PREGNANCY SYMPTOMS: WHAT TO EXPECT THE THIRD TRIMESTER

Almost there! The third trimester is full of expectation, as the moment you will hold the baby in your arms approaches. But the excitement comes with a lot of uncomfortable symptoms…

The third trimester lasts from the 7th through the 9th month of pregnancy, that is, from week 28 till the moment you give birth, usually around week 40. This period can be challenging and tiring, as your womb grows and creates a lot of discomfort. Most of the symptoms you will experience are those that appeared during the second trimester, although they will be more intense now: back pain, leg swelling, sleep problems, itchy skin…

But keep a positive attitude! Read this list with the most common symptoms of the last three months of pregnancy and learn what you can do to relieve them. We will focus on the symptoms that appear during the third trimester, or that are somewhat different now. This is what you can expect:

1) Abdominal muscle separation

As your uterus grows, it pushes against the abdominal wall and stretches its muscles (the ‘six pack’ muscles), which will start separating in the middle and cause a bulge, or gap  in the middle of the abdomen. This condition, called diastasis recti abdominis, is more evident when the abdominal muscles are tense, such as during coughing or getting up from a lying down position. Diastasis recti can cause lower back pain, making it difficult to carry out certain activities, such as lifting objects.

Not all women develop abdominal muscle separation; you are more likely to get it if you are older than 35 years-old, have a multiple pregnancy or carry a large baby, or have repeated pregnancies.

What can you do about it:

  • Muscle separation lessens in the months that follow delivery, although some degree of separation may remain. Certain exercises will help you regain abdominal strength after childbirth.
  • During pregnancy, avoid aggressive abdominal exercises (such as sit-ups), which may provoke or worsen diastasis recti.
  • If abdominal muscle weakness associated with diastasis recti is interfering with your daily activities, seek the advice of your care provider or a specialized physiotherapist, who can indicate certain strength and postural correction exercises.

2) Breast leakage

By the end of pregnancy, you may notice a yellowish fluid leaking from your nipples, and this is normal. This substance, called colostrum, will nourish your baby in the first few days after birth.

While some women leak quite a lot of colostrum, others don’t leak at all. Leaking won’t make any difference to how much milk you will produce once your baby is born.

What can you do about it:

  • If you just leak a few drops, then you don’t need to do anything. But if it bothers you, you may wear nursing pads inside your bra to absorb the milk.
  • You should call your doctor or midwife if the nipple discharge becomes bloodstained.

3) Carpal tunnel syndrome

Tingling, numbness, weakness and pain in the hands during the last trimester are usually caused by a condition called carpal tunnel syndrome (CTS).

CTS is common in pregnancy, and happens due to the fluid retention in the tissues of the wrist, which in turn squeezes a nerve (the median nerve), that runs down to your hand and fingers. Women that keep doing forceful or repetitive hand and finger movements (such as long hours at a computer, or the use of vibrating equipment) may have worse symptoms.

What can you do about it:

CTS usually disappears without treatment after childbirth, when pregnancy-related fluid buildup is relieved. In the meantime, you may try the following:

  • Avoid activities that may be causing symptoms.
  • Wear a wrist splint to keep your wrist straight, especially at night, when the symptoms can be more bothersome.
  • Do exercises to stretch and strengthen the muscles in the hand and arm.
  • Alternative therapies, such as acupuncture might help relieve hand pain.
  • If nothing works, talk to your doctor, who may prescribe certain medications.
  • Surgery is the last resort treatment, but unless CTS become intolerable, it will be delayed until after birth.

4) Dreams and nightmares

You knew about the sleep problems during pregnancy. But you may get surprised, even disturbed when you start getting frequent and vivid dreams, occasionally nightmares; you may also realize that you remember your dreams more clearly.

The exact reason of these changes in the dream pattern is not clear, but they seem to be related to hormonal and emotional factors, as well as the frequent sleep disruptions that come with pregnancy (read more here).

What can you do about it:

  • If your dreams are just more frequent or more vivid, you will just have to cope with them.
  • However, if you have frequent nightmares, that are too disturbing, don’t let you sleep or cause you intense anxiety, you may consider sharing them with a friend, your doctor, or a therapist.

5) Clumsiness, waddling

You may have noticed that, as pregnancy progresses, you get clumsier: things fall from you hands, you bump into doors, you may accidentally fall down! It is not just you, clumsiness is normal in pregnancy and is related to many factors: you are heavier and your growing womb changes the center of gravity, making it more difficult to move; your “pregnancy brain” makes it harder for you to concentrate on your activities; in addition, a hormone called relaxin relaxes all the joints in your body. Therefore, you won’t have the balance or dexterity you used to have.

The same reasons explain why, at the end of pregnancy, you will start waddling, which in turn will make you even clumsier!

What can you do about it:

Clumsiness is normal and there is not much you can do to prevent it. However, it is important that you take measures to protect yourself -and others- from accidents:

  • Avoid situations where you have a high risk of falling, such as standing on a ladder, using stairs, riding a bicycle, etc.
  • Wear comfortable shoes, that should not be neither too flat or too high (read more here).
  • Pay attention whenever you walk on wet, icy, or uneven surfaces.
  • Avoid gaining too much weight, which will make clumsiness much worse.
  • Call your doctor if, besides clumsy, you feel dizzy or lightheaded, your have blurred vision, headache, or any pain.

6) Emotional changes

As you get closer to childbirth, your anticipation grows, so do your anxiety, fears and concerns! Besides all the hormonal-related emotional changes, you may start getting worried about the delivery itself, as well as all the changes the baby will bring, your role as a parent, etc (see here).

What can you do about it:

  • Stay calm, mild physical activity can help (read here), eat well (here), indulge yourself with a beauty treatment! (here).
  • Taking childbirth classes can help you feel more prepared to face labor and delivery.
  • Discuss your emotions and fears with your doctor or midwife.
  • Sharing your feelings with friends, your partner or other moms-to-be can be very helpful.
  • Nevertheless, if you feel constantly down or overwhelmed, if you have negative or suicidal thoughts, if you can’t go ahead with your daily life you must discuss it with your doctor.

7) Fatigue

Forget the energy you had during the second trimester: fatigue is back! Carrying extra weight, waking up several times during the night to go to the bathroom, and dealing with the anxiety of preparing for a baby can all decrease your energy level.

What can you do about it:

  • Eat healthy, frequent and small meals: it’s a good idea to keep with you healthy snacks that you can grab whenever you feel out of energy.
  • If you work, take regular, small breaks; you may even consider taking a quick nap!
  • Light exercise can make you feel more energetic: walking, swimming or prenatal yoga are good options, but listen to your body! Don’t force yourself.
  • Check with your doctor if you feel extremely tired, so that she/he may do some blood test to rule out anemia or other problems.

8) Forgetfulness (“Pregnancy brain”)

It’s not a myth: intense forgetfulness, known as “pregnancy brain” is a normal symptom of pregnancy, which nevertheless can be very annoying!

It is mostly related to pregnancy hormones, but sleep disturbances and fatigue can make it worse.

What can you do about it:

Don’t worry! Your brain will work normally again after delivery. Well, sort of, as you will have to deal with the sleepless nights while taking care of your baby 😉

In the meantime, these tips may help:

  • Stay organized! Write down what you need to do, technology may help: reminders on your phone or to-do lists in your computer will make it easier.
  • Ask for help: cut down on what you’re responsible for by delegating some jobs to others.
  • Eat well: certain foods may boost your memory: eating plenty of choline-rich foods and DHA-rich foods during pregnancy may help boost your -and your baby’s- brain function.

9) Frequent urination, urinary incontinence

As your baby grows, the pressure on your bladder increases, causing a constant feeling you need to go to pee. This may be worse during the night, because when you lie down, the fluids you retained in your legs and feet during the day make its way back into your bloodstream and eventually into your bladder.

Many women also experience stress urinary incontinence, that is, they lose some urine when they cough, laugh, sneeze, lift heavy objects, or exercise.

What can you do about it:

To reduce frequent urination:

  • Avoid beverages that contain caffein, which has diuretic effect.
  • It’s not a good idea to cut down on fluids, as your body needs plenty of them during pregnancy. Instead, you may reduce fluid intake in the hours before you go to bed.
  • Lean forward when you urinate: this helps empty out your bladder better.

To avoid incontinence:

  • Empty your bladder before exercising.
  • Wear a panty liner to catch any unexpected leakage.
  • Kegel exercises, which strengthen the muscles of the pelvic floor, can also help minimize stress incontinence.

You should inform your doctor or midwife if you feel pain or burning with urination, if your see blood when you wipe or if you feel the urge to pee even when you produce just a few drops at a time. These could be signs of a urinary tract infection (UTI).

10) Heartburn

Another symptom you may have experienced during the first three months of pregnancy, got better during the second trimester but now came back! While the heartburn you experienced during the first trimester was hormone-related, now your enlarged uterus is to blame, as it crowds the abdomen, pushing the stomach acids upward.

What can you do about it:

  • Eat small, frequent meals, don’t eat too much before going to bed.
  • Avoid too spicy, greasy, acidic or sweet foods.
  • Don’t lie flat, sleep with two or more pillows to have your head at a higher level than your body.
  • Call your doctor if you can’t cope with heartburn, who can prescribe you an antiacid medication that is safe for pregnancy.

11) Pelvic pain

Once you’re in your third trimester, you may experience pain and pressure in your pelvic region, as the weight of your growing fetus presses down on certain nerves that run into the legs; for the same reason you may also feel tingling, numbness and pain along the outer thigh; which can be very annoying for some women.

Relaxed pelvic joints are a common cause of pelvic pain: toward the end of your pregnancy the hormone relaxin helps the ligaments become loose in preparation for childbirth. This hormone can also loosen your pelvic joint, and even cause it to separate a bit. It’s common to feel pain near your pubic bone, and you may also feel like your legs are unstable. This is called Symphysis pubic dysfunction (SPD).

Your fetus’s head can also to rub your tailbone, causing tailbone pain and pressure. The condition is called coccydynia and occasionally the pain can be very intense.

Braxton Hicks contractions can also cause pressure and tightening in the pelvis (see below). Constipation also can cause pelvic pain or discomfort (see here).

What can you do about it:

Be patient! Once your baby is born, all the pressure-related symptoms will be gone; in addition, relaxin production will cease and the joints will be firm again, easing your pain. In the meantime:

  • Get plenty of rest;  a change of position that shifts the pelvic pressure away from the nerves responsible for the pain should provide some relief.
  • Avoid lifting heavy things.
  • Warm compresses on the painful the area may ease soreness.
  • Pelvic support belts can help stabilize the area.
  • If the pain is severe enough, ask your doctor about painkillers.

12) Swelling

During the second trimester some women experience some swelling of the ankles and feet. Now, swelling – or edema will be also evident in the hands, face and upper legs.

Swelling is normal and is caused by the excess blood and fluids your body produces to meet the baby’s needs. This extra fluid will also soften the body and help it expand as the baby grows, and prepare the joints and tissues to open more easily during delivery.

Swelling is usually worse with warm weather, if you stand up for long periods of time, if you consume too much caffeine or salty foods, or if your diet is low in potassium.

What can you do about it:

  • Reduce salt intake, avoid adding extra salt to meals.
  • Avoid caffeine consumption.
  • Eat foods high in potassium (such as bananas).
  • Minimize outdoor time when it’s hot.
  • Avoid long periods of standing or sitting.
  • Move regularly your feet, or keep your legs elevated while sitting.
  • Wear comfortable shoes (read more here).
  • Avoid clothes that are tight around your wrists or ankles.
  • Wear supportive tights or stockings.
  • Get plenty of rest, swimming may also help.
  • Use cold compresses on swollen areas.

13) Shortness of breath

As your pregnancy progresses you may start feeling breathless after minimal amounts of physical exertion, or even when talking!

Mild breathlessness is totally normal; during early pregnancy is due to pregnancy hormones, which make you take more and deeper breaths, so that you get additional oxygen for the baby. But in the third trimester, shortness of breath  is mostly related to your expanding uterus putting pressure on the lungs and diaphragm, making it harder to take a deep breath.

What can you do about it:

  • Don’t overdo it with your daily activities or while exercising; when you feel breathless, slow down.
  • Make room for your lungs to take air: stand up straight, don’t sit down for long periods of time, sleep propped up on pillows.
  • If the shortness of breath is severe, you have chest pain or a quick pulse, call your doctor immediately.

14) Vaginal discharge

Increased vaginal secretions are completely normal and start during the first trimester. These discharge helps prevent infections travelling up from the vagina to the womb.Towards the end of pregnancy, the amount of discharge increases and can be confused with urine; close to delivery it may even contain streaks of thick mucus and some blood (this is called “bloody show”; we will discuss more about it in another post). Vaginal secretions should be white or clear, and should not smell unpleasant.

What can you do about it:

  • You may wear panty liners, but do not use tampons.
  • Prefer cotton underwear, avoid string or thongs that may cause intense rubbing, which together with the increased discharge can favor yeast or other infections.
  • Avoid vaginal douching (which is never a good idea, but especially during pregnancy).
  • Pay attention to washes and wipes that could be irritating, increasing your chances of a vaginal infection.
  • Call your doctor or midwife if you have discharge that is yellow, green or foul-smelling, if you have intense itching or burning, symptoms that may show that you have a vaginal infection. Likewise, call your healthcare provider if you have a lot of watery, vaginal discharge, which may signal that you broke your water bag.

15) Vulvar varicose veins

If you feel something “like worms” on your genital area, together with some pressure, swelling of discomfort in the vulva, don’t panic! These are dilated vulvar veins and occur due to the increased blood flow to the area, and the pressure the growing uterus puts on the veins of your lower body. Vulvar varicosities are seen quite often during pregnancy, either alone or with varicose veins of the legs, or hemorrhoids. Long periods of standing, exercise and sex can aggravate them. Occasionally though, they are completely asymptomatic, and the only way you’ll know you have them is because your doctor tells you.

What can you do about it:

Most of the times, vulvar varicosities don’t affect your mode of delivery, and they go away on their own after birth. If they are bothersome, you may try the following:

  • Wear support garment specifically designed for vulvar varicosities.
  • Avoid standing for long periods of time.
  • Swimming helps lift the baby from the pelvis and improves blood flow, relieving your pain.
  • Elevate your hips slightly when lying down to promote circulation; you may place a folded towel beneath your hips.
  • Cold compresses applied to your vulva may ease discomfort.

What else to expect

Baby movements

  • During the second trimester and beginning of the third, your baby has plenty of room in the womb, so most likely you will feel pushing, swirling, twisting, and kicking. But as he/she grows bigger, there is less space for movement; thus probably you won’t get the punches and kicks you were used to. Instead, you’ll feel more wiggles, stretches and turns. Although by the end of pregnancy mobility may be reduced when he gets engaged in the pelvis, the baby should keep moving until the moment he is born.
  • Keep in mind though that the baby is not constantly on the move: there are times when she sleeps. Towards the end of your pregnancy, the baby rests for about 20 minutes at a time, but occasionally the rest periods may be as long as 50 or 75 minutes.
  • Although you may have read or heard you need to count the baby’s kicks, there is a huge variation among babies, and no normal values for baby’s kicks have been determined; therefore, a written record of your baby’s movements is not necessary. Since every baby has a different pattern of waking and sleeping, what is important is to follow up on your baby’s own pattern of movements. If you notice a change in your baby’s pattern of movements, or are worried at any stage, contact your midwife or doctor, so that they can check the baby’s wellbeing with certain specific tests.
  • At some point you may not be sure whether you felt your baby kicking. Keep in mind that you’re more likely to be aware of your baby’s movements when you’re lying down rather than sitting or standing. Therefore, in the doubt, have a snack, particularly something sweet, lie down on your side and wait. You may also try making some noise, or playing loud music. If your baby starts moving around, most likely everything is fine.

But you should contact your midwife or doctor right away if you notice any of the following:

  • You don’t feel several movements while lying on your side for two hours.
  • Your baby doesn’t start to move in response to noise or some other stimulus.
  • There’s a big decrease in your baby’s movements, or a gradual decrease over several days.

Weight gain

  • You should aim for a weight gain of about 1-2 kg per month during your third trimester, but it is not unusual to lose 1 or 2 kilos by the end of pregnancy, as your stomach gets compressed by the baby and you get a feeling of fullness even with small meals. In total, you should have put on about 12 kg (8-16 kg). However, your doctor may recommend that you gain more or less weight if you started out your pregnancy underweight or overweight.
  • It is very important that your weight gain doesn’t exceed these limits, as it may lead to several complications in pregnancy and delivery, such as high blood pressure, gestational diabetes, backache or delivery complications due to increased fetus weight. Not to mention that it will be more difficult to get back to your pre-pregnancy weight…

Braxton Hicks contractions

  • Pressure or tightening in the pelvis that comes and goes could be contractions, but if they’re sporadic and not painful, they’re most likely Braxton Hicks contractions. They usually begin as early as the second trimester; however, they are most commonly experienced in the third trimester.
  • Braxton Hicks are also called “practice contractions” because they are a preparation for labor. They are irregular in intensity and frequency, usually painless or just uncomfortable (although sometimes they may be painful).
  • As Braxton Hicks intensify close to the time of delivery, they are often referred to as “false labor” and they may help prepare the uterus for delivery. These practice contractions may be more intense or frequent when you are too tired, your baby is very active, after sex or due to dehydration.

If you are not sure whether the contractions you feel are true or false labor, try the following:

  • Lie down, get some rest and wait.
  • Take a warm shower or bath.
  • Drink some fluids.

If none of these steps works at any stage of pregnancy; or if you are less that 37 weeks pregnant and you have contractions every 15 minutes or closer that persist over two hours, contact your health care provider.

Signs of Labor

When getting closer to the due date, most certainly you will start wondering: What are the signs labor is coming? How will it feel? and mainly: Will I understand when it’s time? A post answering these questions will follow soon… Stay tuned!

When to worry

Any of these symptoms could be a sign that something is wrong with your pregnancy. Call your doctor right away if you experience any of these symptoms:

  • Severe abdominal pain or cramping
  • Severe nausea or vomiting
  • Bleeding
  • Severe dizziness or fainting
  • Rapid weight gain or intense swelling
  • Fever (unrelated to a cold)
  • Pain or burning during urination
  • Watery vaginal discharge
  • Abundant green, yellow, foul-smelling discharge.

This list of not exhaustive; do not hesitate to contact your healthcare provider for any other symptom you are unsure whether it’s normal or not.

References

  • NICE: Antenatal Care- Routine Care for the Healthy Pregnant Woman. March 2008, UK
  • HAS: Comment mieux informer les femmes enceintes? Avril 2005, France

Photo credits

Intro: Flickr.com; 1) lifeopedia.com; 2) sheknows.com; 3) momjunction.com; 4) answerforsleep.com; 5) health.com; 6) Flickr.com; 7) healthymamabrand.com; 8) healthywomen.org; 9) intimina.com; 10) baby-pedia.com; 11) onlymyhealth.com; 12) medicmagic.net; 13) dnaindia.com; 14) pinterest.com; 15) amazon.com; Baby movements: babycenter.ca; Weight gain: parenthub.com.au; Braxton Hicks: birthcentered.com; When to worry: herb.co

GENITAL HERPES: ALL YOU NEED TO KNOW

Just got diagnosed with genital herpes? You are not alone! You should know that this is a very common condition, and that usually does not cause any serious health problem; however, anxiety, anger or even depression are common feelings every time the virus makes its appearance… And, as with HPV infection, misinformation makes things worse…

In this article you will find the most important facts regarding genital herpes:

Getting to know genital herpes

Genital herpes is a sexually transmitted infection (STI). It is caused by a virus called herpes simplex virus (HSV).

The herpes virus causes painful sores and blisters in the genital area, the anus, the thighs and the buttocks. Sometimes though, the HSV infection causes no symptoms at all; in fact many people are infected with HSV and don’t know it.

There are two types of HSV: HSV-1 and HSV-2. In general, type 2 affects the genital area and HSV-1 is the main cause of cold sores on the mouth or face. However, both types can cause either genital or oral infections.

How common is it?

It is estimated that 1 or 2 in 10 people (10-20%) are infected with the HSV; of those, 80% don’t have any symptoms. Genital herpes is more common in women than in men.

How did I get genital herpes? 

  • As stated before, genital herpes is sexually transmitted: the HSV is spread through direct contact with herpes sores during vaginal, oral or anal sex. The virus can be passed to others during a first infection, with subsequent outbreaks or even if there are no evident sores (see below).
  • The HSV dies quickly away from the body; thus, it’s extremely unlikely -if not impossible- to get genital herpes any other way than by sexual contact, such as from towels, toilet sits or hot tubs.
  • It is possible to get infected by sharing sex toys with a partner who has the virus.
  • Infected people can transmit the virus to other parts of their own bodies (for example if you touch your cold sore on the mouth and then you touch your genitals). This process, known as autoinoculation, although theoretically possible is extremely rare, as our body develops -in most cases- antibodies that protect us against autoinoculation.

Is there any way of knowing how long I’ve had the herpes virus?

When a person is first infected with HSV, symptoms appear about 2–20 days after the virus enters the body.

However, many people have genital herpes for years or even decades without knowing it; that is, the virus remains silent for years, and at some point it becomes symptomatic. This situation can create misunderstanding in a monogamous couple, as a person assumes his/her partner was unfaithful, which may not be true.

What are the symptoms of genital herpes?

The symptoms are different the first time and the recurrent episodes.

During the first herpes infection you may have:

  • flu-like symptoms: such as fever, chills, muscle aches, fatigue and nausea;
  • swelling of the lymph nodes in the groin;
  • stinging or burning feeling while urinating.
  • sores: initially small, fluid-filled blisters, often grouped in clusters; the area where the sores appear may be swollen and tender. Over a period of days, the sores open and release fluid, become crusted and then heal without leaving scars.

The first outbreak of genital herpes may last 2-4 weeks.

After this first infection, HSV remains in the body for life, within some specific nerve cells. Under certain circumstances (see below), the virus becomes active again: it travels along the nerves back to the genital area, and causes a new outbreak of sores. This is called a recurrence.

-During the recurrent outbreaks the symptoms are:

  • a prodrome: a burning, itching, or tingling sensation in the lower back, buttocks, thighs, or knees;
  • few hours later, sores may appear, usually without fever or swelling in the genital area.

The sores heal more quickly, within 3-7 days in most cases. Also, recurrent outbreaks usually are less painful.

What can trigger herpes outbreaks?

Although it is not always clear why or when the herpes virus will reactivate, certain factors are known to trigger herpes outbreaks. The most common are:

  • Stress: either physical (fatigue) or emotional (depression, anxiety).
  • Weak immune system: caused by sickness, infections, certain medications, etc.
  • Trauma or irritation of the genital area: due to vigorous sex, intense sweating, tight clothes, etc.
  • Exposure to sunlight or ultraviolet light.
  • Hormone fluctuations: some women may notice that outbreaks are more common right before their period, or during pregnancy.
  • Excessive alcohol consumption.
  • Certain foods: some studies (here and here) have found L-arginine, an amino acid present in food can aggravate or cause more frequent herpes outbreaks. Foods high in arginine include: nuts (almonds, walnuts, cashews, peanuts), grains (whole wheat, oats, brown rice, flour products), chocolate and caffeinated beverages.

How often will I have symptoms of genital herpes?

  • The frequency and intensity of the outbreaks vary with each person. While some people have frequent, painful outbreaks with many sores, others have only rare and mild symptoms.
  • Outbreaks usually are most frequent in the first year after infection. For many people, the number of outbreaks decreases over time.

Is genital herpes a serious condition?

  • Genital herpes is not life threatening in itself.
  • One of the biggest problems of genital herpes is the emotional burden. The fact that genital herpes causes painful symptoms, imposes certain limitations on sexual activity, and it’s a lifelong condition may lead to frustration, anxiety, anger and depression (read more here). Don’t hesitate to discuss your feelings with your doctor, who can advise you how to cope with them.
  • Having herpes sores makes it easier for HIV (the virus that causes AIDS) to enter the body. Moreover, having both viruses together may make each one worse.
  • A pregnant woman can pass herpes on to her baby (see below). Therefore, it is very important that you inform your doctor if you are pregnant and have herpes.

How can I find out if I have the herpes virus?  

If you think you have genital herpes you should consult a healthcare provider, who can diagnose herpes by performing a physical exam and certain laboratory tests:

  • If sores are present, a sample of fluid taken from a sore can show if you have the virus and what type of HSV it is. The sample may be tested with several techniques, of which cultures and polymerase chain reaction (PCR) are the most utilized.
  • Blood tests can detect the antibodies our body produces to fight the virus; these tests can show the type of HSV as well.

How is genital herpes treated?

  • There is no cure for genital herpes.
  •  However, antiviral medicationsaciclovir, famciclovir and valaciclovir – can reduce the duration of the outbreak and make symptoms less severe. There is some evidence that these drugs also reduce the risk of giving herpes to someone else.
  • When taken on a daily basis, medications can decrease or completely prevent the outbreaks. This is called suppressive therapy and is indicated, among other situations, in persons suffering very frequent outbreaks (usually more than six episodes per year).

How can genital herpes be prevented?

  • Condoms may reduce your risk of passing or getting HSV, but do not provide complete protection: areas of skin that have the virus but are not covered by the condom can spread the infection.
  • Avoid sexual intercourse if you or your partner has visible sores on the genitals; likewise, you shouldn’t receive oral sex from someone who has a sore on the mouth. Also, pay close attention to the prodromic symptoms announcing an outbreak: sexual contact should be avoided from the time you feel the prodrome until a few days after the sores have gone away.  Although less contagious, herpes can be spread even if there are no visible lesions, through a process known as shedding (means that the herpes virus is active on the skin). Unfortunately, there is no way to know when a person is shedding.
  • Wash your hands thoroughly after any possible contact with sores, in order to avoid reinfecting yourself or passing the virus to someone else.
  • In certain cases, suppressive therapy may be proposed to reduce the risk of passing the infection to your partner.
  • Once you got the virus, avoiding known triggers may reduce the frequency and intensity of outbreaks: a good diet, enough rest, stress management may all help.

Will herpes affect my pregnancy or my baby?

  • If you are pregnant and infected with HSV you may pass it to your baby, who may eventually develop a severe infection called neonatal herpes.
  • Although the virus may rarely spread through the placenta, most babies get infected during a vaginal birth, with the passage through the infected birth canal (vagina).
  • This is most likely to occur if you first become infected with HSV during pregnancy and if you have your first outbreak late in pregnancy. It is possible to transmit the virus even if you were infected before pregnancy and you have a recurrent outbreak near delivery, but the risk is much lower.
  •  In certain cases, you may be offered herpes medicine towards the end of your pregnancy to reduce the risk of having any symptoms and passing the virus to your baby.
  • If you have sores or warning signs of an outbreak at the time of delivery, you may need to have a cesarean section to reduce the odds of infecting your baby.

Can I breastfeed my baby if I have the herpes virus?

  • In most cases you will be able to breastfeed; in fact, herpes virus is not transmitted through breast milk.
  • Whether you breastfeed or not, the baby may get infected by touching a sore on your body. To avoid spreading the virus, cover your sores and thoroughly wash your hands before holding your baby. If you have a herpes blister on your breast don’t nurse from that side until the area has completely cleared up.

 

References

Centers for Disease Control and Infections: Genital Herpes: CDC Fact Sheet (USA)

The American College of Obstetricians and Gynecologists: Genital Herpes (USA)

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 3)

In the Part 1 of Home birth: Smart choice or risky business? we analyzed the issues of personal satisfaction, maternal safety and baby’s risks. Part 2 dealt with hospital transfers, water birth and the situation in the Netherlands. Check out the last three reasons women choose home birth, and read the final conclusion to decide whether home birth is a clever or a dangerous option…

7) Home birth is cheap

home-birth-call-the-midwifeHome birth is cheaper… provided that no transfer is needed and nothing goes wrong

Cost-effectiveness is an important issue in every country with an organized health system. Countries like England or the Netherlands, where the National Health System (NHS) covers the cost of deliveries, have calculated that is cheaper that women deliver at home, avoiding a more expensive hospital admission. For example, the UK NHS “prices” home birth £1066 and birth at a hospital £1631. The economical factor is one of the reasons certain professional organizations support home labor, such as the Royal College of Obstetrics and Gynaecologists (RCOG) which states that: “home birth is the most cost-effective place for delivery”.

But this cost analysis has been challenged, as it does not take in consideration the high transport rates; in fact, a Dutch report calculates a general 3-fold increase of costs in patients transported during labor, when the costs of the midwife, the transport system, the obstetrician and the hospital are included. In addition, the costs derived from the maintenance of an adequate transport system (ambulances and trained staff) should not be neglected. Assuming increased neonatal risks, admissions to the neonatal intensive care unit, the lifetime costs of supporting neurologically disabled children and potentially increased professional liability costs resulting from a complicated home birth can potentially inflate the costs.

Indicative of these unexpected expenses is the article Home birth: What the hell was I thinking?  A journalist from The Guardian went on a mission following a home birth. After managing to deliver her child at home, both the woman and her baby had a complication and needed to be transferred to a hospital. Since the baby and the mother were not allowed to be in the same ambulance, two ambulances were required…

Regarding the costs arising from a private home birth, the situation varies in different countries; in the USA home births are not covered by health insurances, and a couple is expected to pay $1500 to 4500 to the midwife. Hospital births can range from $3,296 to 37,227, although they are usually covered totally or partially by the insurance. Of note: a doctor gets paid about $2500-4000, same as a midwife. Ιn Europe, a couple is expected to pay about 2000-3000 €; recently the Italian newspaper La Stampa published the article Home birth: a 3000 €  luxury that does not convince doctors.

8) “Birth is not a disease, it’s a natural thing. Mother nature can’t go wrong”

home-birth-birth-in-natureUnassisted childbirth: don’t try this at home – or anywhere else

Indeed, Mother nature is great. If you think about it, the whole process of labor and delivery seems to be so perfect, almost magical… But “natural” is not a synonym of “risk-free”. Sometimes Mother nature can play strange games. We may believe we have everything under control, but things may flip just in a second: think earthquakes, or tsunamis… Exactly the same thing applies to childbirth: even when someone seems to be “low risk”, disaster can strike without any warning …

Childbirth is inherently dangerous,” writes in her blog Amy Tuteur, an American obstetrician gynecologist. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood”. Finally, she adds: “Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”

The absolute confidence in a woman body’s ability to deliver is expressed by supporters of unassisted childbirth (UC), the “hard core” version of home birth, which, although practised already since the 70s, it has lately seen a resurgence. Also known as freebirth, DIY (do-it-yourself) birth, unhindered birth, or unassisted home birth, it refers to women that intentionally deliver without the assistance of a physician or midwife; they may be completely alone (“solo birth”) or assisted by a lay person, such as the spouse, family, friend, or a non-professional birth attendant. There are no data on safety of UC, except that coming from a religious group in Indiana (USA) that found a perinatal mortality rate 2,7 times higher, and a maternal mortality rate 97 times higher than the state average.

Among the most famous UC advocates is Janet Fraser who, ironically, lost her baby after five days of home labour; in spite of that she continues to advocate for freebirth. In fact, UC is not endorsed by any scientific organization, as it is considered too dangerous. According to André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC):“Freebirth is the equivalent of playing Russian roulette with your child”.

9) I have the right to deliver wherever I want

home-birth-collageA home birth oxymoron: right to privacy vs. social media exposure

This is a very complex issue with ethical and legal connotations, which has originated intense debate among experts. Even scientific organizations differ in their recommendations. For example, The American College of Obstetricians and Gynecologists, until recently opposed to home births, has decided to temper its position: “…hospitals and birthing centers are the safest setting for birth, but it respects the right of a woman to make a medically informed decision about delivery.” On the other side, the American College of Nurse-Midwives (ACNM) maintains that “every family has a right to experience child birth in an environment where human dignity, self-determination, and the family’s cultural context are respected” and that “every woman has a right to an informed choice regarding place of birth and access to safe home birth services”. Let’s analyze the ethical and legal aspects of home birth:

Ethical issues

These are some of the ethicals dilemmas related to home birth:

Mother vs child safety. Although hospital birth seems to increase maternal interventions in all studies (apparently without increasing severe risk), the baby’s safety remains a subject of debate; taking though in consideration all the studies, there seems to be increased risk for the baby. Let’s take for example the Birthplace study (which is in somewhere in the middle). This study found that, particularly for first time mothers, the baby’s risk is 3 times higher (of which more that half of the cases are death and brain damage). Is it ethically acceptable for a woman to value her birth experience over her baby’s welfare? Is maternal emotional wellbeing so important to justify risking the baby’s health?

Respect for dignity and privacy. “Dignity” may have a different meaning for each person. Some home births supporters feel that the presence of a doctor and the hospital staff make them feel “degraded”; moreover “for some women the possibility of the loss of privacy is a major issue, because privacy is a valued possession”.

Is it not contradictory that so many women, zealous advocates of home birth and their right to privacy, do not hesitate to publish their home birth photographs and videos -some of them with incredible details- in every social media site, where they are exposed to the eyes of millions of people?

Self-determination. In order to make truly informed decisions about childbirth options, women need to be informed of what they are and have the possibility to discuss them. Is it ethical to offer the option of home birth knowing that there is increased risk for her baby? 

In theory, the person informing the pregnant woman should inform her objectively and avoid being paternalistic. The problem is that, informed decision-making implies accurate assessment of risks and benefits, but the safety of home birth remains debatable. Is it possible to inform objectively a pregnant woman about home birth? Or the information will be biased according to the health care provider beliefs or experiences?

Other possible ethical issues:

  • In the home birth situation, are a woman’s reproductive rights and medical responsibility incompatible with each other?
  • Where do a woman’s rights end and medical responsibility begins, especially considering that the physician is also responsible for the baby’s welfare?
  • In case of a baby adverse outcome that could have been prevented in a hospital setting, what will be the psychological consequences for the couple?
  • What is the psychological burden of a home birth in a family’s older children witnessing a home birth? What if a complication occur in their presence?

Legal issues

Legal issues can affect a woman’s decision to give birth at home in different countries. In certain places, home births are restricted, and even possibly criminally punishable, and family homes have been turned into crime scenes when women who have opted for homebirths experienced complications. In others countries, there are no regulating laws.

In Europe, the European Court of Human Rights (ECtHR) ruled in 2010 that Hungary had violated Article 8 of the European Convention on Human Rights (ECHR) because it had interfered with a woman’s right to choose where to give birth. Ms Ternovszky wanted to give birth at home but argued that she was prevented from doing so because a government decree dissuaded health care professionals from assisting home births. This case was the first decision by an international human rights organization on the right to choose the circumstances of giving birth, and was heralded by home birth advocates across Europe.

However, in a recent case against the Czech Republic, the Human rights judges decided that national authorities of each country has “considerable room for manoeuvre” when regulating home births, a matter for which there is no European consensus and which involves complex issues of health-care policy as well as allocation of State resources.

So, is home birth a smart choice or a risky business?

The Monty Python satirize the medicalisation of childbirth in The Meaning of Life

As an obstetrician who supports natural birth, I hear many times the women’s complaints about the excessive medicalization of childbirth. And I feel that sometimes they are right. However, being a mother myself, I never regretted my choice of a hospital birth for my children. After having helped so many women deliver their babies, I have seen many times complications that were totally unpredictable. Occasionally, these sudden complications are so serious, that we have to run -literally- from the delivery room to the operating room to save the baby or the mother! Therefore, even when having skilled professionals attending your home birth, even in countries with very organized structures, the distance to a hospital can prove fatal. Is for this reason that, in my opinion, a hospital birth is without any doubt the best choice for every woman. A birthing center attached to a hospital may also be a good choice.

True, the studies results are controversial, but for me “almost as safe as a hospital birth” is not enough to make me change my mind.

True also, a hospital birth is related to more epidurals, cesarean sections, instrumental deliveries and episiotomies. Regarding the epidural, if you can do it without one, that’s great! But sometimes labor pain is unbearable, and it’s not uncommon to see women without any pain relief who, when the moment to push comes, they are so exhausted and their pain is so overwhelming that they literally lose it. On the contrary, women with an epidural can be more focused and relaxed. The bottom line is: natural birth is not for everybody. And women don’t have to feel guilty because they chose to have an epidural. It’s better to have nice memories of your birth, and for that the epidural can help!

Whether too many cesareans sections are being done is a topic more controversial than home birth itself, and it would deserve a separate article. But what I can say is that, when cesarean sections are done in a judicious way by a conscious physician, they can save your life and your baby’s life. Since hospital births result in better neonatal outcome, it is clear to me that most interventions are an inevitable trade-off to save more babies or to avoid severe damage. The same goes for the controversial fetal monitoring, which may lead to more cesarean sections, it may not decrease perinatal mortality, but it reduces by 50% the risk of  brain damage. Personally, I would do anything in my power to reduce the chances of having a brain damaged baby.

Of course, a lot that should be done -and can be done- to improve hospital birth: create home-like conditions to help women be relaxed and empowered, allow women to walk during labor, give them possibility to push and deliver in any position they wish, avoid unnecessary interventions such as systematic episiotomies, etc. I believe that some efforts are slowly being done worldwide, but we still have a long way to go!

In conclusion, a woman has the right to choose where to deliver; however, until the risks are clarified, maternal wellbeing may undermine the child’s welfare. Therefore, in my opinion, a natural hospital birth is the safest choice. Natural hospital birth IS possible! You just need motivation and a supportive team…

Hospitals should increase their efforts to provide women with a friendly environment so they can deliver their babies in comfort and total safety. Every baby is precious, every mother is precious!

Photo credits

7) screenterrier.blogspot.gr; 8) news.com.au; 9) vimeo.com, Wikimedia Commons, thebirthhour.com, Flickr.comvimeo.com, homebirthaustralia.orgmindfulmamabirth.comFlickr.comhuffingtonpost.co.uklifedaily.com

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 2)

In the first part of this article we analyzed three important issues related to home birth: personal satisfaction, the mother’s safety and the baby’s risks. Check out the next three reasons women choose a home birth…

4) “I plan to have a home birth, but if something should happen I will go to a hospital

home-birth-preparing-for-home-birthEven when properly prepared for a home birth, transfer to a hospital is commonly required

As previously mentioned, hospital transportation is a common event: about 1 out of 2 first time mothers and 2 out of 10 second or subsequent time mothers need to be transferred to a hospital; moreover, hospital transfer is almost always perceived by the couple as a negative and disruptive experience (see part 1).

The need for transportation to a hospital can occur before, during of after birth, and can be related to the mother, the baby or both. The top reasons may vary in different countries, although prolonged labour is the first cause of transfer in almost every study, followed by pain relief or the midwife’s unavailability at the onset of labor.

In the UK, the most common reasons for transfer are:

  • Prolonged labour (32.4%)
  • Meconium staining (12.2%)
  • Repair of a perineal tear (10.9%)
  • Abnormal fetal heart rate (7.0%)
  • Retained placenta (7.0%)
  • Request for regional analgesia (epidural, spinal) (5.1%)
  • Neonatal concerns (postpartum) (5.1%)
  • Others (20.1%)
Australian Caroline Lovell died of complications after giving birth to her daughter in a pool. Justice found that her death was preventable.

Home birth activist Caroline Lovell died of complications after giving birth her second child at home. Her death was preventable, justice says.

Other reasons include:

During labor: maternal fever, fetal malpresentation, shoulder dystocia (baby’s shoulders getting stuck inside the mother), cord prolapse, uterine rupture, acute bleeding, placental abruption, vasa previa, acute sepsis.

After birth: tears of the vagina or cervix, sphincter rupture, uterine atony, placenta accreta, increta, or percreta.

Baby-related (post partum): unexpected very low or very high birthweight, neonatal depression, signs of respiratory distress, unexpected malformations, acute sepsis.

These are some important facts to keep in mind:

  • Maternal and fetal necessity for transport is often impossible to predict.
  • For unpredictable, extremely sudden complications, even rapid transport may not prevent the baby or the woman from death or severe harm, such as shoulder dystocia, sudden cardiopulmonary arrest, or maternal exsaguination (bleeding to death, read Caroline Lovell story here).
  • Women with severe hemorrhage  may already be in shock when arriving at a hospital. Even though the adequate treatment can be immediately instituted, death may nevertheless occur.
  • Perinatal mortality is higher when transport to the hospital is required.

5) At home I can have a water birth

home-birth-poolThe latest years there has been an increasing demand for water birth

Immersion in water during labor and delivery, although available for several decades, has seen a greatly renewed interest the latest years. In fact, even certain hospitals and birth centers have incorporated birth pools to their facilities. The results of studies analyzing maternal and fetal benefits and risks of water birth are inconsistent, and many times contradictory. The American College of Obstetricians and Gynecologists (ACOG) has just reviewed the subject and a few days ago (November 2016) published an updated statement. What are then the proposed pros and cons of water birth?

home-birth-waterbirth-babyThe benefits

For the mother. A Cochrane study  found the following results:

  • Less need for regional analgesia (epidural, spinal, or paracervical; studies show a slight reduction, RR 0.90; 95% CI 0.82–0.99)
  • Shorter duration of the first stage of labor (32.4 minutes shorter in water immersion)
  • Improvement in satisfaction among those women delivering in water.
  • Studies results are contradictory regarding the reduced occurrence perineal tears (including third-degree and fourth-degree lacerations) and need for episiotomy.
  • One study found less antepartum transfers to hospitals, both from home and midwifery birth units.

Other possible benefits: Increased feelings of relaxation, warmth, privacy, improved ability to maintain control during labor (here, here, here).

For the babySupporters of water birth believe that the transition to the outside world is less traumatic for babies born in water as the warm water of the pool may feel like the amniotic fluid; thus water-born babies are supposedly calmer than babies born in air. In fact, no benefits for the newborn were found with maternal immersion during labor or delivery, neither in 2 systematic reviews including 12 studies and 29 studies respectively, neither in the 2009 Cochrane systematic review, or any individual trials included in ACOG’s review.

home-birth-water-birth-realThe risks

For the mother. ACOG’s review did not find increased risk for maternal infections or postpartum hemorrhage. However, this conclusion must be tempered by the lack of data on rare serious outcomes, such as severe morbidity and mortality.

For the baby. Most studies found that immersion during labor does not increase fetal or neonatal risk. However, concerns have been expressed that immersion during delivery may predispose the infant to potentially serious neonatal complications. Several studies have reported several serious adverse outcomes among neonates delivered in water, these include :

  • Infection: cases of severe infections with certain bacteria, mainly Pseudomonas aeruginosa (here, here) and Legionella pneumophila (here, here, here, here) have been observed, some of which were fatal. The bacteria causing infections my come from the woman’s body, the water or the pool itself. Recently, a fatal infection by a virus (adenovirus) was reported in a baby born from a mother with gastroenteritis giving birth in a pool.
  • Water aspiration (drowning or near-drowning): it has been claimed that babies delivered into the water do not breathe or swallow water because of the protective “diving reflex”; however, it has been demonstrated that in compromised newborns the diving reflex is overridden, leading to gasping and aspiration of water. Actually,  it seems that even healthy babies may be at risk of water aspiration, which may result in hyponatremia and seizures.
  • Umbilical cord avulsion (cord “snapping” or cord rupture): this complication may happen in 1 out of 288 water births and occurs when the baby is lifted out of the water; in some instances the affected newborns have required intensive care unit admission and transfusion.

Other possible inconvenients:home-birth-bloody-water-birth

  • The mess: setting a pool at home may be messy and even challenging in certain situations, such as living in a small apartment.
  • Unpleasant environment: women may feel uncomfortable about accidentally defecating in the pool; which, as stated above, may also predispose the baby to severe infections.
  • Disappointment with pain relief: for some women, immersion in water is not enough to relieve pain.
  • Monitoring and emergencies: it may be difficult to quantify blood loss (see photo); in cases of concern about the baby’s heartbeat, monitoring may be difficult; moreover, in the event of a severe maternal complication (such as fainting or heavy hemorrhage) it may be difficult to move the pregnant woman out of the water.

Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water. According to ACOG, immersion in water during the first stage of labor may have benefits for the mother and may be offered to healthy women with uncomplicated pregnancies; however, there are insufficient data regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, “it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water”. The British National Institute for Health and Care Excellence (NICE) recommendations are in agreement with the ACOG.

6) In the Netherlands women have been delivering at home for more than fifty years

home-birth-netherlands-1948The Netherlands has the highest percentage of home births in the Western world

The Netherlands is a country with a long tradition of home birth, with well-trained midwifes, organized transport system and short distances to hospitals. However, it is one of the few countries in the world where the incidence of home births is decreasing: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to about 20% in 2013. Moreover, Dutch women have to pay an extra amount (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician or a midwife (here). According to Professor Simone Buitendijk, head of the child health programme at the Netherlands Organisation for Applied Scientific Research, “… home birth rates have dropped like a stone. Soon, there will not be enough demand to justify the infrastructure” she says. “Then the system will collapse – and let there be no misunderstanding: we won’t be able to rebuild it”.

This drop in home births seems to be related to the increasing awareness of the media, patients, and obstetricians about the risks of home birth (here). Even more skepticism originated the results of the Euro-Peristat studythe Netherlands is one of the countries with the worst perinatal outcomes of Western Europe.

 

Read the third part here:  Home birth: smart choice or risky business? (Part 3)

Photo credits

4) birthbootcamp.com, dailymail.co.uk; 5) flickr.commthoodwomenshealth.compopsugar.comgravidanzaonline.it; 6) currystrumpet.com

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 1)

home-birth-bw-flickr-resized

Home births have been, for a long time now, the subject of endless controversy and polarized discussions among physicians, midwives and strongly opinionated women. Indeed, the idea of giving birth at home sounds attractive. With the growing  interest for an “all natural” lifestyle, natural home birth looks like a logical way to go. What’s more, celebrities are doing itand midwives are becoming a status symbol!

home-birth-gisele-pregnant-resizedEven mass media has embraced the trend: since 2008, when the documentary The business of being born was aired in the USA many women were “converted” to fanatic home birth supporters. This documentary follows a New York midwife who delivers babies at home, while it “uncovers” -what they consider- the major business childbirth has become for doctors and hospitals. In the UK, the series Call the midwife, with its empathetic view of midwives have experts hoping that “it will spark a resurgence in home births…as women see the holistic care that midwives can deliver”.

home-birth-business-of-being-bornAnd all this “campaign” seems to have worked! Home births have seen a considerable increase in many countries, including the USA, Canada, UK and Australia.

So why the fuss about giving birth at home? Why do women want to deliver like in the 1900s? The answer to these questions is not straightforward…

While reviewing the bibliography on home birth, I realized how massive the amount of information on this subject is, both in scientific and lay sites, and how contradictory it becomes sometimes…

If you are considering home birth, check out this article where I analyze the reasons women choose to have their child at home. In order to simplify reading, I divided it in three parts; read all three so that you can make your responsible and educated choice.

1) “A delivery at home is a wonderful experience”

                          Satisfaction is home birth’s raison d’être

There is no doubt that birth is a unique, life-changing experience for every woman, and no one can deny the importance of the emotional and psychological aspects of a bringing a child to the world. As mentioned earlier, the reasons women choose a home birth are many: some women feel that the privacy of their home will make them feel more comfortable, less stressed out, and with more control of their own labor. Others find that being surrounded by friends, relatives, or their older children is of utmost importance. Finally, many woman choose home birth out of curiosity, as they have heard so many stories about amazing, empowering, ecstatic, or even “orgasmic” home births. Actually, personal satisfaction seems to be the main reason women want to deliver at home.

home-birth-transfer-primiparousBut is home birth always this pleasurable, fantastic experience women expect?  Unfortunately, this is not always the case. According to Birthplace, a recent British study, a high percentage of women will need a hospital transfer: up to 45% of first-time mums (nulliparous) and 13% of second and subsequent time mothers (multiparous) were transferred to a hospital. Similar figures are reported in the Netherlands, a country with a long tradition of home birth: 49% of primiparous and 17% of multiparous women are transported during labor. Most of the times, transfer to a hospital is not a great experience for the couple, as their expectations for a home birth are not fulfilled; this has been uniformly demonstrated by several studies from different countries (such as Sweden, Netherlands and Belgium). Moreover, a Dutch study evaluating women’s views of their birth experience 3 years after the event revealed persistent levels of frustration, including serious psychologic problems, in transported women compared with those who delivered at a hospital.

home-birth-transfer-multiparous

There is another fact we should not ignore: labor is inherently painful. Even though at home women may be more comfortable and this may result in less pain, sometimes it may be impossible to cope with pain and an epidural may be necessary. Pain relief is actually one of the most common reasons for transport to the hospital, since pain can become overwhelming, In fact, a recent study showed that inability to control labor pain may increase the risk of developing postpartum depression.

2) “Home births are safe for the mother”

home-birth-painfulHome births result in less interventions, including pain relief…

Besides personal satisfaction, another common reason women choose home birth is because it’s less invasive. The dreadful “cascade of events“, that is, one intervention leading to another during a hospital birth fills with terror most home birth supporters. Indeed, almost every study shows that home births are associated with less interventions as compared to hospital births. The term “interventions” includes: epidural anesthesia, ventouse or forceps delivery, cesarean section and episiotomy (see also here, here and here).

Another controversial intervention that has gained a bad reputation among home birth supporters is continuous fetal monitoring, as they think that it is not needed, it gets in the way of the natural birthing process and it increases interventions such as cesarean section and forceps delivery. But what is the scientific evidence on this subject? According to a Cochrane review, the use of fetal monitoring increases the cesarean delivery rate, vacuum and forceps operative vaginal delivery; in addition, fetal monitoring does not seem to reduce perinatal mortality, neither cerebral palsy risk; however, it reduces by 50% the risk of neonatal seizures, that is, of brain damage.

home-birth-helpBut while some women may experience fetal monitoring, episiotomy or vacuum delivery as a traumatic experience, others may not get particularly bothered by an episiotomy -and many will feel blessed by the epidural “intervention”. So maybe a more important question is: What about severe maternal complications and maternal deaths? In regard to this matter, there is not much information, and the studies’ conclusions are contradictory. A Dutch study  looked at “severe acute maternal morbidity” (such as admission to intensive care unit, uterine rupture, blood transfusion, etc) and found that women who delivered their first baby at home had the same risk with women delivering at a hospital, but parous women had increased risk of postpartum hemorrhage and blood transfusion when delivering at a hospital; however, another study, also from the Netherlands, did not confirm these findings. Therefore, a hospital birth leads to more interventions, but it does not seem to increase the risk of serious maternal complications. Regarding maternal deaths, they are a rare event; thus it is not possible to draw conclusions from the studies.

There is something that every woman considering home birth should understand: the studies results apply only to very low-risk pregnancies. Higher risk women, such as those with twin pregnancies, previous cesarean sections, prematures, post term pregnancies, were excluded from most studies, although it is no secret that they are also having home births (it’s easy to realize it just by checking the social media…). It is certain that for these women the risks is much higher, not only for them, but also for their babies.

3) Home births are safe for the baby

A healthy baby and a healthy mother are supposed to be a birth’s ultimate goal…

Studies analyzing the baby’s risk yield completely different results according to the country they were done, but they also differ in different areas of the same country, or according to the scientist analyzing the data! In here, I mention the most important studies evaluating neonatal risk by country of origin:

home-birth-canada-babyCanada: A recent study showed that planned home birth was not associated with a difference in serious adverse neonatal outcomes as compared to hospital births (Hutton et al, 2016). This study was limited to the Ontario area, had very strict inclusion criteria and high transport rates (see below).

home-birth-dutch-pregnantThe Netherlands: The Netherlands are usually considered the “gold standard” due to their long tradition in home births. In 2009, de Jonge  showed that home birth does not increase the risk of perinatal mortality and severe perinatal morbidity among low-risk women. However, some aspects of this paper may have underestimated the risk (e.g.,  paediatric data on intensive care admissions was missing for 50% of non-teaching hospitals, among others). In fact, a subsequent Dutch study showed that infants of pregnant woman at low risk under the supervision of a midwife had 2,3 times higher risk of perinatal death than infants of pregnant women at high risk  under the supervision of an obstetrician. Moreover, infants of women who were referred by a midwife to an obstetrician during labor had a 3,66 times higher risk of delivery related perinatal death than women who started labor supervised by an obstetrician (See below for more details on home births in the Netherlands).

home-birth-british-babyEngland: A 2011 large study, the Birthplace study showed that, for low-risk women,  home birth had 60% higher chances of “baby events”. The events included death (13%), neonatal encephalopathy (brain damage due to lack of oxygen, 46%), meconium aspiration syndrome (the baby swallows stools, a sign of suffering, 30%), brachial plexus injury (damage of the nerves of the arm, 8%), fractured humerus or clavicle (4%); if the analysis was restricted only to nulliparous women, this risk was almost 3 times higher. For multiparous women (2 or more children), there were no significant differences in the incidence of adverse outcome by planned place of birth.

home-birth-australian-babyAustralia: in a paper by Kennare et al, although there were no differences in perinatal mortality, home birth was associated with 7-times higher risk of intrapartum death, and 27-times higher risk of death from intrapartum asphyxia (lack of oxygen). Interesting enough, one of the authors (Dr. Keirse) was the chairperson of the working party that developed the Policy for Planned Birth at Home in South Australia.

home-birth-american-babyUSA: The largest American study comparing home and hospital births was published in 2013, including data on more than 13 million births. This study indicated that babies born at home are 10 times more likely to be born dead and have almost 4 times higher risk to have neonatal seizures or serious neurological dysfunction (that is, brain damage) when compared to babies born in hospitals. Moreover, the risk of stillbirth in women delivering their first baby at home was 14 times the risk of hospital births. Dr. Grunebaum, one of the authors, explains that most likely the risks are even higher than that: “… the outcomes for patients whose care began out of the hospital but were then transferred to the hospital due to complications are reported as hospital deliveries. If the data were corrected, the risk of out-of-hospital delivery is likely to be much greater.” Another American study confirmed these findings, which, contrary to the British study, showed that the neonatal outcome was worse both for nulliparous and multiparous delivering at home.

home-birth-international-babyPooled data from USA, Australia, Switzerland, Netherlands, Sweden, Canada & UK: A study by Wax et al. showed that home births are associated with a risk of neonatal death three times higher as compared to hospital births. The results of this study led the reputed medical journal The Lancet to write an editorial stating “Home birth: proceed with caution”. Wax’s study though was highly criticized on methodological grounds.

Why such a disparity in the results of the different studies?

There are many possible explanations:

  • The lack of randomized trials, as it is not possible to force women to deliver at home or at a hospital against their will. It is clear from different studies that women delivering at home are different from those delivering at hospitals (usually home birthers are more educated and come from a more socioeconomically advantaged area); populations may also differ from country to country.
  • Underreport. In many home births studies there are missing data; in others home births that were transferred to hospitals are included in the hospital group.
  • Midwives’ training. In most European countries and Canada, home births are attended only by midwives or physicians; midwives have a university degree and undergo intensive training. In most states of the United States, besides certified nurse midwives (with formation equivalent to European midwives), births are also attended by “direct-entry midwives” with no university degree and diverse training; the only requirement for them to practice is a high school degree.home-birth-all-babies
  • Eligibility criteria for a home birth. Studies with good outcome had very strict inclusion criteria for home birth, that is, they excluded women with twin pregnancies, preterm labor, preeclampsia, etc.
  • Transport rates. Best outcome was associated with a very high transportation rate: about 40-50% for nulliparous, 10-20% for multiparous. On the contrary, the US studies -with more adverse results- report overall transportation rates of about 10%.
  • Efficiency of transport system, midwives’ integration to hospitals. Rapid availability of ambulances -such as the so-called Obstetric flying squad in the UK- and hospitals in tight collaboration with midwives working in the community seem to be essential. But even so, some complications may not be solved, even by the most efficient form of transport.
  • Distance to the hospital. Although shorter distance to hospital seems to be crucial, even this may not prevent certain complications. Hospitals have what is called the “decision to incision” rule, that is, the maximum time that should pass between the decision to make an emergency cesarean section and the time it is actually done. This rule is 20 or 30 minutes, according to different countries. It is clear that this time frame cannot be achieved with home birth, not even with close distance to a hospital.

 

Read the second part here:  Home birth: smart choice or risky business? (Part 2)

Photo Credits:

Intro: Flickr.comPinterest.comWikipedia.org; 1) Gettyimages.comwhich.co.ukwhich.co.uk; 2) booshparrot.com, herb.co; 3) Flickr.commoveoneinc.com, Pinterest.com, sheknows.com, blogqpot.combabynames.allparenting.com,  mercatornet.comlaineygossip.com

WHEN SEX IS PAINFUL: 8 COMMON PROBLEMS – AND HOW TO FIX THEM

Sexual intercourse is supposed to provide pleasure, satisfaction and fulfilment. We -particularly women- tend to expect flawless, movie-like sex, romantic, luscious or passionate, with music playing in the background! Well, in real life sex is not always that perfect: according to an American survey, about 1 out of 3 women reported pain the last time that they have had sex. What’s more, many women feel ashamed to talk about it, giving up the idea of pleasurable sex. It is not unusual for these women to avoid having intercourse, leading to couple conflicts and eventually to psychological problems…

But why so many women feel pain while making love?

Whether it happens each time or occasionally, you feel just some discomfort or unbearable pain, dyspareunia (painful intercourse) can be related to a gynecological or medical problem, to your emotions or your state of mind; occasionally your partner is to blame, or maybe both of you, let’s not forget that it takes two to tango!

Below you will find 8 common painful situations you may encounter during intercourse. Understanding the type and location of the pain will help us pinpoint its cause, so that you can take some measures to get over it!

Problem # 1: “I feel a burning sensation outside the vagina”

painful-intercourse-burning-loveYou may feel a painful, burning sensation in your vulva (the external genitals), the area may be red and eventually swollen.

Possible causes:

  • Yeasts or other infections: a yeast infection will cause “cottage cheese-like” discharge; other bacteria can produce yellow or green discharge which may also be foul-smelling.
  • Contact dermatitis: you may realize that the problem starts after using certain lubricant, soap or cream, laundry soaps or softener; certain clothes can also be responsible.
  • Allergic reaction to condoms: the burning feeling starts after having sex, usually within 48 hours.
  • Menopause: although menopause generally causes vaginal dryness, some women also feel intense burning, which gets worse with intercourse.

What to do about it:  

  • Check with your doctor, who can give you a treatment for your yeast infection, if you are prone to get them, over-the-counter medications are available.
  • In the doubt, your doctor may order a culture, to see which bacteria is responsible for your symptoms.
  • In case of dermatitis or allergic reaction, stay away from possible irritants, your doctor can prescribe you a cream to soothe discomfort.
  • If you are allergic to latex (the material condoms are made of), stick to non-latex condoms.

Problem # 2: “I have a painful bump in my vulva”

painful-sex-bumpYou may feel a sharp, localized pain; while trying to precise its location you may touch a “bump” in the vulva. If you look with a mirror you may be able to identify the spot. Sex, due to rubbing, will make it even more painful.

Possible causes:

  • Pimple or ingrown hair: these are the commonest “bumps” appearing in the genitals. They can be quite sore if they become infected. A clogged sweat gland can also cause a painful pimple.
  • Bartholin gland cyst: they are soft cysts arising at the opening of the vagina. They can be very large (like a walnut) and become extremely painful if they get infected.
  • Herpes: genital herpes is a sexually transmitted infection. It causes itchy, burning and painful lesions that often start as a sore spot, becoming over a few days one or several blisters. Read more here.
  • Other dermatological or medical problems: rarely, diseases causing genital ulcers may be the cause of pain.

What to do about it:

  • Check with your doctor if you are not sure what is causing you pain.
  • Pimples may require a local cream to relief pain. If they are infected antibiotics may be necessary; more rarely incision and drainage are needed.
  • Bartholin cysts are treated with warm sitz baths. If infected antibiotics, incision and drainage may be necessary.
  • Herpes is managed with antiviral medications (locally or by mouth), painkillers may also be required.

Problem # 3: “I’ve tried everything, but penetration is impossible and triggers excruciating pain”

painful-intercourse-obstacleYou were never able to have penetration; even introducing tampons is impossible because you feel there is an “obstacle”.

Possible causes:

  • Hymen problems: you hymen may be abnormally thick, or imperforate.
  • Vaginal problems: your vagina can be too narrow or have a septum.
  • Vaginismus: see below.

What to do about it:

If penetration was never possible, check with your doctor who can rule out any anatomical problem; most of them can be solved with a simple surgical intervention.

Problem # 4: “I have intense pain in the opening of the vagina during penetration”

painful-intercourse-pins-and-needlesEven if you are aroused and willing to have sex, penetration triggers an intense pain in the entrance of the vagina; this is called entry dyspareunia.

Possible causes:

  • First time: we tend to have high expectations about our first intercourse; however many times it is less extraordinary than expected, and this includes pain; sometimes (but not always) bleeding may occur.
  • Trauma: this can be the result of childbirth (a tear or an episiotomy) or surgery; occasionally injury can be sex-related.
  • Vaginitis: due to yeast or other infection (see above).
  • Vulvodynia: it is a distressing, long-lasting condition in which the vulva is so sensitive that just touching the area makes the woman jump with pain. When pain is confined to the vestibule (the area around the opening of the vagina), it is known as vulvar vestibulitis syndrome (VVS). Its cause is unknown.
  • Emotional reasons: see below.

What to do about it:

  • If it is your first time, don’t worry too much about it. Many women have pain or discomfort during their first intercourse, an even a larger percentage will not have an orgasm. Be patient, try to be as relaxed as possible, discuss with your partner the means to reduce pain. If the problem persists, discuss it with a doctor.
  • If your just delivered, wait to have intercourse for at least six weeks after childbirth; some discomfort may persist for a few months, especially if you breastfeed, since your vagina also feels dry (see below). If pain continues for a long time or is very intense, talk to your doctor.
  • Vulvodynia may require medications, or eventually surgery. Read more here.

Problem # 5: “My vagina feels too dry”

Vaginal dryness is extremely common, and does not always mean problem. While some women produce  a lot of vaginal secretions, others are drier. However, there are factors that influence natural lubrication levels: sexual stimulation increases the amount of secretions; therefore, adequate and prolonged foreplay will help you being aroused. Sometimes though, your vagina keeps being dry and sex becomes painful.

Possible causes:

  • Menopause: due to the low level of estrogen (the hormone in charge of lubricating your genitals), your vagina will feel extremely dry and sex can be very painful, sometimes impossible.
  • Breastfeeding: also related to low estrogen.
  • Medications: some medications such as birth control pills, decongestants and antihistaminics may reduce vaginal moisture; contraceptive pills can also decrease sexual desire.
  • Medical problems: certain medical conditions can indirectly affect sexual response: diabetes, cancer, and thyroid problems, among others.
  • Your emotions: see below.

What to do about it:

  • Use a lubricant. Water-soluble lubricants are the best choice if you experience vaginal irritation. Silicone- based lubricants last longer and are more slippery. Do not use petroleum jelly, baby oil, or body lotion with condoms, as they can cause the condom to break (read more here).
  • For chronic cases, you may try long-acting vaginal moisturizers which, unlike lubricants, are absorbed into the vaginal lining for 3 to 4 days, mimicking natural secretions.
  • For menopausal women, when lubricants or moisturizers won’t work, a vaginal estrogen product may be necessary. More info here.
  • In any case, talk to your doctor if lubricants or moisturizers don’t help.

Problem # 6: “My vagina is just not opening”

Each time you try to have sexual intercourse, your vagina “closes”; any attempt of penetration is painful, and usually impossible.

Possible causes:

  • Vaginismus: it is a tightening (or reflex contraction) of the muscles of your vagina which occurs during penetration, but eventually also while attempting to insert a tampon, or during a gynecological exam. Its cause is unknown, although it is frequently related to anxiety, or fear of having pain during sex. Learn more here.
  • Your emotions: see below.

What to do about it:

  • Progressive desensitization consists of special exercises aimed at learning to relax your vaginal muscles.
  • Medical treatment may be useful in certain situations.
  • For women whose vaginismus is related to fear or anxiety, psychotherapy usually helps.

Problem # 7: I feel pain in my bladder during intercourse together with constant urge to urinate

painful-intercourse-tap-waterWhile having intercourse, you feel low abdominal pain and a persistent need to pee.

Possible causes:

  • Cystitis: read more here.
  • Interstitial cystitis (IC): also called bladder pain syndrome (BPS) is a chronic problem, which causes a feeling of pain and pressure in the bladder area, together with burning during urination. IC may feel like a bladder infection, but it’s not an infection; in fact, its cause is unknown.

What to do about it:

  • Read here to see what you can do if you have a bladder infection, particularly if you get one very often.
  • Regarding BPS, check with your doctor. No single treatment works for every woman, it should rather be individualized and based on symptoms. Learn more here.

Problem # 8: “I feel a deep pain in my abdomen during sex”

A deep pain or cramping in your abdomen during sex -or deep dyspareunia – can be the result of numerous problems.

Possible causes:

  • Gynecological problems: endometriosis, fibroids, ovarian cyst, adhesions, or infection (pelvic inflammatory disease). Many of these also cause painful periods.
  • Irritable bowel syndrome: a chronic condition that affects the large intestine; it commonly causes cramping, abdominal pain, bloating, gas, diarrhea and constipation. More info here.
  • Collision dyspareunia”: a funny name to describe the pain you may feel if the tip of your partner’s penis hits your cervix. This can happen if your partner is longer than average, if you’re not fully aroused, or if your cervix is unusually positioned. Read more here.
  • Other reasons: constipation, a retroverted uterus, a forgotten object in the vagina (usually a tampon).

What to do about it: 

Although many of the causes of deep dyspareunia are not important, some of them can be serious; therefore, you should see a doctor, especially if it is a new-onset problem. Many of these situations will be treated with medications, others require surgical intervention.

THE EMOTIONAL FACTOR

Our emotions are tightly related to our sexual life; thus, negative emotions are frequently the source of painful sex. Some examples are:

  • The way you feel about having sex: fear, embarrassment, guilt, being concerned about your physical appearance, being to too anxious about “doing it right” can all may make you unable to relax; therefore, arousal is difficult and you end up having pain.
  • Stress, fatigue, anxiety, depression: your everyday life problems can affect your desire to have sex. In addition, your vaginal muscles tend to tighten; this can also contribute to painful sex.
  • Relationship problems: problems with your partner may be related to painful sex by reducing arousal or provoking vaginismus.
  • A previous bad sexual experience: such as women with a history of sexual abuse, who tend to relate sex with something bad or negative.

WHEN YOUR PARTNER IS THE PROBLEM…

Painful sex is not always your fault!

  • Your partner may have sexual problem, which in turn can make you feel anxious about sex.
  • If your partner is taking a drug for erectile dysfunction, he may have delayed orgasm, causing long and painful intercourse.
  • Size problem: feel that your partner is “too big”? In fact, when a woman is aroused and relaxed, the vagina extends by several inches – so most women should be able to accommodate most males! Nevertheless, if size is indeed a problem, try a lubricant, and check which sex positions are less likely to make you hurt. Come close, a new device can be a good option for you.

SHARED PROBLEM: SEXUAL MISMATCH

Besides size mismatch, or differences in the way you both enjoy sex, a common issue leading to painful sex is mismatched sexual desire. Read more here.

TAKE HOME MESSAGE

painful-intercourse-dont-want-to-talk

If you have pain during sex, talk about it! It may be embarrassing to discuss your sexual problems with a doctor, but you should know that, with proper care most problems can be solved; therefore there is no reason to condemn yourself to a pleasureless, painful sexual life!

In the meantime, these are some tips that may help you relieve your pain:

  • Talk to your partner: mutual communication is essential. Discuss with your partner where and how is the pain, so you can both find ways to avoid it or minimize it.
  • Use a lubricant: a simple measure that can ease your suffering. It’s a good idea to keep always one with you.
  • Make time for sex: not always easy to include sex into our busy schedules! Nevertheless, try to find a moment of the day when you and your partner will be less tired or anxious.
  • Engage in sexual activities that don’t cause pain: if penetration is painful, you may consider other forms of pleasure, such as oral sex.
  • Try different sex positions: if you have deep dyspareunia, it can be worse in certain positions. Try to find those that are less likely to trigger pain.
  • Include relaxing activities: your partner may give a massage.
  • Take steps to relieve pain before making love: take a warm bath, empty your bladder, take a painkiller.
  • If you experience burning after intercourse: apply a frozen gel pack or some ice wrapped in a towel to your vulva.

References

  1. The American College of Obstetricians and Gynecologists: When sex is painful.
  2. Lori J, Heim LTC: Evaluation and Differential Diagnosis of Dyspareunia. Am Fam Physician. 2001 Apr 15;63(8):1535-1545.
  3. NHS UK: Why does sex hurt?

Photo credits

Intro: dailymedicalinfo.com; 1: rascoecam.wordpress.com; 2:liferunning.wordpress.com; 3: daroachbooks.blogspot.gr; 4: pixabay.com; 5: scienceclarified.com; 6: newauthors.wordpress.com; 7:diversehealthservices.wordpress.com; 8: everythingselectric.com; Take home: pinterest.com

HPV VACCINE: THE CONTROVERSY CONTINUES…

HPV Vaccine 2 adThis year is the HPV vaccine’s 10th anniversary, as the first cervical cancer vaccine was licensed by the US Food and Drug Administration (FDA) in June 2006. Should we celebrate or not? Arguably the HPV vaccine is one of the most controversial vaccines ever released…

In October 2015 I published the article: “The HPV vaccine controversy: science, media… and marketing”, where I included the information available on the vaccine, focusing on its safety and efficacy. A lot has happened since then, many articles have been published which, instead of clarifying the situation, have rather divided even more both the general public and the scientific community. The result: doctors hesitate to recommend the vaccine, parents and young women are even more confused when they have to decide whether to get vaccinated or not…

In this article I outline the recent events related to the HPV vaccine, focusing on new indications, safety statements and current controversies.

 

HPV-Associated Cancers are on rise

Malignancies related to HPV include cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal cancers.

According to a new report from the USA Centers for Disease Control and Prevention (CDC), HPV-associated cancer incidence have increased from 10.8 per 100,000 persons during 2004–2008 to 11.7 per 100,000 persons during 2008–2012. The most common cancers are cervical and oropharyngeal (although not all oropharyngeal cancers are HPV-related).

The report stresses that a large number of these cancers are associated with the HPV types included in the vaccine, thus vaccination may potentially reduce the incidence of cancer in the future.

The same trend is observed in other countries such as the UK: while the incidence rates of cervical cancer for women aged 25-34 initially decreased by 35% between 1985-1987 and 2000-2002, rates have since increased by 50% in this age group.

 

More medical societies urge to increase HPV vaccination rates

HPV vaccine 2 ASCODespite many professional organisations recommending HPV vaccination, vaccine uptake in the United States remains low: about 39% of girls and 21% of boys have received the full schedule of HPV vaccines.

Taking into consideration these data, the American Society of Clinical Oncology (ASCO) has recently issued a statement urging to increase vaccination rates. In this article “ASCO stresses (…) the need to increase the proportion of adolescent boys and girls receiving the HPV vaccine (…) which could lead to complete eradication of HPV-related cancers in men and women”. They further emphasize its safety by stating that “Both Gardasil and Cervarix vaccines reported excellent short- and long-term safety results in clinical trials”.

But some issues in the ASCO statement have been questioned, namely the “complete eradication of HPV-related cancers” (as none of the available vaccines is 100% effective), and the “excellent safety results”, as worldwide reports of adolescents with chronic side effects after HPV vaccination continue to be published (see below). In addition, the report does not mention anything about screening tests (Pap smears), which are an indispensable tool for preventing cancer by early detection of precancerous lesions.

 

Changes in the HPV vaccination schedule

The CDC recently published the new 2016 recommended immunization schedule for children and adolescents. The schedule for HPV vaccination introduces the ninevalent (9vHPV) vaccine for males and females. While females may receive any of the three available vaccine types: 9vHPV (Gardasil 9), 4-valent (Gardasil) or 2-valent (Cervarix), only Gardasil 9 or Gardasil may be used for males.

The CDC also states that HPV vaccine should be administered beginning at age 9 years to children and youth with any history of sexual abuse or assault who have not initiated or completed the 3-dose series.

 

More studies confirming reduction in the prevalence of HPV, cervical abnormalities and genital warts 

Reduction of HPV prevalence

An American study confirms previous observations of HPV vaccine impact: within 6 years of vaccine introduction, there was a 64% decrease in the four HPV types included in the vaccine among females aged 14 to 19 years and a 34% decrease among those aged 20 to 24 years.

Decrease in condylomas in women and men

In Denmark, girls and young women have been vaccinated since 2008. A recent study shows a significant reduction in the incidence of genital warts, not only in women, but also in men, This means that the vaccine has caused what is called herd immunity. The study concludes: “The reduction is seen in both women up to 35 years of age and men aged 12 to 29 years, suggesting that HPV vaccination is highly efficient and that herd protection has developed.”

Reduction of abnormal Pap tests in high-risk patients

A new study demonstrated the HPV vaccine is effective in a real-world setting of high-risk patients (low-income females, engaging in high-risk sexual behaviors) many of whom had not completed the HPV vaccine schedule.

After following 4127 girls and young women from 11 through 20 years of age who underwent Pap smears, they found that abnormal cytology was less common in vaccinated vs unvaccinated females (8 vs 13 % respectively). The risk was lower if  the 3-dose vaccine series was completed or if the vaccine was administered from 11 through 14 years of age.

 

The European Medicines Agency concludes HPV vaccine is safe

In my previous article, I mentioned that the European Medicines Agency (EMA) would conduct a safety review of HPV vaccines, mainly due to the numerous reports on severe side effects, not only in lay media, but also in medical journals. The main concern was the occurrence of two particular syndromes, namely complex regional pain syndrome (CRPS) and postural orthostatic tachycardia syndrome (POTS) (see here for more details), suspected to be related with HPV vaccination.

The long awaited EMA review was published in November 2015, and concluded that “the evidence does not support that HPV vaccines (Cervarix, Gardasil, Gardasil 9, Silgard) cause CRPS or POTS. The benefits of HPV vaccines continue to outweigh their risks”. Read their press release here.

After this review, a World Health Organization – Global Advisory Committee on Vaccine safety (GAVCS) Statement on Safety of HPV vaccines followed in December 2015, which declares ” The GACVS has systematically investigated safety concerns raised about HPV vaccines and has issued several reports in this regard. To date, it has not found any safety issue that would alter its recommendations for the use of the vaccine”. The statement refers specifically to CRPS and POTS, but also to the increased incidence of Guillain-Barre syndrome found in a French study (see my previous article).

 

Danish scientists skeptical about EMA’s conclusions, start independent research

It was Denmark that had requested the safety review of HPV vaccines from the EMA, as this country, with a high vaccine uptake, reported that more than 1300 girls and young women with chronic symptoms (POTS, CRPS) have been referred to specialized centers.

Not convinced with EMA’s conclusion, Denmark is conducting its own investigation into the issue. The Ministry of Heath has given 7 million DKK (US$1.01 million) for research leaded by specialists who are seeing girls with symptoms after HPV vaccination and who are independent of the pharmaceutical industry.

 

Nordic Cochrane Centre accuses EMA of maladministration and scientific misconduct

HPV vaccine 2 Cochrane NordicRecently, the reputed Nordic Cochrane Centre filed a complaint to the EMA expressing their concern about EMA’s handling of the HPV vaccine safety issue.

The Nordic group says that the EMA report is flawed, and points out several issues. Briefly:

  • The EMA has concluded that there is no causal link between CRPS / POTS and the HPV vaccine, but the Nordic Cochrane group says “The EMA’s official report gives the impression of a unanimous rejection of the suspected harms. However, the EMA’s internal report (…) tells a very different story. This “internal report is confidential but has been leaked,” the group notes, and it “reveals that several experts had the opinion that the vaccine might not be safe and called for further research, but there was nothing about this in the official report.”
  • “The EMA asked the pharmaceutical companies to search for side effects of the vaccine in their own databases and did not check the companies’ work for accuracy,” they say. They also allege that their criteria to consider cases as POTS were extremely restrictive: “In the search for cases coded as POTS (…)  almost half (40 cases) are dismissed for not meeting the case definition for POTS”.  “This is extraordinary, as the companies have a huge vested interest in not finding these possible harms in their databases,” the Nordic group comments.
  • Another issue is the placebo that was used in the clinical trials of HPV vaccines. “In all the vaccine trials apart from a small one, the control group was given a placebo that contained an aluminium adjuvant, which is suspected of being neurotoxic,” they note. The group quotes information contained in the leaked internal documents: “Initially, the vaccine was compared with a placebo group being vaccinated with physiological serum, whereby the number of adverse reactions was much higher and much more serious than in the control group. After comparing 320 patients in the saline placebo group, a quick move was made to an aluminium-containing placebo, in order to be able to only evaluate the effects of the active substance. However, this distorted the comparison (…)”. “We believe this constitutes scientific misconduct,” the Nordic group says.
  • The group highlights the “extreme levels of secrecy” that surround the EMA review process, in which experts who are involved in the process are not named and are bound by lifelong secrecy about what was discussed. Nordic Cochrane argues that instead, all documents involving HPV vaccination safety should be made publicly available.
  • They also question whether EMA has behaved fairly, in particular towards Dr. Louise Brinth, the Danish whistle-blower who first described cases of POTS in the medical literature, as EMA accuses her to report on “a sample of patients, apparently chosen to fit a pre-specified hypothesis of vaccine-induced injury”. The Nordic group concludes “We find that the EMA’s comments are unprofessional, misleading, inappropriate and pejorative, and that the EMA’s approach (…) is unscientific”.

Dr Brinth, who cosigns the Nordic Cochrane complaint, has published her own 63-page response to the EMA review (it’s really worth a read).

The situation in Japan

Japan puts in place a scheme to manage symptoms after HPV vaccination

HPV vaccine 2 japanese girls

Japan has put in place a scheme to manage symptoms, especially generalized chronic pain, that have arisen after HPV vaccination. Guidelines for the evaluation and management of symptoms that begin after HPV vaccine injection were issued to healthcare professionals and approved by the Japan Medical Association and the Japanese Association of Medical Sciences.

Class action lawsuit filed against Japanese government and vaccine manufacturers

Sixty-three women and girls who reported side effects from cervical cancer vaccines sued the Japanese government and drugmakers. “More plaintiffs are expected to join the suit “, The Japan Times recently reported.  According to the Japanese Ministry of Health, Labor and Welfare, 2,945 of the 3.39 million women who had received the vaccines, or 0.09 percent, have reported side effects.

Scientist accuses WHO, GAVCS, CDC of misconduct

In an open letter of complaint to the World Health Organization (WHO), Japanese Dr. Sin Hang Lee expresses concerns regarding the conduct of certain members of GACVS, WHO, CDC and other scientific/health professionals. “I have come into possession of documentation which leads me to believe multiple individuals and organizations deliberately set out to mislead Japanese authorities regarding the safety of the human papillomavirus (HPV) vaccines, Gardasil and Cervarix”, he writes.  In his letter he explains that there is at least one known mechanism of action explaining why serious adverse reactions occur more often in people injected with HPV vaccines than other vaccines, and why certain predisposed individuals may suffer a sudden unexplained death as a result, but he alleges that this information was deliberately “ignored” by the experts.

 

Potential risk of Primary Ovarian Failure associated with HPV vaccination

HPV vaccine 2 American-College-of-PediatriciansThe American College of Pediatricians (ACP) issued a statement in January 2016 warning of a potential relationship between Primary Ovarian Failure and HPV vaccination.

“It has recently come to the attention of the College that one of the recommended vaccines could possibly be associated with the very rare but serious condition of premature ovarian failure (POF), also known as premature menopause“, they report.

They further state that, although most physicians are probably unaware of a possible association between the HPV vaccine  and POF, and may not consider reporting cases or prolonged amenorrhea (missing menstrual periods) to the Vaccine Adverse Event Reporting System (VAERS), 213 cases were reported. When the cases are more carefully chosen:  “86/89 cases are associated with Gardasil, 3/89 with Cervarix, and 0/89 with other vaccines administered independently of an HPV vaccine. Using the same criteria, there are only 7 reports of amenorrhea from 1990 through 2005″.

“While there is no strong evidence of a causal relationship between HPV4 and ovarian dysfunction, this information should be public knowledge for physicians and patients considering these vaccines”, they conclude.

A possible association between ovarian problems and the HPV vaccine had been already reported by Dr Deirdre Little, an Australian gynecologist:

It should be mentioned that the ACP statement, as well as Dr. Little’s research have been heavily criticized by other physicians.

 

Conclusions

HPV vaccine 2 Should I get HPV Vaccine

I was hoping that, with the new available information on the HPV vaccine safety, I could reach a conclusion on how to counsel, as a physician, young women and mothers asking me whether to get the HPV vaccine or not. I was expecting to have a thorough review stating loud and clear the HPV vaccine expected benefits vs. the documented risks.  Unfortunately, no conclusion can be easily drawn so far. It is extremely difficult to find a balance between the scientific evidence -with studies not always well-designed-, the experts’ opinions and the increasing criticism surrounding this vaccine.

While most professional societies urge us to promote vaccination, the constant reports on serious side effects coming from all around the globe cannot be ignored. It’s unfortunate to see a woman dying of a cancer that could have been prevented, but it is equally heart-breaking to see a healthy teenager, full of life, suddenly prostrated in a wheelchair…

I have no doubt that vaccines are an invaluable public health tool against fatal diseases, and it’s imperative that we all continue to believe in vaccines. However, it’s my opinion that the HPV vaccine in particular deserves further study.

The unanswered questions are too many, not only about potential risks, but also about potential benefits. Therefore, I believe that further independent research is urgently warranted – not just in Denmark, but worldwide. With  more than 175 millions vaccine doses distributed in 63 countries, it is certain that a coordinated, global effort would shed light on some aspects of this controversial vaccine.

Acknowledgement

I am genuinely grateful to Ms Caron Ryalls, who kindly contacted me and provided me with some of the information presented here.