Request to My Readers...
Sunday, April 27, 2008
Kenneth F. Trofatter, Jr., MD, PhD
The “Chair” role has been especially taxing. Despite my training as a “Medical Scientist,” I learned a long while back that my strength was in patient care and, indeed, even the research I have done since graduate and medical school has mostly been in the ‘clinical trials’ arena. Being a chairman requires an entirely different skill set and the endless meetings are more exhausting than any 36-hour period I have ever spent on Labor and Delivery! I knew this when I took the position, told the powers that be that I did not want to be considered for the permanent job as a condition for taking the interim role, and continue to pray daily that the ‘Search Committee’ does its job quickly and well! Please, pray along with me on that score and say a LOUD AMEN!
The long and the short of this is that I have not been able to write as frequently as I would have liked recently. Even though this is not a ‘peer review’ journal, I do actually research many of the topics I have either come up with on my own or developed in response to readers’ queries. And, that takes both considerable time and energy, both of which have been rather scarce lately. I have told others with whom I work that “my brain feels like it has been sucked dry.”
I have continued to keep up with your many comments and questions and answer just about every one (that actually gets to me). It has been especially gratifying that several of the topics we have discussed (such as miscarriage, recurrent early pregnancy loss, understanding Rh-negative status and Rh-isoimmunization, cytomegalovirus infections, fetal cystic hygromas, and others) have resulted in hundreds of queries from our readers – many continuing to be generated from posts that I made at the beginning of my tenure here. Recognition of this is very important because it highlights where YOUR interests lie and where you are looking for more information or better explanation. After all, that’s what I intended for this blog at the outset and in many ways our success makes it fairly unique among ‘medical blogs’ in that regard.
In going forward, I am soliciting your help. Several topics I would like to address in the near future include: 1) Dr T’s approach to cervical cerclage; 2) Toxoplasmosis in pregnancy; 3) Twins; 4) High order multiple gestations (i.e., more than twins); 5) autoimmune hepatitis in pregnancy; 6) Understanding antepartum fetal assessment, and, perhaps; 7) Fetal heart rate monitoring, and ; 8) Stillbirth - intrauterine fetal demise. I will, eventually, try to cover all of these topics and if you have preferences for any, please let me know.
However, I would also like to know what YOU would like to hear about. It could be a very basic topic (NO QUESTION IS TOO SIMPLE) related to routine or complicated pregnancies or as complex as you think I could handle! Of course, I reserve the right to respectfully decline to respond if it is clearly outside my realm of expertise as I have done in the past. I do know my limitations, but don’t mind when you push me to them either!
Please give this some serious thought because this is YOUR site as much as it is mine. I will stay here as long as I can, but will not over stay my welcome when your interest wanes! Thanks to all of you for reading…and for what you continue to give to me….
Dr T
*******I also have another favor to ask of all our readers. Healthline has been nominated for the prestigious Webby Award in the category of “Health”.
The International Academy of Digital Arts and Sciences will choose Webby Award winners, but the People’s Choice Webby lets you decide. It’s easy:
· Simply log on to http://peoplesvoice.webbyawards.com/
· Register to vote (or log in if you are a returnee)
· After registration, click on the Web site icon and find the Living section, under which the Health category falls
· Vote for Healthline.
And be sure to pass this pass along to your friends and encourage them to vote as well!
Thanks to all of you for being such loyal readers!
Dr T*******
18 Comments:
At Tue Apr 29, 08:29:00 AM 2008,
Anonymous said…
Thank you, Dr.T! My suggestion for a topic is differentiation between normal pregnancy symptoms and symptoms that might be of concern. In my reading, it seems that many of them are the same and I'm not sure when to be concerned. An example is cramping. Some is normal, some may indicate a problem. The books all say severe cramping is the key, but I'm not sure what that is, exactly. Thanks for your continued efforts, which I find to be very helpful!
At Fri May 02, 03:28:00 PM 2008,
Julia Mangan said…
Thank you for all your work on the blog and answering our comments!
I would love for you to address Asherman's Syndrome at some point and the risks of D&C's.
At Mon May 05, 04:13:00 PM 2008,
kfox said…
HI I Am writing with a concern about ectopic pregnancy. I really would like your input before I go in for my next HCg reading to make a long story short i was diagnosed with an ecotpic pregnancy in feb 08 with Beta HCG level of 9000+ I was in stable condition with not much pain so I was able to get the methtrexate shot I got the shot at the ER once. I read everywhere on the net depending on your level a person can go in for another dose. I was not given another dose since on the my next HCG level reading went into the 4000s. my level continued to drop every four days by 50% so my doctor decided to come in every 2 or three weeks until i get to 0 my last reading in April was 103 and 2 weeks later it was only 70. I havent been back to get another reading but Its may and the HCG levels are going down slower. I am very Concern i may need another shot of methotrexate.. what would you suggest me to do in the situation being it is MAY and i was diagnosed in Feb.
Thank You
worried out of my mind by the way my doc does not want me to get another shot since intially it was going down fast.
At Fri May 09, 06:14:00 PM 2008,
Anonymous said…
Dear Doctor,
My sister-in-law was just told by her doctor that she has type1 herpes when she went for her initial pregnancy tests. She said the the reading was 3.2 which I do not understand. The situation is this that I am also going to have a baby soon and am really concerned about the health of the entire family. She lives in the US and was visiting our family in India when she got pregnant. She also has a thyroid problem and has had one bad pregnancy a couple of months back when the doctors had to do a DNC on her. I on the other hand, live in Dubai with my husband. Now my concerns are this,
For her, 1. She thinks that she might have contracted it from the DNC procedure that was done. Is it possible? She says that she got some such tests done before the operation and they were negative. 2. Her husband has some relative near them who all husband, wife and child have some kind of STD( sorry but the kind could not be specified by her). She helped them out a lot with the kid after he was born. Is that a possibilty? 3. She is asymptomatic as far as we know( she is scared and has gone into a shell..won't talk much and it seems impolite of me to ask). Does that make it any less dangerous? 4. Now that she is pregnant, does it make the pregnancy complicated combined with her thyroid problem? What about the child ? The doctor said something about the delivery being the crucial time.
For me, the family and our kid, 1. Could any of the other family members have contracted it from her but might be still unaware of it? Should we also get the tests done? 2. How do we avoid contracting it ourselves? Should we take some special care considering that we live in the same house and share beds, toilets,towels, hugs, kisses and touching with each other? 3. I am also concerned about my unborn child. I myself have been blessed after many painful years of surgeries and procedures. I do not want anything to go wrong with this child as it is my last hope and chance, medically. I am very healthy but have a weak immunity. Should I take any special care? 4. Also after the child is born can the child be infected by her touch and kisses and other shows of affection?
I know I might sound a bit edgy, but the truth is that these are difficult times for our family and I would love to have some answers that I cannot ask anyone else.
Thank you and God bless
At Tue May 13, 06:57:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To kfox May 5: Sorry for not responding sooner, but for some reason your comment never got to my mailbox and I just now found it. I think your hCG has taken a long time to fall simply because it was SO high to start with. You were quite fortuante to have responded to MTX. Now that it is below 100, you probably will not need another shot. Be patient awhile longer and good luck! Dr T
At Tue May 13, 07:09:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 9:
1) She did NOT get this from the D%C procedure
2) More than 50% of all adults have type 1 HSV (this is the virus that is usually associated with fever blisters) and most people don't even know they have the virus. As in her case it was picked up at the time of routine serologic testing. Once you have any herpesvirus, you carry it for life!
3) Type 1 HSV typically is NOT the cause of recurrent genital erpes and it typically is not a 'STD, although it certainly can be, it is usually transmitted between people by kissing. That means DIRECT CONTACT with another individual is necessary (in most circumstances) to pass the virus on to someone else.
4) It is most infectious when there is an actual fever blister present
5) Her thyroid disease has NOTHING to do with the fact that she caught HSV from someone else (probably her mother or father!) in the past
6) The baby is at almost NO RISK at this time or at delivery unless she has genital HSV. The baby may catch it from her or anyone else who has a fever blister after delivery.
7) Your baby is at no risk at this time for the same reasons.
8) Rather than agonizing over all this, I strongly you suggest you discuss this with a local infectious disease expert who understands HSV and can put this in perspective for ALL of you because right now, your concerns are blown out of proportion by misinformation.
Dr T
At Sun May 18, 11:54:00 PM 2008,
Anonymous said…
I would be very interested in hearing your approach to cervical cerclage. I have a history of this condition, including one loss at 17weeks, and a subsequent pregnancy with a McDonald cerclage. During that pregnancy I was found to be funneled past my stitch (via ultrasound) at 24 weeks, with no apparent pre-term labor or other signs of a problem. Strict bedrest resulted in our now 2 year-old, born at 37.5 weeks by c-section. We are contemplating another pregnancy; we're terrified of another loss, and months of strict bedrest will be harder this time. Is a Shirodkar or an abdominal cerclage ever a consideration for someone like me whose cerclage didn't actually fail...but almost did? Thank you for your help. Thanks also for writing this blog, it's very informative and helpful.
At Tue May 20, 08:28:00 AM 2008,
Anonymous said…
Could you discuss Symphysis Pubic Dysfunction?
At Thu May 22, 11:51:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 18: I will address a full post to that subject in the near future. Thanks for asking. Dr T
At Thu May 22, 12:01:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 20: The symphysis pubis is the point in your lower abdomen in the midline where the pelvic bones come together. The bones are 'glued' together (and separated) by a tough ligament. Ligaments are made up of connective tissue (not bone), they have the consistency of a rubber eraser, and they tend to be 'hormonally responsive.' During pregnancy, many ligaments in the body loosen under the influence, mostly, of pregoesterone. They appear to do this by taking on more water and perhaps losing some of the cross-linking of the connective tissue. Sometimes they loosen so much in the spine or the pelvis that the bones to which they are connected become more mobile and can dislodge from their usual anatomic position. This is frequently accompanied by pain and in the case of the pubic symphysis, this can become quite uncomfortable and even make the pelvis so unstable that it becomes difficult to walk. Unfortunately there is not much that can (or should) be done about this until after you have delivered and the hormone levels have returned to normal. By the way, if the ligaments that hold your pelvis bones did not loosen up during pregnancy, It would be much harder for the pelvis to stretch and accomodate the baby moving through the birth canal. Hope this helps! Good luck. Dr T
At Mon Jun 30, 04:00:00 PM 2008,
Anonymous said…
Dr. T - I have thoroughly enjoyed your very comprehensive responses to the questions and posts out there. As for a topic that is of interest for me is treatment of PCOS in women who are thin. I am one of these women, so would love to hear more from you on this topic.
To give you some context for my case: I am 36 years old and also have hypothalmic amennohrea, so do not respond to Clomid. I thought I just needed help to ovulate, and had one round of stimulation meds (menapur) to induce ovulation, but had OHSS. I was triggered but did not get pregnant. During the next cycle, I was over-responding again with the same stimulation meds, and switched to IVF. With 20 eggs at retreival, I only had 1 blast at the 5 day transfer, and none left to freeze. I did get pregnant but had a m/c at 7 weeks and had a D&C (found to be Trisomy 10). It took 3.5 months for my Beta to come back negative. For the second IVF I was on follistim, had 30 eggs at retreival, transferred 2 blasts and none left to freeze. That time I only had a chemical pregnancy (Beta = 9 two weeks after transfer).
My current RE said that even with my high e2 readings (3500+, 2000+)my endometrium lining was too thin during IVF - 5 mm and 4.7mm at transfer, respectively. He also said protocols need to be different with PCOS women, since avoiding OHSS is key for healthy eggs/embryos. I keep reading how hard it is to keep PCOS women from OHSS. Can you discuss appropriate stimulation protocols? What is your view on adequate endometrium lining? When should Clomid be used, and when should alternate treatment be looked into? (It seems many Dr's prescribe this, even if prometrium or provera do not work to produce a period.) Also, in my case my doctor is recommending mock cycle(s) so he can monitor my endometrium response and adjust the stimulation protocol to incorporate estrogen with lower levels of stimualtion medications. From what I've read, it seems mock cycles are used primarily for donor egg cycles.
Sorry for the long post, but any insight on PCOS, especially for thin women, would be of great interest to me!
At Fri Jul 04, 08:20:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 30: One of the things I learned a long time ago is to keep quiet when I really don't know the answers. Your situation is fascinating and I promise to learn more myself, but my specialty is maternalfetal medicine with niche interests as are addressed in my posts. I am NOT by training an REI. It sounds like you are in good hands, but there is no harm in asking your doctors if there might be someone else around the country or world who might be better thatn they are in these situations or who might offer some advice. Tell you what...you are a set up for all kinds of problems even AFTER you conceive, so why don't you get back wth me once the REI docs have gotten you to 9-10 weeks! Best of luck and I really am sorry I am not smart about some things! Dr T
At Tue Jul 08, 12:55:00 PM 2008,
Anonymous June 30 said…
Thanks Dr. T. I thought you may have seen women who had to deal with stimulation protocols before coming to you, but totally understand REI is not your expertise! Hopefully I will be able to get to 9-10 weeks eventually, and I'll definitely ask your opinion. I have to say your comment of that "I'm set up for all kinds of problems even after I conceive" sounds scary. I do hope in my case the hard work will be getting pregnant, and hopefully all will be much smoother after that. Will definitely be in touch...
At Sat Jul 12, 04:48:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
You are welcome. Good luck and look forward to hearing back from you! Dr T
At Sat Sep 13, 07:12:00 AM 2008,
Anonymous said…
Thank you for all of the interesting topics you cover in your blog. I would like to hear your thoughts on the risks & benefits to VBAC's. They are such a hot topic and the information is so conflicting. I am pregnant with my second child. I progressed to 8 cm with my first but was given a c-section due to fetal distress, which I think was justified. However, I would like to try a vbac this time. My provider will allow me to try but is not at all happy with the idea due to a bicornate uterus. Would love to hear your experiences & thoughts on this topic.
At Tue Sep 23, 05:20:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 13: Thanks for the kind words! I will discuss VBAC sometime over the next couple of months. Can't believe I haven't to this point! Thanks for reading. Dr T
At Sun Oct 05, 08:27:00 PM 2008,
Andi said…
Thank you so much for all the wonderful work you do here. I am in the care of a very respected national practice, and the doctors all agree they can't really determine what might be wrong with our baby so I thought perhaps you may have encountered this group of symptoms before. At 18 weeks, our son had slightly low fluid which was attributed to dehydration since I had just moved to a desert climate. At 24 weeks, his ultrasound showed a cystic hygroma (which definitely wasn't there before) and revealed he has only one kidney. The fluid was lower with an AFI around 6. We've had countless ultrasounds since and have been monitoring every other day since. Our fluid is down to 2 AFI and everyone agrees the baby will require dialysis and a transplant at some point as the kidney seems to be developing small cysts. Anatomically, everything else looks fine and the bladder is always full on the scans. The growth on the back of his neck still there, although the doctors now aren't sure it's a hygroma as it didn't go away and hydrops never developed. All amnio results were fine and his brain structures and heart have been evaluated and seem to be fine. We have spent a lot of time with a genetic counselor and he has no other symptoms so we haven't been able to name a syndrome of any sort. He is always missing the "critical" markers for things that are possibilities. I am now 32 weeks and will go into the hospital soon for constant monitoring. His growth does seem to be slowing somewhat, he is about 2 weeks behind dates so if it stops altogether the plan is to take him at that time. I would love to hear your perspective on the symptoms and circumstances. Thank you again.
At Tue Oct 07, 05:31:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Andi Oct 5: I think based on what you have told me, your baby may have a condition called Meckel-Gruber syndrome. The "cystic hygroma" might be an occipital encephalocele and that accompanied by the baby's renal dysplasia would fit the characteristics of that syndrome. I am concerned that your baby's lungs will not have developed (pulmonary hypoplasia) either because of the low amniotic fluid during the critical stages of lung development. Have the genetic counselor discuss this possibility with your doctors and let me know what you find out. I am so sorry. Kind regards, Dr T
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