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Adam S. Levine, M.D. recently finished his fellowship in reproductive endocrinology and infertility within the department of gynecology and obstetrics at the Johns Hopkins University School of Medicine. His areas of expertise include reproductive endocrinology, infertility, assisted reproductive technology, reproductive surgery, pediatric and adolescent gynecology, and menopause.

 

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pregnancy

Q:    Would drinking and/or doing drugs while pregnant have any impact on the child's memory?	A:   Any substance used during pregnancy can potentially affect the exposed child. While memory itself is difficult to measure, alcohol use during pregnancy can result in fetal alcohol syndrome. Further, cocaine, crack and other recreationally abused substances can all result in similar syndromes. The amount of any substance necessary to cause one of these syndromes is unknown. Many of these syndromes result in behavioral difficulties, attention disorders and developmental delay. In addition to cognitive impairment, these syndromes may also result in physical abnormalities. Long-term evaluation and follow-up of children who have been exposed to alcohol and other abused recreational substances are currently underway. Children who either have had known exposure or had potential exposure to alcohol or abused recreational substances may benefit from specialized pediatric care.
Q:   I am currently taking 40 mg of Prozac daily, and also Ativan, when necessary. I want to become pregnant. Will these medications decrease my chances of becoming pregnant? Also, if I were to become pregnant while taking these medications, would the health of the baby be affected?	A:   The first eight to 12 weeks of a pregnancy are a critical time during which the fetal organs are forming. Women with chronic medical conditions, or women using prescription medications on a regular basis, will benefit from a pre-conception visit with their obstetrician. Women who have ongoing medical conditions, or are using prescription medications, and find they are pregnant, should see their obstetrician or maternal-fetal medicine specialist (high-risk obstetrician) as soon as possible. Unfortunately, it is usually not possible to accurately predict pregnancy outcome following prenatal exposure to medications; even those associated with known congenital defects. Obstetricians generally recommend that during this time, women limit their exposure to any substances that are not necessary for their continued well being (such as anti-epileptic medications).    When it is necessary to use medications in pregnancy, we are often guided by limited data. Prozac is an antidepressant that is used to treat a variety of conditions and may be used in pregnancy, provided the benefits of treatment outweigh the risks associated with its use. However, Ativan is an anxiolytic and has been associated with fetal malformations. Neither medication should prevent someone from becoming pregnant. In this case it would be important to meet with the physician who prescribed the medications, and discuss future plans to become pregnant.
Q:   What are the symptoms of a tubal pregnancy? What other conditions have similar symptoms?	A:   A tubal pregnancy is technically referred to as an ectopic pregnancy. This occurs when an embryo implants and grows in the fallopian tubes instead of the uterus. An ectopic pregnancy may occur following pelvic inflammatory disease, because the lining of the tube becomes damaged. Ectopic pregnancies or suspected ectopic pregnancies are medical emergencies and require immediate attention. They are not viable pregnancies, cannot be replaced in the uterus and could result in severe internal bleeding resulting in loss of life.    Like numerous other problems such as endometriosis, ovarian cysts or appendicitis, pain is a common complaint in women with ectopic pregnancies. Women with ectopic pregnancies will commonly either have a delayed menstrual cycle or miss a menstrual cycle, and experience sharp pain on either the right or left side. In some cases, these women may already have a positive pregnancy test. In all cases, women who suspect that they have an ectopic pregnancy should seek immediate medical attention. A sensitive pregnancy test will determine if there is a pregnancy, and an ultrasound will determine if the pregnancy is in the uterus or it is ectopic. Ectopic pregnancies may be treated either by surgery or medications, depending on the individual circumstances.
Q:   Is a dilatation and curettage (D&C) always necessary after a miscarriage?	A:   A D&C is an operative procedure where the cervix is gently opened (dilatation) and a very superficial layer of the endometrium (lining of the uterus) is removed. A D&C may be performed for diagnostic reasons (such as making sure post-menopausal bleeding is not from cancer) or therapeutic reasons (such as in heavy bleeding or miscarriage).    In answer to your question: The simple answer is No--a D&C is not always necessary after a miscarriage. However, they are commonly performed after miscarriage for several reasons, including preventing heavy bleeding and obtaining tissue for chromosomal (genetic) analysis.    In many cases, the length of a pregnancy before miscarriage may affect the necessity for D&C. For example, a very early miscarriage often results from a blighted (abnormal or damaged) ovum. In this case, a woman's body reacts to an abnormal pregnancy as if she were pregnant. However, the blighted ovum will never develop into a viable pregnancy. A D&C is usually suggested to remove the blighted ovum. Another example occurs later during a pregnancy when a woman has a miscarriage. The placenta may remain densely attached to the uterus, resulting in heavy bleeding. In this case a D&C is performed to remove the remaining placenta and reduce bleeding.
Q:   I am a top amateur aerobic fitness competitor, and my boyfriend is a professional bodybuilder. We're planning to try to conceive in September. I'm concerned about the steroids that my boyfriend has taken over the years and the nutritional supplements that I take (I have a high protein intake--in order to maintain muscle). Are there any specific risks that we may have conceiving?	A:   There are several different issues involved with answering this question. Conception is an equation composed of a male factor, a female factor and a couple factor. In some cases, steroid use may have a deleterious effect on male fertility. The easiest way to evaluate male fertility is with a semen analysis. Aside from a direct effect on the potential ability to conceive, his past steroid use should not affect the pregnancy.    Some female athletes have irregular menses or ovulatory disorders which are related to a lower than normal body fat content. There are several different methods that may be used to evaluate whether ovulation (where an egg is released from the ovary) occurs every month. One way is to use a home LH kit and carefully follow the instructions that come with it. A visit with a Reproductive Endocrinologist (fertility expert) may be helpful to coordinate any necessary evaluation. A second, and perhaps ultimately more important issue, is what to do when you become pregnant. There is a limited amount of information surrounding exercise and pregnancy. A pre-conception visit with a Perinatologist (high risk obstetrician) would be extremely beneficial.    Finally, I am personally not a fan of vitamin and mineral supplements. They are not regulated by the United States Food and Drug Administration and their labels may be inaccurate. Further, there is very little data regarding specific vitamin and mineral supplement use during pregnancy.
Q:   My 24-year-old daughter had a baby five months ago. During the latter part of her pregnancy, she was very short of breath most of the time. Since the baby has been born, she still seems winded. Iron supplements help somewhat. What could be the problem?	A:   To begin, anyone who is short of breath should seek medical attention. The technical term for feeling short of breath is dyspnea. Dyspnea may occur in some individuals with chronic anemia (low red blood cell count); red blood cells carry oxygen throughout the body. Potentially, if the anemia were caused by an iron deficiency, iron supplementation would correct the anemia and lessen the feeling of dyspnea.    There are several reasons a pregnant woman may become short of breath. In fact, between 60 and 70 percent of pregnant women feel as if they are short of breath. This feeling usually begins after 10 to 12 weeks of pregnancy. During pregnancy, a woman' s body undergoes several physiologic changes. The change that most women experience is an increased amount of air that is inspired and expired with each breath. In your daughter's case, I would recommend a medical evaluation.
Q:   During a recent doctor's appointment to confirm my second pregnancy, an internal ultrasound also showed a fibroid. The information I have found says women usually develop fibroids after age 35. Is this something that I should be concerned about?	A:   Uterine fibroid tumors, also known as myomas or leiomyomas, are usually benign growths of muscle cells that make up the uterus. They may cause the uterus to enlarge and also are a source of pain, increased menstrual cramping and bleeding, and/or irregular menstrual bleeding. Fibroids grow in response to the naturally occurring female hormonal environment.    Many fibroids will stop growing, and maydecrease in size during menopause. Fibroids may develop at any age. Usually younger women have smaller fibroids that can not be felt during a pelvic examination. The fibroids generally grow slowly and can be felt during an examination when the patient is older. The location of the fibroid is important, in that it may theoretically affect pregnancy, labor and delivery. In the majority of cases, fibroids are benign and should not elicit concern. However, because their size and location may be important, consultation with an obstetrician-gynecologist may be helpful.
Q:   I had a miscarriage earlier this year, and was told to wait until I'd had three normal menstrual cycles before trying to get pregnant again. I had a D&C on March 8, and had a completely normal period April 15 to 20. Now, I find I'm pregnant. I must have conceived around May 1. What are the risks of getting pregnant so soon after miscarriage and D&C?	A:   There are basically two reasons that women are asked to delay becoming pregnant following a miscarriage. Delaying subsequent pregnancies allows a woman's body enough time to restore normal physiologic function (women's bodies normally undergo several changes during pregnancy that may take several weeks to recover from) and replenish nutrients (such as iron) lost during the pregnancy. For example, many menstruating women are mildly anemic (low red blood cell count usually secondary to iron deficiency) before becoming pregnant. The anemia worsens during the beginning of a pregnancy for several reasons. Another reason some women are asked to delay pregnancy is if they are undergoing an evaluation for more than one miscarriage. An intervening pregnancy will prevent completion of the evaluation before a possible cause for the recurrent miscarriages is found.
Q:   Are there any risks associated with the use of herbs during pregnancy and while nursing? Specifically, I'm wondering about any contraindications, since I have heard mixed information about ginger, licorice and gingko.	A:   Dietary supplements such as gingko, ginger and licorice are not regulated by the United States Food and Drug Administration. Therefore, their composition and purity vary by brand and lot number. Unfortunately, with the exception of folate, there are few scientific studies examining the effect of dietary supplements on pregnancy and subsequent breast-feeding.    Because the first few weeks of a pregnancy are critical to normal fetal development, I generally recommend a well-balanced diet supplemented only with prenatal vitamins and iron. Although most prenatal vitamins contain folate, some women will also benefit from additional folate supplementation. Following pregnancy, women should continue prenatal vitamins and iron if they are breast-feeding.    There is very little reliable information that's available regarding dietary supplementation during breast-feeding. Since breast milk has a tendency to concentrate some substances, I generally recommend that nursing women only supplement their healthy diet with prenatal vitamins and iron.
Q:   My wife hasn't had her period for two weeks. We did a home pregnancy test which indicated she was pregnant. Her doctor is out of town, and today she spotted. Now she is not sure what to think. Is spotting normal during the early stages of pregnancy?	A:   It is reasonable to check a pregnancy test (either blood or urine) if a woman's menses is delayed more than one week. Pregnancy tests can be checked at a physician's office or at home. A home urine pregnancy tests should be able to detect a pregnancy at the time of a missed period. Blood pregnancy tests, available at a physician's office, are more sensitive at detecting earlier pregnancies.    A pregnancy is initially established in the fallopian tube when a single sperm cell fertilizes an egg. Approximately 96 hours after fertilization, the early embryo leaves the fallopian tube and enters the uterus where it will eventually implant (grow into) into the uterine lining. During this implantation, a small amount of vaginal spotting or bleeding may occur. This spotting or bleeding will often mislead a woman into believing that her period is earlier and lighter than usual.    Vaginal spotting or bleeding during the first few weeks of a woman's pregnancy is common. In many cases, the pregnancy will progress without further complications. However, women who experience vaginal spotting or bleeding during pregnancy should be evaluated by their physician. Most physicians share after-hours responsibilities with another physician who may also cover their practice when they are on vacation. If a woman is not able to reach her physician or experiences severe pain or heavy bleeding she should go to an emergency room.
Q:   As I understand it, if a pregnant woman tests positive for the anti-ssa and/or anti-ssb autoantibodies, her infant is at risk for congenital complete heart block. If her physician knows of this test result, is there anything he/she can do to protect the fetus from developing heart block? Can this knowledge be used to change the outcome for her baby? How? What are the odds that a woman who tests positive for these autoantibodies will give birth to an affected child? (She was diagnosed with primary Sjorgens after the birth of her second, healthy child.)	A:   Basically, the immune system is responsible for recognizing "self" from "not self" in the body. Anything that is found that is "not self" (a bacterium for example) is broken down and removed to protect the body from outside agents. Connective-tissue disorders (also called collagen vascular diseases) include such processes as rheumatoid arthritis and systemic lupus erythematosus (or lupus). They are the result of a defective immune system where "self" is not recognized. The immune system then makes autoantibodies (cells which break down and remove "self") to different tissues (blood cells, skin, heart cells). Some of these autoantibodies can cross the placenta in a pregnant woman and affect an unborn baby.    In this case, Sjorgens syndrome is one form of systemic lupus erythematosus. Approximately 30 percent of women with lupus have anti-SSA (anti-Ro) autoantibodies and 10 percent of women with lupus have anti-SSB (anti-la) autoantibodies. These two autoantibodies can cross the placenta and damage the fetal heart. The area of the fetal heart that is damaged is essential for the heart's normal electrical activity. This results in a partial or a complete heart block (a situation in which the heart does not beat regularly or at all). This situation is fairly uncommon and is referred to as congenital heart block. Between 4% and 9% of pregnant women with systemic lupus erythematosus will have infants affected by congenital heart block.    The general recommendation for women with connective tissue disorders is to be carefully followed by a high-risk obstetrician (maternal fetal medicine expert). Equally important is for babies that may be affected to be delivered at a center that can provide them with whatever medical therapy is necessary (some may need to be delivered very early and some may require sophisticated cardiac care). Women with connective tissue disorders or other women at risk may be screened for anti-SSA and anti-SSB. During affected pregnancies there are a variety of tests may be employed to evaluate fetal cardiac function (fetal sonography or ultrasound, fetal echocardiography (ultrasound of the fetal heart and blood flow), etc.) Maternal treatment may involve observation and/or medication. Following delivery, affected infants may need to be treated with a pacemaker (device to regulate the hearts electrical activity).
Q:   Are there any anti-depressants that will not pass into breastmilk? Are there some with minimal side effects for the baby?	A:   Most pharmaceutical substances that are used by nursing women are found in their breast milk. What needs to be clear, however, is that the actual concentration of those medications in the breast milk is usually extremely low. These concentrations are so low that they usually have no effect on infants. The American Academy of Pediatricians Committee on Drugs compiled a comprehensive listing of drugs and other chemical that are transferred into breast milk. They defined four categories. Category 1 includes drugs of abuse that should not be used while breast-feeding (cocaine, etc.). Category 2 includes drugs that require a temporary cessation of breast-feeding while they are being used (radioactive substances, etc.). Category 3 includes drugs whose effect on nursing infants is unknown, but may be of concern (anti-depressants, etc.). Category 4 includes medications that have effected the nursing infants and should be used with caution (includes a wide variety of drugs, including such common medications as allergy preparations).    Anti-depressants currently available in the United States are generally all found in breast milk following use. Most of the anti-depressants fall into the American Academy of Pediatrics Committee on Drugs Category 3. However, some of them are contraindicated (Category 1, such as lithium). Several new types of anti-depressants have recently become available in the United States. Their manufacturers state that they are safer than some of the older preparations. These include medications such as Buproprion (Wellbutrin), Fluoxetine (Prozac), and Sertraline (Zoloft).    There is a great deal of data that supports the idea that breast-feeding is beneficial. Unfortunately, there is very little real clinical data regarding the use of most medications in breast-feeding women and the effect of these medications on their infants. The use of antidepressants in breast- feeding women is possible but should be done in conjunction with a physician. As in all areas of medicine, a balance must be struck between the potential risks of treatment versus the potential benefits of treatment.
Q:   Is Claritin an antihistamine or decongestant? Which one is better to use when you are pregnant, if you must take something? How harmful can these medications be to a fetus?	A:   Claritin (Loratadine) is an antihistamine. It is a class B medication (see below) and may be used in pregnancy. It is generally taken once per day. However, for many of the reasons listed below, women are generally advised to limit all medication use (prescription and over-the-counter) in pregnancy.    The first eight to 12 weeks of pregnancy are a critical period during which the organs are forming. Exposure to teratogenic agents (things that cause birth defects such as alcohol, lead, etc.) during this time may result in congenital anomalies (birth defects). Obstetricians generally recommend that during this time, women limit their exposure to any substances that are not necessary for their continued well-being (such as anti-epileptic medications). When it is necessary to use medications in pregnancy, we are often guided by limited data.    Medications are grouped into an ABCDX classification scheme where class A medications (pre-natal vitamins) are proven safe in pregnancy and class X medications (Isotretinoin [Retin-A]) are known teratogens. Class B medications (Penicillin, along with Claritin) are generally also thought to be safe in pregnancy, as demonstrated by human data. Class C medications (Diphenhydramine [Benadryl]) may be used when the benefits of their use outweigh their risks. However, there are no adequate studies to assure that these medications are safe in human pregnancies. Class D medications (Phenytoin [Dilantin]) confer an extremely limited risk and may be used when the benefits of their use outweigh their risks.
Q:   Will taking coumadin prior to the knowledge of being pregnant or taking it during the first month of pregnancy likely to cause birth defects to the child?	A:   Coumadin (warfarin) is an anticoagulant (blood thinner) that is used for a variety of reasons. Coumadin passes through the placenta to a developing fetus and is associated with a variety of congenital abnormalities. Because of this, coumadin is not used during pregnancy and women taking it may be changed to a different type of blood thinner that does not cross the placenta. Women who are using coumadin who wish to become pregnant should first consult with their physician, an obstetrician, or a maternal-fetal medicine specialist (high-risk obstetrician). If a woman is using coumadin and finds that she is pregnant she should consult with her obstetrician, or a maternal-fetal medicine specialist as soon as possible. They may recommend meeting with a genetics counselor who can discuss the specifics of prenatal exposure to coumadin. The first 12 weeks of a pregnancy is a critical time during which the fetal organs are forming. However, it is difficult to predict exactly what effect that drug exposure will have.
Q:   What is Dandy-Walker Syndrome? How would it affect the future of a 34-week-old fetus?	A:   In order to understand Dandy Walker syndrome, it’s important to understand some basic anatomy. Inside the brain are ventricles (spaces) that are filled with cerebrospinal fluid. The fluid is produced by the lining of the ventricles, and drains into the spinal cord. If the fluid is blocked, the ventricles will swell (technically called hydrocephaly). This compresses the brain inside the skull. In some cases, a shunt (tube) can be placed to relieve the pressure and drain the fluid into the abdominal cavity.    Dandy-Walker Syndrome is a form of congenital hydrocephaly. In this syndrome, the small passages (foramina of Lushka and Magendi) in the skull that permit the flow of cerebrospinal fluid into the spinal cord are blocked. In addition, this syndrome is commonly associated with other malformations within the brain. Both the exact cause of Dandy-Walker Syndrome and its risk of recurrence are not clear. Unfortunately, it is not possible to accurately predict the outcome of infants with Dandy-Walker Syndrome. In these cases, consultation with obstetric specialists, neonatal specialists and neurosurgeons may be helpful.
Q:   I just found out that I am 6 weeks pregnant. I have been taking several medications--relafen, prozac, trazadone, and occasionally aspirin--and I want to know if I should be concerned. . Since discovering that I was pregnant, I have reduced the prozac to 20 mg, stopped the trazadone and relafen and not taken any aspirin. Please tell me if I have any reason for concern.	A:   The first 8 to 12 weeks of a pregnancy are a critical time during which the fetal organs are forming. Women with chronic medical conditions or women using prescription medications on a regular basis will benefit from a pre-conception visit with their obstetrician. Women who have ongoing medical conditions or who are using prescription medications and find they are pregnant should see their obstetrician or maternal-fetal medicine specialist (high-risk obstetrician) as soon as possible.    Unfortunately, it is usually not possible to accurately predict pregnancy outcome following prenatal exposure to medications; even those associated with known congenital defects.    Obstetricians generally recommend that during this time, women limit their exposure to any substances that are not necessary for their continued well being. When it is necessary to use medications in pregnancy, we are often guided by limited data. Medications are grouped into an ABCDX classification scheme, where category A medications (pre-natal vitamins) are proven safe during pregnancy, and class X medications (Isotretinoin [Retin-A]) are known teratogens. Category B medications (Penicillin) are generally also thought to be safe in pregnancy, as demonstrated by human data. Category C medications (Diphenhydramine [Benadryl]) may be used when the benefits of their use outweigh their risks. However, there are no adequate studies to assure that these medications are safe in human pregnancies. Category D medications (Phenytoin [Dilantin]) confer an extremely limited risk and may be used when the benefits of their use outweigh their risks.    Relafen is a non-steroidal anti-inflammatory (NSAID) medication. It is a category C medication. Under closely monitored circumstances, some obstetricians may elect to use NSAIDs to treat pregnancy complications such as preterm labor. However, NSAID use is associated with fetal cardiovascular changes, fetal renal changes and decreases in amniotic fluid volume. NSAIDs should only be used under the direction of an obstetrician. Aspirin is similar to Relafen and should not be used in pregnancy. Prozac is an antidepressant that is used to treat a variety of conditions; it is a category B medication and may be used in pregnancy, provided the benefits of treatment outweigh the risks associated with its use. Trazodone is an antidepressant medication that is category C. It also may be used in pregnancy, provided its benefits outweigh its risks.
Q:   I have heard that when a woman is pregnant, her eyesight may be affected by hormones and fluid retention. I cannot find any information to tell me if this problem continues while she is breast-feeding. When does the vision return to normal?	A:   Pregnancy results in profound, temporary physiologic alterations in a woman's body. However, not all women experience the same changes. Vision may be potentially affected. During pregnancy and lactation (breast-feeding), some women transiently lose the ability to focus (technically called accommodation) on near or far objects. The surface of the eye (cornea) can become less sensitive to irritation (contact) and swell. This swelling may cause contact lenses to become uncomfortable. Other changes (such as a decrease in pressure within the eye) are not generally appreciated. These physiologic alterations will return to normal over the post-partum period. However, sudden visual changes in pregnancy or post-partum may represent significant medical complications. Therefore, it is extremely important for any woman (pregnant or post-partum) to immediately report sudden visual changes (feelings of pressure, spots, blurry vision) to their obstetrician.
Q:   How soon after a woman becomes pregnant can paternity be determined and by what means?	A:   The most common and least invasive way that paternity may be determined is by blood testing following birth. To accomplish this, blood samples from the baby, the father and perhaps the mother, are analyzed. This type of testing is limited to after delivery. There are times during an ongoing pregnancy when it is necessary to analyze fetal blood or other tissues. For example, an amniocentesis (using a needle which passes through the mother's abdomen and uterus to remove a sample of fluid from around the baby) may be performed to determine if a baby has a chromosome abnormality such as Down's Syndrome. However, because this type of testing is invasive and may potentially interfere with the ongoing pregnancy, it is not generally used for paternity testing. If determining paternity is important, I would discuss the situation with the woman's health care provider and arrange for testing following the birth.
Q:   I have been using an herb called Chitosan, marketed by GNC, under Optibolic Chitosan Plus. I just found out that I am pregnant. Will this harm my baby in any way? What herbs are considered safe for pregnant women?	A:   The first few weeks of a pregnancy are critical to normal development. It is during these first few weeks that the organs are forming. Later, as the pregnancy progresses, the organs grow and mature. There are a number of substances that have been shown to effect organ development and growth. Alcohol use, for example, may lead to fetal alcohol syndrome. Whereas, folate use prevents neural tube defects. A woman's nutritional requirements during pregnancy should be met by a well balanced diet that may be supplemented with prenatal vitamins and iron.    Unfortunately, there are very few studies that have evaluated the use of other dietary supplements in pregnancy. In fact, dietary supplements such as herbs are not regulated by the United States Food and Drug Administration. Therefore, their composition and purity may vary. For these reasons I recommend that women only use supplements in consultation with their obstetrician. I have not been able to locate any information regarding the use of Optibolic Chitosan Plus in pregnancy nor was GNC able to provide any.    Women who are planning a pregnancy may wish to supplement their healthy diet with prenatal vitamins and iron before they become pregnant. They may also wish to either take folate as a dietary supplement or increase their dietary folate (leafy green vegetables). A consultation with their physician, a nutritionist, or a dietitian may be helpful.
Q:   My wife would like to know how long you should wait after a Cesarean section to get pregnant again? Is there any health risk if you get pregnant too soon after a C-section?	A:   One general recommendation is to allow at least six to 12 months to pass between pregnancies. However, this is not an absolute requirement. During pregnancy, a woman's body undergoes significant physiologic changes. These changes develop over the nine-month course of a pregnancy and resolve following delivery. For example, most women have borderline to low iron reserves (iron is necessary for blood production). During pregnancy, the developing baby uses most of a woman's iron reserve; even if she is taking supplemental iron. Ultimately, reserve iron is replenished after delivery. Further, restoration of a normal pre-pregnancy physiology (such as iron) is delayed if a woman is breast-feeding.    Cesarean sections are major surgery. They involve making a large abdominal incision, as well as an incision into the uterus. Potentially, a uterine incision can open (rupture) when the uterus becomes distended in a subsequent pregnancy. Fortunately, this is an extremely rare event if the uterus is given enough time to heal completely. Individuals contemplating a repeat pregnancy soon after another pregnancy should discuss it with their obstetrician.