Nadia Barghouthi, MD, MPH, (near right) and Jessica Perini, MD, MS, colleagues in the Department of Endocrinology and Metabolism at West Virginia University School of Medicine, talk to Endocrine News about their new book, Endocrine Diseases in Pregnancy and the Postpartum Period, what they discovered while researching it and who needs this book in their library.
Although writing a book had always been on her “bucket list,” Nadia Barghouthi, MD, MPH, interim section chief and assistant professor, endocrinology and metabolism and assistant program director of the WVU Endocrinology Fellowship in the WVU Department of Medicine, Morgantown, WV, just assumed it would be about her cat. That all changed when she was in her first year as an endocrinology fellow when she was approached about writing a book centering around endocrinology.
Barghouthi drafted Jessica A. Perini, MD, MS, her colleague at WVU, an associate professor of endocrinology and metabolism as well as the program director of WVU Endocrine Fellowship and the medical director of WVUH Inpatient Diabetes in the Department of Internal Medicine at the WVU School of Medicine, to come to a meeting with publisher Taylor & Francis in New Orleans at ENDO 2019.
The topic tackling endocrine disorders during pregnancy was decided upon since there weren’t a lot of books on that topic out there and a new one was sorely needed. The co-editors talks to Endocrine News about their new book, the surprises they discovered along the way, and their contemporary look at transgender health during pregnancy.
Endocrine News: What inspired you to undertake writing Endocrine Diseases in Pregnancy and the Postpartum Period?
Nadia Barghouthi, MD, MPH: Writing a book was on my list of life goals but I thought my first book would be a children’s book about my cat, Mars. When I was a first-year endocrinology fellow, I was approached by the commissioning editor of medical sciences at CRC Press, Taylor & Francis and asked if I had any ideas for a book. We set up a meeting at ENDO 2019 in New Orleans. At that time, I had only written a couple of case reports and was still learning to be an endocrinologist, so I asked my program director (now colleague), Jessica Perini, to come to the meeting with me. We knew that there weren’t that many books out there dedicated specifically to the diagnosis and treatment of endocrine diseases in pregnancy, so we were excited for the opportunity to write a book to help this patient population.
Jessica A. Perini, MD MS: Nadia made me do it. Nadia was approached by a publisher after they saw a case report she had written and asked her if she would be willing to write a textbook. I was there during the conversation with the publisher and so Nadia and I both agreed to come up with a general theme we would want to focus on for the book and then start the long process of putting it together. We chose endocrine and pregnancy as there were very few publications focusing on this and this topic seemed to give us the opportunity to touch on all aspects of endocrinology, like we would want to do, yet with some unique and specific perspective.
EN: In researching Endocrine Diseases in Pregnancy and the Postpartum Period, what surprised you the most? In other words, from a content perspective, what did you learn from the book that you didn’t already know?
NB: There are guidelines to help with diagnosis and management for diabetes and thyroid disease in pregnancy, however most other diseases we reviewed have no clear guidelines. Many adrenal and pituitary disorders have very limited information which comes mostly from case reports. There is so much to learn regarding normal physiology in pregnancy which is necessary in order to understand when something is abnormal. For example, growth hormone (GH) physiology in pregnancy is very interesting. The placenta regulates the somatotropic system during pregnancy, as it becomes the main source of GH, while GH secretion by the pituitary is inhibited. The placenta produces a variant GH (GH-V) which contributes to stimulation of IGF-1, which then increases insulin resistance in the mother and directs glucose to the fetus to promote fetal growth. In the first trimester, pituitary GH (GH-N) is the predominant form of GH in the maternal serum. It does not cross the placenta and is not necessary for gestation and normal fetal development. Rising estradiol levels induce a state of GH resistance as reflected by a significant decline in IGF-1 levels. After this, GH-V levels begin to rise and overcome GH resistance as reflected by increasing IGF-1 levels. By gestational week 36, the GH-V level is comparable to GH levels in women with acromegaly, therefore making the diagnosis of acromegaly in pregnant patients extremely difficult.
“A good part of the content of the book is review of fundamental endocrine issues but some of the basic physiology, as it pertains to pregnancy, was fascinating. The physiologic changes that the body goes through during pregnancy, the production or inactivation or adjustment of hormones to carry a pregnancy to term, are amazing.”Jessica Perini, MD, MS, associate professor, endocrinology and metabolism; program director, WVU Endocrine Fellowship; medical director, WVUH Inpatient Diabetes, Department of Internal Medicine, WVU School of Medicine, Morgantown, W.V.
JP: A good part of the content of the book is review of fundamental endocrine issues but some of the basic physiology, as it pertains to pregnancy, was fascinating. The physiologic changes that the body goes through during pregnancy, the production or inactivation or adjustment of hormones to carry a pregnancy to term, are amazing. During the several times that Nadia and I were reading the entire book out loud to each other to proofread and edit, we were constantly saying to each other, “Oh my gosh, that is so cool!”
EN: What hormone disorders are most concerning during a pregnancy?
NB: Any untreated hormone excess or deficiency carries significant risk of morbidity to the mother and fetus. True endocrine emergencies are rare but have high mortality if not promptly diagnosed with examples including adrenal crisis, thyroid storm, and pituitary apoplexy. So, it is important for clinicians to be aware of how these disorders can present in pregnancy and to maintain a high suspicion for endocrine disorders in the right clinical setting.
JP: Honestly, they all are if not treated. Uncontrolled diabetes can lead to many complications, ranging from fetal malformations to fetal and maternal mortality. Uncontrolled thyroid problems are also risky to both the fetus and the patient. Disorders of cortisol are often difficult to diagnose in pregnancy and can lead to complications. Some hormonal conditions, such as growth hormone deficiency, we just don’t know enough about yet to know for certain how to treat and our guidelines cannot give us clear instructions as to whether to continue treatment during pregnancy. Although this example of growth hormone replacement during pregnancy is not particularly concerning, it raises the point that there are many safety aspects of medications in pregnancy that we still don’t know much about.
EN: Dr. Perini, you authored the chapter on transgender health during pregnancy and the postpartum period. Can you give us an overview of what this chapter covers and what are some of the most surprising aspects of transgender pregnancy care you discovered?
JP: The chapter regarding pregnancy in transgender men covers the minimal information that exists so far regarding pregnancy in this population. One of the most important things we need to be aware of when providing care to transgender people is that very often their experiences with the medical world have been negative, hence many trans men who are pregnant do not even seek pre- or perinatal care. Testosterone is category X in pregnancy, meaning that it should be stopped during pregnancy; however, stopping gender-affirming hormones can worsen gender dysphoria, potentially complicating the pregnancy. Trans men who are pregnant may face uncomfortable questions. Preferred terminology, such as patient’s preferred pronouns, how the patient wants to be called as the parent (father, mother, etc.), how the patient wants to refer to nursing the infant (chest-feeding, etc.), must always be considered and patient preferences adhered to diligently.
One of the most surprising things I learned while researching this topic was how quickly trans men may recover ovulatory function even after years of gender-affirming testosterone use. Up to 80% of people who stop their testosterone have resumption of menses within six months. I personally have a patient who stopped his testosterone on purpose to become pregnant and was pregnant within one month of testosterone cessation, then carried the pregnancy successfully to term. For those who do not regain ovulatory function, fertility treatments have been successful for many people. In addition, although the majority of trans men have not had a hysterectomy, for those who have and are desiring pregnancy, there is some minimal data showing that uterine transplants could be considered, although very experimental at this time.
EN: Who would be the ideal audience for Endocrine Diseases in Pregnancy and the Postpartum Period?
NB: Anyone who treats pregnant patients, including endocrinologists, obstetricians and gynecologists, and primary care providers.
JP: Everyone who wants a good comprehensive pocket guide to all things endocrine should get the book. Although the book title includes pregnancy, the vast majority of endocrine topics are included in the book and can pertain to non-pregnant people as well. We made the book somewhat bullet-point so that it is easy to find what you are looking for in each chapter. Medical students, internal or family medicine residents, Ob/Gyn residents, endocrine fellows, and endocrinologists will find the book user-friendly and comprehensive.
“True endocrine emergencies are rare but have high mortality if not promptly diagnosed with examples including adrenal crisis, thyroid storm, and pituitary apoplexy. So, it is important for clinicians to be aware of how these disorders can present in pregnancy and to maintain a high suspicion for endocrine disorders in the right clinical setting.”Nadia Barghouthi, MD, MPH, interim section chief, assistant professor, endocrinology and metabolism; assistant program director, WVU Endocrinology Fellowship, WVU Department of Medicine, Morgantown, W.V.
EN: Anything else you would like to add?
NB: I am proud of all the hard work and effort of every author who contributed. We were very fortunate to have authors from various specialties contribute including obstetrician/gynecologists, nephrologists, obesity medicine specialists, and of course, many endocrinologists. I sincerely hope this book will help many clinicians in their care of pregnant patients.
JP: This was a true collaborative effort, with many different people contributing their knowledge and time to this project. It was also a huge undertaking — much more time-consuming than I had ever thought it would be. Thanks to Nadia for being very organized. If anyone thinks they want to produce a book with someone else, they need to make sure that they both have similar work styles, writing styles, and patience levels. I was very lucky to have worked on this with Nadia.
Newman has been the Editor of Endocrine News since 2013.
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