1.
Pre-pregnancy 101 Melissa Stoffel D.O. Marshfield Clinic OB/GYN May 26, 2009

2.
Preconceptual Counseling <ul><li>Definition: Identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management. </li></ul><ul><li>Goal: Help the mother maintain her well-being and achieve a healthy outcome not only for herself, but for her unborn child. </li></ul>

3.
Preconceptual Counseling <ul><li>Optimal time to assess, manage and treat many conditions/complications before conception. </li></ul><ul><li>Improves pregnancy outcomes. </li></ul><ul><li>Reduced maternal/neonatal morbidity and mortality. </li></ul>

4.
Components <ul><li>Identification of pregnancy related risks </li></ul><ul><li>Pt education regarding pregnancy risks, management options, and reproductive alternatives </li></ul><ul><li>Initiation of interventions, when possible, to provide optimum pregnancy outcome </li></ul>

5.
What to Expect <ul><li>Complete medical/family history </li></ul><ul><li>Physical exam </li></ul><ul><li>laboratory </li></ul>

6.
Comprehensive History <ul><li>Age </li></ul><ul><ul><li>Teens – nutritional/emotional needs, STD’s </li></ul></ul><ul><ul><li>>35 yrs – increase pregnancy risks </li></ul></ul><ul><ul><li>Father >age of 55 </li></ul></ul>

7.
Comprehensive History <ul><li>Reproductive history (obstetrical/gynecologic) </li></ul><ul><ul><li>May identify factors that may contribute to infertility or pregnancy complications </li></ul></ul><ul><ul><li>Menstrual calendar (accurate dating is critical for obstetric decision making) </li></ul></ul>

9.
Personal Medical History <ul><li>Medications </li></ul><ul><li>STI hx </li></ul><ul><li>Chronic medical conditions </li></ul><ul><li>Immunization hx – up to date </li></ul><ul><li>Surgeries </li></ul><ul><li>Mental Health </li></ul>

11.
Family History <ul><li>Helps identify genetic risks to fetus and maternal medical risks </li></ul><ul><li>Ethnicity </li></ul>

12.
Psychosocial Issues <ul><li>Stress, financial issues, mental health </li></ul><ul><li>Maternal suffering can lead to poor compliance, nutrition, substance abuse, or disturbed relationship between mom and baby </li></ul>

13.
Weight and pregnancy <ul><li>Obesity is associated with decreased fertility </li></ul><ul><li>Normal Pre-pregnancy BMI 19.8 – 26.0 </li></ul><ul><li>Increased pregnancy complications with extremes of BMI </li></ul><ul><li>Weight reduction attempted prior to pregnancy </li></ul>

14.
Exercise <ul><li>Mild – moderate exercise while pregnant is not harmful if done on a regular basis prior to pregnancy </li></ul><ul><li>Do not initiate a strenuous exercise regime during pregnancy </li></ul><ul><li>Low impact routine </li></ul>

15.
Substance Use <ul><li>Tobacco </li></ul><ul><ul><li>Increase miscarriage, prematurity, and low-birth weight infants, IUGR, placenta abruption, </li></ul></ul><ul><ul><li>Smoking cessation/decreased amount during pregnancy improves pregnancy outcomes </li></ul></ul><ul><ul><li>Chantix not used in pregnancy </li></ul></ul>

16.
Substance Use <ul><li>Alcohol and Illicit Drugs </li></ul><ul><ul><li>Increase preterm delivery, IUGR, FAS, neonatal withdrawal </li></ul></ul><ul><ul><li>Avoidance of all = better pregnancy outcomes </li></ul></ul><ul><ul><li>Methadone Clinic </li></ul></ul>

17.
Substance Use <ul><li>Caffeine </li></ul><ul><ul><li>Limit 300mg/d </li></ul></ul><ul><ul><li>Consumption of >250mg/d can decrease fertility </li></ul></ul><ul><ul><li>>500mg/d increase miscarriage, stillbirth, low-birth weight infants </li></ul></ul>

19.
Environmental Exposures <ul><li>Avoid organic solvents </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>Mercury </li></ul><ul><li>Lead (paint, arts/crafts) </li></ul><ul><li>No harm from computer monitors, electric blankets, heated water beds, microwave </li></ul><ul><li>Work place (OSHA) </li></ul>

20.
Nutrition <ul><li>The fetal environment affects infant and childhood development. </li></ul><ul><li>Dietary changes that optimize growth and development have life long health benefits. </li></ul><ul><li>Vegetarian diets lack adequate amts of amino acids and iron, vitamin B12 and complex lipids. </li></ul>

21.
Nutrition <ul><li>Discontinue megavitamins, non-essential dietary supplements, and herbal preparations. (not studied to evaluate fetal risk) </li></ul><ul><li>No evidence that Nutrasweet, Splenda, Sweet N’ Low increase risk of birth defects above the general population. </li></ul><ul><li>Multivitamin/prenatal vitamin with 400mcg (0.4mg) of folic acid needed </li></ul>

22.
Physical Exam <ul><li>General head/toe exam </li></ul><ul><ul><li>Thyroid/dental carries </li></ul></ul><ul><li>Pelvic exam </li></ul><ul><li>Pap </li></ul><ul><li>Gonorrhea/chlamydia cultures </li></ul>

23.
Laboratory <ul><li>Rubella titer </li></ul><ul><li>Varicella titer </li></ul><ul><li>Hepatitis B </li></ul><ul><li>CBC (anemia) </li></ul><ul><li>Blood type and RH factor </li></ul><ul><li>HIV </li></ul><ul><li>Glucose screen </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>CMV </li></ul>

24.
Maternal Medical Conditions <ul><li>-Optimal management </li></ul><ul><li>-Change in medications that are safer in pregnancy prior to conception </li></ul>

25.
Maternal Medical Conditions <ul><li>Diabetes </li></ul><ul><ul><li>Referral to endocrinology </li></ul></ul><ul><ul><li>Achieve tight glycemic control prior to conception </li></ul></ul><ul><ul><li>Dietary consultation </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>BP control prior to pregnancy </li></ul></ul><ul><ul><li>Safer meds (no ACE inhibitors) </li></ul></ul>

26.
Maternal Medical Conditions <ul><li>Asthma </li></ul><ul><ul><li>Good control prior to pregnancy </li></ul></ul><ul><ul><li>Most meds safe in pregnancy </li></ul></ul><ul><li>Thyroid disease </li></ul><ul><ul><li>Close monitoring of thyroid function </li></ul></ul><ul><ul><li>Adjusting medication dose common </li></ul></ul><ul><ul><li>Neuropsychological impairment </li></ul></ul>

27.
Maternal Medical Conditions <ul><li>Epilepsy </li></ul><ul><ul><li>Neurology referral for drug adjustments </li></ul></ul><ul><ul><li>Frequent blood levels </li></ul></ul><ul><ul><li>Extra folic acid 1gram </li></ul></ul><ul><ul><li>Vitamin K (36wks – delivery) </li></ul></ul><ul><li>Lupus </li></ul><ul><ul><li>Better prognosis for both mom and baby is quiescent for 6 mos before conception </li></ul></ul><ul><ul><li>Better prognosis if normal renal function </li></ul></ul>

28.
Maternal Medical Conditions <ul><li>Anemia </li></ul><ul><ul><li>HGB 6g/dl (decreased AFI, abnormal FHT, increase fetal death) </li></ul></ul><ul><li>Depression </li></ul><ul><ul><li>If controlled and doing well on medication = continue taking drug </li></ul></ul>

29.
Prenatal Education <ul><li>Pt education leads to better self-care and pregnancy outcomes. </li></ul><ul><li>Radiologic studies (dental/radiologic) </li></ul><ul><ul><li>Can be performed when indicated </li></ul></ul><ul><ul><li>Delay if elective </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Take only medications approved or prescribed by your doctor. When in doubt…ask! </li></ul></ul>

30.
Prenatal Education <ul><li>Nutrition </li></ul><ul><ul><li>Iron 30mg/d (take between meals, empty stomach) </li></ul></ul><ul><ul><ul><li>Necessary for fetal/placenta development and to expand the maternal RBC mass </li></ul></ul></ul><ul><ul><li>Calories: increase by 340 – 450 kcal/d </li></ul></ul><ul><ul><li>Calcium 1000mg/d </li></ul></ul><ul><ul><li>Three servings of dairy daily </li></ul></ul>

33.
Weight Gain <ul><li>3-6# wt gain in first trimester </li></ul><ul><li>0.5 – 1#/wk in last 2 trimesters </li></ul><ul><li>Inadequate wt gain during pregnancy is associated with increase low-birth-weight infants, and preterm delivery. </li></ul>

34.
Weight Gain <ul><li>Underweight women </li></ul><ul><ul><li>BMI <19.8 kg/m2 </li></ul></ul><ul><ul><li>26-40# </li></ul></ul><ul><li>Normal weight women </li></ul><ul><ul><li>BMI 19.9-26.0 kg/m2 </li></ul></ul><ul><ul><li>26-35# </li></ul></ul><ul><li>Overweight women </li></ul><ul><ul><li>BMI 26-29 kg/m2 </li></ul></ul><ul><ul><li>15-26# </li></ul></ul><ul><li>Obese women </li></ul><ul><ul><li>BMI >29 </li></ul></ul><ul><ul><li>15# </li></ul></ul>

35.
Weight Gain <ul><li>2-3# = increased fluid volume </li></ul><ul><li>3-4# = increased blood volume </li></ul><ul><li>1-2# = breast enlargement </li></ul><ul><li>2# = enlarged uterus </li></ul><ul><li>2# = amniotic fluid </li></ul><ul><li>6-8# = baby </li></ul><ul><li>1-2# = placenta </li></ul><ul><li>4-6# = maternal stores of fat and protein (lactation) </li></ul>

36.
Prenatal Education <ul><li>Activity and Employment </li></ul><ul><ul><li>Avoid heavy lifting (25-30#) </li></ul></ul><ul><ul><li>Most are able to maintain normal activity level </li></ul></ul><ul><li>Travel </li></ul><ul><ul><li>Avoid prolonged sitting in car/plane (clotting risk) </li></ul></ul><ul><ul><li>Support hose </li></ul></ul><ul><ul><li>Seat belt </li></ul></ul><ul><ul><li>Driving 6 hours/d (stop every 2 hours for 10 min) </li></ul></ul>

37.
Prenatal Education <ul><li>Nausea and vomiting </li></ul><ul><ul><li>Avoid greasy/spicy foods </li></ul></ul><ul><ul><li>Frequent small meals </li></ul></ul><ul><ul><li>Crackers at bedside </li></ul></ul><ul><ul><li>Protein snack at night </li></ul></ul><ul><li>GERD </li></ul><ul><ul><li>Relaxation of esophogeal sphincter </li></ul></ul><ul><ul><li>Don’t eat before lying down </li></ul></ul><ul><ul><li>Worse with overeating and spicy foods </li></ul></ul><ul><li>Hemorrhoids </li></ul><ul><ul><li>Varicose veins of rectum </li></ul></ul><ul><ul><li>Avoid constipation/straining/prolonged sitting </li></ul></ul><ul><ul><li>Regress after delivery (not go away completely) </li></ul></ul>

38.
Prenatal Education <ul><li>Constipation </li></ul><ul><ul><li>Decrease bowel transit time </li></ul></ul><ul><ul><li>Fresh fruit/veggies/water </li></ul></ul><ul><ul><li>Metamucil/colace </li></ul></ul><ul><li>Urinary frequency </li></ul><ul><ul><li>Growing uterus and fetal head increase pressure on the bladder. </li></ul></ul><ul><li>Round ligament pain </li></ul><ul><ul><li>Sharp groin pains = spasm of round ligament associated with movement </li></ul></ul><ul><ul><li>Right > left </li></ul></ul><ul><ul><li>Local heat, gradual rising/sitting, avoid sudden movement </li></ul></ul>

39.
Prenatal Education <ul><li>Syncope </li></ul><ul><ul><li>Compression of veins in legs from the growing uterus causes venous pooling with prolonged standing = faint </li></ul></ul><ul><ul><li>Compression stockings </li></ul></ul><ul><li>Back ache </li></ul><ul><ul><li>Prevented by excessive weight gain </li></ul></ul><ul><ul><li>Exercises to strengthen back muscles </li></ul></ul><ul><ul><li>Posture, sensible shoes </li></ul></ul><ul><li>Intercourse </li></ul><ul><ul><li>Usually no restrictions </li></ul></ul><ul><ul><li>May cause increase uterine activity and spotting </li></ul></ul>

40.
Prenatal Education <ul><li>Breast feeding </li></ul><ul><ul><li>Avoid soap/lotions on breasts </li></ul></ul><ul><li>Preparation for childbirth </li></ul><ul><ul><li>Studies have shown that prepared childbirth can have a beneficial effect on performance in labor and delivery </li></ul></ul>

41.
Questions <ul><li>How long after a miscarriage should I wait before trying to get pregnant again? </li></ul>

42.
Questions <ul><li>Are there any cosmetics or body lotions that should be avoided if I’m trying to get pregnant? </li></ul>

43.
Questions <ul><li>When in the menstrual cycle would I most likely get pregnant? </li></ul>

44.
Questions <ul><li>How long after a person stops taking oral contraception do recommend waiting before trying to get pregnant? </li></ul>

45.
Questions <ul><li>Do women who have had abnormal pap smears and a colposcopy have problems getting pregnant or delivering a baby? </li></ul>

46.
Questions <ul><li>How often during the menstrual cycle should I have intercourse? </li></ul>

47.
Questions <ul><li>Can I use natural planning to help get pregnant? </li></ul>

48.
Questions <ul><li>If you are considering getting pregnant or are already pregnant and you need to choose a doctor what are the reasons to choose an OB versus choosing a family practitioner, what things should a person think about when making that decision? </li></ul>

49.
Questions <ul><li>If you had a pre-term delivery in the past would there be something you would recommend to do differently during the pre-pregnancy planning stage or during the first trimester? </li></ul>

50.
Questions <ul><li>Hot tubs in pregnancy? </li></ul>

51.
Questions <ul><li>How much fish can I eat during pregnancy? </li></ul>

52.
Questions <ul><li>What about using sunscreen when you’re pregnant? </li></ul>

53.
Questions <ul><li>Is there anything out there to help prevent stretch marks? </li></ul>

54.
Questions <ul><li>I’ve seen some women where a belt during pregnancy, what is that for? </li></ul>

55.
Questions <ul><li>What about chiropractic care or messages during pregnancy? </li></ul>

56.
Questions <ul><li>When can I begin to slim down post pregnancy? </li></ul>