Help! I’m Pregnant And Bleeding – Part 1

Intro and guest introduction 0:00

Is my lighting okay? Yeah, it's good. It's because I have like an added light just because the light in this room is not that great, so. Okay, no, that's fine. Should be alright. I don't think people are looking at me, honestly, I'm just saying. Nobody listens to this anyway. No one's looking, someone's listening to us so it doesn't matter. Hello again, and welcome everybody to this episode of the Jaffercast. I am your host, Dr. Mark Papadakis. Nobody particularly special, just another frickin' ER doctor.

This episode, we're going to be talking about vaginal bleeding specifically, first trimester vaginobleeding. Pregnancy loss, abortion, miscarriage, all those terms that you've heard a lot about in the news recently, but may have a little bit of misconceptions about and also questions about too. So, one of my colleagues, I went to medical school with Dr T. Beezer, she's going be joining us. She's OB-GYN, so we are going have good conversation, So let's bring her in here. Alright, I'm here with Dr.

Teague Beezer-Teague. Hello, how you doing? Hi, it's good to see you. Good to you too. I think it has been quite a few years since we talked to each other. You graduated from my alma mater, Toro, in 2017. How you doin'? You know. You're living the dream, I'm living The Waking Nightmare. It's fine. After Toro, you went to Cooper, actually, for residency in New Jersey, and I'd forgotten about that. Okay, and then you did a fellowship at University of Rochester Medical Center. Now, what was your fellowship in?

Maternal fetal medicine, so high-risk pregnancies. Gotcha. All right, walk me through because maternal fetus medicine I did not realize is actually its own separate fellowship and high risk pregnacies. Yes, so a lot of ultrasound. So we're the ones who traditionally read your ultrasounds when a person finds out they're pregnant, date their pregnancy, look at their anatomic ultrasound.

Maternal-fetal medicine and OB training 1:57

If there are any fetal concerns, we'll read the ultrasound, send mom. or the caring parent to the appropriate specialist. We also do consultations for women with complex medical problems in pregnancy, make recommendations. Some people refer to us as like the IM of pregnancy. you know, take care of all the chronic medical conditions. Did you want to do OB-GYN like the entire time you're in medical school? Like how did that kind of come about? I actually really wanted to be ENT, which is so weird because now that is weird.

How'd you go from here down to... I know. I had a reality check with step one and I was like, Oh, I don't think that's for me. And also then when I went on my rotation, loved my OB rotation. It was at Trinitas in Elizabeth, New Jersey. Oh yes. I liked that there was a little bit of primary care, a bit surgery. You can follow patients throughout the course of their lives. Um, you have two patients at once. And it's interesting that you mentioned that because in emergency medicine training, we consider, two patient at one, the mother being the primary patient and the fetus, child being secondary.

You know, there's a lot of push, um, lately in the news and politics, whatever, you know with the abortion legislations and all that, how do we reconcile the health of the mother versus health with child? And for emergency medicine, it is fairly straightforward in a sense that we prioritize the Health of The Mother. If you don't have a healthy mother, You don' have healthy child. Um, so our focus is kind of on that. Is that also kind your, your world as well, Yes, I want to say that it is not that we ignore the baby, of course not.

No, that's a good point. That's good. We don't ignore the babies. Definitely not. Babies are very important to us. But yes, maternal health is primary, because if you don' have a healthy mother, you do not have healthy baby. And there are also instances in where the health of the baby actually truly compromises the help of mom. Not to get into the nitty gritty, but the age of viability is incredibly important, which varies by institution, But overall is somewhere between 22 to 24 weeks. usually in the ED majority of the time you are seeing patients when they're not even viable, usually.

that's a factor that is incredibly important and gets overlooked more than we would like in legislature by people who are not physicians, not obstetricians. Yep. Nobody has ever had laid a hands on an actual patient before writing some of these laws. So before we get into the The popular stuff that's in the news right now, we got to talk about the one thing I want to mention on your resume.

Pregnancy, COVID vaccine, and public trust 4:46

It says that you were the face of the New York state COVID vaccine and pregnancy campaign. You partnered with the new York city department of health. So when you say that I took your face on flyers, like, can I actually Google you and you're, you know, smiling on a brochure somewhere, what was that like? And Google me, I was on the subway, buses. Alright. Actually where I got my eyebrow threaded in Rochester, they actually had a sign. I don't know why, but it was even there. Yes. Do your patients recognize you?

No, some have given me weird looks. Okay, like I had that in the when it was first out. I have people like look and I also did a verbal ad and my voice unfortunately is unique. So I think people recognize my boys but they couldn't put their finger on where so I got a lot of that like. That's awesome. And you actually, so you worked on a congenital syphilis project for the New York City Department of Health as well. For almost, for like two and a half years, two years. Yes. Okay. So what was that like?

How did you get involved in something like this? Infectious disease and pregnancy, do they seek you out? Do you just kind of, are you in the same room and this is discussed and they just, you know, get picked on randomly? So I actually had a lovely mentor and somebody who is on staff at the University of Rochester who works on the maternal mortality board, Dr. Christopher Glantz, amazing human being, taught me many things that I know or don't know when I ask him on below. Now, he's wonderful. He actually has suggested me because in 2021 slash 2022, I was pregnant with my first child.

And I had received the COVID vaccine and pregnancy in 2020 or sorry, I have received it in pregnancy during my 2021 pregnancy. And i had also received that when it first came out like all of us as a physician on the front line. So we're looking for your pregnant so because I got December 2020. Yes. And I had mine, I think like end of December, 2020 as well. Then I got pregnant 2021, got it again when I was 20 weeks pregnant. They were looking for somebody to be the face of this campaign to try to encourage moms to get the COVID vaccine in pregnancy.

Did you have reservations about the vaccine at all? Was that something that you were cautious about? Did look at something? How did your decision-making process evolve to get the vaccines while you're pregnant? So, fortunately, in between the time that I had got it, the first time, December 2020, and by the I got while I was pregnant, a study had come out showing that getting the COVID vaccine did not affect fertility. which I think was monumental in my decision making going forward. I wanted the vaccine so that I could pass on antibodies to my baby.

And I was also working during Omicron to mass on delivering women in the ICU who were incredibly sick with COVID. Faces I will never forget were also incredibly paramount in reason why I got the COVID vaccine. So I'd seen the worst of the for worse. I was reading the literature about its safety profile in women trying to conceive and women who were pregnant. And I wanted to give my newborn protection who wouldn't be able to get the Covid vaccine until they were six months. And like a lot of healthcare workers too at the time, you know, we wanted to be the face of the vaccination campaign in general.

So that's why a lots of us lined up to kind of say, hey, this is safe. It's really important that you actually did that to show pregnant women it was safe too. Cause I remember that was a concern that we had and data was coming out slowly, but surely. That's great. And also as a woman of color too, to try to the faced of attempting to gain trust within the community was really to me as well. Yeah, 100%. The patient population that I treat, very unfortunately poor, low socioeconomic status, is a huge underserved community.

And I remember at the time we were getting out a campaign to try and push for that vaccination because there was a lot of mistrust in that community that even I see with regards to vaccination and medical treatments. I'm never having more than one conversation with my patients, young, healthy patients whatever, about the vaccine. concerns about either efficacy or side effects. I remember that was a big, still is in many ways, a major step to try and get the word out about mass vaccination. And really quickly, I do want to put this in, even though you're like, nobody has been listening to this, but I have to say this.

I know that recently the recommendation for pregnant women has been walked back by the government. I don't agree with that. Women are still at a higher, pregnant patients particularly, are at higher risk to get severe disease. They stand by their recommendation to the COVID vaccine while you're pregnant. There is a robust amount of data proving that it is safe. and effective and decreases your chances of morbidity and even mortality within your pregnancy. We don't think about this, but pregnancy is considered an immunocompromised state.

Yes, it is. And something that we have to understand is your bodies, women's bodies are primed from puberty really to carry a child in the sense that when now a childhood is developing inside of them, What prevents your own body from attacking this baby? It is a parasite that is leeching nutrients from you and the body needs to go and say, this is bad thing for our own self. And it's because the immune system is tapered down. It's not as robust as it usually is. It's actually one of the theories why women are more prone to autoimmune diseases, because if you have an immune system that is basically overcompensating for the times when they are not pregnant, that's when you can see auto immune issues.

So now you an immunocompromised individual dealing with a virus that can cause, like you said, significant morbidity and mortality. Yeah, you guys are prime candidates for this vaccine, even though others really don't think that and you, well, your work is funny because you work in infectious disease and pregnancy kind of lends your own unique voice to this too. You see a lot of congenital stuff coming about. you see other issues that people don't think about during pregnancy, namely syphilis. And then all of a sudden a woman gets sick with COVID, you know, what do you do?

Also, just physiologically, you have a fetus and a growing uterus sitting on your diaphragm, decreasing literally the amount of space your lungs have to expand and deflate. So that makes ventilating you incredibly difficult when you severe COVID. Yes, people are nuts because I have had the privilege of seeing the worst of the worse of It's a no-brainer, you need this vaccination. You don't want this to be you. But it's hard to tell people. People want to experience it for themselves. That's right.

Yeah, exactly. They want see what life is on the other side is like, and it is not pretty. It is good. Now, have you seen pregnancy lost due to COVID?

COVID, flu, and pregnancy risks 12:04

Yes. Yes, while I myself was pregnant. Yes. I will never forget I was in fellowship and before that too, but in Fellowship, a woman, I want to say she was like in their 30-ish weeks. So late term. We're talking third trimester. Yeah. I remember her face. She had very bad COVID and had a demise. And we had to delay management of the demise, meaning delivery, because she was so sick. It was horrible. So she had pregnancy loss because of how sick she, was not because the virus was at home. Yeah, we believe.

Please don't come at me. I don' have the autopsy. Yeah, no, she was hypoxic and we believe that that had led to the demise. She was satting 78% when she came in. Yeah. I've seen that a lot of times, especially in the first two waves where patients come in, they're saturating 60, 70%. They're talking to you, but their auction level is still so incredibly low. immunocompromised, more at risk of severe disease, especially women. That fetus, that baby, takes up a lot of the oxygen. So in a normal pregnancy, in normal pregnancies, we normally see heart rates rise just because the body is trying to get blood to the baby in addition to you.

Can you imagine the strain that's undergoing the bodies trying get oxygenated blood into both you and the babies in that situation? It's not good and I can see how it can lead to some pretty bad outcomes. Now, that being said, the virus itself, have you seen a lot of that recently? No. It's been five, you know, four or five years since really two deadliest waves kind of came through. Omnicron obviously caused another spike, but we didn't see nearly as much morbidity and mortality, death and destruction compared to the first two waves.

What about these subsequent waves? Are we seeing a lots of still now in in pregnant women, you know, babies, whatever. So I will put a disclaimer out that I was not practicing for half of the winter. I started my attending job in December, and I'm mostly outpatient now. December of what year? December 2024. Okay. My, I graduated July, had time off my contract, started December. so I wasn't really in the mix, mix mix. i will say flu was tough this year. Yes. Yes, 100%. We saw more flu, I would say, more morbidity from flu than COVID.

I'd say last year when I was in the mix and also pregnant, so 2023 to 2024, a lot of flu. Not great. We a little COVID, but I say flu was dominant the last two seasons, if it were from my clinical experience. Yeah, and you're primarily now outpatient, correct? You're no longer really in the hospital setting. And that's been my experience in ER too, is really a bad flu season. RSV has been bad for the last two years as well. Flu has outpaced COVID in terms of the severity of disease, largely for a combination of reasons.

You can talk about mutated strains, vaccination campaigns, whatever the case is. But, you know, the risk factor for pregnant women is still the same when it comes to a lot of these viruses. It can devastate the person, which can therefore devastates the baby. And that's how a lots of this stuff comes about. I want to switch gears a little bit and we need to talk about vaginal bleeding, the main topic for obviously this show. Vaginal Bleeding does correlate with pregnancy loss in many ways. So people think now, okay, I'm bleeding.

I vaginally bleeding I am pregnant. Therefore, this is likely a miscarriage. Not all the time. Yeah, yeah. It's distressing. Absolutely. Yes. So, when is vaginal bleeding a miscarriage? When is it normal? Are there signs that we can look at? Is there something that women can say, okay, this is likely not a mismarriage, but what should we do here? You are at home having vagina bleeding and you know you're pregnant. You need to seek some sort of medical attention. Please never ignore vagin bleeding in pregnancy, whether it's you love the Oh, it's only when I wiped.

Don't care. I'm bleeding through a pad. Please see somebody. Whether you're wiping and spotting, bleeding a through pad, you need evaluation for a myriad of reasons. It is never normal in pregnancy. Yeah. And that's one of the biggest things that, you know, women come in and they say, I wasn't sure.

First-trimester vaginal bleeding basics 16:40

I don't know. It was only a little bit. Then I'm like, well, it doesn't matter. If you're getting ultrasound, if you getting blood work, then you are getting the whole nine yards. This is what it is. That's exactly what I would recommend. Yes, there are times where we can't find a cause and everything looks okay, and that is fine. But I never want a person to ignore vaginal bleeding in pregnancy. You need some sort of evaluation. What? What is a common cause? Let's say that I have a patient who comes in and they've been spotting a little bit, maybe a lot of blood, a bit of cramping, but okay, we see a baby in there.

Let say there are seven or eight weeks we've seen a heartbeat. Now what can I tell my patients that it could be this or it's most likely this? It could be one, threatened miscarriage, so threatened abortion. So your pregnancy looks okay right now, but we should follow up in a couple of weeks, especially in first trimester. Not sure what this could lead to. That's number one. Cervical friability. We see that a lot because the cervix is very soft. and sensitive in the beginning of pregnancy, so it's not uncommon to have intercourse and your cervix starts to bleed because it is very sensitive.

So that could be a cause. Also, infection. It could chlamydia, gonorrhea, some sort of STI irritating the cervx. So should I be swabbing these patients out for STIs? Does every vaginal bleeder get swabbed for an STI? So that's tough for me to determine for you because then you guys are the ones receiving the results, right? And I'm sure you want that, correct? I want you to say yes, and then, you're going to get the hate of every single emergency medicine physician in the country. I already do, I really do.

Don't come for me, don't do it. I do that. But I personally, when I would see a patient in OB triage when i was a resident, if they had bleeding, i would absolutely swab them. If I saw that they have a swab within the last week or two and no new partners and it was negative, then I wouldn't probably re-swab them I'd look incredibly closely as well to what I'm seeing on the cervix. STIs can look really nasty. There could be a polyp to a cervical poly, a growth on the cervix causing bleeding. Other things that can fool us are hemorrhoids.

People think they're bleeding from their vagina, but actually it's a hemorhoid that is incredibly engorged and painful and causing the bleeding Yeah, and that's a very common issue that women have when they're pregnant because all of a sudden, now there's increased pressure to your abdomen, there is pressure on your bladder, you can get constipated more easily now and all the sudden you get external hemorrhoids and this happens obviously much more frequently after and during childbirth and child delivery but yeah, it's problem in pregnancy though.

Yeah. And then like later on out of the first trimester, probably mid-trimester so second trimest or third trimestre, bleeding is concerning. Are we missing a previa? Meaning the placenta is covering the cervix. You have to be very careful when you're examining a pregnant patient saying that they're bleeding. Do you know where their placent is? Have we ruled out a preview? Just things to Be mindful. Yeah, and if you think about it logically, right, your placenta is a thing that gives your baby blood, oxygen, nutrients, all that stuff.

And usually it's sitting somewhere up higher away from the cervix, but now it is covering the cervical. How is the baby supposed to even get through the Cervix if there's something blocking the way that has a lot of blood vessels in it? And so you have leaking going on there that also has to be diagnosed ideally before the patient goes to deliver as well because then they need a C-section. They can't just go right through there. So how is that even diagnosed? What is the usual method for that? By ultrasound, by ultrasound at your anatomic ultrasounds, we are always looking at the relationship of the placenta to the cervix.

Now, can you see that early on like the first trimester? Yes, but many people had Previas in the first trimester and it doesn't mean anything because as the uterus, it's, sorry, It's not that it does mean it anything. It is not as clinically significant because that's probably the case for everybody. As the Uterus expands, the placenta kind of shifts backwards. Doesn't literally walk and move. That would be cool if it did. A neat trick. I wonder if we would have more rights if it did, right? No, probably not.

Probably not, honestly. So yeah, it wouldn't be uncommon at least 12, 14, 16 weeks to see the placenta coming down pretty low towards the cervix.

Placenta previa and C-section considerations 21:08

We become more worried about it when you're in your mid-second trimester. And we still look again in third trimesters too, sorry. And if somebody has a previa in the past, are they more at risk for a preview later on? Yes, they are. So that usually means that they're going to be getting multiple C-sections. If you've had one C section, chances are good you're gonna need a Csection for the rest of your pregnancies, correct? Not all the time. You can try for vaginal birth after cesarean section after one c-section depending on the indications for your original c section.

So, breach, non-reassuring fetal heart tracing, like baby's heart rate drops. Yes, you could try for vaginal birth after cesarean. Times when you cannot tolac, trial of labor after caesareans. So times you can not to lack is if you've had a... It's a new one for me too. Oh, really? Oh my god. Yeah, I've never heard of that one before. I'm just a dumb ass emergency medicine doctor, okay? All these fancy terms you're throwing at me I don't know about. All right, that wraps up another episode of the Jaffer Gas.

We had to cut this one short because we have a lot more to cover. Dr. Teague Beezer, thank you for coming on and we're going to get her back in here to talk more about first trimester vaginal bleeding along with miscarriage, ectopic pregnancy, things like that. So we are going split it up into two separate episodes. Already, we talked about getting the COVID vaccine during pregnancy. Women are especially at higher risk during the pregnancy period, their immunocompromised and therefore should consider getting a COVID booster when it becomes available, if it become available.

And of course, vaginal bleeding in the first trimester can be normal, however, it should never be blown off and should always be evaluated by a doctor, either in OB-GYN or in an emergency department. As always, I encourage constructive thoughts, comments, and suggestions. You can leave them in comment section for those on YouTube or email them to me at jeffordcast at gmail.com. If you're in the healthcare field and interested in being in a show to discuss topics in healthcare, or if you have a passing interest in health care topics, please feel free to reach out to me as well.

Closing remarks 23:08

Like with anything though, don't take my word for it. Do your own research, talk to your doctor, because at the end of the day, like I keep getting reminded at work, I'm just another friggin' ER doctor. Make good choices, everybody.