Episode 34: Pregnancy Complications - Placenta Previa & Falls

Dr. Sophia:
Hello everyone and welcome to the Dr. Sophia ObGyn podcast. Today I figured we would talk about something that's a little close and near and dear to my heart, which is always pregnant people. I figured I'd talk about some complications that can affect both mommy and baby and really my kind of top three. It actually happens to be preeclampsia awareness month right now in May. And so why not use the opportunity to bring awareness and highlight a very common disorder that can happen in pregnancy and why it can be so nerve wracking. So without further ado, of course I am here with my co-host and good friend Touseef Mirza.

Touseef Mirza:
Hi everybody. So yeah, so when Sophia and I were talking, and since preeclampsia is happening in May, we actually did one episode last year when it was preeclampsia month last year in 2024. This time we thought we'd do it just a little bit differently and not just focus on preeclampsia, but also talk about other types of potential complications that are not necessarily medically similar, but that affect pregnancies from a mother's side and also potentially from a baby side. So the two other ones that we're also going to be talking about is placenta previa.

Dr. Sophia:
Placenta previa and also the concept of falls and accidents that can happen during pregnancy. Let's start with preeclampsia. Basically, preeclampsia is a multi-organ condition that usually presents with elevated blood pressure and new onset of something called protein in your urine that occurs after 20 weeks of pregnancy. And what happens is, is that, you know, when a woman comes for her routine prenatal visit, we always check something called a UA or urinalysis or urine dip. And that's because we're looking to see if a woman has any protein in her urine that may then kind of prompt us to look for other issues or problems that may be occurring. And one of those things happens to be also looking to see, well, is her blood pressure normal?

Touseef Mirza:
So this is just routine.

Dr. Sophia:
Yeah. Routine stuff. And there are multiple reasons to have protein in your urine. That includes something like a urinary tract infection, which is also very common, but at least it kind of is a little light bulb. Okay. Let me just make sure that we're not dealing with anything more serious, such as preeclampsia. So like I said, it can affect multiple organs, but usually presents itself with the high blood pressure alongside this protein in the urine. Outside of that, the mother can start to experience symptoms such as headaches, changes in her vision, abdominal pain that's not related to contractions. The abdominal pain can be in the mid upper belly. It could be on the right, what we call the right upper quadrant near where her liver would be, and she may just feel out of it, dizziness, lightheadedness, along with all these other things.

Touseef Mirza:
So around what time do these symptoms usually appear in the pregnancy?

Dr. Sophia:
We consider anybody greater than 20 weeks with any of these symptoms, along with things like a blood pressure issue and a new protein issue as the potential of having preeclampsia. And so that would prompt us to then do further workup through blood, usually through blood work. And if we do have an, what we consider as an early diagnosis of preeclampsia, that usually holds a higher risk to the pregnancy itself, both for the mother and for the baby, because the likelihood of needing a preterm delivery, for example, increases-

Touseef Mirza:
Preterm delivery.

Dr. Sophia:
Premature delivery. And the majority of preeclampsia cases usually occur in the third trimester. So we're talking about well after, you know, 28 weeks and really more so even in that last month of pregnancy, somewhere between 36 and and 40 weeks is when the majority of preeclampsia tends to occur.

Touseef Mirza:
Does it mean that at 20 weeks you might still have everything normal in your urine analysis? But then it's only in the third trimester, that thing starts to change.

Dr. Sophia:
Okay. Yes. So women oftentimes will have a completely uncomplicated pregnancy and then all of a sudden start to develop changes such as protein in their urine, or they start to have small, you know, incremental elevations in their blood pressure. That would lead one to think, is this possibly preeclampsia? Now, the cousin of preeclampsia, so to speak, could be considered something called gestational hypertension, which is a blood pressure problem.

Touseef Mirza:
Gestational hypertension.

Dr. Sophia:
Okay. That's a blood pressure problem that happens, but doesn't carry the protein association and usually is a much milder problem or course managed. Very similarly in that we continue to monitor you both with lab work, we continue to monitor your blood pressure. We have you check your blood pressure at home. We ask you constantly about symptoms such as the headaches, any changes in your vision, we have you go for sonograms more often. So all of those things are happening simultaneously . For both conditions. But in terms of preeclampsia, we typically would say, okay, once we know that you are safe, and at full term is usually a good indication for delivery because we know that the longer you stay pregnant, the more severe the preeclampsia can become. And the cure for preeclampsia is in fact delivery.

Touseef Mirza:
So, all right. So I have two questions. The first one is, with every single pregnant woman that comes to see you or comes to see an obgyn, do you check for preeclampsia? Potentiality? For every single individual?

Dr. Sophia:
Every single patient has the potential to develop preeclampsia. Now, there are some groups that have higher risks for developing preeclampsia. For example, obese patients. For example, patients who have had preeclampsia in a previous pregnancy, black patients, first time pregnancy, young women who are pregnant for the first time, older women who are pregnant for the first time, women who are pregnant due to reproductive technologies such as IVF, women who have diabetes where they have, whether they have diabetes before the pregnancy or during the pregnancy, something called gestational diabetes. So all of these things have the potential to increase your risk for preeclampsia.

Touseef Mirza:
Since you are, you're basically talking to all of the pregnant women about this, is that something that has a tendency to really concern them? Or like how do you talk to them about that? Like are you saying, you know, this is a serious thing, but we'll follow it. Or once you talk about this to the women, do they become fearful about it? Like how, how does that interaction happen?

Dr. Sophia:
That's actually an interesting question. Like I said, in every single prenatal visit, we are monitoring for this, we are checking, like I said, we do the urine analysis to see if there's protein. We always check blood pressure for a patient who's pregnant, especially after 20 weeks, because we are trying to identify what are the potential red flags or what could be showing us signs that you could be becoming preeclamptic. And of course for those patients with any of those, you know, risk factors that I just discussed, we're watching it even more like a hawk. You know, like, could this be preeclampsia? And so what I would say is the discussion about preeclampsia can happen at any point in the pregnancy. If it's someone who has any of those risk factors or who develops one of the risk factors, let's say gestational diabetes, which is something we typically diagnose after 24 weeks of pregnancy.

So that then becomes a conversation, okay, you've now been diagnosed with gestational diabetes and our concern for you is without really good sugar management, and even if you have really good sugar management, unfortunately this still puts you at an increased risk for developing preeclampsia. And at that point, it may become an indicator for us to do not only really good sugar management, whether that's just with diet alone or if that means that you have to then start perhaps some medications in order to control your blood sugar. And we may start you on something like a baby aspirin, for example, in order to help, again, to prevent or act like what we call prophylaxis against preeclampsia. But when we have that discussion, it's more so to give you as the patient the understanding and the awareness of what are the potential signs and symptoms of preeclampsia.

What are the potential things that can happen that make you, you know, know is this a possibility? You know, and I think that's a conversation that we can have basically throughout. Sometimes women show up and they may have protein in their urine and they have no high blood pressure and they have no other signs or symptoms of preeclampsia. And so we're not here to be alarmists, you know, and like I said, you can have protein in your urine for so many other reasons. A urinary tract infection is a big common reason why sometimes women have a little bit of blood in their urine just because everything is a lot more juicy , as far as the vagina is concerned. And so sometimes you have small micro abrasions or small breaks and little capillaries around the vagina because the vagina becomes so engorged with blood vessels, it's getting ready. It's just, you know, yeah. You can have small breaks just as the cervix is changing and developing. Especially later on in pregnancy. And all of that can lead to maybe some evidence of small protein in the urine. The thing is, if you have it, it needs to be investigated.

Touseef Mirza:
When you talked about some of the symptoms as headaches-

Dr. Sophia:
Yeah. Headaches or vision changes. Anything that's kind of like a new onset. Like you never had this before. You're not a person who suffers from migraines. And even if you are, it should always be kind of like a thought process and like, Hey, I have a headache. It's not going away. I tried taking Tylenol. It's still not going away. What's going on? And then especially if you didn't have an issue with your blood pressure before, it might trigger the concept of, Hey, maybe I should check my blood pressure then, or maybe I need to let my doctor know I've been having a headache and I've tried to drink more water, eat and take some Tylenol, and nothing seems to be helping. It's either a reason for you to even be seen in the labor and delivery, or certainly a reason to bring that up with your physician or your provider, whether that's a midwife . You know, a nurse practitioner, whoever's taking care of you. So that way we can then start to do an analysis of what could be going on in order to, you know, rule in or rule out preeclampsia.

Touseef Mirza:
Because I haven't been pregnant, but I'm assuming that with pregnancy and all these different changes that are happening, even if you don't have preeclampsia, you probably could have headaches, right?

Dr. Sophia:
That is correct. So you can have a headache. I mean, dehydration causes a headache. Right? And pregnant women can be dehydrated because they're peeing all the time. And why even have this big conversation about preeclampsia in the first place is because of the dangers of if it progresses, becomes severe and the fact that it can happen. So all of a sudden it can lead to things such as something called eclampsia, which is when you have a seizure in the pregnancy that's related, it's a pregnancy related seizure that's like an end result of preeclampsia. Or sometimes we even think of it as its own thing, though very much connected to preeclampsia. It's a seizure that happens and it can be very severe and can lead to other strokes, and ultimately preeclampsia can even lead to death. And so it's the reason why they are so focused and hypervigilant and concerned, and it can be scary. And really the most important part is trying to identify it.

Touseef Mirza:
So preeclampsia can then evolve into-

Dr. Sophia:
Eclampsia.

Touseef Mirza:
Which we do not want

Dr. Sophia:
Absolutely. Under any circumstance.

Touseef Mirza:
Right. When we talk about the prevention of it or the solution of it is delivery, what do you mean by that?

Dr. Sophia:
I mean that your baby needs to come out and no, it doesn't mean that you need a C-section. If we are able to recognize preeclampsia in the early stages, and you happen to be at full term, because the, the thing is, is that at the end of the day, we are always managing two patients as an obgyn who delivers babies. You have both the mother and the baby as your patient. The balancing act is between a healthy mom and a healthy baby. And we don't wanna have a, a baby that's severely premature, for example, if we can avoid that, if we can avoid a baby that's born at 26 weeks, if that is the first time you are diagnosed with preeclampsia, the goal is to see, okay, can we manage your preeclampsia and for how long? So that way we can buy some time because literally every week that you stay pregnant is every week that that baby doesn't have to stay in the NICU or the neonatal ICU.

Touseef Mirza:
Which is what we want

Dr. Sophia:
We want to keep the baby out of the NICU as much as we can, but we also need to make sure that the mother doesn't develop severe preeclampsia and eclampsia and the potential for stroke and heart problems, heart disease, cardiomyopathy, and all these other things that can be related to preeclampsia.

Touseef Mirza:
So we were trying to keep the baby in the belly as long as, as long as while keeping the mom, the mother safe?

Dr. Sophia:
That is the balancing act, right? That is the balancing act. How can we keep mommy safe and how can we keep baby cooking?

Touseef Mirza:
Right. We want the baby to be as fully developed as possible.

Dr. Sophia:
So actually, and I mean to the point at least most of preeclampsia happens in the later part of pregnancy, meaning, you know, let's say over the majority happens with over 36 weeks, thank goodness. And so at that point, most of the time, I mean the baby is, in terms of development per se, fully developed. We're still very much concerned though with respiratory issues at birth. And this is why it's so important to deliver the best you can.

Touseef Mirza:
So when you say closest to term, you're saying closest to the-

Dr. Sophia:
Time to 37 weeks and beyond.

Touseef Mirza:
Okay. And usually the time in which we feel that a pregnancy is in its full term?

Dr. Sophia:
40 weeks. It's 40 weeks.

Touseef Mirza:
Okay. Yes. Just making, so between 37 to 40, that's more of a safe zone, I guess? Because at 37, if the baby comes out at 37 weeks,

Dr. Sophia:
That's what we think of as nine months.

Touseef Mirza:
It is nine months. So it is, at what point is it considered still premature?

Dr. Sophia:
Less than 37 weeks.

Touseef Mirza:
That's it. Less than, so just three weeks.

Dr. Sophia:
Less than less, less than 37 weeks. If you're 36 weeks in five days, your baby was born premature. 37 weeks and beyond is considered full term. 40 weeks is considered, is typically what we call your due date at the 40 week mark. And so really we're pregnant for 10 months or at the end of nine months. But yeah, 37 and beyond full term. And if you have preeclampsia, the goal is to make sure you don't, the pre preeclampsia just gets worse and worse and worse. It's just a matter of how quickly it progresses. And that's where the balancing act comes in. Because it requires monitoring.

Touseef Mirza:
Monitoring in order to understand, like, what I give in terms of the treatment.

Touseef Mirza:
And it, yeah.

Dr. Sophia:
How do I manage this pregnancy? Let's say a mother who presents at, you know, 32 weeks who has high blood pressure and protein in her urine. I'm going to do what I can to help this baby mature faster. You know, because the likelihood is, is that I'm gonna have to deliver this baby before we get to 37 weeks.

Touseef Mirza:
Because she has preeclampsia.

Dr. Sophia:
She has preeclampsia. That is correct.

Touseef Mirza:
So how, what do you do in order to help the baby develop faster?

Dr. Sophia:
So what we're looking at is for fetal lung, what we call fetal lung maturity, or the helping the baby have its lungs functional faster. And so we give a medication to the mom that then gets passed on to the baby, and it's a steroid that we give to the mother in order to help with the baby's lung maturity. So these are all things that we are kind of like balancing. Now, let's take for example, a mom who also has, I don't know, she can have diabetes. We have to balance the fact that what if she needs that steroid? What if it's preeclampsia ? We've diagnosed preeclampsia. It's not quite yet in the severe range where I say, okay, there's nothing more we can do. We have to get this baby delivered. Whether that's a vaginal delivery or a cesarean delivery depending on how severe and how quickly we need to deliver.

The thing is, betamethasone will help with baby's lung maturity, but in a woman who has diabetes, it has the potential to raise her blood sugar significantly. And so the balancing act there is how do I manage her blood sugar while still managing the baby? It's a constant kind of teetering,

Touseef Mirza:
It's a benefit risk and not only benefit risk.

Dr. Sophia:
Well, it's a benefit risk to whom it's a benefit risk to two people. It sometimes can be extremely nerve wracking. And it's always interesting to me because people are always like, well, just save the baby. You know, we gotta do whatever we have to do for the baby, but we have to do whatever we have to do for the mom.

Touseef Mirza:
Is it because most women at that point, they don't think that it's going to affect them as much?

Dr. Sophia:
Definitely. I definitely think there is a feeling of, well, I wanna do whatever it takes, whatever I have to do at all costs for the baby. And though that is true, we have to do the same as the same, we have to have the exact same sentiment in terms of the safety of the mother. You know, and so this is where the balancing act comes in. And this is something that happens with all the three complications that we were just, we mentioned earlier. So we just talked about preeclampsia. That also is the same concept, whether we're talking about placenta previa and whether we're talking about accidents and falls. It all matters in terms of what is the gestational age, meaning how pregnant is the patient and what is the condition of the mother and what is the condition of the baby. In order for us to decide when is a good time for us to deliver, how should they be delivered? Whether there's time for a vaginal delivery, whether there's time to do an induction for example. Or do we need to do something like a cesarean section? Because we need to have delivery immediately?

Touseef Mirza:
Induction is basically to promote the patient.

Dr. Sophia:
To promote, to provoke pregnancy, to provoke labor. Exactly. In order to hopefully get the end goal of a vaginal delivery.

Touseef Mirza:
So I wanna go back to when you said that the solution is delivery, it means that if you delivered the baby, then you will not have preeclampsia.

Dr. Sophia:
Great question. So preeclampsia is a pregnancy related disease. And so the relief of the pregnancy, meaning delivery, helps to start to resolve that issue. However, pre-eclampsia can also develop after delivery. And so that's what makes it a little bit of a conundrum. So you may actually have signs or symptoms of preeclampsia before delivery that may go unnoticed or that may not present themselves, that it's only we've delivered the baby. And then it's only afterwards do we then see continuing signs of preeclampsia. So you're still at risk, you're still at risk for the seizure, you're still at risk for the stroke, you're still at risk for heart problems and you're still at risk for death. And so that's why even in the postpartum period, it's still so important to monitor a mother's blood pressure, for example, and to look for signs and symptoms of preeclampsia, meaning the headaches, the change in the vision, the, just a weird feeling in the body at times. It could be sometimes the only thing that they say.

Touseef Mirza:
So it means that when we say the solution is delivery, it's the solution for the baby. Because the baby is now safe because it's out. But then even after delivery, the mom can still have issues with preeclampsia.

Dr. Sophia:
Now, when I say that the cure for preeclampsia is delivery, we do know that the more the mother stays pregnant in the face of preeclampsia, the worse the preeclampsia will become. So that's why we say the cure for preeclampsia is delivery. And for women who develop preeclampsia postpartum, they probably were brewing it even before, you know, meaning that that preeclampsia was already starting to brew even before they delivered. You know, but we just didn't have the evidence of it perhaps until afterwards. And yes, of course they can just completely spontaneously develop preeclampsia in the postpartum period. And in that case, we have to manage it with, you know, medications. We have to be really strategic in terms of keeping a very careful eye, both on blood pressure and on symptoms and giving them things to prevent seizure, which is something called magnesium. Because it can still happen even after delivery.

Touseef Mirza:
What is the timeframe usually like after postpartum is like after you give birth.

Dr. Sophia:
The majority of postpartum preeclampsia happens within the first three to five days. But it can still happen even three to six weeks later, which is what's so bizarre.

Touseef Mirza:
That's scary. Yeah,

Dr. Sophia:
It is.

Touseef Mirza:
So you always have to be aware of what's going on in your body if all of a sudden something is a little bit off. And notice it. Yes. And not take it for granted.

Dr. Sophia:
And not take it for granted. Bring it up to your provider, go to your postpartum visits. So many women don't go to their postpartum visits. They think, oh, I'm fine. I'm okay. Oh, I have a headache, but it must be because I'm tired because I'm up with the baby all the time and I'm not taking anything away from that. That is actually very true. Okay. But we can manage it. If we know about it, we really can manage it. And if you within yourself know that you feel like something is off or you're even thinking about it, then it's, you're more likely to bring it up to the provider or even just tell someone else in your family that can then say, I think you should go to the doctor. And that's the concept of when we say, just always kind of try your best to be in tune with yourself.

Touseef Mirza:
So what would you say is the percentage of pregnant women that develop preeclampsia?

Dr. Sophia:
So the reason why preeclampsia is so like an important condition to understand is because up to 10% of all pregnancies can actually develop preeclampsia. And then out of that two to 3% can develop eclampsia, which is so severe. And it may seem like a small number, but when we're talking about thousands and thousands of babies and, you know, thousands and thousands of moms, this becomes a much bigger problem. And preeclampsia affects 10% of pregnancies, we're still talking about moms even in the postpartum period in terms of still being able to develop eclampsia. So that's why it's so important to understand it as a condition that can happen in pregnancy.

Touseef Mirza:
And because the effects are just so severe, potentially severe. Even if you might say, oh, you know, it's just 10% and then it's even less eclampsia, it's still there.

Dr. Sophia:
Not only is it still there, but then when we even break that out even more and stratify it, it's so much more persistent and prevalent in, let's say black women for example. Okay. And so when we really bring in the concept of let's say black, black maternal health, now those numbers are even higher. So we're talking about more than just 10% of pregnancies. 10% of pregnancies is overall all pregnancies. But in terms of black mothers, that number is significantly higher.

Touseef Mirza:
Alright. So that was a good refresher of preeclampsia eclampsia.

Dr. Sophia:
Thank you as always for joining us on the Dr. Sophia ObGyn podcast. I hope you found this episode interesting and helpful. We are so excited to bring awareness to preeclampsia. Until next time. Bye.