Category: Blogs by Dr. Nikhil Datar

When the baby in the womb moves for the first time, she is elated. It is the first perception of the new life within her body! From then onwards,the fetal movements or kicks become regular and some times painful too. She is bombarded with instructions… “keep a count, be vigilant”. Most of the websites on pregnancy stress so much on fetal kicks that these pregnant girls almost get into the role of a “detective on high alert”. Now a days there are mobile apps that help the mother to count!On the other hand you might come across articles from reputed medical journals stating that keeping kick count is not as useful as it is told!!! (1) Confused?
In this article I am going to explain the need, importance and correct ways of counting movements.
Remember the sentence, Watching for fetal movements is important but very inaccurate method.
What is fetal movement or kick?
Baby is floating in the fluid in the mother’s womb and it does move frequently. Any kind of movement kick, jab, rotation of the baby is called as fetal movement. Many a times woman complaints that she cannot feel the kick but she feels movements! This is perfectly fine.

initially they may be felt just like a “butterfly inside” or ” something like rumbling of gas” and as the baby grows big they can be felt strongly.
When does one start to feel the movement?
Generally around 20 weeks of pregnancy women can feel some kind of movement. First time mothers may feel it little late and experienced mothers may feel it little early.
Before 20 weeks, what is felt unlikely to be the baby’s movements but movements of intestines.

What are various types of movements?
Not only kicks, but role overs, jabs, small rotations, small movements even hiccup is also a movement. Generally the number of movements increase up to 32 weeks. After that the number of movements may stay same but the type of movement will change. Generally women experience that big movements like kicks become less and small movements increase at the end of pregnancy. This is because of less space for the baby to move.

Hiccups type movement donot suggest that there is some thing wrong there.
Which factors influence feeling of movements? (2)
Lying down position is the best position to perceive the movements. In Sitting and standing positions you are less likely to feel all the movements.
If a woman is moving or engrossed in something else she is less likely to feel movements.
If placenta is close to the abdominal wall called “anterior placenta”, it works as a shock absorber and hence some movements may not be well felt.
In early weeks of pregnancy, movements may not be felt strongly as the baby is small.
Fetal movements are better felt when the mother’s glucose levels are elevated, typically after food.
If the baby is in certain position (when spine is anterior) many a times movements are not felt that well. n specific position
Studies have shown that maximum movements are felt during late evening hours. (3)
Obese patients may not feel movements that well as fat on the tummy may again work as shock absorber.
Most importantly the babies do sleep for 20—40 minutes, rarely up to 90 minutes when in the womb. Naturally you will not feel the movements at that time. (4)
It is clear that the mother may not be able to feel movements or feel them less due to many reasons. So even if baby is doing well in the womb, woman may feel reduced movements. Mothers become very anxious if they feel less movements. They panic regarding the health of the baby. That is why why I say that this method is quite inaccurate at the beginning. There is a lot of scientific medical evidence that only women with certain high risk conditions may benefit by keeping a chart on daily basis.
Of course the feel of the movement ensures the mother that the baby is doing good. And more over, it is the easiest and cheapest way check that out !
So the right balance between unnecessary anxiety and vigilant watch can be achieved by the strategy that I suggest to my patients.
Do not keep watching for movements all the time. Don’t become a detective.
Be aware of your baby’s pattern. Studies have shown the babies can move 4-100 times in an hour. (5) So it is your baby’s pattern and not the count just because some websites says so.
Keep a dedicated time of the day, for say one hour .. where you can lie down or sit at one place, preferably after having food to watch for movements. Even if there are small movements it is absolutely ok.
There are many methods of keeping count of movements. If you don’t get even 10 movements in 2-3 hours 12 hours it is advisable to go to the hospital. (6) Most often the doctors will check you and the baby. The doctor may check the growth, heart sounds , may do a sonography. Most often the doctor confirms that all is good and you come back home happy and relaxed.
Bibliography:
1. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2818%2931543-5. [Online]
2. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg57/. [Online]
3. https://www.webmd.com/baby/fetal-movement-feeling-baby-kick#1. [Online]
4. https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/pi-your-babys-movements-in-pregnancy.pdf. [Online]
5. https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1576/toag.11.4.245.27527. [Online]
6. https://www.ncbi.nlm.nih.gov/books/NBK470566/. [Online]

Reena is a new age, smart, educated, working professional. She is particular about everything, from her dress… to her make- up… to her exercise schedule ….to her career plan. She wants to plan the childbirth well. Right from maternity photoshoot to shopping. She wants to have her bag packed and go fully prepared when “the time” comes! Being her Obstetrician, I have already calculated her EDD ( expected due date) but every sonography report gives her a different due date!! So she just wants to know the answer to the million-dollar question:
Will I deliver on the due date?
So let me give one-line answer:
And the answer is a BIG NO.
Even if the due date is calculated by the most reliable method, only 5 % babies arrive on the due date!

Expected due date is an important but a very rough calculation!!!!!

Why is due date important?
Doctors refer to the expected due date all the time. Once the doctor calculates the age of a pregnancy (gestational age), the doctor can check if the pregnancy is growing appropriately. According to the stage of pregnancy the doctor advises specific tests.
When does the baby come out?
Almost 80% of women deliver within the two weeks before the due date [ between 38-40 weeks]. Very few, around 7% women go beyond the due date.
All babies born within a span of three weeks before the due date ( 37-40 weeks) are called “Full term”. The baby gets fully mature three weeks before the due date.
Few women cross over the due date. In such cases, one has to be cautious about the health of the baby.
How is the due date calculated?
The baby stays in the womb roughly for around 266 days. Studies have shown that Asians and black people have a slightly short pregnancy as compared to white.
No one can surely predict the exact date when the egg got fertilised (Exception: IVF procedure). So the calculation is backtracked to the first day of last menstrual period by adding 14 days( 266+14= 280 days). Thus we add 280 days or 40 weeks to the first day of the last menstrual period to predict the expected due date.
This formula works only if you have when a woman has a regular menstrual cycle of 28 days. More the irregularity in cycles more inaccurate the calculation is.

Is due date calculated by sonography more accurate?
The sonography machine calculates the age of pregnancy based on the size of the baby and predicts the due date. Due date calculated by sonography is little more reliable than from Last menstrual period. The due date calculated by sonography done in the first three months is more reliable than sonographies done in later pregnancy. In cases of IVF pregnancy, one can be most sure of the due date.
Yet, despite meticulous calculations, only 5% of babies will come out on the exact day.
Should one calculate month-wise or week-wise?
Both mean the same thing. Many find it very confusing to do these calculations. The reason is simple. Except for the month of February, all other months have 30/31 days. This means that a typical month is of four weeks and 2/3 days extra to it. If we add up these 2/3 extra days over three months span, one can say that three months almost becomes 13 weeks and not 12 weeks. Thus six months equal to 26 weeks and nine months equal to 39 weeks.
In conclusion:
• Expected due date is a rough estimation.
• Most women deliver between 38-40 weeks
• Babies born after 37 weeks are full term babies
• No one can surely predict the day when the baby will be born. So watch for signs of labour especially when you are in last 15 days and be ready for “the day”.

What is corona or Covid- 19 infection?
Corona (Covid 19) is a virus. It is not a bacteria. Most of the antibiotics work on bacteria. Since this is a viral infection common antibiotics do not work on this infection. Research is going on to find an antiviral medicine that can directly work on this virus.
Are pregnant women more prone to catch corona infection?
The evidence at this time does not show that pregnant women are more likely to catch infection. The evidence from similar viral infections show that if infected, pregnant patients are more likely to become critical as compared to non- pregnant women.
Any person, pregnant or otherwise suffering from diabetes, asthma, respiratory problems, HIV and other diseases has weaker immunity and more likely to suffer due to corona infection. Interestingly the data shows that more males have been infected so far. The data also shows that elderly people are more likely to suffer from serious disease.

Can Corona virus affect the baby in the womb?
There is no evidence that Corona per say can cause miscarriage, growth restrictions, death or poor growth of the baby. Only if the woman having corona infection develops pneumonia or becomes serious then there are chances of complications.

Can corona positive woman cause infection to the baby while breastfeeding?
Corona virus does not go through the breast milk. The virus can spread to the baby through hand contact or through droplets from coughing/ sneezing.
So the mother must use face mask and wash hands frequently/ use hand sanitizer before handling the baby. This will prevent the infection going to the baby. She may consider expressing the milk and other family members can feed the baby so that direct contact is avoided.

Should pregnant women get themselves tested even if they don’t have cough, fever or have no contact with any person suffering from corona infection?
The recommendations and guidelines are changing every day. At this time, the Indian council of medical research has recommended that the pregnant women should be tested if:
• They have symptoms of cough, cold, fever
• They have come in contact with a person with the infection even though they don’t have any symptoms.
• If a pregnant woman is nearing delivery, even if is not having any symptoms, but coming from the hotspot areas must be tested.

You should discuss about this with your doctor will be able to tell more about it.
How should pregnant women take care of themselves and avoid this infection?
For this we should understand how this virus spreads.
These are few common routes:
1 When an infected person coughs or sneezes, the virus is shed out via droplets. Another person close by may inhale the virus and get infection.
2 When infected person coughs and sneezes , the virus is shed out via droplets. These droplets settle down on objects around the person. Another person touches the objects and gets the virus on his hand. When he touches his nose or face, the virus goes into the breathing.
3 When infected person coughs or sneezes in his hands and then touches some object by hands. The virus is transferred from nose to hand to object. When another person touches the object the virus goes to another person.

Thus to avoid the infection, following strategies work:
1. Social distancing:
Staying at home, not meeting or mingling with people or visiting crowded places. This will automatically protect you from infection. It is generally found that the droplets travel for about one meter when someone coughs or sneezes. So maintaining physical distance will help. Avoiding hand shake, handling articles used by other people as far as possible.
2. Cough etiquette:
Instead of using hands to cover nose and mouth, use tissue paper. Dispose the tissue paper into a container which is closed.
3. Hand washing / hand sanitizers:
Wash your hands frequently with soap and water for at least 20 seconds. One can use hand sanitizer as well. Before touching the hands to mouth or face wash your hands.
4. Boost your Immunity:
Vitamin C is a good immune booster. It is available in citrus fruits like lemons and oranges. There are many home remedies or foods that can help boost the immunity. The AYUSH department of Ministry of health and family welfare has given a guidance on home remedies that can help to boost immunity.
5. Breathing exercises and other exercises at home
6. “Arogya setu” App developed by the Indian government :
This App gives a signal if you are close to any contentment area or hot spot. Or if a person having infection comes close to you, you are notified again. I am giving the link for authentic information.

Reference:
1 https://www.fogsi.org/fogsi-faqs-for-covid-19/
2 https://economictimes.indiatimes.com/tech/software/aarogya-setus-not-all-that-healthy-for-a-persons-privacy/articleshow/75112687.cms

Six months pregnant, Reena was at my clinic for a routine check-up. She was doing well. She asked with excitement, “Doctor, we are planning a babymoon. Can I go by air?” Harish, her husband, who is a tech guy, quickly brushed it off saying, “No. That is unsafe.” He had concerns about the exposure to cosmic rays, radiation, air pressure during the flight and of course the vibrations caused by air turbulence. Reena ignored him and asked a straight question to me:
Is it safe to travel by air when pregnant?
Here is my answer:

Does air travel increase the chance of miscarriage or push you into labour?
There is no scientific evidence to say that air travel increases the chance of miscarriage or labour.
Why do airlines restrict air travel after 34 weeks then?
Most airlines have their own policy on air travel during pregnancy and restrict pregnant women close to term (34 to 36 weeks and beyond) from boarding the flight. Basically, the closer you are to term, higher are the chances that labour could start. Thus, the airlines simply want to minimise the chance of the aircraft returning or needing to deviate from the route in case the passenger on board goes in labour. But air travel per se does not push pregnant woman into labour.
Are the scanners at the airport safe?
Yes. There is no evidence to suggest that pregnant woman should avoid scanners.
Does one get exposed to radiation during air travel?
At higher altitudes, the atmosphere is thin. Thus, one does get exposed to cosmic rays and radiation from the sun. The dose is so miniscule that it does not cause any harm to the foetus.
However, if a pregnant woman is likely to undertake air travel too frequently, say if she is a pilot or an air-hostess, then she needs to be concerned about this.
Should seatbelts be used during travel?
Yes. They are safe. If you need an extension, do call for it.

What are the common problems that a pregnant woman may experience during air travel?
Some pregnant women may experience discomfort during flying. This is mainly due to prolonged hours of sitting and changes in the air pressure and humidity. You may have:
Swelling of your legs due to fluid retention (oedema).
Nasal congestion/problems with your ears.
Pregnancy sickness: If you experience motion sickness during the flight, it can make your sickness worse.
Deep vein thrombosis (DVT): This a rare but dreadful complication. When blood clots are formed in the deep veins of legs or pelvis it is called as DVT. If the clot it travels to the lungs (pulmonary embolism), it can be life threatening. During pregnancy, the blood develops a tendency towards easy clot formation. Thus, when you are pregnant and for up to six weeks after the birth of your baby, you have a higher risk of developing a DVT compared with women who are not pregnant. Prolonged sitting in one position in the flight causes the blood to clot.
The risk is higher if you are obese, a smoker and have other medical conditions that cause clotting tendencies.
What can I do to reduce the risk of DVT?
If you are taking a short haul flight (less than four hours), it is unlikely that you will need to take any special measures. To minimise the risk of DVT on a medium or a long haul flight (over four hours) following things can be done:
• Wear loose clothing and comfortable shoes.
• Try to get an aisle seat and take regular walks around the plane.
• Do stretching exercises every 30 minutes or so.
• Have water at regular intervals throughout your flight and keep yourself hydrated.
• Cut down on drinks that contain alcohol or caffeine (coffee, fizzy drinks).
• Wear graduated elastic compression stockings or do calf exercises in the seat.
Are there any medicines that can help?
Medicines have to be taken as per the doctor’s advice only. They are required in rare situations. When you are at a high risk for DVT, you may be advised to have heparin injections. These will thin your blood and help prevent DVT. For security reasons, you will need a letter from your doctor to enable you to carry these injections onto the plane. Low-dose aspirin does not appear to reduce the risk of a DVT but you should continue to take it if it has been prescribed for another reason.
Finally, how can we take the decision for air travel?
Air travel is pretty safe during pregnancy. Here are few questions that may help you in making your decision:
• Why do you want to fly at this particular time?
• How long is your flight? Will this increase your risk of medical problems?
• How many weeks pregnant will you be when you travel and when you return?
• What are the medical facilities at your destination in the event of an unexpected complication with your pregnancy?
• Have you had all the relevant immunisation and/or medication for the country you are travelling to? Have you checked with your doctor how these affect your pregnancy?
• Does your travel insurance cover pregnancy and/or care for your newborn baby if you give birth unexpectedly?
• How are you going to ensure that you get hygienic food and water at the destination?
Before you embark on the air journey do ensure that:
• Your case papers are with you.
• Your medications are with you.
• Common medications for common problems are with you.
• You have travel insurance (especially for foreign travel).

(I am happy that this article was published by Indian Express)

Reena is a new age, smart, educated, working professional. She is particular about everything, from her dress… to her make- up… to her exercise schedule ….to her career plan. This agile, young, healthy girl, Reena is now pregnant. And she is so happy! As she discloses the news to her near and dear ones, she is suddenly bombarded with so many inputs about do’s and don’ts.
Reena believes that being pregnant is a natural event. Then why should her lifestyle go upside down suddenly? Why should there be restrictions on things that she always liked to do for so many years? On the other hand she is a perfectionist…wanting to keep no stone unturned to achieve the “best results”!
She has so many questions and no one can convincingly answer them… neither her Mom or Mom in law not even Google!
Finally, Reena comes to me and she asks:
Can I eat a mango?
And here is my answer:

Mango is actually power packed fruit. Mangoes are rich in antioxidants, such as beta carotene and vitamin A, C and D. Antioxidants have been shown to play an important role in the prevention of cancer and heart disease. They also contain bioflavonoids, the compounds which boost immune system. Mangoes also supply potassium and fiber. This high fibre prevents constipation.

Mango is a rich source of calories and sugars.So it is obvious that mango has nothing that can harm the baby in the womb. Yes, it has high caloric load. So mango consumption can definitely cause significant weight gain and can increase the blood sugar levels. Thus it is not advisable to have the fruit for obese mothers or diabetic mothers.

Mango is rich in iron… although not the best source of iron. Given that many pregnant women in India have low haemoglobin it can help prevent anemia.

How does Ayurveda look at mango eating in pregnancy?

The “king of fruits” is known to Indians for at least 6,000 years. This fruit is described in the ancient Sanskrit literature such as “Valmiki’s Ramayana”. Ayurveda considers ripe mango sweet and heating.
It balances all the three doshas and acts as an energizer. The
ayurvedic qualities of green mango are sour, astringent and cooling. I spoke to my Ayurvedic doctor colleagues about their perspective on eating mango during pregnancy. And surprise! Surprise! All of them clarified that Ayurveda too does not consider mango to be unsafe for
consumption during pregnancy.

Why the myth that mango should not be eaten during pregnancy?

No one knows the reason really. For many years the mangoes were picked unripe from the trees and ripened artificially with calcium carbide, dangerous chemical. This might be a reason for which it was advised to avoid mangoes during pregnancy. Any ways, Since 2016 Indian FDA has
banned use of this chemical for artificially ripening the mangoes.

Enjoy the mangos but take care of:
• Donot overdo mangoes. They are calorie bombs
• It is generally a good strategy to consume any high calorie food at
breakfast but not at dinner
• Wash the fruit thoroughly so that all chemicals are removed from the skin
• Prefer eating organic fruits of good quality
• Avoid extra calories by adding cream, ice-cream or sugar.
• Try to reduce intake of pickle as it is high on salt and oil. It can increase acidity too.
• If you are an overweight mom or diabetic mom avoid it. Instead
consume low Calorie seasonal fruits like melons
• Balance your calories all the time. 8 Peel of the skin before eating the fruit.

I am happy that this article was published by indian express .

Lata rushed into my consulting room with tears rolling down her cheeks. She was angry and visibly
upset. Lata’s both kids were delivered by me. She was an experienced mother. She was very diligent
about the baby’s health and never missed on the vaccination schedule. She used to take her kids to
the same pediatrician for years together. On one fine day, her pediatrician informed her that the
child was given a vaccine which had expired one month back…and Lata was shattered. Like many of
my patients who consider me to be their “friend- philosopher- guide” besides being their
gynecologist, Lata came to me for help and guidance.
Lata was literally fuming. She said. “I trusted that doctor so much and how could she be so negligent
to me and my child?” It was a clear case of medical error. The pediatrician was extremely apologetic
and felt sorry about the whole incidence. We know that medication errors are the commonest errors
in healthcare. Actually. this mistake was caused because of a goof up in the pattern of writing expiry
date. We know that the Americans write the date in “mm/dd” format and In India we use “dd/mm”
format. Precisely this was the cause of this blunder.
Lata was extremely worried and tensed about the ill effects of the expired medication. “Doctor, I
even check a loaf of bread for the “consume best before” date. I don’t allow anyone to eat even a
slice after that date. We make fresh food every day. We don’t consume “Basi” (stale) food at home.
And look here. My little one has been injected with a vaccine which has expired a month back!!!”
Lata blew off.
She was not wrong at all. Most people believe that medication post expiry, like food, may rot or turn
into some poisonous substance and be very harmful if consumed. So is this true? What is the
meaning of expiry date? This article focuses on these issues.

(source: google)
A few years back US air force found a huge stock of medications worth thousands of dollars stored in
odd places like bathrooms at various locations in the country. They had just dumped those expired
medicines as they did not know what to do with them. Purely out of interest some intelligent
pharmacologist decided to conduct a study on these drugs. And Bingo! Almost 90% of the medicines
had retained their potency although they had expired few months to few years back. On the basis of
these finding US air force and Food and Drug Administration created a programme called “Shelf life
extension programme”. Under this programme. the expired medicines were rechecked for potency,
revalidated and re-used for medical treatment successfully. It saved millions of dollars for the
government. Few medicines … sprays, liquids had more chance of losing their potency as compared
to injections and vials containing medicine in powdered form. But one thing came out loud and clear
… none turned into poisonous substances or created harm!
The system of writing expiry date began in in the United States in 1978. The same system was
followed across the world. So what does the expiry date mean? Is it the date beyond which medicine
becomes completely ineffective? Is it the date after which the drug will rather cause harm? The
answer to both the questions is “No”. The expiry date is the date beyond which the company does
not assure of full potency of the medical ingredients. It is a conservative estimate by the company. In
a way, it helps the sales of the company as expired medicines will be discarded and new stock will be
ordered! In order to strike the right balance between cost and benefit, the American Medical
Association asked FDA to review the system of giving expiry date in 2006.

Few clear messages emerge out of research on this topic:

•   Medicines do not get stale or rot or turn poisonous post-expiry.
•  The above sentence may not hold true especially in case of syrups containing substances like
  glucose.
•  If the bottle/ vial is opened then bacteria can grow into it. But if the injections or vials
  containing dry powders are stored correctly in a sealed pack they cannot “rot” or get
  infected.
• The expired medications may not have the same potency. Hence one may need to revalidate
  the potency or simply take an additional dose.
•  In nutshell, if expired medications ( tablets/ injections) get used inadvertently, no guarantee
  can be given about its effectiveness but it will not cause harm or untoward effect too.

So what did Lata do? Lata met two pediatricians and discussed the matter. Both suggested that the
child should be given another dose of vaccine. Sadly, the child had to take additional injection but
Lata was sure that there is no harm caused to the child. Her pediatrician gave an additional dose of
vaccine to the baby. Lata continues to follow up with the same doctor. She and her doctor both have
become more vigilant about the medications as they both know that human errors are possible in
any one’s hand.