96. Pregnancy Complications & Stopping Misinformation on Women's Health | Dayna Smith, MD

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. Our guest today is board certified OBGYN physician Dr. Dana Smith. Dr. Smith received her medical degree from Mount Sinai Medical Center in New York, then completed her residency in OBGYN at UMDNJ in New York, New Jersey. After completing her training, she served as an associate professor at Columbia's New York Presbyterian Hospital. She then moved to Atlanta, Georgia, where she currently practices. Along with her practice, which she has for about 20 years, she also has a website called myobmd.org that's focused all about women's health and really talking about things like obstetrics, gynecology, infertility, adolescent health, and gynecological oncology. She's on a mission to really hush out the misinformation and raise the voices that truly matter when it comes to understanding women's health and the topics I just mentioned. So in this episode, we're going to dive into Dr. Smith's journey and background. What inspired her to practice women's health? We then transition in terms of talking about what women should think about when seeing an OBGYN or their specific preventive measures or certain things that they should bring up and ask. We then pivot in terms of pregnancy. We're going to be talking about optimizing lifestyle factors to ensure that those pregnancy complications that can occur, like preeclampsia and gestational diabetes, that those risks can be reduced. Now, for a lot of the medical practitioners out there, this might be a flashback in terms of those first two years of medical school because we really do deep dive in terms of those pregnancy complications. And then last but not least, we're going to talk about how these complications can affect care later, not necessarily in just the pregnancy time period, you know, from 20 years old up to 40 years old, which is where most women get pregnant. But what about after that? How do these pregnancy complications set up care in the time periods after those 40 years? All right. So let's get to this episode. I think it's going to be an awesome one for you all to hear. And if you're a woman in joy, I really hope this strikes home and that you gain a lot of insight from it. Well, Dr. Smith, welcome to the show. Thank you. Thank you for having me. I'm excited to be here. I'll tell you the pleasure is all ours. You know, we've been excited for this conversation for quite some time. I know we were just chatting offline before we had record here about how we all connected and kind of our background. And I wanted to say most of it so you can kind of tell us and the listeners are a little bit about your journey and what brings you here. But you know, just to give a little background in terms of I don't think that we've had somebody from your specialty, we've been doing this a little over two years, right, Darce? Yeah. So I'm excited to kind of offer some, you know, new tidbits, new pieces of information, but a new perspective on really what medicine is about health means to a lot of people. And I think particularly our female listeners, but also our male listeners are going to be quite informed after this discussion. So with that, you know, I want to give you the mic and let you tell the listeners a little bit about who you are, your journey, and kind of where you did your training and all that good stuff. Okay. Yeah. So I'm Dr. Dana Smith and I'm an OBGYN physician. I am board certified practicing OBGYN practicing now for close to 20 years. And I am most recently the founder of a website called my OBMD.org, which I'm very proud of. It's a site that was created because I felt that there was a need in the, on the internet space for ladies who are seeking to get medical information. I felt like they were, they were not being given the truth about their health and some of the information that they were being given was actually damaging. And so I really felt strongly that we really needed as physicians, we needed to have a voice in that platform. And we needed to want, be the ones to tell the story and let patients know the real truth behind their health, the medical, medically accurate information, real world application. And so that is the most recent, my most recent venture that I'm really excited about. So I'm going to jump in right there. And just because, you know, there's an interesting word that you use. You said, you felt like that ladies are not being told the truth. We're big fans of that word right here, but that word, I mean, it means different things to different people, right? Say a little bit more about that. What do you mean by that? Are we talking about misinformation? Are we just talking about lack of information? What does it that you mean? I think a lot of people who publish information online, they have an agenda. And that agenda may not necessarily be to inform. It may be to influence, it may be to dissuade, but it's not always to simply inform the reader on the topic that they're seeking knowledge on. And so it becomes, it can be used as a tool, misinformation, misinformation can be used as a tool for manipulation, I were to get people to think a certain way or to dissuade people from thinking certain ways. And so I feel it's an insult to the lady who wants to learn about her health for us to insert ourselves in that process for the purpose of influencing her thought process. Patients who are seeking knowledge on their health, they're intelligent. They just want the information and they can make the decisions on what they need to do with that information. We should not be in the position of providing editorial commentary or any bias, insert in any bias in that information process. It does the patient a disservice. I love that. That's the cold heart facts, no opinions, unless asked for. That's so hard though, you know, we were just talking about some of our training and you know, I did, I guess technically if you included medical school nine years, I think with your specialty, did you do a fellowship? No, I did not, but that's also, yeah, was done. Resoncies also five years from, right? Yes. So all in all, a total of nine years of training where you have to kind of reserve your thoughts right? You have to hold it in because there's always somebody, right? You have an attending, you have a chief, you have a senior, somebody and you're like the quote unquote, low man, woman on the total pole and you have to just reserve your thoughts and then finally you become an attending, you're like, yes, nine years I've been waiting and it's my opinion matters. And so now you're telling people, no, no, nobody cares. You know, I say a little bit of that in Jess, but I suppose you can agenda is it's worth a while now that we're trying to get a sense of what your makeup is, what you're excited about today. I'd even like to go back and learn about what inspired you to go down this path and even think about helping women, particularly OB, QIN, that kind of stuff. I had an experience where a patient came in and the patient, she was having pain, she was pregnant, she was having a lot of pain and the pain had started several days prior. So rather than contacting her physician, she Googled, you know, she went online, what should I do? I'm pregnant and I'm having pain and based on her research, she concluded that she was having Braxton Hicks contractions, which she felt, okay, I'll just stay home. That's a benign process, Braxton Hicks contraction. In reality, she was having a placental eruption, which is extremely different, life threatening. This patient lost her baby because she was misinformed. Even though she felt she was doing the right thing, she was seeking the knowledge on what might be going on with her body. That process became detrimental to her and fatal to her child and that was a wake up call for me because I felt like this is an intelligent person, this is a well-read intelligent woman and she was not able to navigate the information process to find accurate information. So by not having us as physicians in that arena, we're advocating our role and leaving it to others and those others are not informed whether intentionally or not and they're not knowledgeable enough to provide that information that the patients are seeking. So I do feel strongly that as physicians, we really need to occupy that space because as much as a lot of physicians, we say and just, hey, the patients referred to Dr. Google or the patient did this, the patient, but that's where the patients are. Their patients are doing that whether we like it or not, their online research and their medical conditions. And so once we are aware of that fact, we have to somehow find a way to enter that space so that that process becomes more informative and creates less harm. Was this case, when was it during your training, medical school or was it in residency? That was after I completed my training. So you saw it after, okay, and that's kind of that inspired you to say, hey, let me start the real education online and a better source. Awesome, I love that. Yeah, and I think all three of us have some sort of calling, some sort of experiences that we've all had, whether it's within our families, whether it's with our patients, whether it's just the world we see, right? It's just ever evolving so quickly and I think we're all trying to do our part as physicians to say, hey, how can I get the best information out there as we see medicine change so rapidly? So I love what you're doing, but let's start educating the audience. Let's start talking about OB-GYN, women's preventative health. So of course, you know, a woman is going to become pregnant and that child will hopefully see a pediatrician, right? Once that girl starts to grow up, go through puberty, et cetera, what should they really start to think about seeing a gynecologist? So Dr. Smith, actually, let me jump back there. There might be somebody listening who actually doesn't know the difference between a gynecologist and an obstetrician. Would you care to just define those two and then Darce's question? Yes. Thank you for pointing that out, absolutely. So in our training as OB-GYN doctors, we're trained in the care of women who are pregnant, which is obstetrics, and we're trained in the care of the woman who is not pregnant, which is a gynecologist. So we are able to take care of ladies who are pregnant and not pregnant. So the gynecologist, the gynecology portion of our field, refers to the care of the non-pregnant lady and the obstetrics portion of our field, refers to the care of the pregnant patient. Okay. So thank you for clarifying that even. You know, I knew that, but I guess it's nice to hear those terms, even for me, because again, I think I've just done one rotation, my first rotation of third year medical school within OB-GYN. Awesome. So, okay. So I'm assuming they would see a gynecologist primarily, right, unless a teenager is getting pregnant or something, they would typically see a gynecologist first. Around one age, is there a guideline for what age a woman should start seeing a gynecologist? Right. And most of us practice, most of us physicians that we practice both obstetrics and gynecology. So when you walk into the office, you're seeing an OB-GYN, or OB-GYN, whichever people want to call it. So the ACOG recommendation, which is the American College of Obstetrics and Gynecology, so their recommendation is, hey, by age 21, you need to see a gynecologist. If you're sexually active prior to age 21, then you should see a gynecologist at that time. However, by age 21, regardless, then you should be seeing a gynecologist. And it's really important, because at that time, we're educating you on your body, and because the educational process on reproduction in our reproductive system is not consistent across the United States. And so it's a great opportunity for us to just debunk any myths and shore up the facts about your reproductive health. And a lot of patients are weary about going to the gynecologist and they say, oh, I'm not having sex. So am I going? Well, we actually provide a lot of counseling on how to stay healthy and how to prevent infections and all sorts of things. And so it's truly an essential part of staying unhealthy. And keep in mind that when you go to the gynecologist, especially for the non-the patient who is not sexually active, you don't have to have a pelvic your first visit. Your first visit could just be a talk visit. We could just discuss what concerns you. We could make suggestions and make recommendations. But there is no, we should not be fearful of the process of going to the gynecologist. And I do want to mention that on the myobmd.org site, we actually did a video on this very topic that discusses, when should you see your gynecologist? When should you start seeing your gynecologist? So viewers can always refer to that for more information. But truly, by age 21, everybody should be seeing their every female patient should be seeing their gynecologist. Gotcha. I do have a couple questions. So you did mention kind of that first visit can be conversational, right? So let's say somebody, you have the first couple visits, two or three visits. Is there anything specific from a gynecologist perspective that you are bringing up in terms of maybe lab markers or specifically preventative health? And then the second question is, is there anything that the patient should bring up specifically to a gynecologist that would make more sense rather than a primary care physician? So at that point, when you go to see the gyne doctor, you are going to discuss your menstrual health, what your cycles are like, what they should be, because some ladies do have abnormal cycles, but because they have nothing to compare it to, they are not aware that they have an abnormal cycle. And so that becomes an important part of the educational process, what cycle, what is it within your cycle that may be worrisome, where you need to seek additional medical surveillance. So that's always a good start. And some primary care doctors may be comfortable with that, some may not. The other thing, of course, is your sexual health. So whether you want to engage in intercourse or not, order some of the things that you can do to help prevent infection to do that to enter into that stage of life safely, and to also plan your family, if that's something that you would like to also discuss. So there are plenty of opportunities to discuss lots of parts of the reproductive health that is not just pregnancy, but is very salient to your, to the patient's overall health. Could you, you mentioned normal menstrual cycle, and I think that that can be a vague term for a lot of people, right? And so could you just outline what a normal cycle in terms of time duration, what that ranges, right? There's a wide range as I understand it. So what is that entail that may be, if you think it's worthwhile, just kind of talking about the different phases in a normal menstrual cycle, and what are typical changes a woman can experience. It can be hormonally, it can be physiologically, however you see a fit. So first, you should have your mencies. So for the adolescent, we were talking initially about the adolescent patient. So for the adolescent patient, most adolescents will start their cycle by age 15 or 16. If you haven't started your cycle by age 17, you need to go to the gynecologist. Something is not quite right. If you haven't started your cycle, or you don't have any breast development by age 15, that's also not something that's an indicator that there may be something wrong. So those are just some of the initial problems that may present itself that may need to be further looked at. Now when you start having your cycles, it's normal for it to be kind of wacky, right? Because you just started and your body is just kind of starting to figure out this axis between your brain and your pelvic organs. And so it's not the first few years, you may not get it regularly. And by regularly, I mean anywhere from 21 to 32 days. And then the duration is typically 5 to 7 days. So that's the quote unquote normal. And so, but when you first start, if you're not meeting those criteria, we're really not going to be too concerned about that. However, as you progress and you become 18, 19 years old, it's not been a few years, that if you find that, hey, it's not really kind of going, my periods are still wacky. They're not coming when I expect them to come or they're very heavy or they're then that may indicate some other condition that may need to be evaluated possible PCOS, there's a slew of different conditions that you may need to be evaluated for. And so that's kind of what we kind of educate the patient on during that visit as well. Like, hey, this is what we would expect from your cycle. If you're changing your, if you're changing your sanitary like every hour and it's soaked all the way through and you're having to double up, that's not normal. But again, if this is all this patient has ever experienced in her mind, that's normal, but it's not. So it really does, we become that that sounding board for them, for them to say, hey, this is what this is concerning or this is not so concerning, don't worry. Right, thank you for that. And I thought it was important just because we started this conversation talking about people googling things. And I think it's a really scary place. I actually felt a victim to this personally where something happened with the family member and it's something I didn't quite remember from medical school. So of course, it's just instinct to Google, right? And the first couple of things were pretty scary and I had to call somebody who was in this specialty to ask, hey, like, what should I be worried about just because the first things from my instinct that I had read, I was like, okay, this is concerning. But unfortunately, patients don't know enough to know when to not look at the information that's readily available, right? So, so thank you for that. I'd like to make somewhat of a sharp turn here. Maybe not that sharp because we did start talking about OB. I loved that a moment ago we were talking about getting ahead, right? We're talking about prevention and what I've learned over the last, maybe a little over a year now, that's all my daughter is, that, you know, parenthood and the time during pregnancy, which is an incredibly sensitive time. We've spent our fair share talking about this particular time in a woman's life, really, in both parents life, with Jade Wu recently came on, amazing conversation about period, it'll sleep and how to prepare for that. Talked about it with Dan Pope about how your identity changes when you become a father, right? Again, it's very, very important. And the one thing that the message that stuck out to me time and time again is you really have to prepare for this time, right? It's going to be hard and a quote from Martin Rooney's sticks in mind, it's like, you know, if you fail to plan, you plan to fail. So, with that long tangent, I want to ask about when somebody or a patient is thinking about pregnancy, maybe getting pregnant, maybe it's, you know, young parents, whoever it might be, they don't have any children, and they're in that process and they come to your office, they have a conversation with you, said, Dr. Smith, we're thinking about getting pregnant, what is it we're supposed to be doing? You know, what should we be getting checked up, our screens or vaccines or specific labs? I'd like to talk all about that. Give me your framework of how you'd like to start that conversation, like what are your criteria that you like to start with? So always kudos to the patient that is proactive in seeking counseling, pre-pregnancy counseling because it's not, unfortunately, it's not that common, but it is part of the recommended process of pregnancy that you start preparing for your pregnancy before you actually become pregnant. So, with that being said, there are a few things that they should and should not do. So if they have any bad habits, most people know they need to stop that. So if any tobacco, you really need to stop any tobacco that you may be using, alcohol, the same thing, and the reason those things are so important, it's a few, it's twofold. One, most ladies will not know their pregnant until they're well into their first trimester, at least halfway through their first trimester. And of course, by that time, the organ formation process has already started, it's booming, it's going, you know? So, and that's the most vulnerable time for that child. So if they're exposed to toxins, then that may be a problem, right? So it's always best to kind of stop all of those things. The other thing, particularly about tobacco, I want to point out, tobacco, you really, it's quite harmful because what happens is for patients who are, who smoke, their placenta is very likely abnormal, okay? So if you're smoking and your placenta is forming while you are actively smoking, that placenta is likely very abnormal. And so what happens is that that then puts your whole pregnancy on a trajectory of complications because now with an abnormal placenta, you can have a baby that doesn't grow, as well as it should, that's a UGR in, in true uterine growth retardation. You can have pre-clamsia, you can have placenta lubruption. So those the tobacco, people who are planning pregnancy should definitely not smoke and eliminate or severely limit their alcohol intake. The other thing is if you have any chronic medical conditions, chronic medical conditions need to be optimized. So for instance, hypertension. Same thing as tobacco, if your blood pressures are high in your placenta is forming almost always that placenta will not be a healthy placenta and it has all the risks we just talked about. Diabetes patients who have diabetes, the blood glucose levels, if it's, if your sugars are really high, those sugars become a taratogen because they can actually create malformation within your child. And so it's an opportunity to optimize your health. Now continue doing your exercise, continue doing everything else that you're doing, but any of those bad habits just kind of, you really have to stop or eliminate. The other thing I tell patients is, you know, when you become pregnant, we just don't know what will happen, right? We don't know what your complications may be. So it's not a bad idea to just start putting away some money because you may be taken out of the workforce for some time whether voluntarily or involuntarily. So it's, you may want to just have a little bit of a nest egg, your disability may not kick in if you are actually disabled for a little while and or you may just feel like, hey, I'm just not just every day and I don't want to go to work. So it would reduce the stress if you actually have a little bit of a reserve financially because I do feel there were patients who are really pressured financially to work and they don't feel up to work in. And if they had a choice, they would choose not to work if all else were equal. So those are like the main things that I um that I counsel patients on is just to kind of optimize their health and to stop the any bad habits and prenatal vitamins, folic acid. So folic acid we know folic acid is great at preventing neural tube defects, right? Like spina bifida. So it actually works best if you've been taking it for three months before conceiving. So if you know you plan on getting pregnant, just go ahead and start taking their folic acid. In fact, every reproductive age woman I recommend just take folic acid. It's a part of your, because most people just don't know when they're gonna become pregnant. So just go ahead and take folic acid. It's in all women's multivitamin, except if it's except the ones that are silver, because silver is like menopausal ladies and they may not need the folic acid. But it's in all women's multivitamin. So if you take a woman's multivitamin, then you're covered. So I think something important and I'm hazy on the details one thing. I think a regular multivitamin might have something around 400 micrograms if I'm getting the dosage. Right. However, during pregnancy or maybe in that preconception phase, you're supposed to be taking, is it 4,000 micro? Like what's the dose that you're supposed to be taking in their prenatal phase? 400 microgram for the patient that has average risk. Okay. Average risk of neural tube defect. It's 400 micrograms of folic acid. If for some reason, you have an increased risk of neural tube defect, then you can go up to 1 milligram. Got. Okay. So 400, even if you're pregnant with average risk. Good. Absolutely. Yeah. But most of my, most of my, excuse me, most vitamins have like 1 milligram. Oh, okay. All right. For some reason, I thought it was much less than that. But the other term that you mentioned preclampsia, I think that's something very important for us to just clarify a little bit for people with people, you know, mentioned it during recently, some of my readings, when I was learning about the association or correlation between obesity and or higher BMI and risk of preclampsia and how tightly coupled they are, could you just define what preclampsia specifically means for the medical providers? We know why that's such a concern, but for those listening, not have heard of that. What is it? Why does it matter? Why does it matter? Let's start with that. So when I was training the number one killer of pregnant ladies in my state was blood loss. So when patients would have a baby, they hemorrhage and that hemorrhage would put them at risk of dying and that and some would die and that was actually the leading cause of death. Blood loss is no longer the number one killer for pregnant ladies. It's high blood pressure. And so that is, we have to be respectful of preclampsia and we have to be vigilant in our surveillance of it and also as much as we can to help prevent it from happening. So preclampsia is a condition. It's a disease. It is unique to pregnant women. Only pregnant women can have this condition. And it had several names in the past, Toxemia of pregnancy that's outdated, but essentially the condition describes in pregnancy, the patient's body has a negative reaction to the pregnancy and she develops certain symptoms, primarily elevated blood pressures. So that's the primary one and the blood pressures can become quite high, some are mild, some are severe and in addition to that they can also have, it can also affect your kidneys. So you start spilling a lot of protein in your urine and it can also develop, excuse me, it can also affect your liver. So your liver becomes affected and other symptom, other system is your neurological, your brain. So a lot of patients have headaches and they can have seizures which would be then eclampsia. So it's a, it's a very serious condition because the problem with preclampsia is the cure, the only cure is delivery. So if you're pregnant and you have preclampsia, we know one of two things will happen. You'll either maintain the preclampsia at the state where it is for your entire pregnancy and hopefully that is mild and it doesn't progress or it will progress and worsen. And there's no way for us to predict who will have what experience. And so we know, we consult patient, this is a progressive condition, it will not get better until after you have your baby. We know that for a fact. So if you develop it early in pregnancy, it's unfortunately going to put you at a very high risk of preterm delivery because if you get very sick, we have no choice what to deliver you because you, we cannot allow you to have that state of health, it's not good for you or your baby actually. So it's something that is, is quite serious and now I don't want to make it sound like after you deliver, there's the faucet is turned off and now you're fine. What after you deliver, you will start getting better but you may not start getting better immediately. It may take some time before you become, become well again and even in the postpartum period, it's still quite risky so patients still have to be super vigilant about monitoring their blood pressures, monitoring their symptoms. And some patients are re-admitted to the hospital after giving birth for managing their pre-clampsia because it can be quite, it can be quite labile and the changes that your body goes through, it's, it can be wild, you know, some patients, they'll have a normal blood pressure and then 15 minutes later their blood pressure is severely high and so it's very, it's something that is, that we do have to have a healthy amount of respect for because this condition is, is quite serious, it can be quite serious. Absolutely and thank you for highlighting that. I think that's again worthwhile discussing and really clarifying for people. A question for you, if somebody has pre-clampsia during their first or second pregnancy, the subsequent pregnancies, the risk I imagine much like anything else in medicine is much higher that you're going to have pre-clampsia again. That's exactly right and so we now know that actually taking baby aspirin in those patients can help reduce the risk of pre-clampsia and so we have, if you have a history of pre-clampsia in a previous pregnancy, then your doctor will likely recommend that you start taking baby aspirin. I do not want anyone to go and start taking baby aspirin on their own. Absolutely. But you can always speak with your doctor about whether or not that is suitable for you because that is one of the preventative measures that we are now using for to help prevent pre-clampsia from occurring. Yep, this is just education, a conversation between a couple of colleagues. It is not medical advice, so please consult your physician and we will tell you this disclaimer again at the very end. But you mentioned an outdated term and speaking of outdated terminology, I want to talk about geriatric pregnancies. I only recently learned that that's what they refer to and for those who don't know, it's anybody I think considered over the age of 35, they call them geriatric pregnancy. It's like the worst term, I don't know why you would say that to somebody. I'm wondering, I love that you talked about optimizing lifestyle, pollutants, toxins, things of that nature that can really affect the fetus, the growth, all the organ systems that are developing over the first couple of weeks of the pregnancy. Specifically as people get older, they have a lot of concern about different defects that the children could be born with, complications, things that you've already touched on and risks to the mother as well. Are there specific things, that same conversation that the patient came into you, now somebody might be 38, 39 years old, closer to 40, which is not uncommon today, right? I mean most of us, particularly in our field, we go through medicine, your whole 20s, 30s, and now your, is the conversation slightly different? Are there something specific that you're looking at, maybe different angle that you might approach it as? So for the older patient, the more mature lady, who is delayed childbirth. So the term, I've heard the term geriatric pregnancy, I don't use that term and I'm not clear on whether that became more of a slang because I don't see it in the medical literature. Thankfully, patients who will be 35 years or older at the time of birth, medically they're referred to as advanced maternal age or AMA for short. And the reason why that distinction is made is because their pregnancy does pose a greater risk. There is greater risk of genetic complications with the baby, some of things like Down syndrome. And in addition to that, high blood pressure is also more common in patients who are older, diabetes. So you just see more of those kind of hodgepodge of complications that occur. They're going to be more common in the patient who is in that age group than the patient who is not. But granted that pregnancy is monitored very well. And typically, I don't want anyone to not be discouraged from pregnancy at age 35 because most of the time it goes well. We're going to scream you more, we're going to counsel you more. But most of the time you go, you have your baby, you're fine. Yeah, I think it's especially with modern science now too. And like Ultimarch said, it's becoming a lot more common. So we are more aware of that. But like you said, you know, after 35, it can pose more risk. There's more pregnancy complications. So I would love to start getting into talking about pregnancy complications. You highlighted, you highlighted Clampsia, excuse me a little bit. But before we get into it, I think it's important to define terms within pregnancy, right? I think a lot of people hear premature baby or, you know, full term or late. What exactly does that mean? And what are the cutoffs for each week? Okay. So if you, a term pregnancy is anyone that is within three weeks of their due date. So your due date, we call that your 40 weeks, 40 weeks pregnant. So 37 weeks or greater is a term pregnancy. Anything before that is a preterm pregnancy. Now some patients may choose to carry their pregnancy past their due date. And that's okay. As long as they don't have any of those risks that we talked about and they're being monitored very diligently. But by 42 weeks, recommendation is for you to have your baby. So we don't recommend any pregnancy going past 42 weeks. And to be honest, there are very few patients that desire that because most patients are so miserable by that time, they're like begging you to kind of, please, let me just have a child. So those are the terminologies. 37 weeks to 37 weeks. And then after 42 weeks, you would say post dates. And before 37 weeks is a preterm baby. Okay. Thank you. So I think it's at this point, let's get into kind of common risk factors as well as the complications within each of those. So let's start with prematurely. So what would be the common risk factors that you're seeing in women that would cause them to have a premature baby? So the preterm, a preterm baby, so a history of a preterm delivery is the number one risk factor for preterm delivery. So if you've had a preterm baby before, you're more likely to have a preterm baby in your subsequent pregnancy. Now things, other things are where your preterm, because we may say, hey, we need to get your baby out sooner than later. So your doctor may say, I know you're not yet term, but something is going on either with you or with your baby. And we need to deliver the baby sooner, even though you're not term. So whether that baby may be showing signs of distress in utero or mom may be negatively affected by the pregnancy in conditions such as preclampsia or eruption, things of that nature. Advanced maternal age is actually another risk factor for preterm delivery and for C-section. But so there are a slew of conditions that can that can trigger a preterm, preterm delivery. Thankfully, in most cases, you can be prepared and we kind of we optimize that process by giving the patient steroids, which helps to mature the baby's organ development. And so the babies that are exposed to steroids in utero who are later born preterm, they actually do better than those who are not. And so we do have for those that are planned preterm, we do have those options to go ahead and try to mitigate that. We also do, depending if they're 32 weeks or less, then we also do magnesium. And the purpose of that is to reduce the risk of cerebral palsy. So we do have some measures that we can take to help mitigate some of what the preterm baby experiences, but of course none of that is foolproof, but they're there and they do help. Awesome. Okay, so that definitely explains a lot, it's funny. After one rotation and forgetting so much, you're just starting to bring back all these things in my head. I'm thinking of first date and I'm saying, that's right, the common risk factor for prematurely it would be a prior preterm baby. Okay, so what else is there then that women should kind of be on the lookout for or other complications that are more lifestyle related? And what can women do from a lifestyle perspective to either prevent those complications from happening or at least prevent them from progressing? So there are a few complications that I think it would really benefit everyone, physicians and patients to have more knowledge of. And the reason for that is because patients who experience these particular complications in pregnancy, their risk factors for medical complications later in life lingers well beyond their pregnancy termination. So for instance, we talked about preclampsia. We know that patients that have preclampsia. They have over 60% risk of experiencing heart conditions later on in life. And so if your primary care doctor is not aware that you have had preclampsia in your pregnancy, they may not be aware of your cardiac risk. And so even if you go to the ER with chest pain, it's important for that ER physician to know, hey, this patient had preclampsia during her pregnancy. Her cardiac risk is not the same as the lady who did not have that experience. Let me be more vigilant about screening for possible heart attack if she's having some chest discomfort or some atypical type of pain that I cannot explain. So I think that there, you know, we know that the risk continues even can continue for as long as 30 years. So even if this patient has a 30-year-old child, excuse me, 30-year-old adult child, then they still have that risk factor even though it has been so long. And so I would like to see more of these pregnancy complications in the not just as an OB history, but as part of patient's medical history, because it really does alert us to what their medical vulnerabilities are so we can better counsel them. Patients with diabetes, with gestational diabetes. So if you have gestational diabetes, your risk of developing diabetes over the next 10 years is about 60%. And that's quite high, right? That's more than half of them will go on to develop diabetes. So I always tell them, hey, just get screened for diabetes every year, but am I the one screening? No, because they may stop seeing me as their gynecologist. They're going to go on to see their primary care doctor. And so are their doctors still recommending, hey, let's screen you for diabetes because you had diabetes in your pregnancy and we want to make sure we can catch it earlier or at least diagnose you with insulin resistance if that's the case so that we can make some changes in reverse course. So it's some, you know, some of these gestational diabetes, it needs to be a part of your past medical history. So patients really need to when they go to their primary care doctor and they're saying, hey, any medical conditions, any problems, you know, just tell them, hey, when I was pregnant, I had this condition. And so at least they're starting to kind of bring their attention, bring it into their, into their radar, right? Like, hey, I had this condition. So let me go ahead and make sure I counsel her regarding her risk factors and screen her for conditions that may develop as a result of that. What are the conditions I want to mention is the rather serious condition called peripartium cardiomyopathy. And that's just a fancy way of saying they're patients, there are some patients who become pregnant and their heart's reaction to to their pregnancy load is it they they get dilated heart, right? So they get they get dilated cardiomyopathy. And that's that's quite serious, right? It's because those ladies have a very high risk of developing heart failure and that risk is a lifetime risk. So even after they have delivered and the cardiologist has treated them, then they still need to be monitored because their heart failure risk is higher, higher than average now because they've had this condition. And especially if they have multiple multiple pregnancies even beyond that diagnosis, even more so. So there are some I really would like for us to be more to practice medicine as a team. So we know that hey, even though this patient has this issue with her pregnancy, I still need to be aware of it, right? I still need to be aware of it and I still need to to be aware of what her risks are based on that diagnosis and counsel her and and screen her as needed for any vulnerabilities because of that. So I wish I'm that's that's just my thing. I try to I try to educate as much as I can my colleagues and you know and most of course are want to have this knowledge and I think it's just that because we're so removed from it, right? It's like you said, you finished residency and then hey, this information we're not practicing it anymore. It kind of when kind of becomes is stashed away somewhere in the inactive part of her brain. But yeah, as long as the patients now is shared starts sharing that knowledge or we start querying the patient about their experience in pregnancy, then that becomes more at we're going to start talking about it more, which means that we're going to start addressing it more. I have been thinking about just this concept of education, particularly for the patients a lot lately. And I do agree that I think it's important for physicians to become more informed or at least rehash some of this knowledge that we've gotten at some point in our training. I'd argue though that it's far more important for patients. Let me tell you why. I think as we mentioned, a lot of patients, if they don't have an HMO plan where they need to see a primary care provider, they end up going seeing a specialist for something, right? Or often, you know, with the good primary care providers are able to manage things such as diabetes and hypertension and cardiomyopathy and things of that nature, right? But a lot of times they get deferred or referred out to an expert, right? A cardiologist, a nephrologist maybe for blood pressure or something like that or even a cardiologist for blood pressure for diabetes and endocrinologist. And often what happens is that even the primary care provider isn't in the loop with all the things that are happening, right? The adjustments that are being made if the insulin is being corrected or the additional blood pressure medication, et cetera, et cetera. And so I often tell the patients, hey, your primary care provider is your quarterback, your point guard, whatever you want to use. But, you know, with these chronic conditions, especially, and if patients are going to more and more specialists, the primary care is out of the loop. And then the challenge becomes, okay, well, then who's actually looking at the 50,000-foot overview and seeing the big picture, right? Because, you know, somebody recently I heard somebody in a podcast talk about, unfortunately, you know, medicine, at least 2.0, the way that we practice it right now is there isn't a lot of effective communication between specialties, right? Whether it's an EMR limitation, whether it's just not enough time to pick up the phone or call a provider because I can't even get through, et cetera, et cetera. And so all that being said, I think the most important thing is for the patient to be their own advocate. Know their own personal medical history, as you suggested, like the back of their hand, know what procedures they had done, know what the issues they had during the first pregnancy, second pregnancy, et cetera, et cetera. And so with that, I want to get your guidance on how patients can advocate for themselves even more. You know, having had a child now, I know, and I get this from almost every single person who's been pregnant, is you know how you find an OB and you want to stick with the same OB, right, throughout the visits, because you feel comfortable with them. But then some people have this philosophy where like, no, you want it as much exposure to multiple providers. You don't know who's going to be on call because we don't know when the baby's coming, right, unless it's a plan C section. Those circumstances aside, I'm wondering you mentioned a lot of things that patients have to be educated for and have to advocate for themselves. Hey, this is what I need to know. These are the things. Is there a way that you might suggest that patients do advocate for themselves given everything that I talked about in terms of patients being their own greatest advocate and being an active participate in their care? Yes. So the patient, it is important for the patient to advocate for themselves. How do they do that? So they want to be informed. So when they have their visits, make sure they are riding down their questions in advance and they are asking the questions and make sure they feel satisfied that the information that they have been given that they understand it and that it was complete and that they don't feel rushed. So that's, I think that's basic that we really do all our patients, right? We should and recognizing that yes, we ourselves are rushed, but we should not rush the patient out of the office who simply wants to learn more about their condition. The patient themselves, when they have knowledge of that, that it's especially patients with multiple medical conditions or or long history, they should write it down. They should write it down or at the very least a lot of patients now they have access to their medical records on their phone. So make sure they have access to that so they can share it with another provider if needed, if they go out of town and they have an emergency, they can access that information and share it. If the patient is with a provider and they don't feel like this provider is taking them seriously, they're asking questions, their, you know, the provider's hands are on the door as they're answering your question, then part of advocating for yourself maybe to choose another provider because that provider is not, if you're not feeling heard and you are telling this provider, hey, you know, the last time I was here I felt rushed, I felt that and if they're not apologetic and trying to correct that, then that provider may not be the best person to take care of you, you may need to move on to someone else and that is part of advocating for yourself, whether you move on within that group, if you're in a group practice and you choose to see another provider within the group or you move outside of the group, whatever they feel comfortable doing, but that is part of advocating for ourselves. I will say that patients always, you know, patients are going to look online like we first started talking about, whatever information you get online, make sure you verify that information with your physician, to be sure that that information applies to you, but that I think that those are the primary ways that they can advocate for themselves. Sometimes it's difficult, you know, because I just think about like in pregnancy, it's really hard because the most patients they're working, they may have a family already established, they have household responsibilities, job responsibilities and they want to feel like, hey, I'm with this provider, this office, this practice, I don't want to feel like I need to now go and find someone else, it's just one another thing to do on the very long list of things to do. So it's not easy, however, in particular, pregnancy is an extremely vulnerable state of health, and so I get that, patients may not, it may be easier to just continue in that practice, even though you're not pleased, but it's not the wise decision, it's not the wise decision, the wise decision would be to put the term and the effort into being with the providers or the practice that you feel you're in good hands with. Yeah, no, I think you nailed it, and like all through our set, I think it's just so important, like you said, to have that patient be the advocate as much as possible, because there's a lot of flaws within the system, and there's too many roles sometimes, right, too many cooks in the kitchens and as physicians, we're definitely trying our best to provide that care, but we're also not able to understand the full care because of things like epic, things like not knowing how to even tell a patient how to get onto their portal. You know, I was never taught that I get that asked every day. So there are things out there that a physician, as much as we're trying, we're just unable to fully help, and so if the patient can, like you said, it's so stressful. It's another thing on their plate, but as much as they can prepare ahead of time, as much as they can get their records, as much as they can be organized, I mean, that goes such a long way. I mean, you know, sometimes there's only those 15, 20, 30 minutes, and a lot of that time, you know, half that time sometimes can just be spent talking about. So what are your issues? What's your past medical history? Rather than if a patient came in and said, hey, here you go in a very organized fashion. I mean, man, those 15 minutes almost feel like 40 an hour, you know, you can get a lot more accomplished. But on that note, Dr. Smith, I do just want to get your opinion. So I know you said misinformation, you know, is one of the biggest things that you're focusing on to provide better education. And then another thing is making sure women hear that they need to be advocates, especially during a vulnerable time, like pregnancy, as women's health continues to evolve, as medicine continues to be redefined, if I can say. What are the other things that you see changing right now in women's health? What are the things that you're hoping to see? Obviously, there's a lot of biases within our world, unfortunately, towards women, towards females, especially in healthcare. Things are slowly starting to change, it seems like, but we still haven't caught up yet. But what are some of those things? What I would love to see, and I think, would make a huge difference in delivery of women's healthcare is portability of our health insurance, to be honest, because if you think about the pregnant patient, someone gets pregnant. Right now, we're very mobile, right? We're very nomadic, right? I live up north, I'm now in the south, I'm we're all over the place. But when we get when someone becomes pregnant, they start thinking about where should I settle? Should I go back to where my family is? Should I stay where I am? Should I go with my husband, you know, whatever. Now, because if that patient has insurance, for instance, and let's, for instance, say New York, and she decides to now just go live right across in New Jersey. Her insurance is not the same, right? She has a different set of providers, she has to get a new policy, even worse for patients that move to South South from up north, they've traveled several states over. And the fact that they cannot, they cannot rely on that insurance to provide care in their new state, they have to get new insurance, that is a process that will allow, that will make them have a gap in their care. And it can be a lengthy process in a tedious process. So I would just love to see where we have some kind of portability of health insurance. I think that would just go such a long way in preventing some of these gaps that we see in healthcare, because even patients that travel a lot, right? Some patients live in one state working in another state. Well, they have to go back to their home state to see their primary care doctor. It's silly, right? It's silly. It's not conducive to our lifestyle, because we are, we're nomads and we travel. So I think it's time for our insurance to catch up. Yeah, no, for sure. That's a great solution too. And one that I have heard and scattered beats, but not one that I've at least seen a movement on. So I'm sure there's somebody out there trying to advocate and make that change. But absolutely. Well, Dr. Smith, this has been a fascinating, fascinating conversation. Thank you so much. Like I said in the beginning, it's funny how much you forget, but then when you start to hear the terminology again, it also always starts to come back. And then ultimately, I know you've been living this too with the one-year-old. So it's probably more fresh in your mind. But why don't we tell our listeners where they can find you? We're definitely going to link your website as well to our show notes, but anywhere else, anywhere else on Instagram or any other socials. Yep. So we are on Facebook and Instagram at my OBMD. And email is info at myobmd.org. And of course the website myobmd.org. Perfect. Awesome. And hey, last question we like to ask all our guests is, how do we add the health back in health care? I think when we look at when we look at trends in medicine, we think, you know, we're always as physicians, we look at, well, how do we treat it, right? But nothing happens in the vacuum. So we have to really start looking at root causes. So even for instance, the fact that pre-clampsia is now the number one killer of women in the US who are pregnant, you know, we have to ask ourselves why, excuse me, high blood pressure is the number one killer. So we have to ask ourselves why, right? And we know it's linked to an rise in obesity. And we have to ask ourselves why, why is there more obese people? And what can we do to prevent that, right? Are people more stressed than they're just stressed eating, right? Are people having less access to healthy food? Are people not having access to sidewalks? I mean, what can we do to kind of turn that boat around because nothing happens in a vacuum? And so the fact that these mortalities have flipped, it tells us that we're doing something wrong. We're doing something wrong and we need to address it and we need to fix it. Starts with why? Awesome. Thank you so much for tuning into this episode. Our hope is to really bring on guests that can highlight and deep dive into the research on women's health. I often believe that it is a topic that is neglected but we are starting to see strides as far as a lot of women practitioners speaking on topics about women's health. So if you enjoy this episode or you know somebody else that will please be sure to send them the podcast link so that they can enjoy it as well. If you want to check out Dr. Smith's website, myobnv.org, we will be putting that in the show notes for easy access. I want to thank the team for the production of this podcast, Iman Bashiri, Harita Yapori, and Ethan Chiu. And as always, our medical disclaimer, everything in this podcast is for educational purposes only. It does not constitute the priceless medicine and we are not providing medical advice. No physician, patient relationship is formed and anything discussed in this podcast does not represent the views of our employers. We recommend that you see the guidance of your personal physician regarding any specific health related issues.