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Pregnancy

AHCJ15, Ethics, Events, Patient Care, Pediatrics, Pregnancy

Counseling parents of the earliest-born preemies: A mom and two physicians talk about the challenges

Counseling parents of the earliest-born preemies: A mom and two physicians talk about the challenges

preemie toesWhen Juniper French was born in April 2011, her mom had been pregnant for 23 weeks and 6 days – a little more than half of a typical 40-week pregnancy. Shortly before her birth, doctors had to try to explain the possible consequences of her very early arrival to her parents.

“Prematurity is a very unusual condition because it can affect any corner of the body or the mind to any degree,” Kelley Benham French, Juniper’s mother, told a group of journalists at the Association of Health Care Journalism 2015 conference this past weekend. French and her husband were informed that, even with intense medical intervention at birth, their daughter had an 80 percent chance of death or morbidity. Not only was that staggering, but their doctors couldn’t be very specific about what this number might mean if Juniper did survive: “We asked, ‘Do you mean life on a ventilator or asthma? Do you mean blindness or a wheelchair?'” French recalled. “They said, ‘We don’t know.'”

These same uncertainties are faced by all parents of babies born near the edge of viability, between 22 and 25 weeks of gestation. French, a reporter, eventually wrote an award-winning series about Juniper for the Tampa Bay Times that explains the swirl of emotions and statistics she and her husband, Tom, had to navigate in deciding to ask their doctors to resuscitate Juniper at birth. As French told the conference attendees, the choice was excruciating; they desperately wanted to be parents but didn’t want their baby to suffer. They wondered if “it might be less selfish to just let her die.”

Two Stanford experts joined French in Friday’s presentation to discuss difficult conversations about very early preemies.

Neonatologist Henry Lee, MD, gave a sampling of the information he must present to parents when he has these conversations as part of his work at Lucile Packard Children’s Hospital Stanford: Not only are these babies at risk of dying, they face daunting early-life medical complications. Lee rattled off a list: retinopathy of prematurity; necrotizing enterocolitis; bronchopulmonary dysplasia; intraventricular hemorrhage. Referring to the last item on this list, he said “You can imagine, talking to a parent, telling them that ‘Your baby is at risk for having bleeding into their brain’ can cause a lot of anxiety. And often this is the patient’s first time meeting this doctor or nurse. They don’t have any relationship, but they’re talking about these weighty matters.”

Stanford obstetrician Amen Ness, MD, added that women in preterm labor are often asked to make critical medical decisions quickly. Do they want steroids to mature the baby’s lungs? Are they OK with receiving a classical c-section to deliver the baby, which produces a large vertical scar that increases the risk of placenta accreta in future pregnancies? How much fetal monitoring do they want?

Most of these decisions would feel more comfortable if the patient had a few days to think things over and could return for later conversations with more questions. “You really need that time but you don’t always have it,” Ness said.

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Evolution, Genetics, Microbiology, Pregnancy, Research, Science, Stanford News, Stem Cells

My baby, my… virus? Stanford researchers find viral proteins in human embryonic cells

My baby, my... virus? Stanford researchers find viral proteins in human embryonic cells

Wysocka - 560

One thing I really enjoy about my job is the opportunity to constantly be learning something new. For example, I hadn’t realized that about eight percent of human DNA is actually left-behind detritus from ancient viral infections. I knew they were there, but eight percent? That’s a lot of genetic baggage.

These sequences are often inactive in mature cells, but recent research has shown they can become activated in some tumor cells or in human embryonic stem cells. Now developmental biologist Joanna Wysocka, PhD, and graduate student Edward Grow, have shown that some of these viral bits and pieces spring back to life in early human embryos and may even affect their development.

Their research was published today in Nature. As I describe in our press release:

Retroviruses are a class of virus that insert their DNA into the genome of the host cell for later reactivation. In this stealth mode, the virus bides its time, taking advantage of cellular DNA replication to spread to each of an infected cell’s progeny every time the cell divides. HIV is one well-known example of a retrovirus that infects humans.

When a retrovirus infects a germ cell, which makes sperm and eggs, or infects a very early-stage embryo before the germ cells have arisen, the viral DNA is passed along to future generations. Over evolutionary time, however, these viral genomes often become mutated and inactivated. About 8 percent of the human genome is made up of viral sequences left behind during past infections. One retrovirus, HERVK, however, infected humans repeatedly relatively recently — within about 200,000 years. Much of HERVK’s genome is still snuggled, intact, in each of our cells.

Wysocka and Grow found that human embryonic cells begin making viral proteins from these HERVK sequences within just a few days after conception. What’s more, the non-human proteins have a noticeable effect on the cells, increasing the expression of a cell surface protein that makes them less susceptible to subsequent viral infection and also modulating human gene expression.

More from our release:

But it’s not clear whether this sequence of events is the result of thousands of years of co-existence, a kind of evolutionary symbiosis, or if it represents an ongoing battle between humans and viruses.

“Does the virus selfishly benefit by switching itself on in these early embryonic cells?” said Grow. “Or is the embryo instead commandeering the viral proteins to protect itself? Can they both benefit? That’s possible, but we don’t really know.”

Wysocka describes the findings as “fascinating, but a little creepy.” I agree. But I can’t wait to hear what they discover next.

Previously: Viruses can cause warts on your DNA, Stanford researcher wins Vilcek Prize for Creative Promise in Biomedical Science and Species-specific differences among placentas due to long-ago viral infection, say Stanford researchers
Photo of Joanna Wysocka by Steve Fisch

Global Health, In the News, Medical Education, Pregnancy, Women's Health

Project aims to improve maternal and newborn health in sub-Saharan Africa

Project aims to improve maternal and newborn health in sub-Saharan Africa

5567854013_6bd1e2b76b_zIn sub-Saharan Africa, maternal and neonatal outcomes are some of the worst in the world. What would happen to those numbers if 1,000 new obstetrician/gynecologists were trained with state-of-the-art educational materials in the region over the next ten years? The 1000+OBGYN Project, a collaborative training effort between American and African universities, aims to do just that.

The University of Michigan’s Open.Michigan initiative, in partnership with the UM Medical School’s Department of Obstetrics and Gynecology and Department of Learning Health Sciences, just released four new collections into the 1000+OBGYN Project’s open-access database, thanks to a grant from the World Bank.

A UM press release published today describes the new contributions, which cover a diverse range of subjects, including abnormal uterine bleeding, pregnancy complications, vaginal surgeries, pelvic masses, newborn care, postpartum care and family planning. The materials are all free, publicly available, and licensed for students, teachers and practitioners to modify according to their own curricular context.

Frank Anderson, MD, MPH, associate professor in the UM Department of Obstetrics and Gynecology and director of the 1000+OBYGN Project, comments in the release:

There is an urgent need to train Obgyns [sic] in sub-Saharan Africa, but their institutions don’t always have access to the same body of educational materials as doctors in developed countries have… Many newborn and maternal deaths are preventable. We want to ensure that future Obgyns in low resource countries have access to the same high-quality learning materials available here so they are equipped to provide the best care possible for mothers and babies.

The project hopes to overcome local barriers to good education, such as availability of training materials, licensing costs, and unreliable internet access. To make the materials available offline, the initiative partnered with the Global Library of Women’s Medicine, which compresses research onto USB flash drives and distributes them globally, particularly to women’s health professionals in Africa.

Previously: Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival, Gates Foundation makes bold moves toward open access publication of grantee research, Improving maternal mortality rate in Africa through good design and Using family planning counseling to reduce number of HIV-positive children in Africa
Photo by DFID – UK Department for International Development

Events, Pediatrics, Pregnancy, Research, Stanford News

Join us for two days of live tweeting from Childx

Join us for two days of live tweeting from Childx

Group of five happy children jumping on meadow.

Today and tomorrow, we’ll be live tweeting Stanford’s inaugural Childx conference, which brings together some of the top voices in pediatric and maternal health. We’ll be using @StanfordMed and the #StanfordChildx hashtag.

The action kicks off early today, with an 8 a.m. welcome by Lloyd Minor, MD, dean of the School of Medicine. Keynote speaker Alan Guttmacher, MD, director of the Eunice Kennedy Shriver National Institute on Child Health and Human Development, who talked with Scope last week, speaks at 8:15 a.m.

Check back throughout the day to learn about fetal, developmental and adult health at 9 a.m. and stem cell and gene therapy at 11:10 a.m. After lunch, the conference reconvenes to discuss child and maternal health at 2:20 p.m. with Alan Greene, MD, who leads the popular Dr.Greene.com. The speaking presentations wrap up at 5 p.m.

On Friday, Stanford’s Dennis Wall, PhD, will kick the conversation off at 8 a.m., followed at 8:10 a.m. by Rajiv Shah, MD, former head of the United States Agency for International Development. At 8:35 a.m., Stanford’s Euan Ashley, MD, DPhil, will lead a discussion on precision medicine for rare childhood diseases. Tune in to learn more about the health ecosystem at 10:30 a.m. and for a special presentation by Stanford’s Mary Leonard, MD at 11:55 a.m.

The complete schedule is available here.

Previously: Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survivalCountdown to Childx: Q&A with pediatric health expert Alan Guttmacher, Countdown to Childx: Stanford expert highlights future of stem cell and gene therapies and Stanford hosts inaugural Childx conference this spring
Photo by Lighttruth

In the News, NIH, Parenting, Pediatrics, Pregnancy, Research

Maternal interaction helps pre-term infants grow, study shows

Maternal interaction helps pre-term infants grow, study shows

new mom with baby

It’s not surprising that interaction with their mothers is helpful to babies who are born prematurely – but new research spotlights some of the specific benefits. Featured in an NIH press release today, a study of a method called H-HOPE (Hospital to Home: Optimizing the Premature Infant’s Environment) found that it correlated with a marked improvement in infant weight gain, length growth, and muscular ability to feed from a bottle.

The H-HOPE program has two parts: First, it teaches mothers to use a multi-sensory intervention that features auditory, tactile, visual, and vestibular stimulation (an “ATVV intervention”), and then it trains mothers to recognize their infants’ subtle communication cues, which are much more discreet than those of term infants. Instead of crying and putting their hand in their mouth to indicate hunger, for example, pre-term babies may weakly lift their hand towards their mouth. The fifteen-minute ATVV intervention, which was administered twice daily before feedings, started with a soft female voice, followed by a gentle massage, eye-to-eye contact, and then rocking-in-arms.

The initial study, published in the Journal of Perinatology, was headed by Rosemary C. White-Traut, PhD, RN, professor emeritus in the department of Women, Children and Family Health Science at the University of Illinois at Chicago College of Nursing. The 183 babies in the study were born between 29 and 34 weeks gestation, and their mothers were involved in the H-HOPE program from the time the baby reached 31 weeks until one month after the approximate date the baby would have been born had the pregnancy reached term. The mothers each received visits from a nurse-community health advocate to make sure the procedures were going smoothly, twice in the hospital and twice after discharge.

Each of the participants had at least two social-environmental risk factors, and half of them were Hispanic, a group with a high rate of prematurity. As White-Traut commented in the release, “When we planned our research, we thought that preterm infants from impoverished backgrounds likely would benefit the most from this intervention. Poverty is linked to poorer long-term health and infant development. And as with other negative health influences, preterm infants usually are affected more strongly than term infants.”

White-Traut’s study showed improved weight gain and growth in the babies; a follow up study (to be published in Advances in Neonatal Care) showed that infants also had better muscular ability to suck from a bottle just after receiving the ATVV intervention, via a sensor placed on the bottle’s nipple while they ate.

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Patient Care, Pregnancy, Stanford News, Women's Health

New obstetric hemorrhage tool kit released today

New obstetric hemorrhage tool kit released today

pregnantbelly-3A few years ago, when my niece was born, my sister had a severe postpartum hemorrhage. I remember getting off the phone with my mom, who had just delivered the simultaneous news of the baby’s birth and my sister’s serious condition, and feeling terrified. My sister was being taken into surgery to try to stop the bleeding. What if she died? In the U.S., deaths from postpartum hemorrhage are rare, but they do happen.

The first thing that gave me a sense of reassurance, strangely, was a search of the medical database PubMed. After I got off the phone, I sat at my laptop looking at a multicolored flow chart that summarized how to stop an obstetric hemorrhage. All of the steps taken by my sister’s medical team were listed. Although she was hundreds of miles away, I felt comforted by the knowledge that her doctors were following well-established, evidence-based guidelines for what to do.

It wasn’t until a few minutes later that I realized the flow chart was developed by doctors I know. It was part of the Obstetric Hemorrhage Toolkit, a set of guidelines published by the California Maternal Quality Care Collaborative (CMQCC). I had first heard of the toolkit from a Stanford obstetric anesthesiologist who helped put it together, but had never imagined it might save someone in my family.

The toolkit was developed because maternal hemorrhages are rare, risky, and extremely time-sensitive. The kit gives medical teams the information they need to rehearse for, recognize and treat these hemorrhages immediately, without wasting minutes that could save the patient’s life.

Today, the CMQCC is releasing a new version of the toolkit. The update strengthens several areas of the kit, providing clearer parameters for use of certain medications and blood products and more information about how to support patients and families after a maternal hemorrhage, for instance.

And the flow chart I found calming is still there, on page 21 of this .pdf file. I’m so happy to see it again because, for me, it symbolizes the doctors, patients and families who will benefit from the kit in the future.

As for my family’s story, my mom called back later on the evening of my niece’s birth to tell me that the bleeding had stopped and my sister was recovering. Her introduction to motherhood was rougher than most, but today my sister and her daughter are fine: My favorite moment of a recent family gathering was seeing my chubby-cheeked niece racing toward me yelling “Aunnnnntie Errrrin!” with my beloved sister in hot pursuit behind her.

Previously: In poorest countries, increase in midwives could save mothers and their babies, Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms and Program focuses on treatment of placental disorders
Photo by bies

Pediatrics, Pregnancy, Stanford News, Surgery

A difficult decision that saved three young lives

A difficult decision that saved three young lives

Estrada-Triplets_013I first met Lily Estrada and her identical triplets almost a year ago. The three babies, who were nearly ready to go home from Lucile Packard Children’s Hospital Stanford, looked pretty ordinary. In fact, that’s why I love the photo at the right, which was taken at the time. Baby Pedro, in blue, was gazing at his mom; Ayden, in orange, was wiggling; and William, in grey, was sucking contentedly on his pacifier.

But they had survived an extraordinarily complicated and rare prenatal disorder. The single placenta that connected all three boys to their mother during pregnancy developed a vascular problem called twin-to-twin transfusion syndrome. Blood flowing through the placenta was not being shared equally between the fetuses, straining their hearts and putting all of them at risk of dying before birth.

When Estrada was diagnosed in late 2013, she and her husband, Guillermo Luevanos, faced a difficult decision. A surgery on the placenta might help save the babies, but it was by no means a sure bet. And, at the time, no one at Stanford performed the procedure, although a new partnership between our maternal-fetal medicine experts and their counterparts at Texas Children’s Hospital, in Houston, provided an opportunity for Estrada to be treated there. In the Stanford Medicine magazine story I wrote about the case, Estrada described how her family felt:

“We were saddened and sort of confused,” Estrada says, recalling the first reactions that she and her husband had to the news. “It was: We could wait and see what happened, but the likelihood was that we were going to have no baby, or we could terminate one and see what happened with the other two, or take the risk, go to Houston, have the surgery and hope it worked for all three. But they didn’t guarantee anything.”

One piece of background that helped inform the couple’s decision was the fact that when the surgery worked, research had shown it helped moms stay pregnant about four weeks longer, allowing their babies more time to develop before birth. (Because the uterus gets so crowded, twins and other multiples are almost always born early, but a less premature delivery makes a huge difference for the babies’ health.) Sealing the connecting blood vessels also seemed to protect surviving fetuses in the event that one died. “We’re separating, or attempting to separate, their fates,” [Estrada’s obstetrician] Yair Blumenfeld, MD, says.

After a lot of counseling and discussion with the Stanford team, “we decided to go for it and do surgery,” Estrada says.

Once they had made the choice, they had no second thoughts. “My husband was a little bit stronger,” Estrada recalls. “He just wanted me to go for it, and see what happened.”

triplets-medresThe surgery, performed at Texas Children’s by Michael Belfort, MD, PhD, was a success. And, as my story describes, the collaboration between the two institutions is going well, too. Stanford researcher Christopher Contag, PhD, and colleagues are studying how to make better and safer surgical tools for future maternal-fetal surgeries, while surgeons here have advanced their capabilities and now offer the surgery for twin-to-twin transfusion here in Palo Alto.

Meanwhile, William, Ayden and Pedro are doing well. My favorite moment in preparing the story was when I got to see our new photo of them, above. As their mom told me, “They’re really happy babies.”

Previously: NIH puts focus on the placenta, the “fascinating” and “least understood” organStanford Medicine magazine reports on time’s intersection with healthPlacenta: the video game and Program focuses on the treatment of placental disorders
Photo of triplets as infants by Norbert von der Groeben; photo of triplets as toddlers by Gregg Segal

In the News, Men's Health, Mental Health, Parenting, Pregnancy, Research

Examining how fathers’ postpartum depression affects toddlers

Examining how fathers' postpartum depression affects toddlers

Zoe walking with GilPostpartum depression doesn’t only affect moms, and new research shows that fathers who suffer from it have just as great an effect on their kids as depressed mothers do. As described in a press release from Northwestern University late last week, toddlers who have a depressed parent of either sex can experience emotional turmoil that manifests both internally and externally, through behaviors such as hitting, sadness, anxiety, lying, and jitteriness.

Most previous studies on the consequences of postpartum depression have focused only on women; this study (subscription required), published in Couple and Family Psychology: Research and Practice, is one of the first to examine how toddlers are affected by depression in either parent. It was led by Sheehan Fisher, PhD, professor of psychiatry at Northwestern University’s Feinberg School of Medicine.

As quoted in the release, Fisher states:

Father’s emotions affect their children. New fathers should be screened and treated for postpartum depression, just as we do for mothers… Early intervention is the key. If we can catch parents with depression earlier and treat them, then there won’t be a continuation of symptoms, and, maybe even as importantly, their child won’t be affected by a parent with depression.

Data for the study was collected from nearly 200 couples; questionnaires were administered both in the first few months after their child’s birth, and when their child was three years old. The forms were completed by each partner independently. Parents who reported signs of postpartum depression soon after the birth of their child also showed these signs three years later – the symptoms didn’t self-resolve. The questionnaire also asked about fighting between parents, which, interestingly, did not contribute to children’s emotionally troubled behaviors as much as having a depressed mother or father did.

Fisher stated in the release that depressed parents may smile and make eye contact less than parents who are not depressed, and that such emotional disengagement may make it hard for the child to form close attachments and healthy emotions.

Previous studies have shown that fathers are at a greater risk of depression after the birth of a child than at any other time in a typical male’s life.

Previously: A telephone lifeline for moms with postpartum depression, 2020 Mom Project promotes awareness of perinatal mood disorders, In study, health professionals helped prevent postpartum depressionDads get postpartum depression too and A call for depression screening for pregnant women, moms
Photo by Michelle Brandt

Imaging, In the News, NIH, Pregnancy, Research, Women's Health

NIH puts focus on the placenta, the “fascinating” and “least understood” organ

NIH puts focus on the placenta, the "fascinating" and "least understood" organ

ultrasoundLast week, the NIH announced its support for an initiative to study how new technologies can shed light on the placenta’s function and health during pregnancy. Considering how crucial the placenta is to not only the health of a woman and her fetus during pregnancy, but also to the lifelong health of both, it’s surprising to hear the NIH call it “the least understood human organ.”

Currently, doctors and scientists can only gather information about the placenta by using ultrasounds and blood tests, and by examining it after delivery. What if new sensors could track how well blood, oxygen, and nutrients are flowing to the fetus, or if new imaging technologies could assess how well the placenta is attaching to the uterine wall? What if biotechnology could assess the effects of environmental factors on the placenta, such as air pollution, maternal diet, and medications?

Better understanding and monitoring of this temporary organ promises to improve maternal and child health. Placental issues can contribute to negative pregnancy outcomes such as preeclampsia, gestational diabetes, preterm birth, and stillbirth, and they’ve also been linked to a higher risk of heart disease later in life, for both mother and child.

This is the third and largest funding announcement for the NIH’s Human Placenta Project, led by the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development and cosponsored by the NIH’s National Institute of Biomedical Imaging and Bioengineering.

Calling the placenta a “fascinating organ” and the “lifeline that gives us our start in the world” Alan E. Guttmacher, MD, director of the NICHHD, also said in an NIH press release:

We hope this funding opportunity will attract a broad range of researchers and clinicians to help — placental biologists, obstetricians, and experts in imaging, bioengineering, and other arenas… For researchers who want to apply their skills in an area of medicine that isn’t being looked at as much as both scientific opportunity and human health warrant, this is a wonderful chance.

Previously: Placenta, the video game, The placenta sacrifices itself to keep baby healthy in case of starvation and Program focuses on the treatment of placental disorders
Related: Too deeply attached and A most mysterious organ
Photo by thinkpanama

Mental Health, Parenting, Pregnancy, Women's Health

A telephone lifeline for moms with postpartum depression

A telephone lifeline for moms with postpartum depression

Van_Gogh_-_Madame_Augustine_Roulin_mit_BabyI’m currently pregnant and due in less than two weeks. It’s my second child, so I’m not as worried about caring for a newborn as I was the first time around. But one nagging worry I have is the risk of postpartum depression, sometimes called postnatal depression. I have a family history of depression and that puts me at higher risk. Luckily, it wasn’t a problem with my firstborn, but it can crop up in later pregnancies – and scientists don’t entirely understand the reasons for it.

Postpartum depression usually hits four to six weeks after delivery—though it can show up months later. It’s characterized by feeling overwhelmed, trapped, guilty or inadequate, along with crying, irritability, problems concentrating, loss of appetite or libido, or sleep problems. An estimated 9 to 16 percent of new mothers are affected by postpartum depression. Even men are known to suffer from it sometimes. PPD affects not just the mother (or father), but can have lasting effects on the child as well, so helping these parents through a difficult and isolating time is critical

Now, a study published in Journal of Advanced Nursing shows that providing a social network for new moms, via phone calls from other mothers who had recovered from PPD, could alleviate symptoms for moms in the study for up to two years after delivery. A news release summarized the findings:

For the present quasi-experimental study, researchers recruited 64 mothers with depression up to two years after delivery who were living in New Brunswick. Peer volunteers who recovered from postnatal depression were trained as peer support and provided an average of nine support calls. The average age of mothers was 26 years, with 77% reporting depressive symptoms prior to pregnancy and 57% having pregnancy complications. There were 16 women (35%) who were taking medication for depression since the birth.

I find the idea that this insidious problem could be tackled with a phone version of the ubiquitous and valuable moms’ groups an uplifting one. Compared to drug treatments, regular phone calls from a peer who’s gone through something similar is a relatively cheap treatment. Further studies are needed, but I’ll be watching to see whether this approach takes hold as a standard intervention for PPD.

Previously: “2020 Mom Project” promotes awareness of perinatal mood disorders,  Is postpartum depression more of an urban problem?, Helping moms emerge from the darkness of postpartum depression, Breastfeeding difficulties may lead to depression in new moms, and Dads get postpartum depression, too
Image by Van Gogh

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