Health Q&A

While your friends are well meaning, a pregnant person should not sit with their legs elevated. That position could actually increase your swelling, as well as increase your chances for other problems.

The following is a discussion taken from your PRENATAL INSTRUCTION BOOKLET. If, after following these recommendations, you notice that the swelling is increasing, please call the office and bring that to the attention of your provider.

LYING ON YOUR SIDE: During pregnancy, as the uterus continues to grow, it places more weight upon the blood vessels which supply your kidneys. This is particularly noticeable when a pregnant woman is standing, sitting or when she is lying on her back. The increased compression of the blood vessels which supply your kidneys prevents the kidneys from removing excess water from the body. As a consequence, swelling of your fingers, your feet, and your face are usually noticeable. More importantly, an increase in your blood pressure may result.

The only way we can prevent this from happening is to ask patients to lie on their side. This increases the blood flow to the kidneys, allowing them to remove some of the water. In addition, lying on your side will increase blood flow to the uterus, thereby supplying the baby with more oxygen and nourishment. All pregnant women should get into the habit of lying on their side early in their pregnancies. It is assumed that you are in this position while you sleep. The extra time mentioned here refers to daylight hours.

If the doctor notices that you are beginning to retain water, or if your blood pressure is beginning to increase, he may very well suggest to you that you spend more time lying on your side. We suggest spending one hour at least three times during the day. You need not sleep. You may read, watch TV, watch the children play. It is only important that your position is flat and that you are either on your left or right side. Do not sit with your feet elevated!

If you awaken in the morning and notice that there is still swelling of your fingers or your feet, then you should try to spend more than the three hours that day lying on your side. Learn to increase the amount of time that you spend in this position yourself and adjust it accordingly.

It has been shown that if a woman takes a daily dose of .4 mg. of folic acid each day several months prior to becoming pregnant, it can lessen chance for neural tube defects in her baby. These defects result in malformation of either the brain or the spinal cord. It is not necessary to take a high priced vitamin supplement. Any nonprescription prenatal vitamin will usually suffice.

The combined weight of the baby, increased size of the uterus, increase in blood and amniotic fluid, as well as the placenta usually totals about 26 pounds. Weight gain during pregnancy of more than this amount usually is accounted for by increased fat deposits in the patient, or fluid retention.

During the first 16 weeks of the pregnancy, we would encourage you not to focus too much concern on your weight. Some people will actually lose weight during these weeks, due to nausea, vomiting, or perhaps to even better eating habits than they had prior to getting pregnant. Others may gain more weight than they would like because they find that starchy foods help make their stomach feel better.

After 16 weeks of pregnancy, however, we encourage you to try to limit your weight gain to 2 1/2 to 3 pounds for each month remaining during your pregnancy. There are some exceptions to this guideline. For example, people who start their pregnancy very underweight and malnourished may benefit by a few added pounds of weight gain. It is important to remember that during the last few months of pregnancy, excessive weight gain in the patient will usually also be associated with increased weight of the baby at birth. What might have been a 7 1/2 lb. baby could easily result in a baby weighing 9 1/2 to 10 lbs. Obviously, this increase in the baby’s weight will often be reflected in a more prolonged and possibly difficult delivery. A few hints in helping the patient to limit her monthly weight gain amounts are listed below:

• Avoid fruit juice, lemonade and soda pop – While a very small amount of fruit juice each day could be appropriate, remember that fruit juice generally contains an incredible amount of calories.
• Avoid starchy foods – Limit the amount of bread and pasta that you consume.
• Avoid snacks (i.e. ice cream, cookies, candy, etc.) – While fresh fruit can be very healthy (apples, grapes, etc.) try to limit the amount of melons, pineapple and other fruit that are particularly high in sugar content.

During the first 8-10 weeks of pregnancy, a small amount of spotting or brown discharge is exceedingly common. As the developing placenta attaches itself to the wall of the uterus, it will frequently generate a few drops of blood, which the patient will notice as a slight blood-tinged discharge, small spotting or a brownish discharge. This usually resolves spontaneously and does not affect the rest of the pregnancy.

Unfortunately, if the pregnancy, for whatever reason, was not developing normally or it was not continuing, this small amount of bleeding could signify that a miscarriage will be forthcoming. If the pregnancy is less than 7 weeks by dates, it frequently is impossible to tell which of the above outcomes will occur, even when we use ultrasound. When an early pregnant patient does experience bleeding in the early weeks of her gestation, we recommend the following:

• Call the office when it opens the next morning and report the spotting.
• For at least 2 weeks, or unless directed otherwise, avoid intercourse or any strenuous exercise or activity. It is not necessary to stay flat in bed, nor is it beneficial to elevate your legs. If the bleeding should progress to the amount where it would be that of a very heavy period, please call the office or the exchange immediately. Remember most of the time this small amount of bleeding is self limited and the pregnancy should continue normally.

Female sexuality is a hugely complex subject. In a recent pole, 43% of the women were dissatisfied in one form or another with their sexual life. I would strongly recommend the book, I’m Not In the Mood, by Judith Reichman, M.D. This is a very comprehensive book and goes into many types of sexual dysfunction and their possible causes and treatments in great detail. We have copies in our lending library and it can be obtained through any major bookstore or on-line.

There are several components to the female sexual response and they generally follow the pattern below. This was taken from the American College of Ob/Gyn patient education pamphlet on sexuality and sexual problems:

The Sexual Response Cycle

A woman’s body follows a regular pattern when she has sex. There are four stages:

• Desire – The feeling that you want to have sex.
• Arousal – Physical changes that take place. Your vagina and vulva get moist and the muscles of the opening of the vagina relax. The clitoris swells and enlarges. The uterus lifts up and the vagina gets deeper and wider.
• Orgasm – The peak of the response. The muscles of the vagina and uterus contract and create a strong feeling of pleasure. The clitoris can feel orgasm, too.
• Resolution – The vagina, clitoris and uterus return to their normal size.

The possible cause, and therefore treatments, of your particular sexual unhappiness may very well depend upon which of the above categories that you think best reflects your situation. We would encourage you to discuss these issues with your provider. Hopefully you will be able to review the above mentioned book prior to your visit with your physician.

During his residency training in obstetrics and gynecology, Michael R. Mirwald, M.D. completed a three month elective rotation on human sexuality and sexual dysfunction. This was offered by the Psychiatric Department, Loyola University Stritch School of Medicine, in Chicago. It was headed by Domeena Renshaw, M.D. Dr. Renshaw maintains this program in Chicago and is a frequent guest on television programs and has been published extensively.

Unless you have a medical condition and your physician has told you to avoid increasing your calcium, it is generally felt that most people, particularly women, should take extra calcium supplementation in addition to their regular diet. Below is a chart of recommended doses of calcium that was produced by the National Academy of Sciences in 1997. For infants and children please consult your Pediatrician prior to adding any extra calcium to their daily diet. A woman’s peak bone density mass should occur when she is approximately 30-35 years of age. If, because of her diet, other medications, or medical illnesses, she has not absorbed sufficient calcium during her early years of life, she will frequently not maximize her bone density by the time she is 30-35 years of age. When menopause occurs it is anticipated that there will be a rather dramatic decrease in bone loss for all women, particularly during the following 5-6 years. For those people who have not maximized their bone density when they were younger, this can put them at risk for osteoporosis.

It is important to remember a few facts about calcium supplementation:

CALCIUM

For Adults under the age of 50, 1000mg of calcium a day.

For Adults over the age of 50, strive to get 1200mg of calcium a day.

The best source is through your diet:

• 8 oz of milk = 300mg of calcium
• 2oz of swiss chesse = 530 mg of calcium
• 6oz of yogurt = 300mg of calcium

You can add calcium supplements to get the recommended 1200mg/day. Remember some important facts :

• Calcium can only be absorbed in doses of 500-600mgs at a time. Therefore divide your doses throughout the day.
• Most calcium supplements are absorbed better when taken with a meal(not at bedtime).
• If you are taking a daily vitamin, make sure you do NOT take your calcium supplement at the same time. Some of the calcium will not be absorbed.
• If you are taking Thyroid Supplemental medication, do not take your calcium supplement within 4 hours of taking the thyroid medication.

CALCIUM CARBONATE

This is the most common form. It may cause gas, bloating and constipation. This form of supplements needs to be taken with a meal. It should come in 600mg pills or chewable tablets and it should also contain 400 units of Vitamin d3. Some examples are CALTRATE +D, VIACTIV, and OSCAL +D

CALCIUM CITRATE

This causes less stomach upset or constipation. It is more easily absorbed and does not need to be taken with meals. Also, because of the ease of absorption, the total daily recommended mgs. may be less than the 1200mg recommended above for Calcium Carbonate. Therefore READ THE DIRECTIONS ON THE BOTTLE CAREFULLY – if the directions say “Take one to two tablets twice a day”, then make sure you take TWO TABLETS TWICE A DAY (4 tablets total/each day).
An example is Citracal +D.

VITAMIN D

This vitamin is normally produced in our skin when exposed to sunlight. Over half of the population is considered to be vitamin D deficient! In addition to helping us absorb and utilize calcium, Vitamin D may also decrease some types of cancers, lessen some of the pain of fibromyalgia, help regulate blood pressure and help alleviate some mood alterations.

The recommended daily dose is being continually increased as new information is discovered. Presently, for people over the age of 50, 800-1000 units/day is considered a minimum dose. It appears that up to 2000 units/day is well within the safe level.

For Adults under the age of 50, 400-800 units of Vitamin D3 daily is considered a minimum dose

Add up what you are getting through the benefit of your calcium supplement (see above) and then buy Vitamin D3 in 400 unit capsules (at a minimal cost) to make up the remainder of your daily requirements

HPV stands for Human Papilloma Virus. This virus actually consists of many different subgroups. It is generally thought that a person gets the virus through sexual contact. It is by far the most common sexually transmitted organism and a large portion of the population already has the virus in their systems. It is important for at least two reasons – occasionally it will cause warty growth to develop in the genital area. Also, it has the capability over time of altering the cells on the cervix portion of the uterus. This is identified by abnormal pap smears and, infrequently, it can actually result in cervical cancer.

It is important to keep in mind several aspects regarding this virus:

• Once it enters the body it is thought to remain there forever.
• It frequently will cause no identifiable symptoms.
• If warty growths develop or abnormal pap smears are identified, the original exposure to that virus could have come many years ago.
• There presently is no means of treating the virus itself. Treatment consists of either treating the warty growths if they develop, or evaluating and treating the abnormal cells on the cervix.
• Since it can be sexually transmitted, condom protection is a major line of defense.
• It can also be transmitted through oral sexual contact, and in some cases cause warty growths to develop on the vocal cords.
• It usually does not intefere with pregnancy and delivery. However, there have been cases where an infant did have the vocal cord warty growth, by following delivery of a person who had active shedding of the HPV virus.
• A patient can shed the virus and therefore be contagious to other people, without having any symptom themselves.
• It can be very difficult to tell if someone already has the virus in their systems. Occasionally a special culture will identify the viral particles, but often these cultures will not definitively tell if the person has been exposed.

*Main points to remember – use condom protection as much as possible. Have regular pap smear surveillance and report any questionable warty growths that you may notice to your provider.

The HPV vaccine (brand name Gardasil) is currently recommended by both the American College of Obstetrics and Gynecology (ACOG) and the Centers for Disease Control (CDC). The vaccine works to prevent the most common types of HPV that cause 70% of cervical cancers and 90% of warts. It is given as a three vaccine series over the course of six months. It is recommended for ages 9 through 26.
Below is the link to the CDC’s website for more information:
http://www.cdc.gov/std/HPV/STDFact-HPV.htm

First of all, it is important to understand the word menopause. Menopause is the time in a person’s life when their ovaries cease functioning and therefore fail to produce sufficient estrogen, progesterone and other hormones. Once a person reaches menopause, they will be in menopause for the rest of their lives. That is a normal stage in a lifespan of a woman. “Premenopause” or “perimenopause” refers to a variable amount of time preceeding the stoppage of hormone production by the ovary. This timespan varies tremendously and may consist of just a few months or may actually last for several years. As the ovary ages, it will usually fail to produce an adequate amount of hormones in the right proportion many years prior to the ovary ceasing function. This will often cause the periods to become more irregular, typically the cycles are closer together. But often the flow is normal, or even heavy. The heaviness of a menstrual flow usually implies that the woman still has “plenty of estrogen in her body” and therefore actual onset of menopause is most likely not close. Other symptoms commonly associated with “pre or perimenopause” is an increase in PMS symptoms, sometimes an increase in menstrual cramps with her period, frequent mood changes, easy irritability and even an increase in acne production. These symptoms are very common and if they are relatively minor, they should cause no major concern. If that is not the case, however, bring your symptoms to the attention of your provider, since there are treatments available that can relieve many of the symptoms of premenopause.

Although some women seem to have a greater tendency to develop a UTI, most women can reduce their risk by following these suggestions:

• Always wipe from front to back
• Avoid pantyhose, tights, bodysuits
• Avoid lying around in a wet bathing suit
• Wear white, all cotton underwear
• Urinate before and shortly after intercourse
• Drink at least 6-8 glasses of fluids during the day, especially water and cranberry juice
• Empty your bladder as soon as you get the urge
• Avoid tub bathing with bubble bath and powders, creams, lotions and douches to the genital area
• If the occurrence of a UTI seems to increase with the use of a diaphragm, your diaphragm may need to be refitted. If the problem still continues, you may need to consider other birth control methods.

If the above measures are ineffective and you should develop a UTI frequently (2-3 within 6 months), it is recommended that you consult a Urologist. If you have any questions about Urinary Tract Infections or suspect you suffer from such an infection, , please call the office to speak with your physician.

The symptoms of a UTI can be very specific or quite vague. Chronic or recurrent infections or infections in pregnant women may have less severe symptoms and may easily be overlooked. You should suspect a UTI if you have any combination of these symptoms:

• Cloudy, bloody or foul-smelling urine
• Lower back pain
• Low grade fever (usually less than 101 degrees)
• Urgent need to urinate in frequent, small amounts
• Pain or burning on urination
• Bladder pressure or cramping, tenderness in the bladder area

The symptoms of a UTI can be very specific or quite vague. Chronic or recurrent infections or infections in pregnant women may have less severe symptoms and may easily be overlooked. You should suspect a UTI if you have any combination of these symptoms:

• Cloudy, bloody or foul-smelling urine
• Lower back pain
• Low grade fever (usually less than 101 degrees)
• Urgent need to urinate in frequent, small amounts
• Pain or burning on urination
• Bladder pressure or cramping, tenderness in the bladder area

The symptoms of a UTI can be very specific or quite vague. Chronic or recurrent infections or infections in pregnant women may have less severe symptoms and may easily be overlooked. You should suspect a UTI if you have any combination of these symptoms:

• Cloudy, bloody or foul-smelling urine
• Lower back pain
• Low grade fever (usually less than 101 degrees)
• Urgent need to urinate in frequent, small amounts
• Pain or burning on urination
• Bladder pressure or cramping, tenderness in the bladder area