Welcome to the kick your Expert led podcast, helping you explore and learn everything about getting pregnant, pregnancy, birth, and becoming a parent.

On the podcast and our online pregnancy program grow My Baby, we share my experience of helping more than four thousand babies to be born.

And our experience of running a women's health clinic and parenting for boys.

We're here to help everyone to feel empowered in pregnancy and birth with real life, practical information.

Well, welcome everyone.

I'm bridge In Maloney and I'm obstatrician doctor Patrick.

Maloney, and today we've got a Q and a some written, some speak pipes.

Okay, yeah, all very exciting, and so we're going to get straight into it because we've already established we don't like the chit chat.

I like it when people's contact us on speak pipe.

Yes, absolutely, So if people don't know what we're talking about when we say speak pipe, it's we'll put the link in the bottom of the podcast episode.

Just click on that.

It'll go straight to a website.

You don't have to sign up to anything, You just record your message.

Then you get an option to either keep or redo.

I'm sure people get really sort of I.

Don't overthink, and then it just means that when your question gets answered, we've got your actual voice.

Yea, yeah, which sounds really great.

Yeah.

Good.

All right, Well I'm going to start with this one.

First.

Hi, my name is Amy.

I'm thirty three weeks pregnant with my second baby.

I was diagnosed with Graves disease ten months postpartum with my first, and I've had a total thyrodectomy.

My thyroid levels throughout this pregnancy have just been all over the place.

My last TSH was thirty four.

I've just been doing a bit of research about it, and I'm concerned about the health implications for not only myself but my baby, in particular their brain function.

None of the specialists involved have advised to deliver early or any complications for the baby.

I'm just wondering how concerned I should be about my high TSH and any implications that it has for the baby.

This is amazing, Like, I didn't know Graves disease was even a thing until we got asked a question about Graves disease in our last Q and A.

Right, and he's another person asking about.

Yeah, Graves disease is a very common form of thyroid dysfunction more common in women, affects plenty of young women and is active around the pregnancy years.

So thank you for getting in touch with your situation.

I'm imagining that the Graves disease must have been reasonably severe for your care is to have contemplated a total thyrodectomy, because that's a surgical removal of the thyroid gland, and it's not commonly necessary to control thyroid disease.

I'm sure it can be, but when the thyroid is completely removed, then the whole point of doing that is that you can then on a clean slate, just put the thyroid hormone back in and create a much more stable and predictable, predictable thyroid environment than your dysfunctional gland could manage.

And so it's interesting and a problem that the thyroid control has been poor despite that.

I don't want to say I don't know the answer, but the actual day to day management of that is outside my area of expertise, and that's why we use endochronologists thirolid experts to help us manage this.

We're definitely in a situation like this need to not just be under the care of the obstetric team, but also a care of a physician unit who can manage thyroid disease and try and get this as stable as possible.

It is important for the growing health of the baby that the thyroid is stable, but it's also important for the newborn that the baby's thyroid condition is maximized as particularly if there's been transplacental crossing of thyroid autoantibodies, so pediatricians get involved as well.

And just recently I saw, you know, in Australia, and I'm sure in most of our countries, they have a test where the baby gets a heel prick there after the birth.

And one of the things that's test on that test and for on that heelprick is is congenital hypothorroid is.

So if the baby's got basically no thyroid function, it'll be picked up on that heel prick.

And for the first time my entire career, just recently, somebody's baby was a heel pricked positive for absent thyroid hormone and when they imaged the baby's neck there was no thiroid glanded tour, so that baby went straight onto thyroid supplementation, and that's what that whole he'll prick thing is for, so we take this seriously.

I'm sure that the situation is in.

This situation is able to be corrected, but it does need expert management.

Can I just ask in your anatomical scan at week twenty, would it pick up things like thyroid?

Well not really, so they can look at the anatomy of the baby's neck, but it's a bit hard to see that the ultrasound it's a little bit imprecise for that issue.

And and because of that they had to use the heel prick system because we weren't picking these up.

Yeah.

Well, I'm going to move on to one of our written questions comes from Michelle.

Hello, wonderful humans, what you do for the wider community and world will always be appreciated with the love heart.

I've listened to every single podcast episode in one year and wait until Tuesdays for the next one.

I've also completed the Grow My Baby program both preconception and pregnancy.

I'm currently completing the program a second time as I'm currently ten weeks pregnant.

My question is my GP placed me on met Foreman back in February twenty twenty five due to my PCOS diagnosis mild insulin resistance.

I was told to keep taking the medication until the end of my first trimester and when the placenta can take over.

I'm an average weight I worry that if I stopped taking it a problem might occur, such as miscarriage.

Do I stop taking met forman after thirteen weeks or continue?

For context, I am thirty two years old.

Thank you well, Thanks for caning touch.

This is an interesting situation because there's actually mixed evidence that continuing the met forman into the pregnancy, whether it's necessary at all, they won't harm you.

But one of the problems with taking medication in pregnancy if you've been advised to take it, is that then people get nervous about stopping it.

So there's absolutely no need to be concerned about that.

It's not to have a miscarriage if you stop.

The medication question is to really need it.

So one of the things we use met foreman for is for is for things like insulin resistance where there's some borderline concerning sugars but don't rise to the level of fully diagnosed diabetes.

So what I would do in this situation is whether I continue the met formant or not, I would consider this to be somebody who'd be worthwhile doing it.

A formal fasting glucose tolerance test twice at the start and at twenty.

Eight weeks, which is kind of in line with the updated diabetes guidelines that we went through in a previous episode.

Yeah, if you're if you're at high risk, it's different.

I think we have to remember that the standard drink the drink and do the test of twenty eight weeks.

That's for normal, that's a low, that's for lowis, that's for screen.

But if somebody is at high risk, then it's different.

All right, Michelle.

I hope that helps you, and thank you so much for joining us along the ride twice.

Yeah, amazing, Yeah, amazing.

All right, Pat, let's move on to maybe a speak pipe now.

Hi, Doctor Paton Bridget.

At eight weeks pregnant, I had a bleed which was the result of a subcaronic hematonoma.

On the ultrasound reporter findings, it was measured at four point two mills.

My question is what is the likelihood of reoccurring bleeding and what does a subcaronic chematoma mean for the rest of my pregnancy?

I'm also lover of all things physical activity and exercise, so I'm just wondering, is this something that is going to impact my ability to continue exercising throughout the rest of my pregnancy, As in my first pregnancy, I was able to exercise quite intensely all the way up until the day I delivered.

Thank you.

I'd love to hear your thoughts and advice on this.

Now.

We've actually got two questions about sub choreonic hematoma.

In the same Wow.

Yeah, yeah, right.

So, sub choreonic chemotomas are little blood clots that form near the developing pregnancy, just under the under the pregnancy sack in the in the first trimester of pregnancy, and they're really common and they mostly do nothing bad.

The whole the whole system is basically made up of blood vessels.

That's what the places is for, isn't it.

If you if you take if you you know, if you've just had a baby, you have a look at the placenta.

It's just all made up of great, big blood vessels.

And at the early stage of pregnancism, it's a miracle they don't all bleed.

Made up of tons of rapidly growing and multiplying blood vessels, and sometimes they will bleed after a minor trauma, after intercourse or all by themselves.

And then we go into an ultrasound and they say, yeah, pregnancy looks good.

The little fetal pile of developing fetus is the right length, there's heartbeat, but there's a clot next to the sack called a subcaron achematoma.

And then basically it's roughly true that if the development of that heemotoma wasn't big enough or severe enough to whend the pregnancy then and there, then it probably won't and it'll sit there and dissolve over the coming weeks.

And if you have a look two or three weeks later on another ultras not that you need to which can, it'll typically be caorn.

They are associated with miscarriage.

But if you have not miscarried but they noticed that the sub qoranic humotomu is there, then it wasn't bad enough to cause the miscarriage in the first place, and it probably won't.

Do you think you know we're using ultrasound more, I mean, this is not a new thing's sub qaranic humotimes.

But perhaps people weren't told that by their sonographer previously.

Absolutely, so there are an ultrasound finding that we tell people about because they're there.

But what people really need to know is have I miscarried or not?

And we're talking about a very small thing.

So that I will sometimes say to people intercourse in early pregnancy does not cause a miscarriage.

But if you've got a blood clot sitting there and you have plenty of intercourse it, shoot, it might shake some more blood loose, which is going to frighten you, take all the fun out of it, and you may not want to do that until things have said on that for a couple of weeks.

I no bleeding for a couple of weeks in a row, and then try again.

There's no reason why someone shouldn't be exercising if they've previously been diagnosed with a subcarate chemotomer, except if that exercise is making them bleed, because again, it may not change the outcome, but it'll upset you.

So if you're not bleeding and you haven't been bleeding, then carry on sper normal.

All right, Well, let's listen to the other one about sakaryonic hemotoma.

I just like probably saying it by now, here we go.

Hi.

My name's Alex.

I love your podcast.

I'm currently fifteen weeks pregnant.

This is my second pregnancy and the first one.

I went into my nine week scan thinking everything was all good because I'd seen the heart beat twice, and it turns out that the baby had died two weeks before.

It was very traumatic.

I'm still not over it.

It's made me a completely different person.

It's changed me forever.

I had to get surgery, which I didn't expect, and it feels like no one around me has been through this.

People didn't really understand.

They just said things that were hurtful and told me to get over it.

I just wondered how common is a missed miscarriage.

Also, in both pregnancies, I had a sub choreonic chematoma and that ended up like I had lots of bleeding and had to go to ED a few times thinking I was miscarrying.

For both pregnancies.

In the first one, it got bigger when the baby had died, and so I'm I kind of worried that it killed the baby.

There's really not much info online.

It's more common in IVF pregnancies older women, women with lots of children.

I don't meet any of that, and so I just wondered, how common is the sub choreonic chematoma?

Do you know anything about it?

Sure, I'm so sorry to hear that.

What a horrible story.

Pregnancy loss, that's that's terrible, and you know, we're sorry to hear about your your loss and your pain.

This is an example of somebody whose subchematoma was cleaning significant.

Yeah, now we'll never know whether that was the exact cause of the miscarriage, or it might have been a genetically abnormal baby or a chromosomal baby or something like that.

But the so the presence of the little blood clot on the early ultrasound may or may not have caused the miscarriage.

Unfortunately, we'll never know that.

Plenty of people have got subcornachemotomas seen as an incidental finding on ultrasound.

They've never bled, they don't miscarry it, and the pregnancy is perfectly normal.

They can't be treated okay anyway, And so the relevance to this person, you know, the actual relevance to the to the outcome is not something that we can really determine.

I just want to pick up on her saying that she felt like no one around her.

Yeah, that's the problem, is the problem.

Yeah, okay, so you're not alone.

Yeah, you're not alone.

Pregnancy loss is a is a near universal human experience for women, unfortunately.

And when I say that, not everybody's had a miscarriage, but not everybody knows they've had a miscarriage.

But the studies show that if you're if you're sexually active, a woman trying for a pregnancy and not on any contraception, small conceptions of very early pregnancies happen much more often than the woman is strictly aware of.

And what appears to be a period that came a couple of days later was unusually heavy, can be an early pregnancy loss.

And those monitoring and you know, doing all the tests and everything kind of clock those.

If you're in a study and you're being monitored, they would know, yeah, so that you would.

You would be giving them a urine specimen every month, so every week, and they would know if a pregnancy had come and gone, but you may not know.

So that those studies have been done and have proven that these little pregnancies come and go a fair bit in couples trying for pregnancy, but are not always identified as a pregnancy.

What I'm saying is that is that you're not alone.

This is a challenge for society to deal with better because unfortunately, early pregnancy loss is a fact of reproductive life.

I'm sorry to hear that at this stage it feels like you'll never be the same if it's of any consolation.

My experience is my experience looking after hundreds of women in your circumstances that it gets a lot better.

So people's resilience continues to amaze me.

Even this lad in my career and what appears to be a profoundly upsetting and traumatic event at the time, it's remarkable how well that's integrated into a woman's general experience of life as time goes by, and how little it is associated with significant maladapt or the development of a mental illness or anything you know of depression or anything like that.

It's amazing how resilient people can be.

Now that's not just say you'll forget about it.

In fact, I've looked after women in their nineties who have told me about their pregnancy losses.

It's not that it's not that they're forgotten about it.

For one moment.

It's just that it stopped hurting a long time ago.

You should be hopeful that it will not hurt this much forever.

Okay, how can we do this better?

One of the things that we've covered in our podcast in the past is like a cheat sheet for the people around you on how to speak to people who've had a pregnancy loss.

And to be honest, it's not that hard, but like all of the things that we find difficult to talk about, it feels hard.

Yeah, it feels hard.

So if somebody that you know has had a pregnancy loss, the worst thing you can do is not contact them at all.

In my opinion, that would be interpreted by that person as deeply unkind.

And the second worst thing would be to say something.

It would be to contact the person, but say something clearly inappropriate.

And if you're going through the pain, things that trivialize the pain are not at all helpful.

Yeah.

I think that is the reason why people don't contact people in the.

First place, because they're sad about it.

Yeah.

Yeah, So what we need is a new language around this, and we as a society have done reasonably well with new languages.

So, you know, knowing somebody who was gay in mainstream society used to be a deeply problematic and shameful thing, and now it's not the You know what I mean that we have evolved not only in our attitudes to things, but our language, and we should this one shouldn't be this hard.

Yeah.

So I think that's referring to episode twenty seven.

I know that because I think in a previous episode we're talking about it because of this very thing.

Some of the easy sentences that you can have in your brain that you can just recall if you're in that situation where someone's just told you that they've had a miscarriage, just so you know straight away, like this is an appropriate thing to say, this will help that person, instead of going, oh my god, I don't know what I'm going to say, and whatever I say is going to be wrong, So I'm just not going to say anything.

Yeah, which helps you but doesn't help there.

No, that's right.

So acknowledging the person's loss and acknowledging the person's pain can be as simple as saying, I am sorry to hear about the pain you're going through, and I'm sorry and I'm sorry for your loss.

Good luck, I hope that that has helped go back and have a listen to episode twenty seven, and I think we've got another one on a miscarriage too, but we'll put that in our show notes because I think the title is something like a common pain.

We'll share in silence, and if anything happens with this podcast, I hope it is that we get better at supporting people that have had a miscarriage and it's no longer silence.

Yes, all right, I'm going to read the next one.

Hi there.

I'm trying to learn more about medications SLASH medical care to prepare for disappointment at week twenty one that I have with a doctor in the public system.

I choose to refuse transfusions of blood and blood fractions, so we are putting together a plan earlier to more cautiously stop SLASH reduce bleeding earlier in all possible scenarios vaginal birth, assisted birth, cesarian section.

I see you care as well as in the care for my baby upon delivery, such as the laid cord clamping, vitamin K injection.

As a participant in the Grow My Baby program and avid listener of the Kick, I would love to hear your opinion of what to consider in these scenarios based on your experience Otherwise, I'm generally healthy, considered low risk.

I work as a researcher and allied health professional, but would like the opinion of an experienced specialist obstetrician as I anticipate I may see a junior doctor in the public hospital system for this appointment.

We had not planned this pregnancy, so going public was what was recommended by my GP.

Great, there's so much there.

It is so great.

Yeah, yeah, yeah good.

A couple of things stand out for me.

This one is that helping you make this plan within the public system is not a job for a junior doctor.

When you're going to be seen, you might see the world's best junior doctor, but that's not the point.

This is a job for an experienced clinician who knows tons about this situation.

Okay, so you don't have to see the boss of the boss of the department every time you go in, but you should be seeing a senior specialist at least once or twice or three times in your pregnancy care to make sure that a plan for this situation is lockdown, all right, And that's not a job for junior people.

A junior person could sit and learn tons, but that's not a situation where a junior person would help you make the disease.

In my experience, people who are refusing blood or blood products, it's typically typically for religious reasons and it's not for safety reasons.

In Australia, donated blood is extremely safe.

There's been some issues in the distant past, but these days are different things.

Triple and quadruple tested for infectious infections, so we're typically talking about a group who resist a blood transfusion for religious reasons.

Needing a blood transfusion as a result of a pregnancy outcome is an unusual thing to happen, very unusual thing to happen, but by no means an impossible thing to happen.

So we need a plan.

The best thing that can be done for the planning is that bleeding's better prevented than treated.

What we tend to do on the labelard in hospital, if we've got no patience, if no one's coming in labor that day, done it very often.

But if it does, then we don't waste our time.

We sit around, we sit around running drills.

We'll say the seeing people say the genior people, right, here missus blogs comes in and said, babies come out, and then she just starts hosting our blood.

In a major post partum hemorrhage, what are you going to do?

And we train for it so that on the day it happens, the responses are automatic and immediate.

And whilst most people are at what we call standard risk of a hemorrhage, if we've got a patient who's at high risk of a hemorrhage, for example, I have had a really bad postpartum hemorrhage before, or they have a known blood clotting problem, or they are seriously obese, or a number of the conditions that are known to predispose to postpartum hemorrhage twins percent a previa, then we don't just sit there running drills.

We actually treat that person preventatively and a little more aggressively because we know their hemorrhage is much better prevented than treated.

Yeah, and if there's somebody who's refusing blood, then my approach to that is usually to say, right, let's never get to the blood part of the algorithm.

Right, let's stop bleeding in its tracks long before we get down to give transfusion, which is at the bottom.

And so what I might recommend to somebody who was refusing blood is, let's be more aggressive at the top of the flow chart and for example, make sure that there's a short interval between the baby being out and the placenta being out.

Let's do things like rubbing the fundus, okay, rubbing the top of the uterus to help it contract to rapidly expel the placenta, which we might not do at all in a low risk situation, but we might do as a simple intervention in a high risk situation to make sure we never get to the bottom of the float chart.

And then give some preventative medications to help the placenta be expelled more quickly and prevent postpartum hemorrhage.

And then sometimes give medications non blood, things that can be given preventatively, like misoprostal tablets that you're putting your bottom up the baby comes out, to help you stay well contracted.

And the whole idea is to do a lot of things at the top of the page that are highly acceptable to the patient so that you never get to the bottom.

How easy or difficult is it?

And I like how she already knows that there's a possibility, a high possibility, that if you didn't have an issue, you would see a junior doctor in a public system.

Yep, so she knows that already.

But how difficult is it for somebody to say, look, this is I would like to see the senior consultant.

In a well functioning unit.

The patient shouldn't have to bring that to your bring that to your attention.

Okay.

The whole point of booking in and not just turning up in labor, The whole point of booking into a health service for the management of the antipathm care during the pregnancy care is that so that somebody's senior with some obstetric experience can have a look at the situation and ask the right questions and help make a plan, help that patient make a plan for their care for the remainder of the pregnancy.

And if you don't know what you don't know, then you don't ask the right questions and the right plan doesn't get made.

That's why we want people to see a senior person at least once.

Now, the job of the senior person in a public antiinaital clinic, certainly, the way I used to look at it was that if I'm going to be the only senior person to see this woman, then my job today is to spend plenty of time with her and make a detailed plan that the junior people can just follow from then on.

And so to make it to help this lady make a detailed plan for safe care of her pregnancy.

If blood's off the table, then we're going to make a plan with a senior experienced person.

And then the other visits, the non planning visits, just the use your blood pressure, okay, is your baby growing?

Visits can be done by a junior person, and then we come back to the senior person to review the plan, make sure we're happy, and then institute that plan when we come in to have the baby.

She is it only postpartum hemorrhage that is the problem with bleeding blood products, because she said that she wants a plan for all possible scenarios, whether it's vaginal birth, assisted bursas arian.

Yeah, so so, but the problem is going to be going to be postpartum hemorrhage.

Yeah, that's the only problem that you would you need a blood transfusion.

For pretty much.

Yeah, so it's rare.

Out of Caesar, you would never bleed so much at a caesar from just a you know, you cut the urus and that bleeds.

That's not transfusion type bleeding.

The transfusion type bleeding is when you cut it is when you cut the uteris of bleeds a little bit, but you put some stitches through that like you normally would close it up, and it still won't stop bleeding.

Okay, So that's postpartum hemorrhage.

Same with a vaginal birth.

Some postpartum hemorrhages that are caused by tears in the vagina, but they are rare, relatively straightforward, usually to put some big stitches through and the bleeding stops.

The big ones that we worried about, what's called atonic bleeds, where the uterus is big and floppy and can't be contracted, and we give a bunch of drugs and it still won't behave itself, and we do this, and we do that, and if I didn't have access to my bottom, wrong to my sort of Okay, we're in trouble here.

We're going to have to give some blood.

If that was off the table, then I would be doing everything at the top of the page sooner more aggressively, more preventatively, so that I never had to get to the plot of the page.

She mentions the care for the baby upond delivery like delayed cord clamping and vitamin K injection.

Are they is a vitamin K injection?

Is that a blood product?

No, it's not a blog product.

So vitamin K injections are to prevent a rarebit serious complication of newborns where their blood clotting system isn't working to a well and they're going to have severe or life threatening bleeding.

And the problem with that is we never know which baby's going to have that.

Yeah, so it's a bit like vaccination.

You have to treat tons of people to save a few, And so because we don't know who's going to get it, we'd like to give every baby a shot of vitamin K that fixes the problem, and then the small number that we're going to have the problem are fixed and all the babies that weren't going to have the problem, vitamin K doesn't harm them.

That would that's not a blood product, And you know, I would recommend that to this to this.

Patients a good plan for her to do a vitamin K inge.

Actually, yes, but I would recommend that to everybody.

Yeah, what was the other delayed cord clim Oh yeah, yeah, So so a plan should be made for delayed cord clamping because they're there.

There's a scenario in which you might want to not use delaid cord clamping because what you really want to do is clamp the cord, get the placenta out, and get that uterus contracted as soon as possible.

Yeah, if if one was bleeding, yeah, right, right, So i'd have I'd have a flexible plan in place here where I said, if your baby comes out and there's no bleeding at all, then fine, let's let's let's beat on with a blaid cord clamp and it's only a couple of minutes.

Let all the blood drain out of the placenta down into the baby.

But if you are already bleeding heavily, then that two minutes of waiting for the blood to go into the baby could be highly significant in your overall losses.

And considering we can't give you blood, I would, I would.

I would encourage this woman to work on a plan where she said, right, if we can't use blood, let's never get into the situation where we need blood, and perhaps that might mean cutting their control.

The blaid cord clamp are short, because what we really want to do is get the percent of back at the uterus contracted and stop the bleeding in the first place.

Yeah, these are all good suggestions.

I hope that this helps you in your chat to wherever you're having your baby, and just have a plan and know that that plan is this in your file.

Yeah, planning, Yeah, planning.

So hospitals have got proper a form more paperwork for this.

That's good to know.

Yeah, so there's a document and it clearly says I'll accept this, but I won't accept this, this and this, and it requires the whole situation to have been overseen by a senior person.

Great, well, everyone, that's us for the week.

Thank you so much for listening.

You might have seen that we read out some from our grow My Baby participants.

That's the way you get up the speak pope.

So yeah, more than welcome to join us on in that program.

And the link is in the show notes or otherwise, it's on our website, which is Growmybaby dot com dot AU.

All right, thank you for listening.

We hope that you have a really fabulous week and we'll spe in your ears next week.

It's been fun.

Thanks for listening, everybody, All right, bye for now.

I just need to remind you that this podcast is for informational purposes only.

We share lots of medical insights and experience, but everything we talk about is general in nature and may not apply to your specific situation.

Please always consult with your own healthcare provider for your individual medical advice.

When you grow your baby,