How to take control of your pregnancy (UCLH web chat) 

Dr Anna David

As we celebrated the 150th anniversary of Elizabeth Garrett Anderson becoming the first woman to qualify as a doctor, we asked one of UCLH’s leading consultants from our Elizabeth Garrett Anderson maternity wing to answer your questions on how to take control of your pregnancy and how research is shedding new light on prenatal medicine.

Dr Anna David is consultant in obstetrics and maternal/fetal medicine at UCLH and Reader at the Institute for Women's Health, UCL. As well as running regular clinics at the EGA wing, Anna leads research into fetal medicine and prenatal diagnosis, fetal therapy, prevention of preterm birth and ethical issues in obstetrics.

Anna was online to answer your questions. You can read a transcript of the web chat below.


12:31 UCLH: 

Good afternoon and welcome to our web chat. We will begin at 1pm but you can submit your questions now in preparation for the chat. Please note: your questions will not appear in the main chat window until after 1pm.

Dr Anna David will be joining us to take your questions on 'Taking control of your pregnancy' and will try to answer as many questions as possible within the hour long web chat. It may not be possible to answer all questions during the hour.

 
12:34 Dr Anna David: 
Before we begin at 1pm, here is some background information about pregnancy and the Elizabeth Garrett Anderson Wing (EGA)...

Maternal deaths weren’t recorded until 1837 and the estimates before 1870 (when it was mandatory to report) are relatively inaccurate. In 1880 the maternal mortality rate was 40 per 1000 births - these aren’t separated into antenatal or intrapartum unfortunately. Absolute rates of other conditions are also not available

The big news around the time EGA qualified was puerperal sepsis. Semmelweis published on the aetiology of childbed fever in 1858. It was not popular with midwives and obstetricians who didn’t want to believe that they were responsible for the deaths… The first figures are actually from 1911 and between one and two women per 1000 total births died from puerperal sepsis. Pasteur had shown back in 1879 that most cases were caused by streptococcus; antibiotics were not used until the late 30s and were not widespread until the 40s - and it was only then that the rates declined.

Placenta praevia was an important cause of haemorrhage. In the second half of the nineteenth century Lawson Tait pioneered caesarean section to limit maternal bleeding from placenta praevia; unfortunately, many of the babies were preterm and most died. The practice of admitting women who had bled and keeping them in hospital until term and then doing their section started in the mid 40s. Women were treated with blood transfusions in the meantime. Post partum haemorrhage was a bit easier to manage; ergot had been available (as a tea!) since the early nineteenth century. By the early twentieth century it was being used (injection) prophylactically.

Pre-eclampsia was well recognised in the nineteenth century. The link between proteinuria and fits was described by John Lever in 1843 but the association with raised BP wasn’t established until the early twentieth century. At this point, treatment in the UK was sedation if the women fitted, and admission with bedrest if they had proteinuria and hypertension. Interestingly, magnesium sulphate has been used in the US to treat eclampsia since the 1920s - it is far more recent here.

Infant mortality in 1865 was around 150 per 1000 births and declined rapidly from 1900. The neonatal deaths are caught up in this figure. Stillbirths were not registered before 1939; at that point the rate was about 40 per 1000 total births - estimating rates before then is tricky! Preterm births are hidden away in the IMR and SB rate.

Data about miscarriage is limited to individual accounts (even now - we quote a rate of 15-40% but pregnancy losses are not reportable so there is no “rate” as such. I think this is a good thing…). Likewise hyperemesis, although we do know that Charlotte Bronte died in 1855 at about 20 weeks gestation having had dreadful hyperemesis!

Life expectancy at birth for men born in 1865 was 38 and for women was 41. At that time, women had on average 6 children!
 
1:02 [Comment From Jules: ] 
Hello Dr David, how can i avoid an amniocentesis in pregnancy?
 
1:02 Dr Anna David: 
Hi Jules,
Thanks for your question.
Currently we use amniocentesis (taking a sample of amniotic fluid from around the baby) to make a prenatal diagnosis. It’s a really safe technique when done by specialists but it still carries a risk of miscarriage (about 1%).

It’s a really exciting time in the development of new diagnostic techniques that can avoid women needing to have an amniocentesis. Researchers are developing a non-invasive test for some inherited genetic conditions such as thalassaemia, a common blood disorder. This uses a sample of the pregnant woman’s blood to find DNA (genetic material) from the baby. There is a test for Down’s Syndrome that’s close to being rolled out that will be a 99.7 per cent reliable screening test by taking blood from the mum. I’m hopeful that we’ll see that in the NHS within the next year or two.
 
1:03 [Comment From Debs: ] 
Can you screen for pre-eclampsia?
 
1:07 Dr Anna David: 
Thanks Debs.
Pre-eclampsia is when pregnant women develop high blood pressure, protein in the urine and symptoms such as headaches, blurred vision.
We’re still a way off having the means to predict who will develop pre-eclampsia from early in pregnancy. There are a few new tests becoming available that can predict whether someone will need delivery when they develop pre-eclampsia. One marker is placental growth factor or PlGF which can be tested for in the mother's blood. A low level can indicate that a pregnant woman will develop pre-eclampsia in the next two weeks. This could help doctors and midwives alert the woman to symptoms and signs to watch for, and may help improve outcomes for women who develop pre-eclampsia.
 
1:07 [Comment From Carly: ] 
Hello Anna, thanks for taking time to do this online chat. I am 42 years old and want to have another child, but I'm worried about my health and risks to the child because of my age. Do you have any advice on being an older mother in pregnancy?
 
1:09 Dr Anna David: 
Hi Carly

It’s a fact that the average age that women are choosing to have first children is increasing – it’s a trend linked to cultural, social and career changes. But while it’s true that the risk of certain things goes up as you get older – growth restriction (when the baby does not grow as well), for example, or gestational diabetes – that doesn’t mean that having a baby after you’re 35 is ‘high-risk’.

The majority of women who become pregnant in their late 30s and early 40s have perfectly healthy pregnancies and babies. Nevertheless, as a society we’ve changed the way we plan our lives, so it’s good to be informed and aware.

Good luck and I hope all goes well!
 
1:09 [Comment From Martin: ] 
Our second child was delivered early after doctors found he was growth restricted at 34 weeks. He's perfectly healthy now but it was a really distressing time and I'm worried that if we get pregnant again the same thing could happen. Are there any ways of knowing if your pregnancy is more inclined to go this way?
 
1:16 Dr Anna David: 
Hi Martin
Thanks for your question. I am glad to hear your son is doing well.

Fetal growth restriction is when the baby’s growth in the womb is less good than it should be, and it is relatively common, affecting about 3% of all pregnancies. We’re still a way off having the means to predict fetal growth restriction from early in pregnancy. We know that giving low doses of aspirin by 16 weeks of pregnancy may reduce the risk of developing it.

We can also do a scan of the blood flow to the womb and placenta at or around mid-pregnancy. If the circulation has developed well then the risk of having a growth restricted pregnancy is reduced. If the circulation is not so well developed then it is important to regularly check the baby's growth. We offer regular ultrasound growth scans, usually every 3-4 weeks in pregnancy to check that the baby is growing ok.

I hope this is helpful and good luck with the next baby.
 
1:16 [Comment From Francis: ] 
Hi Dr David, I unfortunately had a still birth last year. Is there any research being done that can help identify people at risk during pregnancy?
 
1:24 Dr Anna David: 
For more information about pre-eclampsia you can visit the action on pre-eclampsia website at: www.apec.org.uk or follow on twitter @APEC_UK
 
1:25 Dr Anna David: 
Hi Francis, thank you for your question. I am sorry to hear about your loss. That must have been devastating for you and your family.

There’s lots of work going on trying to identify pregnant women who are more likely to have a stillbirth. . It’s very early days, and the fact is that it’s such an unusual event – there are just a few in every 1,000 births in the UK that have a stillbirth so it makes any research challenging. There are studies being done to see if and how improving the monitoring of baby’s movements in the womb might help us predict if the baby is at risk.

If women are worried about their baby’s movements it is important that they mention it to their midwife or doctor so that some investigations (such as an ultrasound scan) can be done. If the baby is found to be small or unwell then we sometimes deliver the baby earlier, usually with a good outcome.
 
1:26 [Comment From Sian: ] 
How much monitoring should I be getting for my baby during my pregnancy? I worried that I'm not having enough check ups.
 
1:26 Dr Anna David: 
If you're affected by any of the issues in today's pregnancy webchat such as about stillbirth, you can contact @SandsUK for more support
 
1:34 Dr Anna David: 
Hi Sian
It’s a very good question. Ideally what is needed is to be able to discriminate between mums who need lots of care and those who don’t. We don’t have the right tests at the moment to be able to predict this from early in pregnancy, but they are likely to be developed in the next decade.

How much monitoring you need very much depends on how well you and the baby are, and your health when you became pregnant. If you are healthy then you would not need much monitoring apart from checking that your blood pressure is ok, and that the baby is growing well and moving normally. These checks can be done by your midwife.

If you have any previous medical problems eg high blood pressure or diabetes, then it is sensible to have more frequent checks with your midwife and obstetrician. These could involve more frequent ultrasound scans and blood tests.

If you are worried about the frequency of your check-ups you should discuss this with your midwife. I hope your pregnancy continues well.
 
1:34 [Comment From Veronica: ] 
Hi Dr David, I'm thinking about having a c-section for my first child. I'm worried abou the pain of natural birth. Is it better to have a natural birth if a c-section isn't needed?
 
1:38 Dr Anna David: 
Hi Veronica
That’s a great question.
Women are avoiding having a vaginal delivery for lots of reasons, many of them non-medical, and sometimes if they are worried about natural birth.

C-section is a life-saving operation for the mother and baby when used appropriately. But it’s difficult to justify a C-section in some cases – we’re talking about a serious medical intervention when often there’s no underlying medical indication for it, and that should never be undertaken lightly.

C-section has a higher rate of complications such as infection or bleeding when compared to having a vaginal birth. There is also increasing evidence to suggest that delivering vaginally brings other benefits for the baby such as protection from obesity, allergies and immune-related diseases. C-section also puts an additional burden on the health service: a vaginal delivery needs a midwife or maybe two, some input from an anaesthetist or obstetrician if necessary. A C-section involves a whole theatre of staff: one midwife, two obstetricians, two anaesthetists, scrub nurses, a runner, and so on. And all the while they’re working in that theatre, those staff aren’t available to help other women in labour.

There are of course some really good reasons why some mums should have a C-section, so we should preserve our resources for them.

If you are worried about pain in labour, then we are lucky to have available lots of different types of pain relief. You can discuss these with your midwife.
 
1:38 [Comment From EllieEllie: ] 
Hi Dr David. When my baby was born premature I was told breastfeeding could make a huge difference to her health - are there benefits especially for early babies?
 
1:43 Dr Anna David: 
Dear Ellie
Thanks for your query. I hope your baby is now doing well.

Having a premature baby can be a very stressful time and it can be difficult to breast feed at this time. It is true that breastfeeding your premature baby brings many benefits, not least because you get to cuddle your baby which is nice. Skin-to-skin contact with your premature baby helps to stabilise their heart rate and breathing. Even if you can’t hold your baby, your breast milk is good for your baby. Breastmilk from mums with preterm babies contains special proteins and fats for the premature infant. The milk also helps their bowel development and their immune system. The staff in the neonatal unit are really good at helping mums to breastfeed their premature infant and can give lots of advice.
 
1:43 [Comment From Lizzie: ] 
Are women doctors much better off now than when the first woman doctor qualified? There are still far less women than men in medicine.
 
1:49 Dr Anna David: 
Dear Lizzie

Thanks for your question. Things have changed so much since Elizabeth Garrett Anderson qualified. She had a real struggle to qualify but it is much easier now. Although overall there are far more male than female doctors, women medical students currently outnumber male medical students at many UK medical schools so it is changing rapidly.
In some specialties eg anaesthetics, paediatrics, pathology, there are more female than male doctors. In others, especially the craft specialties such as surgery and orthopaedics, there are still more men than women. The flexible nature of a career in medicine makes some specialties popular for women if they decide to have children. Increasingly women and men doctors have a portfolio career, where they move according to their interests. The important thing is that we get the best people to qualify as doctors, whatever their gender.
 
1:50 [Comment From SumaiyahSumaiyah: ] 
Hi, I'm 12 weeks pregnant and I used to enjoy going to gym regularly before. Since pregnancy I've not been very active for two reasons. One because I'm constantly feeling fatigued and I work as a full time teacher too. Secondly, all the advice I see online suggests that I shouldn't excercise, especially in my first trimester. I'd like some more clear guidlines on what is good for me and my baby. I used to enjoy running on the treadmill but have heard people saying that running is bad whilst pregnant - though I've heard stories of 9 month pregnant women running marathons. Please advise what is safe so I can remain active and well through my next 6 months and beyond.
 
2:00 Dr Anna David: 
Hi Sumaiyah
Thanks for your question. It’s something that I frequently get asked by pregnant women in my clinic.
It’s common to feel very fatigued in early pregnancy. This is probably related to important pregnancy hormones such as progesterone for example. They cause key pregnancy changes early on such as increasing your blood volume which helps the pregnancy to develop normally. Women commonly feel much more energetic in the middle third of pregnancy. It’s important that your blood levels of haemoglobin (the oxygen carrying protein in the blood) are normal, and this will be checked routinely in your first trimester “booking bloods”.

If you are used to running and feel fit enough to do so then it is probably safe. Some women do continue to run even competitively when they are pregnant and there is no evidence to show that this is detrimental to their pregnancy. You may find more gentle exercise such as walking on a treadmill or swimming is easier on your body if you are feeling tired. But it is important to keep fit when you are pregnant.

I hope you get some of your energy back soon!
 
2:00 [Comment From Linda: ] 
Hi. I'm weighing up the pros and cons of having an epidural when I give birth. Any advice?

2:10 Dr Anna David: 
Hi Linda
Having an epidural is very safe. We are fortunate these days that we have access to good pain relief in labour, something that was not available when Elizabeth Garrett Anderson qualified 150 years ago.

It is important to have an epidural when you are in established labour. There are lots of other choices of pain relief, ranging from paracetamol, TENS machines and acupuncture in early pregnancy, to gas and air (Entonox) and warm water when you are in established labour.

An epidural can provide very good pain relief, but it's not always 100% effective in labour and about one in eight women who have an epidural during labour need to use other methods of pain relief. 
 
To have an epidural you will need to have a drip that will run fluid through a needle into a vein in your arm. To place the epidural the anaesthetist will position you on your side or sit up in a curled position, clean your back with antiseptic, numb a small area with some local anaesthetic and then introduce a needle into your back. They then pass a very thin tube through the needle into your back near the nerves that carry pain impulses from the uterus. Drugs, usually a mixture of local anaesthetic and opioid, are administered through this tube. It takes about 10 minutes to set up the epidural, and another 10 to 15 minutes for it to work. It doesn't always work perfectly at first and may need adjusting. The epidural can be topped up by your midwife or you may be able to top up the epidural yourself through a machine. You will need your contractions and the baby's heart rate to be continuously monitored once you have an epidural.
 
There are some side effects to be aware of. The epidural may make your legs feel heavy, depending on the local anaesthetic used. Sometimes it can temporarily drop your blood pressure although this is rare since the fluid in the drip maintains good blood pressure. Epidurals can prolong the second stage of labour when you push the baby out. You may find it difficult to pass urine as a result of the epidural. If so, a small tube called a catheter may be put into your bladder to help you. About one in 100 women gets a headache after an epidural, but this is treatable. Your back might be a bit sore for a day or two, but epidurals don't cause long-term backache. About one in 2,000 women feels tingles or pins and needles down one leg after having a baby.

Overall epidurals are very safe and the most effective form of pain relief in labour.
 
2:10 [Comment From Beci: ] 
I've got a Mitrofanoff and looking into having a baby. Do you encourage natural births or c-sections? Also are there more problems associated with woman who have other medical problem I regards to conception, carrying and delivery? Thanks
 
2:17 Dr Anna David: 
Hi Beci
Thanks for your question. For those out there who do not know, a Mitrofanoff is a surgical procedure done for people who depend on catheterization to eliminate their urine. The appendix or bowel is used to create a conduit between the skin surface and the bladder.
We look after pregnant women who have had these procedures at UCLH, and we have close liaison between the obstetric team and the urological team who will know you well. Most women birth their baby by Caesarean section, which is performed with the urological surgeon there in case they need to repair your bladder. Women with Mitrofanoff generally have a good outcome of their pregnancy although it is important to have regular checkups on baby’s growth with ultrasound scans, and urine culture to check for urine infections. If you are thinking of having a baby it is worth discussing with your urology team who know your history well.
Good luck!
 
2:18 Dr Anna David: 
Hi there.
Thanks for all your great questions and I hope you enjoyed reading the answers! Hopefully we can do another web-chat in the near future. Best wishes. Anna
 

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