People

Physiologic Adaptation

Related people

• Gestational Diabetes
• Kathryn Gray

Episodes

• #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D.The Peter Attia Drive

Notes

• ▶ Why Does Most Labor Pain Come From Contractions Instead of Delivery of the Head? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 1:45:30 Share Transcript

  Contractions cause most labor pain. Delivery of the head forms only a thirty second part of labor while contractions continue for hours.

  Most of labor is contractions. The delivery of the head is a thirty second part of the whole thing. Contractions go on for hours. A nurse described the pain of contractions to a husband who did not want an epidural by comparing the sensation to having balls slammed in a drawer again and again and again. The pain goes on for so long. Delivery of the head is very very painful. An epidural was used with all three labors. On the third one the medicine was more dilute and supposed to spread around better to give better coverage. There was no coverage right at t

• ▶ Why Does Missing One Feeding Make Lactation Not a Good Form of Birth Control? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 1:24:48 Share Transcript

  Most women possess the physiologic capacity to produce breast milk. Breastfeeding requires a maternal and neonatal partnership. Complex hormonal interplay in the endocrine system drives milk production. A lactating woman has a harder time ovulating. Lactation was generally viewed as one method of birth control.

  Missing one feeding makes lactation not a good form of birth control. A lactating woman will have very suppressed levels of estrogen and progesterone. If a woman skips any feeds then suppression of the cycle stops. Lactation only works as birth control when a mother maintains an uninterrupted feeding schedule. Women should not rely on lactation for birth control because one missed fe

• ▶ Why Does Premature Preterm Rupture of the Membranes at 28 Weeks Result in Delivery Within Seven Days for About Half of Patients? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 1:21:17 Share Transcript

  Premature preterm rupture of the membranes at 28 weeks requires hospital admission. About half of patients deliver in the next seven days. The remaining patients stay in the hospital with ruptured membranes and receive monitoring all the way up until 34 weeks if everything looks reassuring. Antibiotics given at presentation help prolong latency without preventing all infections.

  When water breaks at 28 weeks doctors call the condition premature preterm rupture of the membranes. Patients come into the hospital. About half of patients deliver in the next seven days after spontaneous labor begins. Other patients sit with membranes ruptured and low amniotic fluid but continue to make the fluid

• ▶ Why Does a Classical C-section Carry a Ten Percent Risk of Uterine Rupture During Labor? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 1:06:34 Share Transcript

  A uterine rupture is an emergency and a surgical emergency. Surgery on the uterus from big fibroid removal or a prior classical C-section cuts through the musculature of the uterus. The type of incision from a classical C-section is much more likely to rupture during labor with a risk of like ten percent. Ten percent risk is too high so the group should not labor.

  A low transverse C-section is preferred in term patients where it is almost always possible. Delivery of a preterm baby is one of the most common reasons for a classical C-section. The uterus has not expanded enough and the lower uterine segment is not developed. An incision in the lower part of the uterine segment may not safely

• ▶ Why Did the C-section Rate in the United States Increase From Ten Percent to Thirty Percent Over the Last Fifty Years? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 1:03:19 Share Transcript

  C-section rates in the United States increased dramatically from ten percent to thirty percent over the last fifty years. Different drivers explain the three X increase. Pregnancies are higher risk than they used to be. An increase in maternal obesity has raised the number of larger fetuses or cases where labor does not progress normally. The switch to continuous fetal monitoring during the active phase of labor in most hospitals leads to more C-sections when the tracing is not reassuring.

  Once a patient has one C-section, the patient is more likely to have another one. Multiple C-sections increase the risk for abnormal placentation in the next pregnancy. The specific issue is placenta accr

• ▶ How Long Does Hypertension From Preeclampsia Take to Resolve After Delivery? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 53:11 Share Transcript

  Hypertension from preeclampsia follows a different resolution timeline than gestational diabetes does after delivery. A woman can be off insulin by the time she goes home when gestational diabetes resolves. Hypertension from preeclampsia does not resolve in the same way. Some women will have hypertension resolve very quickly after delivery. Many women need antihypertensive medications for several weeks after delivery because hypertension can take six to twelve weeks to come back to more of a baseline.

  There are other women who will have persistent hypertension after delivery and never quite resolve the hypertension. Lots of women will come back and develop hypertension within the next five

• ▶ Why Does Every Woman Become Insulin Resistant During Pregnancy to Preferentially Direct Nutrients to the Fetus? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 35:51 Share Transcript

  It is not an oversimplification to say that every woman has to become insulin resistant during pregnancy because the adaptive response preferentially directs nutrients to the fetus. Genetic factors probably amplify the response in some women. Environmental factors would also amplify the response in some women. The environmental factors could be stress, sleep, nutrition, et cetera. The framework is a great one for the point.

  Interestingly, gestational diabetes does not always recur in every pregnancy. The process is not fully understood. Like almost everything in medicine, if a woman has had gestational diabetes before, the woman is more likely to have gestational diabetes again. Not everyon

• ▶ Why Does Insulin Serve as First Line Medication for Gestational Diabetes When More Than Half the Values Exceed Fasting Ninety Five or One Hour Postprandial One Forty? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 32:50 Share Transcript

  First line treatment for gestational diabetes consists of dietary modifications along with nutrition consultation and glucose monitoring in women who presented metabolically healthy prior to pregnancy. Targets include fasting values under ninety five and one hour postprandial values under one forty. Monitoring continues until more than half the values stay below targets.

  The short interval between diagnosis at twenty eight weeks and delivery limits lifestyle intervention to roughly two weeks. Elevated values in the first week lead directly to medication rather than extended attempts at control through diet alone. Insulin functions as first line medication during pregnancy due to insufficien

• ▶ Why Should Women of Childbearing Age Take Prenatal Vitamins When Fifty Percent of Pregnancies Are Unplanned? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 19:02 Share Transcript

  Folic acid must be at adequate levels prior to conception. Good evidence shows that folic acid deficiency increases the risk of having a neural tube defect in the baby. By the time a woman recognizes the pregnancy, it is already too late to bring up folic acid levels if a deficiency had been present. Folic acid is one of the most essential things early on.

  Fifty percent of pregnancies are unplanned. Prenatal vitamins should be recommended to all women of childbearing age. A well-balanced diet works because much of the food supply is supplemented with B vitamins and folic acid along with other nutrients that women need to replenish during pregnancy.

• ▶ How Did Genetics Identify the GDF15 Gene as Important in Driving Hyperemesis Gravidarum? The Peter Attia Drive · #410 ‒ The biology of pregnancy: physiologic adaptation, gestational diabetes, preeclampsia, childbirth, and long-term maternal health | Kathryn Gray, M.D., Ph.D. · at 11:06 Share Transcript

  Genetics provided great insight into hyperemesis gravidarum by flagging the GDF15 gene as really important in driving the condition. The GDF15 gene is now a developing target for therapeutics and the discovery suggests prior understanding of causes for hyperemesis gravidarum was not correct.

  For a long time people thought HCG caused nausea and vomiting of pregnancy. Researchers studied folks who had hyperemesis gravidarum and found a signal at the GDF15 gene. Women who experience hyperemesis gravidarum in a first pregnancy often experience hyperemesis gravidarum in all pregnancies. Less than one percent of folks require hospitalization for hyperemesis gravidarum with IV hydration and even I