Twin pregnancies are becoming increasingly more common in Amercia secondary to women choosing to have children at a later age and the increased use of assisted reproductive technology to aid in achieving pregnancy. Twins are either monozygotic (one egg fertilized by one sperm splitting into two eggs) or dizygotic (two eggs fertililzed by two different sperm). Monozygotic twins are identical genetically where dizygotic are different genetically. The frequency of dizygotic twins increase as a woman ages and has more children.
Twin pregnancies have more risks associated with them and require increased monitoring. Twins have an increased risk for intrauterine growth restricion(small baby), premature delivery, congenital birth defects, abnormal placental development and stillbirth. Because of these risks, a woman who has a twin pregnancy will need frequent doctor visits, ultrasounds and prenatal testing.
When a woman is diagnosed with a twin pregnancy, it is important to determine by ultrasound whether the twins have two placentas and two sacs, one placenta and two sacs, or one placenta and one sac. The risks of the above mentioned complications are more common in pregnancies with one placenta and one sac.
It is also important to consider genetic testing for chromosomal abnormalities in twin pregnancies. A woman has a double risk of chromosomal abnormalities with twins secondary to having two fetuses instead of one. Screening tests include a first trimester ultrasound and blood test. Invasive diagnositic testing is also available in the first trimester by chorionic villus sampling. (Please see my previous post on genetic screening in pregnancy for more detail regarding these tests and procedures).
It is important for a woman with twins to obtain a detailed anatomy ultrasound of the fetuses between 18-22 weeks. As twins have an increased risk of congential birth defects, it is important to try to detect these during this ultrasound.
As a woman progresses further in pregnancy it is important to monitor the fetal growth by ultrasound. Twins tend to grow at the same rate of single pregnancies until 32 weeks and then have slower growth. Twins can also have vascular connections in their placenta which enable one twin to grow larger than another. It is important to monitor this because if one twin is larger than another by greater than 10 % weight, the smaller twin has an increased risk of stillbirth.
It is also important to monitor the fetal well being during pregnancy by antepartum testing. This involves monitoring the fetuses heart rate for approximately 30 minutes twice per week and checking the amniotic fluid once per week. This testing reveals whether the uterus is still a good environment for the fetuses allowing them to grow and obtain adequate blood flow. This testing will usually begin at 32 weeks and continue until delivery.
A woman has increased risk of medical complications associated with twin gestation as well. She is more likely to develop gestational diabetes or pre-eclampsia (elevated blood pressure in pregnancy). It is important to have regular doctor visits to monitor for these symptoms.
The average age for twin delivery is 35 weeks. This delivery age would change depending on what type of twin gestation a woman has. The route of delivery (vaginal versus cesarean) depends on a number of factors. For a twin pregnancy consisting of one sac and one placenta, the optimal route of delivery will always be cesarean delivery usually around 32 weeks. For twins with two sacs and one placenta, optimal delivery is usually between 36-37 weeks gestation. The route of delivery depends on the presentation of the fetuses. If both fetusus are vertex (head down), vaginal delivery is recommended. If the first fetus is breech (bottom or feet down) cesarean delivery is recommended. If the first fetus is vertex and the second fetus is breech, vaginal delivery is possible as long as the second fetus is not greater than 20 % of the first fetus's weight. For twins with two sacs and two placentas, delivery is usually recommended at 38 weeks. The route of delivery depends on the same factors listed above.
It is important to be under an obstetrician's care during pregnancy to facilitate the best pregnancy outcome possible. Please read further for more info:
http://www.acog.org/~/media/For%20Patients/faq092.ashx
Tuesday, December 20, 2011
Tuesday, December 13, 2011
Body changes in the first trimester of pregnancy
A woman's body goes under significant changes during pregnancy due to hormonal changes and the growth of the fetus. These changes can cause concern if it is your first pregnancy. This post will discuss normal changes in the first trimester of pregnancy.
A woman's threshold signal for thirst is altered causing a woman to drink more often which in turn causes a woman to need to urinate more often. The change in thirst occurs to increase a woman's total volume of water in her body. This increase allows a woman to increase her blood volume as well as contribute to the fluid content in the placenta and the amniotic fluid.
A woman's appetite will increase during the first trimester in general, depending on how nauseated they feel. A recommended amount of increased calories per day is 300 calories per day throughout the pregnancy.
Nausea and vomiting affect approximately 70 % of pregnancies. It usually begins during the 4-8th week of pregnancy and usually stops by the 14-16th week. Eating small meals frequently, ginger supplements, vitamin B6 or accupuncture wrist bands may be helpful. There are also anti-nausea medication for women with more severe symptoms.
Constipation or diarrhea are also common in the first trimester which likely due to changes in the motility of the small intestines and large intestines.
Breast changes associated with early pregnancy include tenderness and tingling sensations. This occurs beginning the 4th week throught the 8th week. The breasts continue to enlarge throughout pregnancy to prepare for lactation. The nipples and the areola also enlarge.
Skin changes also occur during pregnancy. Women may notice increaed acne which is due to the changes in hormones. A woman may also noticed increased pigmentation (or darkening of the skin) during pregnancy. This will usually resolve after delivery but may persist for some women.
A woman will also notice fatigue during pregnancy, especially the first trimester. This usually improves during the second trimester but may redevelop during the third trimester.
Changes or symptoms that may occur during the first trimester that should prompt contact with your physician include vaginal bleeding, cramping, or severe nausea with an inability to maintain food intake.
I try to encourage my patients to hang in there through the first trimester. Most patients will feel much better during the second trimester!
A woman's threshold signal for thirst is altered causing a woman to drink more often which in turn causes a woman to need to urinate more often. The change in thirst occurs to increase a woman's total volume of water in her body. This increase allows a woman to increase her blood volume as well as contribute to the fluid content in the placenta and the amniotic fluid.
A woman's appetite will increase during the first trimester in general, depending on how nauseated they feel. A recommended amount of increased calories per day is 300 calories per day throughout the pregnancy.
Nausea and vomiting affect approximately 70 % of pregnancies. It usually begins during the 4-8th week of pregnancy and usually stops by the 14-16th week. Eating small meals frequently, ginger supplements, vitamin B6 or accupuncture wrist bands may be helpful. There are also anti-nausea medication for women with more severe symptoms.
Constipation or diarrhea are also common in the first trimester which likely due to changes in the motility of the small intestines and large intestines.
Breast changes associated with early pregnancy include tenderness and tingling sensations. This occurs beginning the 4th week throught the 8th week. The breasts continue to enlarge throughout pregnancy to prepare for lactation. The nipples and the areola also enlarge.
Skin changes also occur during pregnancy. Women may notice increaed acne which is due to the changes in hormones. A woman may also noticed increased pigmentation (or darkening of the skin) during pregnancy. This will usually resolve after delivery but may persist for some women.
A woman will also notice fatigue during pregnancy, especially the first trimester. This usually improves during the second trimester but may redevelop during the third trimester.
Changes or symptoms that may occur during the first trimester that should prompt contact with your physician include vaginal bleeding, cramping, or severe nausea with an inability to maintain food intake.
I try to encourage my patients to hang in there through the first trimester. Most patients will feel much better during the second trimester!
Wednesday, December 7, 2011
Infertily Evaluation
Infertily can be a frustrating and nerve wracking experience for couples. Most couple will conceive within one year of attempting pregnancy. Approximately 70% of couples conceive within the first 6 months and 85-90% by 12 months. However, 10-15% of couples have not conceived after one year of unprotected intercourse. A couple may choose to pursue evaluation at any point in their attempts at conception. Most physicians recommend evaluation after one year of trying; however, a couple may want to present for earlier evaluation depending on their age.
The three main causes of infertility include ovulation dysfunction or anovulation(no ovulation occurring), fallopian tube scarring or disease, and sperm abnormalities. An evaluation by a physician for infertility will focus on a careful history and physical examination. A physician will want to know if a patient is having regular menstrual cycles which indicate regular ovulation. For a patient with irregular menstrual cycles, it is possibile that a low frequency of ovulation is occurring which would contribute to infertility. A physician will also want to know if a patient has a history of sexually transmitted diseases such as chlamydia. A history of chlamydia can cause fallopian tube scarring which makes it difficult or impossible for the egg to enter the uterine cavity. A physician will also want to know if a couple has had a previous pregnancy together or if the partner has fathered any other pregnancies. It is also important to know if a patient has had any previous surgeries on her cervix or in her uterus that could be affecting the sperm's ability to enter the uterus or a fertilized egg's ability to implant in the uterus.
Initial diagnostic testing for infertility include male partner semen analysis. Sperm abnormalities account for 35 % of infertility cases. A semen anlaysis is simple to perform. A man provides an ejaculate sample to the lab within 30 minutes of ejaculation. A man should refrain from intercourse or ejaculation for 48 hours prior to the test. The semen analysis will evaluate for total sperm count, sperm motility (number of sperm moving), sperm morphology (number of sperm shaped normally), and progressive motility (sperm moving in the forward direction). Abnormalities in these areas can contribute to infertility. If abnormalities are found, a second semen analysis is usually performed to verify the test. If the abnormalities persist, a man is usually referred to a urologist for evaluation of the cause of sperm abnormalities.
Other diagnostic testing for infertility include testing for ovulatory function. This can be done by evaluating a patient's menstrual calendar, testing a woman's basal body temperature and tracking it throughout her cycle, testing progesterone levels in the blood, or testing a woman't urine for luteinizing hormone(the hormone which signals the ovary to release an egg). For women who are menstruating at regular intervals, having cycles in similar length and experiencing premenstrual and menstrual symptoms usually confirms ovulation. A woman whose basal body temperature rises consistently is also likely ovulating. A blood progesterone level can be checked usually one week after ovulation, and if elevated, indicates ovulation has occurred. The "ovulation indicator kit" will generally become positive one day before ovulation occurs. This kit is testing a woman's urine for luteinizing hormone. A woman should use this kit daily approximately 2-3 days prior to the expected day of ovulation. Ovulation dysfunction affects approximately 15 % of couples experiencing infertility.
Fallopian tube abnormalities are a common cause of infertility and occur in 30-35% of infertile couples. Abnormalities may be due to previous infection, ectopic pregnancies, or surgeries on the fallopian tube. Endometriosis can also cause fallopian tube scarring. To evaluate for fallopian tube abnormalities a physician may choose a radiologic test called a hysterosalpingram. This test involves injecting fluorescent dye into the uterine cavity and evaluating the dye as it moves through the fallopian tubes. The test is usually performed 2-5 days after the last day of menses. Another testing option would be laparoscopy (minimally invasive surgery) to directly evaluate the fallopian tubes as dye is injected into the uterus. This allows a thorough evaluation of the pelvic organs.
Further resources regarding infertility evaluation include:
http://www.uptodate.com/contents/patient-information-evaluation-of-the-infertile-couple?source=see_link
http://www.acog.org/~/media/For%20Patients/faq136.ashx
http://www.reproductivefacts.org/
The three main causes of infertility include ovulation dysfunction or anovulation(no ovulation occurring), fallopian tube scarring or disease, and sperm abnormalities. An evaluation by a physician for infertility will focus on a careful history and physical examination. A physician will want to know if a patient is having regular menstrual cycles which indicate regular ovulation. For a patient with irregular menstrual cycles, it is possibile that a low frequency of ovulation is occurring which would contribute to infertility. A physician will also want to know if a patient has a history of sexually transmitted diseases such as chlamydia. A history of chlamydia can cause fallopian tube scarring which makes it difficult or impossible for the egg to enter the uterine cavity. A physician will also want to know if a couple has had a previous pregnancy together or if the partner has fathered any other pregnancies. It is also important to know if a patient has had any previous surgeries on her cervix or in her uterus that could be affecting the sperm's ability to enter the uterus or a fertilized egg's ability to implant in the uterus.
Initial diagnostic testing for infertility include male partner semen analysis. Sperm abnormalities account for 35 % of infertility cases. A semen anlaysis is simple to perform. A man provides an ejaculate sample to the lab within 30 minutes of ejaculation. A man should refrain from intercourse or ejaculation for 48 hours prior to the test. The semen analysis will evaluate for total sperm count, sperm motility (number of sperm moving), sperm morphology (number of sperm shaped normally), and progressive motility (sperm moving in the forward direction). Abnormalities in these areas can contribute to infertility. If abnormalities are found, a second semen analysis is usually performed to verify the test. If the abnormalities persist, a man is usually referred to a urologist for evaluation of the cause of sperm abnormalities.
Other diagnostic testing for infertility include testing for ovulatory function. This can be done by evaluating a patient's menstrual calendar, testing a woman's basal body temperature and tracking it throughout her cycle, testing progesterone levels in the blood, or testing a woman't urine for luteinizing hormone(the hormone which signals the ovary to release an egg). For women who are menstruating at regular intervals, having cycles in similar length and experiencing premenstrual and menstrual symptoms usually confirms ovulation. A woman whose basal body temperature rises consistently is also likely ovulating. A blood progesterone level can be checked usually one week after ovulation, and if elevated, indicates ovulation has occurred. The "ovulation indicator kit" will generally become positive one day before ovulation occurs. This kit is testing a woman's urine for luteinizing hormone. A woman should use this kit daily approximately 2-3 days prior to the expected day of ovulation. Ovulation dysfunction affects approximately 15 % of couples experiencing infertility.
Fallopian tube abnormalities are a common cause of infertility and occur in 30-35% of infertile couples. Abnormalities may be due to previous infection, ectopic pregnancies, or surgeries on the fallopian tube. Endometriosis can also cause fallopian tube scarring. To evaluate for fallopian tube abnormalities a physician may choose a radiologic test called a hysterosalpingram. This test involves injecting fluorescent dye into the uterine cavity and evaluating the dye as it moves through the fallopian tubes. The test is usually performed 2-5 days after the last day of menses. Another testing option would be laparoscopy (minimally invasive surgery) to directly evaluate the fallopian tubes as dye is injected into the uterus. This allows a thorough evaluation of the pelvic organs.
Further resources regarding infertility evaluation include:
http://www.uptodate.com/contents/patient-information-evaluation-of-the-infertile-couple?source=see_link
http://www.acog.org/~/media/For%20Patients/faq136.ashx
http://www.reproductivefacts.org/
Monday, December 5, 2011
Urinary incontinence
Urinary incontinence is a very common symptom in women, particularly as one ages or after having children. However, just because it is common does not mean it is normal and one has to live with it. High blood pressure and diabetes are common in the American population and health care professionals do not recommend just dealing with it. There are two most common types of urinary incontinence are stress incontinence and urge incontinence. The classic symptoms of stress incontinence include leaking urine when laughing, coughing, sneezing, exercising, bending over, ect. Essentially, any activity that increases the abdominal pressure in the abdomen can cause leaking of urine. The classic symptoms of urge incontinece include leaking of urine after feeling a sudden and strong urge to urinate and not being able to make it to the bathroom in time. Women often have certain triggers that cause these urges such as putting the key in the door, running water, brushing their teeth, ect. A woman can also have symptoms of both types of incontinence which is call mixed incontinence. There are treatment options for both types of incontinence.
For a woman with stress incontinence, it is important to identify how often it is happening, how much she leaks when it happens, what activities cause it to happen, and how much it is bothering her when it happens. For some women, they leak only a small amount when they have a cold and have coughing. This small amount of leaking may not be bothersome for her. Other women may leak every time they run, laugh, sneeze, cough or do heavy lifting. This frequency of leaking could be very bothersome to her. For a woman presenting for evaluation of her symptoms, I would recommend a careful history and physical examination, focusing on the above questions. During the exam, it is important to determine whether the urethra has support or if ligaments that normally support the urethra have been damaged. It is also important to recreate a scenario in which the woman leaks. This is done by filling her bladder with sterile saline and then having her cough or laugh. This examination helps to determine which treatment would be beneficial.
Treatment options for stress incontinence include expectant management (meaning monitoring symptoms over time until the symptoms become bothersome enough that one would like to proceed with therapy). Other options include pelvic physical therapy. There are physical therapists who specialize in strengthening the pelvic muscles which help women to have better support for their urethra and bladder and decrease the amount of leaking that occurs. This therapy does involve a physical therapist performing a pelvic exam. This treatment option is ideal for women with mild symptoms who are motivated to perform physical therapy. Another treatment option includes a pessary. A pessary is a device that is placed into the vagina. The pessary creates support for the bladder and urethra. It is placed in the vagina and normally removed once per week by the woman for cleaning. The physician will fit the patient for a pessary that is comfortable and does not fall out. The pessary works well for women with mild to moderate stress incontinence who do not or are not able to perform physical therapy or surgery. The disadvantage of the pessary include needing to remove it for cleaning and intercourse and also the slight possibility of the pessary causing an erosion into the vagina. Another treatment option for stress incontinence is surgical management. Surgery involves placing a small mesh sling underneath the urethra which then recreates the supportive ligaments that have been damaged. The surgery is an outpatient procedure and a woman is able to resume her normal activities quickly but is recommended to refrain from intercourse and heavy lifting for 4 weeks. Surgery is very effective with approximately 90% of women having no leaking of urine or markedly less urine loss. The risks include damage to nearby organs, risk of bleeding, risk of infection, and the risk of continued symptoms. Surgery is a good option for women with moderate to severe symptoms who have failed other treatment options or who desire surgical management.
Urge incontinence is usually treated with behavior modifications and medication. Urge incontinence occurs because the bladder contracts to urinate even though a woman may not be ready for urination. The bladder may contract because it is too full with urine, or because of certain foods or liquids that cause irritation. The bladder may also contract due to certain medications such as diurectics which a woman may be on due to medical problems such as high blood pressure and heart failure. When a woman presents for evaluation of urge incontinence, it is again important to perform a thorough history and physical exam. It is important to determine how often a woman has urge symptoms, what triggers her urge symptoms, to evaluate her medications, fluid intake, and food intake. It also important to determine how often a woman is going to the bathroom and whether they feel they have emptied their bladder.
Treatment options include behavioral therapy, restriction of fluids, avoidance of certain bladder irritants or medications, and treatment with medications. Behavioral therapy includes retraining one's bladder to not send a message to one's brain every 30 minutes that it is time to urinate or to not send that message during certain situations such as hearing running water or brushing one's teeth. Many women may leak because they are consuming too many liquids. If one is drinking more than 64 ounces of fluid per day, their bladder may sense that it is full often and contract in response. A treatment option includes restriction of fluid. Avoidance of caffeinated beverages and bladder irritants such as acidic foods can also help decrease urinary urge symptoms. Medication therapy includes medicine that decreases the frequency of bladder contractions. If the bladder is contracting less, then one has less urge symptoms and less leaking. The side effects of medication include dry mouth and constipation.
I recommend for any women experiencing bothersome urinary incontinence symptoms to be evaluated by either her gynecologist or urologist that is trained in treating urinary incontinence in women. There are many noninvasive and minimally invasive treatment options that can signficantly improve their quality of life.
Additional resources include:
The American Urogynecology Society
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