FAQs

Preterm Labor

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Preterm labor is defined as the presence of uterine contractions along with progressive cervical shortening before the 37th week of gestation. Preterm labor does not necessarily lead to preterm delivery, which is defined as the delivery of a neonate before completion of the 37th week of gestation. The same is true of preterm deliveries, which can occur in the absence of preterm labor. In such cases, delivery is induced due to complications that affect either the mother or the fetus or both such as pre-eclampsia, diabetes, infection, growth failure, etc.

Preterm labor may be the result of an intrauterine infection, non-infectious intrauterine inflammation, placental ischemia (reduced placental blood flow), placental abruption, and placental thrombosis. In addition, preterm labor may often occur for reasons that we cannot identify (a.k.a. idiopathic). At KOFINAS PERINATAL we have successfully treated thousands of patients with tendencies for preterm labor. From our experience, most patients encounter preterm labor due to some degree of non-infectious inflammation. The use of the anti-inflammatory agent Indomethacin has been instrumental in the successful treatment of such patients.

The word "toco-lysis" is a derivative of the Greek words toketos, which means labor and lysis, which means, Òto bring to an end.Ó Together they mean the process of ending labor. Over the years, a number of drugs were used to achieve tocolysis. The most commonly used tocolytics are Indomethacin, Procardia, Terbutaline, Ritodrine and Magnesium Sulfate. At KOFINAS PERINATAL, after 25 years of experience with all kinds of tocolytics, we have developed a protocol for outpatient treatment by using Indomethacin and Procardia in various combinations according to the patient's particular condition. Rarely, and only, if we have absolutely no other choice, do we use hospitalization with Magnesium Sulfate. Terbutaline and Ritodrine have never convincingly shown that they can successfully prevent preterm delivery. On the contrary, chronic use of Terbutaline may cause increased irritability of the uterus due to its stimulation of the enzyme cAMP - phosphodiesterase.

Indomethacin is a non-steroidal, anti-inflammatory medication, which was primarily used for treating arthritis (similar to Motrin). Because labor involves the activation of compounds known as inflammatory cytokines, Indomethacin is the most potent medication used to effectively stop the production of these compounds, thus preventing preterm labor.

Use of Indomethacin does not result in any serious side effects for the mother. The most common effects are mild gastrointestinal symptoms and fluid retention. Occasionally, patients complain of headaches. It is important to note however, that most of these symptoms subside within 2-3 days. In rare cases we have been forced to reduce the dosage in order to get rid of some symptoms, but more often than not the symptoms subside on their own. Indomethacin has been found to cause temporary constriction of the ductus arteriosus if used after 34 weeks and for more than 48 hours. At KOFINAS PERINATAL we never use Indomethacin after 32 weeks and we have never seen any signs of constriction in fetuses prior to 32 weeks when the medication is in use according to our protocol. We rarely use Indomethacin for more than seven days, and we always monitor the condition of the ductus arteriosus with color and pulsed wave Doppler before and after the treatment. Another fetal side effect is oligohydramnios (reduction in volume of the amniotic fluid). We have seen a few cases where amniotic fluid volumes dropped slightly, but as soon as we stopped the medication, the fluid rebounded to normal levels. Overall, the benefits of Indomethacin far outweigh any theoretical risks.

Procardia (a.k.a. Nifedipine) is a calcium channel blocker used primarily as an anti-hypertensive medication (blood pressure lowering medication). Procardia achieves this by relaxing the muscular fibers, which compose the vessels, allowing the blood to flow more freely. Because the uterine muscle responds the same way to Procardia, the medication causes relaxation of the uterine muscle fibers and thus stops preterm contractions. Although Procardia can be used throughout the entire pregnancy, it achieves its best results when used after 15 weeks gestation.

Procardia is a very safe medication, and we have never been forced to terminate its use because of side effects. Use of procardia may drop the blood pressure of a normal individual slightly, but this does not affect a patient's ability to continue taking her medication. Some patients experience mild palpitations for the same reason and others complain of skin redness in the bodyÕs lower extremities when standing upright, but this often disappears when the patient goes to bed. There are no known fetal complications caused by the use of Procardia, and in many instances in the past we used Nifedipine to treat fetal tachycardia (fast heart rate).

When the placenta has clots present either inside it (placental thrombosis) or under it (sub placental clots), it means that a portion of the placenta has been damaged, resulting in less efficient blood flow to and from the mother. In such cases, the fetus cannot receive the necessary nutrients and ultimately, the necessary oxygen for healthy development. Fetuses with such placentas are at risk for growth failure, preterm delivery, brain damage and even death. The risk for brain damage and death is highest during labor due to the additional stress imposed by the labor process.

Labor is usually induced for medical reasons. Reasons may relate to both the mother and the fetus. With respect to the mother some common indications are poor maternal health, severe hypertension, maternal uterine infection, rupture of the fetal membranes prior to the onset of spontaneous labor etc. With respect to the fetus common indications are growth failure, non-reassuring fetal condition (stressed fetus), decreasing fetal activity, decreased amniotic fluid (oligohydramnios), etc. Many Obstetricians choose to induce labor if spontaneous labor does not commence by 39-40 weeks because fetal morbidity and fetal mortality increase exponentially after 39 weeks.

Most preterm deliveries are caused directly by poor placental development, which itself is often caused by an underlying and recurrent problem in the mother. This is why patients who delivered prematurely in a previous pregnancy, are as much as 60% more likely to experience a premature delivery in the next. Chronic inflammation of the placenta due to poor placental blood flow and tissue necrosis (tissue death) may cause preterm labor. At Kofinas Perinatal, we are able to reduce the number of preterm deliveries by 50% in both singleton and multiple gestations simply by helping the placenta develop normally and to its full capacity. Early placental development (prior to 12 weeks) is of paramount importance, something that other physicians do not recognize. In addition, our outpatient management of preterm labor with Indomethacin and Ca++ (calcium) channel blockers helps us in our quest against prematurity.

Terbutaline is one of the worst medications ever used in patients with preterm labor. All the studies over the last 20 years have failed to prove any significant effects in stopping labor or prolonging pregnancy. In contrast, many studies have clearly demonstrated that terbutaline is dangerous for the mother and the unborn and continuous use of it in oral and subcutaneous use (via a pump) increases the frequency of contractions. Many mothers exposed to terbutaline for preterm labor inhibition, have experienced severe and in many instances lethal cardiovascular complications. Other studies have shown that its use increases the risk for neonatal brain damage, hemorrhage and developmental delays. This is a really dangerous drug that should never by used to stop preterm labor. Unfortunately, it has been and still is the standard of care despite two very strong warnings from the FDA. Only recently, when the FDA issued its last warning using very strong language, many perinatologists decided to stop using it.

IVF pregnancies are more 35% more likely to be born prematurely, 30% more likely to be born growth retarded and 4-times more likely to die in the first year of life. There is nothing wrong with IVF that causes these problems. It is the same underlying reason that causes the infertility to begin with, which is responsible for the placental problems that cause prematurity, growth failure and fetal death. The most common underlying problem is an imbalance in the hemostatic (coagulation) system known as thrombophilia. Many individually insignificant thrombophilia factors can cause much more damage than one significant factor such as Factor V Leiden. Unfortunately, most obstetricians will tell you that you do not have thrombophilia if you do not have Factor V Leiden. This is a disaster and responsible for many losses and many more patients who never make it to have a baby. The combination of two or more minor factors can affect the placental development to various degrees and this in turn affects the quality of the pregnancy and the outcome. Poor implantation due to genetic thrombophilia and autoimmune conditions are mostly responsible for failed implantation and infertility or poor placenta development leading to poor pregnancy outcomes in IVF pregnancies.

Terbutaline is one of the worst medications ever used in patients with Preterm labor. All the studies over the last 20 years have failed to prove any significant effects in stopping labor or prolonging pregnancy. In contrast, many studies have clearly demonstrated that terbutaline is dangerous for the mother and the unborn and continuous use of it in oral and subcutaneous use (via a pump) increases the frequency of contractions. Many mothers exposed to terbutaline for Preterm labor inhibition, have experienced severe and in many instances lethal cardiovascular complications. Other studies have shown that its use increases the risk for neonatal brain damage, hemorrhage and developmental delays. This is a really dangerous drug that should never by used to stop Preterm labor. Unfortunately, it has been and still is the standard of care despite two very strong warnings from the FDA. Only recently, when the FDA issued its last warning using very strong language, many perinatologists decided to stop using it.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Most preterm deliveries are caused directly by poor placental development, which itself is often caused by an underlying and recurrent problem in the mother. This is why patients who delivered prematurely in a previous pregnancy, are as much as 60% more likely to experience a premature delivery in the next. Chronic inflammation of the placenta due to poor placental blood flow and tissue necrosis (tissue death) may cause preterm labor. At Kofinas Perinatal, we are able to reduce the number of preterm deliveries by 50% in both singleton and multiple gestations simply by helping the placenta develop normally and to its full capacity. Early placental development (prior to 12 weeks) is of paramount importance, something that other physicians do not recognize. In addition, our outpatient management of preterm labor with Indomethacin and Ca++ (calcium) channel blockers helps us in our quest against prematurity.

Pregnancy Loss

Brain sparing is a physiological mechanism used by the fetus to increase delivery of oxygenated blood to the brain at the expense of other organs. Unlike fully formed adults, only three organs are of importance to the fetus: the brain, the heart, and the adrenals (glands which produce adrenaline and natural steroids). When a fetus senses that the amount of oxygen in its blood is decreasing it makes an effort to protect its three most vital organs at the expense of all others, such as the liver, kidneys, muscles etc. This is achieved by a sophisticated cardiovascular response, which diverts more well-oxygenated blood to the important organs. This mechanism can protect the baby for up to 3 weeks.

It is well known that women who have recurrent vaginal bleeding during the first 12 weeks of pregnancy have an increased risk to suffer from a miscarriage. However, if the pregnancy continues past 12 weeks, then the risks of prematurity, growth failure and other adverse pregnancy outcomes are increasingly likely to happen. The risk for growth restriction and premature delivery is 2-3 times higher in such patients. If this happens then the baby may suffer the consequences of restricted growth failure and prematurity for the rest of his/her adult life. It is now recognized by most researchers that intrauterine growth restriction is the main cause of adult diseases such as diabetes, hypertension , cardiovascular diseases, stroke, premature lung failure and premature failure of many other organs. At KOFINAS PERINATAL we search for the cause of such bleeding as early as possible and treat such patients aggressively according to the specific problem. The result is a healthy pregnancy with a well developed neonate.

Pregnancy loss in the third trimester may be the result of an accident, such as an umbilical cord compression, which may be caused for a variety of reasons. Such accidents can only rarely be prevented. Most of the fetal losses in the second and third trimester are due to placental failure, and as such are preventable as long as the cause of fetal death can be identified. Careful history and pathologic examination of the placenta along with fetal autopsy can identify more than 80% of the causes and thus help us manage the next pregnancy safely. At KOFINAS PERINATAL, we have been able to help a large number of patients take home a healthy baby despite having suffered a previous loss.

Placenta abruption (placental detachment) is a condition that occurs infrequently (1 in 300 pregnancies). However, once it happens the risk of recurrence in the next pregnancy is 20 times higher, and after two successive pregnancies with abruption the risk jumps to almost 1 in 3. This is because placenta abruption occurs in patients with some form of underlined chronic condition, which affects the mother's vessels and thus leads to poor placental development. The most common causes of this condition (pre-eclampsia, chronic hypertension, lupus erythematosus, preterm labor, etc.) are linked one way or another to thrombophilia.

This is not true. Bleeding in the first trimester was traditionally associated with pregnancy loss before the usage of ultrasound technology became prevalent. This was because bleeding was usually the first sign of a pregnancy that was already lost and not one that was in danger of being lost. Bleeding during the first trimester may be a good reason for your obstetrician to test you for thrombophilia, which according to our experience is the most common cause of bleeding. When a patient experiences bleeding, they should stay in bed until it eases or stops completely. Subsequently, a vaginal sonography should be conducted in order to evaluate the cause of bleeding, which in turn can most effectively guide the ensuing treatment.

The answer is resoundingly yes. Many years ago we realized that such pregnancies suffer from serious placental pathologies that can cause all kinds of pregnancy complications. Because of this understanding, we have developed, in conjunction with the KOFINAS FERTILITY INSTITUTE, management protocols that have increased the success rates of these pregnancies and the quality of the fetuses. Despite the fact that several studies have reported increased incidence of abnormal pregnancy outcomes (preterm delivery, growth failure and increased pregnancy loss), our patients continuously achieve outcomes that are better than those of the so-called “low-risk” patients.

The answer is yes. Even 2 losses should be enough to trigger proper investigation in an effort to avoid subsequent losses. Also, in women older than 35, even one pregnancy loss is a good enough reason to be evaluated for possible preventable causes, since the risk for a second pregnancy loss in such women is almost 35%. This is very common today and proper consultation should be requested.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss. These pregnancies are of the highest risk because they experience placental problems. If treated according to Kofinas Perinatal protocols, the success rate with a healthy and fully developed child is 98%.

There is strong association between stillbirth in the first pregnancy and subsequent adverse outcomes.(ischemic placental disease, fetal distress, chorioamnionitis, extreme preterm birth, and early neonatal mortality)
The etiology of such adverse outcomes is usually chronic and recurrent. Maternal and / or paternal thrombotic conditions may be responsible.
The placenta should be thoroughly examined both, during pregnancy by means of ultrasound and after birth by means of pathologic examination. A pathologist experienced in perinatal pathology should be the only one involved in the assessment of the placenta.
Women with a history of stillbirth should be thoroughly investigated prior to pregnancy for thrombophilic abnormalities and if present, be treated accordingly during the pregnancy.
The best way to monitor future pregnancies in such patients is by means of fetal and maternal placental Doppler; this is the best and most reliable way to monitor treatment success and prevent perinatal adverse events.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

There is nothing normal about losing a baby in the first trimester. Any woman who lost a baby in the first trimester has a 25% (1 in 4) risk of losing the next pregnancy as well. However, this also means that she has a 75% chance of keeping the baby past the first trimester, so the percentages are still in her favor. If the baby that was lost was her first pregnancy ever, then the risk of losing the next one can be as high as 35%. What is of importance however, is the fact that although the next pregnancy may not be lost, it may be complicated by placenta related issues (growth failure, preterm birth, pre-eclampsia, etc.). The reason for this is that conditions causing pregnancy loss may also cause variable degrees of placental damage, which would in turn lead to the complications mentioned above.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Incompetent Cervix

Cerclage is a procedure in which a suture (stitch) is placed around the cervix in a purse-string fashion with the intention of keeping the cervix closed and thus sustaining the pregnancy. Most Obstetricians today use the Macdonald type of removable suture, and when the pregnancy gets to term they remove the suture to allow for vaginal delivery. A permanent type of cerclage is the Shirodkar type of cerclage, which when successful, is left in place for future pregnancies. Today, this has fallen out of favor and the vast majority of Obstetricians use the Macdonald type. The procedure is usually outpatient, lasting only 10-15 minutes and performed under spinal anesthesia.

No, this is not correct. At KOFINAS PERINATAL we have shown that abdominal cerclage belongs in the history books and not in the operating room. The only exception is when the cervix is not accessible for any reason through the vagina and the diagnosis of incompetent cervix is certain. We have treated a large number of patients who were referred to us originally for abdominal cerclage due to multiple prior losses despite the use of conventional cerclage in their previous pregnancies. These patients achieved the desired number of successive term pregnancies with proper management of cervical incompetence and preterm labor and without abdominal cerclage. At least three randomized clinical trials have shown that cerclage alone has always failed to improve pregnancy outcomes in patients with short cervix. It is the obstetrician/perinatologist who fails to realize that most patients with second trimester losses suffer from a mixture of cervical weakness and premature labor. Unless both problems are addressed, the pregnancy will fail again and again.

The answer is resoundingly yes. Many years ago we realized that such pregnancies suffer from serious placental pathologies that can cause all kinds of pregnancy complications. Because of this understanding, we have developed, in conjunction with the KOFINAS FERTILITY INSTITUTE, management protocols that have increased the success rates of these pregnancies and the quality of the fetuses. Despite the fact that several studies have reported increased incidence of abnormal pregnancy outcomes (preterm delivery, growth failure and increased pregnancy loss), our patients continuously achieve outcomes that are better than those of the so-called “low-risk” patients.

Terbutaline is one of the worst medications ever used in patients with preterm labor. All the studies over the last 20 years have failed to prove any significant effects in stopping labor or prolonging pregnancy. In contrast, many studies have clearly demonstrated that terbutaline is dangerous for the mother and the unborn and continuous use of it in oral and subcutaneous use (via a pump) increases the frequency of contractions. Many mothers exposed to terbutaline for preterm labor inhibition, have experienced severe and in many instances lethal cardiovascular complications. Other studies have shown that its use increases the risk for neonatal brain damage, hemorrhage and developmental delays. This is a really dangerous drug that should never by used to stop preterm labor. Unfortunately, it has been and still is the standard of care despite two very strong warnings from the FDA. Only recently, when the FDA issued its last warning using very strong language, many perinatologists decided to stop using it.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Incompetent cervix is a condition where the cervix shortens and then dilates early in the pregnancy. This leads to either pregnancy loss (spontaneous abortion in the second trimester) or an extremely premature delivery of less than 34 weeks gestation. This loss occurs with no traditional signs or symptoms of premature labor. Patients who suffer from incompetent cervix can still achieve successful term pregnancies with the placement of a cerclage, which can then be removed at the proper time.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Nutrition & Exercise

There are several types of artificial sweeteners on the market today. The most popular to date has been Equal (Aspartame), though there is also the new sweetener known and Splenda (Sucralose) as well as the familiar brand SweetÕnÕ Low (Saccharin). Concerns have been raised about the possibility that such sweeteners may in fact cause fetal defects, reproductive complications, and cancer. Unfortunately, limited studies have been conducted with human subjects, and those, which have been conducted, failed to show any specific risks during pregnancy. However, since research in this area has yet to be exhausted and the results up to this point do not offer any guarantees, we would suggest that you abstain from any excessive use of these products during the course of your pregnancy. Saccharin has been in use for more than 40 years and to date, there have been no scientific studies in humans to indicate any harmful effects from its use.

Caffeine has been associated in some animal studies with an increased risk of miscarriage. Studies that reported such correlations were conducted on rats, which have little in common with humans. In most of the studies the amount of caffeine given to the animals was equal to 12 cups of coffee a day. These studies identify 300 mg as the threshold, above which toxicity may occur. One cup of coffee contains 100 mg of caffeine on average, whereas a can of soda contains roughly 50 mg. Therefore, these studies suggest that 1-2 cups of coffee a day can be consumed without risk for miscarriage. In addition, caffeine may exert a beneficial relaxing effect on the uterine muscle through its inhibitory effect on cyclic-AMP phosphodiesterase.

Recent analyses of dozens of brands of fish oil supplements, including testing by ConsumerLab.com, have not found significant levels of mercury or unsafe levels of PCBs, dioxins, or other contaminants—in inexpensive or pricey brands. This is not surprising, since mercury tends to accumulate in larger fish, and supplements are made from smaller species (such as anchovies or sardines) or algae (which supply only DHA). Moreover, mercury is water‐soluble and thus tends to accumulate in the flesh of the fish, not in the fat or oil. Finally, most supplements are processed to reduce levels of PCBs and other contaminants.

No. As long as the motherÕs health is normal and the pregnancy is not complicated, cardiovascular activity is actually beneficial to both the mother and the baby. In fact, increased cardiovascular activity during the first trimester has been associated with improved fetal growth and pregnancy outcomes.

To start with, pregnant women should avoid all fish cultivated in fish farms. Fish farms utilize byproducts of large fish processing as part of the mix that makes fish food for the farm-raised fish. Large fish such as sharks, swordfish, tuna, and any other fish that have long life spans and are high in the food chain, are more likely to accumulate larger amounts of ocean pollutants in their bodies. Such pollutants include mercury and various dioxins. It is known that mercury causes brain damage and dioxins are potent carcinogens. Therefore, pregnant women should seek out small, wild fish that are less polluted. Such fish include among others, red snapper, sea bass, striped bass, sardines and wild Alaskan Salmon.

Pica is an insatiable appetite for non-nutritional materials such as ice, clay, wall plaster, etc. Patients with pica suffer nutritional deficiencies because their appetite for non-nutritional foods often leads to an under consumption of ÒregularÓ foods (i.e. nutritional foods). It is unclear what causes women to develop pica, although iron deficiency has been associated with it.

Thrombophilia

There are two reasons that thrombophilia is particularly dangerous to pregnant women. First, the pregnant woman is more likely to form clots in her body because pregnancy increases the general risk for clot formation. In women with thrombophilia this risk is magnified many times over. Second, pregnancy outcomes are dependent on a healthy placenta, and in women with thrombophilia the placenta may be adversely affected by excessive clotting, which then affects the pregnancy in various ways.

Anti-phospholipid antibodies are molecules abnormally produced by our immune system, for reasons that are still unclear to us. What is important to note however, is that the release of such antibodies can often cause clotting disorders such as thrombophilia.

Once again, because the placenta functions as a filter between mother and child, it depends on the free flow of blood from both parties to work efficiently. Because thrombophilia accelerates the bodyÕs tendency to form blood clots, the result could lead to a less permeable placenta, which would then be less able to facilitate the absorption of the neighboring blood supply. Although the vast majority of placentas experience a small degree of clotting naturally, significant clotting can lead to diminished supplies of oxygen and essential nutrients to the fetus. This in turn leads to some of the most serious complications of pregnancy, such as preterm labor and preterm birth, growth restriction, fetal death, placenta abruption (detachment), cerebral stroke, cerebral palsy, pre-eclampsia, maternal brain injury, and even maternal death.

The answer is both yes and no. When the mother has genetic thrombophilia, the baby's risk of obtaining some form of the condition can be either 50% or 100%, depending on whether the mother has both of the abnormal genes or only one. What is more important and least understood by most obstetricians is the fact that the mother may be healthy and yet the placenta and the fetus may suffer from genetic fetal thrombophilia, which was inherited from the father. In other words, the risk of the baby to have genetic thrombophilia as well as the severity of it depend on whether the mother, the father or both of them have some form of genetic thrombophilia. At KOFINAS PERINATAL we are very successful in identifying this condition because we pay keen attention to the placental development and not just to the maternal blood tests. On numerous occasions, we have prevented health setbacks in the extended family by advising testing of the fatherÕs lineage. When the mother has acquired thrombophilia there is no direct and absolute risk of developing this condition during fetal life. There may be a slight increase in the risk of developing the same condition in adulthood but this risk is not known.

It depends on the type of thrombophilia. Most thrombophilias affect the unborn indirectly by damaging the placenta and reducing the amount of oxygen and nutrients that it transfers to the baby. However, one of the genetic thrombophilias known as Factor V Leiden gene mutation has been associated with fetal and neonatal strokes. This happens only if the baby has inherited the defective gene from the mother. By exercising intense maternal treatment in order to optimize the placental function, we may be able to avoid such complications in utero.

About 60% of our blood is water, meaning that it must remain in a liquid state at all times for as long as our vascular system is intact and to clot only at times of injury in order to protect us from excess bleeding. In patients with thrombophilia the blood inside an intact vessel forms a clot (thrombus), which blocks the free flow of blood. This leads to an obstruction of the vessels, much like a damn obstructs the flow of water in a river, only in this case we want the river to flow naturally without any sort of obstacles. If the river of blood slows down its movement or ceases to flow entirely, then subsequent damage of the body's organic tissues can occur since blood flow is the means by which our body provides itself with oxygen. This is the cause of conditions such as, DVT (clots in the veins of the legs), stroke (clot in any brain vessel), heart attack (blockage of the heart vessels), arterial thrombosis of various organs (liver, kidneys, intestine, etc.). In short, the answer is most certainly yes.

The answer is no. Most patients go on to have a normal pregnancy as long as they continue their treatment with Lovenox and Aspirin. As upsetting as bleeding is, it is usually just a nuisance whose effects are not detrimental to the either the mother or the babyÕs health. Regardless, 90% of the fetuses we loose in the first trimester are genetically abnormal and not compatible with life. Bleeding in patients with thrombophilia is caused by the trombophiliaÕs effect on the placenta, and this is exactly why we recommend Lovenox and Aspirin, which counteract the bleeding and lead to a safe pregnancy.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss.

IVF pregnancies are more 35% more likely to be born prematurely, 30% more likely to be born growth retarded and 4-times more likely to die in the first year of life. There is nothing wrong with IVF that causes these problems. It is the same underlying reason that causes the infertility to begin with, which is responsible for the placental problems that cause prematurity, growth failure and fetal death. The most common underlying problem is an imbalance in the hemostatic (coagulation) system known as thrombophilia. Many individually insignificant thrombophilia factors can cause much more damage than one significant factor such as Factor V Leiden. Unfortunately, most obstetricians will tell you that you do not have thrombophilia if you do not have Factor V Leiden. This is a disaster and responsible for many losses and many more patients who never make it to have a baby. The combination of two or more minor factors can affect the placental development to various degrees and this in turn affects the quality of the pregnancy and the outcome. Poor implantation due to genetic thrombophilia and autoimmune conditions are mostly responsible for failed implantation and infertility or poor placenta development leading to poor pregnancy outcomes in IVF pregnancies.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss. These pregnancies are of the highest risk because they experience placental problems. If treated according to Kofinas Perinatal protocols, the success rate with a healthy and fully developed child is 98%.

Contrary to previous thinking, such concerns are unfounded. An interaction with anticlotting medication (anticoagulants, such as warfarin, Low Molecular Heparin and Heparin) is theoretically possible, but recent research has found no significant risk, even at high doses. People taking anticlotting drugs should be monitored as usual by their doctors. Similarly, you needn’t worry about interactions with aspirin, which also has an anti‐clotting effect. Indeed, the American Heart Association advises low‐dose aspirin and omega‐3s for people with heart disease.

In the United States alone, 2 million people die every year because of this condition. To put this in perspective, all cancers in the US combined kill only 500,000 people per year. However, looking at the death toll can be deceiving since many people who suffer from strokes or other blood clotting episodes may survive but remain disabled. Overall, 30-50% of all people suffer from either genetic or acquired thrombophilia.

Thrombophilia is a combination of two Greek words. The word "thrombos" means clot, and the word "philia" means friendship. In short, thrombophilia is a condition, which increases the body's tendency to form blood clots.

There are two types of thrombophilia: genetic and acquired. A defective gene from our parents usually transmits genetic thrombophilia. Occasionally, the gene defect (mutation) that causes thrombophilia may appear for the first time in a child whose parents do not carry the gene (de novo mutation). Acquired thrombophilia is the result of an immune system malfunction, which causes the production of anti-bodies that interfere with the clotting mechanism. The most common acquired thrombophilia is the one caused by antiphospholipid antibodies.

Fetal Monitoring

Genetic amniocentesis is the procedure used to obtain amniotic fluid, which contains fetal skin cells. These cells are then used to check the baby's chromosomes for Down syndrome and other chromosomal anomalies. Amniocentesis is performed at 16 weeks or later and has a risk for pregnancy loss of 1 in 300. When amniocentesis is done before 16 weeks, the risk of pregnancy loss can be as high as 3.4 %. CVS is done at 12 weeks and is as safe as amniocentesis. At KOFINAS PERINATAL we offer both procedures but we prefer CVS, because in our experience the benefits of CVS outweigh those of amniocentesis. We do not use amniocentesis for the prenatal diagnosis of spina bifida. This condition can be reliably diagnosed only with ultrasound. After the ultrasound, an amniocentesis is then performed to check the chromosomes since such fetuses may suffer from chromosomal anomalies as well.

PUBS is a procedure in which we obtain fetal blood directly from the umbilical vein. Fetal blood is sometimes needed to assess the fetal health. The most common reason for this procedure today is for the assessment of fetal anemia and for fetal transfusion.

CVS is a procedure by which we obtain a small amount of tissue from the fetal placenta in order to test the baby' chromosomes in patients who are at risk of having a baby with Down syndrome or other genetic abnormalities. CVS is the safest procedure available at 12 weeks and the only procedure that can be performed safely before 16 weeks gestation. CVS has been shown to be as safe or safer than amniocentesis, which can only be performed at 16 weeks or later. The procedure involves the insertion of a 20-gauge needle through the abdominal wall and 3-4 mg of placental tissue is removed. The size of the needle is the same as that used for an amniocentesis. CVS was originally conducted through the vagina. This method is not as safe as the transabdominal approach and most clinicians have abandoned it in favor of the abdominal one. The risk of pregnancy loss because of the procedure is approximately 1 in 300.

HUM involves the use of a special monitoring device, which monitors pregnant women while they remain at home. The monitoring device is used to record contractions, and if there are more than 4 contractions per hour, the patient goes to the emergency room for further assessment. HUM has not been shown to prevent prematurity in randomized clinical trials; in fact it is extremely expensive at a direct cost of $800 per day. Furthermore, HUM has increased the number of patient visits to the emergency room, while at the same time failing to reduce prematurity all together. A visit to the emergency room for such a reason may cost more than $2,000 raising the total cost of the procedure significantly. In addition to the direct costs incurred by this method, one has to also consider the inconvenience and loss of productive time for all involved. At KOFINAS PERINATAL, we do not use HUM and our results have proven superior to any service that does.

Nuchal translucency is the thickening of a babyÕs neck, specifically in the back. This is usually noted between the 11th and 14th week of pregnancy and is the result of water accumulation under the baby's skin. The degree of thickness, or water accumulation, correlates directly with the probability of Down syndrome in the neonate. Therefore, as the volume of water in the neck increases, so too does the probability that the baby has Down syndrome. When the babyÕs chromosomes are normal (test results indicate that baby does not have Down syndrome) and nuchal translucency is still present, the risk for fetal cardiac defects increases substantially.

NT in combination with pregnancy associated plasma protein (P-APP) and the free beta subunit of human chorionic gonadotropin (§-hCG) constitutes the Ultra-screen test, which is used to detect fetuses with Down syndrome. The accuracy of the test is 90% and is the most effective test available for the first trimester. Performed between 11 and 14 weeks gestation, the Ultra-screen test involves an ultrasound assessment, which includes measurements of the NT as well as a blood test obtained from the mother. The results take about a week and when negative, reduce the risk for Down syndrome to an acceptable level. The ultra-screen test is available only for singleton and twin gestations. If a patient is carrying 3 or more fetuses she can still use NT by itself, which reduces the risk of Down syndrome by about 80%.

Cardiac echo is the examination of the fetal heart using ultrasound imaging. This involves different modalities including 2D gray scale, color Doppler, pulsed wave Doppler and M-mode imaging. Fetal echo can detect up to 90% of major cardiac defects if done by an experienced physician. However, there are certain cardiac defects, which cannot be detected prenatally, and therefore a negative test does not preclude entirely the possibility of their existence.

A contraction stress test is conducted in order to evaluate the amount of placental reserve available to the fetus. The placental reserve signifies the placentaÕs Òback-upÓ capacity in case it is put under heavy strain by the fetus or mother. By putting the placenta under artificial strain through this test, we are able to observe how it would react if such conditions were actually to occur naturally, and therefore work to prevent possible complications. The problem with this test however, is that it is time consuming as well as potentially dangerous to the mother and the fetus, and as such is advised against in many high-risk conditions. With today's knowledge and advanced technologies, the contraction stress test has become obsolete.

As many as 30% of all fetuses are born with their umbilical cords wrapped around their necks, and in most cases there is no evidence of any harmful effects. On the other hand, most of the fetuses that sustain damage during labor do so because of cord compression. This is often caused by a variety of reasons, the most common of which have their roots in nuchal cord. In addition, there are many factors, which may exacerbate or alleviate such a condition. Examples are cord length, cord tissue quality (Wharton's jelly), quality of the placenta as well as the site on which the cord is inserted (site located somewhere on the placenta). At KOFINAS PERINATAL, we screen all pregnancies for the above-mentioned conditions, and although we recognize that preventing fetal damage in its entirety is impossible, we are proud to report that we have prevented more than 20 fetuses from suffering serious brain damage and even death. In such cases the fetuses were delivered immediately by emergency cesarean section or the patient's obstetrician was warned about the potential problem, thus protecting the fetuses involved.

Selective reduction is a surgical procedure by which multiple gestations with more than 3 fetuses are transformed into twin gestations (2 viable fetuses). This procedure is performed only after thorough assessment of the pregnancy in combination with extensive counseling of the parents. This procedure runs the risk of total pregnancy loss, and is performed only when it is expected to benefit the majority of fetuses involved.

Pregnancies with unexplained low PAPP-A are at increased risk for adverse perinatal outcomes including fetal death. In most patients, this is the result of poor placental development and placental insufficiency. First we test such patients for thrombophilia and immune issues to identify the most probable cause so we can treat the patient accordingly. Patients who test positive are treated with anticoagulants for thrombophilia and if they have immune issues also, they are treated with steroids or other immune treatments according to the findings. Most patients in our experience suffer from thrombophilia and are treated with anticoagulants only. At Kofinas Perinatal we monitor such pregnancies with ultrasound, fetal, placental, and uterine Doppler every two weeks. The treatment is adjusted according to the findings and the outcomes are excellent without any losses or any of the severe complications that have been reported in the literature.

An NST is done to evaluate fetal well-being. The test is performed by means of weekly electronic fetal heart monitoring and contemporarily is usually combined with a biophysical profile. NST is falsely positive (abnormal) as often as 80% of the time, and results in a great deal of unnecessary additional testing and maternal anxiety. Sometimes this leads to unwarranted precautionary measures, which may in turn harm the fetus. When NST is conducted weekly and shows normal results, the ensuing risk of fetal death in the next 7 days is approximately 3 in 1000. This risk can be reduced further with the addition of a biophysical profile or by increasing the frequency of testing to twice a week. However, the problem with NST, and this is a serious problem, is that when a test comes back as abnormal, the fetus is at high risk to have already sustained some degree of brain damage. For the above reasons, at KOFINAS PERINATAL we rarely use electronic fetal monitoring and only for specific indications other than fetal well-being.

Brain sparing is a physiological mechanism used by the fetus to increase delivery of oxygenated blood to the brain at the expense of other organs. Unlike fully formed adults, only three organs are of importance to the fetus: the brain, the heart, and the adrenals (glands which produce adrenaline and natural steroids). When a fetus senses that the amount of oxygen in its blood is decreasing it makes an effort to protect its three most vital organs at the expense of all others, such as the liver, kidneys, muscles etc. This is achieved by a sophisticated cardiovascular response, which diverts more well-oxygenated blood to the important organs. This mechanism can protect the baby for up to 3 weeks.

CVS is a procedure by which we obtain a small amount of tissue from the fetal placenta in order to test the baby' chromosomes in patients who are at risk of having a baby with Down syndrome or other genetic abnormalities. CVS is the safest procedure available at 12 weeks and the only procedure that can be performed safely before 16 weeks gestation. CVS has been shown to be as safe or safer than amniocentesis, which can only be performed at 16 weeks or later. The procedure involves the insertion of a 20-gauge needle through the abdominal wall and 3-4 mg of placental tissue is removed. The size of the needle is the same as that used for an amniocentesis. CVS was originally conducted through the vagina. This method is not as safe as the trans-abdominal approach and most clinicians have abandoned it in favor of the abdominal one. The risk of pregnancy loss because of the procedure is approximately 1 in 300.

Prescription drugs

Theoretically, if your blood count is in the upper normal range and your body iron storage is full you may give blood once during your pregnancy. However, most women start their pregnancies with a negative iron balance, due to monthly menstruation. Because of fetal iron needs, pregnant women are vulnerable to anemia with advancing gestation. Although maternal blood volume increases during pregnancy by almost 50% most of it is new plasma (watery part of blood). Also, the earlier blood is donated during the course of the pregnancy the lesser the risk to the baby. The baby's increasing needs for oxygen are met by means of increasing maternal blood volume. Therefore, it is not recommended that pregnant women be regular donors during the course of their pregnancy.

Fish oil supplements are rich in omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). There is scientific evidence that these acids decrease triglyceride levels, decrease growth rate of atherosclerotic plaque, decrease the risk of arrhythmias and lower blood pressure to a small degree. These benefits reduce the risk for heart attack and sudden cardiac death. Regarding the developing embryo, omega-3 fatty acids are beneficial to the brain development and may also be beneficial to the overall pregnancy health. However, there is a problem with their use. Most of the available supplements are produced from fish, which are contaminated with mercury and dioxins (carcinogens). Although most manufacturers claim that their product is cleaned, only a handful of the hundreds of products available are suitable for safe consumption. There are also issues regarding dosage and interactions with other medications that the patient may be taking. It is advisable not to consume any omega-3 supplements during pregnancy. Instead, try to obtain the recommended omega-3 by means of food intake rich in omega-3.

Terbutaline is one of the worst medications ever used in patients with preterm labor. All the studies over the last 20 years have failed to prove any significant effects in stopping labor or prolonging pregnancy. In contrast, many studies have clearly demonstrated that terbutaline is dangerous for the mother and the unborn and continuous use of it in oral and subcutaneous use (via a pump) increases the frequency of contractions. Many mothers exposed to terbutaline for preterm labor inhibition, have experienced severe and in many instances lethal cardiovascular complications. Other studies have shown that its use increases the risk for neonatal brain damage, hemorrhage and developmental delays. This is a really dangerous drug that should never by used to stop preterm labor. Unfortunately, it has been and still is the standard of care despite two very strong warnings from the FDA. Only recently, when the FDA issued its last warning using very strong language, many perinatologists decided to stop using it.

Contrary to previous thinking, such concerns are unfounded. An interaction with anticlotting medication (anticoagulants, such as warfarin, Low Molecular Heparin and Heparin) is theoretically possible, but recent research has found no significant risk, even at high doses. People taking anticlotting drugs should be monitored as usual by their doctors. Similarly, you needn’t worry about interactions with aspirin, which also has an anti‐clotting effect. Indeed, the American Heart Association advises low‐dose aspirin and omega‐3s for people with heart disease.

The developing fetus will actively remove one gram of calcium per day for the duration of the pregnancy. This is necessary for the calcification of the babyÕs newly developed bones. If the pregnant woman does not ingest as much calcium per day as needed to replace the losses, then she will have to remove it from her bones in order to make up the difference in order to maintain a healthy amount in her blood level. Women that do not receive supplemental calcium during their pregnancy are destined to loose 5% of their bone mass with each pregnancy. This can be detrimental to your health especially during menopause. In fact, The Center for Disease Control recommends that all women should consume one gram of calcium daily starting at their teenage years continuing until menopause. After menopause, they should consume one and a half grams of calcium a day to reduce the risk of osteoporosis (fragile bones). It is best that pregnant women take a suitable supplement that provides one gram (1000 mg) of calcium per day and also consume foods rich in calcium (milk, cheese, legumes, leafy green vegetables, tofu, nuts and foods where bones are consumed such as sardines and salmon). Women with kidney stones should consult with their physician before they take any calcium supplements.

Very much like calcium, iron is necessary for the babyÕs blood cells. The total amount of iron that is necessary for a healthy pregnancy is 1,000 mg and is shared by the mother and her unborn baby. The mother needs extra iron for the extra blood volume and to replace her daily losses (unavoidable normal losses) and the fetus needs the iron for his/her new red blood cells. Because only a very small portion of iron is absorbed through the intestine, pregnant women should consume a daily supplemental iron dosage of 500 to 1,000 mg (depending on the formulation, since some formulations deliver more elemental iron). Iron supplementation during pregnancy is very important because most menstruating women enter pregnancy already with deficient iron supplies, unless they take iron supplements prior to pregnancy. Because many women become constipated when taking iron supplements they should try to eat foods rich in iron such as enriched breakfast cereals, cooked beans and lentils, pumpkin seeds, clams, oysters, mussels and of course liver.

Folic acid is considered a significant component for the early formation of the fetal nervous system. Lack of folic acid may increase the risk of open neural tube defects such as spina bifida and anencephaly. Because spina bifida and related defects develop 2-3 weeks after conception, al women of childbearing age should consume sufficient folic acid through supplementation (equivalent to 400 mcg). During pregnancy it is recommended that one consume 800-1000 mcg daily.

Cerebral Palsy

Cerebral palsy can occur for several reasons and a number of conditions have been associated with it. Although prematurity is often associated with cerebral palsy, most of the babies that suffer from it are born at term. Often times it is a lack of oxygen to the neonate, leading to asphyxia and brain damage, which may induce cerebral palsy. This is one reason why prematurity is often associated with cerebral palsy, since such babies are more likely to receive inadequate oxygen supplies (before, during and after birth). The presence of inflammatory markers (chemicals) in amniotic fluid and in fetal cord blood has also been associated with cerebral palsy, leading many researchers to believe that infection is one of the causes of cerebral palsy. This however, may be incorrect since many of the inflammatory markers that researchers attributed to the presence of infection were the result of non-infectious inflammatory placental reactions. In a study of neonates with cerebral palsy, it was found that 80% of the placentas exhibited various levels of thrombosis (clot formation) and chorionic tissue necrosis. It is our opinion that in most cerebral palsy cases it is some variation of placental failure, which is the culprit. Conditions such as growth failure (intrauterine fetal growth retardation), preterm labor, placental thrombosis, fetal vessel thrombosis, placenta abruptio and pre-eclampsia are all linked to an increased risk for cerebral palsy. Such complications are often the result of poor placental development.

Brain sparing is a physiological mechanism used by the fetus to increase delivery of oxygenated blood to the brain at the expense of other organs. Unlike fully formed adults, only three organs are of importance to the fetus: the brain, the heart, and the adrenals (glands which produce adrenaline and natural steroids). When a fetus senses that the amount of oxygen in its blood is decreasing it makes an effort to protect its three most vital organs at the expense of all others, such as the liver, kidneys, muscles etc. This is achieved by a sophisticated cardiovascular response, which diverts more well-oxygenated blood to the important organs. This mechanism can protect the baby for up to 3 weeks.

Cerebral palsy, also known as spastic paralysis, is defined as a non-progressive motor deficit of early onset. This may occur in one or more limbs with paralysis, spasticity or problems of motor control representing some of the symptoms. Cerebral palsy is usually the result of brain damage caused by a lack of oxygen. Reasons for oxygen deficiency may vary but are often the result of poor placental function. Cerebral palsy affects 1 in 500 Ð 1000 neonates and its incidence has not decreased despite the millions spent annually for its prevention.

Brain sparing can be identified by Doppler assessment of various fetal vessels. The great value of this assessment lies within the premise that it can identify a fetus at risk for brain damage when the fetus is still healthy. No other test has ever been so reliable in our opinion. In contrast, fetal electronic monitoring (NST) has never been shown to prevent such damage reliably, and when such a test returns as abnormal, the risk for having already sustained some degree of fetal brain damage is almost 40%. At KOFINAS PERINATAL, fetal cardiovascular assessment by means of advanced Doppler technologies is the primary means of assessing fetal well-being, along with a fetal biophysical profile (assessment of fetal behavior by use of real-time ultrasound).

Medical Conditions

The prevailing wisdom among perinatal specialists is that there is no known intervention that might prevent recurrence of intrauterine growth restriction (IUGR). Instead, the only beneficial treatment is to deliver the baby (remove the baby from the hostile intrauterine environment) when the condition is diagnosed. This unfortunately is not true. At Kofinas Perinatal we have been fortunate to realize that planning the next pregnancy and providing appropriate care can help us prevent such adverse outcomes. We believe that a healthy placenta is the most important organ for healthy fetal development. Buy identifying the cause of placental damage early in the pregnancy and with proper treatment, we have been able to almost eliminate IUGR. Patients with history of IUGR in a previous pregnancy must be seen prior to conception in order to achieve the best results. Most cases of IUGR are the result of placenta failure due to placental thrombosis (clotting).

The vast majority of pregnancy failure occurs in the early stages of pregnancy (the first few days after ovulation and conception). As many as 50% of all patients with suspected infertility suffer from some form of implantation failure. KOFINAS PERINATAL in conjunction with the KOFINAS FERTILITY INSTITUTE identified this problem several years ago and has since developed protocols for the successful management of such patients. These protocols involve a thorough assessment of the parents for certain conditions linked to implantation failure, after which individual treatment of each patient is pursued more effectively.

In general maternal illness does not affect the baby as long as the mother's body functions remain normal. However, it is possible for infections to affect the baby independent of the mother's condition. A small number of viruses relating to the common cold known as adenoviruses have been associated with fetal infections, which may lead to fetal loss. However, most of the common cold viruses are benign and do not affect the baby, although it is important to be cautious when you are feeling under the weather, making sure to keep your body temperature at less than 1010 F. Sustained fevers of over 1010 F during the first trimester may be associated with fetal congenital defects.

Miscellaneous

Afterbirth is another name for the placenta. The reason for this nomenclature is that the placenta is the last thing to come out during labor, and thus after the birth of the infant.

There are two vascular components in every placenta; the maternal circulation and the fetal circulation. The maternal component is fully formed roughly by the 24th to 26th week of pregnancy but the fetal circulation continues to grow until 38-40 weeks. The healthy development of the fetus depends on a healthy placenta (afterbirth). The placenta plays the single most vital role in the development of a healthy fetus and is formed by the connection of fetal and maternal vessels. The fetal vessels (thousands of them) are contained within the chorionic villi (microscopic projections of fetal tissue), which are completely submerged in maternal blood. Oxygen and nutrients are therefore exchanged between maternal and fetal blood.

Alpha-fetoprotein is a fetal plasma protein, which is like the adult plasma protein, albumin. Fetuses contain a great deal of AFP and in fact, the level of AFP in the fetal blood is 1000 times that of the maternal serum level. It takes only a few drops of fetal serum or blood to leak into the maternal circulation for the maternal levels of AFP to increase to abnormal levels. In normal pregnancies most, if not all, of the AFP enters the maternal circulation via the amniotic fluid. Fetuses excrete AFP into their urine and this becomes part of the amniotic fluid.

Because AFP normally finds its way into the maternal circulation via the amniotic fluid, anything that increases the amount of AFP in the former will consequently amplify the concentration of AFP in the latter. Such conditions include, open neural tube defects (spina bifida and anencephaly), abdominal wall defects (omphalocele and gastroschisis), sacrococcygeal teratomas (tumors of the lower spine), and other anatomical defects. Excessive fetal urine levels of AFP can occur in cases of fetal renal damage where the kidneys excrete abundant amounts of alpha-fetoprotein. One such condition is called Finnish Nephrosis and is extremely rare (1 in 3000 individuals of Finnish descent). Some conditions may also increase maternal serum AFP in ways other than through the amniotic fluid. In such cases, the AFP finds its way into the maternal circulation directly through the damaged placental vessels. This damage may be the result of endothelial inflammation and breakdown, which leads to leakage of fetal AFP into the maternal vascular space. This may be the most dangerous of all conditions, because it is commonly linked to placental failure with all the usual consequences ranging from fetal growth failure to fetal death. A study in Great Britain recently found that there is a direct relationship between sudden infant death syndrome (SIDS) and elevated AFP. In most instances of elevated AFP due to placental damage, the initial cause is placental thrombosis brought on by acquired or genetic thrombophilia.

Low AFP is usually associated with chromosomal defects. There are several screening methods, which utilize the combination of AFP and other maternal serum proteins (serum markers) in order to identify fetuses at higher risk for Down syndrome. The accuracy of the test may vary from 50-80% depending on the methodology used. Abnormally low AFP does not mean that the baby necessarily has Down syndrome. Instead, it simply means that the mother has a higher risk than the average pregnant woman of giving birth to a baby with Down syndrome. Ultrasound targeted anatomical assessment combined with fetal cardiac echo may reduce this risk to normal. For patients who wish to have the highest level of diagnostic accuracy and to reliably exclude the presence of Down syndrome, amniocentesis for fetal chromosomal analysis may be the best solution. However, amniocentesis is an invasive procedure and therefore caries a normal pregnancy loss risk of 1 in 300.

Implantation is the process by which the early embryo attaches and then imbeds itself into the uterine wall, allowing for the formation of the placenta and eventual growth of the fetus. This is one of the most sophisticated and delicate procedures in human reproduction. Hundreds of highly specialized proteins are involved in complex interactions with each other. These proteins, as well as other molecules, help the fetus get access to maternal vessels without causing a break down of the maternal vascular integrity. The embryo literally perforates the maternal uterine vessels and destroys their muscle fibers, reducing the resistance of these vessels to almost zero and thus assuring continuous and uninterrupted blood supply to the fetus. Failure in this process can lead to all sorts of placental malfunctions, which may in turn lead to some of the most serious prenatal complications ranging from fetal brain damage to pregnancy loss.

So far there is no substantial evidence to support the theory that dying oneÕs hair during pregnancy is harmful to the baby. However, because beauty related products are not regulated it is impossible to know for sure what is and is not harmful. For this reason, we recommend that women avoid using such products entirely during the first trimester and only sparingly during the subsequent 6 months of pregnancy.

Computer monitors emit electromagnetic radiation. So does the human body. The amount emitted is minimal and clinically insignificant. However, a rule of thumb is to keep your body at armÕs length when you have to spend long hours in front of a monitor.

For the most part, the answer is no. However, because during pregnancy the maternal skin vessels are dilated to help the mother eliminate the additional heat produced by the baby, pregnant women are more prone to suffering heat strokes if they remain in the sun for an excessive period of time (in this case sunscreen does not help). It is therefore recommended that pregnant women avoid direct sun exposure for more than a few minutes at a time.

Theoretically your body is ready for another pregnancy when your menstrual cycle resumes after childbirth. If your first pregnancy was uncomplicated and your health in general has been normal, then 13 months is more than enough time. If however, your previous pregnancy was complicated and depending on the type of complications, it is important to consult with your Obstetrician about any time related restrictions that may exist.

Cats are often believed to be potential carriers of a disease known as toxoplasmosis. Toxoplasmosis is a parasitic infection that is not harmful to adults but may cause major damage to the developing fetus. If the mother has never been exposed to toxoplasmosis before and encounters it for the first time during pregnancy, then her fetus is at risk for infection. If the mother, however, has been exposed to the parasite before her pregnancy then she is most likely immune and therefore the risk to her baby is negligible (immunity can be confirmed by blood tests). If you feel that, for any reason, that your baby may have been infected you should immediately see a Maternal-Fetal-Medicine specialist for confirmation.

To best understand the placenta we must first try to understand the nature of the baby in utero. From the instant of conception to the moment of birth the baby never once comes in direct contact with the mother, yet it is fully dependent on the mother for its survival. How is this possible? The answer is the placenta. Because most of the baby's organs like its kidneys and lungs are non-functional (in practical terms, though they do exhibit some elementary form of functionality) during the first 9 months in utero, the baby depends on the mother's equivalent organs for its own survival. If the baby wants to rid itself of waste it must do so through the mother. Likewise, if the baby wishes to breath, in other words to circulate oxygen throughout its body, it must obtain that oxygen from the mother. Most people know about the umbilical cord and how it is a "life line" between the mother and child, but what many people do not realize is that the umbilical cord is nothing more than a hallway or tunnel facilitating the two-way transportation of vital nutrients or harmful wastes to and from the fetus, all of which are filtered through the placenta. The placenta itself is much like an organic sponge but one, which grows as the baby grows, and whose porous spots are constantly filled with blood from the mother. The organic part of the placenta therefore acts much like the revolving door of an office building, facilitating the transfer of nutrients and wastes from the blood supplies of the mother and fetus. You can have all the tunnels you want leading up to a building's doors; if the doors are locked then everyone in the building will starve.

For all practical purposes, the answer to this question is yes. However, some concerns have been raised regarding exposure to cosmic radiation as well as clotting and dehydration during the course of a flight. Regarding exposure to cosmic radiation, the available studies were poorly conducted and dealt only with flight attendants and frequent flyers. There is no evidence to suggest that occasional air travel increases the risk of health problems to the fetus. Because pregnancy increases the affinity for clot formation, the immobile nature of long flights may lead to blood clots in the legs. This condition may in turn be aggravated by the low humidity level in the cabin, leading to dehydration, which in turn leads blood thickening and clot formation. However, if patients make sure to keep themselves hydrated by drinking water and avoiding alcohol consumption, as well as getting up from their seats ever 1-2 hours they should not experience any problem. It is also important to note that any pregnancy, including those identified as low-risk, may spontaneously develop into a high-risk pregnancy. If this were to occur during a flight, it could potentially pose a threat to the baby. However, this can happen anywhere and flying certainly does not increase the probabilities of it occurring.

Nothing. There is absolutely nothing that should be worrying you during your pregnancy, other than perhaps keeping an open mind. Worrying suggests stress, and stress is one of the worst things for your body and for your baby. Let your doctor and your family do all the worrying for you; I guarantee you it will be more than enough to go around.

Nutritional Supplements

Contrary to previous thinking, such concerns are unfounded. An interaction with anticlotting medication (anticoagulants, such as warfarin, Low Molecular Heparin and Heparin) is theoretically possible, but recent research has found no significant risk, even at high doses. People taking anticlotting drugs should be monitored as usual by their doctors. Similarly, you needn’t worry about interactions with aspirin, which also has an anti‐clotting effect. Indeed, the American Heart Association advises low‐dose aspirin and omega‐3s for people with heart disease.

Recent analyses of dozens of brands of fish oil supplements, including testing by ConsumerLab.com, have not found significant levels of mercury or unsafe levels of PCBs, dioxins, or other contaminants—in inexpensive or pricey brands. This is not surprising, since mercury tends to accumulate in larger fish, and supplements are made from smaller species (such as anchovies or sardines) or algae (which supply only DHA). Moreover, mercury is water‐soluble and thus tends to accumulate in the flesh of the fish, not in the fat or oil. Finally, most supplements are processed to reduce levels of PCBs and other contaminants.

IVF pregnancies

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss.

IVF pregnancies are more 35% more likely to be born prematurely, 30% more likely to be born growth retarded and 4-times more likely to die in the first year of life. There is nothing wrong with IVF that causes these problems. It is the same underlying reason that causes the infertility to begin with, which is responsible for the placental problems that cause prematurity, growth failure and fetal death. The most common underlying problem is an imbalance in the hemostatic (coagulation) system known as thrombophilia. Many individually insignificant thrombophilia factors can cause much more damage than one significant factor such as Factor V Leiden. Unfortunately, most obstetricians will tell you that you do not have thrombophilia if you do not have Factor V Leiden. This is a disaster and responsible for many losses and many more patients who never make it to have a baby. The combination of two or more minor factors can affect the placental development to various degrees and this in turn affects the quality of the pregnancy and the outcome. Poor implantation due to genetic thrombophilia and autoimmune conditions are mostly responsible for failed implantation and infertility or poor placenta development leading to poor pregnancy outcomes in IVF pregnancies.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss. These pregnancies are of the highest risk because they experience placental problems. If treated according to Kofinas Perinatal protocols, the success rate with a healthy and fully developed child is 98%.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

The answer is resoundingly yes. Many years ago we realized that such pregnancies suffer from serious placental pathologies that can cause all kinds of pregnancy complications. Because of this understanding, we have developed, in conjunction with the KOFINAS FERTILITY INSTITUTE, management protocols that have increased the success rates of these pregnancies and the quality of the fetuses. Despite the fact that several studies have reported increased incidence of abnormal pregnancy outcomes (preterm delivery, growth failure and increased pregnancy loss), our patients continuously achieve outcomes that are better than those of the so-called “low-risk” patients.

Twin Triplet Pregnancies

Terbutaline is one of the worst medications ever used in patients with preterm labor. All the studies over the last 20 years have failed to prove any significant effects in stopping labor or prolonging pregnancy. In contrast, many studies have clearly demonstrated that terbutaline is dangerous for the mother and the unborn and continuous use of it in oral and subcutaneous use (via a pump) increases the frequency of contractions. Many mothers exposed to terbutaline for preterm labor inhibition, have experienced severe and in many instances lethal cardiovascular complications. Other studies have shown that its use increases the risk for neonatal brain damage, hemorrhage and developmental delays. This is a really dangerous drug that should never by used to stop preterm labor. Unfortunately, it has been and still is the standard of care despite two very strong warnings from the FDA. Only recently, when the FDA issued its last warning using very strong language, many perinatologists decided to stop using it.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss. These pregnancies are of the highest risk because they experience placental problems. If treated according to Kofinas Perinatal protocols, the success rate with a healthy and fully developed child is 98%.

NST testing

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Umbilical Doppler Testing

Pregnancies with unexplained low PAPP-A are at increased risk for adverse perinatal outcomes including fetal death. In most patients, this is the result of poor placental development and placental insufficiency. First we test such patients for thrombophilia and immune issues to identify the most probable cause so we can treat the patient accordingly. Patients who test positive are treated with anticoagulants for thrombophilia and if they have immune issues also, they are treated with steroids or other immune treatments according to the findings. Most patients in our experience suffer from thrombophilia and are treated with anticoagulants only. At Kofinas Perinatal we monitor such pregnancies with ultrasound, fetal, placental, and uterine Doppler every two weeks. The treatment is adjusted according to the findings and the outcomes are excellent without any losses or any of the severe complications that have been reported in the literature.

Uterine Doppler

Pregnancies with unexplained low PAPP-A are at increased risk for adverse perinatal outcomes including fetal death. In most patients, this is the result of poor placental development and placental insufficiency. First we test such patients for thrombophilia and immune issues to identify the most probable cause so we can treat the patient accordingly. Patients who test positive are treated with anticoagulants for thrombophilia and if they have immune issues also, they are treated with steroids or other immune treatments according to the findings. Most patients in our experience suffer from thrombophilia and are treated with anticoagulants only. At Kofinas Perinatal we monitor such pregnancies with ultrasound, fetal, placental, and uterine Doppler every two weeks. The treatment is adjusted according to the findings and the outcomes are excellent without any losses or any of the severe complications that have been reported in the literature.

Biophysical Profile

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Fetal Echo

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Amniotic Fluid

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Cerebral Fetal Doppler

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1st trimester Miscarriage

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss.

2nd Trimester Miscarriage

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Fetal Death

There is strong association between stillbirth in the first pregnancy and subsequent adverse outcomes.(ischemic placental disease, fetal distress, chorioamnionitis, extreme preterm birth, and early neonatal mortality)
The etiology of such adverse outcomes is usually chronic and recurrent. Maternal and / or paternal thrombotic conditions may be responsible.
The placenta should be thoroughly examined both, during pregnancy by means of ultrasound and after birth by means of pathologic examination. A pathologist experienced in perinatal pathology should be the only one involved in the assessment of the placenta.
Women with a history of stillbirth should be thoroughly investigated prior to pregnancy for thrombophilic abnormalities and if present, be treated accordingly during the pregnancy.
The best way to monitor future pregnancies in such patients is by means of fetal and maternal placental Doppler; this is the best and most reliable way to monitor treatment success and prevent perinatal adverse events.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Brain sparing is a physiological mechanism used by the fetus to increase delivery of oxygenated blood to the brain at the expense of other organs. Unlike fully formed adults, only three organs are of importance to the fetus: the brain, the heart, and the adrenals (glands which produce adrenaline and natural steroids). When a fetus senses that the amount of oxygen in its blood is decreasing it makes an effort to protect its three most vital organs at the expense of all others, such as the liver, kidneys, muscles etc. This is achieved by a sophisticated cardiovascular response, which diverts more well-oxygenated blood to the important organs. This mechanism can protect the baby for up to 3 weeks.

Infertility and Pregnancy Risks

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss.

There are many reasons why a couple is infertile. Although we tend to categorize infertility according to various causes (male factor, tubal factor, uterine anomalies, ovulatory dysfunction etc.), the truth is that most couples cannot be classified into any unique category. Instead, most couples suffer from multiple factors that are responsible for their fertility problems. Over the years, we have found that with a few exceptions, implantation problems are the most common reason for infertility. In other words, most infertility patients conceive but the embryo is lost due to intrinsic inability to implant into the uterine cavity. The second most common is early miscarriage due to placental failure in the earliest stages of pregnancy. Thrombophilic disorders are present in >98% or infertility patients and in our experience the most important cause of infertility and early pregnancy loss. These pregnancies are of the highest risk because they experience placental problems. If treated according to Kofinas Perinatal protocols, the success rate with a healthy and fully developed child is 98%.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

Patients with a history of infertility (i.e. experience a difficult time conceiving) who choose to conceive with assisted reproductive technologies (ART) do traditionally experience an increased number of complications during pregnancy. Common complications include preterm delivery, fetal growth failure, and fetal losses and increased rates of fetal loss and neonatal death. These are primarily related to placental failure due to poor placental vascular development. Almost all of these patients suffer from genetic and/or acquired thrombophilia, which is known to cause all of these complications as well as several others.

The answer is resoundingly yes. Many years ago we realized that such pregnancies suffer from serious placental pathologies that can cause all kinds of pregnancy complications. Because of this understanding, we have developed, in conjunction with the KOFINAS FERTILITY INSTITUTE, management protocols that have increased the success rates of these pregnancies and the quality of the fetuses. Despite the fact that several studies have reported increased incidence of abnormal pregnancy outcomes (preterm delivery, growth failure and increased pregnancy loss), our patients continuously achieve outcomes that are better than those of the so-called “low-risk” patients.