Functional Health and Nutrition for a Healthy Pregnancy

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics, as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. That’s DRRUSCIO.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

Dr Ruscio:

Hi everyone. Today I spoke with Sarah Thompson, who is a board-certified acupuncturist and herbalist, and also a certified functional medicine practitioner and a doula. And we went to the topic of maternity pregnancy and how to have a healthy baby. I learned a lot in this episode. She corrected me early on in the podcast, that there’s a difference between a midwife and a doula, which I wasn’t really clear on the delineation between the two. And I have to say I was very much so impressed with her depth of knowledge, but also her practicality.

Dr Ruscio:

There’s a very important clarification she makes on thyroid levels during pregnancy and how the most of the consensus guidelines are finding that a TSH of 2.5 or above can be considered subclinical hypothyroid and require and benefit from treatment, which was incredibly insightful to know, and that this is not often caught by obstetricians. And this is something that you really want to refer to your endocrinologist for. We also discussed Hashimoto’s in pregnancy, the importance of healthy progesterone levels, and nutritional factors that you can use to intervene upstream to make sure that progesterone stays healthy throughout pregnancy. A very important discussion on iodine and its impact during pregnancy. Gut health, exercise, stress, toxins, and COVID were other topics that we discussed.

Dr Ruscio:

Again, this was a great conversation. I very much so appreciated the fact that she was highly knowledgeable but practical. And again, I just really hope that you will listen to this episode and benefit from it with Sarah Thompson on the topic of maternity. And with that, we will now go to the show.

Dr Ruscio:

Hey everyone, welcome back to Dr. Ruscio Radio. This is Dr. Michael Ruscio today joined by Sarah Thompson. And today we will be detailing the topic of maternity and being a healthy mom-to-be, and everything related to this topic—or many of the top points, certainly we’re not going to be able to do everything in 45 minutes or so—but the salient points in an area that when I was writing “Healthy Gut, Healthy You,” I dedicated an entire chapter to early life factors that can lead to a healthy gut microbiota and therefore a healthy immune system.

Dr Ruscio:

And it’s pretty compelling, what you find in the research literature in terms of: if you do things right early on, you can have a positive impact for the entire life of the individual. And if you do things wrong, it’s not to say you’re screwed and there’s nothing you can do, but you do set a certain tone. Which, if we’re trying to intervene as far upstream as possible and be as preventative of as we can, then certainly while the child is developing is one of the furthest upstream interventions that we can have. And with that, Sarah, I’m very, very excited to have you here and to pick your brain.

Sarah Thompson:

Thank you. I’m excited to be here as well.

Dr Ruscio:

Tell us just a short backstory. I know you work as a midwife and a doula, so tell us a bit about how you’re interfacing into child rearing and the like.

Sarah Thompson:

Yeah, well, not to correct you right off the bat, but I’m not a midwife.

Dr Ruscio:

Oh, I’m sorry.

Sarah Thompson:

No, yeah, you’re good. You’re good. I do, I specialize in functional medicine as it applies to pregnancy. So I work in adjunct to OBs and midwives here locally in Colorado and across the country. I fell into this role when I was pregnant with my first child. And prior to that, I had zero interest in anything women’s health, honestly. I’m a traditional Chinese medicine practitioner, is what my base medical degree is. And like most acupuncturists out there, I started a practice in pain management in sports medicine because that’s what every acupuncturist does.

Sarah Thompson:

And it wasn’t until I became pregnant with my own child that I was blown away by the coolness, really, of pregnancy and how nobody talked about it. And I had to know everything there was about it. And prior to my pregnancy, I always used nutrition in practice. It’s the foundation of all health—it’s what every practitioner should base a lot of their practice on. And when it became my own pregnancy, I just engulfed myself into the research and the study of nutrition in pregnancy. And here I am, 13 going on 14 years later. And it is what I do in practice, primarily.

Dr Ruscio:

This is great for me because I’ve been under the impression that a doula and a midwife were very similar. I don’t know if I could say exactly synonyms, but maybe just clarify the difference between those two for me and for us.

Sarah Thompson:

Sure. As a doula, we don’t catch babies. That’s like the big determining factor. Doulas in general are support systems. So we are guides through the prenatal and pregnancy and childbirth process. So with me, in my role, I take a much deeper role in that guiding by guiding women nutritionally and through functional medicine through that whole process, plus being at their delivery to guide them through the actual birth process itself and through the postpartum phase. Midwives, they take over the PCP role and they provide the medical interventions as needed and they catch babies.

Dr Ruscio:

Gotcha. Is it fair to say that midwives tend to be more holistic or is that an incorrect frame that I’m applying to the role of midwife?

Sarah Thompson:

Yeah. Midwives tend to be a little bit more on the holistic side of the birthing world. You have your groups of home-birth midwives, and you have your groups of hospital-based midwives, and they’re still trained in conventional medicine as the way we know it in maternity care. They just don’t have the option of surgical intervention as their primary go-to. And so they tend to lean to: what can we do to avoid that cesarean as long as possible? Where sometimes OBs tend to go that route first.

Dr Ruscio:

Gotcha. Okay. Yeah. Okay. Where do you want to start? Nutrition obviously comes up—and I guess maybe to put one of my concerns on the board as it pertains to pregnancy, and I certainly am no expert here—but one area that I do have a fair degree of expertise is in probiotics. And this is one area where I’ve been a little bit disappointed with how conventional medicine handles this, including as it pertains to pregnant mothers. And it seems the read I’ve gotten through discussing this with my patients who are pregnant is—the perspective on probiotics is—kind of mixed. Some will be supportive—some conventional doctors (either OBs or midwives) I suppose, are supportive. Some are slightly against. And then it seems if there’s any complication with a child there seems to be a, “well, maybe you shouldn’t…”

Dr Ruscio:

And knowing that there’s some pretty impressive data, even for infants in the neonative intensive care unit (NICU) showing improved outcomes with probiotics supplementation makes me concerned that there’s this tendency toward, “well, if we don’t know much about it, we’re just going to say, don’t do it.” And so maybe I’ll put that on the table in terms of, are there any of those canards that you think conventional medicine may not have good evidence to say avoid this natural thing, but they’re just saying avoid it because they don’t know much about it and they’re uncomfortable with it? And there’s actually a decent case to be made for (whatever the given thing is) nutritionally or supplementally or what have you.

Sarah Thompson:

Yeah. I think you kind hit the nail on the head. And I think that’s how a lot of conventional medicine treats all of alternative medicine when it comes to pregnancy, is we don’t know enough about it personally, so don’t do it. And it applies to, I think every aspect of pregnancy, where we have this big fear of the unknown as it’s going to affect the baby. But in that process, we kind of neglect the mom in that scenario. You can see that a lot with nutritional supplements for things like preeclampsia. I’ll have patients who come in quite often with Hellp syndrome and one of the things we do a lot of is we’ll give them a superoxide dismutase and a manganese supplement to help reduce the elevated hemoglobin levels. And I’ve had definitely some OBs be very against that because they don’t understand the mechanism behind why we’re saying we should do this. In their mindset there’s only one way to control this and nutrition isn’t it.

Dr Ruscio:

Right. Okay. So there’s one good example. Are there others like that, that you feel, because maybe we can just start with common misconceptions, if you will. So that if a mother or an individual is going into care, they’re armed a few of these things kind of preventatively. Because I think one of the things here that’s important is knowing this stuff ahead of time, because if something breaks, so to speak, and there’s a problem (preeclampsia what have you) oftentimes, I’m assuming, there’s a little bit of fear and a, “we gotta act quickly” sort of thing and that can make it harder for people to do research or to think. So what would you want to put proactively in people’s heads that are common misconceptions?

Sarah Thompson:

Yeah. So that’s actually a very, very, very hard question. There’s a lot of misconceptions about pregnancy, especially when it comes to the conventional medicine side. And one of those is that nutrition can’t treat disease and it really can. The other thing is that, honestly, we both know that prevention is easier than treatment. Preconception nutrition is going to prevent 90% of pregnancy complications. If we can focus on that preconception nutrition side in the immediate case, there’s a lot of things that when we look at conventional care that they don’t test.

Sarah Thompson:

And as functional medicine practitioners, we want to test, especially if we’re working in pregnancy, because there’s this misconception that it doesn’t apply anymore. One of those is progesterone. In conventional treatment, typically, we test progesterone in the first trimester if we have a history of miscarriage. But once we get past 12 weeks and the placenta starts to product its progesterone, we never test it again. And there’s a misconception there that progesterone doesn’t do anything really after the first trimester to support pregnancy, but it does. And you’ll see that serum levels of progesterone, they nearly triple by the third trimester. And one of the primary things it does is it helps to upregulate the expression of vitamin D receptors.

Sarah Thompson:

And interestingly, we see that progesterone deficiency in the third trimester and vitamin D deficiency in the third trimester can be associated with an increased risk of things like preeclampsia and gestational diabetes. So again, misconception that progesterone doesn’t do anything really to sustain pregnancy after the first trimester, but it does. It just doesn’t do anything to help support the growth of the baby at that point. And one of the things that we have to get away from in maternal care is focusing all of our attention on the growth of the baby. There is another person here and we have lost them in this system. And I’m a big believer that if mother’s healthy, baby is going to be healthy.

Sarah Thompson:

And if we focus our attention to understanding maternal physiology and some of these changes such as things like the progesterone, and we support that maternal physiology, baby is going to be just fine. But we neglect that other person. Other things we see is thyroid. Thyroid is something that—again, a misconception—is that thyroid hormones don’t matter, again, after the first trimester or at least after 20 weeks. So up until 20 weeks, the mother provides thyroid hormone to the baby until the baby can make their own thyroid hormone. And after 20 weeks, mom’s dietary intake of iodine goes to baby and then baby makes their own thyroid hormone.

Sarah Thompson:

And so there’s this misconception that at that point, thyroid hormone doesn’t matter anymore. But we’ll see that thyroid deficiency, hormone deficiency in the third trimester can affect things like labor outcomes. So one of the things that maternal thyroid hormone does is it helps to convert beta carotene to retinoic acid (vitamin A). And in the third trimester we see a sixfold increase in vitamin A, so retinoic acid receptors, in the uterus. And if thyroid hormone is not adequate enough to help convert that beta carotene to retinoic acid, or we’re not getting enough of those retinoids in the diet, what we’ll see is we have low oxytocin receptor formation because vitamin A is required for oxytocin receptor formation. And if we’re not making enough of those oxytocin receptors, then guess what happens when we produce a bunch of oxytocin from the brain—is we don’t have anywhere for it to bind and then we don’t have a functional labor experience. And our risk of cesarean.

Sarah Thompson:

So those are just a couple of examples of some of these misconceptions that we, we think these things don’t matter in pregnancy because they don’t apply to the actual, , tangible growth of the infant, but they absolutely apply to how that mom’s body is going to work throughout pregnancy and childbirth. And if we want to have, , healthy infants who get to have a vaginal birth and get that initial microbiotic initiation, that’s going to set the foundation for their gut health and their immunity throughout those first couple years of life, we have to have a healthy mom who has a healthy labor experience.

Dr Ruscio:

And let’s go into these in a little bit more detail, because there’s a lot there to respond to. So one that I think is definitely worth expanding on is iodine. And there have been a couple of studies, not in pregnancy, but that have shown that longer term—and I believe longer term was defined as two years or longer—adherence to a paleo diet was correlated to some degree of iodine insufficiency. Now I think some of this probably comes from people just avoiding iodized salt and the commonly iodized breads and dairy. So some of this might just be being a bit more proactive and educated on how to make sure you’re getting an adequate nutrient intake on the Paleo diet. But nevertheless, when looking at free living humans who are on this diet, what do they end up doing?

Dr Ruscio:

There does seem to be some degree of eating one’s way into an iodine insufficiency. So for pregnancy, of course, I could see that being even more salient, especially that a subset of this audience in particular, will be on a paleo-like diet. So what do you recommend people do with iodine? Is there a simple, “make sure you’re getting an X amount supplementally,” as a safeguard or is it more nuanced than that?

Sarah Thompson:

Yeah, I mean, there’s a lot of controversy over how much iodine is actually required in the prenatal diet. The current recommendations is 150-250 micrograms—most prenatals now have that in there, but I’m a huge fan of diet. We really do better if we get these foods or these nutrients together with other nutrients that make it work better. Iodine, zinc, selenium—those guys are all needed for thyroid function and they’re found together oftentimes in things like seafood, seaweed, fish—those sorts of things—oysters. And so I’m a big fan of trying to incorporate those things in the diet, into the prenatal diet to make sure we’re getting adequate amounts. Iodine is something I test in all of my pregnant moms, whether they have thyroid insufficiency prior to pregnancy or not. We see that maternal diets that are lower in iodine. We see more learning disabilities in infants later.

Dr Ruscio:

That makes sense. And I think I’ve seen some of that research also.

Sarah Thompson:

Yeah. So it’s something I always test to make sure that once we hit that 20 week mark, [that] mom’s giving baby enough iodine to facilitate their own thyroid hormone formation.

Dr Ruscio:

And one of the things that I believe has been mostly disproven, with some exceptions, in terms of what you eat is fish is high in mercury, therefore avoid the fish globally. Now of course, if you’re eating lots of maybe I believe sword fish and whale (I’m not sure where tuna comes down on this), but the majority of fish that one would typically eat—even though they do contain some mercury due to other nutrients that are in there also to some extent—selenium seems to have this net outcome of better brain health for the child.

Dr Ruscio:

So, this is another reason for audience, just to flag this really quick, why I harp so incessantly on looking at outcome data and not mechanism. Because the mechanistic observation of, “well fish has mercury,” is true. But if you’re not looking at what happens when people eat fish—they have smarter babies essentially, or better neurological outcomes with their children—then you could be vastly misled by the mechanistic observation. But is there any more granularity you can give in terms of types of fish that are better to focus on/better to avoid?

Sarah Thompson:

Yeah. I’m a big fan of oysters. I’m a big fan of sardines. Shrimp is actually a really good one for iodine as well. We do talk a lot about tuna. Tuna does have some iodine in it, but those other ones that I mentioned actually have more per serving. Chicken eggs actually have quite a bit. I think a single chicken egg has anywhere from 75-100 micrograms depending on the quality of that egg. Seaweed’s my other big one. So a single sheet of kombu [seaweed] has 2,500 micrograms.

Dr Ruscio:

And I believe oysters are also high in copper.

Sarah Thompson:

They are high in copper and we need extra. I mean, you’ll see, oh, I’ve used this example before, but copper levels bump up a couple times throughout pregnancy and we’ll see that copper is needed for a number of different enzymatic reactions needed for the doubling of blood volume and a number of things. Copper’s a great, great something to focus on in the diet when pregnant as well.

Dr Ruscio:

Now coming over to progesterone for a moment, what would one do to bolster progesterone levels? Or how do you look at that?

Sarah Thompson:

Sure. Well, again, preconception nutrition (preparing for this originally) really does set you up for better success in pregnancy. Like vitamin E, vitamin A in the diet are really important for how progesterone functions and how we make progesterone. We know there are many, many studies that link vitamin E deficiency and supplementing with vitamin E with changes in progesterone levels in the bloodstream. There’s just not a lot of information on how, what’s the mechanism of action behind how vitamin E affects progesterone. But it is something we do talk a lot about in the preconception diet for women who’ve had progesterone issues in the past. If we’re looking at an acute scenario where we’re in the third trimester and that progesterone level really needs to be close to 200 nanograms per milliliter and we’re really under a hundred, at that point, it becomes like supplementing with progesterone to bring that level back up.

Sarah Thompson:

Something is amiss in the way the placenta is producing progesterone. Maybe it was a zinc deficiency that happened early on and we’re seeing issues with the enzymes that go into that production. It could be vitamin D deficiency. We’ll see that vitamin D is really important for side-chain cleavage enzyme to take your cholesterol and turn it into prednisolone, to turn it into progesterone. We’ll see that being associated with lower progesterone levels in that third trimester. So that’s an interesting one, where you’ll have vitamin D deficiency being associated with low progesterone and low progesterone being associated with low vitamin D receptor formation in the placenta.

Dr Ruscio:

Gotcha. Okay. So it makes sense. You’re going to start with the furthest upstream, ostensibly nutritional, and then depending on how that goes, you’ll consider some sort of, I’m assuming, a biodentical HRT.

Sarah Thompson:

Yeah. Yeah. And sometimes that works. Sometimes we end up having to go the prescription route.

Dr Ruscio:

Gotcha. Okay.

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Dr Ruscio:

Okay. So we talked about progesterone. And thyroid is also one where we’ve been fairly critical on the podcast and at the clinic of how some of the wing of functional medicine has gone too far with, almost at this point, giving out thyroid hormone like PEZ. But there is definitely a line of evidence—and I think we’ve been pretty good about calling this out—that using subclinical hypothyroidism as the example that this mildly elevated TSH, [there is] pretty good data showing that for the majority of cases this will spontaneously remit and they don’t benefit from a thyroid hormone supplementation. But there’s one exceptional case, which is pregnancy.

Sarah Thompson:

That’s right.

Dr Ruscio:

And there’s also some signal that if you have elevated antibodies that you may want to go on hormone replacement. Although I believe the data there is a little bit more mixed and there may have been even a recent meta-analysis (I’d have to double check on this) that found no benefit in those who just had Hashimoto’s and were pregnant in terms of preventing miscarriage or preterm births. Again, I may be misciting that, but…

Sarah Thompson:

No, you’re spot on.

Dr Ruscio:

Okay. So there’s definitely a clear trend for subclinical hypothyroidism. So I’m glad you bring this up. And tell us a little bit more about how you intervene here. Is this fairly straightforward? Most endos catch this? I mean, I would think I would hope most endos do.

Sarah Thompson:

No, they don’t. So OBs and midwives, and even some endos, don’t catch this and they don’t catch it early enough. And I have seen more cases than I’d like to admit, where we look at thyroid and—say they’re coming to me for things like recurrent miscarriage—and they’re losing babies in that first trimester. And outside of pregnancy their thyroid looks great, it doesn’t hardly even look subclinical, but when they become pregnant that’s when it that’s when it rears its ugly head. And what happens is in the first trimester HCG being produced by the embryo hijacks, the thyroid. HCG looks very similar to TSH and it binds to TSH receptors. And when that happens, we get an increase in T4/T3 output. What should happen in the first trimester is regardless of what that preconception TSH was, first trimester TSH should go down. And it should go down because the HCG is actually binding to the thyroid and stimulating the production of T4 and T3.

Sarah Thompson:

So anytime we see a rise in TSH in the first trimester, that’s a problem. And we see studies that show that anything over a 2.5 is a big problem. And your risk of miscarriage goes up. And most fertility doctors monitor this very, very closely simply because they see that this rise in TSH means that their IVF transfers don’t make it.

Dr Ruscio:

Mm. So is it fair to say that…Let’s say [general practitioner], endo, it’d be disappointing if an OB wasn’t familiar with literature showing that the level of elevation being above 2.5 is problematic. Although maybe to play devil’s advocate here, is there not enough consensus in the data and is this maybe a more subtle trend? What would the devil’s advocate position be? Especially, I think if someone’s going to go into a clinical visit and have this discussion with their doctor, let’s give them both sides. So what’s the counter argument and what’s your rationale?

Sarah Thompson:

Yeah. So I think part of it is that a lot of conventional medicine physicians are still following the old protocols. And so the Endocrine Society put out a bulletin and they changed the reference ranges for TSH in the first trimester to 0.2 to 2.5.

Dr Ruscio:

Good.

Sarah Thompson:

And a lot of people haven’t followed suit and, I think, haven’t done their continuing education to stay up to date on that. If that makes any sense. So there are definitely bulletins out there. The endocrinologists, fertility doctors they tend to be, like I said, up to date on this. But I’ve been surprised by some of the pushback from OBs and CNM midwives, where they just aren’t up to date on that. And it sucks because I think we could prevent a lot of recurrent miscarriage if we caught this earlier. I have a patient right now, she had to get a referral from her OB to an endocrinologist to get some thyroid medication because her TSH jumped up from a 1.7 to a 2.7 and she’s six weeks.

Dr Ruscio:

And are you finding that endocrinologists are more current with some of the consensus guidelines and the updates?

Sarah Thompson:

Yeah. And I’m finding that more international endocrinologists are even more so. So I work with patients all over the world and I, sadly, feel like here in the states we are less up to date on these newer guidelines than say the physicians in Canada or the physicians in Australia, where they do see this and they do make changes to their protocols and their medication protocols for patients.

Dr Ruscio:

Interesting. Any idea as to why that is? Is it the system here is more conducive to clinicians being overwhelmed with the high visit density?

Sarah Thompson:

It could be that for sure. I mean, we know that, as of 2020, there was a 60% estimated burnout rate amongst physicians. I think they are overworked. They don’t have the time allotted to really look into a lot of this stuff. Let alone the time to doing continuing education, if you talk to them.

Dr Ruscio:

Yeah. Well, just as a little bit of an aside, but as a plug for the clinic, this is why I’m so exceedingly proud of the fact that we have a dedicated research staff. And and a big thank you to Gavin, because him and I have been really teaming up and he’s been doing a lot of work staying current with—we have this weekly digest, the FFMR Plus, where essentially an hour of reading every day, going through this litany of topics that we have PubMed saved searches. So we get sent an abstract every time there’s a paper published on about 15 different things. And someone has to go through that and throw out all the studies that are kind of irrelevant, let’s say cancer care, (not our area). Okay, we’re going to throw those out.

Dr Ruscio:

But for the things that are relevant, we’re going to look at those and then we compile those into a digest. And they’re also used to periodically update how we’re practicing at the clinic and making sure that we don’t miss guideline updates like this, but it doesn’t happen without a lot of work. And I have a soft spot my heart, as much as I’m critical of doctors not doing a good job, I also understand it’s sometimes hard, especially if reimbursements are going down (especially if you’re in the insurance model). And it’s becoming more and more challenging. So, anyway.

Sarah Thompson:

I’m right there with you. I come from a family of physicians, some of my best friends are physicians, and we have these conversations all the time about the reality of what they’re expected to do in practice and the limited time. And that’s why they need people like us to collaborate with and to be in partnership with, because they can’t do it all. We can’t expect them to do it all.

Dr Ruscio:

Yep. No, this is a great point and I’m so happy you shared this specific guideline, for myself also, of 2.5. We don’t go deep enough into pregnancy care for this to be something that comes up on our radar screen. But knowing this now gives me one more piece when—and this is the scenario that we typically see—where we’re working predominantly with people for GI care, but in some cases also, of course, thyroid when they go into pregnancy. That’s when we kind of go into maintenance mode again, because it’s not our area.

Dr Ruscio:

I do know what therapies, from a GI perspective, we can and cannot use while they’re pregnant. But outside of that, it’s really a, “let’s defer to your Endo/OB.” But now I’m going to make sure patients are better about following up with their Endo if there’s any thyroid issue going on. And I’ll make sure to pass along a note, “be diligent in your TSH assessment because above 2.5 may indicate the need for hormone.” And this is probably something best bounced off your Endo. And do you say that’s the appropriate way to package this up and hand it over to a patient to go forward with?

Sarah Thompson:

Yeah, absolutely. Absolutely. And it’s understanding if you have patients who have this hypothyroid/subclinical hypothyroid pattern preconception, making sure that they aren’t iodine deficient…checking for things like Hashimoto’s. And, you brought up, the controversy and the mixed study results when talking about using things like Synthroid and Levothyroxine with Hashimoto’s patients in the first trimester.

Sarah Thompson:

And it’s interesting because the formula of thyroid hormone used makes a big difference. So a lot of those medications are higher ratios [of] T3 to T4. And T3 doesn’t pass the placenta. So it’s best with a T4 because then the placenta actually converts T4 to T3 and uses it.

Dr Ruscio:

I’m so glad you asked that. That was one of the next one or two questions I had, which was for Hashimoto’s, things like selenium I know have been studied in pregnancy and shown to be safe. And I believe this is a model of actually Graves, trying to prevent the ophthalmal path (or eye damage) in those who are pregnant and had Graves and the children had no deleterious effect[s]. I don’t know if there’s any benefit for the children per se, but there’s one simple, safe intervention of selenium for Hashimoto’s. And then I was going to also pose a question of there there’s a lot of chatter, especially in functional medicine about T3, T3, T3. And I do think there’s a time and a place for that. I think it’s fairly over-stated in terms of how often we need to be concerned with T3. But I’m so glad you made the point that in pregnancy, specifically, “you always need combination T4 plus T3,” isn’t going to carry over into this realm and people are better off going with a T4 formula.

Sarah Thompson:

Right. Right. And I think that’s why the studies show that mix where just because they’re giving a Levothyroxine it doesn’t always mean it saves the pregnancy and we still have that risk of miscarriage because it’s not actually getting to the fetus.

Dr Ruscio:

And so the T4 does and the T3 does not?

Sarah Thompson:

And it has to do with the way the placenta itself converts T3. So the placenta makes its own Deiodinase enzymes.

Dr Ruscio:

So it wants the precursor, not the end product.

Sarah Thompson:

It wants the precursor. Yep. And the T3 can’t pass through.

Dr Ruscio:

And that actually makes at least some degree of sense in terms of maybe this is a way that the placenta has the ability to—if the mother is going into stress and there’s perturbations in T3—[it] can kind of take what it wants (the T4) and not get pulled into some of the T3. That’s more perhaps serving the mom, than it is a placenta.

Sarah Thompson:

Yep. It’s kind of a protective mechanism.

Dr Ruscio:

Yeah. That makes sense.

Sarah Thompson:

First trimester you’ll see increased reverse T3 and then you’ll see serum iodine levels do bump up there, simply because we’re breaking an iodine off of T4 and putting it into the system. There are some interesting studies that talk about like higher levels of thyroid hormone output being associated with morning sickness. And it’s actually an increase in serum iodine causing some of the morning sickness symptoms.

Dr Ruscio:

Interesting. So another reason maybe not to be too bullish on the iodine supplementation and focus on food sources.

Sarah Thompson:

Exactly. Yeah.

Dr Ruscio:

Okay. What about fish oil? I’m assuming this is a supplement that you think is safe and okay for mothers to be using? But I don’t want to assume too much.

Sarah Thompson:

Yeah, I do. For the most part, I don’t like isolated DHA supplements. But in combination, just like a general fish oil that has EPA and DHA? Yes.

Dr Ruscio:

Okay, great. Great. Yeah. And if someone does have Hashimoto’s—to make sure we close that loop—food sources, supplementation, where do you come down in terms of [for a] Hashimoto’s positive mother, what do they do?

Sarah Thompson:

So typically with my Hashimoto’s patients, I mean, obviously I want to catch them earlier so we can bring those antibody levels down as much as we can prior to pregnancy. But we tend to do the gluten-free, dairy-free diets, just because we see in studies that does help to bring down TPO antibody levels. Usually it’s doing things like that. If we didn’t do our due diligence pre-pregnancy to identify if we have food triggers or we have latent viruses that are reactivated parasites, those sorts of things that could be triggering some of this autoimmune reaction, we’re kind of just managing it until postpartum when we can really diagnose it correctly.

Dr Ruscio:

Gotcha. Gotcha. And that opens up the gut health discussion. The can of worms, I guess you could say, in some cases. What are some of the mainstays of what you recommend for keeping a healthy gut, healthy microbiome, I guess, both for mother and for child?

Sarah Thompson:

Yeah. Like you I’m a fan of probiotics. I think they help in many, many ways. But we see that changes in the gut do happen in pregnancy and some of it’s normal and some of it is not normal. But the hormones themselves do affect the microbiome of the gut and it changes just the gut motility in and of itself. So it just depends on, again, that preconception health of mom. If mom’s prone to things like SIBO and as her progesterone levels go up, she’s more prone to constipation, which might flare up a relapse of SIBO and those sorts of things, we want to keep her gut moving and we do that with whatever we can. Maybe it’s a MotilPro, maybe it’s a magnesium supplement, prunes, whatever we can do to keep things moving so we don’t get a backup in the system.

Dr Ruscio:

Gotcha. Okay. So probiotics supplementation. I’m assuming also of probiotics from food. Some sort of motility support, magnesium, MotilPro… Anything else for gut health? And I think those are actually really good places to start. Low FODMAP, how about that? That’s one that seems to be a helpful intervention for some, because we can’t do too much in the antimicrobial camp. There’s some that we can do, but I’d rather not go too, too far down that avenue while a mother is pregnant.

Sarah Thompson:

Yeah. And I’m kind of with you. So I mean, good health is ridiculously important for both mom and for baby at birth. Mom needs a good microbiome to pass on to baby. And if it’s not a good microbiome at birth, then baby gets maybe a mix of some of negative probiotics in there or negative microbes in there and not enough of the good probiotics. Things like GBS, we know that passes from mother to daughter and those sorts of things. But there’s only so much we can do in pregnancy. And it becomes a management-type scenario and less of a treatment strategy.

Dr Ruscio:

Yeah. Yeah.

Sarah Thompson:

Like you said, there’s a lot of those antimicrobial agents we just can’t do in pregnancy. And ideally we help moms before they get down this road.

Dr Ruscio:

Yeah. And I also think this is a good time to be supportive of the system. So something like a low FODMAP diet, it depends on how you’re going to label or vilify a low FODMAP diet. There’s still some remnants of, “you got to feed your gut bacteria and if you don’t, you’re going to kill yourself,” sort of mentality that still have a hard time accepting all of the merits of a low FODMAP diet. Not to say it’s something that we want to be on ardently forever, but it has been shown to reduce leaky gut, reduce symptoms, reduce inflammatory cytokines. So if this is something that is soothing and feels good to a mother, I look at that as a supportive intervention. As I do probiotics. But something like high-dose concentration of a oregano oil or Rifaximin or what have you, I mean, you could, but it seems a little bit outside of how we’d want to intervene with the system at that point in time. And I like how we’re on that same page philosophically.

Sarah Thompson:

Yeah, absolutely. I agree with you a hundred percent. There’s just a time and a place for it and that’s not the time and place. Yeah.

Dr Ruscio:

Now one thing that can help with motility also is movement, exercise. Anything in particular here that you think mothers should be aware of?

Sarah Thompson:

In movement and exercise?

Dr Ruscio:

Yeah. During pregnancy, are you avoiding a certain amount of intensity? I’ve seen certain movements that are supposed to help keep the baby from crowning or whatever, but I know very little about this. So I would love to have you walk me through it.

Sarah Thompson:

Yeah. Exercise is a personal thing. Like we kind of have the general rule of if you did certain exercise—if you were a runner, for example—prior to pregnancy and you want to run through pregnancy, unless we see a reason why not, go for it. Does that make sense?

Dr Ruscio:

It does.

Sarah Thompson:

It’s not the time to start a new exercise regimen. People who are prone to cortisol issues, we may take a closer look at how they’re exercising simply because cortisol plays a huge role in everything pregnancy. And if a woman is prone to adrenal issues, we have insufficiency, they came into this without very much cortisol, and we know that cortisol changes or increases 500% throughout pregnancy (and it does it for darn good reasons), we can’t have her doing a ton of strenuous exercises that are going to deplete her cortisol and stress her body. We need her doing more yoga, meditation-type exercises. Go for a walk, less running, less weight lifting, less CrossFit, that kind of stuff. Other way around, if we have people who are high cortisol, very stressed, they may actually do better with going and releasing some of that cortisol.

Dr Ruscio:

Yep. That makes

Sarah Thompson:

Because too much cortisol and we see things like preterm labor and we don’t want that either.

Dr Ruscio:

Right.

Sarah Thompson:

But we need that cortisol to do things like ripen the cervix. We have to have cortisol in order to change the cervix in preparation for labor. And so that becomes, again, very important for that labor process, which then helps that infant have a better success in life if we can have a nice vaginal delivery.

Dr Ruscio:

And you’re thinking if someone has a fair amount of relational or work or life stress, exercise that is a little bit intense might be more beneficial in that case to have this stress-adaptive response? Or how would you look at that?

Sarah Thompson:

Yeah. And it, again, it depends on the individual person, for sure. Some people do good with that if they are overwhelmed with stress, if they’re in a toxic relationship during pregnancy, or those sorts of things. But [for] other people, it’s too much and they’re better off hanging out and relaxing and doing more meditative type exercises like yoga.

Dr Ruscio:

Gotcha. But then there might be some people for whom if they go for a run or do whatever they feel like they’re de-stress and they feel overall better. Okay. So this seems—like so many things—are just: listen to the person and that will help you determine the path forward for them.

Sarah Thompson:

Yeah. Yeah. Everything within functional medicine is, “differentiate ’til you’re dead,” is what I joke. You want the person in front of you not to have a generic protocol because it’s not going to work for everybody. So in my opinion, you can’t just say, “oh, the best exercises for pregnancy is this, this and this,” because it’s variable based off of the person in the room and that person’s life, that person’s history, their physical and mental health, their nutritional status. There’s a number of things that go into what’s going to work for them, what isn’t going to work for them.

Dr Ruscio:

And like we so often preach at the clinic, we have a suite of therapies on offer. We want to personalize those to the individual. And it’s not to say, “well, we can’t give you anything until we do a test.” I do think over-testing is a huge problem in the field. Some testing can definitely be helpful. But more so here’s the evidence-based and evidence-guided therapies that we have—they don’t all work for everyone or are all a good fit for every person all the time—but what we can do is listen to you and then, like how you said, differentiate or personalize until you’re dead. Or until you really find the ones that are going to be the best fit for the person.

Sarah Thompson:

Yeah. And I always joke that’s one of the best things that I got from my TCM education (as in traditional Chinese medicine). [If] somebody comes in with a migraine, well, we have eight different patterns of migraine and it’s figuring out to a minute detail, what is the pattern that they’re presenting with? And that’s how we treat it.

Dr Ruscio:

Love it.

Sarah Thompson:

And I always joke TCM was functional medicine before functional medicine was cool because of that aspect. And there’s a lot of things that we look at in functional medicine and we can apply it to TCM. Again, I joke, I think cortisol is Chi. Because of all the functions of cortisol and all of the different types of Chi that we see in traditional Chinese medicine, everything from things like lung qi, which is supposed to be your immune system. Well, what does cortisol do for your immune system? We see these patterns mimicking some of the descriptive patterns that we talked about in TCM.

Dr Ruscio:

Yeah. That makes sense. Yeah. And I think functional medicine has stood on the shoulders of many disciplines to offer up, when it’s done correctly, this really integrative and multidisciplinary sort of offering for patients.

Sarah Thompson:

Yeah. I agree.

Dr Ruscio:

One area that can be confusing, I guess, and maybe overwhelming, is toxins. Because there can be toxins in your perfumes, your shampoos, your cosmetics, your fragrances for scented candles, the food that you cook—what it’s kept in? Is it glass, is it plastic? Are you using Teflon? And it would seem prudent to do whatever you can within reason to weed out the low-hanging fruit items, that seem to be fairly well agreed upon. Like don’t microwave your food in plastic every night. Seems reasonable. Are there any items that you think are fairly relevant as it pertains to pregnancy?

Sarah Thompson:

As far as toxins go?

Dr Ruscio:

Yes.

Sarah Thompson:

I think any of the plastics, the endocrine disruptors, they have the propensity to change hormone levels and hormone functions. And again, pregnancy is a super unique time in life where our hormones do the most crazy things and these toxins, more than anything, I think, they affect placenta. We see studies that talk about measuring toxins in the placenta and cord blood after birth. And it really does a good job of filtering and holding these toxins to prevent them from getting to the baby. Which, I could go down the rabbit hole of the eating placentas, encapsulating placentas, and my take on that, because of the fact that the placenta does accumulate so many toxins.

Sarah Thompson:

But what we’ll see is that these toxins actually end up affecting the placenta and how the placenta functions slightly more than it does the mom during pregnancy. And if we have a placenta dysfunction, well that causes a cascade of issues throughout the system. The placenta is responsible for everything in pregnancy. It’s what’s taking the hormones from the fetus itself—things like cortisol and DHEA and other precursors—and turning it into things like progesterone and estrogen, and stimulating the different things from the cervical ripening and all these different changes that have to happen on an internal level.

Sarah Thompson:

And if we have placental dysfunction, then we are more prone to things like preeclampsia, we’re more prone to things like small for gestational-age babies, and intrauterine growth restriction, and those sorts of patterns that we’ll see being highly associated with things like oxidative stress in the placenta, which can be caused by things like these heavy metal build ups and toxins in the system.

Dr Ruscio:

Mm.

Sarah Thompson:

Do I measure for toxins ever? No, not really because you can’t do much about it once we’re in pregnancy. Again, these are like a lot of these things we’re talking about today are these really great functional medicine ideas and test options that are really good preconception. Once we’re pregnant, it becomes sometimes management of those things, more so. And understanding the physiology, for sure, to make sure we’re supporting the maternal physiology and those things correctly, knowing what we have coming into the system.But we’re limited on what we can do.

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Dr Ruscio:

And I’m assuming that eating organic is something, maybe, that you’re not adamant about but you’re making the recommendation to do as best as one can?

Sarah Thompson:

Absolutely. Yeah. And I work, again, with patients all over the world. I work with patients that are in food desert areas and eating organic is not an option for them. And so we’re focusing a lot on, “okay, we need you to have vitamins and minerals at this point. We need you to have these components, these phenols, these arotenoids—all these things for your body to function at this point—so we can sustain you and your baby through this pregnancy. So that you don’t come out of this pregnancy with complications that are going to follow you the rest of your life and we get your baby at a place that we are giving them the best start to life that we can with what you have.”

Sarah Thompson:

And for some people organic, isn’t an option and that’s okay. We’re going to do the best we can with what we have. And sometimes that’s what it is. We’re looking at canned vegetables, we’re looking at what’s in the freezer at their local market, and coming up with, “here are the nutrients you need right now, based off what you’re presenting as. Here’s where you can get them.”

Dr Ruscio:

Hmm. One other question I wanted to ask, I’m thinking of a few friends of mine who had the joy of going through pregnancy during the COVID pandemic. And there was definitely a trend where I noticed some of my friends’ wives just seemed to be paralyzed by fear and were just unable to really think critically. I remember having a conversation and some guideline had come out from the CDC showing that pregnant mothers were at little risk, children were at very low risk, and there was this, “well, there was one case where a kid died in Arkansas.” That’s kind of like my mom sending me the snippet of the person who got in the car accident and telling me to put on my seatbelt when I was like seven, because someone somewhere died in a car accident recently—and just totally devoid of any kind of larger statistical risk. Now, not to say that that is the case, but from what I’ve gathered, children are at low risk. I don’t know what the consensus is on during pregnancy, so maybe there is something that’d be concerned with. But [I’m] wondering what thoughts here you’d want to share with people.

Sarah Thompson:

Yeah. It’s interesting. And we see, I think, very similar outcomes with moms who had COVID and moms who’ve had any other viral infection. We’ve known that the flu, in and of itself, has been known to cause things like small-for-gestational-age babies and stunt-growth of babies. And we saw the same thing with moms who got COVID. Not all of them, but some of them. I have a case in particular where a mom of mine got COVID, and I think it has to do a lot with support and treatment, and nobody gave her anything. There wasn’t anything that they could do for her. And she ended up getting a huge gut component to her COVID case. And she was vomiting all the time.

Sarah Thompson:

And we saw her post-COVID. Her baby didn’t grow during those two weeks she had COVID. So her baby was now two weeks behind. And this happened earlier in gestation, it was 14-16 weeks. And so her baby was measuring at 16 weeks when she went in for her 20-week checkup. And they gave her a very, very poor prognosis on if that baby was going to make it. And it was purely nutritional in her case. And with things like nutrient IV and proper nutrition and making her eat things that she really didn’t want to eat—like a dozen eggs day—we were able to get baby’s growth back up. And that was something we saw with quite a few of our patients. She was the most extreme case who got COVID while they were pregnant. There was this small reduction in growth of the babies during that timeframe that they were fighting the virus.

Dr Ruscio:

What a great resource to have someone like you just to be able to talk a mom through this, because in my friend’s wife’s defense, I can see her wanting to protect her baby with her claws and fierceness to whatever extent that she can. I guess it just depends, if you don’t have anywhere to direct that energy, you can end up in a very fearful place. And, again, just having a resource like you to maybe come to with that fear and anxiety and then have you redirect that to something productive like, ‘Hey, let’s eat our way out of this sort of thing,” is just beautiful.

Sarah Thompson:

Well, and that’s a lot of what we do with maternity functional medicine. As a lot of what we’re doing is, we have a small window of time to make change. It’s not like outside-of-pregnancy functional medicine where we have sometimes years to work with people to get them to where they want to be in health. We can do all this really cool testing. We can check for all these really neat things. Well in pregnancy, things are changing every couple of weeks. And so, in order to be a very dynamic and very accurate functional medicine practitioner, if you’re going to work with pregnancy, you have to understand all these different changes that are happening in the maternal physiology at each of these gestational weeks—because it’s very different—and be able to react more acutely. And sometimes what we’re doing is a little less what we would really hope to do preconception and a little more acute crisis management. Such as things like this, where I had her drinking 16 ounces of milk every meal and eating a dozen eggs a day.

Dr Ruscio:

Yeah. Well that sounds like a fairly tall order but I guess, if given the right rationale, yeah. I mean, you can put down, I guess, four eggs over three sittings. Not, not too crazy.

Sarah Thompson:

Yep. And it’s again, I joke, “eggs have everything you need to grow a baby.” They have a lot of good nutrition in them. And with the dairy aspect, what we were doing is we were supplementing a hormone called basically insulin-like growth factor. Dairy’s chalk full of insulin-like growth factor. Outside of pregnancy, we’re afraid of it. Right. Especially if we’re looking at women who have things like PCOS that can stimulate growth, we know insulin-like growth factors associated with other tissue growth such as endometriosis, cancer cells, that kind of stuff. Well, in pregnancy, the placenta produces its own insulin-like growth factor and it increases throughout pregnancy. And it’s just part of that natural maternal physiology. And what we’ll see is, actually, you can test placental insulin-like growth factor levels in different stages of pregnancy and assess placental function. Because it should be at a certain level. It should be elevated. And if it’s not, it means the placenta isn’t doing what it’s supposed to be doing. And we see that a lot being associated with, again, preeclampsia, but also small babies.

Dr Ruscio:

Yeah. That that’s brilliant. I had no idea that you could have that impact with dairy. I knew of the insulin. I didn’t know it was an insulin-like growth factor in addition to the insulin. But I believe they’re kind of one-in-the-same, so that makes sense. Well, Sarah, this has been fantastic. I feel like I could talk to you here for another hour to go through even more of this, but in respect of your time, let me ask you where people can find you on the internet and connect with you or find some of your work.

Sarah Thompson:

Yeah, absolutely. So my book, “Functional Maternity: Using Functional Medicine and Nutrition to Change Pregnancy and Pregnancy and Childbirth Outcome,” is available on Amazon. And you can order it through your favorite local bookstore. My website is functionalmaternity.com. Or you can reach me at thesacredvesselacupuncture.com, which is the clinic website. And then on social media we are @functionalmaternity.

Dr Ruscio:

Awesome. Well, again, Sarah, this has been a just fantastically refreshing conversation in terms of a whole lot of utility. Nothing that seemed to be too crazy in terms of bells and whistles or elaborate hoops that you’re asking moms to jump through. So as someone who wants to see the functional field move more in this practical and pragmatic direction, just very much so appreciated everything. And I know what book and who I’m going to call for when this is the chapter in my life, that I’ll be segueing over to. So again, just a great conversation, and I really, really appreciate it.

Sarah Thompson:

Yeah. I appreciate your time today. Thank you for having me.

Dr Ruscio:

Yeah. Thank you.

Outro:

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