MTHFR Gene Mutation and Pregnancy

Wednesday, February 23, 2022

MTHFR Gene Mutation and Pregnancy

Every human has the gene known as 5-Methyltetrahydrofolate, but a significant percentage of humans have a mutation of that gene, simply known as MTHFR Mutation. MTHFR mutation boils down to the body’s inability to break down folate. Folate is imperative to the process of making DNA and modifying certain proteins as they relate to DNA. When looking closely into MTHFR, we find that people with this mutation have high levels of homocysteine. Homocysteine is the amino acid produced when proteins are broken down within the body. This high level of homocysteine can lead to arterial damage and blood clots. Hand in hand with this elevated homocysteine level, we find both a folate and vitamin B-12 deficiency. MTHFR mutation is hypothesized to affect 25% of hispanic people and 15% of white, and is likely to affect 40% of the overall population according to the genetic care and rare diseases information center. This mutation is not a random occurrence, in fact it appears to be passed through genetics only, meaning it is very hereditary.

So how does this gene mutation affect pregnancy? Well, the entire answer to this question is still cloaked in uncertainty, but here is what we know. The first clue that may prompt a Dr. to test for the mutation is recurrent miscarriages. However, it is important to note that at this time there is no solid evidence that MTHFR is at fault for these miscarriages. It is anecdotal evidence we have collected in caring for these individuals, but has not been officially studied and scientifically proven. It is hypothesized that these miscarriages could be the result of irregular clotting factors that come with the mutation, as these clots can form within the placenta and interfere with proper development. Alongside the potential risk of miscarriage we find heightened risk for Pre-eclampsia, neural tube defects, spina bifida, anencephaly, and of course blood clots.

Treating pregnant patients with MTHFR mutation has no hard and fast rules. Many Drs may recommend nothing more than a daily aspirin and folate supplement, while others may recommend a similar regime in combination with heparin or lovenox injections through to the second trimester. In patients with a history of blood clots, these shots may be recommended throughout the entire pregnancy and up to 6-8 weeks postpartum. Extra testing and scans may also be recommended as MTHFR gene mutation brings about an increased risk of preeclampsia, neural tube defects, blood clots, preterm birth, and spina bifida. For patients that use lovenox injections, it is recommended that they be replaced with heparin injections at roughly 36 weeks gestation. This is due to the blood thinning factor that can lead to an increased risk of postpartum hemorrhage. In fact, the risk for hemorrhage goes up to 12% in the event that you have been injected within the 24 hours prior to the onset of labor.

The MTHFR gene mutation is still largely a medical mystery. The lack of concrete evidence means that your treatment plan should stay an ongoing and in-depth conversation with your birth team throughout your pregnancy. Remember that you are in the driver’s seat of your pregnancy, labor, birth, and postpartum. A treatment regimen that feels safest to you is imperative to a happy, healthy pregnancy.


No Scientific evidence to link miscarriage to MTHFR is broken down here

The study discussing the risk of postpartum hemorrhage when actively using lovenox injections 24 hours or less before labor-

This blog was written by a former Tranquility by HeHe team member.

Cesarean Section Recovey

Wednesday, February 9, 2022

Cesarean Recovery

No matter how we bring our children into this world, our bodies will have some healing to do. Bringing a baby earthside is physically taxing, and involves so many different systems of the human body. In the case of cesarean delivery, there are a few more steps added to the recovery process. We tend to neglect these steps when leaving the hospital, but it’s important to know what tools are available in your recovery toolbox. Here are the five most impactful tools that ensure a faster and more complete recovery.

Walking- After surgery your epidural or spinal will be removed and over the next few hours the numbness will begin fading away. While you may leave the OR expecting to take it as easy as possible, you will quickly find that the first task on your “to-do list” is getting up and taking a walk through the hospital corridor. While this can be painful and feel like it adds insult to injury, ambulation is imperative to proper recovery. Why? Because it is the action of walking that jumpstarts our body’s routine functionalities. Walking as soon as possible after surgery, and continuing to take several short walks around your home each day encourages proper blood circulation, decreases the risk of blood clots, disperses any built up gas and the pain that it may be causing, has been shown to lower the need for narcotic pain relief, shorten hospital stay length, and ensures that the muscle movements of your digestive tract begin working as soon as possible which will lead to less constipation and discomfort throughout the coming weeks.

Proper Nutrition- Several studies have tested the efficacy of enhanced recovery after surgery pathways (ERAS). These pathways include measures such as decreasing the amount of time patients go without food and drink, encouraging early mobility as we covered above, providing regional anesthesia, etc… One pathway found to be very helpful is not only a proper nutritious diet both before and after surgery, but also ensuring limited interruptions to that diet during the pre and postoperative periods. Keeping fasting to a minimum has shown to have many benefits. These benefits include reducing pain levels, stabilizing blood sugar, and reducing tissue hypoxia. Because of these benefits the American College of Gynecology (ACOG) has encouraged providers to use this pathway. It is now recommended that liquids in moderation should be encouraged up until 2 hours prior to surgery, and instead of no food by mouth policies starting 12 hours prior to surgery it has been decreased to 6 hours. Food and drink is encouraged between two and four hours postoperative.

Abdominal Binders- Abdominal binders are one of the most underutilized recovery tools in the post cesarean (post birth) toolbox. While not widely studied, there are small randomized case studies on their benefits. In a study of 89 patients, all with similar hemoglobin and hematocrit levels, it was found that the group of participants that were given abdominal binders not only had better hemoglobin and hematocrit levels at 36 hours post surgery, but they reported lower pain levels as well. Binders are also instrumental in supporting the return of postpartum abdominal muscles to their original placements. While all mothers will experience some degree of Diastasis Recti, binders can prevent this muscle separation from advancing, and help close the gap overall.

Pain Management- Unfortunately cesarean recovery can come with a great deal of pain. Bending, standing, walking, and even turning over in bed can become difficult tasks even with pain medications, let alone without. Because of this, pain management is one of the most important parts of a proper recovery plan. Not only does adequate pain management keep the patient in a certain level of comfort, It will reduce the overall length of opioid usage, shorten the length of hospital stays, aid in returning to normal functionality, lead to a higher level of maternal satisfaction, which in turn effects breastfeeding, bonding, and postpartum mood. While opioid usage is still the most effective and most common form of pain management, there are local anesthesia options being used in select hospitals that can deliver lidocaine or marcaine directly into the incision. One form of this is known as the ON-Q pump. This small pump delivers numbing medication to the incision site through a small catheter placed within it. These pumps will be sent home with you, and will last an average of three to five days post-op. Afterwards it can be gently pulled out of the incision. While this sounds scary, I assure you from my personal experience that it does not hurt, and in fact is hardly even felt. This mode of pain management is not available at all hospitals and it may be worth inquiring about prior to settling on a birth location. These pain management options may not entirely cut out the use of opioid pain relief, but it is likely to decrease the amount needed and the length of use.

Birth Processing- In many cases, a mother may have arrived on the OR table after a scary or confusing turn of events. The fear of getting to the OR and the fear of Being in the OR can bring about a trauma response, and this may affect her overall feelings about her birth even after that fear has passed. The mental health aspect of birth is overlooked across the board, not just with cesareans, but we commonly see trauma based mental health issues arise after traumatic births. Having access to proper therapies and a support system in place is vital to the postpartum experience. Without these we may see this trauma develop into a myriad of postpartum mood disorders which can leave long lasting impacts in the life of mom, baby, and family. Without mental health, there can be no physical health.

This blog was written by a former Tranquility by HeHe Birth Doula.

The Truth about Glucola Alternatives

Wednesday, February 2, 2022

The Truth about Glucola Alternatives

What is gestational diabetes and how do we diagnose it?

Gestational diabetes testing is a routine screening that almost all pregnant parents will encounter around 26 weeks gestation. To get the big picture of why we screen for this we should discuss how the pregnant body metabolizes sugar in comparison to a body that isn’t pregnant. So let's dive in. When we eat carbohydrates (think bread, rice, pasta) our bodies break them down into glucose. This glucose is what gives us energy as we go through our day, and it is aided by insulin, a hormone produced by the pancreas. Insulin is also capable of turning excess glucose into stored fat. So how does this differ from how glucose is metabolized in a pregnant body?

Think of hormones as the catalyst for nearly all bodily functions. Hormone levels in pregnancy are wildly elevated, and these higher hormone levels can actually impede the body’s ability to use insulin as efficiently. We refer to this as insulin resistance. In some cases our bodies may need up to three times the amount of insulin to metabolize the same level of glucose. These changes are normal and expected in healthy pregnancies. However, when we see the body producing that extra insulin and still not being able to metabolize the body’s glucose level, we deem that too insulin resistant and often diagnose the mother with gestational diabetes.

So how do we carry out this screening?

The glucola drink, often marketed as fruit punch or orange juice flavored, has spanned the nation far and wide and become readily available in all maternity care offices. This drink, containing 50mg of dextrose, a sugar derived from corn syrup, along with citric acid, food dyes, brominated soybean oil, and modified food starch has been considered as harmless for many decades, but have recently come under scrutiny because of both its heavy amount of dyes and the brominated soybean oil. Food dyes have long since been discovered to be less than great for the human body, but the brominated soybean oil being both banned in Europe and marketed as a flame retardant, has parents searching for alternatives. Thankfully to a handful of recent studies, they haven’t had to look far.

What are the alternatives?

In 2014 a small study looked into switching glucola for strawberry flavored hard candy and found that not only did the candy alternative test, sensitivity wise, the same as glucola, it also lead to a lower false positive rate. This study deemed that any sugary food or drink that contained 50g of sugar could be a safe and reliable alternative to the typical glucola drink that so many providers still push. As these findings are being further studied and confirmed we have seen the options expand to things like pancakes with syrup, a handful of jelly beans, and orange juice. The lower rate of false positives has also been noted to be supported by the differing rates of gestational diabetes diagnosis among the US and other developed countries. In many European countries, these alternatives have been part of standard care for several years. A group of nearly forty studies found that Europe’s rate of GD diagnosis is roughly 5.4% of pregnant parents. Whereas the US, still widely using glucola, has a diagnosis rate of 10%. While these studies support this hypothesis, it should be noted that they did not include the varying rates of obesity amongst these countries in their publications which may skew the numbers slightly.

One option for some parents is a relatively new product known as Fresh Test. This drink is marketed as gluten free, vegan, is free of artificial dyes and flavors, and carries the same 50 gram sugar load that glucola carries. One major plus of this product is the short and concise ingredient list. Included in this list are citric acid, lemon oil, lemon juice, and organic peppermint leaf powder, but it is worth noting that it still contains dextrose just as glucola does. While marketed as gluten free and vegan, it is produced in a facility that handles wheat, soy, tree nuts, peanuts, eggs, milk, and shellfish. For many parents, this product may be a perfect alternative to traditional glucola. However there is a dye and flavor free version of glucola should you prefer that.

Opening the conversation

While this article has no intention of standing in as medical advice, it is meant to inform you of your options and encourage an open conversation between you and your provider about whichever screening method feels most aligned to you and your baby. That said, we understand that having these conversations can feel scary and intimidating. So let's take a moment to lay out a few ways you can advocate for your preferences. These conversations can happen whenever and wherever you are comfortable. If you go into pregnancy knowing you won’t be utilizing glucola, you are welcome to have this conversation as early as your first prenatal appointment. Or maybe you plan on waiting until closer to when you’ll do the actual blood test. The call is always yours! Here are a few examples of how opening this conversation can look:

You: So I understand that this office mainly uses glucola for gestational diabetes screening. However after looking at the research I’ve decided that I’d much rather use one of the alternative methods, such as a juice cocktail, a sugary breakfast, or the FreshTest beverage. Is there an alternative that you prefer over the others?

You: I know that my glucose test is coming up very soon and I wanted to take a moment to ask you a few questions. Your knowledge is valuable to me and I’d like to consider it in whatever decision I make pertaining to this test. I have been reading a lot about glucola alternatives, and after looking at the ingredient list of glucola I am really leaning towards choosing an alternative. I know you may prefer your patients to use glucola, but since that doesn’t feel aligned with my needs I’m hoping you can advise me on which alternative you think would be most reliable.

From here, there are two outcomes. Your provider will either pushback, or they will engage in a conversation and offer their opinion. Let’s take a moment to discuss why we might see pushback. First and foremost, Drs can be creatures of habit just like the rest of us. Perhaps they’ve been practicing for forty years and glucola is the only thing they’ve ever used. Letting go of something that feels so reliable might feel counterproductive to them. Or maybe they haven’t read the research. We tend to forget that continuing education requirements for physicians are abysmal and can be used for holistic specialties such as acupuncture. It’s entirely possible that a dr just hasn’t read the research. One of the biggest reasons we see pushback is because many Drs have doubts about the reliability of putting such a test in the hands of the patient. Human error seems to be a large concern among physicians. Handing a patient a 10 ounce bottle of perfectly portioned and formulated glucola seems so much more reliable than a patient with a plate of pancakes and a bottle of syrup. Let’s take another minute to explore what the conversation might look like after a bit of pushback.

Doctor: I know there has been some nuance around glucola, but we use it because it is reliable and it yields the most accurate results. I know there’s a lot of stuff on the internet that can make it seem bad for you, but it’s no worse than a soft drink.

You: I understand. I know it’s been around a long time and I thank you for explaining why you recommend that I use it, but it just isn’t aligned with me so for right now I am giving my informed refusal for glucola, but I would really like to know which alternative you recommend. If at any point I test high for blood sugar, we can revisit this conversation then. I really appreciate you taking the time to give me your feedback.

At the end of the day, it’s important to know that your care is always squarely in your hands. While some providers may push for glucola, it’s ultimately your hands that will put the bottle to your mouth. What’s in that bottle or on those pancakes is entirely up to you. What is most important is that whatever choice you make is informed, and aligns with your needs. While providers may have a preference, if that preference doesn’t match yours? Well, informed refusal is your right.

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