Latest / The Birth Lounge Podcast / Ep. 454: Understanding Placenta Health to Prevent Stillbirth with Dr. Heather Florescue, OBGYN (Re-air of Ep. 274)

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Ep. 454: Understanding Placenta Health to Prevent Stillbirth with Dr. Heather Florescue, OBGYN (Re-air of Ep. 274) · The Birth Lounge Podcast

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The placenta is so undervalued in obstetrics, and it really needs to be something that is taught to every single resident.
Every single doctor needs to learn more about it Hey, y'all, and welcome back to another episode of The Birth Lounge Podcast.
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On to today's episode.
You guys know that preventing stillbirth is very important to me.
About a year ago, I started my work with Count the Kicks and other organizations that really are spearheading the research in what causes stillbirth, how can we better educate the public on stillbirth prevention, and how can we start to educate our medical providers a little bit deeper But not only what causes stillbirth, but how they can support families who come to the hospital and report that their baby's movements have either drastically increased or drastically decreased, and how do we prevent providers from giving out outdated information like, "Drink a glass of water," or, "Chug some juice and let's see if we can't get your baby to move."
We all know that getting the data and the research implemented into hospitals and into practice can take many, many years.
The data actually suggests that it may take up to 17 to 20 years.
So I'm so excited to have an OBGYN on the podcast today who is really heading up this research and really being that push to encourage the medical community to look deeper in this.
I'm very excited to be joined by Dr.
Heather Florescu, who is a board-certified OBGYN practicing in Rochester, New York.
Dr.
Florescu is passionate about the prevention of pregnancy and infant loss, and the care for families who suffer through these terrible tragedies.
She is also the mom of triplets, and overall, just an amazing, amazing human.
I thoroughly enjoyed my time having her on the podcast, and I learned so, so much.
I'm very excited for you guys not only to learn from her, but to hear all of the wonderful data that she has to present, plus how you can be empowered to take these questions and this data and this information back to your provider so that if you notice anything different in your baby's patterns of movement, you have something to share with your provider and you know what your options are.
So without further ado, Dr.
Florescu, welcome to the show.
Thank you so much for having me.
Yeah, absolutely.
I'm so excited to have you and I was telling you before we started recording that this is not a topic I've ever covered on the podcast.
I just now have started to talk about loss and educate people on stillbirth.
for your viewers who have not been personally connected with Stillbirth I hope they listen to this entire broadcast.
by listening to this, you are not increasing your risk of losing your baby.
It is not something that you can catch, and while it's scary to hear about this terrible outcome for pregnancy, I hope that by listening to this and empowering people that It could save your baby's life.
So please, whoever listens to this, don't be fearful of what we're talking about.
Look at it as a way that knowing about this, because when you talk to people who experience stillbirth, many of them said, I never knew this could even happen.
So either they knew something was wrong and they weren't heard, or they truly did not know that baby still died.
And They said if they knew that, they feel like it could have changed things.
And knowing it doesn't make it more likely, it makes it less likely to happen.
Education is power.
And I think that's a really important thing for any pregnant person or somebody who loves a pregnant person who might hear your podcast, is nothing we're talking about is contagious.
In fact, it may be a preventative for you.
Yeah.
to be completely honest, the stillbirth movement just came into my realm about a year ago when I learned about Count the Kicks as an organization.
I had known it was an app, but I did not realize that there was an entire organization out there doing all this fantastic work.
And knowing them led me to go into DC to advocate for stillbirth prevention within our legislation.
And that led me to meeting the Measure the Placenta team, which led me to you.
And so that led us here today.
And I'm super, super excited to talk about almost like a futuristic idea.
We have a little bit of data that tells us not how important the placenta is.
We know that lots of data tells us how important the placenta is, but specifically the size, the weight of our placenta and what that may mean for the health and well being of our babies in our pregnancy.
But The crummy thing is there's not a lot of data about it.
So before we dive into the data that we do have and the data that we don't have, can you start by just explaining what is estimated placental volume? What does that even mean? So basically it is an Relatively simple way on ultrasound to measure the size of the placenta.
You can start it really at 20 weeks.
You can really do it all the way through.
And then Dr.
Harvey Kliman created a app that is free to download.
And so basically you teach your sonographer how to get those images and then you can measure the placenta really at any gestational age.
One of the things that, you're looking at is not necessarily the percentile, but actually the ratio is a really important thing, too.
A baby that is measuring 5th percentile with a 5th percentile placenta is a different thing than a baby who is 95th percentile with a 5th percentile placenta.
Can you explain those? What those, what each of those mean? Yeah we, what we retrospectively know is that stillbirth is commonly caused by a placenta that is Not big enough to be able to support the baby that it grew so, and we don't know necessarily the reason for why that happened, but that you'll have example, a 9 pound baby with a placenta.
That was really meant to feed a 5 pound baby and that, of course, makes pretty obvious sense that the reserve might.
So when we look back at people who've lost their babies, we will often see that the ratio is very high.
So baby to placenta ratio gets higher and higher.
And as I said, we know that another risk factor for stillbirth is a too small of a baby, right? Those times you often see, I've delivered some tiny babies and the placentas are equally tiny.
And in that case, you It may not be the size of the placenta and more some other things such as preeclampsia or diabetes that affected the overall health of the placenta.
It's all about the placenta and I think that is one of the most important things is when we talk about stillbirth, especially term stillbirth.
80 percent are caused by things other than cord accidents, and unfortunately, we have a very strong notion that when a baby is born still a term that it must have been that nuchal cord or it must have, been something related to the cord around the neck, when in reality is a placental based thing, and that is a missed opportunity to, even when we have a healthy birth.
look at the next pregnancy and maybe prevent an adverse outcome.
So you mentioned to me that, the Shine for Autumn Act and going to get more research for that.
We need placenta pathologists.
We need more education and evidence about what makes a placenta healthy, what makes it not, and what is the risk of certain things for future pregnancies as well.
Are there theories about what might cause The placenta to have variations like this, something that might cause a very small placenta with a big baby or just a placenta that doesn't grow.
And is that what's happening? Is the placenta just stopping growing, but the baby continues to grow? I don't know that we've figured that out yet.
Dr.
Kliman may be able to answer it more.
I don't know.
He's, he always says that placentas, they function well.
So these are small placentas that are probably well functioning.
But of course, if let's say you have a patient with chronic hypertension, so they have high blood pressure, their placenta is not the same as the marathon runner without the chronic hypertension.
So somebody who has this, they don't form as healthy a placenta.
So they're going to get malperfusion in it.
If that placenta is smaller than it should be, That may be a bigger risk than a smaller placenta in somebody who has no risk factors.
So this is why prospective studies and why the Shine for Autumn Act is so important because we just don't know and we need to follow every pregnant person in this country and get their placentas and see what the outcomes are and really learn how do we figure out those babies at 20 weeks That are at risk for stillbirth, or what we're starting to term neonatal near misses, the baby that the baby is alive when it's born, but is coded and ends up in the NICU.
Those are babies that may have been passed away the next day.
So there's so much.
The placenta is so undervalued in obstetrics, and it really needs to be something that is taught to every single resident.
Every single doctor needs to learn more about it because when we understand it, we can help our patients have.
better outcomes the next time, but also explain why outcomes maybe weren't ideal the first time as well.
Talk to us a little bit more about that.
What does the placenta do? I've already mentioned like we know that it's really important.
Why? What does it do? Help our audience understand like why the placenta is so important.
I think, my favorite analogy is to use with people is it's the gas tank for the pregnancy.
So it is attached, obviously, to the wall of the uterus, hopefully normally.
That can be a topic for another time.
And it's an interchange between mom and baby.
And there are numerous factors that create The healthy placentas and the less healthy placentas, and when we think about those gas tanks and how much reserve is in them, and we think about medical indications for inductions.
Almost 100 percent of those are going to be because we know that placenta doesn't have the gas left in it that other pregnancies might have.
For example, when you take chronic hypertension, the reason we're delivering sooner than, the due date, ideally 37 to 39 weeks, is we know that gas tank may run out.
If the pregnancy continues longer, so that's why we do these medical induction recommendations.
And just like in our hearts or anything else, this is a vascular organ, right? So it is based on blood vessels opening.
It is based on blood vessels perfusing.
So people who have issues underlying with their health of their vessels, unfortunately, are not going to Have the greatest health in the percentage compared to one to people who don't have those underlying issues.
So it is truly the lifeline of your baby.
So I have a question about velamentous and marginal cord insertions.
Are we seeing any sort of correlation with that in stillbirths? There are a few things that will be associated, and they're probably things that may be increased the risk of a cord accident, potentially again, no perspective studies.
So a lot of this is, we just need bigger data than studies.
But when the court is marginally inserted, or even more concerningly, velamentous insertion, right? So it's not embedded into the placenta.
It's actually dangling.
When you think about that's going to...
Yes, the gas tank's incredibly important, but what happens if the hose going to the baby isn't ideal, right? You're not going to get that same level of great blood flow.
That's the theory with this, but right now, even as high risk OBs have not set a exact standard of how often should we be monitoring a velamentous cord insertion or a marginal cord insertion.
The other parts of cords that we do know have increased risk of stillbirth is the coiling, so if they're undercoiled or overcoiled those have been associated as well.
But again, far and away, the more common thing is that the placenta it's health is just not, where we want it to be.
If there's so little data behind it I have a hard time saying it's not evidence based, but right now we don't have the evidence to know that it's not evidence based because if we studied a bunch of placentas, we got the data, it's possible that this would be a very evidence based practice.
It's not considered standard care right now.
What do patients do? Are they supposed to be asking their doctors about it? Is this something that doctors are going to be recommending? What does that look like with patients? I think one thing that anybody listening to this can ask their doctor is, do I have medical conditions that may affect the health of my placenta? And one of the, when I was thinking about this podcast today, I was thinking about what are things that people should, in alluding to the health of the placenta, ask their OB provider.
And I think the big things I thought about really were.
Do I have risk factors for less healthy placenta? And if I do have those risk factors, what are things that we can do to reassure me that everything is okay with my baby as we progress through? We know that missing a fetal growth restricted baby.
has five to seven times the risk of a stillbirth and not missing it.
So this is a critical piece, I think, of everything we do when we see a patient for obstetrical care is, are they at risk for fetal growth restriction, obviously a common precursor to stillbirth, and how do we not miss that? So sitting down with your OB provider and saying, are there things in my pregnancy that may affect the health of my placenta? And then I think a really important follow up question to that is, should I be on a baby aspirins to help reduce that, help improve the health of the placenta? What are some other risk factors that may lead to complications in the placental health? Yeah, so there are numerous some are modifiable, obviously some are not.
The biggest ones, of course, as I alluded to would be anything that affects vasculature.
So kidney disease, lupus, diabetes high blood pressure.
I've said a lot of times.
Obviously, this is more sense of subject.
But being obese is a risk factor.
That's why it's a risk factor for preeclampsia as well.
And again, That is not passing judgment, and that is simply saying, unfortunately, we do have good evidence that, especially for being over 40, there's increased risk of stillbirth and complications.
IVF is entering into that, again, if you think about the gas tank, right? The, if the placenta is.
Set up in a non traditional way, all these early things that are happening may affect the overall health of the placenta, which is really interesting.
When you think about an embryo being put in is so early that can impact the outcome.
But those are things that we watch multiples.
Obviously, triplets, twins, higher risk.
So there's many things.
And I think it's.
A really important conversation to have another thing, which if we, you want to talk about, the protocols in the UK and Australia is smoking smoking, marijuana use is still, we're still trying to learn more about the marijuana, but really putting that in the same camp.
If you think about it, smoking affects your heart, right? It affects your vasculature and it makes it so your vessels are unhealthy.
So unfortunately.
When people have smoking, which of course is an addiction, but that's going to affect the health of the placenta.
And we do know that puts the baby at risk for things like growth restriction and unfortunately stillbirth.
And fetal growth restriction and IUGR, interuterine growth restriction, are the same thing, is that correct? Yes, but I think we've moved.
I don't ask me.
I don't know exactly the politics for why we moved away from it, but fetal growth restriction has become the term for saying it.
But yes, they are basically synonymous and that's different than so a 5 foot.
100 pound person when they get pregnant, having a little baby makes sense, right? So that, so you can have a patient who has a baby that measures small the entire time, and you look at the patient like what was expecting a nine pounder, right? Versus you have a six foot tall, robust person and they are have a baby that starts at the 80th percentile.
And then we see those percentiles dropping.
That's a kind of that's a different thing.
And so a baby that's chugging along because mom and dad are peanuts really is genetically makes sense and things we can see on ultrasound to suggest that is again baby small all along.
It's symmetrically small.
It's head isn't bigger than the other parts of the body.
They're all uniformly tiny.
When we see field growth restriction, same way as if we're losing weight or we're not getting what we need, we might actually lose a little belly fat, our babies will do the same thing.
So we'll see the abdomen get smaller.
We'll see that percentile drop.
One of the things when we talk about measuring the placenta and kind of what we're going to see, and we need prospective studies for this as well, is the baby that is hovering in the 80th percentile.
But then all of a sudden doesn't grow, whatever reason we're watching the baby doesn't gain appropriately in a time period between ultrasounds.
Those are things that we're still learning more about, but to me say that placenta is not giving this baby what it needs to continue to stay and growing.
When in the pregnancy do we typically see that? At what point are we seeing that kind of stall in growth? Very much.
It makes us very worried if we see it very early.
So the earlier you see it, the more you're thinking about genetic conditions.
So let's say we have a baby that shows up.
Everything's less than the first percentile at 20 weeks.
You're thinking about chromosomal issues, genetic conditions.
Later on, the placenta is when it's going to kick in.
So even our theories about the placenta size and EPV, this is stuff that's going to kick in not at 28 or 29 weeks, because the baby's still small, it's going to kick in when they get to term.
And that's when you're going to start to see these things.
So It's a, it's going to take time.
The placenta is really good at what it does.
It's unlikely to do this without extreme maternal, health issues at 29 or 30 weeks, or, so we say then it's less than 32 weeks.
It's just a very different bird than when you have.
The 39 week baby who you happen to scan and is now measuring small so yeah.
Oh man.
Okay.
So this is a little bit of a problem because we have this information.
We know this might be a thing.
It's not evidence based providers aren't out here offering it to people.
Maybe not the best thing to ask for our provider, but we have other questions that we can dig into.
Our audience is familiar with monitoring fetal movement, count the kicks, but you were sharing before we started recording that the UK and Australia are doing things really differently and they have a lot more criteria of kind of checking out your baby's well being in addition to fetal movement.
Tell us about that.
What else can parents be doing? to keep up with their baby's well being still in utero.
Yeah, And we alluded to it a little bit before.
The head of Scotland who did like a whole medical chief officer she was, she's an OBGYN, and back in 2000, I think it was nine, she had, as a resident, this terrible experience with babies passing away.
And she said, you know what, I'm going to, Prevent stillbirth and she actually created what became the UK saving babies lives protocol.
And then there's also Australia has safer baby bundle and the safer baby bundle has 5 components to it.
And we alluded to it a little bit, but the 1st component is.
quitting smoking helping people quit smoking beer, carbon monoxide monitoring is one way you can do it.
So actually having people see the carbon monoxide that they have as they breathe can help to get an idea of how that's affecting the flow into the placenta.
They have lots of resources available.
The second piece is making sure you don't miss fetal growth restrictions.
Making sure, as I said, having a patient say to their provider, and this is another thing that I like involve doulas with, is having the doula say to your patient, have you asked about things that might lead to your baby not growing well as they get into the third trimester, and are you somebody who should be on that baby aspirin? Or baby aspirin and should you be getting ultrasound and just bringing that to your provider? The 3rd piece is a sleeping type thing.
So making sure that people fall asleep on their side in the 3rd trimester.
What we know is the position you fall asleep, you're going to spend the vast majority of the night in.
Telling people not to panic when they wake up on their back, but just go back over to your side.
And that is really something that we don't think impacts babies with really well functioning placentas.
But, we very much know that if the placenta is not functioning, And it's not as healthy as it could be, that definitely sleeping on their back is going to increase that risk for stillbirth and fetal growth restriction.
So that kind of piece.
The fourth piece, which is something I incorporate in my practice we've incorporated most of this stuff in my practice already, is the fetal movement education piece, which we already talked about.
And that's one of the components, but also how do we respond? To when somebody is worried about fetal movement, because right now, you can get a number of answers.
I think the most important piece is that patients trust their instincts and they feel empowered to call.
My biggest worry is that the internet, social media, unfortunately, family members, friends will try to invalidate their concerns will not tell them to do what the right thing always to do, which is call your provider.
There are many myths about fetal movement, that they slow down, they run out of room.
They don't move in labor, which all of those things really don't make sense, right? Why would your baby run out of room on Tuesday when it was moving fine on Monday? This doesn't make sense.
So having these things out there and then having well meaning family members say, Oh, you're just being overly anxious.
Your baby's just sleeping.
Can result in tragedy.
So we really want to make sure patients are well educated about it, and then empower them to call.
But we also need to make sure that when they're calling, they're not being invalidated by the office.
They're not being told the myths by the office.
And that they're, this is a warning sign.
And we know that decreased real movement is associated with adverse outcomes.
And anything short of We'd like to see you and make sure that we evaluate you, no matter what the gestational age is.
We can do that appropriate gestational age is a missed opportunity.
And if we let's give the example, the 20 week baby that the mom says, I was feeling him yesterday, I don't feel him today, I'm worried.
We're not going to save the 20 week baby, right? The 20 week baby can't survive outside.
But when they call my office, they are brought in for that doptone.
To listen to the baby's heartbeat and then they were empowered and saying, we wanna hear from you again if this happens.
'cause you never know if that 18 weeker gets told, I can't believe you're calling.
You're only 18 weeks when they're 39 weeks and worried are they gonna feel empowered to call? So we have a very dedicated from the UK and Australia protocol that we follow that evaluates the patient appropriate for gestational age.
But also for risk factors.
So if there's somebody at risk for it, checking the fluid, checking the ultrasound, all, the growth, all those things, making sure that we, our patients always are empowered to call again and that and making sure which is part of the protocol as well.
Ask him if they're reassured by the evaluation.
We know from retrospective studies that a gut instinct that something's going to happen, that something is wrong, has 24 times the risk of stillbirth.
So the mother who comes in, sorry, the pregnant person who comes in and is not reassured by the evaluation has a gut instinct that something's not right.
We want to make sure that we're doing everything we can.
To either deliver if they're ready for that, or reassure them with future evaluation to keep them safe.
So that's a big piece of these protocols and then the final piece, which I allude to a little bit is a conversation about timing of delivery making sure that this is an earlier discussion.
And that this is something, I always feel bad if I ever have to pull the rug out from under my patients.
If you know they have a condition, a medical condition that necessitates delivery by a certain gestational age, explaining to them at 19 weeks.
You have.
chronic hypertension, you're on medications.
This means your placenta gas tank doesn't have the reserve that somebody who doesn't have this.
So we're going to recommend based on how you're doing delivery by 39 weeks.
That said at 19 weeks is totally different than the patient walks in at 37, 38 weeks and we say, Oh, by the way, this thing you've had since the beginning of pregnancy is now something that we're going to tell you we need to induce you.
So setting that stage And making sure we are getting those medically indicated deliveries delivered.
So timing that fetal growth restricted baby, timing their birth appropriately based on the size of the baby, those kinds of things.
And if your provider's not saying this and you as the patient know that you have one of the things that Dr.
Florescue has talked about previously in this episode, you can ask that question.
Hey, do I have anything that makes you concerned about needing to be induced early? My placental health, my cardiovascular functioning is there anything that you see that might change my plan at the end of pregnancy that I might want to talk about now? That's amazing.
Okay, so I do have a couple of questions based on what you were just telling about the saver baby.
Kind of prevention bundles and the protocol.
So when someone goes in and they say, I think something is wrong, fetal movement is down, whatever the reason is, what does this evaluation look like? Let's say in this scenario they were greeted really nicely and they took their concerns seriously and now they're back in a patient room.
What can someone expect? So with this protocol, what we do is, so let's take They're 34 weeks we would always do the NST, just do that right off the bat at 34 weeks.
So everybody who calls our office is going to get that when they're appropriate gestational weeks.
And if they have a risk factor for stillbirth, Or fetal growth restriction, even if that NST is reactive.
So it's showing us all the things that we want to see.
The protocol says that we do an ultrasound.
We check the fluid, the growth, and Doppler's if indicated, within 24 hours.
If it's not reactive, honestly, obviously, we're going to be doing whatever we need to do one.
So our patient comes in.
Our nurse says, I hear that you're worried about this.
They schedule the NST if they see that they have risk factors.
So I create a whole flow sheet that my nurses can pull up.
They say, oh, it's your 1st baby risk factor for stillbirth.
We're going to do a growth.
ultrasound.
We're going to check fluid.
And after that's done, and my nurse is now five years out, they do this, they don't even think about it.
They just say, are you reassured by this? And if the patient says, I'm really not reassured, then they bring it to one of us.
And then they say to them, thank you so much for calling.
It's so a message of you didn't bother us.
You are not wasting our time.
This is, I joke around, my best friend's a dermatologist.
So if you're ever interested in talking to a dermatologist, she's lovely.
And she never works weekends.
She never works nights.
She works three days a week.
And I always joke around.
If I wanted to be a dermatologist, I would have been one.
But I came on OB GYN because I love it, and because we love it, I know I'm going to be woken up at 2 in the morning, and that's okay.
And the last thing I ever want is a patient afraid to call, and something tragic happens to them or their baby.
And, I think one of the things that's so important when we talk about stillbirth and so many things is health disparities and Black women are two to three times more likely to experience stillbirth.
And I think when we look at care in general for people who are, BIPOC status, they are not feeling as empowered, right? They often express this.
I wasn't feeling heard.
I was, terms like gaslighting.
I wasn't being validated.
One of the things I think, since we've implemented this in 2019 in our practice, is When this doesn't only make us validate the fetal movement concern, it validates everything, right? If my patients are always being validated when they call a fetal movement, it naturally translates to the, I hear you're worried about your head.
I hear, and it teaches this mantra of, we care about you.
You know your body and your baby better than anybody else.
And we trust your instincts.
And why I want so much.
For what they're doing in the UK and Australia to be a national standard of care is I think it's going to address health disparities as well, because it really touches on that, right? A big critical piece of it is you have to ask the patient if they're reassured, and if we do that with every headache, every pain, everything that somebody comes in with, how much more are we going to catch? The preeclampsia, the other things that might be going on that the patient being asked a question and knowing that the provider cares about the answer.
What can we do with that too? Yeah, it's really, it does go back to like just listening to women, listen to your patients, and especially listening to those Black and Brown voices.
Because we know it's not just sober that they are affected by.
It's everything.
If white people are affected by it, Black and Brown people are affected by it more in, in every single category.
One thing that I have learned by Being in the loss community these moms have taught me that many of them did know something was wrong and they went in and they said something's wrong and they were not listened to.
It breaks my heart every time I hear it or every time I talk about it because it's just so sad that we could have caught it.
And it really, Yeah, I think this is so super important for all the health care professionals out there listening that When people say something's wrong just look into it And I had said this before we started recording as well, but the worst that happens is you say, okay Everything's good that mom is reassured and she wasted two hours of her day, right? And you put in an extra scan that didn't have to be the best thing that happens is you listen to that mom she was right and she's in the right place and we get that baby out.
And now we have a family that's complete and not broken.
Okay.
Another question I have is you had mentioned.
Sleeping positions.
Talk to us a little bit more about that.
You had also mentioned don't panic, just get back on your side.
Because I think a lot of people do have a lot of angst about sleeping positions.
What else do we need to know? And also why would being on your back be compromising? Yeah, so the reason why I ban the back is compromising is that there's a major vessel that goes back into the heart the inferior vena cava, and you're going to put more pressure on that vessel when you lie on your back, and that's why third trimester is when we talk about this, because the gravity uterus isn't doing as much prior to that.
So we always went for this left side thing, and the reason for the left side is that the inferior vena cava comes a little bit more to the right than the left.
So it's not quite in our midline and.
That was the reason for it, but really looking at sleep, it doesn't seem like it makes a difference.
So you do not have to be on the left always.
You, if you need to be on your right side, you can be on your right side.
And and the falling asleep on that side, when they've watched people sleep, they found that really the side you fall asleep and the side you're going to stay on.
So I never want anybody to panic that way.
When we talk about sleep, another really important thing, and this is research that's really, again, not United States getting going as much as this is Australia thing, is sleep apnea.
Oh.
And how common it is in pregnancy, so obstructive sleep apnea so the snoring that many pregnant people do.
If you are, if your partner reports you're snoring, and especially if you have risk factors for it, like obesity, see if you can get evaluated for sleep apnea.
We know that again, if you're not breathing well, you're not getting that oxygen.
You might not be forming that placenta as well.
So when we talk about sleep, another important thing is if you're at risk for sleep apnea of family history, you may be snored before pregnancy.
Now you're snoring a lot.
Talk to your provider about maybe getting evaluated for that.
There are studies showing that may reduce risk of preeclampsia, fetal growth restriction, and I think is really an important piece when we talk about sleep is if your sleep seems to be very interrupted by loud snoring you're having fatigue, reach out to us.
Wow.
That is so interesting.
I knew this stuff about being on your back in the vena cava vein, but that is fascinating.
I've never heard of the sleep apnea stuff.
And now just thinking about all the funny moments we've had in prenatals where, partners have made fun of their person for snoring and it's like a big joke.
And now I'm thinking, Oh no, we, there was an education moment and we missed it, but now going forward, we know to say Oh wow, actually.
Yeah, I think you're gonna, I think you're also going to see though that there's going to be daytime fatigue, right? So if somebody's snoring because they're just, we get congested in pregnancy and it's just like the nasal stuff, that's not, as much as what we're talking about.
But if I have a pregnant person come in who says, my husband says I'm snoring, I'm exhausted.
I feel like I'm sleeping, but I'm tired all day.
I'm having headaches.
Those are the things where you want to prompt is this something that could be sleep apnea related? And again, this is You and I were talking about, and you're saying you're new to this, the amount of effort that's put into figuring out how to prevent stillbirth, how to prevent preeclampsia, and everything related to this placental functioning is so in its infancy but I think as we get five or 10 years from now, we're going to just get more and more where we say, again, talk to your provider and say, I'm having terrible snoring.
Can we refer me for a sleep study? It's a, yeah.
It's a relatively simple thing to do.
It's a low to no risk test, right? And it can help you sleep better while you're pregnant and not be exhausted, as exhausted.
These are just, again, it's having that dialogue with your provider of what can I do to improve my placental health.
Totally.
Does exercise improve placental health? We keep talking about blood flow and we're talking about, yeah, we should be exercising.
Yes.
Oh, I think, It's.
It's hard because we can only, some people aren't able to exercise much when they're pregnant.
So of course, if you're having pain limitations any of those kinds of things, but we know, which I'm sure you have seen as a doula that people who exercise and gain appropriate weight and have less complications seem to have nicer labors and deliveries.
We also see less preeclampsia for them.
So we also see less of the fetal growth restriction.
So as much as somebody is economically and feasibly able to do, Taking walks, sitting on yoga balls, doing activity when you're pregnant.
Of course, anything that helps your heart pump and improve blood flow to the placenta, is certainly a good thing to do while you're pregnant.
Nice.
Okay.
And I do want to circle back to the smoking.
Is there a difference between people? And I guess who are you talking about when we talk about smoking and getting these patients to quit? Are they smoking during pregnancy or are we talking about someone who has smoked at any point in their life? People who smoke up until getting pregnant.
Is there a set number of months? We know that you can quit smoking beforehand How does all that intertwine? So i'm i'm not perfect with the literature on this but I know that quitting before reduces by very significantly.
So I think it's almost the same as if you're a non smoker, if you quit before you're pregnant.
But any point you quit in pregnancy has been shown to improve the outcomes.
So it's going to be more robust in the first and second trimester.
Remember when we were like 14 weeks, that stage, that's where we're opening all those arteries placenta.
So quitting before you get to that stage has been shown to have less risk than if you're quitting later, but they see improvement.
All the way through.
So remember, you're using that placenta like crazy during labor, right? Even if you quit by the time you're in labor, that may help with oxygenation and perfusion.
Again, totally recognize this is an addiction and that it's something that requires, it has nothing to do with how much somebody loves or cares and values their baby.
But there are resources available.
One of the things that's very important is if somebody is smoking, in the range where lozenges or gum and stuff like that would be recommended that half a pack plus amount per day.
Yes, there's nicotine in lozenges and gum, but that's the only risky thing in it.
And we have to remember that smoking cigarettes has far more carcinogens.
It is okay to use those things when you're pregnant and it's important to talk to your provider if you think that would help you quit smoking.
Definitely.
I guess I have just an honest question.
I don't really know anybody that smokes cigarettes anymore other than like older people.
How many people in the U.S.
are still smoking cigarettes? Is it really still a thing? It is.
U.S.
wise, so it was 13 percent in 2006 and down to 7.
2% so right around 10 percent are smoking.
Yeah.
Wow.
Wow.
Yeah.
Okay.
That's still that's not a small number of people.
No, it's not.
And it's again, we THC, it's now legal in New York state.
And.
It really, we need to be careful and make sure patients know that we that vaping all those things that affects our lungs.
So how does that, if we're not getting in the same amount of oxygen, how is that oxygen getting as well to the placenta? So remembering that really just because it's legal now doesn't mean we really need to figure out more THC and that, at least in Rochester seems to be on the rise since it became legal.
So, Okay.
I guess my final question about the protocol that we talked about is the aspirin.
So we know that starting aspirin by about 16 weeks for preeclampsia, for people who are at risk for preeclampsia is what's recommended.
Is that correct? Is it the same thing, or are we waiting until later? Are we adding aspirin once we find a problem? Is there a gestation where we're trying to get this aspirin into people that have, stillbirth risk factors? Where I live, we have studies that show the 81 milligrams that's available, basically, widely, that was shown to help prevent preterm preeclampsia.
Got it.
Studies outside of United States, when they look at, into the low hundreds, hundred and five plus range,.
You start to see a reduction in term preeclampsia and potentially fetal growth restriction in stillbirth.
Wow.
Our local high risk OBs, probably about two years ago, said if it's indicated, let's do two baby aspirins or 162mg.
If somebody's in Canada and they can find 115mg, that's fine, but we just don't have a United States.
If people have high risk for preeclampsia, then we put them on automatically, so that includes the hypertension, the pre pregnancy diabetes, kidney issues, autoimmune issues, history of preeclampsia, or adverse outcomes.
When you look at the stillbirth things from ACOG, they say that you don't need to do it for prior stillbirth.
Unless it was related to placental issues.
So if the stillbirth was a thousand percent.
not related to something vascular in the placenta, then you won't necessarily have to do it.
Let's say the terrible tragedy of a motor vehicle accident, right? That would not be something that you have expected for recurrence.
But I will tell you when you look at the placentas for people who've experienced stillbirth, There's vascular malperfusion in there.
This is all in the continuum.
So the vast majority of people who've experienced stillbirth should be on aspirins.
Unless as I said, the tragedy of a, trauma led to it.
Because then of course it wasn't something that was going to happen regardless of the tra you know, unless a tragedy had happened.
If people have moderate risk factors, more than one, they should be on it as well.
And that includes, I'll read them out because there's a lot of them first baby.
Obesity greater than 30 BMI family history of preeclampsia and your mother or your sister being of a Black race and I'll be careful to say that it's a proxy for underlying racism.
The theory being that you're more at risk for getting sicker from these things because we are not listening as well as we should.
Not because Black people more likely to have it, but as a proxy for health disparities lower income, probably a similar type thing.
Over the age of 35, a previous history of a small baby or adverse outcome greater than 10 years since your last baby and IVF.
And I think the list will go on and on, but.
Basically, I think at some point we're going to have everybody on these aspirins, but that's why when you say, what can you say to your doctor? One of the things you can say is do I, should I be at that first appointment? Should I be somebody who should be starting this? And it's supposed to be started before 16 weeks, optimally, but even has been shown to be beneficial up until 28 weeks.
So this is something that if you miss the mark, the one visit, you can do it further on.
Totally.
Okay.
That.
That helped a lot.
What does that malperfusion look like on a placenta when you're examining them? Does it look like huge vessels, small vessels, no vessels? What are we seeing? I am familiar with what calcification looks like, so I'm super eager to see what you're talking about malperfusion wise.
Yeah, so Malperfusion can look many ways.
If you think about it's similar to a heart, right? So if our heart's not malperfusing, so you can see infarctions, you can see thrombi, so blood clotting in there.
You are totally correct.
You can see overperfusion, so you can see hypermature.
So sometimes when placentas are not getting what they need, these villi and all these things, they actually mature faster than they should.
Which may run out of the gas, right? Because they're saying I need to be as efficient as possible.
We can see something called Chorangiosis, where you actually get a congregation of these, vessels trying to work together more.
Then you can see it from the maternal side.
You could also see from the fetal side evidence of this malperfusion.
And so when you put these two things together, when you look at these placentas, if I see this, so for example.
Let's say I deliver a patient with meconium at 41 weeks.
I send the placenta.
I see evidence of this.
This is a patient I may say, Hey, let's put you on some baby aspirin next pregnancy.
I can't guarantee you that it's going to make a difference, but this is where we need to go.
Whereas when we look at that placenta, especially since we know the risk of aspirin is really small.
If we see.
infarctions, if we see hypervillous, maturity, all these kind of things, if we see fibrin deposition, so you can actually get scar tissue in there.
When we're seeing all those things, should we be saying, how can we make this better the next pregnancy, so not just saying, oh, we have a healthy baby, but we have a healthy baby, but let's see, they had high blood pressure.
Let's see if there's something we can do differently next time.
The baby was small but came out healthy.
What can we do next time? So we don't have a stillbirth or a neonatal near miss.
The next pregnancy, so if you have the hospital, discard your placenta, they're not necessarily evaluating it.
So how do you ensure as a patient that your placenta is being evaluated? Is this something a lab needs to do or you're the doctor that delivers you will do it before they discard your placenta? So that's a great, wonderful question.
Right now, placenta patho[logy] reports are very hard to interpret.
They are very long and cumbersome.
And Placental pathologists, sometimes called perinatal pathologists, they're actually working on making it better.
For, it's been almost two years since we changed our placental reports for my hospital system to actually explain this.
Unfortunately, I think, right now, with no fault of midwives or OBs, they don't They look at the report but they don't actually know how to interpret it.
So we need to improve the education piece from it.
We know to send it if the baby comes out not looking great.
We know to send it for infection.
We know, so there's all these reasons to send it and I don't know that you have to send it every time.
The person who comes in 39 weeks has no issues and had a completely healthy uncomplicated pregnancy but the patient who comes in 40 weeks and they have a couple high blood pressures.
or baby comes out and doesn't do as well as you anticipated, send the placenta.
See what it has to tell you because you may learn a lot and it's very validating for patients if they came in with decreased fetal movement and they're 39 weeks and they're worried and you say let's induce you or anything.
It's very validating if the tracing doesn't look good and I do forceps and it wasn't really what the patient wanted.
When I can see that placenta and say, your baby was showing signs of not getting what they need, this placenta was running out of gas, and this is why that happened.
It's not your fault.
And it can really help people as they process their birth to have an explanation of why more interventions were needed, right? So the patient who didn't want the interventions of the scalp electrode and was hoping for this minimally invasive birth and ends up with anything, but if I debrief with them with the placental findings.
It really helps them come to terms for why things happen, maybe during their birth.
Totally.
It gives them a little bit of closure and does let them know, yeah, it's not my fault.
Okay.
Why is Aspirin not standard of care? Why aren't we just putting everyone on Aspirin? Can you talk a little bit about the risk of why we might not be doing this? I don't know necessarily.
I think if they have no risk factors, which I will tell you, there's very few people who don't have them anymore.
That's what I'm thinking, like just American culture.
I feel like all of us just like being in this society probably would have risk factors.
As I read you that list, Very few people don't have risk factors.
One or more of those moderate risk factors these days, we're all having babies older, right? All those kinds of things, IVF, all those kinds of stuff.
But I think you need a universal study seeing if it actually helps prevent people with truly no risk factors.
So somebody who truly has nothing that I read off to you, there's probably no benefit.
I'm hoping, again, research is the key my triplets just got home from school.
Triplets, huh? How was that? That was insane.
It's funny.
So people ask me all the time, like why I do this? Cause I'm not a loss mom.
And I think some of it is, I just let three healthy kids come in the door, and the stillbirth rate for triplets is very high.
And it actually hasn't changed much since I had them.
And I think facing that down, and somehow being lucky enough to have three incredibly healthy babies come out of me, Is such a blessing that I think it was always part of it.
I think the other reason why I do this work is just, I've always been able to nestle in grief and be able, what led to so much of this prevention, which we hadn't talked about yet was my care for people who've lost babies.
And I never knew that the care I was giving, which was very like.
Patient focused pregnancy after loss care.
I never knew that was unusual.
And I mean that 100 percent honesty.
I thought every patient who lost a baby, their doctors called them all the time and did the things that I naturally did.
And it was funny.
One of my Friends slash patients, I delivered, she lost a twin, I delivered her healthy baby in the end of 18.
And that's what started this whole journey.
And she said, Heather, I want to go teach the Heather way.
And I was like, what do you mean the Heather way? And she used a explorative, because she makes fun of me.
She's you really think that everybody does what you do? I'm like, what, they don't? That led to teaching locally, and then that led to me to go to the STAR Legacy Foundation Summit in 19, and that's where I learned for the first time that stillbirth may be preventable, and it has been a very interesting journey trying to get the OB community to just try, and so much of what we talked about, and I think one of the reasons why I, I feel like doulas are much more of the keystone at this point because so much of the message of doulas is empowerment and advocating for yourself and making sure you're being heard.
And it's sad that getting my colleagues To hear all the things that to doulas comes naturally in terms of how do we prevent this from happening is just not there.
And I think the more that we educate patients and talk about that up to half of term stillbirths might be prevented and 25 percent overall, we can't prevent them all.
But if a patient calls and says, I woke up this morning, my baby's not moving and they get brought in right away.
And the baby has no heartbeat.
They know that they weren't told to stay home.
They know that they were validated and it doesn't bring their baby back, but it is so much different than what you brought up where the patient says something is wrong and a normal NST and ultrasound trump's A patient instinct that something is wrong with their baby.
And until we elevate that, until we let the subjective concerns of our patients over the objective data that we have to make that subjective, something is wrong, go ahead, or else we're not going to affect the patient.
BIPOC, disparities, we're not gonna lower stillbirth because I think when we look at all the patients who have pulmonary embolisms not diagnosed, preeclampsia not diagnosed, or they are stillbirth, in the so many of these stories is, I wasn't validated in my concerns and my feelings.
And I think that's such a key piece to all of this, which is, I think why this work is also so incredibly important to me, because I think when we make an effort as a society to do the pieces that we talked about today, I think we're going to have improved outcomes for maternal mortality as well, and maternal morbidity, a patient saying, I am sick, I am in pain, and being heard over the objective data, over the fact that their vital signs are stable, fine, their vital signs are stable, they're telling you something is wrong.
And just the active listening that comes from stillbirth prevention isn't just about that, it's going to translate everywhere else.
Yeah, I just got back from the AWHONN conference and that's the the Association for Women's Health and Obstetric Neonatal Nursing for People listening being like, what's AWHONN? It's basically for your labor and delivery nurses your postpartum nurses your NICU nurses There were all sorts of women's health nurses anybody who takes care of you in your women's health journey They were all there and the theme this year.
It was an unspoken theme It wasn't like the theme of the conference But something that I found sprinkled in almost every single talk was we have to start listening to our patients We have to start listening to the people coming in telling us about their pregnancies.
We have to start listening to the Black and Brown voices.
We have to start listening to the people saying something's not right.
I don't think this is right.
I'm nervous and I don't think this is anxiety.
Like I think I'm having a gut instinct.
And it was just really powerful for me because.
You've mentioned I am new to this and the loss community has taught me like I did know something was wrong and I was sloughed off, I wasn't listened to, I was dismissed and so to hear it just again, it just drives it, it really drives it home that there has to be this shift that we start elevating our patients and for us, we use the term client's voices because their instincts are really strong, even if the data doesn't back up what they're saying.
And I have a patient who she when I look at pre implementation of this versus post, one of the stories I like to tell so she was having her first baby and she had a marginal cord insertion.
So we got, we're getting an ultrasound.
She was 37 and one and we got an ultrasound at 37, one because of the marginal cord insertion, normal fluid, normal growth.
The following day She called and said, my baby's not moving as much.
So 37 and two, and she came in when we did the NST, it looks great.
And she actually said, I'm really reassured by the NST.
And we had just done the ultrasound the day before.
So she had the normal growth and fluid the day before she felt reassured.
Nothing more needed to be done.
She called me two days later at 37 and four saying that she had a little bit of bleeding, thought maybe her water broke and that the baby wasn't moving.
Okay.
She comes in 37, four weeks, and it was the most beautiful NST you've ever seen.
And I asked her, are you reassured? She's I am not.
Something is wrong.
And she goes, I don't care what on that screen.
Something is wrong.
And I remember sitting there and saying, what am I going to do? I have a great NST and then I remembered hey, the protocol and I was like, wait, I have not checked that fluid in three days now.
Let's just see what I see.
And I thought, at the very least she can see her baby moving on there and maybe that'll help us get to reassurance.
So I put down the ultrasound probe, and she now has oligohydramnios, and we delivered her that day, because, indication deliver, and it really is a marker for how the protocol was so influential in there.
Totally.
I would like to think that I would have told her.
I would have done that, somehow I would have figured something out.
I'd like to think that, but I don't think I would have.
I think I would have said the fluid was normal a few days ago, this NST is great, and even though I like to think of myself as a doctor who listens really well, as much as I possibly can.
I think this protocol that we adapted and what I learned in 2019 from, what they're doing in other countries is the reason why she has a beautiful, healthy baby potentially.
And I can't say that this baby wouldn't have survived to the next day.
I know that.
I can't say this was saving the baby's life, but I can say that.
I was doing better active listening that her subjective gut instinct was listened to.
And she knows this, we've talked about she had a perfectly healthy baby.
And the interesting is she's moved away, but had a, the next pregnancy had no concerns, none.
The pregnancy, the baby's moving great.
She never hit a point in her pregnancy where she was worried, and it really shows that this is not something that you have over anxiety, right? This is not the things that we like to blame it on.
This is truly, can be an individual thing in an individual pregnancy and, that the empowering and listening is so much to be gained.
And as, as we've said numerous times on this, if we have one message to say is that if we empower ourselves to listen, to try to prevent stillbirth, we're going to listen to all the other things better too.
Yeah.
And that parental instinct is just so important.
It's very strong.
It's there for a reason, right? That birthing person knows, Oh my gosh, I believe in that so much.
Okay.
So I do have a one final question to wrap us up.
Why would having your first baby be a risk factor for stillbirth? I am not sure we know the answer to that.
Are there any theories? Is it because your body's never done this and we're just, and you know it's trying to figure it out? It could be exposure for the first time, to But I don't think we know.
We know that's associated, but I don't, as far as I know, I don't think we know the reason why.
Let me see if I can find that for you.
Yeah.
Because, and we see it's also actually a little bit more common in male, which is interesting.
Oh, that is interesting.
Now, if you have a baby that is stillborn, Does that increase your risk in subsequent pregnancies of also experiencing a stillbirth? Yes, so we know there's an increased risk.
And I think again, because cord is not the problem.
It's the placenta.
So if we're managing that next, so Tommy's, what is it called? Tommy's something I can look it up.
The UK kind of has a wonderful thing.
That is basically so Dr.
Alex is L is considered Okay.
One of the experts in the entire world on this subject he's a lovely man in the UK, and he formed Tommies, oh, it's just Tommies which basically is the think tank in the UK for stillbirth prevention and research and all those kind of things And he started the beginning of the Rainbow Clinic kind of thing, which I was always organically doing, but he's the one who really started this off.
And the interesting thing is, as long as he's had the Rainbow Clinic, he's not seen a recurrence of stillbirth for a person.
Wow.
And I think it's because of the fact that He is listening, right? The hallmark of this pregnancy after loss care is individualized care.
It's recognizing why that stillbirth happened and maybe delivering before it happens again, right? So if I have a baby that was stillborn due to meconium aspiration at 41 weeks, I'm going to deliver the baby sooner.
It's probably not going to have that.
So it's an understanding of why did this happen in the first place and what can we do to prevent the recurrence of it.
Totally I'm trying to think.
Oh, here.
Fetal factors.
Let's see.
It says talks about male, I do not see anywhere that it talks about why it's a bigger risk.
Something we don't know.
Yeah.
That's unfortunate.
It really is.
It's unfortunate.
We don't have a lot of data on this, but it is really inspiring that we've got a lot of growth and hopefully we can bring this to the forefront of obstetricians.
And it seems like we're making some good headway with our legislators.
We're getting some stillbirth prevention bills passed there.
So I think the wave is starting.
In terms of getting this data, what would we need? To see be done or should hospitals be asking patients if they can Have their placenta and run labs on them and just analyze every single placenta Is that the ideal goal? I think well, it's a wonderful goal, but I think the first step is So one of the things I joke around about with this community is that If you send a breast biopsy, do you ever get back the report and not interpret what it says? What we have to do is really educate providers, like if I do a biopsy of someone's uterine lining, and I don't see a term I know, I'm going to look it up, right? And I really don't think there's a single obstetrician who's not going to do the same thing.
But for some reason, we see these, Very confusing placental reports, and I think nobody is really finding the time.
So making these more user friendly, educating our residents, making sure that every family medicine, midwife, student, OBGYN resident is spending just a week or two.
One or two sessions on placenta pathology and how to read the placenta report.
One of the things that's really cool is residency is only four years.
So over the course that I've been doing this, my residents are doing all the things that we want them to do.
And they don't even know that it ever wasn't that way.
I love, I listen to them talk and they'll be like, Oh, this patient came in for decreased fetal movement.
Her NST looks good.
The ultrasound looks.
Good, and she's reassured, and they don't know that it ever wasn't that way, and that's the thing, and I joke around with Samantha about this a lot, we're not going to teach an old dog new tricks, we're never going to get the 65 year old, sorry, 65 year old plus people, physicians To change their ways, but boy can we educate the new generation because the new generation is going to push the older generation to do more current stuff, ACOG, everybody's working hard on this medical disparities thing, they're working hard to, if we just educate better at the beginning, this is not going to be something that's an issue down the line, and we need to focus on our newest learners and graduates, and that includes teaching, pathology residents, placental pathology, improving the reports, making sure that a resident that comes out now, when they get a report in their box, thinks about it the same way as a breast biopsy, a vulvar biopsy, or an endometrial biopsy.
And that can happen so easily because they are so ready to learn when they graduate from medical school.
We just have to get them there.
We're not going to get them at the twilight of their career.
I love that.
I love that so much.
I have this dream that I can teach residents in hospitals some of the skills that I've learned as a doula and people always ask me why residents, like, why not go after the doctors that are already practicing? And I say the same thing.
I say, I don't know.
I just, I feel so invigorated by the residents.
They are the movers, the shakers, they're coming in.
They're the new wave of healthcare.
care.
They're the people who are so focused on consent and I would rather lay a great foundation with our new doctors that have 50 years left in the practice rather than focus on someone who's going to retire in the next five.
And so I feel the same exact way.
Oh my goodness.
Okay.
I feel So educated on this.
I feel like I really have so much of a better understanding on A placenta health.
I didn't know nearly as much as I do now coming into this conversation.
I really understand, I think, a lot more risk factors because before this conversation, Fetal movement really was all I was familiar with so it's so amazing to hear all of these other things.
Is there anything else that we haven't talked about in terms of placental health, EPV, fetal movement, loss, anything that you are like we should talk about this before we wrap up because people need to know? I guess what I always like to remind people is this is not contagious.
Yeah.
Dr.
Florescue, you are such a unicorn OB.
I so appreciate you being here with me today and sharing your time with all of us today and specifically doing the work that you're doing to get this message out there, encourage the research, Collect these communities of mamas who are doing the work and pushing this forward in women's health.
So thank you so much.
If people either have experienced a loss and they want to share their story with you or get information from you, if someone's just interested in learning more about what you're doing, the research, if people have questions, they want to connect with you, where can they do that? So really, the biggest, best way is via the Instagram thing.
So at DrFlorescueObgyn, I do ask, I'm always happy to hear a story of a baby who's died, but I don't give personal medical advice for obvious reasons.
I need to know the whole story to be able to do that, but many people from around the world have shared with me their stories, and I would Read yours.
I will respond to you.
And I, going on to websites such as the Star Legacy Foundation, Count the Kicks, and Push for Empowered Pregnancy is a great way to get some resources on a subject or Tommies, as I talked about in the UK all have really good resources and read about the Saving Babies Lives You care bundle measure the placenta, all the things, all that stuff is on there.
But read about these protocols and sit down with your doctor and talk about your placental health for your individual pregnancy.
Absolutely.
Oh my gosh.
Thank you.
Truly.
Thank you so much.
All right, y'all, I will see you in the next episode.
Be sure to follow Dr.
Florescue on social media, and you can find me at tranquility by HeHe, and at the dot birth dot lounge until next time, head to your app store and download the birth lounge app for evidence based childbirth education and data driven postpartum support delivered straight to your phone.
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