Speaker 1: Welcome to the Kick Your Expert led podcast, helping you
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Speaker 1: a parent.
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Speaker 1: Welcome everyone. I'm Bridget Maloney.
Speaker 2: And I'm obstetrician doctor Patrick Maloney.
Speaker 1: And today we've got a really important podcast to share
Speaker 1: with everybody.
Speaker 2: I think, yeah, recurrent miscarriage is a such a big
Speaker 2: topic within obstetrics. It's such a heartbreaking problem for a
Speaker 2: couple to have. And the interesting thing is that the
Speaker 2: Australian guidelines have just been redone on this topic to
Speaker 2: give us perhaps a more certainty on when we're supposed
Speaker 2: to intervene and what tests are of high value to do,
Speaker 2: and hopefully how we can help people move on from
Speaker 2: our current miscarriage situation to having the family size that
Speaker 2: they desire.
Speaker 1: As we go through the guidelines, it will sound like
Speaker 1: where I read them and thought well, they're kind of
Speaker 1: hedging their bets.
Speaker 2: A little bit.
Speaker 1: Yeah, but can you just describe to the audience what
Speaker 1: are guidelines for and who has developed these guidelines.
Speaker 2: Yeah. So these guidelines are developed by RAN's COG with
Speaker 2: the Australian og College and it's a worthwhile thing to
Speaker 2: do to produce guidelines. It's important that we remember that
Speaker 2: that's all they are. They're guidelines. They're not the law
Speaker 2: that you must intervene at this point or you must
Speaker 2: do these tests. One thing when they produce guidelines is
Speaker 2: that they tend to look at things that have already
Speaker 2: been done in the past, such as a certain test,
Speaker 2: and rate it on the evidence behind actually doing that.
Speaker 2: And sometimes the evidence for something that we've always done
Speaker 2: turns out to be pretty disappointing, and there are a
Speaker 2: couple of potential explanations for that that we have to remember.
Speaker 2: So if a test has very little evidence that it
Speaker 2: actually helps, that just means that the evidence is not there.
Speaker 2: It doesn't mean that it doesn't actually help. It might
Speaker 2: actually be good, but the evidence does not exist to
Speaker 2: say this has been proven to help.
Speaker 1: And I read a lot of them are based on
Speaker 1: the findings of an RCT or a randomized control trial,
Speaker 1: just really quickly, what is that?
Speaker 2: Yeah, So these guidelines always rate a current practice in
Speaker 2: terms of how much evidence there is behind it. And
Speaker 2: there's a scale from excellent evidence, which would be a
Speaker 2: really well constructed, really big randomized control trial where we
Speaker 2: yet half the people with the problem to agree to
Speaker 2: have treatment x and half the people that have the
Speaker 2: problem to agree to have treatment why, and look at
Speaker 2: which group does the better? And obviously we have some
Speaker 2: of those in obstetrics, some really really well constructed ones,
Speaker 2: and lots of what we do in medicine obstetrics is
Speaker 2: no exception. We're looking at evidence way less persuasive than
Speaker 2: a double blinded randomized control trial. So sometimes it might
Speaker 2: say that the evidence behind course of action ABC is
Speaker 2: nowhere near A level evidence. It might be Z level evidence,
Speaker 2: which is just it's the way I was taught by
Speaker 2: my professor Will as a student.
Speaker 1: Yeah, And it's anecdotal and observation.
Speaker 2: Yeah. Yeah, the last time I did this at work,
Speaker 2: therefore I did it the next time.
Speaker 1: It worked again treatment. But it's not a sample size
Speaker 1: that has any you know, real high clarity or high
Speaker 1: level of evidence.
Speaker 2: Absolute, So Whilst we should be Whilst we should always
Speaker 2: be reaching for better levels of evidence in our medical practice,
Speaker 2: we also have to remember that sometimes we have to
Speaker 2: make a decision to do something or not do something,
Speaker 2: and the evidence may be lacking, and then we're going
Speaker 2: to or high grade evidence may be lacking, and then
Speaker 2: we kind of accept whatever evidence there is, remembering, of course,
Speaker 2: there's no randomized control trial that says you could you
Speaker 2: should go to hospital if you cut your legg off.
Speaker 2: And yet it seems like a good idea. Okay, so
Speaker 2: we don't do nothing just because we don't have an RCT.
Speaker 1: So in some circumstances, an RCT may not be approved
Speaker 1: by ethics either, yes, it's actually going to do harm
Speaker 1: to their control group.
Speaker 2: That's right. It might be that you just can't get
Speaker 2: such a study up and going. It might be that
Speaker 2: ethics would never approve it. It might be too much
Speaker 2: to ask of people to be randomized. Often at the
Speaker 2: start of a randomized control study, when you're approaching someone
Speaker 2: to be part of it, we've got two treatments. We're
Speaker 2: trying to work out which is the best one, and
Speaker 2: sometimes the post will just give me the one that
Speaker 2: you think really works, and well we don't know. That's
Speaker 2: why we're doing the trial.
Speaker 1: Good, all right, well let's get into it. I think, firstly,
Speaker 1: how is rans COG now defining what a recurrent miscarriage is?
Speaker 2: Yeah, so that's tightened up a lot, and that's that's
Speaker 2: that's of interest. So we used to really define a
Speaker 2: recurrent miscarriage and certainly intervene when somebody had had three
Speaker 2: in a row. So three early pregnancy losses less than
Speaker 2: twenty weeks in a row, and we would we would
Speaker 2: attach more significance to say, someone who lost an otherwise
Speaker 2: normal pregnancy at fifteen weeks, to somebody who had a
Speaker 2: positive pregnancy test at five weeks and then it was
Speaker 2: gone a week later. But still it was three in
Speaker 2: a row. And now they're saying that we should be
Speaker 2: considering it a recurrent miscarriage hit situation. If a woman's
Speaker 2: lost two pregnancies under twenty weeks under any circumstances, not
Speaker 2: necessarily in a row.
Speaker 1: Gosh, that's a big change, isn't it.
Speaker 2: Yes, so it would it would capture more people, It
Speaker 2: would encapsulate a greater group of women, some of whom
Speaker 2: had been previously told that they didn't reach the criteria
Speaker 2: to have the tests that have.
Speaker 1: Further investigations, and like, if you're thinking about three consecutive miscarriages,
Speaker 1: might have taken that woman a few months to get
Speaker 1: pregnant in the first time, so that in the first place,
Speaker 1: so that could be a few years.
Speaker 2: Yes, yes, and so on the one hand, with the
Speaker 2: old system, we must have been telling some people who
Speaker 2: had a significant issue, don't worry, just try again, and
Speaker 2: they may actually get the necessary tests earlier with the
Speaker 2: new definition. On the other hand, surely with the new
Speaker 2: definition will be investigating some people who don't have much
Speaker 2: wrong with them and would have conceived normally if they
Speaker 2: just tried again.
Speaker 1: Yeah. And this definition is a bit different wherever you
Speaker 1: are in the world. I did see that Europe it's
Speaker 1: a loss of two or more pregnancies, but in the
Speaker 1: UK it's a loss of three or more first trimester losses. Yes,
Speaker 1: all right, before we go on, Patty, can we just
Speaker 1: very basically talk about what does the research say that
Speaker 1: causes recurrent miscarriages?
Speaker 2: Yeah? That's the question at the heart of all of this,
Speaker 2: isn't it. Because if only we knew most of the
Speaker 2: cases we don't identify. Course and that makes guidelines difficult,
Speaker 2: But there are some known causes. It's very relevant maternal
Speaker 2: and paternal age, some lifestyle factors like alcohol and smoking,
Speaker 2: The woman's obstetric history is quite relevant. Medical maternal medical
Speaker 2: conditions like diabetes or hypothyroidism known to be relevant in
Speaker 2: particular if those diseases that are there and are untreated.
Speaker 2: But plenty of cases we never identify exactly what the
Speaker 2: cause is too.
Speaker 1: All right, so someone's just come in and you know
Speaker 1: it's their second miscarriage. What screening tests does rang Skog
Speaker 1: now recommend that you do according to the guidelines.
Speaker 2: So there's a list, But we have to remember that
Speaker 2: this is not a one size fits all problem, and
Speaker 2: we have to remember that the tests that we might
Speaker 2: do for someone who'd lost two very very early pregnancies
Speaker 2: before there was even something seen in the uterus, you know,
Speaker 2: a five and a half week loss might be different
Speaker 2: to someone who's two losses were both at eighteen weeks.
Speaker 2: And that's important that the advice is personalized. But certainly
Speaker 2: the tests that they recommend concentrate on potentially untreated maternal
Speaker 2: Nothing we can do about maternal age or paternal age
Speaker 2: in most cases. But untreated maternal disease is important, and
Speaker 2: of course lifestyle factors are very important. So a test
Speaker 2: for maternal diabet is a test for thyroid disease.
Speaker 1: All right, So we'll get into the screening tests because
Speaker 1: that all depends on the different conditions that they want
Speaker 1: to test for, which have changed a little bit. But
Speaker 1: let's go to this recommendation, which is that in previous
Speaker 1: recommendations in recurrent miscarriages, there was a routine analysis of
Speaker 1: the pregnancy tissue. This has changed is that?
Speaker 2: Well, I think it used to be said that whenever possible,
Speaker 2: if we were doing a curate for a pregnancy loss, then
Speaker 2: if there was a chance to get the tissue that
Speaker 2: was evacuated from the uterus and send it for genetic analysis,
Speaker 2: that that would be that that was a highly worthwhile
Speaker 2: thing to do. The new guidelines aren't so fast about that,
Speaker 2: and suggests that knowing that genetic analysis is rarely important,
Speaker 2: there would be some scenarios where a genetic basis to
Speaker 2: the recurrent miscarriage was strongly suspected, where that might still
Speaker 2: be a worthwhile thing to do. But these guidelines are
Speaker 2: more in favor of a maternal and paternal carrier type
Speaker 2: where the genes of the parents are analyzed rather than
Speaker 2: necessarily going to the lengths of analyzing the genetics of
Speaker 2: the material from the miscarriage.
Speaker 1: So the next recommendation is around thrombophilia. Can we start
Speaker 1: with the definition?
Speaker 2: What is that? Yeah, thrombophilias are a group of conditions,
Speaker 2: quite a big group of conditions where the body is
Speaker 2: more likely to form a blood clot. And when I
Speaker 2: did my training, they were identifying more and more of
Speaker 2: these thrombophilias, and they were getting more and more excited
Speaker 2: about them being an identifiable cause of recurrent miscarriage and
Speaker 2: infertility and a potentially treatable cause. And in a lot
Speaker 2: of cases for these various thrombopelias, it's actually been a
Speaker 2: bit disappointing. It has not panned out quite as it
Speaker 2: was originally thought it would be. They thought they'd found
Speaker 2: the holy grail to early pregnancy loss, and unfortunately it's
Speaker 2: been a bit disappointing. Some of them have not had
Speaker 2: the association with early pregnancy loss that was predicted, and
Speaker 2: others have not had a worthwhile treatment. So whether you've
Speaker 2: got it or not, maybe there may be nothing you
Speaker 2: can do about it either way. There's a group of
Speaker 2: related there's a relate condition called antiphosphilipid syndrome where the
Speaker 2: body makes an immune response that is more likely to
Speaker 2: form clots. And antiphosphilipid syndrome does have good evidence that
Speaker 2: it's involved in pregnancy loss, and so we should definitely
Speaker 2: be testing for that one.
Speaker 1: So of those issues that caused thrombophilia, what were some
Speaker 1: of the changes in the guidelines.
Speaker 2: Yes, that they were less keen for people to be
Speaker 2: tested for conditions like activated protein C resistance, something that's
Speaker 2: caused by by a common genetic phenomenon called factor five light,
Speaker 2: and there are other conditions and protein C protein s
Speaker 2: and these were part of a handful of tests that
Speaker 2: are commonly done and should be done as part of
Speaker 2: the investigation, say of an adult with bug clot in
Speaker 2: their leg, but have not proven as useful as we
Speaker 2: thought they were going to in the investigation of a
Speaker 2: current miscarriage.
Speaker 1: Right, So you mentioned the anti phospholipid What are some
Speaker 1: of the tests that people have for that.
Speaker 2: It's a blood test. Yeah, yeah, test, and that basically
Speaker 2: says yes, I know, Okay. The reason why that one's
Speaker 2: relevant to know about is that it can there is
Speaker 2: a treatment so that particular condition. For example, if you
Speaker 2: go on to low dose aspirin and a powerful blood
Speaker 2: thinner like Colecksain, that does change pregnancy outcomes.
Speaker 1: So, Patty, you already mentioned about genetic testing, what do
Speaker 1: the guidelines say about that now?
Speaker 2: Well, they say that there's value in doing a maternal
Speaker 2: and paternal carrier type so that both both people and
Speaker 2: the couple go and have their genetics analyzed. And occasionally
Speaker 2: some people have a thing called a balanced translocation where
Speaker 2: they may have a little bit of genetic material that
Speaker 2: has broken off one chromosome and attached to another chromosome.
Speaker 2: And while that's fine for them because all the genetic
Speaker 2: material is there, when their cells goes to divide, they
Speaker 2: can wind up with the wrong amount in the sperm
Speaker 2: or the egg that they're creating. Well, and so knowing
Speaker 2: about balanced translocations is relevant, all right.
Speaker 1: So there's a place in the guideline for talking about
Speaker 1: anatomical factors. What's different there?
Speaker 2: Yeah, it's interesting. These are the ones that they thought
Speaker 2: had Some of them had low evidence, a low degree
Speaker 2: of evidence, but some of them would seem to be
Speaker 2: no brainers. For example, if you did an ultrasound and
Speaker 2: you found that Norman's uterus had a number of polyps
Speaker 2: or a big septum down the middle of it, then
Speaker 2: they're saying there's low evidence that intervening to fix those
Speaker 2: things would help. I suspect that there's an absence of evidence,
Speaker 2: not evidence that doing it doesn't help. Does that make sense? Yeah? Yeah, yeah,
Speaker 2: So in general terms, we would do simple things that
Speaker 2: would help correct the intrauterine environment.
Speaker 1: Just quickly go through what some of the common anatomical
Speaker 1: features that they're talking about in the guidelines. Ah.
Speaker 2: Yes, So they're talking about polyps within the uterus, septums
Speaker 2: within the uterus, like where there's a wall down the middle,
Speaker 2: and then other things that really change the size and
Speaker 2: the shape of the uterus like black fibroids.
Speaker 1: Yeah. And adhesions are read too.
Speaker 2: Yeah, intrauterine adhesions where the front and the back of
Speaker 2: the uterine cavity is stuck together, so called Asherman syndrome,
Speaker 2: which can be seen in people who've had recurrent previous
Speaker 2: curetes with someone with recurrent miscarriage might have had. Then
Speaker 2: that would be relevant, and you break those adhesions down
Speaker 2: and try and let a nice clean lining start again.
Speaker 2: And the other interesting one is caesarean scar niche or
Speaker 2: caesarean scar defect, and it's something really interesting. The last
Speaker 2: gynecological conference I went to there were no few of them,
Speaker 2: about five presentations on exactly this. There's definitely a phenomenon
Speaker 2: where a woman has had apparently normal fertility and she's
Speaker 2: had two or three seasons and then trying to have
Speaker 2: another baby and experiencing a secondary infertility or a secondary
Speaker 2: current pregnancy lost situation where she's previously been fined. And
Speaker 2: it's thought that the cesarean section scar might have developed
Speaker 2: a little niche or or sort of a pocket or
Speaker 2: alcove within it, and that might hang on to fluid
Speaker 2: that inhibits the healthy environment within the uterus. And there's
Speaker 2: a procedure where you can cut the scar out, make
Speaker 2: a new one start again. And like a lot of
Speaker 2: these things, the science of making the operation to fix
Speaker 2: it has surged ahead, well ahead of the evidence that
Speaker 2: suggests that that would actually help. But anecdotally it seems
Speaker 2: to be promising.
Speaker 1: So tricky, isn't it, Because like you've got clinical experience
Speaker 1: of this not just the cesareanscarnage, but like all of
Speaker 1: those anatomical issues, and you've had experience where people have
Speaker 1: had that particular surgery to move a fibrod or a
Speaker 1: poll up or something like that, and then subsequently, yeah,
Speaker 1: they're pregnant. It's really it must be really difficult as
Speaker 1: a governing body to go, Okay, well, what we're working
Speaker 1: with is people that perhaps are all different skill levels
Speaker 1: or all access to different services. We've got to make
Speaker 1: something that is the guideline. I'm going to say it
Speaker 1: for the bare minimum.
Speaker 2: Well, yes, and that's that's what guidelines really are. And
Speaker 2: it's important that we remember that if a guideline says
Speaker 2: that there is a poor a low level of evidence
Speaker 2: for a particular intervention, it doesn't mean that they're saying
Speaker 2: it necessarily should be done. They're saying that there's a
Speaker 2: low level of evidence to support it's better.
Speaker 1: Do you think they make these guidelines with any financial
Speaker 1: constraints in mind or thought in mind?
Speaker 2: I don't think so. I think the clinical practice guidelines
Speaker 2: that probably exist somewhat independently of how much these things cost.
Speaker 2: And if you look at the definition, they've tightened it
Speaker 2: up so there's every chance that this will that this
Speaker 2: will result in more money being spent on this problem,
Speaker 2: not less or right.
Speaker 1: There is something in the guidelines which is like a
Speaker 1: strong recommendation, something we can do something about, and that
Speaker 1: is hypothirotism.
Speaker 2: Yeah, that's got good evidence. So we check the thyroid
Speaker 2: and if someone has been walking around with a low
Speaker 2: thyroid and you correct that, you'll improve their chance of
Speaker 2: holding onto the pregnancy. So that's great. We knew that already,
Speaker 2: but it's good that that's known to have good evidence.
Speaker 2: There's an interesting comment in the guidelines about whether we
Speaker 2: should treat asymptomatic where the blood tests are mildly abnormal
Speaker 2: but the woman looks and feels fine. A lot of
Speaker 2: people in a recurrent miscarriage situation would latch onto any
Speaker 2: mild abnormal the one percenter. Let's just try and get
Speaker 2: everything as normal as we can.
Speaker 1: So what about the person who has a subclinical finding
Speaker 1: about their thyroid.
Speaker 2: Yeah, so they look and feel fine, but there's a
Speaker 2: very mild abnormality to the test, and these guidelines are
Speaker 2: suggesting that there's poor evidence to treat that, but that
Speaker 2: that person should have close attention paid to their thyroid
Speaker 2: as soon.
Speaker 1: As they're pregnant, and again during their pregnancy.
Speaker 2: Yeah, well we check anyone with thorroid disease, which gets
Speaker 2: recurrent checks.
Speaker 1: Yep. And there's this thing called antibody positive youth thyroid.
Speaker 1: What is that.
Speaker 2: That's people who've got a normal level of thyroid function,
Speaker 2: but they have a thing called thyroid auto antibodies where
Speaker 2: your body has made antibodies against thyroid tissue.
Speaker 1: Well, that's the Hashimotos and Graves disease. And yeah, and
Speaker 1: that's treated the same, isn't it. It's just tested to
Speaker 1: see if there's any dis function in the pregnancy once
Speaker 1: you're pregnant. Once you're pregnant. I googled all of that
Speaker 1: because it is all new to me, and Google definitely
Speaker 1: says that that is all the cause of miscarriage. So
Speaker 1: this is where the punters get the information from, isn't
Speaker 1: it in the first place?
Speaker 2: Well? Yes, and I think we have to remember that
Speaker 2: there are multiple sources of information. But the point of
Speaker 2: the guideline is to gather the quality evidence from wherever
Speaker 2: it exists in the world and put it together and
Speaker 2: have a go at recommending what best clinical practice is.
Speaker 1: Yeah. Also, if you avidly googling, you might come across
Speaker 1: intravenous immunoglobular therapy. What is that? That is in the guidelines,
Speaker 1: But can you just quickly define that for us?
Speaker 2: Yeah, you know, globulin therapy is an idea that for
Speaker 2: a current miscarriage that doesn't have much scientific merit behind
Speaker 2: it as far as I can see. Where you know,
Speaker 2: im immune substances are purified from blood donation, could be
Speaker 2: could be injected and used in an attempt to treat
Speaker 2: my current miscarriage. And I don't believe that has any
Speaker 2: serious science behind it at this stage.
Speaker 1: I know that currently it's not a approved use of
Speaker 1: donated blood in Yeah, well, and it must cost a
Speaker 1: lot of money. So that's in the guidelines, but there's
Speaker 1: no recommendations.
Speaker 2: They recommend against.
Speaker 1: It, all right. So this leads us to the last recommendation.
Speaker 1: This is the use of progesterone when someone has had
Speaker 1: recurrent miscarriages.
Speaker 2: This is an interesting one because because you've got to
Speaker 2: remember that recurrent miscarriage is one of those heartbreaking conditions.
Speaker 2: It's very frustrating to treat. There's a certain sort of
Speaker 2: randomness about it. It just people seem to just have
Speaker 2: the pregnancy snatch from them, and there's very little we've
Speaker 2: been able to do about that other than in a
Speaker 2: good other than in a kind way suggesting that we
Speaker 2: go home, nurture our bruised body and heart, and then
Speaker 2: try again. So we've latched upon, we've latched on to
Speaker 2: treatments when they've come along in the hope that they
Speaker 2: are the holy graylmen we can really help people. And
Speaker 2: progesterone certainly has a role in a sort of a
Speaker 2: different problem in pregnancy, which is one of cervical insufficiency,
Speaker 2: where the cervix comes open too early and end in
Speaker 2: a sort of a painless second trimester pregnancy loss. Cervix opens,
Speaker 2: baby comes out, and that I think led to its
Speaker 2: to an increasing focus on its use to try and
Speaker 2: help prevent first trimester pregnancy losses. The evidence for that's
Speaker 2: not quite as good, and in this guideline they recommend
Speaker 2: only doing that if there's bleeding, which is not really
Speaker 2: where frequent everyday clinical practice was sitting prior to this guideline,
Speaker 2: So it'll be interesting to see whether that changes practice. Okay,
Speaker 2: because using a little bit of vaginal progesterone pessories in
Speaker 2: a woman with the recurrent pregnancy lost situation has really
Speaker 2: been seen as a as a safe thing to do,
Speaker 2: as something that might help that won't harm. And it's
Speaker 2: for some people the feeling of doing something is a
Speaker 2: lot more satisfactory than the feeling of doing nothing, even
Speaker 2: if the something doesn't have a lot of evidence behind it. Yeah.
Speaker 1: Yeah, and we can see you know, that is where
Speaker 1: people have agency in their life when it comes to
Speaker 1: recurrent miscarriage. You know, they start to look at their
Speaker 1: lifestyle factors and that can also be somewhere where they
Speaker 1: concentrate on. Yes, but for you, does anything in this
Speaker 1: guideline change how you practice as a clinician?
Speaker 2: It's a good question. I think it's very very real. Sure,
Speaker 2: it's very pleasing to see the evidence summarized in one place.
Speaker 2: I don't think it makes looking after women with this
Speaker 2: problem any easier, to be honest. I think more people
Speaker 2: will probably come forward for an assessment, and I think
Speaker 2: we will have a better opportunity to do the things
Speaker 2: that we know work for a greater number of people
Speaker 2: because more people are going to be caught up in
Speaker 2: the titan definition. Does that make sense?
Speaker 1: Yeah?
Speaker 2: And then so the things that we know help cut
Speaker 2: down alcohol, don't smoke, treat thyroid, those things. We may
Speaker 2: wind up treating more people for those conditions.
Speaker 1: All right, everyone, I guess you've chosen this because you're
Speaker 1: you might have only just had one miscarriage and you're thinking, gosh,
Speaker 1: what if I have another, or you've had two miscarriages,
Speaker 1: all three or more, and you're looking for answers in
Speaker 1: this podcast. We hope you've found some and you can
Speaker 1: just you know, go to the RAMS card guidelines. They're
Speaker 1: readily available for everybody. I can't say that they're like
Speaker 1: a really easy read. They're pretty dense and clinician focus
Speaker 1: and technical and they're a technical piece, but you know,
Speaker 1: you might like to just look at the recommendations and
Speaker 1: just see whether you're on the right.
Speaker 2: Track and make sure to the best of your ability
Speaker 2: that your concerns about this are not dismissed, and in
Speaker 2: particular that your care providers understand that, un by the
Speaker 2: new guidelines, investigations should be started for a couple who've
Speaker 2: had two.
Speaker 1: Yep, great, all right, that's it for us this week.
Speaker 1: Thank you so much for joining.
Speaker 2: Us, Thanks for listening, everybody.
Speaker 1: Bye for now. Hey, even though doctor pat is well
Speaker 1: a doctor, and we get lots of other doctors and
Speaker 1: other experts on our podcast. I just need to remind
Speaker 1: you that this podcast is for informational purposes only. We
Speaker 1: share lots of medical insights and experience, but everything we
Speaker 1: talk about is general in nature and may not apply
Speaker 1: to your specific situation. Please always consult with your own
Speaker 1: healthcare provider for your individual medical advice. When you grow
Speaker 1: your baby,