So I will admit right now that I am a bit of a Geek*.  Love, Love, Love to read. I have a favorite book of all time (Jane Eyre). A favorite modern fiction (The Time Travelers Wife). Favorite text books (tie Speroff and Gabbe).  I have also have a favorite journal: the Journal of American Congress of Obstetrics and Gynecology (ACOG) which is fondly nick-named the “Green Journal” by OB/GYNs (because its green… hey we’re not the most creative bunch out there).  ACOG  sets the standard of care for OB/GYN in the United States, so when my Green Journal comes each month I always get a little excited, tearing off the plastic wrapper to see what new studies or recommendations have come out this month.  I must admit though, these last several months I have been approaching the Green Journal with trepidation, for I fear change is a comin’ in the field of gestational diabetes and I know it will not be a easy transition.

One of the issues with studying gestational diabetes (GDM) is that there has been no global standard on how to diagnose it.  Each country uses a different test to diagnose it, therefor studies done in one country could not be applied to patients in another.  However, last year results from a huge study  involving 25,000 women in 8 different countries was released that looked at GDM and had them all use the same diagnostic criteria: a fasting 2 hour 75 g glucose load, requiring 3 blood draws.  The study was excellent and showed that by implementing this different diagnostic protocol, there was a significant reduction of bad outcomes such as preeclampsia, shoulder dystocia and neonatal admissions to the NICU.  That was very exciting.  But then when you read the fine print, it revealed that under these new criteria the number of people who would have the diagnosis of GDM would be doubled, approaching  17% . Ouch.  I realized this was not going to make my patients happy: to make them all do a more annoying test and to tell twice as many of them that they have gestational diabetes.

When I read these statistics initially, my first thought was, “How can 17% of the population have gestational diabetes?” One of the biggest risk factors for gestational diabetes, though, is obesity.  In American 30% of the population fall in the obese category with 1 in 10 Americans being diabetic or pre-diabetic.  Since gestational diabetes is often a precursor to overt diabetes, perhaps these numbers are not so surprising after all. The good news in the study was that the majority of these patients were able to control their diabetes with diet and exercise instead of insulin, which is encouraging.

Currently several national organizations have endorsed the guidelines, however so far ACOG has remained silent.   I’m pretty sure it just a matter of time until I open up a Green Journal and read a committee opinion that recommends changing to the new more stringent criteria.  Though I will most likely hear some grumbling at first from both patients and staff, I think once implemented, the new criteria should help improve the health of both mother and baby. And that’s what matters most.

*This is perhaps a good quality for a doctor to have

Dr. Rupe

I went into my first pregnancy about 30 pounds overweight. I remember being so afraid the effects of pregnancy would tip the scales (literally) to obesity and utter misery. I made it through the first trimester only gaining a couple of pounds but I figured the worst was yet to come.

I have a condition called PCOS (Polycystic Ovarian Syndrome) which makes me insulin resistant. Ironically, it’s one of the reasons I’ve struggled with weight (that and the fact that I love sweets).  The placenta takes over at around 12 weeks in pregnancy so PCOS patients get tested for Gestational Diabetes at the end of their first trimester because the placenta releases a hormone that makes the pregnant woman even more insulin resistant.

Testing for Gestational Diabetes involves the patient drinking a sugary drink (Glucola) and then having their blood drawn an hour later. This typically happens at around 27 weeks. Again, for PCOS patients the test is done much earlier in their pregnancy due to their already being insulin resistant. If you fail the initial test, a 3-hour confirmatory test is then completed. It involves a fasting blood draw, then drinking the Glucola drink and then a blood draw 1, 2 and 3 hours after you finish the drink (I know this process intimately because I participated in it just this morning).

I can remember the day of my first pregnancy that I received the dreaded call with my glucose screen results. I hung up the phone and cried. Then I called a girlfriend and she said the most amazing thing, “Jess, I think this is going to be a gift from the Lord.” I had no idea how right she was. I visited with a nutritionist and she put me on an eating plan. If I followed the plan and monitored my blood sugar (by pricking my finger 4 times a day), I could avoid insulin shots.

My plan was simple. Normally, people should have around 20 servings of carbs per day (a serving = 15 grams). For those of us with gestational diabetes (GD) we could have 13 servings. In addition to limiting my servings, it was important that I had them at certain times of the day (to spread things out) as well as cutting out fruit before noon as fruit sugars are harder to process in the morning.

So my eating plan looked like this:

Breakfast – 2 servings of carbs, protein, no fruit

Snack – 1 serving of carbs, protein

Lunch – 4 servings of carbs, protein, veggies (some veggies are carbs)

Snack – 1 serving of carbs (fruit)

Dinner – 4 servings of carbs, protein, veggies, maybe fruit

Snack – 1 serving of carbs

After 6 months on this regimented, yet doable plan I felt better than I had felt in years (even 9 months pregnant). One of the dangers of GD is how it effects the baby’s size so Dr. Rupe kept close watch on our little one throughout those months and she seemed to be growing just fine. Dr. Rupe also assured me that the decrease in calories would not have a negative effect on the baby if I focused on eating the right things and kept taking my prenatal vitamins.

In May 2008 right before I delivered Hope I weighed exactly what I weighed when we conceived her. I had not gained a pound. Hope was born a very healthy 6 pounds, 11 ounces. After the delivery (ok, a few days later when I braved the scale), I weighed 20 pounds less than when I got pregnant. This truly was a gift from the Lord for me.

I am sorry to say that I went back to my old ways shortly after I delivered (what with the stress of being a new mom and all) so I’ve gained most of that weight back. As I await the results of my screening this time, I am filled with mixed emotions. I would love the chance to lose the weight again. Not that I couldn’t have done it on my own in the past 2 years but some of us just need a little incentive for these things. But I also want nothing more than to make sure my baby is safely growing inside of me. I know the Lord is holding this baby together in his hands and I trust him no matter what comes my way. If I have GD (which I most likely will), then I will count it as the grace of God giving me a second chance to get healthier. If I do not have it, then I will thank the Lord for not allowing something that could possibly effect the baby and I will ask him for the grace to be purposeful and disciplined to get healthier.

If you find that you do have GD, I hope that you can look at it as an opportunity to finish your pregnancy well so that both you and your baby will be as healthy as possible after delivery. {Most women will not actually lose weight due to GD. That was most likely due to the fact that I was diagnosed so early on and stayed on the plan for 6 months.}

I would love to hear from you if you have had GD in the past or you have it now. How did you deal with thediagnosis? What worked for you?

{Update: March 19, 2012 I did not have GD with my second pregnancy. I even passed the initial screen! Which supports the fact that every pregnancy is unique.}

I recently read an advice column in the news paper concerning how to tell people you are pregnant. The writer was concerned with how to give the good news to a friend who had been struggling with infertility. I was struck by the thoughtfulness of the writer to be so considerate as to realize the mixed emotions that are processed by those wanting children when they hear that someone near them is expecting. The advisor (I think it was Dear Abby, but I can’t specifically remember) recommended to tell the person in private or consider writing a note to inform them, giving them permission to process the news however they needed to emotionally, before they have to see you. I thought this was really good advice.

I remember during my adoption journey, that it didn’t bother me when close friends got pregnant or adopted, but sometimes when I would hear the ‘good news’ from acquaintances it would sometimes upset me, I’m embarrassed to say. I’m not exactly sure why. I guess if it was someone I knew, then I could identify with their journey, but it was harder to process when I didn’t know the entire story. For some strange reason it would also bother me when TV characters had babies. I remember one specific Blue’s Clues I was watching with Ryan. Mr. Salt and Mrs. Pepper were having another baby. Umm, really! Couldn’t they just be happy with a baby Paprika! But NO, here comes cute little baby Cinnamon. It’s funny now, but it really ruined my day.

On a related note I will often get asked by patients when is it safe to tell people that they are pregnant. Especially those that have previously struggled with infertility, I get the sense sometimes, that they feel that if the doctor tells them it’s OK to spread the word then nothing can happen. Each person’s situation is different. I can give them the statistics for their pregnancy, but deciding how and when to tell the good news is a personal decision. Some patient post their pregnancy test on twitter as soon as it comes back with a double line, others anxiously await the second trimester to feel safe to speak a word.

Some reassuring numbers for those waiting to tell:

In a healthy women less than 32 years old with no history of previous miscarriage the chances of having a miscarriage drop to 3% after a heart beat is seen at 7 weeks. This number drops to less than .5% after entering the second trimester. The risk of miscarriage does increase with age >35, smoking, medical condition and history of previous miscarriages. Even with these risk factors, though, the chance of loss decreases with each advancing week. So if you are looking for a ‘safe point’ to tell, after seeing a heart beat is a reassuring time. If you want an even ‘safer’ point, then second trimester is better. Really, the best time to tell, is when you feel it’s the right time to tell.

I get to hear from my patients some cute stories of ‘how’ they spread the news to their family; like framing their ultrasound picture to be opened at holidays, making a video featuring the news or having the good news written on cake. However you tell have fun with it, but be sensitive to those who may have a difficult time with hearing it.

I’d love to hear some feedback on ways you have told people about your pregnancy and also from our readers who have struggled with infertility on how they think is the best way to ‘break the good news’.

After only a few weeks of pregnancy, I was struck by nausea. Constant nausea. There was no “morning sickness” just an all day lingering ‘blah’. I didn’t vomit very much, though most days I wished I would, so that maybe I might feel a little better. Eating seemed to help the nausea, especially carbs. Shakes (from Swensons were the best) would often soothe my upset stomach, though they most likely contributed to my stretch marks. I don’t remember any food aversions I had, though patients often tell me theirs and they are very common at this point in pregnancy.

My two main cravings throughout my pregnancy were apples and Dr. Pepper. I would eat at least two sometimes up to five apples a day. It was during pregnancy that I discovered honeycrisp apples which are perhaps the most delightful of all apples. I would be almost giddy with anticipation as I pulled a fresh honeycrisp out of the fridge and took a huge bite. The sweet crispiness would hit my tongue, while the juices ran down my chin. Then I would be faced with a conundrum: do I take another bite first or do I pause to wipe off the juices? Usually the next bite won the contest, as I attacked the apple much like lions attack antelopes on the Discovery channel.

My rare treat was Dr.Pepper, BUT it had to be in a can and REALLY cold. The best were Dr Peppers that had been in a cooler with the ice half melted so that they were floating in the freezing water. SO cold that it would give a slight chill as it ran down my throat helping, if only for a moment, for me to forget about my heart burn and focus on the sweet, fizzy, cold, wonderfulness that is Dr. Pepper in a can.

What do these crazy cravings mean? Despite being a common symptom of pregnancy there is not a lot of data on pregnancy craving. The first trimester is a pivotal point in pregnancy, where all the tiny organs are forming. This is a key time to avoid chemical/ foods that might cause harm to the baby, leading to malformations. It’s thought that this is why God made that first trimester to have the aversions and nausea, to avoid foods and chemical that might be harmful. Its also important to take your prenatal vitamin daily, as the folic acid gives the spine its building blocks to help it form properly, preventing spina bifida. Carbs, which are a common craving, are one of the easiest foods to digest, full of energy, safe for the baby and can help ease the nausea.

The key with first trimester eating, especially if you are fighting nausea, is to eat small meals through out the day. The baby doesn’t need a large amount of calories at this point, so you don’t need to eat an increased amount of food, but do try to eat small amount of heathly carbs and protein throughout the day: Whole grain bagels, whole grain pasta, applesauce, bananas, rice, toast ect.

If you feel you are eating too much, gaining too much weight or constantly hungry then focus on trying to slow down the speed of your eating: spend 20 minutes eating a bagel.

What if I’m having weird cravings? Some people will crave things that aren’t food, such as dirt, laundry soap, baby powder, ice or paint. This can be a sign of anemia or a vitamin deficiency. If you find that you are eating or craving non-food items please tell your doctor immediately.

Will my baby like the things I crave during pregnancy? I often get asked this question, but medically we don’t know. In my own experience my son does LOVE apples, one the few foods he likes (that’s a whole OTHER post!).

If you have healthy cravings, like fruits and vegetables, then go with it! If you have non-healthy cravings (IE, REALLY cold Dr Pepper in a can) then give in to those once or twice a week, not once or twice a day! If you have non-food craving notify your doctor.

I am 10 weeks along in my pregnancy and all of a sudden I am hungry ALL THE TIME! Dr. Rupe talks about this symptom in the book. Hunger, with cravings and aversions.

I’m hungry all the time but not much sounds good to me. I am blessed in that I don’t suffer from extreme nausea or vomiting during my first trimester. Just a touch of queasiness from time to time. But I have lots of food aversions and honestly, they seem to come and go. One minute chicken sounds good, the next anything related to my feathered friends makes me want to puke. It makes it very challenging to eat healthy during these early stages of pregnancy.

My hope is that after I share my pregnant point of view on this symptom, Dr. Rupe will chime in with another entry that gives the facts and some good, doctorly advice on how to handle this early pregnancy dilemma.

Preparation is perhaps the most important action you can take when trying to eat healthy in your first trimester (and throughout your entire pregnancy for that matter). Since I know that chicken is hit or miss for me right now, I have to be ready with other options. What does sound good? Make a list of foods you have not been averse to and make sure you keep them around. Any kind of meat is tough for most women I talk to in their first trimester. What other forms of protein can you stomach at this stage?

I don’t hear much that fruits and vegetables bother women in pregnancy so focusing on those things is a good idea. I’ve eaten a lot of salads (the tangy vinegar helps the queasiness) along with citrus fruits (sour is great for nausea). When all else fails look to whole grains. Toast and whole wheat pasta are mild and will give you the carbs you need for energy. Try to find some form of protein to add to it though. Cheese is a good idea. Lastly, make sure you drink lots of water to keep you from dehydrating. Water is also just a great cleansing agent. It almost resets my system to drink a tall glass of cold water. Chicken might sound yucky but after downing 8 oz of agua, it might not be so bad.

We’d love to hear your pregnancy menu secrets. What worked for you?

Enter into his gates with thanksgiving, and into his courts with praise: be thankful unto him, and bless his name. Psalm 100:4

Dr. Rupe and I would like to wish all of you a very Happy Thanksgiving! We hope you will be spending the day with your loved ones; focusing on the many blessings in your lives. We have so much to be thankful for. Even in the midst of trials, there are many blessings we can count.

With this post I’d like to offer a feast of thanksgiving and I hope you’ll share with us what you are most thankful for as well.

This year I am thankful for:
1. Jesus, who has allowed me to be real with him this year. In doing so I feel so much closer to him and I am so grateful for his unconditional love.
2. My husband, who is the most servant-hearted man I know.
3. My daughter, Hope, whose life is a daily reminder to me that I don’t have to be afraid as I walk this new journey as a mommy-to-be.
4. My new baby, the life that God has allowed us to conceive in his timing and through his plan. I am thankful for the strong heartbeat that we were able to see this week.
5. My family, who is has been incredibly supportive this year.
6. My friends, some who have moved away and some who remain close. Location does not determine closeness. I am so blessed by the women in my life.
7. Provision, which will look different in the months to come but he’s always provided, why would he stop now?

I am reminded today with all of the thoughts and stresses vying for our attention, that we have to focus our minds on the positive things in our lives. So what are you thankful for? And what are you believing for that you would take a step of faith and thank him for in advance?

May your heart overflow with peace and gratitude this Thanksgiving.
Love,

So I have a cold. It stinks. My throat is raw and my nose is full of snot. It’s hard enough being sick but being sick when you are pregnant is miserable. What I wouldn’t do for some NyQuil right now!

My husband and I were out and about yesterday when I felt this cold coming on and unfortunately, I could not for the life of me remember what medications I could take (despite having read this manuscript 50,000 times). The very uninterested Publix pharmacist did not help although he did remind me I could take Sudafed (which, by the way, I had to sign for). I was not near my own Publix otherwise I would have received a warm welcome, lots of helpful information and a huge congratulations that I am expecting. (Not all Publix stores were created equal).

And now, here I am at home. In front of my computer where I could check my handy, dandy Pregnancy Companion manuscript (don’t you wish you had the book already?!) and here’s what it says:

Colds and upper respiratory illnesses are also quite annoying. Acetaminophen (Tylenol), guaifenesin (Robitussin), and phenylephrine (Sudafed) are generally safe to take during pregnancy. Make sure to avoid products that contain ibuprofen (Motrin or Advil) or aspirin. If you begin to cough up chunky junk (yes, that’s a medical term) or have a fever, you should see your doctor. It is highly recommended that you get the flu shot while you are pregnant. If you do get influenza with body aches, chills, and fevers, you should be started on antiviral drugs quickly. Some OB offices treat their sick pregnant patients in the office; others will have you see your family doctor. Check with your doctor on office policy.

So there you have it. No, I cannot take NyQuil or the myriad other drugs I would normally use to knock myself out, but I can do this:

- Drink lots of water
- Drink decaf tea to soothe my throat (Decaf PG Tips is my favorite)
- Rest
- Take Sudafed and Tylenol
- Sleep with an extra pillow to keep my head elevated
- Sleep with the window cracked for extra air circulation and thus less stuffiness (this is my husband’s trick), of course this requires you raise the heat
- Make an appointment to have my flu shot because let’s face it, I don’t want to feel this yucky again!

Got any pregnancy sickness tips? Leave a comment, we’d love to hear them!

P.S. I LOVE being pregnant and writing this blog. Now I will have real time, real life pregnancy topics to discuss first hand. And believe me, I should have plenty. I experienced about every, silly, little thing you could experience when I was pregnant with Hope!

I hope you all were encouraged by Dr. Rupe’s amazing adoption story. I lived through it with her yet I still get chills every time we talk about it. What an amazing reminder that sometimes the Lord allows us to wait for things so that he will get the most glory when it finally comes about the way he chooses. What a miracle story!

Speaking of miracles. . .Remember how I was believing that I would conceive this month even though, medically it was a long shot? The main reason I felt the grace to believe for such a thing was because of the faith of a friend. A couple of weeks ago I met Heather (sorry, I just can’t call her Dr. Rupe when talking so personally about our friendship) and our friend Donna for dinner. It was right after the appointment I wrote about where my eggs were on the wrong side (remember I only have one tube after my ectopic pregnancy) and I was asked to pay out the wazooo for fertility treatments that didn’t work. I was at a low point on my journey and I truly felt like I wanted to give up. I shared the update with Donna and Heather. Both were very sweet and encouraging but it was Heather’s response that changed everything. Here she was. . .not only my friend but my doctor as well and she said, “That’s no big deal. Your tubes can flop around. I really feel like this is THE month.” Did my OB really just tell me that maybe I could conceive against all odds? It was like a shot in the arm. . .both the reassurance of the slight medical possibility and my sweet friend believing when I didn’t think I could believe any longer.

I left that dinner feeling so hopeful. More hopeful than I had been when the eggs where on the right side. So I began to pray and ask the Lord for the near impossible (but not completely impossible according to my doc). I started to realize that if he did allow me conceive against the odds like this, it would surely bring more glory to him. Having a story like that would make all the waiting and the pain worth it.

So this is it. . .the post I’ve been waiting all year to write. I am pregnant!! Although we remain guarded having been through all we’ve been through in the past, our main hurdle has been cleared: that little bugger safely made it to my uterus (as was confirmed on an early ultrasound yesterday). I’m only 5 weeks along and perhaps I’m crazy to be sharing this news so soon but I feel like you all have walked faithfully with me through this journey so I’m committed to share all of it with you. I appreciate your prayers as we wait in hope for the next milestones: hearing a heartbeat in a week or so and getting through the first trimester. We are guarded yet we believe that he will be faithful to continue this miracle.

So once again I am reminded that sometimes he asks us to wait for things so he can bring them about his way. I am truly honored that he would use me and my story to bring glory to himself.

May you see his glory in your own life this season.
Love,

It’s that time of year again!

No, not fall, at least not in Tennessee where it’s still 90 degrees outside.

No, not football season, at least not in our house.

Its Flu shot time! Or as I like to call, time to argue to strongly encourage patients to get their flu shot. My passion in medicine is prevention. By helping my patient make healthy choices and prevent illness, I feel I am accomplishing so much more than by just passing out a pill to treat their disease. It’s challenging though, to get people to make lifestyle changes at times, but the flu shot is one of the easy things that women (especially pregnant women) can do to improve their health, and prevent illness. The flu shot in young healthy adults reduces the risk of getting the flu by 75%, yet there are still many misconceptions that surround it.

I had a recent conversation with a young mother of an infant (she was not currently pregnant) that went something like this:

Me: It’s recommended that you get a flu shot, because your baby is too young to get one.

Patient: I don’t know…. I’m really worried.

Me : About ????

Patient: autism.

Me : Ummm????? In yourself? But you are 22 years old?

Patient : Yeah

Me: You think you can suddenly ‘catch autism’ from the flu shot at the age of 22?

Patient: yes, I saw it on Oprah.

Me: (working as hard as I can to suppress laughter) Girl, you’ve got your conspiracy theories all mixed up!

This conversation illustrates how fear and misconceptions can interfere with your health.

The risk of being hospitalized from the flu in pregnancy is about 1 in 1000. Those are often life threatening cases. Also, babies born during flu season cannot be immunized and are also at increased risk of flu complications, so having household contacts immunized is helpful. Each year 100 children die of the flu, not a huge number but so preventable! Also, when the flu is contracted, the person is infectious for 24-48 hours before they have any symptoms. This is another reason it’s so important for health care workers to be immunized, especially those that work with babies.

Flu season in the northern hemisphere is October through May. Getting the flu shot as early as possible, will help your body form immunity before the virus becomes widespread in the community. The live nasal mist is not recommended in pregnancy. Also, if you have an egg allergy you should not get the vaccine. Preservative free (thimerosal free) vaccines are also available.

The vaccine is not perfect. Scientists estimate the flu strains that they predict will be the most prevalent and that is not always easy. Also, with age one’s ability to become immune decreases so in the elderly, who are the most vulnerable, it is not as efficacious. Side effects may include pain at the injection site and redness. It’s important to note that the flu shot does not cause the flu!

So the flu shot is not perfect, but it’s the best offense we have. It’s preventative medicine at its best, and I think that’s why I get so worked up about it. So use common sense, lots of hand washing and hand sanitizer, as well as eating a healthy diet rich in fruits and vegetables. In addition, for pregnant women and those with young children, the flu shot is a must.

So today I got to play a part of the most amazing delivery. A beautiful baby boy was born, and as I laid him in his mom’s arms, there wasn’t a dry eye in the room. His mom cuddled him and spoke words of love as dad was so teary he could barely see to cut the cord. Dad juggled with several cameras trying to capture the moment, finally giving up hope of a decent picture and just joining in with the happy tears and laughs. Exuberant phone calls followed, then overjoyed grandparents filed in to smother the new addition with kisses. I noticed even the seasoned nursery nurse in the corner, dabbing the corner of her eye.

Every baby born is a miracle, but there is something about this delivery was different. This baby was fought for. The road that this family had to travel was not easy. There were years of infertility, miscarriages and dashed hopes. I had shed tears with them before, but they had been tears of sadness. They preserved, fought and prayed; and here in their arms was the answer to that prayer.

There is nothing more gratifying in my profession then that moment, the miracle of miracles: Not only the miracle of life, but also the answered pray. God’s promises manifested.

It reminds me of Jessica’s journey for Hope and my journey for Carson. They were filled with disappointments, but in the end God’s faithfulness was proven. Not in the timeline we thought, but never the less, in His perfect timing.

So as I ponder this delivery today, I pray for Jessica’s next miracle. Despite her recent setbacks, I stand with her in faith that one day, hopefully soon, we will once again cry tears of joy together.