Health Maintenance

Mamas on Bedrest: New Recommendations for Tetanus, Diphtheria, Pertussis Vaccination During Pregnancy

October 26th, 2012

On October 24, 2012, The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention voted unanimously to recommend that all pregnant women receive a Tetanus, Diphtheria, Pertussis (Tdap) Vaccination during pregnancy. Additionally, ACIP recommends that all women receive a Tdap during each and every pregnancy.

Vaccinations in the United States are controversial. Vaccination during pregnancy is extremely controversial because of the concern of harm to the unborn child. However, ACIP has found that the risk of newborn infants developing pertussis (whooping cough) greatly outweighs any risk of severe adverse reactions to mama or unborn child receiving the Tdap vaccine.

According to Jennifer Liang, MD, from the CDC National Center for Immunization and Respiratory Diseases, who presented the proposed changes during the ACIP meeting in Atlanta, Georgia,

“Although there are no data to address what we really want to know [the potential for severe adverse events associated with repeat vaccinations for pregnant women who have multiple pregnancies in a short time interval], the data from studies in which healthy adults received 2 doses of Tdap are reassuring, and the historical experience with tetanus toxoid vaccine suggests no excess risk of adverse events with multiple doses.”

What is known is that infants that develop pertussis under two months of age have a much higher rate of complications and are at greater risk of death from the disease. It was previously believed that if Mama was up to date with her vaccinations, then baby would be okay. What the ACIP workgroup found is that many women are unsure of their immunization status or they had their Tdap vaccines so long ago (while still within the 10 yr window of “normal” for adults) that transferal of immunity to there babies was minimal if at all. Initially the CDC recommended that women who were unsure of their vaccine status receive Tdap, but now, given current data, they are recommending that all pregnant women receive Tdap during pregnancy between 27 and 36 weeks gestation.

The biggest change to their recommendations is that ACIP recommends that women have Tdap vaccines with all subsequent pregnancies. Based upon a review of published and unpublished studies on the use of Tdap in pregnant women and Tdap safety data from pregnancy registries and the Vaccine Adverse Event Reporting System, the ACIP Pertussis Vaccine Work Group concluded

“A single dose of Tdap at one pregnancy was insufficient to provide protection for subsequent pregnancies and that the benefits of vaccination outweigh the theoretical risks of severe adverse events.”

The work group found that since most women in the US have no more than 2-3 pregnancies, and given the safety and efficacy of Tdap, the additional doses of vaccine (theoretically) pose no threat to Mamas. (I was wondering if multiple doses of Tdap were safe for women who have pregnancies close together, i.e. children born 13 months apart. But given that infants receive multiple doses of a similar vaccination within the first year, this likely poses no immediate threat to mamas.) The working group supports and recommends continued research and study to definitively assess safety of Tdap administration in multiple (and perhaps close) pregnancies.

Other recommendations include vaccinating women in the immediate post partum if immunization status is unknown or if they were not immunized during pregnancy. ACIP also recommends that the childhood immunization schedules be updated so that teenagers that become pregnant receive Tdap according to this new protocol.

With approval of these recommendations by the US Department of Health and Human Services, they will be published in the 2013 edition of Morbidity and Mortality Weekly Report, the guide routinely referred to by health care providers for the latest recommendations to standards of care.

Resources

MedScape OB/GYN and Women’s Health News

The 2011 ACIP Recommendations for Tdap in Pregnancy

Mamas on Bedrest: Feeling Wiped Out? It may not be pregnancy or motherhood, it may be your thyroid.

August 21st, 2012

Having my son totally knocked out my thyroid and exhausted my adrenal glands.

After I had my daughter, I nursed her for nearly 11 months and when she self weaned, I was back to my lean self within 3 months. I had my daughter 6 weeks shy of turning 37, so I felt pretty good about my ability to “bounce back.”

When I had my son 3 1/2 years later, it was an entirely different story. Despite having a much kinder, gentler pregnancy and a relatively complication free cesarean section delivery, within mere weeks of having my son, I felt as if I had been rolled over by a steam roller. When I mentioned this to my OB at my 2 week check up, she dismissed me with, “You just had your second child at age 40. This is a whole new ball game.” When I brought up the issue of being utterly exhausted at my 6 week check up, she reminded me, “You are now the mother of 2 children 3 and under. You’re going to be tired.”

But it was more than feeling tired. My body ached. I felt as if I had either run a marathon or been in a physical battle and my opponent had clearly had the upper hand.  Although I was actually getting a decent amount of sleep, it was never enough. And unlike with my daughter, the more I nursed my son, the more weight I gained.

I grew more concerned when I noticed that my skin felt dry and leathery and my hair was thinning. Now this second one really caught my attention. When I was pregnant with my son, every thing grew; hair, skin, nails…you name it. But shortly after my son’s birth, I noticed my then almost waist length locks were thinning. As my locks grew from my scalp, they were much thinner than the lower portion of the lock and over time, my locks began to break off. Finally, at about 4 months post partum, my nails began to split down the middle. This combined with my other symptoms lead me to ask my OB to test for thyroid hormone deficiency. As a physician assistant, I was well aware of the signs and symptoms of hypothyroidism and the nail splitting was a huge indicator that something was wrong. My OB honored my wishes and did a blood test. The test came back “normal” and she told me that there was nothing more to do but to take extra care of myself. (Seriously, with a newborn, a 3 1/2 year old and a traveling husband when was that supposed to happen???)

So I suffered and I struggled and I continued on. When my son was 8 months old, I caught some sort of virus and my milk production stopped. No slowing to a trickle, I went to nurse him Thanksgving day and I had no milk to give him. My poor baby, who had never even drank out of a bottle and who had been exclusively breastfed, was now without any food. I tried formulas, baby food, anything-he wouldn’t touch it. I worked feverishly with a lactation consultant to try to stimulate my milk production but to no avail. At the same time, I had my thyroid levels checked by another “holistic” practitioner and again, my result was “within normal range”.

So as I struggled to feed my child and figure out what was going on with my body, I tried all sorts of nutritional supplements and energy boosters (since I was no longer nursing!) and nothing worked. I worked with a holistic practitioner for a while and while I felt better, I still was not at my baseline, some two years later. Finally, 3 years later, I was interviewing a clinician who specialized in bioidentical hormones. As she described the signs and symptoms of hypothyroidism, she also mentioned something new to me-adrenal fatigue. When we finished our interview, I promptly asked her for the intake forms to her clinic and scheduled an appointment.

I had my blood drawn a few days before my office visit and also did saliva tests.  When I met with the physician, he was amazed that I was standing. My tests showed that my adrenal glands were wiped out and that I wasn’t putting out nearly the necessary amounts of adrenal hormones that my body needed. Additionally, my thyroid level was technically within the normal range, but the range was 0.17-3.0 and I was 0.17. With the normal fluctuations that occur during the day I was functioning mostly in the hypothyroid range. The same thing was happening with my adrenal hormones. Most of the time, I was functioning in the deficient range. The news was a relief. No, I wasn’t crazy and I wasn’t a whiner. There really was a medical reason that I felt horrible. But at the same time, I was angry and frustrated. I had been feeling poorly for over 3 years by that time. I had seen at least 3 other clinicians and none of them had been able to help me. Because the blood work that they took at a single given point in time was “within normal limits” (despite being so far at the lower end of normal) nothing had been done. As a result, I had suffered for far too long and my baby had to stop breastfeeding long before either of us was ready to quit.

My new (and current) gynecologist practices “functional medicine“. He looks at what is the level of hormone needed to have a person able to function, able to do their activities of daily living with ease, and he prescribes hormone replacement in doses that keep you in that range. He uses blood and saliva tests as guides, but in my case, he found that my functional thyroid level is on the higher end of the normal range. He also found that I needed adrenal hormone supplementation and he added testosterone because I was low and it would (and has) helped with my weight loss.

I hear so many women struggle post partum with fatigue, body aches, the inability to get good sleep or to lose weight. Many women can barely muster the strength to care for their babies. And far too many women, like me, are unable to sustain breastfeeding because their hormone levels are suboptimal. Mamas, if any of these situations seems familiar to you, ask your doctor to check your hormone levels. What may seem like “post partum fatigue” really may be your thyroid or your adrenal glands pooping out! It’s not normal to feel exhausted all the time even when you get a full night’s sleep. It’s not normal for your hair to simply fall out. It’s not normal for your milk supply to suddenly stop. And all of these problems are preventable and if they are occuring, they are treatable. The key is to find a clinician that will listen to you and who knows a little something about functional medicine and hormones. Many OB/GYN’s and General/family physicians don’t know (and don’t care to learn) about functional medicine. Find a clinician who practices in this area and really understands functional endocrine (the study of hormones) medicine.

It’s been 3 years since I was finally diagnosed and treated for my “subclinical” hypothyroidism (means I didn’t make clinical criteria, but my body was acting hypothyroid!) and adrenal fatigue and I have to say I feel so much better. I am so glad that I persisted in finding a clinician who knew functional medicine because he has also been able to support me as I am now perimenopausal.

If you feel lousy, don’t let your health care provider dismiss it as “normal ” pregnancy or post partum fatigue.  Sometimes this is the case, but often there is a real problem causing the fatigue and it needs to be investigated. Press on until you find someone who will not only listen to you, but who won’t stop until they find what is causing your fatigue and a way to help you to feel better.

Mamas on Bedrest: When Breastfeeding Hurts

August 2nd, 2012

August 1-7 is World breastfeeding Week. Twitter, Facebook, blogs and national and international agencies will all tout the benefits of breastfeeding to convince some, while spurring on others to breastfeed.

I am sure that at this juncture, few if any will dispute the benefits of breastfeeding. Yet, for some mamas, breastfeeding is a tortuous nightmare. Difficulty with latching on, sore and cracked nipples, engorged breasts leading mastitis…will leave some mamas asking if the benefits of breastfeeding are really worth it.

For some mamas, the pain is just too much to endure and they stop breastfeeding. Yet, it doesn’t end there. Many mamas continue to second guess themselves, feel a tremendous sense of guilt and feel tremendous shame when confronted with their decision to cease breastfeeding.

In one of my very first blog posts, Breastfeeding: Natural But Not Always Easy, I recount my own challenges with nursing my children. Still I was lucky. Despite my challenges, I never had cracked nipples nor suffered with Mastitis.

When a mama decides to breastfeed, it is critical that she have a support system. To improve the number of mamas who breastfeed at all as well as the number of mamas who breastfeed long term, Surgeon General Regina Benjamin makes several specific suggestions on ways family, health care professionals, employers and businesses can support nursing mamas. A summary of Dr. Benjamin’s recommendations are listed in our blog post Surgeon General Calls for Support for Breastfeeding.

Finally, How The US Can Overcome Barriers to Breastfeeding, reviews what the US needs to do in order to reduce barriers to breastfeeding and to improve breastfeeding success to achieve the Healthy People 2020 benchmarks.

When it comes to infant nutrition, Breast really is best. However, Mamas need not suffer in order to give their babies a healthy start. With adequate support and education, most mamas who want to breastfeed their babies will be able to do so with minimal discomfort and certainly without pain.