs thoroughly, and avoid unpasteurized soft cheeses.

Dr. Vandna Jerath Denver 7NEWS Interview on cervical cancer screening, HPV, and pap smears

Optima Womens Healthcare Blog — Sun, 12 Dec 2010 07:00:00 GMT

Dr. Vandna Jerath Denver 7NEWS Live Interview on the Flu and Flu shot in Pregnancy

Optima Womens Healthcare Blog — Thu, 18 Nov 2010 05:56:00 GMT

Prevention of the Flu in Pregnancy

Optima Womens Healthcare Blog — Thu, 18 Nov 2010 05:53:00 GMT

By Vandna Jerath, MD

Dr. Jerath will be interviewed live on Denver Channel 7News regarding this topic on October 5, 2010 at 6:30am.

Although the hype may have calmed down about the pandemic 2009 H1N1 flu , both 2009 H1N1 flu and the seasonal flu remain important concerns in pregnancy. The U.S. Public Health Emergency determination for 2009 H1N1 influenza expired on June 23, 2010 and the World Health Organization (WHO ) formally declared an end to the 2009 H1N1 influenza global pandemic on August 10, 2010. The Centers for Disease Control and Prevention (CDC ) feel that the 2009 H1N1 virus will continue to circulate as part of seasonal influenza and have an impact on pregnant women.

Influenza, known as the flu is a respiratory illness with seasonal epidemics typically from October through April with a peak in the U.S. in January. The flu accounts for numerous complications, hospitalizations, and deaths each year. In the U.S., studies have shown that flu related hospitalizations may exceed 200,000 per year and that over the past 30 years deaths may range from 3,000-49,000 per year. People who have a greater chance of serious flu complications include children younger than 2 years old, adults 65 years and older, pregnant and postpartum women, people with chronic medical conditions or weak immune systems, and people younger than 19 years of age on long-term aspirin.

In 2009, only 1% of the population was pregnant, but pregnant women accounted for 5-6% of H1N1 flu-related deaths. Pregnant women have physiologic changes in their bodies with include an altered immune system as well as changes to their circulatory (heart) and respiratory (lungs) systems which results in a decrease in functional residual capacity, an increase in cardiac output, and an increase in oxygen demand. These changes make them more susceptible to severe illness, complications, hospitalization, and even death from the flu. Some of these complications include dehydration, pneumonia, acute respiratory distress syndrome (ARDS ) requiring mechanical ventilation, miscarriage , preterm labor, preterm delivery and birth. An estimated 25 of 10,000 pregnant women in the third trimester will require hospitalization due to flu related problems. During pregnancy, women have a four to fivefold increased rate of serious illness and hospitalization with influenza.

The influenza vaccination is the best way to prevent the flu. Studies have shown the flu shot can reduce your chances of catching the flu by 70-90% in healthy individuals and reduce the risk of hospitalization or death by 50%-80% in high-risk individuals. Studies also show that currently only 15-25% of pregnant women receive the flu shot annually. Flu vaccination of pregnant women can reduce febrile flu illness by more than 30% in mothers and their young infants as well as reduce influenza infections in 0-6 month old infants by 63%. Use of the influenza vaccine reduces costs overall and can result in a savings of $50 per immunized pregnant woman.

On September 15, 2010, The CDC along with the American College of Obstetricians and Gynecologists (ACOG) and nine other medical organizations (AAFP, AAP, ACNM, AMA, ANA, AOA, APhA, AWHONN, and March of Dimes) released a statement recommending that ALL pregnant and postpartum (including after pregnancy loss) women receive the seasonal influenza vaccine for 2010-2011. The key points from this statement are as follows:

Pregnant women are more prone to severe illness from influenza.
Vaccination during pregnancy protects both the mother and her infant (up to 6 months of age).
Influenza vaccine is safe as it has been given to millions of pregnant women and has not demonstrated harm to women or their infants.
Influenza vaccine can be given to pregnant women in any trimester.
Pregnant women should receive the inactivated vaccine (killed virus) or flu shot, but NOT the nasal spray vaccine (live attenuated virus) which is contraindicated.
Postpartum women – especially within two weeks after pregnancy or pregnancy loss – should also receive the flu vaccine and may receive either the shot or nasal spray.
Women who are breastfeeding are encouraged to receive either type of vaccine and can pass antibodies via the breast milk to their infants that may provide passive immunity. This is one of the best ways to protect infants under 6 months of age, who are too young to be vaccinated.

On September 21, 2010, ACOG released a statement encouraging healthcare providers to educate and offer influenza vaccination to all their patients and especially pregnant patients. They stated that ALL pregnant women should get the flu vaccine in any trimester and that flu prevention is an essential part of prenatal care. The CDC also supports that getting the flu shot is the first and most important step in protecting pregnant women and their infants against the flu.

The October 2010 Committee Opinion – Influenza Vaccination During Pregnancy by ACOG, addresses the use of thimerosal , a mercury containing preservative in flu shots, and indicates that it does not cause any adverse effects except for occasional local skin reactions. Numerous studies do not show an association with autism or other problems in infants to immunized mothers. However, for those mothers that remain concerned, a thimerosal –free flu shot is also available.

Symptoms of the flu include fever, cough, sore throat, runny nose, congestion, muscle and body aches, headaches, fatigue, and in some cases vomiting and diarrhea. Sick individuals may be able to infect others and shed the virus starting 1 day before symptoms and up to 5-7 days after becoming ill. In pregnant women, the flu can rapidly progress and worsen. Treatment is typically, supportive care with rest and fluids. Pregnant women are encouraged to treat any fevers with Tylenol, especially because in the first trimester hyperthermia can lead to birth defects and in labor maternal fever can lead to neonatal seizures, encephalopathy or cerebral palsy. Treatment with antivirals may be recommended and ideally work best if started within the first 48 hours of symptoms, but may still provide some benefit if started later. The two FDA approved antivirals are Tamiflu and Relenza. Tamiflu is preferred for pregnant women as it is absorbed systemically. Pregnant women who think they may have the flu should also see their doctor immediately if they experience:

Difficulty breathing or shortness of breath
Pain or pressure in the chest or abdomen
Sudden dizziness
Confusion
Severe or persistent vomiting or diarrhea
High fever not responding to Tylenol or acetaminophen
Decreased fetal movement
Regular uterine contractions with concern for preterm labor
Vaginal bleeding or possible leakage of amniotic fluid

In summary, the CDC outlines “Take 3” key actions to fight the flu:

Take the time to get a flu vaccine. –
- Yearly flu vaccine recommended for EVERYONE 6 months of age or older.
- Particularly important for people at high risk for flu complications including children under 2 years of age, pregnant and postpartum women, people with chronic illness or immuno-compromised, and those over 65 years and older.
- 2010-2011 is a trivalent seasonal vaccine which covers influenza A 2009 H1N1, influenza A H3N2, and influenza B.
- Health care workers, childcare providers, nursing home residents, and caretakers of the high risk or chronically ill should also get vaccinated.
Take everyday preventive actions to stop the spread of germs.
- Cover your nose and mouth when sneezing or coughing.
- Wash your hands.
- Avoid touching eyes, nose, or mouth.
- Avoid close contact with sick people.
- Stay home for at least 24 hours after your fever is gone if you are sick with the flu.
Take flu antiviral drugs if your doctor prescribes them.
- These drugs can shorten the duration of your flu symptoms and help prevent serious flu complications.
- Ideally, antivirals should be started within the first 48 hours of symptoms, especially for those at increased risk for flu complications such as pregnant women, young children, the elderly, or chronically ill individuals.

The flu vaccine should not be given to children younger than 6 months of age, individuals with a severe egg allergy, anyone with a prior severe reaction or a history of Guillian-Barre Syndrome (GBS) after vaccination, or someone with a current fever should wait for immunization until the fever resolves.

The flu vaccination is recommended for everyone over 6 months of age and an important measure for public health prevention. As pregnant women are particularly vulnerable to the flu and more susceptible to increased morbidity and mortality, it is essential for all pregnant women, women planning to be pregnant during flu season, postpartum women, and women breastfeeding to get the flu vaccination. Please get your flu shot for your overall health and wellness and to help prevent this epidemic.

www.optimawomenshealthcare.com

Anthropology of the Due Date

Optima Womens Healthcare Blog — Fri, 13 Aug 2010 23:26:00 GMT

By Shawn A. Tassone, M.D.

Author of “Hands Off My Belly! The Pregnant Woman’s Guide to Surviving Myths, Mothers, and Moods” – Mom’s Choice Gold Recipient and Arizona Book Publisher’s Glyph Award Winner.

So much mysticism and mythology surrounds the pregnancy due date. Much of the mysticism is held by physicians who hold on to the old ways of determining when a pregnant woman will deliver. Believe me, most physicians would love a way to determine the due date so we could plan our lives around the deliveries of our patients, but the truth is only 1-2% of women will actually deliver on their due date. So what determines a due date, and what is the difference between EDC (estimated date of confinement) and EDD (estimated date of delivery) and what the heck is Naegele’s Rule. This post will help show the origins of the due date and how we are currently using a system that is about 250 years old.

Franz Karl Naegele (1778-1851) was the German obstetrician who initially came up with the rule to determine a woman’s due date based on her last menstrual period (LMP). There are many ways to calculate Naegele’s Rule. I use the system where you take the LMP, add 7 days, and subtract three months. So if your LMP was April 1, 2009 then your due date would be January 8, 2010. You can impress your friends at parties with this maneuver. There are problems with Naegele’s Rule and many people have pointed out that this 250 year old method is no longer appropriate for our advanced age. What are some of the potential errors with calculating the EDC in this method?

It assumes that you are having a regular period and that you ovulate on day 14 of your cycle. I am a gynecologist and there are many women out there that have irregular cycles that ovulate on day 20, 25, 12, 15….you get my point. This obviously would add potential error to the EDC determination and could change things by days to weeks.

There is another assumption that the routine pregnancy is 280 days long and that is based on our current calendar system. The problem with this is that there are many months that contain 30 days or 31 days and what happens in a leap year, or if you are not pregnant over the shorter month of February. The point is that there is a movement out there that is trying to say that the number should be 288 days and that we are inducing women that have premature babies. A study done in 1990 stated that the proper method for determining a due date was to take the LMP, count back three months and add fifteen days for a primiparous (first pregnancy) woman or 10 days for a multiparous (subsequent births) woman. This was published in the journal Obstetrics and Gynecology.

There are many that argue this method of calculating the EDC is as archaic as the term EDC itself. Lending to the agrarian societies from whence it came, the EDC literally came from the fact that a woman was confined to her bed for the last part of her pregnancy to prevent preterm labor. While we still prescribe bedrest today as a possible therapy for preterm labor it does seem odd that the medical establishment uses terminology from the 1700’s.

The due date is as individual as the pregnant mother. While the EDC is currently calculated by Naegele’s Rule this does seem a bit archaic and inefficient; especially if we are using this dating method to determine inductions and postdatism. There have been other methods with increased accuracy but they require a woman to measure body temperatures and be move involved in her own self-care. Many reading this article are very involved with birth and feel as though self-care is very important, but there are many women out there that simply choose not to be observant of their own cycle. So, what do we “do” with the “due”. Unfortunately, I think we will keep going with the current system and back it up with ultrasounds which are accurate within 5 days if done in the first trimester.

Approximately 3% of so-called term births (occurring after 37 weeks) are completed with fetal lung immaturity and this could be because the baby may have been between 35-37 weeks and not term.

Are we too involved in the birthing process? Are there better ways to determine the pregnant due date or should we not worry about and just let man/woman be born in his own time. The latin word natura gives rise to the word natural and means “to be born”. Maybe we should just leave well enough alone.

www.handsoffmybellyguide.com
Hands Off My Belly! The Pregnant Woman’s Survival Guide to Myths, Mothers, and Moods is for sale on Amazon and Barnes and Noble and at most brick and mortar stores.

Herbs During Pregnancy

Optima Womens Healthcare Blog — Fri, 02 Apr 2010 03:13:00 GMT

By Michele Conklin, Author/Writer Grow Magazine

Dr. Jerath was interviewed regarding this topic and this article was originally published in the Spring 2010 issue of Grow, a health publication from Parker Adventist Hospital.

Approximately one in 10 pregnant women take some sort of herbal product, potentially risking the health of their pregnancies and babies, according to a study recently published in the American Journal of Obstetrics and Gynecology.

"Women tend to think that herbal products are safe because they are natural, but there are many that can cause miscarriage, premature birth or fetal defects," says Vandna Jerath, M.D., an obstetrician with Parker Adventist Hospital.

Herbs have limited regulation and inconsistent standards of purity and quality. Women should be cautious in using herbs while pregnant and up to three months prior to becoming pregnant, Jerath says.

Typically, herbs that can be eaten in their original plant form or as a vegetable--rather than as concentrated pills, extracts or tonics--are likely safe. Herbs used in small amounts for cooking or seasoning are generally safe.

Very few herbs taken as supplements are considered safe during pregnancy, Jerath says. Some that are likely considered safe—in specific forms--are:

Peppermint leaf - Helpful in relieving nausea/morning sickness and flatulence
Ginger root - Helps relieve nausea and vomiting
Slippery elm bark - Used to help relieve nausea, heartburn, and vaginal irritations (likely safe when the inner bark is taken orally in amounts used in foods)
Oats & oat straw - Rich in calcium and magnesium; helps relieve anxiety, restlessness, and irritated skin
Red raspberry leaf – Rich in iron and considered a safe herbal tea when used in the second and third trimester. Can ease labor pains and increase milk production.

If you're pregnant, always check with your doctor prior to taking an herb. You also can find information online at the National Institutes of Health’s medlineplus.gov.

www.optimawomenshealthcare.com

To Pap or Not To Pap?

Optima Womens Healthcare Blog — Mon, 15 Feb 2010 06:58:00 GMT

By Vandna Jerath, MD

To pap or not to pap . . . that is the question? Cervical cytology also known as the pap smear is the primary reason for a 50% decrease in the incidence of cervical cancer over the past 30 years. For years we as ob/gyn doctors have been taught to do pap tests early and often. Well, really to do them at least yearly or more often if the patient was high risk. We were also advised to do them within three years of our adolescent patient becoming sexually active or by age 18-21; whichever came first. Now, the rules and recommendations have changed . . . and yes, it’s confusing.

ACOG – American College of Obstetricians and Gynecologists of which I am a fellow and consists of over 50,000 of my colleagues came out with some new guidelines for cervical cancer screening in November 2009. These recommendations came on the heels of the controversial new mammography screening guidelines. Although, it may seem that these guidelines were highly restrictive in the pursuit of cancer, they were really meant to be more cost-effective and less invasive. And if we take a deep breath and a step back the cervical cancer screening guidelines actually seem reasonable.

What’s new? Well, there were three major changes in cervical cancer guidelines by ACOG:

1. The age at which to start pap smears – should be age 21 regardless of sexual activity.

2. The pap interval – for those ages 21-29 every two years and for those 30 and over up to every three years is appropriate if they have had three normal paps and are low-risk. And for those who have had a benign hysterectomy, are low risk and have had three normal paps, routine paps may be discontinued.

3. The age at which to stop pap smears - seems to be by age 65-70. Provided that the patient is low-risk and had normal pap smears for the past 10 years, discontinuing pap smears at this age is adequate.

None of these guidelines are meant to replace the annual well woman exam which may still be performed without a pap smear. The annual exam is still typically required and recommended for a variety reasons. These reasons may included a woman’s general well-being, family planning, counseling for sexually transmitted diseases/infections (STDs/STIs), to refill birth control or hormone prescriptions, follow-up on breast examinations, check blood pressure, evaluate pelvic anatomy, and address other gyn conditions.

Cervical cancer occurs in approximately 11,000 women annually in the U.S. and accounts for approximately 4,000 deaths each year. Risk factors for cervical cancer include early onset of sexual activity, increased number of sexual partners, history of STDs/STIs, high risk HPV, history of abnormal pap smears with moderate or severe dysplasia (pre-cancerous changes of the cervix), smoking, HIV or immunocompromised patients, diethylstilbestrol (DES) exposure, poor nutritional status, obesity, teen pregnancy, low income, and in some cases family history. Cervical cancer is most common between the ages of 40-55. Cervical cancer by nature is slow growing and occurs over the course of many years. It is typically diagnosed in women who have not ever had a pap smear or have not had one within the past five years.

Over 95% cervical cancers are caused by a high risk form of HPV – Human Papilloma Virus and 75% of all sexually active adults will have had some form of HPV in their lifetime. Also, HPV infection is more common after the onset of sexual activity and more prevalent in the adolescent population. However, these young women’s immune systems will clear 60-70% of the infections in one year and up to 90% by two years. Meaning most of these new infections will regress and be unlikely to cause cervical cancer. The incidence of cervical cancer under the age of 21 is about 1 in 1,000,000.

So, it makes sense to perhaps wait and test these teens as young adults rather than when they first become sexually active as most will have fought off their HPV infection and lowered their risk for cervical cancer. If they are tested earlier they are likely to have significantly abnormal pap smears which will result in further testing and procedures that are both invasive and can be harmful to their future fertility. These procedures can increase their risk factors for incompetent cervix, cervical scarring, cesarean section and preterm birth in the future.

Although HPV can cause pre-cancerous changes and lead to cervical cancer, it does not do so quickly. Cervical cancer is a slow growing cancer and the disease process takes many years to develop so the two-three year interval on pap smears in a low-risk population seems reasonable.

As for stopping pap smears altogether on those who have had a hysterectomy or are over 65-70 years, well, I struggle with this guideline the most. Logically and statistically, I get it and understand why this guideline has been recommended, but anecdotal evidence speaks to me as I have had several patients with either vulvar or vaginal cancer over the years. It also concerns me that this might possibly be the population that may skip their “annual” exams if no pap smear is needed which may lead to inadequate overall care of the patient. It may not be cost-effective to perform a pap and highly unlikely that these patients are at risk for cancer, but I do feel this is an informed decision that the patient will need to make in conjunction with her doctor.

There are still several factors which will ultimately impact these cervical cancer guidelines. One is the use of the HPV vaccines, Gardasil or Cevarix. Gardasil is FDA recommended for girls ages 11 and 12 and approved for girls/women ages 9-26. It has also recently been FDA approved for boys/men as well. Gardasil has been tested extensively and approximately 40 million girls/women worldwide have been vaccinated. It is considered safe and protective against HPV types 16 & 18 which are the cause of 70% of cervical cancer and types 6 & 11 which are the cause of 90% of genital warts. Cervarix has been distributed to about 7 million girls/women worldwide and is FDA approved for ages 10-25. Ideally, either vaccine should be given prior to onset of sexual activity and is thus, most protective. Some protective benefits may occur in previously sexually active women if they are not already infected with HPV or these particular types of HPV as well. Studies are underway to test the benefits, if any, of the HPV vaccine in women older than 26 years of age. The full impact of the HPV vaccine on cervical cancer will likely not be known for 15 years, but for now vaccinated women will still follow the same new screening guidelines.

Another question that remains is whether to do HPV tests on all patients. Most of us use HPV testing in patients with abnormal pap smears, mainly ASCUS, but the benefits of using it routinely remains to be seen and is still uncertain. ACOG recommends that HPV testing not be done on patients under 30 years of age due to the high likelihood of transient positive results. But, HPV testing may be done as co-testing along with a pap on those low risk patients over 30 years old. And if the pap and HPV testing are both negative, ACOG advises that the patient not be rescreened prior to three years.

Now, back to the original question – to pap or not to pap? Cervical cancer, although slow growing, can be a deadly disease and must be taken seriously. The new guidelines and decreased intervals of pap smears may be adequate to diagnose cervical cancer, but both the doctor and patient must feel comfortable. For a low risk patient, it is important that the doctor communicates these changes and discusses these guidelines with the patient and involves her in the process and course of action. Although reasonable, these screening guidelines must be individualized based upon the patient’s history and needs and discussed with her. Additionally, it is essential that each woman still undergo a well-woman annual exam with or without a pap smear for her overall health and wellness.

Vandna Jerath, MD

Optima Women's Healthcare

www.optimawomenshealthcare.com

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