410 ‒ The biology of pregnancy: physiologic adaptation, childbirth, and long-term maternal health

Key Takeaway

Treat pregnancy as a source of lifelong health data, not a closed chapter. If you experienced gestational diabetes, hypertension, or preeclampsia, tell your primary-care clinician and create a follow-up plan today: confirm postpartum testing was completed, track blood pressure and glucose as appropriate, and prioritize regular exercise, a healthy diet, and weight management. These conditions often resolve after delivery, but they can reveal a higher future risk for type 2 diabetes, hypertension, kidney disease, and cardiovascular disease.

Episode Overview

Peter Attia speaks with maternal-fetal medicine physician-scientist Katie about the extraordinary physiologic adaptations of pregnancy, from placental hormone production and insulin resistance to labor and delivery. They examine gestational diabetes, preeclampsia, HELLP syndrome, cesarean delivery, prenatal screening, postpartum mental health, and why pregnancy complications should inform long-term preventive care. The conversation also highlights persistent gaps in maternal-health access and research funding.

Full Transcript

Transcript of 410 ‒ The biology of pregnancy: physiologic adaptation, childbirth, and long-term maternal health from The Peter Attia Drive Podcast. Auto-generated from episode audio; may contain minor errors.

Hey everyone, welcome to the Drive podcast. I'm your host, Peter Aia. Katie, thank you so much for coming out. It's awesome to meet you and I'm super excited about what we're here to talk about. Yeah, me too. Um, give folks just a little bit of a background in your um maybe what you're doing today, but also kind of the trajectory that got you here. You're a physician scientist, an MD PhD. uh what what led you to this field? I guess that's a good question, but um I think um I've always been interested in in science and I um was in undergrad and um I really liked all my classes and all all the science classes and I was thinking of just going to medical school and then I I had this one advisory meeting with our that was required at the University of Wisconsin where um this in this one meeting this professor sat down and said, "Well, My daughter went to medical school and she really enjoyed it, but I I thought she would have been so much happier if she also did a PhD.

Have you ever heard of that? And I was like, "No, I I've never heard of that." But because of that one conversation, I investigated that further and I um thought that that was fascinating and super interesting and that was the beginning of me pursuing all the rest of the steps that happened after that. And so what just briefly, what did you focus on during your PhD? Yeah. So I um I technically have a PhD in immunology, but what we really did was take um this benzoazipene that was found from a um drug screen uh to and it had been shown by a previous student in the lab to help treat autoimmune lupus uh disease in my lupus um and um but they didn't know how it was working.

So my PhD was focused on understanding the molecular mechanism of this novel benzoazipene um and where it bound and how it actually induced apoptosis in cells. And so um basically I took a lot of cow hearts and isolated mitochondria and did a lot of biochemical assays to show that it acted on the mitochondrial ATPAS. So that is what I spent my time doing. Did that end up having human clinical benefit? actually that um the drug itself is not very soluble. So it was hard to make into like a readily absorbed um drug.

However, um a derivative of that has actually become a treatment for in that's in trials for um inflammatory bowel disease because it can act just in in the gut. And I assume you did your PhD in the sort of normal MSTP fashion where you did the two years of preclinical, you went off to the lab and then you came back for your rotation. So, you come you come out of your PhD, you've got a couple years left of medical school. What drew you to obstetrics and gynecology?

Yeah, I I had always been really interested in women's health. Um, I did all the clinical rotations as a third-year medical student. I really liked everything. I liked medicine. I liked surgery. Um, but I really liked pregnant patients um and and deliveries. And I thought um it was such a unique patient population to take care of because I found people were uniquely motivated about their health during that time in a way that you didn't find in other parts of medicine. And thinking with the research half of of my interest, I also was fascinated that we didn't understand anything like why do people go into labor?

Why do people have pre-term labor? Why do people have preeacclampsia? The answer was we don't we don't know. And so I um I I thought it was a great area of medicine to go into. Well, let's just jump into it then. Um really the first place I kind of wanted to start was understanding the sort of physiologic stress test that is pregnancy. Um obviously I have no personal experience uh but certainly watched my wife go through it three times. actually more unfortunately um but but three successful pregnancies.

Um and I shared with you some personal stuff that I probably won't disclose on the podcast about I' I've I've seen the most extreme sides of it. Um I have to be honest with you, there's a part of me that thinks how did our species propagate? Like I don't understand how all the women and children didn't just die. So it's I know we talk about how infant and maternal mortality was such a huge driver of short life expectancy prior to the modernity of medicine. I'm still surprised it was as successful as it was.

So um in whatever way you want to address it, just maybe talk us through the unbelievable demands that are placed on the women in this species as they have to deal with this uh essential challenge of our uh reproduction. Yeah, I mean I think that's uh and I'm also amazed that that it ever goes well pregnancy that is. So um just uh for how many ways that it it can um go wrong. But I think um you know you um take an adult and um you know they um they become pregnant and immediately the increased demands on their body starts to support this developing fetus.

And so um you know there's great expansion of the the blood volume um you know great uh alterations in the endocrine and metabolism and um those you know are extremely dramatic and persist throughout the whole pregnancy. Um so um you know it's it's hard to pick just like you know one thing but I think you know we um it's a cardiovascular um stress test um because the plasma volume expands um so much um it is um a metabolic stress test because there's increased insulin um resistance especially in the second part of pregnancy um that causes some people to have gestational diabetes.

um and it often can unmask like future predisposition to disease um through um this process. Well, I want to talk about all of those, but maybe we can just start with the beginning. So, shortly after conception, what is sort of the first physiologic interruption that occurs in in in the woman's body? And I'm I mean we could think of this through the lens of some I I I is the if for a woman who is not planning to get pregnant is the first observation typically the menes the the mist period or is it morning sickness like in your experience what is the first uh sign that a woman's pregnant?

Yeah. I think for people who have regular periods like the missed period is often the first um first sign before before an actual symptom. Yeah. Okay. Um, we don't need to explain why that happens. I think that's pretty self-evident. Um, but let's now talk about how the physiology is changing in that first four to 6 weeks. So, um, the implantation has taken place. Obviously, the placenta is starting to grow. What's happening in her endocrine system, for example? Yeah, I mean I think um there's there's certainly different phases of you know at first the ovary is actually supporting um in an endocrine way the development of the the pregnancy and then as the placenta develops the placenta itself um starts to secrete the hormones that um you know support the the pregnancy.

And when does that transition take place? Uh between like you know 8 to 10 10 weeks of pregnancy. So um so that's why when people have IVF um and they're they kind of shut down your own hormone system for that process that supplementary hormones are given for the first several weeks of pregnancy because that there isn't the natural hormones being produced by the the ovary. Okay. So the ovary before that transition is primarily making estradiol as the dominant estrogen and progesterone to support the pregnancy. And then what's happening with hCG uh during that period of time?

Yeah, I mean that starts to you know it goes from being zero to increasing dramatically. And what's the purpose of that? I mean I know it's a it's basically luteinizing hormone, but is it basically the pituitary's way of telling the ovary to make more of these hormones? Is that why it's rising? That's a good question. I um uh I I haven't thought about that in a while. So, is the rise in hCG part of what's driving the morning sickness or the nausea? Do we do we know what's causing that?

For a long time, people actually thought that um but actually um there for people who have extreme nausea and vomiting of pregnancy, so hypermesis graidorum, they um we have very poor treatments for that. And um interestingly, genetics is something that gave us a a great insight about that. Um which is when they they studied folks who had hyperammesis, they found a signal that flagged the GDF-15 gene is uh really important in driving um who developed that condition. And so that's actually now a developing target for therapeutics in that area and suggests that we haven't really gotten it correct as to why people have that.

So it's not that well understood. Is it correlated with anything else? For example, is it correlated with uh a person who easily gets sick being in a car or on a boat? That's a good question. I I don't think all the time that that is the case. Is it also something that is predictive of subsequent I mean if it has a high genetic component I assume the answer is yes. But is it necessarily the case that if a woman's sick during her first pregnancy she's probably in store for this going forward?

We often see people who have hypermesis in all their pregnancies if they have it with their first. So yes. Okay. So again we don't know why it's happening. Um is the biggest risk of that simply nutrition? Is it that the you just it makes it more difficult to get enough nutrition during that period of the pregnancy? Yeah. I think I think so. And I think it's more it's more maternally risky. So usually the fetus at that stage will take what it needs from the mother and so the biggest risk is dehydration and um lack of nutrition during that time.

Yeah. Do you have a rough sense of the prevalence of how often it becomes maybe something that would even require a brief hospitalization or medical even a medical intervention and and by the way is are your standard uh antiimetics uh safe during pregnancy? I can't remember zopran and things like that. Can they be used during pregnancy? Yeah, we they can be used during pregnancy. Um, you know, there's various we could get into the data on that, but in general, we do have some some tools and antiimetics that can be given, but it is um but oftentimes they're not helpful enough for folks and they do end up in the hospital needing IV hydration and even IV nutrition sometimes during pregnancy.

All comers, what's the prevalence of that intervention? I think um it's it's pretty rare, like less than 1% of folks. Um but obviously for the folks that have it, it's very severe. Now, I don't remember my embryology well enough to remember exactly what's happening in the fetus at every week. I obviously we all had to know that in medical school. Um but the first trimester, the the fetus isn't huge, right? Like it's it's it's a pretty nonlinear growth pattern is one of my recollections. But yeah, but but a lot of incredibly important things are happening albeit at a small scale.

So you talked about plasma expansion in the mother. How much of that is occurring in the first trimester? It starts immediately and kind of peaks at being total it it increased by 50% by 28 weeks. And so it's um pretty it it starts immediately and is pretty linear up to the um and really accelerates in the second part of the um second trimester and then kind of levels levels off. So that's pretty remarkable. A 50% increase in plasma volume by 28 weeks. Yeah. Now does is that accompanied by a 50% increase in oxygen carrying capacity?

Is the is the is the uh is the hemoglobin concentration expanding to to compensate for that or is there a relative anemia that's forming? It's a relative anemia that's forming due to that expansion. Again, I I suppose because women are young when they have pregnancy, we don't have to worry about things like CHF, but a 50% plasma increase would would kill some people. Correct. in that there are folks for who have severe enough cardio or pulmonary disease that um they are unable to tolerate that and then the recommendation is really to to not be pregnant.

So wow. So there are women whose heart and lung function is poor enough that an abortion might be necessary to save the mother's life. There's you in other words you couldn't just give them diuretics and treat them the way you would treat someone with CHF because then that would be ineffectively causing the abortion as well. Right. Yeah. That's and and presumably is that a failure of the medical system in the sense that that woman should have known that she was that high risk before? Um h how like that that seems like a a difficult position for someone to be in.

Well, it's it's complex, right? 50% of pregnancies aren't planned. Um you know, uh oftentimes folks uh affected by the most severe medical disease all often lack other resources, insurance, access to care. So there's a lot of barriers. Sometimes disease remains undiagnosed until um someone that uncovers it it is pregnant. So yeah um um okay you talked about this switch from the ovaries providing the sex hormones to now the placenta. You said that takes place did I did you say about eight weeks? Okay. Are they just continuing to go up?

Estrogen progesterone are continuing to rise. um what is their function? How does it differ between a male versus female fetus? Um there there really there aren't a lot of differences for the in that in for a male or or female fetus. Yeah. And so the estrogen and progesterone, what are they doing to support the pregnancy specifically? Yeah. I think um we're we're in the domain of the reproductive endocrinologist here and not the maternal fetal medicine doctor but um but you know they um progesterone has many important functions in pregnancy especially um in maintaining the uterine quesence right so it doesn't contract um and continuing um to support um the development of the the placent itself.

Yeah. and and and how often do women complain of symptoms from the estrogen rise? Because we we know from later in life, so when you think about women who are undergoing hormone replacement therapy, um they can become very symptomatic from the estrogen, but the estrogen that's given during perry and postmenopause is much lower than presumably what she's experiencing in pregnancy. And yet they can still have symptoms like horrible breast tenderness, headaches, and things of that nature. So how often are those occurring in pregnancy as a result of this enormous surge in estrogen?

Yeah, I mean I think with the dramatic change in the beginning of pregnancy um lots of those symptoms are common like breast tenderness and um you know associated estrogen related symptoms but they abate does the you know different everyone experiences it different but I do think that there is some adjust adjustment um but you know that also the hormones often also you know drive the you know other physiologic changes in in the mother across pregnancy as Uh, at what point during the pregnancy does the mother's appetite usually start to increase?

Well, I mean, I mean, I guess it's complicated because you let's let's take out the case of a of of a woman who's got horrible morning sickness and more I'm asking this through the lens of when does the demand when does the metabolic demand of the fetus warrant increased intake by the mother? Well, I think that's that's more like um in the second half of pregnancy when the actual amount that the fetus is growing is is the greatest. There's of there's off often sorry also um increased nutrient demands which is why you know we have folks taking prenatal vitamins um and also um that contain iron because that will also support like the developing blood expansion as well.

So there are increased nutrient demands. So let's talk just specifically about them. I know that many folks probably know what the prenatal stack looks like, but just and you maybe we can just state it. What are the most important vitamins and minerals during from the moment a woman is pregnant or even planning to get pregnant, right? Folic acid is really the one of the things we've really thought about and focused on a lot of having adequate levels prior to conception. And so that's part of the reason we tell tell people to take a prenatal vitamin prior to conception because there's good evidence that folic acid deficiency increases the risk of having a neural tube defect in the baby and by the time you recognize the pregnancy it's already kind of too late um uh to bring up folic acid levels if they have been deficient.

So that's one of the most essential things early on. Now, you said 50% of pregnancies are unplanned, which suggests that prenatal vitamins should be recommended to all women of childbearing age. Correct. Well, or a healthy diet. So, I mean, I think if you have a well-balanced diet and a lot of the food um is now supplemented with, you know, B vitamins and folic acid and things that you want to be replete in with pregnancy. So I think um uh a lot of folks will have adequate levels if they're eating a wellbalanced diet with fruits and vegetables and um whole grains.

So So what is your patient population like? You're in Seattle um but you're you're at a university hospital so you serve a very broad population. How often do you today see a neural tube defect? Well, we're a we're a referral center. It's just it's concentrating there, but right. Yeah. So, um you know, there we we see cases of neural tube defects every month, you know, that come to our center, but we have, you know, again, we're a have a wide catchment area. Explain to folks what that is actually.

I think we're taking that for granted. Yeah. Well, um it's a category of um uh defects like in in any part of the neural tube where it doesn't form correctly. The most common would be like uh myo meninja seal where um at the base of the spine commonly the um spinal cord is is actually exposed. So the overlying skin doesn't form properly and the part of the spinal cord is exposed. When that is diagnosed, is there anything that can be done in uterero or is it now just a case of knowing what to expect at delivery?

Yeah, this is one of the areas where um there have been developments in doing in uterero surgery. So um there I I'm not a fetal interventionist but there are um uh qualifications that make people eligible or not eligible um to have in utero repair. So um so for some folks that is done um in in the right cases it can help improve um long-term ambulatory like lower extremity function bowel and bladder function um uh of the child. So um that is why it is is done sometimes and classically without an intervention if a child is born with a neural tube defect of the type you've described what how does that impact their life?

Well, it is it's very variable. There can be mild effects or pretty severe effects. Um um again, I'm not I'm not a pediatrician either, but um uh there can be a lot of effects on walking, lower extremity strength and function, bowel and bladder function. Um and also um problems with accumulation of fluid in the the brain and need for shunting of that fluid um lifelong. Now this is taking another very very extreme example but it's it's one of the ones I really remember from medical school is this condition anphille um is that something that is not seen typically today or is that are there still cases of that?

Um no we still have cases of that we we have had two this year in our practice that I'm aware of. Can tell can you tell folks what it is? Well, it's also on it the spectrum of neural tube defect, but it's the most um severe where um the um the brain and and cranium does not form um at all. And so those are and I don't think today with the prenatal care that is available to women, children are born with in that condition, although again in medical school, we saw countless examples of this in textbooks and things like that.

Um is this kind of um what determines in the context of a folate deficiency why one woman might have anphily versus which is obviously not survivable or cons you know uh whereas another woman might have a baby that has a small neural tube defect down at the other end of the spine which could be completely survivable like is is that a random chance thing or is it speak to some other factor? The overall answer would be that we don't we don't understand it. There there are cases of these malf formations that are associated with underlying genetic syndromes in the in the baby, but there are also cases that are sporadic where there's no underlying genetic defect identified and and we don't know why.

Okay. Yeah. What are some other very important milestones for the mother and fetus during the first trimester? Um well, another really important thing that's happening entirely in the first trimester is formation of all the organs of the of the fetus. So by the time the first trimester is done, that's basically complete. So the heart has four chambers. The pancreas has considered its little vententral bud rotation. All of that stuff has happened. And and approximate size of the fetus at the end of the first trimester. I mean, so you're you're your whole for those who are listening to us basically an inch and a half, two inches, how many how many grams?

I I couldn't tell you. A few almonds. Yeah. So, it's miniature, but it's perfectly formed. Yeah. Which is unbelievable. Yeah. Okay. At this point, on average, the mother has gained how much weight? 0 to 10 pounds. I mean, yes, it's relatively small. Yeah. There's there's huge variability as you might imagine. Yeah. Okay. So, now we enter the second trimester. We are let me do my math. We're about halfway to that expansion of plasma volume. So, we'd be roughly at 25% plasma expansion. Um, tell me what's happening now in terms of the physiology.

The hormones are are they still going up or have they plateaued at this point? That's a good question. And I I'm not Sorry. I keep It's like your board exam here. I do feel like I'm in an oral board exam, just to be very honest. I'm sorry. I'm sorry. I promise you there's no grade at the end of this podcast. Um, okay. So um tell me tell me what else is happening in that second trimester as far as the the the especially in terms of like what the mother's physiology is doing.

Yeah. Well, there's a lot of fetal growth um during this period and um really you know the the plasma volume has increased somewhat but then there's really an acceleration of that um in the second part of the um uh second trimester. So it's not linear. Um but I would say that you know there's there's more um maternal adaptation to pregnancy. Um the metabolism might switch from like um being insulin sensitive to being more insulin resistance during that part of the pregnancy um given the growth of the placenta.

Um the pregnant person's going to be you know gaining some more weight than the first trimester usually during this time. and also you know they're they become visibly pregnant during this this this part of the pregnancy. So let's talk about that fuel partitioning piece, the insulin sensitivity, insulin resistance. Um there are certain conditions when insulin resistance might be desirable. So one of them is actually fasting. So when a person is fasting for prolonged reasons, the muscles actually become insulin resistant as an adaptive response so that glucose is preferentially spared for the brain.

Um, is the insulin resistance that you describe here in the second trimester equally adaptive or is it necessarily pathologic and and obviously at some levels it's pathologic if it develops into frank diabetes, but but kind of walk me through that. Yeah. Well, I think it can go either way. I mean, the I think it's meant to be adaptive, right? Providing enough fuel for the fetus to grow. Um but for some folks um they um produce more glucose than is needed and their glucose levels stay too high and then they're diagnosed with gestational diabetes.

When did routine screening for that become the norm? As long as I have uh been practicing because the reason it became the norm is that by risk factors we missed half the people who developed gestational diabetes. And so the reason that routine screening started was because um you couldn't predict very well who was going to develop. And what were the consequences of that? And just how significant was it? Like a a woman would show up with a glucose would this carry its way all the pregnancy and or would she present prior to delivery in the way that a person with type 1 diabetes might present with glucosuria and all sorts of other things?

Yeah. I mean it's not like type 1 diabetes. It's more more like a type two diabetic but they would present with glucose in the urine and they may be having other maternal symptoms like you know polyura and polyypipssia from high glucose if it was uncontrolled enough. Um I think the you know the short term of pregnancy is not so much um uh too concerning otherwise from a maternal level from like a short-term mild elevation but really the for the fetus that's very um consequential to see that high level of glucose and so if the fetus sees that they can have excessive growth so you get fetal macrosomeia there's higher risk of developing complications of pregnancy like preeacclampsia where you get high blood pressure and protein in your urine if you have gestational diabetes, especially if it's not well treated.

Um, and then there's all the consequences at delivery of having a baby that is bigger than it should be, which increased risk of of C-section and shoulder dystocia. And then the baby would be at increased risk for having um hypoglycemia as the baby ramps up its own insulin production to try to bring the levels of glucose down. and um then gets detached from the mother and the placenta and then is making too much insulin and then has low glucose after. And then does the fact that the baby had to be effectively locally hyperinsulinemic to manage this during the pregnancy does that have implications for their long-term health visav insulin resistance and diabetes later in life?

And if so, is it epigenetic? Do we know why? Yeah, I think yes, they have a higher risk of um metabolic um issues long term and I think we don't fully understand all the reasons why that is the case. So So for that reason, we've obviously made the wise decision of every woman is going to get screened for this. Uh remind me when in the pregnancy does that screening take place? between 24 and 28 weeks. And presumably that's chosen because if you did it any earlier you would miss people that are gonna present.

Yeah. Yeah. And actually data shows that when you diagnose it earlier it might not improve the outcomes at all. So it seems to be the best window for both like get screening and and identifying people who who are at risk or have um developed um gestational diabetes and having the most impact from treatment. Tell me the diagnosis is made with an oral glucose tolerance test done at fasting and then two hours. What's the criteria? So the way it's done is the one hour glucose test with 50 grams of glucose doesn't have to be a fasting test.

So you just come in, you drink 50 grams of glucose, you have your blood drawn an hour later and tested for the glucose level. I see. If if you don't pass that test, so your glucose is above 130 or 140 depending on which cut off you're using. Um that's actually not that high, Katie. No. So because I'm just the way I'm thinking about it is we always do O GTTS on our patients, but they're fasting now. We're using 75 grams of gluc. I I'm not sure it's apples to apples, but um I can imagine a scenario where a woman comes in from a lunch where she was out at a you know she had she had pasta for lunch.

Her glucose is already 120 or 130 which would be perfectly normal postprandally an hour after 50. I would be surprised if she was back down to 130 or 140. So you you could potentially get into these false positives. Yes. Of of course. Um, so we do a follow-up um, uh, three-hour glucose test where they do have to come in fasting and then um, drink a larger glucose load and then get tested at 1, two, and three hours after that. And then what's the criteria on that?

Is that 75 grams you do for that one? Yeah. And then you um then you look there's a there's a range for each one of those values of what is normal. So if your fasting's elevated from that test, you automatically are diagnosed elevated 110 in that fasting state or 100 or do you um the good news is you are going to get credit. You were going to get you don't have to take your next board exam. This this podcast is the exam. It's okay. So just um uh there we'll put this in the show notes.

Don't worry. Anything you don't know the answer to, just say we'll put it in the show notes. Yeah, we're going to put the values there for you. Okay. So there's some there's a threshold at zero, 1 hour, 2 hour, 3 hour. But relatively speaking, do these compare to what we would use on a a person who we're trying to diagnose type two diabetes in if we don't want to just rely on the A1C. Is it that high? If you ever are over um if the one hour is over 200, you don't do the threeh hour.

Yep. So um I think that's similar to outside of pregnancy. And then um there are ranges for each of the the other ones. Um, and you have to have two elevateds to actually be diagnosed. Um, okay. If it if the fasting is normal. So, what is standard of care in this situation? So, woman shows up, you know, I was going to say passes the test but fails the test, however we want to say it. Um, what is first line, what is second line, when do we ever rely on insulin?

And I'm assuming this is in a woman who is not a type two diabetic outside of pregnancy. So, that we can put that category to the side for a moment. But this is someone who was metabolically healthy prior to and now is not. Um are you going right to are you trying to do this with nutrition first? Are you saying no, we're going to go straight to metformin or some other agent? Yeah. No, first line is actually to um do um dietary modifications, meet with nutrition, monitor the glucose levels, fasting and and postprandial and um with these modifications see if the glucose is is well controlled.

Um so like fasting under 95 1 hour postprandial like you know less than 140. Um and so then we monitor that um at first and then um we go to medications when more than half the values are above where we'd like to see them. Um it's insulin is really first line. Um so that's different than outside of pregnancy. Um, with type 2 diabetics, um, there there may be some differences in management, but in in general, um, we often just go next to to insulin. And what's interesting is if you're doing this test at 28 weeks, you also have to be very quick.

I mean, you're not going to give lifestyle that long. You're not going to say, well, let's do this lifestyle thing for 3 months because no, in three months, you're having the baby. So, how much time are you giving that first lifestyle intervention? Is that two weeks, basically? Yeah. I mean, it depends on the patient, right? If everything is elevated in the first week, you're not going to keep going for another week. But yeah, you have close close followup and lots of communication about what the values are.

And is the reason you go to insulin as first line because of time or is it because there's concern that drugs could have a negative effect on the fetus? Yeah. Well, there's not good data on a lot of the medications for for both efficacy and safety. So metformin um can we think of as fairly safe in pregnancy and potentially helpful um but really insulin is most um effective and we have good safety data and it has the best um influence on improving the neonatal outcomes. How long after delivery does this metabolic pattern return to normal?

In other words, how if a woman is actually initiating insulin, how long does she have to continue this post delivery? Does it fix like that? Yeah. Yeah. So, we check uh we I mean, if you diagnose them with potentially having undiagnosed type 2 diabetes, this might not be the case. But if they if you really think it's justational diabetes, then once they deliver, it seems to, you know, for most folks be resolved. So, we usually check a finger stick while they're still in the hospital. And then the recommendation is also at the six week postpartum um visit to do another um 2-hour glucose test to screen for type 2 diabetes because some people will have type 2 diabetes and then they should also be surveiled for type 2 diabetes more closely following a pregnancy because they're at higher risk.

Is it an oversimplification to say that every woman to some extent has to become insulin resistant during pregnancy because that's the adaptive response to preferentially direct nutrients to the fetus. There are probably genetic factors that amplify this in some women and then there are going to be environmental factors that would also amplify it and that could be stress, sleep, nutrition, etc. Yes. Is that is that at the risk of oversimplifying it? Is that sort of the plan? I think that's a great framework for it. So if a woman is diagnosed with gestational diabetes, goes through treatment, etc., etc., would you counsel her prior to her next pregnancy and say, "Look, this is not a you don't have to go through this again." You might because we don't know how much each of those things was a contributor.

It might be that your genes overwhelmingly made this happen and you're destined for it, but let's see if we can avoid it by doing A, B, and C. or is it basically the case that once it happens during a pregnancy, you almost assume it's going to happen with subsequent pregnancies? No, interestingly, it doesn't always recur in every pregnancy. So, um, and I I don't think we we fully understand it. Um, like almost everything in medicine, if you've had it before, you're more likely to have it again.

Um, but not everyone gets it again. So, okay. Um, let's talk about preeacclampsia. This is obviously a big one. You mentioned it already but do you mind just defining it again? Yeah. So, so preeacclampsia is a pregnancy specific condition where folks develop um new onset high blood pressure or hypertension after 20 weeks gestation and um often accompanied by proteinura. So protein in the urine and also accompanied by other um severe what we would call like severe features but sometimes other symptoms like right upper quadrant pain, vision changes, headaches and this is obviously screened for because most hypertension is asymptomatic.

So that's something that has to be caught during your routine visits. Correct. Yes. Um and um actually the initial schedule for prenatal care was really set up to detect developing preeacclampsia in pregnancy which is why you see like accelerating le you know closer visits at the end of pregnancy compared to early pregnancy is really screened for like blood pressure. Is this defined as blood pressure like 135 over 80? Is that the threshold? Where do we consider that? So um one um uh for systolic it's 140 and for diastolic it's 105 to 110 for to qualify as as having okay and is the diagnosis made in office or do we accept that there's some white coat syndrome and we have the patient monitor at home?

We're always looking at the whole picture, but uh a lot of times people will have some elevateds in the office and we will send them home with a blood pressure cuff and have them monitoring more. Sometimes people present more um uh robustly with like very severe blood pressures from the get-go and other symptoms and then sometimes they get go straight to being admitted to the hospital. So, it can have very different courses for different folks. Like some people will have hypertension for weeks that doesn't seem to be getting so much worse and other people will present just in a very severe format from the very first time they present with hypertension.

And does the diagnosis require both hypertension and proteinura or is one of them if significant enough uh warrant the diagnosis? Yeah, so they've changed the definition over time. So it used to be that to have preeacclampsia you needed to have both um elevated blood pressures at least two six hours apart and then also proteinuria or another severe symptom. Now they've sort of changed it to say like with severe range blood pressures um and um other you know you can get the diagnosis without necessarily having overt um proteinuria all comers what is the incidence of this about 5% of pregnancies 5 to 7% depending on your patient population okay in the in the US and then how does that change if we stratify by age so if we were to limit it to okay just women in the 20s versus women in their 40s.

Does that change things? Well, the the highest risk individuals are those folks who are having their first pregnancy and people who are very young or very old. So, I picked the worst demographic to compare. Yeah. Yeah. Yeah. So, okay. So, first of all, why is that? Um, I think we we don't know. There's lots of reasons why people like there's lots of reasons why folks think that the first pregnancy is at highest risk. Um there may be some um degree of um one of the reasons people wonder is if there is um less um exposure of the mother to the paternal antigens and it's and in that there's some it's an autoimmune response.

It's not autoimmune but there's um yeah there may there is can be an there's a thinking that there can be an immune component to it but it's not it's not just that um but we don't fully understand. Okay. So that would explain the early pregnancy and then presumably there's a sensitization with a subsequent pregnancy tolerance. Yeah. Okay. Um I'm talking to an immunologist. I have to be careful with I have to be accurate. I'm not really No, no, I'm just teasing. I'm just um but that So then what do you think explains the other end of that uh barbell which is the women over 40 for example?

Yeah, I think um women over 40 have uh just increased cardiomatabolic um disease slash uh intolerance to more cardiovascular demand. So I think it's really maternal physiologic changes by the time that you're that age that really drive the increased insulin. Yeah. So because the plasma volume alone could drive the hypertension although I don't know that that would drive the proteinura, right? That seems to be like I mean that tell Yeah. Tell me more about why that's happening because we see that in kidney disease. I mean that's what we're monitoring is for for GFR, right?

Um what so how do we tie those two things together that don't necessarily seem obviously related? Well, that has to in pregnancy um both the hypertension and proteinaria have to do with um angiogenic imbalance. Um so classically um the classic model of preeacclampsia which may not be true for everyone is that um the early in pregnancy the placenta uh the placental trophoblasts um which should invade into the maternal spiral arteries and allow them to become um wider and um lower pressure um uh vessels to supply the placenta with adequate blood flow.

If that is not adequate enough then the placenta has some degree of hypoxia and the placenta itself then releases this anti-angioenic factor called esphlit into the maternal circulation and that molecule soaks up the um uh veaf important growth factor for maintaining um vessel endothelial cell function and that affects both the endothelial cells of the maternal vessels and the endothelial cells in the glomemeus of the kidney. And so that connects like the what's happening physiologically. Super interesting. I had never heard that before. So that that makes sense.

When was that level of understanding brought to the field? Is that something in the last 25 years or um the timing? Um like something you learned during your career or did you know that from was that taught in medical school and I just missed that day? Well, um Anant Kuramomani um who um was a nefologist at um Beth Israel in Boston um was very interested in in preeacclampsia and he actually went around collecting um folks um placentas who had preeacclampsia and did microarrays on them looking for upregulation of um you know different um genes um that might be involved in this syndrome.

and and what he found was this incredible upregulation of of esphlit. And then you know they did a lot more experiments to show that um you know what was happening with that protein and why it could be causally involved in the trajectory of of preeacclampsia. Um, and so I always thought that story was was fascinating and um worked in uh very, you know, Anant was one of my early mentors in in Boston and I really like he's just was always so inspirational in thinking about the science in in this area.

Yeah, it's just a great example of why we we just must have scientists working alongside physicians. Uh it otherwise we just don't learn like we can't we can't learn this stuff. And of course, Judah Fulkman was also at Harvard working of course on anti-vef for cancer which is just kind of another way to tie that together. So um what is the natural uh history of preeacclampsia if left untreated? So in other words before we knew what the heck was going on, how did this uh manifest itself?

Yeah. So pregnant people would develop severe hypertension that would progress to seizures and even death and other maternal complications like stroke and organ failure. So wow. So in other words, this is a totally different type of hypertension because you know in my practice for example, if somebody shows up with hypertension, it could be they they may have had it for 10 years already and they clearly have some renal compromise as a result of it and some coronary artery disease as a result of it, but you know, it wasn't it wasn't going to kill them in nine months.

So there's something about this degree of hypertension that is far more accelerated and far more extreme if it's producing this type of outcome. Um the the treatment option is to reduce is to give anti-hypertensive agents for the hypertension. When women present with preeacclampsia, we do give anti-hypertensive agents. Um that can help us expectantly manage a lot of patients meaning that they can present with hypertension at 30 weeks and we can treat their hypertension and monitor them closely. um and they may um get several more weeks in the in the pregnancy um but ultimately it won't go away until the baby is delivered.

There's nothing that we can do besides that to actually cure it. So what is the I don't want to say the earliest because there's always going to be some edge case but what would you consider to be a very early presentation of preeacclampsia and therefore a potentially risky case because it's you have to wait longer till you get to the point where you can deliver the fetus to ultimately render the cure is is would 25 weeks be considered very early for this to show up? Yeah.

So the earliest we think of it as showing up is is 20 weeks. Um it is very rare to see it at that point of pregnancy. So we consider early onset to be preeacclampsia that shows up before 34 weeks. Um because most of it will show up in the third trimester and actually most of it shows up near term. So and sorry just to do my math third trimester starts around 27 weeks right? Yeah like 28 weeks. Yeah. So it's like halfway into the third trimester would be the sort of standard case of preeacclampsia where you're tech you could if the woman got into trouble you could induce and and safely deliver a fetus at 33 34 weeks right yeah I mean we have um it's not the gestational age of the fetus per se that drives when we decide when to deliver somebody.

It has to do about the severity of their disease. So we do make different decisions about delivery balancing the maternal and the fetal risks um based on where they are in gestation but um like at term we would always deliver somebody who was showing up with even mild hypertension that would be term considered 36 37 weeks and greater. Okay. Um are you ever making this decision based on the severity of the protein ura for fear of renal damage or is it always based on the hypertension?

um we do we don't make decisions based on the proteinura. We often make decisions based on the severity um and of the hypertension. But there's off there's also lab abnormalities that can go along with preeacclampsia like elevated liver function tests and low platelets. There's also fetal concerns that can develop. So the fetus is more likely to be growth restricted. It might have abnormal testing. So sometimes we get into a space where like the mom is doing okay but the baby's testing is not reassuring and we need to deliver.

So there's many reasons why we stop expectantly managing and move towards delivery. Um and so we cons all those things have to be considered when we're making that decision. Is the is the mother ever at risk for uh residual or lasting kidney damage? Yeah, that's a good question. Um for patients who start out with normal kidney function they they generally have recover their um kidney function um after the pregnancy is done. Um however people who have experienced severe preeacclampsia have a longer term risk of kidney disease as well as cardiovascular disease.

So long long term which I I want to come back to this topic because it's become a very interesting recent discussion which which we should spend some time on. LFTs platelets boy this sounds a lot like help syndrome. So I don't remember what help stands for. I just remember it's really really bad. Can you can you remind us what it is? So help syndrome is where the pregnant patient presents with it stands for homolysis um elevated liver enzymes and low platelets. Um, some folks think it's a on the spectrum of preeacclampsia, like it's this very severe version of preeacclampsia.

Other folks think that it may have a completely um different underlying biology but have overlapping features with preeacclampsia. Patients with help syndrome may present with severe hypertension like we described for regular preeacclampsia, but they also might have just like mild range blood pressures and then very severe lab abnormalities. So I've we see it present both ways and it can become pretty scary if it occurs you know in the 20 weeks not 20 but in the 20s right if it's at 28 weeks 29 weeks because you're really balancing the maternal health with maximizing the viability of the fetus and as you said the fetus could be compromised based based on growth I mean this gets very complicated very quickly yeah help syndrome is one of those condition um conditions where we often and give betamethasone um to help mature the baby's lungs and we wait 48 hours and then we deliver because we we don't expectantly manage somebody who has help syndrome.

How often do women get that diagnosis um prior to when they need like in other words is that something that can be I guess by definition you're saying help syndrome implies diagnosis to delivery is a very short window. Yeah. As long as that as as long as that's actually what's going on, but yes. Okay. What's your best guess for the ideology? Great question. We don't I we we do we do not know what causes help syndrome if we assume that preeacclampsia is something distinct or even if it's not do you have a sense of the the I mean we explained the mechanism of preeacclampsia but do we think that this is somewhat genetic part you know largely genetic somewhat environmental not environmental at all?

Uh yeah good questions. Um well preeacclampsia is heritable meaning that there is definitely a genetic component. So um it and it comes from both the fetus and placenta which are the considered to be the same relatively the same genetically and the and the maternal genetics. So they're both important. So um uh so there's been a lot done in the past um you know eight years or so that's come out about the underlying genetics of preeacclampsia. It was a really underststudied field when I started working in this area myself.

There were like no big cohorts that had genetic data and had had the same type of genomewide association studies that had been done for many other complex diseases. And so it was really unknown um what um factors across the genome might contribute. But in the past eight years, there's been a lot more information that's come out about that. Um, which I think is um really great and fascinating because genetics can really help you get at the underlying causal biology behind something. So when you really don't understand what's causing it or what pathways might be important to target um with therapeutics, then genetics can really help help you understand that.

Going back to management of preeacclampsia. If you're going to use anti-hypertensives, what are the agents of choice? Yeah. Um the what you'll see used most is nifetapene and libalol because there's good data about safety um in pregnancy. Um there are other hypertensives that we use sometimes. Um but those are two of two main stays. So interesting because I mean we just don't use those outside of pregnancy at all. Yeah. Because they're not that good. Yeah. Um, so does that mean we do not know or we do know that ACE inhibitors or ARBs, which would be first line in someone who's not pregnant, do we know for sure that those are not safe in pregnancy and is that why they're not chosen?

Correct. We know for sure that they're not safe in pregnancy. Yeah. So they have a negative impact on the fetus presumably. Correct. That's right. Got it. Yeah. But they're good agents postpartum when we're working to control maternal blood pressure. So we often will utilize them after delivery. So when we were talking about gestational diabetes, you pointed out that, you know, the woman could be off insulin by the time she goes home. Oh yeah. That's how quickly it resolves. Yeah. But what you just said makes me think the same is not necessarily true of preeacclampsia and the hypertension.

Yeah, that's correct. So um some people will have their hypertension resolve like very quickly after delivery, but many women need um anti-hypertensive medications for several weeks after delivery. it can take like 6 12 weeks to kind of come back to more of a baseline. And there there are other women who will have persistent hypertension um after delivery that never quite resolves and lots of women who um will come back and develop hypertension within the next 5 to 10 years as well. Wow. Um does the protein ura respond or resolve quickly?

And I assume that's checked until it does. You know, we don't we don't check it, but it and and that is because it it resolves. Is that because once the placenta is out, you've sort of solved the problem that's driving that? Yeah. Yeah. Yeah. So, unless someone when we uh screen their metabolic labs has evidence of renal dysfunction otherw in elevation of their creatinine, then we would be monitoring that. But um most most folks just have the proteinura and for folks without kidney disease that resolves.

By the way does the creat if if a woman has significant proteinuria does she also have a bump in her creatin or cistatin C during the pregnancy? Not in we don't check cistatin C but um the creatinine tends not to bump but when it does if it does get elevated with um preeacclampsia then that's also a severe feature of of the disease. So this is probably a good window to now talk about what you alluded to already, which is something that I was unaware of until I don't know nine months ago, 12 months ago, which was this idea that um in cohort studies preeacclampsia or more specifically hypertension during pregnancy, even if it resolved, was predictive of later life um aoscerotic cardiovascular disease.

um how long have how long has the field of medicine known this and what do we think is the best explanation other than maybe the obvious one which is there's a strong genetic component to it and therefore that same genetic component doesn't go away right um so so good questions there um actually this has been known for for quite a while I just think it hasn't I'm just late to the party which is often the case I can assure you hasn't translated well out of the obstetrics field into like primary care and other fields of medicine like we one like it should Like it should be a question you would ask.

We now ask this question, but you should ask this question during a history and physical of any patient, right? You should say, have oh you noticed you had three kids. Did you have preeacclampsia during those pregnancies? Yeah, the abstetric history is relevant and often not asked about. And in fact, that inhibited genetic studies because people would do these large cohort studies and never ask about obstetric history. It wasn't recorded. The data the data wasn't there. Um when in terms of why when when we've looked at these genetic studies um on the maternal side one of the strongest um shared genetic architectures between preeacclampsia and um uh preeacclampsia is um essential hypertension both systolic and diastolic um hypertension is um uh if you have a higher genetic disposition to that you have a higher risk of preeacclampsia in the very first maternal G-W was of preeacclampsia genomewide association study the top hits that were genomewide significant were some of the top hits in um gen genomewide association studies of hypertension.

So we do know that folks who develop hypertension or preeacclampsia are much more likely to have an underlying genetic disposition to hypertension. So that's definitely part of why they have a higher long-term risk and pregnancy unmasks that predisposition. there's still um a component of the exposure to the hypertensive pregnancy that people think may add on top of the underlying genetics to the future risk. So I think that's an active area of research that people are engaged in like does the pregnancy itself increase the risk and if so how and then of course there's other factors like um social factors like uh otherwise like uh other health conditions that contribute to those risks.

So, it is a multiffactorial um contributors to long-term disease. And remind me, you may have said this and I just missed it. Do women who develop gestational diabetes also have a higher risk for type 2 diabetes? Is that predictive? Yes. Um so 50% of patients who have gational diabetes will develop type 2 diabetes. 50%. Yeah. Interesting. Have there been any intervention studies that have been done and this would be a difficult study to do I I accept because it would take a long time. So the answer is almost assuredly no but where you take women who develop gestational diabetes and then you manage them aggressively.

You know you would randomize them to one intervention versus the other to see if you could delay and or just outright avoid type 2 diabetes. Yeah, I think the the recommendation is that they have frequent followup for um diabetes screening and also should be very much advised on life any lifestyle changes that they could make that would impact the risk of type two diabetes. So we know that healthier diet and um appropriate body weight and regular exercise all all are very important there. So, um it's even more critical for um folks who have a history of destit about about that to decrease their risk.

So, is that sort of the message you're delivering to a woman? Because you're in a very interesting role as a physician in that you play a profound role in the care of her and her baby, but once that baby's gone, she's you're not the one that gets to take care of her. And yet you learned something really profound about her because as you said you saw her during a very high physiologic stress test that gave you an enormous insight into what the rest of her life has in store for her visav metabolic health, cardiovascular disease at a minimum.

I mean by the way we might discover that there are other diseases we're learning about that are predicted through pregnancy. So what is the relationship between a high-risisk or any OB/GYN and the long-term health of the patient to say look this is not your genes are not your destiny but you need to we need to really stay on top of managing these things aggressively and by the way you you should live a normal life as a result of the the the privilege of modern medicine that we we wouldn't have been able to do this you know 50 years ago.

Yeah. Yeah. I mean, I think the counseling is really important and um as a high-risisk obstitrician um you know, some general OBGYNS might see a patient for their pregnancies and then also for their gyn care and have more of a primary care relationship with a patient. Um with our high-risisk obstetric practice, we will only see the patient back in general if they have another pregnancy. Um, and so that transition to a primary care provider with that information um, transmitted is is really essential. And I do think lots of patients who are young and taking care of kids and often don't follow up a lot themselves between pregnancies.

And so um you know stressing the importance of having a primary care provider and following is is really important but certainly there could be you know we can continue to enhance like both education and the communication. I mean electronic health records have helped some right because we can often see now like records and you know if if somebody is tuned into that they can they can get at what happened. Um but they have to know that it's important. So if we did nothing else today, if we accomplished only one thing and it was that women and their primary care doctors were really tuned into what was unmasked during pregnancy and use that for aggressive treatment and prevention, that would be a win.

Yeah, for sure. Okay. Do you have a sense of Well, I mean, it sounds like it's it's a bit of a mixed bag in terms of what's recognized there. Um, okay. So, the other thing I wanted to ask you about is C-section versus vaginal. What are the trends? What are the trade-offs? This is an area where I feel like I have heard so many differing stories. I can't tell what's real. Um, so let's let's kind of walk through what is known and let's acknowledge what is not known.

Yeah. So, what first of all, I don't from a historical perspective, I assume it wasn't until the late 1800s we were doing the first cesarian sections. hope we were at least waiting until we had modern anesthetics. These are these are also good questions that I I I don't know all the answers to. Um but um uh but uh certainly even now there's many parts of the world where people don't have great access to um uh you know surgical intervention during during labor and delivery. And that can really drive a lot of um both still births that people have during the intrapartum phase and like long-term maternal complications like fistulas and other complications from prolonged labor.

So C-section is certainly like a needed and helpful intervention um because not not every baby is going to deliver vaginally. Um and do we just have a sense of again and I don't expect you to know the answer to this so don't worry not on the boards. Um prehistoric times, right? Or ancestral times, you know, go back a thousand years. Do we have a sense of what the frequency was of a still birth? And was the still birth necessarily going to lead to the maternal demise?

Like if you can't get a dead fetus out of a woman, she's going to die of an infection. Correct. Um I Yes. I think like um I I think you often will eventually deliver the the demised fetus, but you know, but but you can't poss I mean maybe you could, but it would seem to me that you would be leaving behind some placenta or there there would be some dead tissue that would remain, wouldn't there? I mean, I wouldn't think of that happening, but like the the a retained pregnancy is certainly going to be risky for the patient.

Okay. So, C-sections have obviously become important. What what do we know about the uh I don't know what the right word to think of it. Is it prevalence or usage or num, you know, what in whatever metric you would use to determine what percentage of deliveries in the United States are vaginal versus C-section? How has that number changed over the last 50 years? Yeah, it's dramatically increased. you know, so we've we've gone from, you know, like 10% C-section rate, say like I don't I I don't have all the exact numbers in my head, to like oftentimes practices have like in an academic medical center like a 30% C-section rate.

And that's all comers, right? You're like accounting for people who've had like previous C-sections and people who can't have a vaginal delivery by because it's not safe for whatever obstetric reason. So um but it has increased um increased dramatically. And what is driving that 3x increase? I think um there there are different drivers. Um the pregnancies are are higher risk than they used to. Um you know if once you have one C-section, you're more likely to have another one. Um uh that the health of the the the patient matters.

A lot of people think that um maternal obesity increasing has increased the number of women who have like um either uh you know have either larger fetuses or fail like labor that doesn't progress normally and therefore leads to a C-section. Um we have you know we went from a time when we were not doing continuous monitoring so fetal monitoring during labor to where we monitor in most hospitals the baby's being monitored during the active phase of labor continuously and when the tracing is not reassuring we um you know move to a C-section.

Um so I think it's it's a complex issue to understand um uh and you know there is a lot of focus on trying to um you know decrease that number or avoid it getting higher than it is now. Why is that? Why why would we be concerned if it's getting too high? So, I think the one um one consequence, and it's not the only one, but for folks who have prior C-sections, multiple prior C-sections, they're at higher risk for abnormal placentation in the next pregnancy, meaning that um the um specifically placenta accreta spectrum.

So the placenta can invade abnormally into the to the uterus during pregnancy and then when it's time to deliver the placenta does not come come out after the baby. Is that the re is that the main reason why once you have a C-section your probability of another C-section goes up because of the placenta or is it because of the pressure on the fascia from that would be required during the exertion of a vaginal delivery? There's a couple different things. So, um there's a couple different kinds of C-section.

So, um meaning um where you cut on the uterus. So, if you cut low down on the uterus in a transverse fashion, um so that's called a low transverse C-section that is in the is not in as muscular of a part of the uterus. And so in general, it's thought that um you are fairly safe to labor in a future pregnancy. Um it with like a 1% um risk or less than 1% that the that old scar might come apart during labor. So that's called a uterine rupture, which is obviously um an emergency.

And that's an that's a surgical emergency. Now you're going Yeah. However, if you have had prior surgery on your uterus, either because you had a big fibroid and you you um had it removed from your uterus or if you had a prior C-section that was what we call a classical C-section where you cut up and down on the uterus, then that cuts through the musculature of the uterus and um that type of incision is much more likely to rupture during labor. They say like 10% for someone who've had a classical C-section, which is too high to even too high.

So we say folks in that group should not labor. So that's right. Remind me why the choice is made between those two incisions. In the first place, we try to do a low transverse C-section and in term patients, you almost always can. But if you need to deliver somebody pre-term, for example, this is one of the most common reasons we would do a classical C-section. the uterus is not ex big enough that expanded enough that they the lower uterine segment is not developed and you may not be able to make an incision down in the lower part of the uterine segment and um uh safely deliver the preterm baby through that.

So if if it's too premature, we often have to do a classical C-section. Sometimes there's other reasons like um surgical complexity, someone's had multiple C-sections, you can't Yeah. can't get around the scar tissue. Other reasons why we can't, but yeah. And you're not entering the parneium when you do this, correct? You're doing this all outside of the abdomen. No, it's in in the ab. You you are you don't you don't separate the fascia and keep the uterus outside. Okay. Um the um when you Okay. So, I'm trying to think of reasons where it was a non-negotiable.

So a breach delivery would you wouldn't ever try to deliver a breach vaginally if you I mean I assume you know this we generally don't um because the biggest the recommendation by ACOG is that we generally don't and it's because the biggest part of the baby is the head and it comes last and and a head enttrapment meaning the head the rest of the baby comes out and then the head doesn't is is very dangerous. So for a singleton, we um generally recommend a C-section. If the baby is breached, there's an opportunity to potentially turn try to turn the baby before labor.

That's called an external syphalic version. So sometimes we can turn the baby to syphalic and then the patient can and how like you would do that in the days leading up to Yeah, we try to do it closer to 37 weeks because if somebody actually goes into labor or breaks their water, then then you really can't turn the baby anymore. How successful is that procedure? 50%. Painful, I'm guessing. Yeah, it can be. You can get anesthesia for it. Um, I'm going to guess the answer is we have no idea why some babies are breached.

Yeah, in general, we don't. There there are cases where um there there are cases where like the head might be very big and it makes sense that the baby was in that position the whole time. Sometimes we do a delivery and we find out the cord was wrapped around the neck like four times and then it made sense that the baby couldn't really turn around. So some so sometimes we see things that you know make us kind of think that's why it was but a lot of the time we don't know.

How often does the cord wrap around the neck at all? Like a third of the time the baby comes out with a cord around the neck. It's very common. It usually doesn't cause a problem. When does it cause a problem? You can't predict when it's going to cause a problem. It can be very tight. Sometimes in certain still births we think it might have been the cause, but we don't really know. Um, more common of of something we would see is that um, you know, we're monitoring this fetal tracing during labor.

Um, some we have patients sometimes who have like recurrent big like variables like a type of deceleration on the fetal heart rate. Um, and um, then they come out and we discover that there was a cord around the neck. So sometimes it just causes like stressful non-reassuring fetal heart tracings but doesn't really ultimately cause any problems. So what's the frequency of still birth in the US? One in 160. That much? Yeah. I thought you were going to say one in 106,000. Um one in 160 is startling.

And just to make sure the definition of a still birth implies it went to near-term. No. Still birth means any um fetal demise after 20 weeks gestation. So it can be any time after 20 weeks that um okay but after 20 weeks you've largely I assume eliminated a lot of the really um lethal tricomies the tricom 18 and things like that. Those those probably we've already taken care of those. So these are usually chromosomally normal fetuses. I mean it depends. I mean there's many um there's patients who don't do testing, there's patients who choose to continue their pregnancies um but in but you're right that like a lot of people who have choice and access to those choices um do um terminate their pregnancies earlier.

Um but um there are many patients carrying pregnancies with various anomalies and other genetic conditions um and hoping that things will work out but maybe they don't. So what what would you say are the most common drivers of a still pregnancy? Yeah, I mean I think um most there's different categories but many of them remain unexplained. Um when we at the time of delivery um the things that help give us the most information about what might have happened was doing pathology of the placenta, doing a fetal autopsy and doing genetics.

So those are the three most useful tests. Also like describing like the baby and the placenta at delivery like just what you see um in terms of you know you might see a big abruption like the placenta came off the uterus. Um there might be like a really tight cord there. So there might be things that you actually see in the delivery room that you you know um help you. Um but um even with the standard workup, we don't understand the cause in a in a big percentage of cases still.

Meaning even when you know the genetics, you've pathologically examined the placenta and there's been an autopsy done on the fetus, you're saying about half the time you still wouldn't be able to identify a cause of death. Yeah. And and a lot of them um there might be contributors, right? So a big there's there's a sub substantial fraction that we may find out are growth restricted and there may a lot have some component of placental insufficiency but it doesn't really explain like that might have been the proximal cause of then what why the baby passed away but it doesn't really explain like what causes that and why that happened at the end of pregnancy you know and and and everything had looked okay up until that point because I'm just trying to understand one these late stage events.

So, let's just say a woman's had normal prenatal care. She's not high risk, but she's still doing all the normal stuff. Every time she goes in for an ultrasound, you obviously see the heartbeat. Presumably, you can tell that the placenta is still attached to the uterus. Um I assume is it is it standard to also do duplex on placental blood vessels or is that not we wouldn't do that level of we're only doing like Doppler monitoring on ultrasound when the baby is growth restricted. So um so when we know that there's fetal growth restriction or there's a few other indications then then we monitor blood flow through the umbilical cord.

But in we don't do that in general because it's not been shown to be a helpful like test otherwise. Yeah. So it it's just mindboggling to me that they're they're from a tragic standpoint um that that a couple could come in to think everything is fine. Um would would their labor pains and labor signs and symptoms under still birth conditions resemble that of non-still birth? Yeah. So let's talk a little bit about that. What triggers labor? Why why what is happening in the body? How does the body know it's time?

Uh we don't know really. Yeah. We So tell me tell me what is actually happening? What what is the what's happening with prolactin and oxytocin and all these other things? Even if we don't know why it's happening, do we do we at least have a sense of those things? Uh a a little bit. But you know um uh you know people have tried to look at the changes that directly precede um labor and and there's some but it's hard to predict right like you monitor somebody like every day to see what's going to happen up to delivery.

So we we really don't have a great sense um you know we think something's changing with the HPA access that's triggering this quiescent state where progesterone is maintaining the uterus not to contract to actually contract. But we really really don't have have a good sense of of what's happening. Is the contraction of the uterus the first sign? Is that the first thing a woman is actually feeling? Yeah. Tell me how you coach a woman through that? Like if let's say you're seeing her in your office and it's what you believe will be the last time you see her prior to her admission to the labor and delivery ward.

It's her first pregnancy. She doesn't know what to expect. Uh her partner is equally clueless. uh and they're scared senseless. What are you saying? Um well, with every third trimester patient, we're saying like, you know, ma monitor like how you're feeling the baby move. Let us know if it's different. Um look out for leaking fluid um and vaginal bleeding if you have any of those things come in. And then um if you start to have contractions like time how frequently they're coming and if they're coming closer than five minutes apart for you know um more than a more than an hour or they're increasing in pain and intensity or accompanied by any of those other things I just described then you should come in to get checked out.

Okay. So that's that's a pretty logical list. Um the I mean having experienced contractions yourself what what does this thing feel like? What does a contraction feel like? Does it feel like a muscle flexing? I think early contractions might kind of be like or you know Braxton Hicks like practice ones might be like having a really bad period like a really bad menstrual cramp. But like real contractions probably more painful than anything else that you know I've experienced before. So it's not subtle. A woman is not there's no she's not thinking to myself is this a contraction?

Well, that that often comes up and there are patients who have very high pain tolerances or experience it differently who come in who are quite dilated without a lot of pain, but I think most people experience it as a pretty painful process. How so I explain to the listener what you mean by dilation and what is the amount of dilation that you would see commonly and not be concerned if there still hasn't been any contraction? I think that's a complicated question to answer but um so the what what I mean by dilution is that um you know at the at the lower part of the uterus inside inside the vagina is the cervix and the cervix is what we're actually monitoring for whether it's dilated or not in pregnancy in early and mid pregnancy you don't want the cervix to be dilated if it is that's like a sign of premature cervical dilation or preterm it can be preterm labor Um but um say you're at term, it would be very common for people to have um a cervix that gets thinner and softer and may start to dilate some.

That's the body um getting ready for um labor. Um and then um we we digitally check how dilated the cervix is to understand like if somebody is in labor and how labor is progressing. It's what we use to monitor the progression of labor um when somebody's in the hospital ready to getting ready to deliver. And how many centimeters of dilation is when you start to say, "Okay, you're not we're we're sitting here till this baby comes out." Well, it's it's it's not just the dilation by itself, right?

It's also the frequency of the contraction, right? I mean, people can sit around at 3 to four centimeters dilated for weeks and not be in labor. There can be other people who come in four centimeters dilated who are contracting painfully every three minutes and they're definitely Is that an anatomic difference? Is that a function of the anatomy of the cervix or is that another mystery of we don't fully understand the whole process of delivery? Well, it's not it's not the same in everyone, right? It's not like there's this, then there's this.

Like in some people the water breaks first in other people they you know that's a smaller percentage of people but that can happen before any labor and then then you either then they either go into labor or you help and and the the quote unquote water breaking is the placental fluid coming out because that c that membrane at the cervix opens the like what's actually happening when the water breaks? Well the the amniotic sack gets a hole. So it can be at any part of it.

It's often um at the part that's in the lower uterine segment or or near where the cervix is opening, but it's that the am the fluid in the amniotic sack gets um released the bag. It's clear fluid clear yellowish or usually it it can it can contain baby's poop like mcconium staining at term. So um or it can be bloody if there's a placental abruption but it's like ideally it's clear. Okay. If it's not, if it has blood in it and the placenta has just started to separate, that's not a problem necessarily.

It just means you got to get on with things. It may be or it might not be. Like if it stays if if the majority of it stays attached long enough for the labor to progress, which it often does quickly if that's what's happening, then um then you potentially can have a vaginal delivery. But if it continues to progress, you know, you're monitoring the baby's heart rate tracing closely and the bleeding closely. So, um, if if things become nonreassuring, you may have to move to a a C-section.

What is the the clock? There's a clock that sort of starts once the water breaks because there's a risk of infection. Correct. Yeah. I mean, you you're mindful of of of how long it's been. What What do you start to say is too long? Well, there's a few steps. Like one when somebody's water breaks, we do recommend that they come in even if they're not contracting because of that risk of the longer the water is broken, we're talking like in a term patient also here. Um if the water's broken and we don't help induce the labor, then there's the risk of infection.

So we recommend coming in getting started on some ptocin and helping the labor progress. Um, you know, we we want to see like labor and progression and ideally delivery within like 24 hours, but there's no absolute clock. Like if everything's fine, there's not an infection, the mom's fine, the baby's fine, labor's progressing, it's not like we just stop it. So, what do you do if the or how often does the water break um before a woman is I don't know, like when she's in 28 weeks or something like that?

That's called PROM, like premature, pre-term rupture of membranes. So, people who have PROM. Um they will come into the hospital. Um about half of patients who have that will deliver in the next seven days. They will go into spontaneous labor. A lot like a fraction of them. Some people will not. They will sit there with their membranes um ruptured and we will monitor them in the hospital um all the way up until 34 weeks if everything looks reassuring. And you are your highest concern is an infection I assume.

Um that's one of the concerns. Infection is a high concern. Progressing rapidly into labor once the bag of water is broken is can be very common. Um if the patient is not syphalic, so not head down, there's a risk of like cord prolapse or another body part like the cervix dilating and then some some part of the pregnancy or cord starting to come through the cervix which can be an emergency. I guess I'm still confused how if if a woman comes in in this situation, does she still retain or just make more amniotic fluid but she's just now making it at a high rate and it's leaking, right?

Um there's they will often continue to have quite low fluid for the rest of the pregnancy, but they will continue to to make the fluid um and and leak the fluid. Got it. Do you ever give antibiotics in that situation or is that a no no? We do. So um it's not continuous. So the the recommendation is to um give antibiotics at the time they um present and that's because it helps prolong latency. It doesn't it doesn't ultimately necessarily pres prevent all infections but it helps prolong the duration of the pregnancy in that situation.

So we do give some antibiotics at the at the start and then like in no more after that. So going back to the C-section versus vaginal discussion, um again my vague recollection is one of the advantages of a vaginal delivery is related to the bacterial transfer between mother and fetus. Is that real or is that something that gets over uh extrapolated? There's a lot of attention to that for how much we really know about it. I would say there's probably something there like the microbiome is important.

It's like there's certainly influences and importance across different areas of medicine. Um, but I think like there's a lot of popular press about that without um probably a lot more of the of the of the basic medical. There seems to be a lot of fear-mongering about it quite frankly, which is almost like shaming women that have C-sections into believing like right you have failed to deliver the appropriate gut biome to your child. And and so is it safe to say that there's the science is not suggesting that?

Well, I I'm not saying that there's no helpful component of that, but I would say of all the things that help determine your health and your baby's health, that's probably not the thing to stress about. Is there some epidemiologic data that suggests, which of course would be confounded by a hundred other things, but is there is there some onoff uh kids that are born via cesarian section are more or less likely to have some gut related? No. So, it's not to my knowledge. Okay. Yeah. Um Yeah.

that not yeah stand standard uh application of social media there um let's talk about breastfeeding a little bit so again one of the things I do remember from medical school is the importance of IgA if I recall as and um so notwithstanding the obvious example of why breastfeeding mattered evolutionarily when we didn't have formula and things like that uh what percentage of women are unable to for some physiologic reason breastfeed need uh I mean pick a duration to answer that question like after x number of weeks.

I mean it's such a complicated question right because um uh most people unless they have had like substantial breast surgery or other endocrine disruptors themselves um have the physiologic capacity to produce breast milk. um there's a lot of um breastfeeding is complex, right? It's like a both a maternal and a neonatal like um partnership. So for people who have very premature babies, for example, who might not be able to like latch and actually breastfeed, the mom would have to like pump and produce breast milk, which is always less effective than the baby actually like directly breastfeeding in terms of effectiveness and stimulation and also the ability for like a mother to keep doing it over time.

Um and um you know uh then you know a breastfeeding mom will have to you know be responsible for expressing breast milk every few hours for many many weeks and being present with with the baby which may or may not be possible for for any given mother. So what's driving that from the endocrine system? Um you mean um the production of milk? Yeah. Um, I mean it's a it's again it's a complex hormonal interplay. So, um, and in theory a lactating woman is going to have a harder time ovulating.

I mean, that was generally viewed as one method of birth control. Correct. But you only have to miss one feeding to um, make it not be a good for form of birth control. So, yes. Um, that's an important message. I think it is. Don't rely on this for birth def definitely not. So it's true that like a lactating woman will have very suppressed levels of estro estrogen and progesterone and is often doesn't um lactate when they're but if they skip any of the feeds then they um stop that suppression of the of their cycle.

So yeah I want to talk about a couple things you would counsel patients on during pregnancy with respect to three things. So, uh, sleeping position, uh, any nutritional things outside of managing, you know, are there any real big dos and don'ts of what you make want to make sure people are eating versus not eating? And then exercise. What restrictions do you place on exercise? So, maybe we'll start with exercise. Yeah, I mean, I think exercise is really important. The more data we get, the more we know like bed rest is bad.

People do better when they exercise. um uh you know we um we tell people not to start like a new intensive program during their pregnancy. So if they weren't that physically active prior to pregnancy, it's not the time to like start to try to run a marathon. But having like regular activity like walking or um uh you know uh low low weightlifting was is fine. Um, for patients who've been doing an exercise program, they're generally if everything in the pregnancy is going fine, it's like generally fine for them to continue it.

Um, things including resistance training if it's like if they if they're used to strenuous resistance training. Yeah. You would be okay with that until what point in the pregnancy? Well, I think um the main risk is like the center of gravity changing the risk of getting injured or or hurt by whatever you're doing. So you just have to do um all the things you're doing in a safe way. So you know we don't recommend downhill skiing in the second part of pregnancy. Um you know we you know horseback riding or or you know things where you might incur trauma to your abdomen are are not good.

But a valva a bearing down during a you know lifting something heavy is okay if a woman's used to that. Yeah. we haven't, you know, if she's having like a healthy pregnancy. Now, for people who have threatened preterm labor or a short cervix or other things going on, we u may tell them to abstain from like heavy lifting and things in um during and a short cervix presumably means you have less resistance to the intraabdominal pressure. Yeah, presumably. I'm I'm not sure. Our data is great, but there there's just like there are certain things where we tell people to have some restrictions.

What about running? So if you had a woman who's a runner, lifelong runner, loves to run. It's one of her favorite forms of exercise, what restrictions do you place on her during pregnancy? I I wouldn't say that we would. So run to your heart's content, and just be mindful of everything you said. At some point, your center of gravity is going to move. Don't overdo it. Try not to fall. Stay well hydrated, right? Like you know, like maybe take it a little easier than you sometimes would.

But yeah, no, we would Okay. People who can it might be uncomfortable for people at the end. they might desire to to stop. But yeah. Yeah. And then what about um uh sleeping position? At some point it starts to become pretty uncomfortable. I would imagine side sleeping is probably ideal. Any truth to this idea that you want to sleep on your left side so you don't compress the vennea on the right side? Yeah. I mean, at the end of pregnancy when the fetus is pretty big, um I think um it it to lay completely flat on your back is probably not the best position to so to have some tilt um if you're laying um towards your back uh would be good because there is um that that part has some truth to it.

But I think um you know people sometimes come in panicked that they woke up on their back and you know I'm like it's it's going to be okay. just like you don't um but okay. Yeah. Um I know that you're not the one as the obstitrician who's taking care of the mom months and months following her pregnancy, but what's your understanding of postpartum depression? Um how often is it showing up even in the hospital? What's our what's our understanding of what's driving that? Yeah. So so postpartum blues are really common like having dramatic changes in the mood.

um uh uh in the first two weeks after delivery, there's just the most tremendous um uh collapse of the estrogen and progesterone levels which are skyhigh during at the end of pregnancy and then drop to like extremely low levels. Um and also a lot of you know changes that are going on in the HPA axis. And so um those things really do cause emotional changes in in most patients. Um but postpartum depression is when those like baby blues like persist um beyond that short term and um uh you know lead to um depressive um symptoms um for weeks um afterwards.

Um we do have standard screening that's recommended during you know both during pregnancy for depression and um postpartum. Um and so we really do work hard to do that at the um postpartum visit and we identify patients who might be at higher risk of postpartum depression due to social stressors and other things and try to hook them up with resources and social work. But I think as we all know across all of health care like the mental health system is stretched thin. People often don't have providers or the access that they need.

Obviously, mothers who are caring for um newborns like don't don't have a lot of time. They may have difficulty getting to appointments. They may have hesitancy to ask for help. They may be told that their feelings aren't normal. So, it's definitely can be very serious and underrecognized and undertreated for all those reasons. And do you think that the biggest source of undertreatment is the failure to differentiate between what is maybe normal in this short-term response to what becomes maladaptive and or persists in an abnormal way and then it just sort of gets turned into like it there's so much going on that this kind of gets uh you know shoved under the rug.

Yeah. I mean, I think it it might be a lot of um mother's instincts just to focus on the baby and not like necessarily take care great care of themselves. So we need a lot of advocacy and encouragement for um you know mothers to like you know present to care, get help like um not feel shame and guilt that you know I think a lot of that goes in like I have a new baby like society tells me I should be really happy and excited and I feel terrible like um so then people like don't present to care because of of feelings that you know they're it's somehow their fault that they're feeling this way.

Let's go back to the other end of the pregnancy which is um on the sort of genetic screening side of things. So um IVF is becoming much more common these days and with IVF comes prenatal screening. But for for couples not undergoing IVF um who are showing up with spontaneous pregnancy, what is the current state-of-the-art in screening? Is it mostly done through sampling amniotic fluid? Is that still viewed as kind of an aggressive thing that you wouldn't really do unless you needed to? How do you think about that?

Yeah. So the the number of diagnostic or invasive procedures that we're doing that include amnocentesis and then coronic villa sampling which we can do even earlier in pregnancy um have decreased um and one of the primary drivers of that is how um screening for chromosomeal disorders like down syndrome has um uh improved with the advent of self-free DNA screening. So just a tube of the maternal blood um we can find fragments of the placental DNA and therefore um screen the pregnancy um for chromosomeal conditions. Um that test is best at screening for tisomies 21 18 and the fetal sex.

It's less good for for other other things. And you can do that within how many weeks of pregnancy? As early as 9 or 10 weeks of pregnancy. So very early on is that considered routine? Yeah. So it is recommended to be offered to all pregnant patients for screening now. Okay. Um so presumably that takes away a lot of the incentive that was present for amnocentesis. Correct. Right. So, previously we had what was called a serum screen that looked at three or four protein markers in the maternal blood.

And if that screen was positive, meaning that the levels of those proteins for the gestational age were um consistent with an increased risk of a chromosomeal disorder, then an amnneoccentesis was recommended. But in those cases only five the positive predictive value of a positive test um was 5% meaning that for everyone who screened positive for potentially having a baby with Down syndrome or tisome 21 only 5% would actually be carrying a baby with Down syndrome. Now is that because the prevalence was too low or because the sensitivity and specificity were too low?

It's because the sensitivity and specificity were too low. Got it. Um, and so self-free DNA has dramatically improved both the sensitivity and the specificity of that testing. So fewer people feel inclined to also pursue a diagnostic procedure. And when the screen is positive, they're they're not 100% guaranteed to have a fetus with that condition, but they're much more likely to to have one. What do you think is the biggest gap in this type of testing? like where where do where would you like to see things in a decade with respect to prenatal screening or or in uterero screening for that matter?

Well, there's different kinds of screening. There's there's ultrasound which has developed a lot so we can actually look structurally at the baby and then there's genetics. Um chromosomal disorders that I mentioned that we are currently screening for from self-free DNA only represent a very small percentage of the all the genetic disorders that can exist in a baby. And so we're missing many serious and um devastating conditions on that cell-free DNA screening. So sometimes people think they've been screened for everything and it's really only these three things basically.

Um so I think um the entire genome is rec is represented in the cell-free DNA and the maternal blood. So potentially we could detect. So what's the limit? Do we just not have enough of it? like why aren't we doing a whole genome sequence on it for the you know or at least screening for 27 different you know metabolic diseases that are quasi common? Well, um there there's many reasons. Um but, um you when you're thinking about a prenatal screening test, you have to think about, you know, um what the cost is um and uh what the implications are in the prenatal space and which things you should be calling out during pregnancy versus like what things are only important later in life.

um to to really um look at all the genes in the whole um genome and well well let's simplify it. Let's look at like say the inborn errors of metabolism which would present early in life that there there would probably be value in knowing that during the first trimester, right? Correct. Um so for serious conditions like that um folks are working on creating like panels of disorders that might be helpful to screen for. It's still complicated because for any given condition, take like cystic fibrosis is a good example, there might be tons of different um genetic variants that a patient has that could cause disease.

So our ability to understand which genetic changes cause disease in a given gene and which ones don't is essential because there's no other phenotype that we can see prenatally for many of these conditions. Right? So for an inborn era of metabolism the baby with in the mom is generally for most of those are it's doing just fine. There's no signs there's no ultrasound features there's nothing else that we're testing. So um uh you know we're we're getting this genetic result but if we don't really know with confidence that like which things actually cause disease then it can be really really tricky and stressful to counsel a patient about that in the prenatal space where they're trying to decide if they should continue the pregnancy or what the implications of that are.

So I think there's a big gap between what we can do from a technology standpoint and and our framework for how we um decide which things to screen for and then the resources of the health care system that it will take to actually counsel people about these conditions um and the and their screening results. What is the most difficult thing you have to do in your role as a as a physician? What what is what's the thing that just uh is so challenging either because of the um the resources that are that are brought to bear or just quite frankly the emotional toll it takes on you or you know you can answer that in any way that makes sense.

There's some really there's some really hard things that we um you know deal with um as physicians. Um I think from from a medical standpoint when we see things in pregnancy um you know people who are who we have to inform of of devastating diagnosis whether it be like an underlying genetic condition, severe fetal anomalies, a stillborn baby when you have to like deliver that news and the implications that it has for for a given family and trying to walk them through that. Um those are those are really tough uh conversations.

Um I also see like um it's just um the the different resources that that people have that bring them to us or that they go back to I think I I think are are very impactful for me to think about too like patients that we treat and then don't have somewhere to stay or you know have really complex other situations that you know they're dealing with. So I think um there there's often feels like you can't do do a lot about about that but you can see you know with your own patient how much uh how much impact it has on on them and their own own health.

Have you ever had the privilege to go and visit another country where the resources are far less and and participate in in in child birth in a in a place like that? Yeah, I haven't I haven't participated in in child birth in another country myself. Um I um I spent a lot of time in the in our own country in in the Appalachian Mountains as um as a as a high schooler on a service project where we go for a week every summer and fix people's homes.

Um and it was really like being somewhere very different than how I I thought of at the time like how our our country is. And I wasn't participating in child birth at that time, but I I've certainly like seen a lot of folks who live in very um you know across many circumstances. So what percentage of women in the United States uh uh use um a midwife for delivery as opposed to an obstitrician? you know, I don't know the exact statistics and it really there are definite trends by state and rur rural versus urban and area of the country.

So, um there's big variations. Um there is a lot of midwife care prevalent throughout the country. Uh midwives do a great job providing obstetric care. they they provide um great access in many places where patients don't have other um access and they their training is a bit different. So folks often they can often reach patients who um are otherwise like skeptical of the medical system or really don't prefer to have a physician taking care of them. So I think they're really important you know component of obstetric care.

I assume a midwife doesn't have the other tools with I'm I'm going to say her because I'm just going to assume most of them are women. But um to say pivot to a C-section if something goes wrong in the pregnancy or or is there ever a scenario where a midwife is there with an anesthesiologist should something change? I mean usually u most practices are set up so that if a a surgical procedure is needed then the there's a backup. Yeah. I see. Okay. Got it. So, it's not like because how often does a woman come in for a delivery?

So, let's just assume it's a woman who's been under your care for the entire pregnancy. She's not high risk. um you are therefore expecting to do a vaginal delivery and one of the many factors we've talked about today that just either there's some rapid deceleration you'd realize the placenta is a little bit detached the cord is wrapped three time any of those things what percentage of those are converting to your surprise to a C-section yeah I mean of of anticipated vaginal deliveries about 20% end up going to C-section so that would imply ly that even for a woman who's been under great care and wants to go and have a baby at home with a midwife, there's at least because I would say it might even be higher, but at least a 20% chance that they're going to need to call in for a backup surgical plan.

Yeah. And well, there's different reasons why people if they're delivering in a birthing center or like even at home with an attended birth um might need to transfer to the hospital. like one is that it's thought that a surgical delivery is needed, but another might just be that the more p like pain control is needed or that just augmentation with oxytocin is needed to help the labor progress. So, we definitely see different different things. So, how does that work if a woman is having her baby in a place that's very remote?

because you mentioned one of the benefits of midwives is they can access patients that don't have great access to a hospital. So, how does that happen? I sort of meant that in the outpatient setting. I mean, we really do try to encourage people to deliver in a birthing center or a place with access to other like types of like medication and um there there obviously patients who do choose to have home births, but they are um it's not it's not our recommendation for this reason presumably.

Well, you and you can't you can't know when things are going to go wrong. So, you know, you like hemorrhage is a big problem and and often like things can change like in the in a second and then you're very far away from where you need to to be to to get care. So, yeah. So, different obstetrical emergencies can happen and usually mostly they don't, but you know, the the the risk to the baby is higher at home deliveries. So, and to the mom. you you alluded to something earlier when referring to contractions and saying that it it's the most painful thing you've ever experienced.

Um that's actually kind of surprising to me. I naively assumed that the most painful part of the delivery was was actually the stretch like the vaginal expansion necessary to get the head out. But is it the actual contraction itself that is causing the majority of the pain during labor? Um well most of the labor is contractions. The delivery of the head is like a 30 secondond part of the whole thing. So you have something goes on hours like not to be too crude, but I had a nurse describe it once as like trying to make a husband understand like who didn't want his wife to have an epidural and she's like it's like having your balls slammed in a drawer again and again and again.

Think of it that way. That's how painful. The husband didn't want her to have an epidural. Right. I see. So, she was sort of saying, "I'll make you a deal. If you let me slam your balls in the door for 4 hours without an epidural, you can you can do this to me." Right. Yeah. Got it. Um, but I mean, it's I only say that to say like really people don't understand. And all kidding aside, that's describing a very deep visceral pain, right? That's how it is.

That's That's what I Because Yeah. Every guy listening to this has been kicked in that region, so they know what that feels like. Yeah. Yeah. No, it is. And it goes on for so long, right? So yes, the the delivery of the head is like very very painful. I mean, I had I had an epidural with all three of my labors. And on on the third one, they were trying out this new thing where the medicine was more dilute and it was supposed to spread around better to give you better coverage.

But apparently there was no coverage like right at the paranium. So I was fine, fine, fine. And then the head was about to come out and it was my third delivery and and I could feel everything and it was like the first time you'd experienced that because right like in the sense that that was the Yeah. So let me ask another question about um a term that I've heard and I don't know what it means which is called back labor. Yeah. What and is that because well anyway explain what it is.

Well, it's just that um it that we have many patients who in the first part of labor especially or or even throughout labor may feel more a lot of pain in their back in addition or or instead of feeling a lot of pain in in the front where the where the uterus is. Um uh so that's not uncommon. I I think um menstrual pain can commonly be both in the in the front and the back. And I think um it for patients whose babies might be facing like sunny side up um that there seems to be like more pain in the in the back during labor.

So normal delivery is head out first face down. Correct. Right. That's the most common. That's the most common position that Yeah. Um, does the mother's body make opioids or other pain suppressing molecules ex endogenously to help make you have amnesia? Yeah. Yeah. Yeah. Well, it's it's kind of a joke, right? Which is it's it's described as the single most painful thing a person can undergo. And yet women are it it seems that that pain immediately vanishes when that baby is out. And then to your point, there's a little bit of amnesia as you say, I can't wait to do this again.

I'm not sure most of us think that right away, but um but um yeah, that's a good question, but um maybe you should and interview an anesthesiologist about it. So yeah, interesting. Um when you when you sort of reflect on this field, um it's they're probably I'd need to think about this because I don't know if it's entirely true. True. I mean, medicine has made so much progress over the last hundred years. Um, but I would be hardressed to think of a field that has had a greater improvement in mortality in the last hundred years than your field.

Right. You you've I mean, it's had I think it's had the single biggest impact on a population's longevity has been fewer mothers and babies dying during this unbelievably hellish process. Right. Yeah, I think that's that's pretty fair to say. So despite that, the United States still doesn't quite stack up to other OECD nations in this arena. Uh this has been a topic that's come up on other podcasts. I had this discussion with a a gentleman, a physician, Sutaria, um when we talked about some of the mortality statistics in the United States.

And um this is a big drag down on our overall mortality, our survival numbers or life expectancy numbers. Um there's all the obvious reasons for it. You've talked about many of them today. Do you do you hold out much hope that there there's a day, you know, in in 10 years, in 20 years, the United States is leading the world in uh maternal fetal health? It doesn't feel that way right now, honestly. Um I I think um uh there's some pretty lowhanging fruit that would help.

Um I think um uh insurance access is a big deal. um uh you know for states that expanded Medicaid um where um you know patients came into pregnancy with better health were were more willing to come to prenatal care or able because they were uh able to get insurance through Medicaid who had extended Medicaid postpartum um for care which is when a lot of mothers die. Um uh you're saying Medicaid previously stopped once you left the hospital. Um it's been like 60 60 days. So there's states that you know in in who in recent years have um you know really expanded access um longer postpartum which is really really impactful for families.

But, you know, I think um you know, overall um we um one of the reasons that our health is poor is because insurance access is um peace meal and it's not guaranteed and health care is expensive even for those who have insurance. Um so what's typically not covered like if someone was going through the Affordable Care Act, buying their own insurance through through the program? um what's the sort of surprise that they end up getting potentially financial surprise where they're saying, "Hey, I I bought my health insurance.

I showed up. This is all taken care of." And then they they get a bill that says, "Actually, we covered this but not this." Yeah. I mean, the system is so complicated that I think most physicians can't actually answer that question because um it's so unpredictable and there are it changes every year with any health plan as we all know. It's like, you know, to have this plan, you have this amount of deductible or you have this other plan and then these are the charges, right?

It's so complex that it's really, really hard to understand. You can't even help a patient navigate the system and try to cater your care to their coverage. No, it's incredibly frustrating and difficult and it it feels you feel very powerless because you would like to provide information. and that's like part of our job, but like there's so many differences between so many different plans that you know um it's it's quite difficult. Which is interesting because that would seem to me an issue that anyone everyone on both sides of the aisle could agree that it's a bad thing to have moms and and babies not cared for and nobody should nobody should really incur uh bankruptcy inducing health health care bills.

Um and everybody's very frustrated with the payers for sure. Um it it it it really is the uh it is the Achilles heel of the US health care system that does not appear in singlepayer solutions. Now again the challenging thing is there are so many wonderful things about the US healthare system that are the result of a two-payer system but at the same time there are so many things and this is a classic example. I I wasn't aware of the for example the Medicaid not necessarily extending post.

So um well I don't mean to end it on a downer but that's uh this has been a super fascinating discussion Katie. Um again I think this idea that um what happens during pregnancy gives you a window into your future health. I think if we if again if the listener both male and female for the takes nothing but that which says use this opportunity to learn what your susceptibilities and risks are in the future. Um, any other really big messages you want to make sure people take away from this as far as improving their health?

Well, I mean, I think I think in the um pregnancy space, we still um really lack interventions in in treatments because of lack of investment in in research in this area. And we um haven't spent a ton of time talking about that today, but I think that um you know, it's been a neglected area in research. It's been an underfunded area of research even at the NIH level. Yes. Even at the NIH level um and you know the um the branch of the NIH the NICD the National Institutes of Child um health and development um nothing in that word has the word pregnancy in it.

So there like that has been the institution that's the closest pregnancy gets to the 17 different right exactly branches. So like that branch has funded the most pregnancy related research of any branch of the NIH. And yet like it's it's it's a title that indicates it's about child health, not about the the moms. Why do you think that is? It seems obvious. I mean sorry what seems obvious is that it should address pregnancy. Do you I mean what's what's your hypothesis? I know that the NIH has areas where it's just doubled down and spends endlessly and then there are gaps presumably.

I mean there I'll give you a gap in my world is the investment in juroscience is it's it's literally basis points of NIH budget. So that's another area that is just completely ignored. Prevention is another area that gets very little funding. Um so I guess we can add pregnancy to that list unfortunately. Yeah. And I think um it's um the recognition of its importance in um the whole lifespan has really has expanded some um you know funding opportunities and um so I think there is more recognition of it now but really um there's need for continued investment in this area because it still remains like underststudied and underresourced to really um help people the most most we could if there were more resources.

So if there are philanthropists listening to this now who are saying look I want to I'm very interested in find funding biomedical research but I I like to fund things that are not otherwise crowded. This is an area yeah how what would their next steps be? How would they find the right scientists and investigators who are asking the questions that can be answered? Yeah I think um there's there's some groups that have um come around trying to advise or advocate for funding. So AOS is the American Gynecic and Obstetric Society.

They've put together this women's health collective to try to advocate for women's health funding and they lots of the key players in leading in this space across um OBGYn are involved in that society. So you can contact leaders of these organizations and they can help direct people. Um various folks have different sometimes people have areas of very specific interest in giving money to sometimes you know there's there's lots of ways to make investments that make a big difference for people. So I think but going to that organization is a place where you could find the investigators and basically figure out who's doing the work you're interested in.

Yeah. Great. Well Katie, thank you so much. I appreciate it and I apologize for the board exam. But on the positive side, you don't you get to sit the next years out. Thanks.

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