Goodbye, Cellulite Thighs?

A new treatment may give new hope to reduce cellulite, the unsightly dimpling of thigh and buttocks skin, researchers say.

It works by injecting an enzyme naturally found in the body to help improve the skin's appearance.

A New York plastic surgeon reported on the new treatment Tuesday at the American Society of Plastic Surgeons annual meeting in San Francisco.

"It's not perfect," Alexander Dagum, MD, associate professor and chief of plastic surgery at State University of New York at Stonybrook, says of the new treatment, which uses the enzyme collagenase. "But most of the patients were quite happy with the results."

The study was small, including only 10 women. He says more work needs to be done to fine-tune the treatment.

Study Results
Dagum injected collagenase five times in a circular pattern at the top of the back of the upper thigh, the area typically most affected by cellulite. Photographs were taken before and after the procedure, and the researchers evaluated how much better the cellulite looked at several time points after the injections.

Within a day, the women had a 77% decrease in the appearance of cellulite, he says, and by one month it was an 89% decrease. "At three months, it was 86% and at six months, 76%," Dagum says. Six months was the end of the follow-up, he says, so "we don't know how often we have to redo."

What Causes Cellulite?
"No one really understands the cause of cellulite," Dagum says. One hypothesis about how cellulite forms, says Dagum, is based on the idea that the connective tissue lattice work under the skin is different in men and women. In women, the lattice work makes it easier for the fat to protrude.

Over time, the woman's lattice work in the thigh and buttocks areas weakens and scars more than a man's, resulting in further irregularities.

In areas with scars, valleys form, he says, and in areas of fat protrusion, hills. The result is the unsightly dimpled appearance. Think of it as a bowl of Jell-O, Dagum says. If you push down on one side (the scarring) it has to come up on the other.

The collagenase, when injected, is thought to break down the areas of scar tissue that hold down the fat and help cause the dimpled look. It also is thought to break down some of the fat tissue, causing them to protrude less, helping to even out the hills and valleys and to restore normal contours.

Reconstructive Surgery

Do you have a child who was born with a birth defect, such as cleft lip or palate? Are you a woman who has undergone a mastectomy? Or, perhaps you've experienced a traumatic injury or disease that has permanently affected some part of your body that you want fixed.

Reconstructive surgery can help repair the part of your body that is affected from any of these issues. According to the American Society of Plastic Surgeons, more than one million reconstructive surgery procedures are performed each year.

What Are the Different Types of Reconstructive Surgery Procedures?
If you can imagine how many injuries, birth defects or disfigurement issues arise in our imperfect lives, there is a procedure that can help improve the problem, whatever it may be. These include:

Breast reconstruction or reduction. These procedures are available for women who have undergone a mastectomy or for women who have abnormally large breasts that are causing back problems or other related health issues; men also undergo breast reduction.
Surgeries for feet and hands. This surgery is available for people affected by any number of maladies, including tumors (cancerous and non-cancerous); webbed toes or fingers; extra fingers or toes. People also can receive treatment for carpal tunnel syndrome.
Wound care. For individuals who have been severely burned or cut, skin grafts or other reconstructive techniques are available.
Microsurgery or flap procedures. These surgeries can be performed to replace parts of the body affected by injury or disease, such as cancer.
Facial surgeries. These can be performed to correct facial defects such as cleft lip, breathing problems or chronic infections, such as those that affect the sinuses, or even snoring.
How Will the Surgeon Evaluate My Case?
Like your issue that you want corrected, your procedure will be very individual. Your surgeon will take a detailed medical history and evaluate your case based on your desired results and medical necessity.

For example, do you have a traumatic burn that affects underlying muscles and impacts your mobility? Have you had cancer and require surgery to multiple body parts? He or she will evaluate the severity of your case and advise you on the available options.

Like the procedures themselves, there are multiple surgical methods to achieve the desired results. Your surgeon will help you weigh all the options and the two of you can decide together which one best suits you.

Will Insurance Cover Reconstructive Surgery?
Unlike elective cosmetic procedures, most insurance carriers do cover reconstructive surgery. To be safe, be sure to have your surgeon write a letter and take photos detailing your case.

How Much Does Ultrasonic-Assisted Lipoplasty Cost?

Ask to talk with a representative who can explain the costs of the procedure and payment options. Like other elective cosmetic procedures, UAL is not covered by health insurance plans.

Are There Risks Involved With Ultrasonic-Assisted Lipoplasty?

UAL has a good safety record to date, but carries the same risks as all liposuction surgery, such as rare occurrence of infection, blood or fat clots; or cosmetic risks like a change in skin pigmentation, or skin texture. Post-operative fluid collections, known as seromas may also form. However these can be drained with a needle and a syringe.

Unique to UAL is the risk of burns caused by heat from the ultrasonic probe. This risk is minimized when performed by a surgeon skilled in lipoplasty. Some patients may have an adverse reaction to the anesthetic, and may develop redness or other pigment changes.

Who Can Perform Ultrasonic-Assisted Lipoplasty?

Board-certified plastic surgeons who have undergone specialized training required by the Ultrasound-Accisted Lipoplasty Task Force can perform lipoplasty. This task force was established by several major plastic surgery societies: Its mission is to set safety standards for the performance of UAL. Do not hesitate to ask your doctor about credentials and training and how many lipoplasty procedures he or she has performed.

Who Is a Good Candidate for Ultrasonic-Assisted Lipoplasty?

A thorough evaluation by a board-certified plastic surgeon experienced in lipoplasty will determine if you are a good candidate. But in general, a good candidate for lipoplasty (as well as other liposuction techniques) is a person of average or only slightly above average weight, in good health, with a localized area of fat that does not respond well to diet and exercise.

Are The Results of Ultrasonic-Assisted Lipoplasty Permanent?

The fat cells are removed permanently, so if you gain weight after the procedure, it will usually not concentrate in the treated area. This is because you now have less cells in the treated area in which fat can be deposited. However, ultrasonic-assisted lipoplasty will not prevent you from regaining weight.

What Happens After Ultrasonic-Assisted Lipoplasty?

Patients are instructed to wear a tight-fitting garment, such as a girdle or thick support hose for up to six weeks after the procedure. Sometimes, postoperative pain medication is not needed because the injected anesthetic solution keeps the area numb for 12 hours or more.

Every person's outcome will vary somewhat based on factors such as volume of fat cells removed and area of removal. Your doctor will discuss what results you can expect to achieve, and how to best maintain your new body shape.

What Happens During Ultrasonic-Assisted Lipoplasty?

Several steps are involved. Similar to traditional liposuction, the skin is marked to indicate the precise area from which the fat will be removed. Next, a large amount of very dilute anesthetic solution is injected into the body site to numb and swell the fatty area (tumescent technique).

Then, in a step unique to lipoplasty, a thin tube-like instrument called an ultrasonic probe is inserted beneath the skin through a small incision. The probe is maneuvered in a crisscross pattern while sound waves generate negative pressure, causing the fat cells to implode, or collapse, and liquefy. The liquefied fat and anesthetic fluid are removed using gentle suction.

What Are the Benefits of Lipoplasty?

Early results by a select group of plastic surgeons internationally have been encouraging. However, further study is needed to determine if lipoplasty will replace existing liposuction techniques.

UAL allows physicians to remove significant amounts of fat in a single session because the fat is liquefied by sound waves. It can be especially useful in areas of dense fat such as the back. The use of sound waves prevents surrounding blood vessels and connective tissue from being damaged because fat cells are selectively destroyed and removed.

How Does Lipoplasty Differ From Other Liposuction Techniques?

UAL uses high-frequency sound waves to liquefy fat beneath the skin's surface before removing it with gentle suction. tradional liposuction and traditional liposuction cannot liquefy fat cells, and this makes the fat more difficult to remove.

Lipoplasty

Some people have stubborn areas of fat cells that will not shrink no matter how much they diet or exercise. The common areas for these fat pockets include the chin, neck, hips, abdomen, thighs, buttocks and even calves and ankles.

A newer technique called ultrasonic-assisted lipoplasty (UAL) may help you address that unwanted fat. UAL is an enhancement to the currently used tumescent liposuction method. To keep your new shape and new weight after this lipoplasty, you will need to follow a proper diet and exercise plan.

Is Liposuction Covered By Insurance?

Because it is a cosmetic procedure, liposuction is not covered by most health insurance plans. Ask to talk with a representative who can explain the costs of the procedure and payment options.

What Are the Risks of Liposuction?

All surgical procedures involve some risk. However, liposuction has a good safety record and the risks associated with the procedure are minimized when performed by a specially trained, board-certified plastic surgeon.

Although rare, risks include infection and skin discoloration. As with all surgery, common sense is important. The risk of medical problems can be minimized by avoiding extremely long procedures or excessive removal of fat.

Are the Results of Liposuction Permanent?

The fat cells are removed permanently, so if you gain weight after the procedure, it usually will not concentrate in the area that was treated. However, it is important to note that liposuction will not prevent you from regaining weight. To keep your new shape and new weight after liposuction, you must follow a proper diet and exercise plan.

Though the basics of liposuction described above remain the same, there are a couple of different techniques that can be used during liposuction. Thes

Under most circumstances, when liposuction is an outpatient procedure, recovery is usually quick. Most people can return to work within a few days and to normal activities within about two weeks. You should expect bruising, swelling and soreness for a least a few weeks. However, every person's outcome will vary based on factors such as volume of fat cells removed and area of removal. Your doctor will discuss what results you can expect to achieve and how to best maintain your new body shape.

Types of Liposuction

Though the basics of liposuction described above remain the same, there are a couple of different techniques that can be used during liposuction. These include:

Tumescent liposuction. During this technique, the surgeon will inject a solution into your fatty areas before the fat is removed. It is made up of a saline solution, a mild painkiller and epinephrine, a drug that contracts your blood vessels. The solution not only helps the surgeon remove the fat more easily but it helps reduce blood loss and provides pain relief during and after surgery.
Ultrasound-assisted liposuction. During ultrasound-assisted liposuction, ultrasonic energy is used to liquefy the fat, after which it is removed from the body.

How Is the Liposuction Procedure Done?

Depending on the type of liposuction you are undergoing, the procedure may be performed as an outpatient procedure at the doctor's office or surgery center, or if large amounts of fat are being removed, the procedure will be done in a hospital and may require an overnight stay.

Before the procedure begins you will be given an anesthetic. Again, depending on the degree of fat being removed and the type of liposuction being performed, anesthesia varies. It may only be locally applied or you may require a general application in which case the surgery will be done while you are sleeping.

Once the anesthesia has taken effect, the liposuction procedure is performed using a suction device attached to a small, stainless steel instrument called a cannula. Through small incisions, the cannula is inserted into fatty areas between skin and muscle where it removes excess fat either using a suction pump or a large syringe. This results in a smoother, improved body contour. The length of the procedure will vary with the amount of fat needing removal.

Cosmetic Procedures: Liposuction

"The battle of the bulge." That tiny, five-word phrase has been shoved in our faces for years, thanks to television, newspapers and magazines. But sometimes, no matter how hard you fight, the bulge has a tougher army. The fact is that certain people have fat cells that will not shrink, despite diet and exercise. You can thank heredity for that in some cases.

Liposuction is an option to remove small bulges that won't budge and to improve your body's shape. The areas most commonly treated include the hips, abdomen, thighs and buttocks and face. Liposuction does not remove cellulite, only fat.

Who Is a Good Candidate For Liposuction?
A good candidate for liposuction should have realistic expectations about the results of this procedure as well as these basic qualities:

Average or only slightly above-average weight
Firm, elastic skin
In good overall health
Concentrated pockets of fat that do not respond well to diet and exercise
Patients with poor skin quality (cellulite) are not good candidates for liposuction because they may develop skin irregularities due to under- or over-correction of localized fat deposits. Age is generally not a major consideration when discussing liposuction; however, older patients often have less elasticity in their skin and thus may not achieve the same benefits of liposuction that a younger patient with tighter skin might achieve.

What Do I Need To Know Before Undergoing Liposuction?
The first step before undergoing liposuction will be to arrange a consultation with your surgeon. During the consultation, your surgeon will discuss which options are best for you, your skin type, the effectiveness and safety of the procedure, the potential financial cost and what your expectations should be. Do not hesitate to ask the surgeon any questions you may have. Now is not the time to be shy.

Once you have decided to undergo liposuction, your surgeon will give you any instructions you will need to prepare for the surgery. This may include dietary guidelines or alcohol restrictions or the taking or avoiding of certain vitamins. Be sure to tell your surgeon of any allergies you have as well as any and all medications you are taking. This includes over-the-counter and prescription medications as well as herbal supplements.

What Is Beautiful? A Brief Look Through History

In ancient China, the 4-inch "lotus foot" was considered a sign of perfect beauty. The practice of foot-binding, uncommonly seen today, involved breaking the bones of the forefoot and folding them forward, then tying the misshapen appendage to prohibit growth.[5] Foot-binding caused severe pain, imbalance, and falls, and eventually osteoporosis, because afflicted women were unable to bear weight and ambulate correctly. Other consequences included hip and knee osteoarthritis, chronic pain, and even joint replacement surgery.[6] Chinese foot binding was also a form of subjugation; as a class, women were even less able to take advantage of already limited educational and economic opportunities.

For ancient Egyptians, Romans, and Persians, sparkling eyes were considered beautiful and they applied the heavy metal antimony to make their conjunctiva sparkle.[5] A woman with a high forehead was considered beautiful during the Elizabethan era, and upper-class Elizabethan women plucked or shaved their frontal hairs to achieve this look. These women also covered their skin with ceruse (lead-based) makeup, which caused peripheral neuropathy, gout, anemia, chronic renal failure, and disfiguring scarring, requiring the application of more ceruse makeup.[5] Chronic users, such as Queen Elizabeth I, acquired a misshapen appearance. Upset over her grisly visage, the Queen banished all mirrors from her castle. Her servants sometimes painted a red dot on her nose, an inside joke mocking her clown-like appearance.[5]

In the court of Louis XVI, noblewomen drew blue veins onto their necks and shoulders to emphasize their exalted status ("bluebloods").[7] In the 16th and 17th centuries, the wealthy used belladonna eyedrops to dilate their pupils.[5] Users acquired an "attractive" doe-like appearance, but they also risked retinal damage, glaucoma, and blindness. During the 18th century, vermilion rouge, concocted of sulphur and mercury, achieved popularity. Users lost teeth, suffered gingivitis, and (unknowingly) risked kidney and nervous system damage from mercury -- not to mention their having to deal with the unpleasant smell of sulphur.[7]

Corseting, popular from the 14th to 19th centuries, originally involved compressing the bosom and constricting the waist with tightly wound whalebone on a steel frame.[5] Shallow breathing, combined with inadequate venous return, produced fainting and swooning. Hiatal hernias caused by overly tight corsets are termed "Sommerring's syndrome" -- after the 18th century physician who first warned of the dangers of tight lacing.[8] Christina Larson points out, "the corset facilitated a pernicious association between physical beauty and virtue, as upright posture and a slender waist came to be regarded as evidence of discipline, modesty, rigor, and refinement. Ladies who abandoned their stays were scorned as both lazy and immoral."[9]

Ideal body weight and shape have fluctuated throughout history, from the rotund Venus of Willendorf of antiquity, to the statuesque, leggy flappers of the 1920s, to the ultra-thin "Twiggy"-inspired look of the 1960s and the "heroin chic" cachexia of the 1990s. In some cultures (eg, Hawaiian royalty), women voluntarily consumed or were force-fed excessive quantities of food to maintain their corpulence, a sign of fertility and power.[5] At other times, women, including those with and without anorexia and bulimia, have dieted, induced vomiting, abused laxatives, and exercised excessively to lose weight. Famed opera singer Maria Callas deliberately infected herself with tapeworms to produce a malabsorption syndrome to maintain her lithe figure.[5]

Today, popular icons of beauty are found in music videos and on commercial television. Large bust size and round, but not excessively large, posteriors are emphasized, for example. To help the average woman achieve this look, a variety of products have become available, such as Wonderbra, which elevates and compresses the breasts, and the Brava bra, a $2500 suction device designed to be worn overnight for 10 weeks. Brava bra makers promise a 1-cup size increase; side effects include skin rash and discomfort.[10] In the United Kingdom, women can buy "Wonderbum" panty hose, made of DuPont lycra to mimic a "perfectly peachy, pert bottom."[11]

Thoroughly routing the idea of a woman-only "beauty myth" is the very real fact that men are a rapidly growing consumer niche in cosmetic surgery. They are getting procedures such as botulinum toxin injections and chemical peels, although they are not yet as willing to admit to their cosmetic habits as women are. One New York plastic surgeon told the Wall Street Journal that "17 percent of his patients undergoing eyelid surgery and about 11 percent choosing facelifts are male, double the percentage of ten years ago." According to the American Academy of Cosmetic Surgery, the most popular procedures for men are botulinum toxin injections, hair transplantation, chemical peels, microdermabrasion, and liposuction. But more than 10,000 men have also had cosmetic surgery to lengthen or widen their penises, as well as calf and pectoral implants to upsize their musculature.[3]

Beauty and Body Modification

Since ancient times, human beings have attempted to modify their physical appearances to conform to cultural ideals of beauty. Many characteristics of human appearance are also considered to be evolutionary adaptations for survival of the human species. Beauty, size, and muscularity advertise one's health and fertility. The ancient Greek ideal equated symmetry with beauty,[1] and more recent scientific studies have shown that symmetry is still valued in both male and female faces. The "ideal woman" is said to have a small chin, delicate jaws, full lips, a small nose, high cheek bones, large and widely spaced eyes, and a waist-to-hip ratio of 0.7. The "ideal man" is taller, with a waist-to-hip ratio of 0.9, and rugged features such as a dominant, rectangular face and chin; deep-set eyes; and a heavy brow, suggesting a strong supply of testosterone.[2]

As Christine Rosen points out, physical appearance has also been linked to moral worth.[3] Those considered good-looking are more likely to get married, be hired, get paid more, and be promoted sooner. Height is associated with income and leadership positions. Strangers are more likely to assist good-looking people in distress. The pretty/handsome are less likely to be reported, caught, accused, or punished for minor and major crimes. On the other hand, attractiveness is recognized as a special gift, and its misuse is not easily tolerated.

Today, women and men of many cultures diet, exercise, apply cosmetics, and undergo a bewildering array of surgical procedures to achieve a desired look. Yet, many techniques of body manipulation have had profound health effects on the individuals practicing them. Moreover, some have been cultural practices designed to control the female sex, even when willingly accepted by women. Others, such as female genital mutilation, again often accepted by women, involve the abrogation of women's right to bodily integrity and sexual fulfillment.[4]

Most interventions have been practiced by women, rather than men, who, as a result of their more privileged position in society, have been able to rely more upon their intellectual, political, and military feats to achieve respectability and to woo prospective mates. Ageism has also historically disproportionately discriminated against women. Whereas older men have been seen as distinguished and sophisticated, women who have completed their childbearing years are more often considered "past their prime" and older women have been the greatest consumers of cosmetic procedures. However, this is changing in American culture particularly, in which "youthfulness" dominates the popular cultural discourse on beauty, and older men comprise an increasingly larger proportion of the cosmetic surgery market.[3]

"Youthfulness is a...desirable commodity, as Americans in the corporate world are learning. A February 2004 report in the Wall Street Journal described a recent survey by ExecuNet that asked senior-level corporate executives about attitudes toward aging. The result found that "82 percent consider age bias a 'serious problem,' up from 78 percent three years ago. And 94 percent of these respondents, who were mostly in their 40s and 50s, said they thought age 'had cost them a shot at a particular job.' Many executives -- male and female -- are turning to cosmetic surgery to help them stay competitive."[3]

This article takes a brief historical look at some of the modifications people (mostly women) have undertaken to try to achieve particular ideals of beauty, and then focuses on some currently fashionable modifications -- namely cosmetics, tanning, body piercing, and botulinum toxin (BOTOX) and dermal fillers. Future articles will consider cosmetic surgery and female genital mutilation.

The Risks of Spa Treatments

bath, get kneaded like a ball of dough, or indulge in any of the other countless treatments available today, you should know the risks involved.

Sure, spas have been around a long time -- since ancient times, in fact, when Roman soldiers in a small Belgium village called Spa first discovered the soothing effects that hot mineral springs had on their aching bodies. Up to the turn of the 20th century, doctors from various cultures routinely sent patients to soak in baths they believed to have restorative powers. But most of the spas of today bear little resemblance to those first "curative" spas.

Yet today, operators of the 10,000 or so spas in the U.S. continue to tout the treatments' health benefits. While most of today's spas promise to restore, refresh, and renew -- and some offer even more explicit health claims -- they generally don't warn you of the potential risks involved. But they do exist. Certain spa treatments can worsen chronic and acute health conditions. All spas can pose risks to the general public, particularly when operated in a state of uncleanliness.

We talked to medical experts and public health officials to learn just what these health risks entail and how you can avoid them.

Chronic Conditions
Pedicures: Dangerous with Diabetes People with diabetes need to take extra precautions when getting foot treatments. "Any break in the skin, potentially from aggressive trimming of a callous or cuticle, can increase the risk of foot infections called cellulitis," says Sharon Horesh, MD, an internal medicine doctor with Emory University's department of medicine.

That's not the only reason for precaution.

You can't always tell how clean a spa's water or supplies are. But you can minimize your risk of becoming infected by contaminated water or supplies. "If you have diabetes and you have ulcerations on your feet, bring your own container of water for a pedicure," says Louise-Ann McNutt, PhD, an epidemiology professor at the University of Albany. She also suggests bringing your own equipment, from bucket to emery boards. "It puts you in charge of how clean the supplies are," she tells WebMD.

Massage: Finding the Right Touch
When it comes to massage, experts say that the degree of risk involved depends on the type of touch applied. "The most important adaptation for chronic disease, like cancer, is touch level," says Kathleen Clayton, a licensed massage therapist and spokeswoman for the American Massage Therapy Association.

"In that instance, I might do a light touch, or foot reflexology."

Finally, she urges all potential massage-goers to receive massages only from licensed massage therapists. "Find somebody who will know what to look for and what to ask the patient," she says.

Acute Conditions
Pregnancy: What's the Rub on Massage?
While off-limits in the first trimester, massage may actually bring pregnant women great relief in the second and third trimesters. But the type of massage matters. "In the second and third trimesters, women should specifically seek a pregnancy massage therapist and avoid massage techniques that involve long strokes along the legs or pressure between the ankle and heels," Horesh tells WebMD.

There's good reason to heed this advice. "There's always a chance that it might make the baby dislodge, or induce premature labor," explains Clayton.

Massage and Menstruation
The combination of massage and menstruation is a double-edged sword. On the downside, it can increase menstruation flow. But because it improves circulation, massage may minimize some symptoms of menstruation. "It can reduce back pain and cramps and diminish the feeling of bloating," Clayton tells WebMD.

Saunas Exacerbate Respiratory Infections
Some people find it extremely relaxing to sit in a sauna, a wooden room infused with dry heat that supposedly eliminates toxins as it opens pores and promotes sweating. But if you have a cold, a respiratory infection, or an asthma flare-up, it's not the place for you. "Dry heat from saunas can make it uncomfortable to breathe," Horesh says. On the flip side, steam rooms with moist heat can improve sinus congestion, asthma, and allergies, she tells WebMD.

Public Health Risks
Chronic and acute conditions aside, all spa-goers need to be alert to the potential risks that may lurk in the very spas intended to relax us. A report released by the CDC in 2004 showed that more than half of all public hot tub spas in the U.S. violate public health safety standards. Of the 5,000 spas inspected, 57% breached at least one safety violation. Poor water quality was the most common violation.

Poor water quality can translate into a breeding ground for bacteria. Indeed, outbreaks of community-acquired infections from spas have occurred. In one such outbreak, more than 115 nail salon patrons contracted severe skin boils from a series of contaminated whirlpool footbaths used as part of the pedicure procedure. The boils resulted from a fast-growing form of bacteria called Mycobacterium fortuitum. Of the 61 clients that investigators tracked, most required a four-month course of antibiotics. The average disease duration was 170 days. The outbreak was reported in a 2004 issue of the journal Clinical Infectious Diseases.

Just how prevalent is this bacteria in salon whirlpool footbaths? In 2004, investigators in California set out to answer that question. They sampled 18 salons from five large counties in different parts of the state. They found the Mycobacterium fortuitum in 14 of the 30 footbaths surveyed. Other types of mycobacterium were also seen. Results were published in the April 2005 issue of the journal Emerging Infectious Diseases.

Short of swearing off pedicures and other spa treatments that involve immersing part or all of your body in heated water, what can you do to reduce your risk of infection at spas?

Do some detective work of your own before taking the plunge. "Look around at the spa for general cleanliness. Talk to people who have been there," McNutt suggests. She also recommends bringing your own equipment to avoid the threat of contamination. And, if you have any open cuts or abrasions, cancel your appointment until they clear. Any open area of your skin can invite infection. That's why it's never wise to shave your legs the day of, or even the day before, a spa treatment that involves immersing your legs, McNutt tells WebMD.

In spite of the potential health risks of spa treatments, most people who frequent them report positive experiences. Knowing the risks that pertain to you and carefully assessing the cleanliness and track record of a spa prior to making an appointment can go a long way to ensuring your safety and satisfaction. If you're uncertain about how a spa treatment might affect you, always consult your doctor first.

Just as in ancient times, many doctors today would agree that, under the right circumstances, a spa treatment can promote wellness. "In general, there are many benefits to spa treatments, perhaps the greatest being the relaxation and stress reduction they offer," Horesh tells WebMD. "They can also relieve muscle tension and pain in people who suffer from chronic back pain, fibromyalgia, or who have had an injury from sports or a car accident."

Magnets Don’t Fight Pain, Study Shows

Magnets don't fight the pain of arthritis or fibromyalgia, according to a new review of research.

Researchers say magnets for pain are a multibillion dollar industry and have been incorporated into arm and leg wraps, mattress pads, necklaces, shoe inserts, and bracelets. They are marketed for reducing pain from a variety of causes, and one survey showed up to 28% of people with rheumatoid arthritis, osteoarthritis, or fibromyalgia use magnets or wear copper bracelets.

But the research has yet to back up the hype behind the use of magnets for pain.

Magnets No Good for Pain Relief
Researchers analyzed nine previous studies on magnets for pain in which the participants were randomly assigned to receive magnet or a dummy device for pain. Each of the studies rated the effects on pain reduction on standard scale.

The results, published in the Canadian Medical Association Journal, showed no significant difference in pain reduction between the groups treated with magnets or the placebo.

Therefore, researcher Max H. Pittler, MD, PhD, of the Peninsula Medical School in Exeter, England, and colleagues say magnets cannot be recommended as an effective treatment for pain.

The only condition for which the evidence did not rule out any hope of a potential effect of magnets on pain was osteoarthritis. Researchers say more research is needed in this area.

Arthritis Hinders Work for Many

The CDC reports that roughly a quarter to a half of U.S. adults of working age with arthritis say their arthritis affects their work.

For the first time, the CDC has state-by-state statistics on the percentage of adults of working age (18-64) with arthritis-related work limitations.

Data came from a 2003 CDC survey of about 350,000 U.S. adults.

Among all adults of working age, the prevalence of those reporting arthritis-related work limitations ranged from 3.4% in Hawaii to 15% in Kentucky.

Participants were asked if they had ever been diagnosed by a doctor or other health professional with some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia.

Among those who answered yes to that question, the prevalence of those reporting arthritis-related work limitations ranged from 25.1% in Nevada to 51.3% in Kentucky.

Nearly 46 million U.S. adults have arthritis, according to background information from the CDC.

Here's how the states, territories, and Washington, D.C., ranked in the prevalence of adults of working age with self-reported arthritis and arthritis-attributable work limitations. Those with the same percentages are listed together.

State Rankings


Kentucky: 51.3%
Mississippi: 44.7%
Oklahoma: 41.9%
Missouri: 41.8%
West Virginia: 41.7%
Tennessee: 40.5%
Guam: 40.2%
Arkansas: 40%
North Carolina: 39.1%
Georgia: 39%
Louisiana: 38.8%
Alabama: 38.1%
South Carolina: 37.2%
Florida: 36.3%
Idaho: 35.8%
California: 35.7%
New York: 35.5%
South Dakota: 35%
Arizona and Texas: 34.8%
Indiana: 34.7%
Minnesota: 34.6%
U.S. Virgin Islands: 34.2%
Virginia: 33.7%
Washington: 33.2%
Maine: 33.1%
New Mexico: 33%
Vermont: 32.6%
Utah: 32.4%
Oregon: 32.3%
Montana: 31.9%
Massachusetts: 31.8%
Ohio: 31.7%
Nebraska and North Dakota: 30.8%
Alaska: 30.7%
Rhode Island: 30.2%
Maryland: 29.6%
Delaware and Wyoming: 29.1%
Wisconsin: 28.7%
Pennsylvania: 28.6%
Iowa: 28.2%
Colorado: 28%
Illinois: 27.9%
New Hampshire: 27.7%
Kansas: 27.5%
New Jersey: 26.9%
Hawaii: 26.5%
Connecticut: 25.7%
Washington, D.C. and Puerto Rico: 25.5%
Nevada: 25.1%

Your Guide to Spinal Compression Fractures: Treatments and Pain Relief

If osteoporosis has caused a compression fracture, the treatment should address the pain, the fracture, and the underlying osteoporosis to prevent future fractures.

All components of treatment have improved greatly in the last decade, says Michael Schaufele, MD, a physiatrist and professor of orthopaedics at Emory University School of Medicine in Atlanta. "We have better interventional options to treat fractures, and better treatments to prevent future fractures," he tells WebMD.

The majority of fractures heal with pain medication, reduction in activity, medications to stabilize bone density, and a good back brace to minimize motion during the healing process. Most people return to their everyday activities. Some may need further treatment, such as surgery.

Nonsurgical Treatment
Pain from a compression fracture allowed to heal naturally can last as long as three months. But the pain usually improves significantly in a matter of days or weeks.

Pain management may include analgesic pain medicines, bed rest, back bracing, and physical activity.

Pain medications. A carefully prescribed "cocktail" of pain medications can relieve bone-on-bone, muscle, and nerve pain, explains F. Todd Wetzel, MD, professor of orthopaedics and neurosurgery at Temple University School of Medicine in Philadelphia. "If it's prescribed correctly, you can reduce doses of the individual drugs in the cocktail."

Over-the-counter pain medications are often sufficient in relieving pain. Two types of non-prescription medications - acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) -- are recommended. Narcotic pain medications and muscle relaxants are often prescribed for short periods of time, since there is risk of addiction. Antidepressants can also help relieve nerve-related pain.

Activity modification. Bed rest may help with acute pain, but it can also lead to further bone loss and worsening osteoporosis, which raises your risk for future compression fractures. Doctors may recommend a short period of bed rest for no more than a few days. However, prolonged inactivity should be avoided.

Back bracing. A back brace provides external support to limit the motion of fractured vertebrae - much like applying a cast on a wrist fracture. The rigid style of back brace limits spine-related motion significantly, which may help reduce pain. Newer elastic braces and corsets are more comfortable to wear - but don't work, says Wetzel. "There's an old saying, 'The inconvenience of the brace is directly proportional to its effectiveness,'" he tells WebMD.

Osteoporosis treatment. Bone-strengthening drugs such as bisphosphonates (such as Actonel, Boniva, and Fosamax) help stabilize or restore bone loss. This is a critical part of treatment to help prevent further compression fractures.

Surgical Treatment
When chronic pain persists despite rest, activity modification, back bracing, and pain medication, surgery is the next step. Surgical procedures used to treat spinal fractures are:

Vertebroplasty
Kyphoplasty
Spinal fusion surgery
Vertebroplasty and Kyphoplasty
These procedures:

Involve small, minimally invasive incisions, so they require very little healing time.
Utilize acrylic bone cement that hardens quickly, stabilizing the spinal bone fragments and therefore stabilizing the spine immediately.
Most patients go home the same day or after one night's hospital stay.
Vertebroplasty. This procedure is effective for relieving pain from compression fractures and helping to stabilize the fracture. During this procedure:

A needle is inserted into the damaged vertebrae.
X-rays during the procedure help ensure that it's done with accuracy.
The doctor injects a bone cement mixture into the fractured vertebrae.
The cement mixture hardens in about 10 minutes.
The patient typically goes home the same day or after a one-night hospital stay.

Kyphoplasty: This procedure helps correct the bone deformity and relieves the pain associated with compression fractures. During the procedure:

Through a half inch cut in the back, a tube is inserted into the damaged vertebrae. X-rays help ensure the accuracy of the procedure.
A thin catheter tube - with a balloon at the tip -- is guided into the vertebra.
The balloon is inflated to create a cavity in which liquid bone cement is injected.
The balloon is then deflated and removed, and bone cement is injected into the cavity.
The cement mixture hardens in about 10 minutes.
"These procedures are amazing, when you look at how well patients do," says Rex Marco, MD, chief of spine surgery and musculoskeletal oncology at the University of Texas Health Science Center at Houston. "They're often in terrible, terrible pain, and it's not going away. But with two small incisions we can take care of something that needed a huge operation in the past but without really good results."

"We do everything we can to make the operation go as smoothly as possible," says Marco. "Antibiotics decrease the chance of infection. And a special x-ray machine helps us get the needle into the bone and assure that cement goes into the bone and stays in the bone."

Spinal Fusion Surgery
Spinal fusion surgery is sometimes used for compression fractures to eliminate motion between two vertebrae and relieve pain. The procedure connects two or more vertebrae together, holds them in the correct position, and keeps them from moving until they have a chance to grow together, or fuse.

Metal screws are placed through a small tube of bone and into the vertebrae. The screws are attached to metal plates or metal rods that are bolted together in the back of the spine. The hardware holds the vertebrae in place. This stops movement, allowing the vertebrae to fuse. Bone is grafted into the spaces between vertebrae.

"Spinal fusion is often the last resort," Wetzel tells WebMD. "If the bone is more than 50% compressed in height - if patients are in a great deal of pain -- and if they have had complications from another spinal surgery, we suggest spinal fusion surgery."

The patient's own bone or bone from a bone bank can be used to create a graft. The patient's own bone marrow or blood platelets -- or a bioengineered molecule -- can be used to stimulate growth of bone for the procedure.

Recovery from spinal fusion surgery takes longer than with other types of spinal surgery. Patients often have a three- or four-day hospital stay, with a possible stay on a rehabilitation unit. Patients typically wear a brace immediately after surgery. Rehabilitation is often necessary to rebuild strength and functioning. Activity level is gradually increased. Depending on the patient's age and health status, getting back to normal functioning can happen within two months or up to six months later.

There are drawbacks to spinal fusion surgery. It eliminates the natural movement of the two vertebrae, which limits the person's movement. Also, it puts more stress on vertebrae next to the fusion - increasing the chance of fracture in those vertebrae. Even after healing is complete, patients may need to avoid certain lifting and twisting activities to prevent putting excess stress on the spine.

"But if someone has persistent pain from the fracture - and they have been aggressively treated for osteoporosis - they can do very well with spinal fusion," says Wetzel.

How Is Pain Treated?

The goal of pain management is to improve function, enabling individuals to work, attend school, or participate in other day-to-day activities. Patients and their physicians have a number of options for the treatment of pain; some are more effective than others. Sometimes, relaxation and the use of imagery as a distraction provide relief. These methods can be powerful and effective, according to those who advocate their use. Whatever the treatment regime, it is important to remember that pain is treatable. The following treatments are among the most common.

Acetaminophen is the basic ingredient found in Tylenol® and its many generic equivalents. It is sold over the counter, in a prescription-strength preparation, and in combination with codeine (also by prescription).

Acupuncture dates back 2,500 years and involves the application of needles to precise points on the body. It is part of a general category of healing called traditional Chinese or Oriental medicine. Acupuncture remains controversial but is quite popular and may one day prove to be useful for a variety of conditions as it continues to be explored by practitioners, patients, and investigators.

Analgesic refers to the class of drugs that includes most painkillers, such as aspirin, acetaminophen, and ibuprofen. The word analgesic is derived from ancient Greek and means to reduce or stop pain. Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription pain relievers, sold through a pharmacy under the direction of a physician, are used for more moderate to severe pain.

Anticonvulsants are used for the treatment of seizure disorders but are also sometimes prescribed for the treatment of pain. Carbamazepine in particular is used to treat a number of painful conditions, including trigeminal neuralgia. Another antiepileptic drug, gabapentin, is being studied for its pain-relieving properties, especially as a treatment for neuropathic pain.

Antidepressants are sometimes used for the treatment of pain and, along with neuroleptics and lithium, belong to a category of drugs called psychotropic drugs. In addition, anti-anxiety drugs called benzodiazepines also act as muscle relaxants and are sometimes used as pain relievers. Physicians usually try to treat the condition with analgesics before prescribing these drugs.

Antimigraine drugs include the triptans- sumatriptan (Imitrex®), naratriptan (Amerge®), and zolmitriptan (Zomig®)-and are used specifically for migraine headaches. They can have serious side effects in some people and therefore, as with all prescription medicines, should be used only under a doctor's care.

Aspirin may be the most widely used pain-relief agent and has been sold over the counter since 1905 as a treatment for fever, headache, and muscle soreness.

Biofeedback is used for the treatment of many common pain problems, most notably headache and back pain. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature. The individual can then learn to effect a change in his or her responses to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects. Similarly, the use of relaxation techniques in the treatment of pain can increase the patient's feeling of well-being.

Capsaicin is a chemical found in chili peppers that is also a primary ingredient in pain-relieving creams (see Chili Peppers, Capsaicin, and Pain in the Appendix).

Chemonucleolysis is a treatment in which an enzyme, chymopapain, is injected directly into a herniated lumbar disc (see Spine Basics in the Appendix) in an effort to dissolve material around the disc, thus reducing pressure and pain. The procedure's use is extremely limited, in part because some patients may have a life-threatening allergic reaction to chymopapain.

Chiropractic refers to hand manipulation of the spine, usually for relief of back pain, and is a treatment option that continues to grow in popularity among many people who simply seek relief from back disorders. It has never been without controversy, however. Chiropractic's usefulness as a treatment for back pain is, for the most part, restricted to a select group of individuals with uncomplicated acute low back pain who may derive relief from the massage component of the therapy.

Cognitive-behavioral therapy involves a wide variety of coping skills and relaxation methods to help prepare for and cope with pain. It is used for postoperative pain, cancer pain, and the pain of childbirth.

Counseling can give a patient suffering from pain much needed support, whether it is derived from family, group, or individual counseling. Support groups can provide an important adjunct to drug or surgical treatment. Psychological treatment can also help patients learn about the physiological changes produced by pain.

COX-2 inhibitors may be effective for individuals with arthritis. For many years scientists have wanted to develop a drug that works as well as morphine but without its negative side effects. Nonsteroidal anti-inflammatory drugs (NSAIDs) work by blocking two enzymes, cyclooxygenase-1 and cyclooxygenase-2, both of which promote production of hormones called prostaglandins , which in turn cause inflammation, fever, and pain. The newer COX-2 inhibitors primarily block cyclooxygenase-2 and are less likely to have the gastrointestinal side effects sometimes produced by NSAIDs.

In 1999, the Food and Drug Administration approved a COX-2 inhibitor-celecoxib-for use in cases of chronic pain. The long-term effects of all COX-2 inhibitors are still being evaluated, especially in light of new information suggesting that these drugs may increase the risk of heart attack and stroke. Patients taking any of the COX-2 inhibitors should review their drug treatment with their doctors.

Electrical stimulation, including transcutaneous electrical stimulation (TENS), implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day extension of age-old practices in which the nerves of muscles are subjected to a variety of stimuli, including heat or massage. Electrical stimulation, no matter what form, involves a major surgical procedure and is not for everyone, nor is it 100 percent effective. The following techniques each require specialized equipment and personnel trained in the specific procedure being used:

TENS uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. There is also evidence that TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level, in much the same way that shaking your hand can reduce pain.
Peripheral nerve stimulation uses electrodes placed surgically on a carefully selected area of the body. The patient is then able to deliver an electrical current as needed to the affected area, using an antenna and transmitter.
Spinal cord stimulation uses electrodes surgically inserted within the epidural space of the spinal cord. The patient is able to deliver a pulse of electricity to the spinal cord using a small box-like receiver and an antenna taped to the skin.
Deep brain or intracerebral stimulation is considered an extreme treatment and involves surgical stimulation of the brain, usually the thalamus. It is used for a limited number of conditions, including severe pain, central pain syndrome, cancer pain, phantom limb pain, and other neuropathic pains.
Exercise has come to be a prescribed part of some doctors' treatment regimes for patients with pain. Because there is a known link between many types of chronic pain and tense, weak muscles, exercise-even light to moderate exercise such as walking or swimming-can contribute to an overall sense of well-being by improving blood and oxygen flow to muscles. Just as we know that stress contributes to pain, we also know that exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Exercise has been proven to help many people with low back pain. It is important, however, that patients carefully follow the routine laid out by their physicians.

Hypnosis, first approved for medical use by the American Medical Association in 1958, continues to grow in popularity, especially as an adjunct to pain medication. In general, hypnosis is used to control physical function or response, that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood. Some believe that hypnosis delivers the patient into a trance-like state, while others feel that the individual is simply better able to concentrate and relax or is more responsive to suggestion. Hypnosis may result in relief of pain by acting on chemicals in the nervous system, slowing impulses. Whether and how hypnosis works involves greater insight-and research-into the mechanisms underlying human consciousness.

Ibuprofen is a member of the aspirin family of analgesics, the so-called nonsteroidal anti-inflammatory drugs (see below). It is sold over the counter and also comes in prescription-strength preparations.

Low-power lasers have been used occasionally by some physical therapists as a treatment for pain, but like many other treatments, this method is not without controversy.

Magnets are increasingly popular with athletes who swear by their effectiveness for the control of sports-related pain and other painful conditions. Usually worn as a collar or wristwatch, the use of magnets as a treatment dates back to the ancient Egyptians and Greeks. While it is often dismissed as quackery and pseudoscience by skeptics, proponents offer the theory that magnets may effect changes in cells or body chemistry, thus producing pain relief.

Narcotics (see Opioids, below).

Nerve blocks employ the use of drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. There are many different names for the procedure, depending on the technique or agent used. Types of surgical nerve blocks include neurectomy; spinal dorsal, cranial, and trigeminal rhizotomy; and sympathectomy, also called sympathetic blockade (see Nerve Blocks in the Appendix).

Nonsteroidal anti-inflammatory drugs (NSAIDs) (including aspirin and ibuprofen) are widely prescribed and sometimes called non-narcotic or non-opioid analgesics. They work by reducing inflammatory responses in tissues. Many of these drugs irritate the stomach and for that reason are usually taken with food. Although acetaminophen may have some anti-inflammatory effects, it is generally distinguished from the traditional NSAIDs.

Opioids are derived from the poppy plant and are among the oldest drugs known to humankind. They include codeine and perhaps the most well-known narcotic of all, morphine. Morphine can be administered in a variety of forms, including a pump for patient self-administration. Opioids have a narcotic effect, that is, they induce sedation as well as pain relief, and some patients may become physically dependent upon them. For these reasons, patients given opioids should be monitored carefully; in some cases stimulants may be prescribed to counteract the sedative side effects. In addition to drowsiness, other common side effects include constipation, nausea, and vomiting.

Physical therapy and rehabilitation date back to the ancient practice of using physical techniques and methods, such as heat, cold, exercise, massage, and manipulation, in the treatment of certain conditions. These may be applied to increase function, control pain, and speed the patient toward full recovery.

Placebos offer some individuals pain relief although whether and how they have an effect is mysterious and somewhat controversial. Placebos are inactive substances, such as sugar pills, or harmless procedures, such as saline injections or sham surgeries, generally used in clinical studies as control factors to help determine the efficacy of active treatments. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many pain conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This positive response is known as the placebo effect, which is defined as the observable or measurable change that can occur in patients after administration of a placebo. Some experts believe the effect is psychological and that placebos work because the patients believe or expect them to work. Others say placebos relieve pain by stimulating the brain's own analgesics and setting the body's self-healing forces in motion. A third theory suggests that the act of taking placebos relieves stress and anxiety-which are known to aggravate some painful conditions-and, thus, cause the patients to feel better. Still, placebos are considered controversial because by definition they are inactive and have no actual curative value.

R.I.C.E.-Rest, Ice, Compression, and Elevation-are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint conditions, such as sprains or strains. While many common orthopedic problems can be controlled with these four simple steps, especially when combined with over-the-counter pain relievers, more serious conditions may require surgery or physical therapy, including exercise, joint movement or manipulation, and stimulation of muscles.

Surgery, although not always an option, may be required to relieve pain, especially pain caused by back problems or serious musculoskeletal injuries. Surgery may take the form of a nerve block (see Nerve Blocks in the Appendix) or it may involve an operation to relieve pain from a ruptured disc. Surgical procedures for back problems include discectomy or, when microsurgical techniques are used, microdiscectomy, in which the entire disc is removed; laminectomy, a procedure in which a surgeon removes only a disc fragment, gaining access by entering through the arched portion of a vertebra; and spinal fusion, a procedure where the entire disc is removed and replaced with a bone graft. In a spinal fusion, the two vertebrae are then fused together. Although the operation can cause the spine to stiffen, resulting in lost flexibility, the procedure serves one critical purpose: protection of the spinal cord. Other operations for pain include rhizotomy, in which a nerve close to the spinal cord is cut, and cordotomy, where bundles of nerves within the spinal cord are severed. Cordotomy is generally used only for the pain of terminal cancer that does not respond to other therapies. Another operation for pain is the dorsal root entry zone operation, or DREZ, in which spinal neurons corresponding to the patient's pain are destroyed surgically. Because surgery can result in scar tissue formation that may cause additional problems, patients are well advised to seek a second opinion before proceeding. Occasionally, surgery is carried out with electrodes that selectively damage neurons in a targeted area of the brain. These procedures rarely result in long-term pain relief, but both physician and patient may decide that the surgical procedure will be effective enough that it justifies the expense and risk. In some cases, the results of an operation are remarkable. For example, many individuals suffering from trigeminal neuralgia who are not responsive to drug treatment have had great success with a procedure called microvascular decompression, in which tiny blood vessels are surgically separated from surrounding nerves.

Trigger Point Injections

Trigger point injection is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. During this procedure, a health care professional, using a small needle, injects a local anesthetic that sometimes includes a steroid into a trigger point. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief.

Trigger point injection is used to treat muscle pain in the arms, legs, lower back, and neck. In addition, this approach has been used to treat fibromyalgia, tension headaches, and myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment.

Surgical Implants
When standard medicines and physical therapy fail to offer adequate pain relief, you may be a candidate for a surgical implant to help you control pain. There are two main types of implants to control pain:

Intrathecal Drug Delivery. Also called infusion pain pumps or spinal drug delivery systems. The surgeon makes a pocket under the skin that's large enough to hold a medicine pump. The pump is usually about one inch thick and three inches wide. The surgeon also inserts a catheter, which carries pain medicine from the pump to the intrathecal space around the spinal cord. The implants deliver medicines directly to the spinal cord, where pain signals travel. For this reason, intrathecal drug delivery can provide significant pain control with a fraction of the dose that would be required with pills. In addition, the system can cause fewer side effects than oral medications because less medicine is required to control pain.


Spinal Cord Stimulation Implants. In spinal cord stimulation, low-level electrical signals are transmitted to the spinal cord or to specific nerves to block pain signals from reaching the brain. In this procedure, a device that delivers the electrical signals is surgically implanted in the body. A remote control is used by the patient to turn the current off and on or to adjust the intensity of the signals. Most people describe the feelings from the simulator as being pleasant and tingling.

Two kinds of spinal cord stimulation systems are available. The unit that is more commonly used is fully implanted and has a pulse generator and a non-rechargeable battery. The other system includes an antenna, transmitter, and a receiver that relies upon radio frequency. The latter system's antenna and transmitter are carried outside the body, while the receiver is implanted inside the body.

Pain Management: Treatment Overview

What Are the Treatments for Chronic Pain?
The treatments for chronic pain are as diverse as the causes. From over-the-counter and prescription drugs to mind/body techniques to acupuncture, if one approach doesn't work, another one might. But when it comes to treating chronic pain, no single technique is guaranteed to produce complete pain relief. Relief may be found by using a combination of treatment options.

Drug Therapy: Nonprescription and Prescription
Milder forms of pain may be relieved by over-the-counter medications such as Tylenol (acetaminophen) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and Aleve. Both acetaminophen and NSAIDs relieve pain caused by muscle aches and stiffness, but only NSAIDs can also reduce inflammation (swelling and irritation). Topical pain relievers are also available, such as creams, lotions, or sprays that are applied to the skin in order to relieve pain from sore muscles and arthritis.

If over-the-counter drugs do not provide relief, your doctor may prescribe stronger medications, such as muscle relaxants, anti-anxiety drugs (such as Valium), antidepressants, prescription NSAIDs such as Celebrex, or a short course of stronger painkillers (such as Codeine, Fentanyl, Percocet or Vicodin). A limited number of steroid injections at the site of a joint problem can reduce swelling and inflammation.

In April 2005, the FDA asked that Celebrex carry new warnings about the potential risk of heart attacks and strokes as well as potential stomach ulcer bleeding risks. At the same time the FDA asked that over-the-counter anti-inflammatory drugs -- except for aspirin – revise their labels to include information about potential heart and stomach ulcer bleeding risks.

Patient-controlled analgesia (PCA) is another method of pain control. By pushing a button on a computerized pump, the patient is able to self administer a premeasured dose of pain medicine. The pump is connected to a small tube that allows medicine to be injected intravenously (into a vein), subcutaneously (just under the skin), or into the spinal area. This is often used in the hospital to treat pain.

Sometimes, a group of nerves that causes pain to a specific organ or body region can be blocked with local medication. The injection of this nerve-numbing substance is called a nerve block. Although many kinds of nerve blocks exist, this treatment cannot always be used. Often blocks are not possible, are too dangerous, or are not the best treatment for the problem. You doctor can advise you as to whether this treatment is appropriate for you.

Can Medicine Make You Fat?

In a word, yes. Here’s what to do when the drugs you need also put on the pounds.

When you start putting on weight, you look to the usual suspects: the dusty treadmill or that stash of chocolate in your desk drawer.

But for 30-year-old Chelley Thelen, the culprit sat in her medicine cabinet. In six years, Thelen gained 60 pounds from taking prednisone, a steroid used to treat her arthritis.

Thelen is just one of a growing number of women who can blame their excess pounds on the drugs they’re taking for everything from allergies to migraines. The chances of finding yourself on a drug that can lead to weight gain have more than doubled in the last 20 years.

In fact, the number has increased from one in ten to one in four, says George Blackburn, MD, associate director of the Harvard Medical School Division of Nutrition. The problem is so critical that Blackburn teaches a course for physicians on the weight-gain side effects of medications.

“The drugs we’re most concerned about are drugs for chronic diseases, like diabetes and psychiatric problems, because you have to be medicated for life,” Blackburn says. But even innocuous-sounding meds like over-the-counter sleep aids can cause snug-jeans syndrome—some by slowing your metabolism, others by altering the hormones in your body that control your appetite.

And the problem isn’t just affecting women’s waistlines: Some are even choosing not to take drugs critical to their health for weight-control reasons. If you suspect that meds are making you gain weight, check our list below for the most common culprits and expert advice on what to do about it.

Drugs that can pile on pounds
Antihistamines

The fat effect: Allergy drugs containing diphenhydramine (such as Benadryl) have a sedating effect that saps your energy if you take them regularly. You’re not as active, so you’re burning fewer calories, Blackburn says.

What to do: Ask about another antihistamine like Claritin or Zyrtec that doesn’t include sedating ingredients

Antidepressants

The fat effect: Some antidepressants affect neurotransmitters in your brain that control appetite and mood, both of which can make you eat more.

What to do: See a psychiatrist instead of a family physician or internist and ask about antidepressants that don’t typically cause weight gain, such as Wellbutrin or Zyban.

Birth control pills

The fat effect: Birth control pills may add up to five pounds because the estrogen in them can cause you to retain water.

What to do: Ask about a low-estrogen pill like Yasmin, or the progestin-only minipill. Or consider trying the NuvaRing, which releases lower doses of hormones than the birth control pill, or try an intrauterine device.

Sleep aids

The fat effect: You’ll find the same culprit, diphen-hydramine, in over-the-counter sleep aids, such as Tylenol Simply Sleep, Sominex, or Nytol, or “nighttime” versions of cold and pain medicines, like Sudafed PE Nighttime Cold or Excedrin PM.

What to do: Your doctor may prescribe an option like Ambien that’s designed to cut carryover sedating effects.

Migraine meds

The fat effect: Depakote and Depakene, medicines which are sometimes used to prevent recurring migraines, can make you want to eat more, says Harminder Sikand, clinical director of pharm-acy at Scripps Mercy Hospital in San Diego.

What to do: Ask your doctor about Imitrex or other migraine drugs that are less likely to increase your appetite.

Steroids

The fat effect: Prednisone, often used to treat rheumatoid arthritis and chronic inflammation, can make you feel ravenously hungry.

What to do: Your doctor may be able to give you prescription-strength NSAIDs (nonsteroidal anti-inflammatory drugs, such as ibuprofen) to help. If you need to stay on steroids, work with a trainer to increase the calories you’re burning.

Preventing Aches and Pains During Pregnancy

The unflattering "waddle" often associated with a pregnant woman's gait appears to be no more than a myth, according to new research. Although investigators have found that women walk the same way before and during pregnancy, the changes in their body mass and distribution do leave them at increased risk for low back, hip, and calf pain due to overuse.

"With big changes in body weight and distribution, regular exercise prevents joint wear and tear, especially in the pelvis, hips, and ankles," says study author Theresa Foti, PhD, a kinesiologist at Shriners Hospital for Children in Greenville, S.C.

Foti explored gait patterns in 15 women between the ages of 25 and 38 during their final weeks of pregnancy. Participants were videotaped walking across a room, and their strides were compared using motion analysis software. The process was repeated a year later for all but two participants, who were tested prior to pregnancy.

Overall, gait patterns were remarkably unchanged during pregnancy. There was no evidence of a waddling gait, but there were significant increases in hip and ankle forces, indicating that muscles and joints compensate for changes in body mass. These adjustments allow for a normal stride but place muscles and joints at high risk for overuse injuries, particularly among inactive women. The research was published in the current issue of The Journal of Bone and Joint Surgery.

Fortunately, exercise helps prevent overuse injuries and has many other benefits as well. "Most physicians now recommend mild to moderate exercise during pregnancy, even for women who didn't exercise previously," says Michael Lindsey, MD, director of maternal/fetal medicine at Emory University Hospital and associate professor of obstetrics/gynecology at Emory University School of Medicine, both in Atlanta.

Regular exercise is associated with shorter labor and faster postpartum recovery, although safety remains an important consideration. "Maintaining a basic level of fitness is fine, but pregnancy is not the time for vigorous exercise or weight loss," adds Lindsey. "After the first trimester, I also advise against sit-ups and weight training, particularly in women at risk for preterm labor."

But low-impact exercise offsets hormonal changes that weaken the joints. "During pregnancy, the body secretes relaxin to widen the birth canal, but it loosens up all the other joints too," says Lisa Stone, deputy director of the Georgia Commission on Physical Fitness and Sports and founder of "Fit for 2," an exercise program designed for expectant mothers.

Stone, who is certified as a pre- and postnatal fitness instructor by the American Council on Exercise, tells WebMD that strengthening exercise stabilizes the joints and stretching exercise prevents muscle strains. Aerobic exercise, a third Fit for 2 component, burns fat and holds weight gain to a healthy maximum of 25-35 pounds.

Pregnant women should also drink plenty of water before, during, and after exercise. "Unlike you, your baby can't sweat to prevent overheating," says Stone. "So it's a good idea to take a swig of water every 10-15 minutes. Another rule of thumb is to stop exercise well before the point of exhaustion."

"I was running five miles a day until I became pregnant, but I had to stop because it was too uncomfortable," says first-time mother Shannon Powers-Jones, a freelance writer in Atlanta, who adds that exercise helped improve her psychological health.



Vital Information
Low back, hip, and calf pain often experienced during pregnancy can be prevented with stretching, strengthening, and aerobic exercise.
In compensating for changes in body weight and distribution, regular exercise helps prevent overuse injuries, particularly in the pelvis, hips, and ankles.
Exercise offsets hormonal changes that weaken the joints, but sit-ups and weight training should be avoided after the first trimester, particularly in women at risk for preterm labor.

New aches and pains, severe allergies, and other lesser-known symptoms happen to many pregnant women.

Sure, you've heard about morning sickness. You've probably heard the horror stories about how first trimester morning sickness sometimes becomes all-through-the-pregnancy-all-day-long sickness. And you might even be excited about the prospect of a new bra size. (Hmm, could you really go from a 32A to a 34C?)

But what about all those other symptoms of pregnancy, the ones you weren't prepared for? We've talked to moms and moms-to-be who've been through it, and a midwife who's been through it with them, and persuaded them to tell all.

Here are a few lesser-known tales about what you can expect when you're expecting.

New Pains in New Places
Many pregnant women notice pains in parts of their bodies they previously paid little attention to. Ro Harvey, the Michigan mother of three sons, reports the "joyful discovery of my sciatic nerve" during her pregnancies. "My middle son parked his baby butt on my sciatic nerve during the fifth month and never left until the day he was born. Well, except for during the times he was performing acrobatic feats inside my uterus," Harvey says. "I'd lie in bed watching his head peak at my belly button, then his back, then his feet. I'd get a hard pinch on the sciatic as his head passed, and then a dull ache when he settled back in position. No one warned me that babies seem to have an instinct for what the absolute most uncomfortable position in the world is!"

The Nutrition Dos and Don'ts of Pregnancy

You may also find yourself waking up at night with restless leg syndrome, like Jessica Miller, a first-time mom in central New Jersey who's now 35 weeks pregnant. "I had no idea that this condition even existed until someone else in a pregnancy group said she had it," Jessica says. "It's a tingling, numb feeling and extreme feeling of restlessness in the legs. I only get it at night; sometimes it happens while I'm lying on the couch. My legs just crawl and I feel like I have to move them. Once I'm up and walking, it's fine."

If you have allergies, pregnancy can aggravate them to an unbearable degree. Pennsylvanian Dawn Beck had mild allergies to cats before she got pregnant. Now 18 weeks along with her first child, she reports, "I seem to be severely allergic to cats, dogs, pretty much anything with hair!" In fact, she recently had to give her beloved dog a temporary new home with her mother-in-law because she couldn't breathe. "This has come on quite suddenly, and as time goes on it keeps getting worse," she says. "I hope it goes away after the pregnancy so I can get my dog back!"

"An empty bladder does not exist when you're pregnant!" Harvey declares. "I wasn't warned about the bladder jabs. I'd go to the bathroom, feel that joyous sense of relief, and continue on about my work. About 10 minutes after I'd left the bathroom I'd feel a foot, or an elbow, impacting on my supposedly empty bladder with the force of a stampede. Maxi-pads became my best friends."

All of these symptoms are likely to be that much more frustrating since you're going to be exhausted much of the time. "The books all tell you about fatigue, but I think all women are surprised by just how bad it can get," says Lynn Himmelreich, CNM, MPH, a midwife in the obstetrics and gynecology department at the University of Iowa in Iowa City. "Women come in and tell me, 'I was exercising up until I found out I was pregnant, and now I'm so exhausted I just can't do it.'" You may be beat, but even a little exercise can go a long way toward alleviating that exhaustion, and sometimes other symptoms as well. "Believe it or not, it really does energize you once you get up and do it."

Not all surprising pregnancy symptoms are physical. Carrie Hutton, a new mom from Arlington, Va., whose son is now four months old, describes what some call "pregnancy amnesia." "For some reason, no matter how competent you were in your pre-pregnancy life, you can no longer connect the dots. You're lucky you can still remember your name, address, and phone number!" she says.

I'm Feeling Nothing!
What if you're expecting the whole Pregnancy Platter of Symptoms -- morning sickness, swollen and tender breasts, the works -- and they fail to show up? In most cases, just consider yourself lucky and go about your business. "I get more questions from people who don't get the symptoms that the books mention than those who do," says Himmelreich. "They're concerned that it means something's wrong."

Is something wrong? Not usually. "There are plenty of pregnancies in which the woman doesn't have morning sickness or sore breasts. That's normal," Himmelreich says. (Just don't brag about it too much to the woman in the next office who can't keep a saltine down.) When you should be concerned: if pregnancy symptoms you've had suddenly disappear. "It's not usually a problem if you don't have tender breasts, for example, but it's more concerning if you had those symptoms at first and then suddenly at seven or eight weeks, they stopped," Himmelreich says.

And not all pregnancy surprises are negative. "The one thing that surprised me most was that I loved my pregnant body," Hutton says. "Although over time I became awkward, achy, and tired, I loved the way I looked while pregnant. I loved my round breasts and belly, so full of life. My skin and hair have never looked better. When I was pregnant, I felt beautiful. I had never noticed how beautiful pregnant women were before."

Coping with a High-Risk Pregnancy

GET THE SCOOP ON…
What being "high risk" means to you and your baby . Chronic conditions that can place a pregnancy at risk . Conditions that can develop during pregnancy . Coping with your anxiety . Staying sane while you're on bed rest

Coping with a High-Risk Pregnancy
There's nothing warm and fuzzy about the term high-risk pregnancy. In fact, it can be downright scary. What many people don't realize, however, is that the term high-risk pregnancy is a catch-all term that's used to describe women who are on the risk continuum at any point during their pregnancy: women who are at a slightly higher-than-average risk of experiencing complications during pregnancy or birth, or giving birth to a baby with a minor birth defect; and those who have the odds of a happy outcome firmly stacked against them, but who are willing nonetheless to take their chances at starting a family.

If you are at the low end of the risk continuum, your pregnancy may be, for all intents and purposes, perfectly normal. If, on the other hand, you're at high risk of experiencing complications, your pregnancy will be a major commitment—one that will change virtually every aspect of your life during the months ahead.

In this chapter, we talk about what being high risk is likely to mean to you and your baby. Then we discuss both chronic conditions that require special management during pregnancy and conditions that can arise during pregnancy and plunge a low-risk pregnancy into the high-risk category in the blink of an eye. We wrap up the chapter by discussing what it feels like to experience a high-risk pregnancy and offering some practical tips on staying sane during bed rest—one of the biggest challenges many women face during a high-risk pregnancy.

" Your perfect pregnancy—the one we're brought up to believe every woman gets to experience—has now become that other thing you read about in magazines. You are now in the high-risk category. Everyone, from your obstetrician to your own mother, is behaving differently toward you.
—Laurie A. Rich, When Pregnancy Isn't Perfect: A Layperson's Guide to Complications in Pregnancy "

What being high risk means to you and your baby
The term high risk is used to describe pregnancies in which the mother, the baby, or both are at higher-than-average risk of experiencing complications. You are likely to be classified as high risk if you have

a chronic medical condition that may affect your pregnancy,


a history of previous pregnancy-related complications or pregnancy-related complications during your current pregnancy,


a history of pregnancy loss.
As you can see from the following checklist, there are a number of reasons why your pregnancy may be classified as high risk.

CHECKLIST: IS YOUR PREGNANCY HIGH RISK?
Your pregnancy may be treated as high risk if

you are over 35 years old and are therefore at increased risk of giving birth to a child with a chromosomal anomaly;


you are under 17 and are therefore at increased risk of experiencing intrauterine growth restriction;


you are carrying more than one baby and are therefore at risk of experiencing a number of pregnancy-related complications, including preterm labor;


you have a chronic health condition such as diabetes, heart problems, or a blood-clotting disorder that has the potential to affect your pregnancy;


you have a history of gynecological problems such as pelvic inflammatory disease (PID), endometriosis, or large symptomatic fibroids;


you have a history of pregnancy loss (miscarriage, ectopic pregnancy, or stillbirth) or premature birth;


you have an STD, including HIV, that could be transmitted to your baby during pregnancy or at the time of birth;


you are pregnant as a result of assisted reproductive technologies (something that may put you at increased risk of having a multiple pregnancy);


you have had two or more second-trimester abortions (which may increase your chances of having problems with an incompetent cervix);


your mother took DES during her pregnancy (which may increase your chances of having difficulty carrying a pregnancy to term);


you conceived while using an IUD (something that increases your chances of experiencing a miscarriage);


you have a child with a genetic disorder or are a carrier for a genetic disorder (something that may increase your risk of giving birth to a child with that particular genetic disorder).

Watch Out!
Any pregnancy can become high risk. Although the occurrence of any of the following symptoms may not necessarily indicate a problem, you should call your caregiver immediately if you experience

vaginal bleeding or spotting

swelling in the face or fingers

a leakage of fluid or increased vaginal discharge

severe or persistent headaches

pain in the abdomen or shoulder

persistent vomiting that is not related to morning sickness

chills or a fever

a noticeable change in the frequency or strength of your baby's movements

painful or urgent urination

dizziness or faintness
" Because of my heart murmur, I need to take antibiotics before any procedure in which I will bleed. I was striving for a natural delivery, so I wasn't thrilled at the prospect of having to be attached to an IV pole, but as it turned out, the IV pole was not a hindrance at all. I was able to walk around, change positions, even get in the shower.
—Tracy, 30, mother of one "

If your doctor or midwife lacks the specialized expertise to deal with someone with your particular risk factors, you may need to switch to a high-risk-pregnancy specialist. You may find this upsetting if you've established a good rapport with your current caregiver, but switching caregivers is probably the best option for you and your baby. Candace Hurley, the founder of Sidelines (a national support group for moms on bed rest) put it this way in a recent interview with the Los Angeles Times: "You're not a Ford anymore, you're a Ferrari. You need a mechanic who works on Ferraris."

Regardless of who your caregiver is, however, your pregnancy will be more closely monitored than it would be if your pregnancy were classified as low-risk. Consequently, you may be required to make more frequent visits to the doctor, and your doctor may recommend additional tests. If complications do arise—or seem likely to arise—your doctor may prescribe certain types of medications or bed rest.

Chronic conditions that place a pregnancy at risk
Advances in obstetrical medicine have made motherhood a possibility for large numbers of women who might have been discouraged from starting a family a generation ago. Not everyone, however, is able to have a baby. Some chronic conditions place such a tremendous burden on the body that pregnancy is unlikely to occur in the first place, or if it does, the odds of miscarriage, stillbirth, or neonatal loss are extremely high. In certain situations, a woman with a serious medical condition who manages to beat the odds and become pregnant will be encouraged to terminate her pregnancy because the risks to herself or her baby, or both, are simply far too high.

If you are dealing with such a condition, the time to weigh the risks and benefits of a pregnancy is before you become pregnant. Set up an appointment with your doctor to discuss how your pregnancy may affect your condition, how your condition may affect your pregnancy, how past treatments (chemotherapy, radiation therapy, surgery, and so on) for your condition may affect your pregnancy and delivery, what warning signs you need to be aware of, what prenatal tests you may wish to consider, and what—if anything—can be done to minimize the risks to you and your baby.

Bright Idea
If you are at risk of experiencing blood-pressure problems during pregnancy, purchase a blood-pressure gauge at your local drugstore or medical supply store so that you can keep track of your blood pressure between prenatal checkups.





High blood pressure
There's high blood pressure—and then there's really high blood pressure.
If you have mild or moderate hypertension (that is, your blood pressure is from 140/90 to 160/105) and it is not complicated by other factors such as kidney disease or heart disease, your odds of developing preeclampsia are just 10%, and your chances of having a healthy baby are excellent.

If, however, you suffer from severe chronic hypertension (that is, your blood pressure is over 160/105 or your condition is complicated by either kidney disease or heart disease), having a baby will be a fairly risky venture for you. You have a 50% chance of developing preeclampsia and a 10% chance of experiencing a placental abruption, and you are at increased risk of intrauterine growth restriction, premature delivery, and maternal complications such as stroke and cardiovascular problems.

You are at highest risk of experiencing blood-pressure-related problems during your pregnancy if

you are over 40;


you have a lengthy history of hypertension (you've had problems with your blood pressure for more than 15 years);


your blood pressure is higher than 160/110 early on in your pregnancy;


you have diabetes, cardiomyopathy (a disease of the heart muscle caused by either hypertension or other problems), kidney disease, or connective tissue disease (for example, lupus);


you have previously experienced blood-clot complications;


you developed severe preeclampsia early on in a previous pregnancy;


you experienced a placental abruption in a previous pregnancy.


Watch Out!
Don't stop taking your medications without talking to your doctor first. Although certain medications (for example, epilepsy drugs) may be harmful to your baby, the risks of not taking your medications may be even higher. Only your doctor can help you decide whether it's safe to discontinue your medications during pregnancy and, if so, how you can safely wean yourself off them.



Women with extremely complicated cases of hypertension typically spend 15 days in the hospital during their pregnancies. What's more, they have a 50% chance of requiring a cesarean section, a 50% chance of experiencing major complications such as deteriorating kidney function, and a 50% chance of developing preeclampsia—with a 25% chance that the baby will die.

Heart disease
The increased blood volume during pregnancy means that your heart already has to work 50% harder than usual. That's why women with preexisting heart problems can run into difficulty during pregnancy.

Unofficially…
Heart disease is the third-leading cause of maternal death during pregnancy, exceeded only by hemorrhage and infection.



Here are the facts on some common types of heart disease and pregnancy:

Rheumatic heart disease: Rheumatic heart disease is caused by rheumatic fever—an autoimmune response to an infection (typically, untreated strep throat). If it results in mitral stenosis—a particular form of heart-valve damage—the rate of maternal mortality during pregnancy is high. Women affected by this condition require intensive monitoring and multiple cardiac drugs during labor.


Congenital heart diseases: Although the majority of congenital heart defects are mild or repair themselves spontaneously during childhood, some more serious types of congenital heart diseases can endanger a pregnant woman and her baby. Some of these diseases have maternal mortality rates of 50% and fetal mortality rates of 25% to 50%. What's more, babies who survive are also at increased risk of developing congenital heart defects themselves. Women with Eisenmenger's syndrome and primary pulmonary hypertension are advised to avoid pregnancy because of the high rates of maternal mortality associated with these problems. Women with mitral valve prolapse (a disorder in which the heart valve clicks and murmurs) don't face any significant risk during pregnancy, although some caregivers will prescribe antibiotics during labor to prevent potential complications.
Lung disorders
Like the heart, the lungs have to work harder during pregnancy. Although most pre-existing lung diseases (for example, tuberculosis and sarcoidosis) don't cause problems during pregnancy, asthma warrants special monitoring and care.

According to the U.S. Department of Health and Human Services, approximately 1% of pregnant women have chronic asthma, and another 1% will develop the disease as a complication of pregnancy.

Some women with asthma will experience an improvement (25%), others will experience a deterioration (25%), and others will find that their condition remains stable (50%). Unfortunately, there's no way to predict in advance what will happen to any particular woman.

If you are asthmatic and become pregnant, you should

avoid substances that tend to trigger asthma attacks,


minimize your exposure to colds, flus, and respiratory infections,


consider having a flu shot (particularly if you will be pregnant during flu season),


continue to take your allergy shots (with your doctor's approval),


continue to use your asthma medications (with your doctor's approval),


treat asthma attacks immediately to avoid depriving your baby of oxygen.
Kidney disease
The kidneys—which are responsible for filtering the blood—are also required to work harder during pregnancy because they must contend with the waste products that the baby releases into the mother's blood stream, as well as the increased volume of blood.

Here are the facts on kidney disease and pregnancy:

Women with mild kidney disease experience very few problems during pregnancy, but those who have more severe forms of the disease are at risk of developing pyelonephritis (an acute kidney infection that can cause permanent damage), experiencing a premature delivery, or having a baby with intrauterine growth restriction.
Watch Out!
An untreated urinary-tract infection can spread to the kidneys, causing kidney damage or premature delivery.



Women who have both chronic kidney disease and high blood pressure have a 50% chance of developing severe hypertension during pregnancy.


Women who are on dialysis prior to pregnancy will require dialysis treatments more frequently during pregnancy.


Women who are pregnant after a kidney transplant will continue to require medications to prevent rejection of the kidney. They have a 33% chance of developing preeclampsia, a 50% chance of experiencing a premature delivery, an increased risk of having a baby with intrauterine growth restriction, and a higher risk of cesarean due to pelvic bone disease or narrowing of the birth canal.
Note: To maximize their chances of giving birth to a health baby, women who have had a kidney transplant should wait two to five years before attempting a pregnancy. Women who have minimal protein in their urine, normal blood pressure, and no evidence of kidney rejection are considered to be the best candidates for a pregnancy.



Liver disorders
The liver plays a role in a number of important bodily functions. It produces substances the body needs in order to metabolize fats, vitamins, minerals, proteins, and carbohydrates; it controls blood sugar level and lipids; it stores essential vitamins, minerals, and glucose; and it detoxifies substances such as drugs, alcohol, and chemicals.

Although most forms of hepatitis do not appear to worsen during pregnancy and therefore don't appear to pose a significantly increased risk to the mother, certain liver disorders can endanger the fetus (for example, it's possible that a woman with hepatitis B or C could transmit the disease to her baby).

Some women develop a particular form of jaundice during pregnancy (intrahepatic cholestasis). It tends to develop during the third trimester, and it results in severe itching and mild jaundice. It disappears spontaneously within two days of delivery.
Note: Some studies have shown that women who experience jaundice during pregnancy may be at increased risk of experiencing a premature delivery or a stillbirth.

" If you have previously given birth to a premature baby, make sure you see a high-risk- pregnancy specialist during your next pregnancy. Ask for every test available, particularly if they don't know the cause of your first premature labor.
—Susan, 33, mother of two boys who were each premature "



Diabetes mellitus
Pregnancy can be risky for a woman with diabetes. Hormonal changes cause an increase in insulin requirements that a diabetic woman's body can't meet. If a pregnant woman does not manage to keep her blood sugars under control, she is at increased risk of experiencing miscarriage, stillbirth, or fetal death, or of giving birth to a baby with heart, kidney, or spinal defects. She is also more likely to give birth to an extremely large baby—something that can lead to problems during the delivery or necessitate a cesarean section.

Watch Out!
A family history of diabetes is one of the factors that increases your risk of developing gestational diabetes during your pregnancy.



A diabetic woman is likely to experience the best possible outcome if she manages to tightly control her blood sugars during the two months prior to becoming pregnant, as well as through her pregnancy. Blood sugar levels of 70 to 140 milligrams/deciliter in the months prior to pregnancy and an average of 80 to 87 milligrams/deciliter during pregnancy are associated with positive pregnancy outcomes. A diabetic woman can find out how well her blood sugars are under control by taking a glycosylated hemoglobin (hemoglobin Alc) test at two to three months of pregnancy. A favorable result on the test indicates that she is at no greater risk of giving birth to a baby with birth defects than any other pregnant woman.

Most of the damage that causes birth defects occurs during the first trimester. Some of the problems that can result are minor and correctable; others can be fatal. That's why it's important for a diabetic pregnant woman to check her blood levels up to six or seven times daily using a home glucose monitor and to report any problems in controlling her blood sugar levels to her caregiver. If blood sugar levels cannot be controlled through diet alone, insulin doses may be required. (Women with pre-existing diabetes—as opposed to gestational diabetes—always need insulin.)

A diabetic woman may require additional tests during pregnancy to check on the status of her eyes, her kidneys, the placenta, and the baby. What's more, her baby may need to be checked over in the neonatal intensive care unit after delivery to be observed for both respiratory problems and hypoglycemia.

Thyroid disorders
The thyroid is responsible for regulating the body's metabolic processes.

Watch Out!
The leading cause of maternal death during pregnancy is motor-vehicle accidents.

If it is overactive—a condition known as hyperthyroidism—the metabolism speeds up; the heart rate increases; and such symptoms as muscle weakness, nervousness, anxiety, heat sensitivity, flushed skin, bulging eyes, weight loss, and goiter are experienced. Pregnant women with hyperthyroidism can develop thyroid storm—a severe form of the disorder—during pregnancy. Thyroid storm is associated with an increased risk of premature delivery and low birthweight.

If the thyroid is underactive—a condition known as hypothyroidism—the metabolism slows down, causing lethargy, aching muscles, intolerance to cold, constipation, weight gain, voice deepening, facial puffiness, and dry skin.

Thyroid function needs to be monitored closely in pregnant women with either type of disorder, and where appropriate, medication should be prescribed.

Parathyroid disorders
The parathyroid is located behind the thyroid gland. It plays a role in regulating calcium levels in the body.

Too much parathyroid—a condition known as hyperparathyroidism—results in fatigue, muscle weakness, abdominal pain, bone pain and fractures, frequent urination, thirst, kidney stones, pancreatitis, stomach ulcers, and constipation. Pregnant women with this disorder are at slightly increased risk of experiencing a stillbirth or neonatal death or of giving birth to a baby with tetany (severe muscle spasms and paralysis caused by inadequate levels of calcium).

Too little parathyroid—a condition known as hypoparathyroidism—can cause bone-weakening disorders in the developing baby. Consequently, women with this disorder will be prescribed calcium and vitamin D supplements.

Pituitary disorders
The pituitary gland is responsible for regulating the flow of hormones in the body. A couple of pituitary-related disorders can cause problems during pregnancy:

Pituitary tumors: Some women have undetected pituitary tumors. Pregnancy hormones can cause these tumors to grow, causing severe headaches and visual-field disturbances (that is, spots before the eyes or obstructions to vision). If this occurs, the pregnant woman will need to be monitored by a team of specialists, including an obstetrician, an endocrinologist, and an opthamologist.


Diabetes inspidus: Diabetes inspidus is a rare condition caused by a deficiency in an antidiuretic hormone manufactured by the pituitary gland. This disorder causes increased thirst and a correspondingly increased output of urine. The condition tends to get worse during pregnancy but can be controlled through medication.


Pituitary insufficiency: Pituitary insufficiency—a deficiency in overall pituitary function—can be caused by damage from a tumor, surgery, radiation, or complications from a previous pregnancy. If the condition is not corrected during pregnancy, a woman has only a 54% chance of having a healthy baby. Women who have had previous surgery or radiation in the pituitary region or who have experienced a severe hemorrhage during a previous pregnancy—particularly if the hemorrhage was followed by an inability to lactate—should be tested for pituitary insufficiency.
Bright Idea
Read up on high-risk pregnancy at the Johns Hopkins Health Information Web site: www.intellihealth.com.

Adrenal gland disorders
The adrenal glands are responsible for maintaining the correct levels of salt in the body, for producing sex steroids (hormones), and for manufacturing other hormones known as glucocorticoids. Two types of adrenal gland disorders tend to cause problems during pregnancy:

Cushing's syndrome—the result of too much cortisone—is associated with a high rate of premature delivery and stillbirth. The syndrome is characterized by muscle weakness and wasting; thinning and reddening of the skin; an accumulation of excess fat on the face, neck, and torso; and excessive hair growth. Later stages of the syndrome may also result in high blood pressure, diabetes mellitus, and an increased susceptibility to various infections. It is difficult to diagnose during pregnancy because many of the symptoms are also associated with pregnancy: weakness, weight gain, edema, stretch marks, high blood pressure, and diabetic tendencies.


Addison's disease—the result of inadequate adrenal production—can result in life- threatening infections. It is characterized by fatigue, loss of appetite, nausea, dizziness, fainting, skin darkening, and abdominal pain.


Blood disorders
The following five blood disorders can cause problems during pregnancy:

Anemia: Anemia—a blood disorder that is caused by deficiencies in iron, vitamin B12, and folic acid—can result in fatigue; weakness; shortness of breath; dizziness; tingling in the hands and feet; a lack of balance and coordination; irritability; depression; heart palpitations; a loss of color in the skin, gums, and fingernails; jaundice of the skin and eyes; and—in particularly serious cases—heart failure. Because many women become anemic during pregnancy, you're at increased risk of experiencing these types of difficulties if you are anemic prior to pregnancy.


Sickle-cell anemia: Sickle-cell anemia is a hereditary blood disease. Women with sickle-cell anemia who become pregnant have a 25% chance of miscarriage, an 8% to 10% chance of stillbirth, and a 15% chance of neonatal death. They have a 33% chance of developing high blood pressure and toxemia and also tend to have problems with urinary tract infections, pneumonia, and lung tissue damage. Sickle-cell crises—painful episodes that can lead to organ damage due to the lack of proper blood flow into the fine capillaries—are more likely to occur during pregnancy. As if that weren't enough, a pregnant woman runs the risk of passing along sickle-cell anemia to her baby if her partner also happens to carry the gene for the disease.


Thalassemia: Thalassemia is another hereditary blood disease. Although most people with Cooley's anemia (alpha-thalassemia) die before they reach childbearing age, the handful of women who do live long enough to become pregnant often suffer severe anemia and congestive heart failure requiring blood transfusions. Those pregnant women who have the less-severe form of thalassemia (beta- thalassemia) may require blood transfusions during pregnancy and run the risk of giving birth to a baby with the disease if their partner is also a carrier.


Thrombocytopenia: Women with thrombocytopenia—a deficiency of blood platelets—are at increased risk of requiring a cesarean section. Babies born vaginally to mothers with severe thrombocytopenia may have decreased platelet counts and problems with hemorrhaging— particularly around the brain.


Von Willebrand's disease: Von Willebrand's disease is an inherited disorder that affects the blood's capability to clot. It can lead to severe blood loss during surgery, accidents, or delivery, which is why pregnant women with this disease need to be treated with intravenous clotting factors.
Autoimmune disorders
Autoimmune disorders occur when the body's immune system develops antibodies to its own body tissue, resulting in damage to its own major organs.

Here are the facts on four of the most common autoimmune disorders and pregnancy:

Lupus: A generation ago, women with lupus were advised not to have any children because of the risks to both the mother and the baby. Today, a growing number of women with the disorder are trying to have children. This is not to say that it's an easy journey to make: according to the Lupus Foundation of America, although 50% of women with lupus can expect to enjoy a normal pregnancy, 25% will experience either stillbirth or a miscarriage, and another 25% will experience preterm labor. What's more, 20% of women with lupus develop preeclampsia, and 3% give birth to babies with "neonatal lupus"—a form of the disease that lasts until the baby is six months old and that may cause a permanent heart abnormality. Women with moderate-to-severe involvement of the central nervous system, lungs, heart, kidneys, or other internal organs are advised to avoid pregnancy.
Unofficially…
Babies born before 25 weeks who weigh more than two pounds have a 50% chance of survival if they're born in a hospital that is equipped to deal with a baby who is this premature. On the other hand, babies who weigh in at three pounds or more have a 95% chance of survival.



Rheumatoid arthritis: Rheumatoid arthritis is a common form of arthritis. Its symptoms include joint pain and swelling, and stiffness (especially in the morning). Almost all women with rheumatoid arthritis go into remission during pregnancy. Unfortunately, the disease recurs in 90% of women after they give birth—25% within a month of the delivery.


Scleroderma: Scleroderma is a progressive connective tissue disorder that can cause lung, heart, kidney, and organ damage and that is characterized by both joint inflammation and reduced mobility. In 40% of cases the disease worsens during pregnancy, in another 40% there is no change, and in the remaining 20% of cases the condition actually improves. Pregnant women with the disorder face an increased risk of premature delivery and stillbirth, but the majority of babies born to mothers with scleroderma are born healthy.


Myasthenia gravis: Myasthenia gravis is an autoimmune disease that causes skeletal muscle weakness and easy fatigability. Thirty percent of women with the condition experience no change to their condition during pregnancy, 40% experience a worsening of symptoms, and 30% go into remission. There is a 25% rate of premature delivery associated with the disorder and a 10% to 20% chance that the baby will experience a temporary case of myasthenia gravis within two days of delivery.
Gastrointestinal disorders
Here's what you need to know about chronic gastrointestinal disorders and pregnancy:

Peptic ulcers: Peptic ulcers are chronic sores that protrude through the gastrointestinal tract lining and can penetrate the muscle tissue in the duodenum, stomach, or esophagus. Forty-four percent of women with peptic ulcers experience an improvement during pregnancy because the high levels of progesterone in the body stimulate the production of mucus, which can help to provide a protective shield in the stomach lining. Another 44% experience no change in their condition, however, and the remaining 12% actually report a deterioration.


Ulcerative colitis: Ulcerative colitis is an inflammatory disease of the colon and rectum. It can lead to bloody stools, diarrhea, cramping, abdominal pain, weight loss, and dehydration. It can also be linked to fever, anemia, and a high white-blood-cell count. A woman whose colitis is inactive when she becomes pregnant has a 50% to 70% chance of having it remain inactive during pregnancy—good news for both her and her baby. The condition tends to be a significant problem only if emergency surgery is required, because this type of surgery can cause premature labor or necessitate a cesarean delivery.


Crohn's disease: Crohn's disease is similar to ulcerative colitis, but it affects the entire gastrointestinal tract (that is, from the mouth to the anus), although it tends to be focused in the intestines. If Crohn's disease is active at the time of conception, a pregnant woman faces 50% odds of miscarrying. If, however, she is in remission, she has an 85% chance of having the remission continue during her pregnancy.


Bright Idea
You can reduce the likelihood of experiencing problems with your epilepsy if you take your medications as prescribed. Studies have shown that women who take their epilepsy medications as directed have an 85% to 90% chance of giving birth to a healthy baby. If morning sickness is making it difficult for you to keep your medications down, try taking them at times when your nausea is less severe or with plain crackers and a drink of milk.

Neurological disorders
Here's what you need to know about neurological disorders and pregnancy:

Epilepsy and seizure disorders: Pregnancy is risky business for a woman with epilepsy. Many of the drugs used to control the disorder are linked to birth defects; facial, skull, and limb deformities; fatal hemorrhages in newborns; unusual childhood cancers; cleft palate or lip; congenital heart disease; spina bifida; intrauterine growth restriction; and fetal death. Women with epilepsy also have a 1 in 30 chance of giving birth to a child with a seizure disorder. Not everyone faces an equal risk of running into problems;
however: women who experience frequent seizures prior to becoming pregnant are four times as likely to experience problems during pregnancy as women who don't.


Migraines: Nearly one in five pregnant women suffers from migraine headaches. Fortunately, 80% find that their condition improves during pregnancy, and others are able to avoid problems by avoiding such dietary triggers as MSG (found in Chinese food), sodium nitrates and nitrites (found in cured meats), and tyramine (found in strong cheese).


Watch Out!
If you're subject to migraines, don't allow yourself to get too hungry. Low blood sugar can trigger migraines .



Multiple sclerosis: Multiple sclerosis is a disease in which the insulating material covering the body's nerve fibers is destroyed, causing weakness in the legs, vision problems, poor coordination and balance, spasticity or trembling in one hand, loss of bladder control, and other difficulties. Women with multiple sclerosis are able to give birth to perfectly healthy babies since there is only a 1% to 5% chance that the baby will develop the disease. Women with a lack of sensation in their lower bodies are monitored closely during the ninth month in case they are unable to detect the onset of labor. They also may require a forceps or vacuum-assisted delivery since the disorder can affect their ability to push.


Cerebrovascular disease
Pregnancy can pose a significant risk to women with a history of strokes, hemorrhages, and blood clots. If a pregnant woman has a known blood-vessel disorder of the brain, such as an arteriovenous malformation, she has a 33% chance of dying during pregnancy.

Malignant diseases
As a rule of thumb, women with cancer should delay becoming pregnant until they are reasonably sure that a recurrence won't occur during pregnancy. This is because women who are diagnosed with cancer during pregnancy are often advised to terminate their pregnancy so that they can obtain the medical treatment they need. Delaying treatment can, in many cases, reduce their odds for long-term survival.



Bright Idea
You and your doctor can obtain the latest information on the effects of chemotherapeutic agents on pregnancy through the Registry of Pregnancies Exposed to Chemotherapeutic Agents. The database contains details on the known effects of cancer drugs during specific stages of pregnancy. Contact the Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA 15261, 412-624-9951, bgettig@helix.hgen.pitt.edu.



Phenylketonuria (PKU)
Phenylketonuria is a genetically transmitted disorder that can cause severe mental retardation in the newborn if it is undetected within two days of birth. People with PKU are deficient in a particular liver enzyme needed to metabolize phenylalanine, an amino acid found in most foods. Pregnant women with PKU face a higher risk of miscarriage and tend to give birth to more children with microcephaly, heart defects, mental retardation, growth restriction, and low birthweight. Women with PKU must follow a special diet during pregnancy. Studies have shown, however, that women who begin following the diet prior to becoming pregnant have better outcomes.

Group B beta-hemolytic strep
Group B Beta-hemolytic strep is a strain of bacteria that is carried by somewhere between 20% and 40% of pregnant women. Two percent of babies born to women who are infected with the bacteria develop Group B strep disease—a serious condition with a 6% mortality rate. Group B strep is more likely to be a problem if a baby is premature, if the membranes have been ruptured for more than 30 hours when labor commences, or if the woman had a previous baby who contracted a Group B strep infection. Most caregivers screen for Group B strep when a woman is 35 to 37 weeks' pregnant and prescribe antibiotics during labor to women who are carriers or who have other risk factors. (See Chapter 16).

Sexually transmitted diseases
Nearly two million pregnant women experience STDs each year. (See Table 10.1.) If you or your partner has had unprotected sex with someone since your last STD screening, you should be retested. STDs can occur at any time—even during pregnancy—and can be harmful to the unborn baby. Fortunately, there are treatments available to minimize the risk to the baby. Consider the facts for yourself:

Babies of HIV-positive mothers who have been treated with AZT prior to birth and who are delivered by cesearean section have, for example, a less than 1% chance of developing HIV, according to the National Institute for Child Health and Human Development. Babies born to women who do not receive any form of treatment, on the other hand, have a 20% to 32% chance of developing the disease.


Babies whose mothers test positive for hepatitis B can usually avoid developing the disease if they are given hepatitis B vaccine and immune globulin within 12 hours of birth. These treatments are repeated one month and six months later.
Unofficially…
According to a recent study in the British Journal of Obstetrics and Gynaecology, women with hepatitis C have an excellent chance of giving birth to perfectly healthy babies. Pregnancy doesn't worsen the disease, and it has not been linked with any pregnancy-related complications.

Psychiatric illness
Psychiatric illness is relatively common in women of reproductive age. Between 8% and 10% of women of childbearing age experience depression and approximately 1% are schizophrenic.

Although certain drugs used to treat psychiatric illness have been linked with birth defects, others are considered to be relatively safe for use during pregnancy (although, ideally, you will want to avoid taking any drug during your first trimester). Your obstetrician or your psychiatrist will be able to provide you with information on the use of your medication during pregnancy.

If you suffer from an eating disorder, you may find it difficult to allow yourself to gain weight during pregnancy. You may wish to continue with an existing treatment program or seek the services of a professional to ensure that you are able to give your baby the best possible start in life.



Unofficially…
Pregnant women are particularly susceptible to diabetes because the placenta produces hormones that counteract the effects of insulin. As a result, a pregnant woman's body needs to produce 30% more insulin than normal.


TABLE 10.1: THE NUMBER OF PREGNANT WOMEN IN THE U.S. WITH STDS EACH YEAR
STD Estimated Number of Pregnant
Women Who Get the Disease Each Year

Bacterial vaginosis 800,000

Herpes simplex 800,000

Chlamydia 200,000

Trichomoniasis 80,000

Gonorrhea 40,000

Hepatitis B 40,000

HIV 8,000

Syphilis 8,000

Total 1,976,000

Source: Goldenberg et al., 1997

Conditions that can develop during pregnancy
As we mentioned earlier, any pregnancy can change from low risk to high risk in the blink of an eye. That's why it's important to be prepared to spot the warning signals of the most common pregnancy-related complications.

Risk factors:

subsequent pregnancy,

family history of diabetes,

have previously given birth to a baby over 9 lbs.,

have experienced unexplained pregnancy losses,

overweight,

high blood pressure,

recurrent yeast infections.
You may be admitted to a hospital if your blood sugar remains high despite efforts to control your sugar levels through diet. You may require insulin injections.


Symptoms of early-stage preeclampsia include swelling of hands and feet, sudden weight gain, high blood pressure (140/90 or higher), increased protein in the urine, and headaches. Most likely to occur in:

first-time mothers,

women carrying multiples,

women with chronic high blood pressure, diabetes, kidney disease, or a family history of preeclampsia.
Mild cases can be treated through bed rest. Severe cases require hospitalization for treatment with antihypertensive drugs. The condition is cured when the baby is born, although the danger period extends to approximately 24 hours after delivery. Labor may be induced or cesarean performed if the condition progresses to a certain point.


Condition What Can Happen Risk Factors and
Warning Signs Treatment

Hyperemesis gravidarum (severe morning sickness)
Can lead to malnutrition and dehydration.
Occurs in 1/200 pregnancies. More common in first-time mothers, women carrying multiples, and mothers who have experienced the disorder during a previous pregnancy.
You will usually be hospitalized so that intravenous drugs and fluids can be administered.


Chorioamnionitis (an infection of the amniotic fluid and fetal membranes)
Can lead to premature rupture of the membranes or premature labor.
Occurs in 1/100 pregnancies. Often there are no symptoms early on except a rapid heartbeat and a fever over 100.4° F.
Treatment options include antibiotics and/or prompt delivery.


Gestational diabetes
Can lead to excessive fetal growth. An overly large baby may have to be delivered by cesarean section and may have difficulties at birth. The diabetes may continue after delivery or recur later in life.


Preeclampsia (also known as toxemia)
Associated with increased risk of placental abruption and fetal distress. In severe forms, it can cause a life-threatening condition that includes blood clotting problems, liver dysfunction, stroke, and possibly even the death of the mother or baby. When seizures are present, it is known as eclampsia.


Intrauterine growth restriction (IUGR) (also known as intrauterine growth retardation)
Can result in low-birthweight babies or infants who are less alert and responsive.
Diagnosed when the developing baby consistently measures small for dates. Most likely to occur in:

women with chronic health problems or an unhealthy lifestyle,

women with high blood pressure,

women carrying multiples,

woman having first or fifth (or later) pregnancy,

a fetus with chromosomal abnormalities.
Bed rest and/or hospitalization. Labor may be induced if it is felt that the baby will do better in the nursery than in the relatively hostile uterine environment.


Amniotic fluid-level problems: polyhydramnios (too much fluid) or oligohydramnios (too little fluid)
Polyhydramnios may indicate Rh-incompatibility problems, diabetes, or the presence of multiple fetuses. Oligohydramnios may indicate a malfunction or absence of fetal kidneys or leakage of amniotic fluid due to premature rupture of the membranes.
Suspected when a woman measures too large or too small for dates; diagnosed via ultrasound.
Polyhydramnios: If severe and causes significant symptoms or fetal compromise, can be treated by removing excess liquid through amniocentesis. Oligohydramnios: This is a serious condition that is generally treated by delivering the baby as soon as it is considered safe to do so.


Condition What Can Happen Risk Factors and
Warning Signs Treatment

Premature labor
Health of premature newborn is determined by week of gestation, type of neonatal care available, birthweight, and general health.
Contractions accompanied by cervical dilation, vaginal bleeding or discharge, or vaginal pressure between the 20th and 37th week of pregnancy. Other symptoms include menstrual-like cramps, with possible diarrhea, nausea, or indigestion. Risk factors include smoking, urinary tract infections, poor general health, diabetes or thyroid problems, bacterial infections or STDs, placental problems, physical trauma (car accident, spouse abuse), a history of premature labor, multiple fetuses, abdominal surgery during pregnancy, or a history of two second trimester miscarriages.
Bed rest, intravenous fluids, and/or the prescription of drugs to prevent labor. Note: Medications are generally effective only if your cervix is dilated less than three centimeters and is not yet effaced.


Placenta previa (placenta covering the cervical opening)
The baby cannot pass out of the mother's body without dislodging the placenta and disrupting its own blood supply. A postpartum hemorrhage may occur after the birth of the baby.
Bleeding can be triggered by coughing, straining, or sexual intercourse. More common in women who have had several children. Occurs in 1/200 pregnancies.
Bed rest, monitoring, and/or hospitalization. A cesarean section may be required.Note: If placenta previa is diagnosed n 2nd trimester, the condition may correct itself by the time you deliver.


Placental abruption (placenta prematurely separates from uterus, either partially or wholly)
Can be harmful—even fatal—to mother and baby.
Warning signs include heavy vaginal bleeding, premature labor, contractions, uterine tenderness, and lower back pain. More common in women who have had two or more children, who smoke, who have high blood pressure, or who have had a previous placental abruption. Sometimes caused by the trauma of an automobile accident. Occurs in 1/150 pregnancies.
Bed rest and careful monitoring. If fetus goes into distress, an emergency cesarean section may be necessary.


Placental insufficiency
Can result in a low-birthweight baby.
Can be caused by abnormal development, restricted blood flow due to a clot, a partial abruption, a placenta that is too small or poorly developed, a pregnancy that is postdate, or maternal diabetes.
Sometimes warrants the delivery of the baby before term.


Bright Idea
Check out the online guide to gestational diabetes at www.mediconsult.com/pregnancy/shareware/gest/.

Coping with the stress of a high-risk pregnancy
Nine months can seem like an impossibly long time when you're dealing with the stress of a high-risk pregnancy. If your pregnancy has been categorized as high risk, you may be dealing with a lot of conflicting emotions. "At some point during your confinement, you can expect to feel angry at your baby (for keeping you in bed), your husband (for getting you into bed in the first place), your doctor (for not fixing the problem), and everyone else you can think of," explains Laurie A. Rich, author of When Pregnancy Isn't Perfect: A Layman's Guide to Compli-cations in Pregnancy.