Letting it All Out: Nausea and vomiting in pregnancy

I enjoyed seeing just how many euphemisms there are for vomiting on this webpage:  http://jakersdelight.blogspot.com/2009/08/vomit-euphemisms.html.  Every pregnant woman knows, however, that there's nothing funny about the nausea (aka "morning sickness") that affects most women at some point during pregnancy.  Some of us can suffer for half or more of the pregnancy, while most women peak at 7--12 weeks then find that the symptoms decrease and then disappear.  So what's to be done about it?  Well,  if there's just nausea but no vomiting it is certainly reasonable to try just modifying one's diet to foods that seem to agree with them (which will be different for everyone, but typically bland foods low in fat and higher in carbs work for many).  Vitamin B6 or pyridoxine, 100mg daily, can also be helpful.  Some women also try "sea-bands" and accupuncture to help themselves.  Sipping lemonade or sucking on lemon drops can take away some of that bad taste women frequently complain about.  Being careful during tooth brushing not to stimulate too much retching is also a challenge, but a fluoride mouthwash can help you keep up with your oral hygiene.

I tell my patients that some weight loss is not as concerning in the beginning as is dehydration.  If a patient calls with an inability to hold down fluids for more than 12 hrs, I usually have them come to the hospital for IV hydration in order to help break the cycle of nausea and vomiting that can often ensue from getting dehydrated.  This is true both for pregnancy-related nausea and vomiting, as well as gastroenteritis or food poisoning.  Late in pregnancy the dehydration can also cause preterm contractions, which is another reason we like to intervene sooner than later.

Medications that we use for nausea in pregnancy include promethazine or Phenergan, Reglan, and Zofran.  Promethazine can be sedating and Zofran can cause constipation, so being prepared for side effects is a good thing.  In extreme cases we occassionally hospitalize patients and even more rarely send them home with long-term intravenous nutrition formulas for home infusion.  Having severe nausea can also lead to depression, so we monitor these patients closely for those signs and symptoms too.

The good news is that the reason many women suffer with nausea is that the level of their hormones is nice and high, often an indicator of a normally developing pregnancy.  All pregnancies are associated with a plateau in these levels around 10 wks or so, and that's why most women can expect their symptoms to wane shortly thereafter.

"I'm feeling so HORMONAL lately!" Mood Swings in Women

Many patients will come to the office saying they're feeling "hormonal" at various times.  When pressed, what I almost always learn is that what they are really saying is that they are feeling depressed, anxious, irritable or generally moody. While certain times of the menstrual cycle (a week before the onset of menses to about 2 days into the period) can produce transient mood changes, I'm always careful not to allow my patients to blame all of their emotional changes simply on their hormone fluctuations.  Mood problems are very common in both men and women (23--46% chance) and can wax and wane over one's lifetime for a variety of reasons.  Some people are more prone than others to disturbances in their moods, and looking at your family history can often give a clue as to whether there are some vulnerabilities that may have been passed down the family tree.  This includes not only formally diagnosed conditions such as depression, anxiety, bipolar disorder, etc. but also a tendency toward substance abuse (often associated with self-medication of mood disorders).

20% of pregnant women may experience mood disorders and up to 80% of postpartum patients experience some level of "the blues".  Fortunately less than 1--2% suffer postpartum psychosis.  We monitor all our pregnant and postpartum patients for such symptoms.  Often patients who are struggling to conceive a pregnancy or who have had prior poor pregnancy outcomes are vulnerable to mood changes and require special attention.

PMS is often manageable with excercise, lifestyle changes, dietary modifications, and sometimes medications (hormonal and non-hormonal) given part or all of the month.  Mood changes associated with the transition to menopause (the "peri-menopause") are frequently related to the hot flashes, night sweats and disruption of normal sleep patterns.  Addressing those symptoms so that a woman gets good rest can go a long way toward helping restore a more stable mood.  Low dose hormonal contraceptives can also help regulate fluctuations in hormones during this transition as well, making periods more predictable.  This is an option even for those who have had tubal ligations or other long term/permanent contraceptive methods of birth control.

After the menopause transition, mood problems are no more common than in the general population, but certainly managing chronic health conditions, changing levels of independence, and the grief of losing a spouse or other friends and family members can produce changes in mental health that should be addressed regularly by one's physician or mental health professional.

http://www.34-menopause-symptoms.com/mood-swings.htm

"I Didn't Sleep a Wink Last Night, Doc!" Part 2, Nonpregnant patients

For those who don't have a baby inside nudging them awake all night long, there are still lots of reasons  why you might have trouble sleeping.  Stress, excess stimulation, various types of physical discomfort, anxiety/depression, and age-related changes in the need for sleep can all be involved.

There are basically two types of insomnia:  the kind where you can't fall asleep and the kind where you fall asleep just fine but awaken earlier than you'd like and then you can't fall back to sleep.  The second kind in general is frequently associated with anxiety and depression, so getting those problems treated is very important as well as reducing those sources of stress that you can control.  I've had several patients with longstanding insomnia that resolved after finally leaving a stressful job, for instance.

Physical discomfort can also awaken people during the night, including the need to urinate.  It is considered abnormal if you have to get up more than twice a night to empty one's bladder.  I often look at a patient's medications to see if they are using diuretics to manage high blood pressure.  While diuretics are great medications for blood pressure, there are also lots of alternatives out there that may do just as good of a job without causing frequent urination.  (Of course, your family/internal medicine doctor would need to be consulted regarding the best plan for your blood pressure management.)  Caffeine and alcohol are also potent diuretics that should be avoided close to bedtime, and avoiding drinking fluids for two hours prior to bedtime can also help keep your bladder from becoming excessively full during the night.

Other medications that can be excessively stimulating for many patients are those used to treat nasal congestion caused by allergies or upper respiratory tract infections.  Antihistamines in general are more sedating while decongestants are more stimulating.  Neti pots are a good non-pharmaceutical alternative to managing chronic nasal congestion.

Other sources of physical pain and discomfort need to be addressed if they interfere with sleep, as lack of sleep tends to perpetuate pain syndromes.  Many chronic pain patients can be managed well with certain antidepressants, anti-seizures medications, and other agents that reduce pain without leading to drug dependence.

One of the more serious issues of sleeplessness is sleep apnea.  Common symptoms are snoring reported by one's sleeping partner along with periods of absent breathing followed by a sudden intake of breath.  This can be associated with obesity, alcohol intake, certain medications, sleeping position (mostly back sleepers), and certain anatomic conditions of the neck and throat.  Untreated, sleep apnea can be very hard on the heart and is associated with an increased risk for sudden cardiac death.  Many local neurology practices offer sleep studies to help identify the extent of the condition and recommend treatment options, which may include a special breathing machine called CPAP.

As people age, many do not need as many hours of sleep at night as they might have in preceding years.  If you awaken after 6 hours of sleep feeling refreshed and don't develop significant fatigue during the day thereafter, that may be all you require.

If daytime fatigue is a problem, there are a number of ways to help yourself get back to sleep including avoiding bright lights/computer screens/TV/suspenseful books, etc.  Avoiding heavy meals close to bedtime is also important, particularly for those who tend to suffer with heartburn.  Making sure your bedroom is dark, quiet and that the temperature is right around 70 degrees, and sticking to a regular sleep schedule all work toward good sleep hygiene.  I like to use a white noisemaker myself to drown out random noises around my house.  Warm milk, a light snack or herbal teas can be relaxing, or even a warm bath.  Meditation techniques to control persistent worrisome thoughts are also very effective for many people.  Daytime exercise (ending at least 4 hours before bedtime) is also associated with a variety of health benefits, including more sound sleep.  Short naps in the daytime can be a wonderful way to refresh oneself, but long naps (more than 45 minutes) can interfere with nightime sleep.   Short term sleeping medications are useful for acute insomnia, although in older patients, I worry about sedatives contributing to falls at night. 

"I Didn't Sleep a Wink Last Night, Doc!" Part 1--Pregnancy Insomnia

I'm often asked by pregnant patients and their partners what they can do to help them get better sleep.  Oftentimes, they are physically uncomfortable in the back and hips and cannot seem to find a comfortable sleeping position.  Other times hand numbness/tingling/discomfort is the culprit, and nasal congestion and shortness of breath can also be reasons for difficulty resting.  Finally, a very common source of insomnia for both pregnant and non-pregnant patients is stress and anxiety.

The most common sleep aid I recommend is a "body pillow" to provide support for the full length of the body while sleeping on either the left or right side (after 16 weeks it's a no-no to sleep on one's back in pregnancy).  Other smaller pillows may also be useful to support the enlarging abdomen or to place in the lumbar area.  If the bed is just not comfortable to sleep in at some point, it may be necessary to find another place in the house that's more comfortable--the guest room bed, the couch, the recliner, etc.  I always say "whatever works".  

For those with hand discomfort, wrist braces can be purchased at a pharmacy that carries medical supplies and adjusted to keep the hand(s) at a neutral position during sleep, decreasing compression on the nerves.  Avoiding hi sodium/salty foods is also useful in reducing fluid retention and nerve compression in the wrists as well.

For those with nasal congestion, using saline nasal spray and/or a humidifier can be helpful, and many of my patients with chronic sinus congestion swear by the "Neti Pot" irrigation techniques.  We only recommend nasal decongestants for short term (i.e. 3 days or less) management of upper respiratory tract infections, as they are stimulants to the cardiovascular system, and can actually worsen insomnia as well.

Shortness of breath is a very common symptom in advancing pregnancy, in part due to the compression of the diaphragm from below as well as to other physiologic changes in pregnancy.  Proper positioning and posture can help, as well as elimination of common allergens such as pet dander (no sleeping with Fido!), mold/dust (break out the vacuum, Dad!), and appropriate prescription medications for those who suffer with asthma.  Of course, we always recommend avoiding smoking in pregnancy and exposure to second hand smoke.

Stress and anxiety are very common, especially with the excitement of impending birth and changes to family structure, financial concerns, relationship issues, and so on.  This is particularly true if you are carrying a high risk pregnancy that has caused you to be on bedrest or to modify your work hours.  There are also lots of patients who were anxious people long before they conceived a pregnancy.  Doing what you can to control the sources of stress in your life is an obvious (though not always easy) fix.  Avoiding stimulants such as caffeine, exercising close to bedtime, too much screentime (TV, computer, smartphone, etc) close to bedtime, and so on can be very effective.  Sometimes sleep aids are recommended short term such as diphenhydramine, Ambien, etc., but we like to clear the system prior to the onset of labor of any sedative medications that may hang around longer in baby than in mom.  Finally for those who are clinically depressed/anxious, certain prescription medications may be recommended to avoid the consequences of those conditions in pregnancy, including insomnia.

Finally, one of the most frequent complaints I get from pregnant women is that they have to urinate all the time, including during the night.  Clearly avoiding over-drinking prior to bedtime can help, and as long as your urine is a light yellow color you don't have to worry about being dehydrated.  If there is burning with frequent urination, a urine culture should be done to rule-out infection.

Sometimes I look at a little insomnia as God's way of getting us ready for the true sleep deprivation yet to come after baby's arrival, but getting as much sleep as you can before baby is a gift to yourself.  Happy dreams!

When should I call the doctor in labor?

If you are full term (37--41 weeks) and you are having contractions lasting at least 30--60 seconds every 5 minutes for more than an hour, they are getting intense enough to make you not be able to converse normally during the contraction, and they don't go away with rest and fluids, then you may very well be in labor.  If it's during office hours, feel free to call us there.  If not, The Birthing Inn is always open and the staff there will be happy to evaluate your contraction pattern and cervical exam and determine if it's false labor or the real thing.  If you are just not sure you can call us on the on-call number any time after hours at (703)740-5378.  If you have a history of having had rapid labors in the past, or you have already had cervical dilitation of 3 or more centimeters, we may want you to come in a little sooner, especially if you live distant from Leesburg.

If you are contracting prior to being full-term, drink lots of water, empty your bladder, lie down, and if the contractions continue to occur more than 5 or 6 times in an hour, come over to TBI to be evaluated.  If you think your water has broken or if you have significant vaginal bleeding, we'd like you to be evaluated as well.  Finally, the baby should move at least a dozen times a day in the last 2 months of pregnancy.  If you think it is moving less than that, we would like to have you monitored at TBI.  

Is it HOT in here or is it just me?

Oftentimes we have patients complaining about hot flashes or night sweats.  About 80% of women will have some degree of these symptoms as they enter menopause.  Those who enter surgical menopause (by having both ovaries removed in their pre-menopausal years) have the most dramatic onset of symptoms.   Hormone replacement therapy (available in a wide variety of forms) has gotten a bad rap over the last decade, but in reasonably low doses used short term, it is still a very effective and safe option for many patients. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

For those patients who are unable or unwilling to use hormone replacement, there are also a number of alternative behavioral, nutritional and pharmeceutical options as well.  For patients with mild to moderate symptoms, we often start simply by recommending dressing in layers in natural fibers, using fans at home and work, avoiding alcohol and spicy foods, etc.  Aerobic exercise on a regular basis also has been shown to reduce hot flashes.  Soy supplements contain plant estrogens and can be helpful.  Estroven is one such supplement, although drinking soy milk or eating tofu or edamame can give you similar benefits.  The benefit of black cohosh products is controversial, although I have had patients say Remifemin works for them. http://www.menopause.org/for-women/menopauseflashes/the-experts-do-agree-about-hormone-therapy

I have also had patients do well with accupuncture in some cases as well.   Many patients find relief on an antihypertensive medication called Clonidine (aka Catapress).   It is usually given once a day in a 0.1mg dose.  It can also be given as a patch.  There are a number of antidepressant medications that have been shown to have benefit for patients with hot flashes including Effexor and Pristiq.  Gabapentin has also been shown to help reduce symptoms, although it usually has to be given 2 or 3 times a day.  Most patient's symptoms will reduce spontaneously without treatment within a year, and those using hormone therapy are generally recommended not to stop treament "cold turkey" but rather to do a gradual wean in order to prevent recurrent symptoms. 

Healthy Bones and How to Keep Them

How does one keep from getting osteoporosis?

Well, the most important thing is probably paying more attention to building a good skeleton in childhood and adolescence by giving ourselves lots of calcium-rich foods.  We want to encourage girls to be lean and active, but intense physical exercise or dieting that leads to the disappearance of periods is bad for the bones. 

As we age, our bones naturally start to lose minerals and become thinner starting in our late 20's.  The most rapid period of decline is in the first few years after menopause.  The National Osteoporosis Foundation and other organizations agree that for low risk women without a history of fracture, the first test of bone density should be at 65 and then periodically thereafter if indicated.  Higher risk patients may need to be evaluated earlier, especially heavy smokers and drinkers, very thin patients, anyone on chronic steroid therapies, those with a strong family history of osteoporosis/fracture, or those with a premature onset of menopause.  

Most medications available to treat osteoporosis are not indicated for the pre-menopausal patient population, but there are a number of nutritional and lifestyle recommendations that are helpful, particularly with regard to Vitamin D and Calcium intake.  Medications include bisphosphonates, estrogen replacement,  raloxifene, and Prolia injections.  

For post-menopausal patients, we use prescription medications for those diagnosed with osteoporosis (T score of -2.5 or worse) or for patients with osteopenia (T score -1.0 to -2.4) who have fractured or who have a FRAX score indicating a high risk of fracture.  Go to the  FRAX calculation tool at http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 to calculate your risk of fracture.  

Given the increasing lifespan of women, it is vital we start early in preventing fractures that can disable us as we age and rob us of our independence.