Prenatal Care Before Getting Pregnant
Ideally, prenatal care should start before you get pregnant. If you’re planning a pregnancy, see your health care provider for a complete checkup. He or she can do routine testing to make sure you’re in good health and that you don’t have any illnesses or other conditions that could affect your pregnancy. If you’ve been experiencing any unusual symptoms, this is a good time to report them.
If you’re already being treated for a chronic condition, such as diabetes, asthma, hypertension (high blood pressure), a heart problem, allergies, lupus (an inflammatory disorder that can affect several body systems), depression, or some other condition, you should talk to your doctor about how it could affect your pregnancy. In some cases, you may need to change or eliminate medications — especially during the first trimester (12 weeks) — to reduce risk to the fetus. Or, you may need to be even more vigilant about managing your condition.
For example, women with diabetes must be especially careful about keeping their blood glucose levels under control, both before they begin trying to conceive and during their pregnancy. Abnormal levels increase the risk of birth defects and other complications.
This is also a good time to talk with your health care provider about other habits that can pose a risk to your baby, such as drinking alcohol or smoking. Ask about starting a prenatal vitamin that contains folic acid, calcium, and iron.
It’s especially important for women who are planning to become pregnant to take vitamins with folic acid beforehand, because neural tube defects (problems with the normal development of the spine and nervous system) happen in the first 28 days of pregnancy, often before a woman even knows she’s pregnant.
If you have or your partner has a family history of a significant genetic disorder and you suspect either of you may be a carrier, then genetic testing may be advisable. Talk this over with your health care provider, who can refer you to a genetic counselor if necessary.
If you find out that you’re pregnant before you do any of this, don’t worry. It’s not too late to get the care that will help to ensure your health and that of your baby.
Am I Pregnant?
If you’re unusually tuned into your body, you might begin to suspect that you’re pregnant within the first few days of pregnancy. Most women, however, don’t suspect they are pregnant until they miss a period, and a few don’t suspect or believe they are pregnant for months after conception.
Five very common signs of early pregnancy are as follows. You might experience all, some, or none of these symptoms, as pregnancy symptoms vary from woman to woman.
1. A missed period — Missing your period is the most clear-cut sign of pregnancy. But it is not definitive. Stress, excessive exercise, dieting, and other factors might cause irregular periods.
2. Frequent trips to the bathroom — Even before missing a period, many pregnant women report having to urinate more often. You might even have to get up during the night. This occurs after the embryo has implanted in the uterus and begins producing the pregnancy hormone called human chorionic gonadotropin (hCG). This hormone triggers frequent urination.
3. Fatigue — Utter exhaustion is a very early sign of pregnancy. Fatigue is a result of high levels of the hormone progesterone.
4. Morning (and noon and night.) sickness — Guess what? That queasy feeling isn’t limited to mornings. Most pregnant women who experience morning sickness — which can begin two weeks to two months after conception — feel slightly nauseated at other times during the day. About half have vomiting, but very few have severe enough morning sickness to develop dehydration and malnutrition.
5. Sore (and enlarging) breasts — If you’re pregnant, your breasts will probably become increasingly tender to the touch, similar to the way they feel before your period, only more so. Your nipples might also begin to darken and enlarge. Once your body grows accustomed to the increase in hormones, the pain will subside.
Other signs of pregnancy can include:
•Implantation bleeding (spotting) — Some women experience a light spotting or a brownish discharge. This spotting can occur at about the time the regular period would occur and can last for a few days to a few weeks.
•Food cravings, constant hunger — Some women begin to crave certain foods, constantly feel that they are hungry, or might avoid foods that they previously liked.
•Metallic taste in the mouth — Many women complain of a metallic taste in their mouths during the early stages of pregnancy.
•Headaches and dizziness — Headaches and the feelings of lightheadedness and dizziness are common during early pregnancy and are the result of hormonal changes and changes in blood volume.
•Cramping — Some women experience period-like cramps. If cramps are felt mainly on one side or are severe, it’s important to contact your doctor immediately.
Calculating Your Estimated Date:
One simple and common method for calculating your delivery date is as follows:
•Mark down the date when your last period started
•Add seven days
•Count back three months
•Add a whole year
For example, if the first day of your last period was September 9, 2000, adding 7 days will make the date September 16, 2000. Counting back 3 months results in the date of June 16. Finally, adding a year yields an estimated delivery date of June 16, 2001.
The above strategy is based on the assumption that conception occurred 14 days after the start of your last menstrual period. Also, it’s important to remember that no matter what ‘pen and paper’ calculations you use to estimate your delivery date, these methods are just that – estimates. Most babies are born between 38 and 42 weeks (the normal pregnancy is considered to be 40 weeks in length counting from the first day of your last menstrual cycle) and only a small percentage of women actually deliver on their estimated due date.
Your doctor can use more reliable methods to provide you with your delivery date, such as measuring the size of the uterus through a clinical exam or conducting an ultrasound examination.
Expecting Twin or Triplets
How do multiple pregnancies occur?
A multiple pregnancy occurs when one egg (ovum) splits before implanting or when separate eggs are each fertilized by a different sperm.
Identical twins or triplets occur with the fertilization of a single egg that later divides into two or three identical embryos. Identical twins or triplets have the same genetic identity, are always the same sex, and look almost exactly the same.
Fraternal multiples develop from separate eggs, each fertilized by a different sperm. Fraternal twins might or might not be of the same sex and might not necessarily resemble each other any more than two siblings from the same parents might.
In a pregnancy with triplets or more, the babies can be all identical, all fraternal, or a mixture of both. This can happen when multiple eggs are released by the mother and fertilized. If one or more of these fertilized eggs divides into two or more embryos, a mixture of identical and fraternal multiples will occur.
What increases the chance of a multiple pregnancy?
The chance that a woman will have fraternal multiples is higher if a woman is older, taller, and heavier. In addition, twins are more likely if a woman is herself a twin, or if having twins runs in the maternal side of the family. The use of fertility drugs increases a woman’s chance of having a multiple birth. Infertility procedures such as in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) increase the chance of a multiple pregnancy. These procedures often involve the transfer of more than one fertilized eggs into the mother’s womb to increase the odds of pregnancy occurring.
How common are multiple births?
Multiple births have become more common in recent years because more couples are using fertility drugs and treatments such as in-vitro fertilization (IVF) to help them conceive. In about 95 percent of multiple pregnancies, the mother is carrying twins.
What complications are linked to multiple births?
Most doctors consider multiple pregnancies higher risk than single pregnancies, but this does not mean that women who are pregnant with multiples automatically have problems. Some complications that can occur in multiple births include:
•Premature labor — The most common complication of multiple births is premature labor. Mothers carrying multiple babies go into premature labor (usually defined as before 37 weeks) more often than do women carrying only one baby. Many women strive to reach 38 weeks, considered full-term in a twin pregnancy, to increase the odds that their babies will be born healthy and at a good weight
•Pre-eclampsia, or pregnancy-induced high blood pressure — This complication occurs at twice the rate in women carrying multiples than in women pregnant with one baby. The condition also tends to develop earlier and be more severe in women carrying two or more babies.
•Placenta abruption — This condition occurs when the placenta detaches from the uterine wall before delivery. Placenta abruption is also more common when a woman is carrying more than one baby.
•Fetal growth restriction — This condition can occur when one or both twins is not growing at the proper rate. The condition might cause the babies to be born prematurely or at a low birth-weight. Up to nearly half of pregnancies with more than one baby have this problem, compared with slightly more than 10 percent of single pregnancies.
What can a woman do to stay healthy during a multiple pregnancy?
Eating nutritious foods, getting enough rest, and visiting the doctor regularly are important steps for any pregnant woman to take toward a healthy pregnancy, but these steps are particularly important during multiple pregnancies.
Women who are expecting multiple births have additional dietary needs to meet. Getting enough protein and enough hydration are important, as is getting extra calories for the developing fetuses. One rule of thumb is to eat an extra 300 calories a day per baby that is expected.
Women who are expecting multiples can experience the typical discomforts of pregnancy more intensely. Good self-care and getting plenty of rest can help to ease the stress of pregnancy.
Finally, women expecting multiples should find health care professionals who have experience with multiple births. Specialized health care can help ensure that mother and babies receive the best care available. The need for frequent, intensive prenatal care is very important in a multiple pregnancy. A family doctor or obstetrician/gynecologist can recommend a facility that specializes in multiple births.
Medical Care During Pregnancy
According to the Centers for Disease Control and Prevention (CDC), almost 4 million American women give birth every year. Nearly one third of them will have some kind of pregnancy-related complication. Those who don’t get adequate prenatal care run the risk that such complications will go undetected or won’t be dealt with soon enough. That, in turn, can lead to potentially serious consequences for both the mother and her baby.
These statistics aren’t meant to alarm you, but rather to convey the importance of starting prenatal care as early as possible — ideally, before you even become pregnant. Of course, this isn’t always possible or practical. But the sooner in your pregnancy you begin, the better your chances of ensuring your own health and that of your baby.
Finding Medical Care
Pregnant women are typically cared for by:
•obstetricians (doctors who specialize in pregnancy and childbirth)
•obstetricians/gynecologists (OB/GYNs) (doctors who specialize in pregnancy and childbirth, as well as women’s health care)
•family practitioners (doctors who provide a range of services for patients of all ages — in some cases, this includes obstetrical care — instead of specializing in one area)
•certified nurse-midwife (an advanced practice nurse specializing in women’s health care needs, including prenatal care, labor and delivery, and postpartum care for pregnancies without complications)
Any of these care providers is a good choice if you’re healthy and there’s no reason to anticipate complications with your pregnancy and delivery. However, nurse-midwives do need to have a doctor available for the delivery in case a cesarean section has to be performed.
Your health care provider may refer you to a doctor with expertise in high-risk pregnancies if you:
•have a chronic condition like diabetes or heart problems
•have an increased risk of preterm labor
•are older than 35
•have some other complicating factor that might put you in a high-risk category
Even if your pregnancy isn’t high-risk, this may still be a good time to make a change in health care providers if you’re not comfortable with your current doctor.
Your First Visit
Your should call and schedule your first examination during the first 6 to 8 weeks of your pregnancy, or when your menstrual period is 2 to 4 weeks late. Doing so now helps your health care provider estimate the duration of your pregnancy and predict your delivery date.
During your first visit, you can expect to have a full physical, including a pelvic and rectal examination. A blood sample will be taken and used for a series of tests:
•a complete blood cell count (CBC)
•blood typing and screening for Rh antibodies (antibodies against a substance found in the red blood cells of most people)
•for syphilis, hepatitis, gonorrhea, chlamydia, and other sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)
•for evidence of previous exposure to chickenpox (varicella), measles (rubeola), mumps, or German measles (rubella)
•for cystic fibrosis (health care providers have just recently started to routinely offer this to individuals even if there’s no family history of the disorder)
Women of African or Mediterranean descent are usually tested for sickle cell trait or disease because they’re at higher risk for having sickle cell anemia — a chronic blood disease — or carrying the trait, which can be passed on to their children.
During the first visit, you also can expect to provide a urine sample for testing and to have a Pap test (or smear) for cervical cancer. To do a Pap smear, your health care provider uses what looks like a very long mascara wand or cotton swab to gently scrape the inside of the cervix (the opening to the uterus that’s located at the very top of the vagina). This generally doesn’t hurt; some women say they feel a little twinge, but it only lasts a second.
Routine Visits and Testing
If you’re healthy and there are no complicating risk factors, you can expect to see your health care provider:
•every 4 weeks until the 28th week of pregnancy
•then every 2 weeks until 36 weeks
•then once a week until delivery
At each examination, your weight and blood pressure are usually recorded. The size and shape of your uterus may also be measured, starting at the 22nd week, to determine whether the fetus is growing and developing normally.
During one or more of your visits, you’ll be asked to provide a small urine sample to be tested for sugar and protein. Protein may indicate preeclampsia (a condition that develops in late pregnancy and is characterized by a sudden rise in blood pressure and excessive weight gain, with fluid retention and protein in the urine).
Screening for diabetes usually takes place at 12 weeks for women who are at higher risk of having gestational diabetes (diabetes that occurs during pregnancy). That includes women who:
•have previously had a baby that weighs more than 9 pounds (4.1 kilograms)
•have a family history of diabetes
•are obese
All other pregnant women are tested for diabetes at 24 to 28 weeks. This test involves drinking a sugary liquid and having a blood glucose test (which involves having blood drawn) after an hour. If the sugar level in the blood is high, further testing may be done to diagnose gestational diabetes.
Many expectant parents also choose to have one or more of the following prenatal tests, which can help predict the likelihood, or even detect the presence, of certain developmental or chromosomal abnormalities in the fetus:
Alpha-fetoprotein screening (AFP): Between 16 and 18 weeks, the level of alpha-fetoprotein, a protein produced by the fetus, can be measured in the woman’s blood. If the level is high, she may be carrying more than one fetus or a fetus with spina bifida or other neural tube defects. A high level can also indicate that the date of conception was miscalculated. If the level is low, the fetus may have chromosomal abnormalities, such as Down syndrome. It’s important to keep in mind that low or high results don’t automatically indicate a problem; rather, they indicate the need for further testing, which yields normal results in many cases.
Multiple marker screening (also called a maternal serum screening, triple screen, triple marker, quadruple screen, quad screen, quadruple marker, or quad marker): Also between 16 and 18 weeks, your health care provider may measure the levels of certain hormones in your blood, along with AFP. For this screening, a sample of blood is drawn from the mother to measure the level of AFP, as well as the levels of hCG (human chorionic gonadotropin) and estriol, which are produced by the placenta. The levels of these three substances (which is why the test is often called the triple screen or triple marker) in the blood can help doctors identify a fetus at risk for certain birth defects or chromosomal abnormalities. The test is called a quadruple screen (or marker) when the level of an additional substance, called inhibin-A, is also measured.
Amniocentesis (also called an amnio): In this test, a needle is used to remove a sample of the amniotic fluid from the womb; it’s generally performed between 15 and 20 weeks. Testing the fluid can identify certain fetal abnormalities such as Down syndrome or spina bifida. Typically, amniocentesis is recommended only if there is reason to believe that the risk for such conditions is higher than usual, perhaps due to maternal age (35 or older), abnormal AFP or multiple marker screening results, or family history. Although the test poses a small risk for causing preterm labor and inducing miscarriage, the large majority are performed without any problem.
Chorionic villus sampling (CVS): This procedure is used during the first trimester for the same purposes as an amniocentesis. (Women usually have one or the other, but not both, if such testing is deemed necessary.) It involves taking a sample of the tissue that attaches the amniotic sac (the sac around the fetus) to the wall of the uterus. Like amniocentesis, CVS is typically done only when there are certain risk factors; its primary advantage is that results are available sooner. CVS also carries a slightly increased risk of miscarriage and other complications.
Ultrasound (also called a sonogram, sonograph, echogram, or ultrasonogram): You’ll likely have at least one ultrasound examination to make sure the pregnancy is progressing normally and to verify the expected date of delivery. Usually, an ultrasound is performed at 18 to 20 weeks to look at the baby’s anatomy, but can be done sooner or later and sometimes more than once. An ultrasound poses no risk to you or your baby.
Some health care providers may have the equipment and trained personnel necessary to provide in-office ultrasounds, whereas others may have you go to a local hospital or radiology center.
Wherever the ultrasound is done, a technician will coat your abdomen with a gel and then run a wand-like instrument over it. High-frequency sound waves “echo” off your body and create a picture of the fetus inside on a computer screen.
Ultrasound scanning is used to:
•determine whether the fetus is growing at a normal rate
•record fetal heartbeat or breathing movements
•see whether you might be carrying more than one fetus
•identify a variety of abnormalities that might affect the remainder of the pregnancy or delivery
There are ultrasounds available at shopping malls as a way to have a “portrait” of your baby. However, the individuals using the equipment are not necessarily trained as ultrasound technicians. Before committing to having one of these done, it would be wise to discuss it with your health care provider.
Common Concerns
Some women are concerned about preexisting medical conditions, such as diabetes, and how they could affect a pregnancy. It’s important to discuss these concerns with your health care provider, who may recommend a change in medication or treatment approaches that could ease your concerns.
Whether or not you have a preexisting condition, you may be concerned about some of the other conditions that can be associated with pregnancy including:
•gestational diabetes: Up to 8% of pregnant women develop this condition, usually after the first trimester. During pregnancy, the placenta, which provides the fetus with nutrients and oxygen, also produces hormones that change the way insulin works. Insulin is a substance that’s made by the pancreas. It helps the body store the sugar in food so that later it can be converted to energy. When someone has gestational diabetes, the problem with the insulin leads to a high blood sugar level as well.
•preeclampsia (also called toxemia of pregnancy): An abnormal condition that develops after the sixth month, it causes high blood pressure, edema (accumulation of fluid in body tissues resulting in swelling of the hands, feet, or face), and protein in the urine.
•Rh-negative mother/Rh-positive fetus (also called Rh incompatibility): Rh factor is a substance found in the red blood cells of most people (a simple blood test can determine your Rh factor). If you don’t have it, then you’re considered Rh negative. If your baby does have the factor and is Rh positive, problems can result when the baby’s blood cells enter your bloodstream. That’s because your body may react by producing antibodies that can pass into the fetus’ bloodstream and destroy red blood cells.
These conditions are serious but manageable, so it’s important to educate yourself about them and discuss them with your health care provider.
Pregnant women also frequently worry about weight gain. It’s generally recommended that a woman of normal weight gain approximately 25 to 30 pounds during pregnancy. For individuals who start their pregnancy overweight, their total weight gain should be closer to 15 to 25 pounds. And those who are underweight should gain 28 to 40 pounds.
Pregnancy is not a good time to start a diet, however, it can be a great time to start eating healthy food if you didn’t before. It’s also a good time to get regular, low-impact exercise.
Controlling weight gain is more difficult later in a pregnancy, so try to avoid gaining a lot of weight during the first few months. However, not gaining enough weight can cause problems too, such as inadequate fetal growth and premature labor.
Taking Care of Yourself
For your baby’s sake and yours, it’s important to take especially good care of yourself during your pregnancy. Follow the basics:
•Don’t smoke, drink alcohol, or take drugs.
•Get enough rest.
•Eat a healthy diet.
Doctors generally recommend that women add about 300 calories to their daily intake to provide nourishment for the developing fetus. Although protein should supply most of these calories, your diet needs to be well-balanced, including fresh fruits, grains, and vegetables. Your health care provider will likely prescribe a prenatal vitamin to make sure you get enough folic acid, iron, and calcium.
Over-the-counter medications are generally considered off-limits because of their potential effects on the fetus. Most doctors will recommend that you don’t take any over-the-counter medications at all, but they might offer a list of those they think are safe to take. Be sure to discuss any questions about medications, including natural remedies, supplements, and vitamins, with your health care provider.
When you’re pregnant, it’s also important to avoid food-borne illnesses, such as listeriosis and toxoplasmosis, which can be life threatening to an unborn baby and may cause birth defects or miscarriage. Foods you’ll want to steer clear of include:
•soft, unpasteurized cheeses (often advertised as “fresh”) such as feta, goat, Brie, Camembert, and blue cheese
•unpasteurized milk, juices, and apple cider
•raw eggs or foods containing raw eggs, including mousse and tiramisu
•raw or undercooked meats, fish, or shellfish
•processed meats such as hot dogs and deli meats (these should be well cooked)
You should also avoid eating shark, swordfish, king mackerel, or tilefish. Although fish and shellfish can be an extremely healthy part of your pregnancy diet (they contain beneficial omega-3 fatty acids and are high in protein and low in saturated fat), these types of fish may contain high levels of mercury, which can cause damage to the developing brain of a fetus.
Pregnancy also can cause a number of uncomfortable, although not necessarily serious, side effects, including:
•nausea and vomiting, especially early in the pregnancy
•leg swelling
•varicose veins in the legs and the area around the vaginal opening
•hemorrhoids
•heartburn and constipation
•backache
•fatigue
•sleep loss
If you experience one or more of these side effects, keep in mind that you’re not alone! Talk to your doctor about strategies for alleviating any discomfort.
Talking to Your Health Care Provider
When your body is going through physical changes that may be completely new to you, it isn’t always easy to talk to your health care provider. Maybe you’re wondering whether you can have sex or what to do about hemorrhoids or constipation, or maybe you’re feeling a great deal of anxiety about the delivery.
You might feel embarrassed to ask these or other questions, but it’s important to do so — your health care provider has probably heard them all before. Keep a running list of questions between your appointments, and take that list with you to each visit.
It’s also strongly recommended that you call your health care provider immediately if you experience:
•heavy bleeding
•a sudden loss of fluid
•a marked absence of movement by the baby once he or she has begun moving
•more than three contractions in an hour
Staying Healthy During Pregnancy:
Now that you’re pregnant, taking care of yourself has never been more important. Of course, you’ll probably get advice from everyone — your doctor, family members, friends, co-workers, and even complete strangers — about what you should and shouldn’t be doing.
But staying healthy during pregnancy depends on you, so it’s crucial to arm yourself with information about the many ways to keep you and your baby as healthy as possible.
Prenatal Health Care
Key to protecting the health of your child is to get regular prenatal care. If you think you’re pregnant, call your health care provider to schedule an appointment. You should schedule your first examination as soon as you think that you are pregnant.
At this first visit, your health care provider likely do a pregnancy test, and will figure out how many weeks pregnant you are based on a physical examination and the date of your last period. He or she will also use this information to predict your delivery date (however, an ultrasound performed sometime during your pregnancy will help to verify that date).
If you’re healthy and there are no complicating risk factors, most health care providers will want to see you:
•every 4 weeks until the 28th week of pregnancy
•then every 2 weeks until 36 weeks
•then once a week until delivery
Throughout your pregnancy, your health care provider will check your weight and blood pressure while also checking the growth and development of your baby (by doing things like feeling your abdomen, listening for the fetal heartbeat starting during the second trimester, and measuring your belly). During the span of your pregnancy, you’ll also have prenatal tests, including blood, urine, and cervical tests, and probably at least one ultrasound.
If you still need to choose a health care provider to counsel and treat you during your pregnancy, there are several options:
•obstetricians/gynecologists (also known as OB/GYNs — doctors who specialize in pregnancy and childbirth, as well as women’s health care)
•family practitioners (doctors who provide a range of services for patients of all ages — in some cases, this includes obstetrical care)
•certified nurse-midwives (advanced practice nurses specializing in women’s health care needs, including prenatal care, labor and delivery, and postpartum care for uncomplicated pregnancies; there are also other kinds of midwives, but you should look for one with formal training who’s been certified in the field)
Any of these is a good choice if you’re healthy and there’s no reason to anticipate complications with your pregnancy and delivery. However, nurse-midwives do need to have a doctor available for the delivery in case an unexpected problem arises or a cesarean section (C-section) has to be performed.
Nutrition and Supplements
Now that you’re eating for two (or more!), this is not the time to cut calories or go on a diet. In fact, it’s just the opposite — you need about 300 extra calories a day, especially later in your pregnancy when your baby grows quickly. If you’re very thin, very active, or carrying multiples, you’ll need even more. But if you’re overweight, your health care provider may advise that you consume fewer extra calories.
Healthy eating is always important, but especially when you’re pregnant. So, make sure your calories come from nutritious foods that will contribute to your baby’s growth and development.
Try to maintain a well-balanced diet that incorporates the dietary guidelines including:
•lean meats
•fruits
•vegetables
•whole-grain breads
•low-fat dairy product
By eating a healthy, balanced diet you’re more likely to get the nutrients you need. But you will need more of the essential nutrients (especially calcium, iron, and folic acid) than you did before you became pregnant. Your health care provider will prescribe prenatal vitamins to be sure both you and your growing baby are getting enough.
But taking prenatal vitamins doesn’t mean you can eat a diet that’s lacking in nutrients. It’s important to remember that you still need to eat well while pregnant. Prenatal vitamins are meant to supplement your diet not be your only source of much-needed nutrients.
Calcium
Most women 19 and older — including those who are pregnant — don’t often get the daily 1,000 mg of calcium that’s recommended. Because your growing baby’s calcium demands are high, you should increase your calcium consumption to prevent a loss of calcium from your own bones. Your doctor will also likely prescribe prenatal vitamins for you, which may contain some extra calcium.
Good sources of calcium include:
•low-fat dairy products including milk, pasteurized cheese, and yogurt
•calcium-fortified products, including orange juice, soy milk, and cereals
•dark green vegetables including spinach, kale, and broccoli
•tofu
•dried beans
•almonds
Iron
Pregnant women need about 30 mg of iron every day. Why? Because iron is needed to make hemoglobin, the oxygen-carrying component of red blood cells. Red blood cells circulate throughout the body to deliver oxygen to all its cells.
Without enough iron, the body can’t make enough red blood cells and the body’s tissues and organs won’t get the oxygen they need to function well. So it’s especially important for pregnant women to get enough iron in their daily diets — for themselves and their growing babies.
Although the nutrient can be found in various kinds of foods, iron from meat sources is more easily absorbed by the body than iron found in plant foods. Iron-rich foods include:
•red meat
•dark poultry
•salmon
•eggs
•tofu
•enriched grains
•dried beans and peas
•dried fruits
•dark leafy green vegetables
•blackstrap molasses
•iron-fortified breakfast cereals
Folate (Folic Acid)
The Centers for Disease Control and Prevention (CDC) recommends that all women of childbearing age — and especially those who are planning a pregnancy — get about 400 micrograms (0.4 milligrams) of folic acid supplements every day. That can be from a multivitamin or folic acid supplement in addition to the folic acid found in food.
So, why is folic acid so important? Studies have shown that taking folic acid supplements 1 month prior to and throughout the first 3 months of pregnancy decrease the risk of neural tube defects by up to 70%.
The neural tube — formed during the several weeks of the pregnancy, possibly before a woman even knows she’s pregnant — goes on to become the baby’s developing brain and spinal cord. When the neural tube doesn’t form properly, the result is a neural tube defect such as spina bifida.
Again, your health care provider can prescribe a prenatal vitamin that contains the right amount of folic acid. Some pregnancy health care providers even recommend taking an additional folic acid supplement, especially if a woman has previously had a child with a neural tube defect.
If you’re buying an over-the-counter supplement, keep in mind that most multivitamins contain folic acid, but not all of them have enough folic acid to meet the nutritional needs of a pregnant woman. So, be sure to check labels carefully before choosing one and check with your health care provider.
Fluids
It’s also important to drink plenty of fluids, especially water, during pregnancy. A woman’s blood volume increases dramatically during pregnancy, and drinking enough water each day can help prevent common problems such as dehydration and constipation.
Exercise
The U.S. Department of Health and Human Services recommends at least 150 minutes (that’s 2 hours and 30 minutes) of moderate-intensity aerobic activity each week if you’re not already highly active or doing vigorous-intensity activity. If you are very active or did intense aerobic activities before becoming pregnant, you may be able to keep up your workouts, as long as your doctor says it’s safe. Before beginning — or continuing — any exercise regimen talk to your doctor first.
Exercising during pregnancy has been shown to be extremely beneficial. Regular exercise can help:
•prevent excess weight gain
•reduce pregnancy related problems, like back pain, swelling, and constipation
•improve sleep
•increase energy
•improve outlook
•prepare for labor
•lessen recovery time
Low-impact, moderate-intensity exercise activities (such as walking and swimming) are great choices. You can also opt for yoga or Pilates classes, DVDs, or videos that are tailored for pregnancy. These are both low-impact and work on strength, flexibility, and relaxation.
But you should limit high-impact aerobics and avoid certain sports and activities that pose a risk of falling or abdominal injury. Typical limitations include contact sports, downhill skiing, and horseback riding.
It’s also important to be aware of how your body changes. During pregnancy, your body produces a hormone known as relaxin, which is believed to help prepare the pubic area and the cervix for the birth. The relaxin loosens the ligaments in your body, making you less stable and more prone to injury.
So, it’s easy to overstretch or strain yourself, especially the joints in your pelvis, lower back, and knees. In addition, your center of gravity shifts as your pregnancy progresses, so you may feel off-balance and at risk of falling. Keep these in mind when you choose an activity and don’t overdo it.
Whatever type of exercise you choose, make sure to take frequent breaks and remember to drink plenty of fluids. And use common sense — slow down or stop if you get short of breath or feel uncomfortable. If you have any questions about doing a certain sport or activity during your pregnancy, talk to your health care provider for specific guidelines.
Sleep
It’s important to get enough sleep during your pregnancy. Your body is working hard to accommodate a new life, so you’ll probably feel more tired than usual. And as your baby gets bigger, it will be harder to find a comfortable position when you’re trying to sleep.
Lying on your side with your knees bent is likely to be the most comfortable position as your pregnancy progresses. It also makes your heart’s job easier because it keeps the baby’s weight from applying pressure to the large blood vessels that carry blood to and from your heart and your feet and legs. Lying on your side can also help prevent or reduce varicose veins, hemorrhoids, and swelling in your legs.
Some doctors specifically recommend that pregnant women sleep on the left side. Because one of those big blood vessels is on the right side of your abdomen, lying on your left side helps keep the uterus off of it. Lying on your left side optimizes blood flow to the placenta and, therefore, your baby.
Ask what your health care provider recommends. In most cases, lying on either side should do the trick and help take some pressure off your back. To create a more comfortable resting position either way, prop pillows between your legs, behind your back, and underneath your belly.
Some Things to Avoid
When you’re pregnant, what you don’t put into your body (or expose your body to) is almost as important as what you do. Here are some things to avoid:
Alcohol
Although it may seem harmless to have a glass of wine at dinner or a mug of beer out with friends, no one has determined what’s a “safe amount” of alcohol to consume during pregnancy. One of the most common known causes of mental and physical birth defects, alcohol can cause severe abnormalities in a developing fetus.
Alcohol is easily passed along to the baby, who is less equipped to eliminate alcohol than the mother. That means an unborn baby tends to develop a high concentration of alcohol, which stays in the baby’s system for longer periods than it would in the mother’s. And moderate alcohol intake, as well as periodic binge drinking, can damage a baby’s developing nervous system.
If you had a drink or two before you even knew you were pregnant (as many women do), don’t worry too much about it. But your best bet is to not drink any alcohol at all for the rest of your pregnancy.
Recreational Drugs
Pregnant women who use drugs may be placing their unborn babies at risk for premature birth, poor growth, birth defects, and behavior and learning problems. And their babies could also be born addicted to those drugs themselves.
If you’re pregnant and using drugs, a health clinic such as Planned Parenthood can recommend health care providers, at little or no cost, who can help you quit your habit and have a healthier pregnancy.
If you’ve used any drugs at any time during your pregnancy, it’s important to inform your health care provider. Even if you’ve quit, your unborn child could still be at risk for health problems.
Nicotine
You wouldn’t light a cigarette, put it in your baby’s mouth, and encourage your little one to puff away. As ridiculous as this scenario seems, pregnant women who continue to smoke are allowing their fetus to smoke, too. The smoking mother passes nicotine and carbon monoxide to her growing baby.
The risks of smoking to the fetus include:
•stillbirth
•prematurity
•low birth weight
•sudden infant death syndrome (SIDS)
•asthma and other respiratory problems
If you smoke, having a baby may be the motivation you need to quit. Talk to your health care provider about options for stopping your smoking habit.
Caffeine
High caffeine consumption has been linked to an increased risk of miscarriage, so it’s probably wise to limit or even avoid caffeine altogether if you can.
If you’re having a hard time cutting out coffee cold turkey, here’s how you can start:
•Cut your consumption down to one or two cups a day.
•Gradually reduce the amount by combining decaffeinated coffee with regular coffee.
•Eventually try to cut out the regular coffee altogether.
And remember that caffeine is not limited to coffee. Many teas, colas, and other soft drinks contain caffeine. Try switching to decaffeinated products (which may still have some caffeine, but in much smaller amounts) or caffeine-free alternatives.
If you’re wondering whether chocolate, which also contains caffeine, is a concern, the good news is that you can have it in moderation. Whereas the average chocolate bar has anywhere from 5 to 30 milligrams of caffeine, there’s 95 to 135 milligrams in a cup of brewed coffee. So, small amounts of chocolate are fine.
Certain Foods
Although you need to eat plenty of healthy foods during pregnancy, you also need to avoid food-borne illnesses, such as listeriosis and toxoplasmosis, which can be life-threatening to an unborn baby and may cause birth defects or miscarriage.
Foods you’ll want to steer clear of include:
•soft, unpasteurized cheeses (often advertised as “fresh”) such as feta, goat, Brie, Camembert, and blue cheese
•unpasteurized milk, juices, and apple cider
•raw eggs or foods containing raw eggs, including mousse, tiramisu, raw cookie dough, homemade ice cream, and Caesar dressing (although some store-bought brands of the dressing may not contain raw eggs)
•raw or undercooked meats, fish (sushi), or shellfish
•processed meats such as hot dogs and deli meats (unless they are reheated until steaming)
Also, although fish and shellfish can be an extremely healthy part of your pregnancy diet (they contain beneficial omega-3 fatty acids and are high in protein and low in saturated fat), you should avoid eating:
•shark
•swordfish
•king mackerel
•tilefish
•tuna steak
These types of fish may contain high levels of mercury, which can cause damage to the developing brain of a fetus. When you choose seafood, limit the total amount to about 12 ounces per week — that’s about two meals. Also, if you eat canned tuna, limit consumption to no more than 6 ounces per week. Also, check any local advisories before consuming recreationally caught fish.
Changing the Litter Box
Pregnancy is the prime time to get out of cleaning kitty’s litter box. Why? Because toxoplasmosis can be spread through soiled cat litter boxes and can cause serious problems, including prematurity, poor growth, and severe eye and brain damage. A pregnant woman who becomes infected often has no symptoms but can still pass the infection on to her developing baby.
Over-the-Counter and Prescription Medications
Even common over-the-counter medications that are generally safe may be considered off-limits during pregnancy because of their potential effects on the baby. And certain prescription medications may also cause harm to the developing fetus.
To make sure you don’t take anything that could be harmful to your baby:
•Ask your health care provider which medicines — both over-the-counter and prescription — are safe to take during pregnancy.
•Talk to your health care provider about any prescription drugs you’re taking.
•Let all of your health care providers know that you’re pregnant so that they’ll keep that in mind when recommending or prescribing any medications.
•Also remember to discuss natural remedies, supplements, and vitamins.
If you were prescribed a medication before you became pregnant for an illness, disease, or condition you still have, consult with your health care provider, who can help you weigh potential benefits and risks of continuing your prescription.
If you become sick (e.g., with a cold) or have symptoms that are causing you discomfort or pain (like a headache or backache), talk to your health care provider about medications you can take and alternative ways to help you feel better without medication.
Healthy Pregnancy Habits: From Start to Finish
During pregnancy, from the first week to the fortieth, it’s important to take care of yourself in order to take care of your baby. Even though you have to take some precautions and be ever-aware of how what you what you do — and don’t do — may affect your baby, many women say they’ve never felt healthier than when they carried their children.
Sex During Pregnancy
Pregnancy is a time of physical and emotional change. Personal history, symptoms and attitudes about becoming a parent influence the feelings that a woman has about her body and about making love during pregnancy. The pregnancy may alter how a woman and her partner feel about making love, and differences in sexual need may arise. The best way to deal with these differences is to talk, to listen and to be open to each other’s feelings and concerns. In addition, questions about sexual practices and their effect on the baby and the pregnancy should be discussed with a health care provider during prenatal visits.
Pregnancy Changes and Sexuality
For many women, the first three months of pregnancy can bring fatigue and nausea. If these symptoms are present, a woman may not feel like making love.
Pregnancy brings an increased blood supply to the pelvic area. During the second three months of pregnancy, after the first trimester symptoms have passed and before the growing uterus makes positioning more of a challenge, many women enjoy sexual intercourse. A woman’s breasts increase in size during pregnancy, enlarging even more with sexual arousal. For some women this is the first time that they truly enjoy having their breasts fondled, while others experience these changes as uncomfortable breast tenderness.
As the pregnancy progresses and a woman begins to lose her waistline, positioning and comfort become important in lovemaking. A woman may become depressed as the shape of her body changes. As the baby begins to move down into the pelvis, a woman may be bothered by increased pelvic pressure. She may not like the idea of intercourse and her partner also may worry about hurting the baby. In addition, orgasm may be somewhat frightening during pregnancy. Upon reaching orgasm, the uterus contracts in a rhythmical fashion. In a pregnant woman, these contractions last longer and in the third trimester they can occasionally turn into long, hard contractions that may feel uncomfortable. Sensitivity to each other’s wishes is vital. Cuddling and massage may be an alternate way to share time together.
Pregnancy and Safe Sex
Partners need to be honest and realistic about sex during pregnancy. Open communication may help to defuse frustration. Because AIDS/HIV infection is transmitted through sexual activity, always practice safe sex. HIV infections can be transmitted to the unborn child. If you have questions about what is safe sex and want to discuss concerns in confidence, call 1-800-FOR-AIDS and ask for a health provider.
Sexuality and High Risk Pregnancy
For most women and their partners, sex during pregnancy is fine as long as both partners consent and are comfortable. However, certain problems can occur during pregnancy that put the fetus at risk for premature delivery. If you are experiencing vaginal bleeding, preterm labor or ruptured membranes, you should not have sexual intercourse and you should avoid having orgasms. Your health care provider will tell you if sex could be harmful and do not hesitate to ask if you have questions or concerns.
Suggestions for Making Love During Pregnancy
Some hints for satisfying and comfortable sexuality during pregnancy include:
Positioning
•Side lying — partner behind woman
•Woman on hands and knees, partner kneeling behind
•Woman sitting on partner’s lap
Lubrication
•Water soluble lubricant jelly, such as Astroglide, KY Jelly. Do not use baby oil or Vaseline.
•Lubricated condom
Alternatives
•Cuddling
•Full body massage
Safe Skin Care During Pregnancy:
Highlights
Retinoids
Salicylic acid
Soy
Acne products
Hair removers & minimizers
Sunscreens
Makeup
The final word
Most pregnant women know that what they put (or don’t put) in their bodies is important to the well-being of their growing baby, whether it’s the right kind of protein, too much caffeine, or certain types of fish. But many pregnant women might not know that what they put on their bodies is just as important.
Most of us slather on oceans of lotions every day, but we don’t think about what might be passing the skin barrier and being absorbed into our bodies. With a developing baby in your belly, this is a vital concern.
“Everything you eat, apply, or come into contact with may affect not only you but also your baby,” says Sandra Marchese Johnson, a dermatologist with Johnson Dermatology in Fort Smith, Arkansas.
“Because some topical ingredients get absorbed into the bloodstream, there are some you want to avoid,” adds Leslie Baumann, a professor of dermatology at the University of Miami and author of The Skin Type Solution (Bantam, 2006).
The more powerful and targeted products get, the more we need to be careful about what we have in our skin-care regimens during pregnancy. While most commonly used products are completely safe, there’s a handful of ingredients considered potentially harmful to a growing baby. Below, see our guide to what to look for when shopping the beauty aisle.
If you plan to breastfeed, adds Johnson, continue following the guidelines noted below until you stop nursing.
Retinoids
These powerful substances, found in some antiaging moisturizers, are lauded for helping reduce wrinkles and improve skin tone. Retinoids are a type of vitamin A that speeds up cell division (quickening your skin’s renewal) and prevent skin collagen from breaking down.
But retinoids are one of the skin-care ingredients that experts, including Baumann, recommend that expectant moms stay away from. Some studies have shown that high doses of vitamin A during pregnancy can be harmful to an unborn child. And oral retinoids, such as isotretinoin (Accutane, an acne treatment), are known to cause birth defects.
If you’ve been using a skin cream that contains a retinoid, don’t panic. Retinoids have not been shown to cause problems in their topical form in pregnant women.
“There is no data to show these retinoids ingredients are harmful when used on the skin — doctors are just being extra cautious,” explains Baumann.
On the label:
Differin (adapelene)
Retin-A, Renova (tretinoin)
Retinoic acid
Retinol
Retinyl linoleate
Retinyl palmitate
Tazorac and avage (Tazarotene)
Bottom line:
Best to avoid
Salicylic acid
This mild acid is used to treat certain skin disorders, including acne, and you can find it in a number of skin products, such as cleansers and toners. It can penetrate facial oils to get deep into pores and clean out dead skin cells. Salicylic acid is in the aspirin family, so it can also help reduce inflammation or redness. BHA, or beta hydroxy acid, is a form of salicylic acid and is used in some topical exfoliants to reverse signs of aging.
But salicylic acid is another no-no for pregnant women. High doses of the acid in its oral form have been shown in studies to cause birth defects and various pregnancy complications.
Again, doctors are being cautious by recommending that pregnant women avoid the topical use of salicylic acid. Small amounts applied to the skin — such as a salicylic acid-containing toner used once or twice a day — are considered safe, says Johnson.
But the concern is stronger about face and body peels containing salicylic acid. “This kind of ‘soaking’ in the ingredient is similar to taking one or more aspirin when pregnant,” she explains.
“More product used equals more absorption into the bloodstream,” adds Baumann. Always check with your doctor before having a peel treatment. Better yet, she advises, if you must have a peel, have it done professionally at your dermatologist’s office. A dermatologist will know how to do it safely during pregnancy.
On the label:
Salicylic acid
Beta hydroxy acid
BHA
Note: Alpha hydroxy acids, sometimes listed as AHAs, glycolic acid, or lactic acid, are safe.
Soy
Some moms-to-be seek out natural ingredients such as soy in their skin-care products, thinking that they’re free from harmful effects. But that’s not necessarily the case, says Baumann.
While soy-based lotions and facial products are generally safe to use, “Soy can make the ‘mask of pregnancy’ (dark splotches on facial skin) worse, as can oil of bergamot, which is in many organic products,” she says.
Soy has estrogenic effects, which can make those dark patches, also known as melasma or chloasma, worse, Baumann explains. “The ‘active soy’ found in some product lines is okay, however, because the estrogenic components have been taken out.”
On the label:
Lethicin
Phosphatidylcholine
Soy
Textured vegetable protein (TVP)
Bottom line:
If you have dark skin or melasma, avoid these products, or choose ‘active soy’ products instead. Otherwise it’s safe to use.
Acne products
Many women have breakouts in the first trimester because of changing estrogen levels, even if they’ve always had clear skin. If you’re dealing with pregnancy-induced acne, a dermatologist can likely give you a safe topical antibiotic, advises Baumann. You can find a dermatologist in your area through your health insurance company or at the American Academy of Dermatology Web site.
But if you prefer to avoid yet another doctor appointment, Baumann recommends using a facial wash that contains no more than 2 percent salicylic acid (look for the percentage on the product label). This small amount is considered safe.
If you want to be doubly sure, ask your obstetrician or midwife before use. As for what to avoid when it comes to treating acne, stay away from leave-on acne lotions, gels, and creams, as well as at-home peels, which can contain salicylic acid or retinoids, says Baumann. And, of course, steer clear of the oral form of the retinoid Accutane.
On the label:
Beta hydroxy acid
BHA
Differin (adapelene)
Retin-A, Renova (tretinoin)
Retinoic acid
Retinol
Retinyl linoleate
Retinyl palmitate
Salicylic acid
Tazorac and avage (Tazarotene)
Tretinoin
Note: Glycolic acid is an AHA, and safe to use.
Bottom line:
Consult your dermatologist, or use mild over-the-counter cleansers only.
Hair removers & minimizers
Lotions that remove your hair chemically (depilatories) or that minimize hair between shaves sound like a dream come true when you can barely reach — not to mention see — your legs. The good news is that these products are considered risk-free.
“There are no specific ingredients to avoid when it comes to these types of products,” . “The only risk is an allergy.”
Catherine Lynch, director of the division of general obstetrics and gynecology at the University of South Florida, says, “As long as you use [chemical hair removers] as directed, they shouldn’t be a problem. It’s a topical solution that isn’t absorbed into your bloodstream, so it can’t have any effect on the baby.”
If you’ve had an allergic skin reaction to hair minimizers or removal creams in the past, then you should avoid these products during pregnancy as well.
Also, some women’s skin gets extra sensitive during pregnancy, so you may have a reaction to these ingredients even if you haven’t before. Before slathering your whole leg, do a patch test on a small piece of skin behind your knee and wait 24 hours to see if you react.
On the label:
Potassium Thioglycolate (depilatory)
Calcium Thioglycolate (depilatory)
Sodium Hydroxide (minimizer)
Sanguisorba Officinalis Root Extract (minimizer)
Hydrolyzed Soy Protein (minimizer)
Bottom line:
Safe to use
Sunscreens
Just because you’re pregnant doesn’t mean you can’t hit the beach. In fact, feeling the sand between your toes and that warm breeze in your hair may provide that perfect “relaxation point” your Lamaze instructor has been talking about. And as your mom always told you: Don’t forget the sunscreen.
Sunscreens, including those with ingredients that penetrate the skin, are perfectly safe when you’ve got your own bun in the oven, says Baumann.
“[Ingredients] that do go deep into the skin do so in such small concentrations” that they’re not worth worrying about, says Johnson. “I personally prefer titanium dioxide and zinc oxide — they are powerful physical sunscreens and do not penetrate the skin.”
She adds, “In addition to sunscreen, we advise sun-smart behaviors — avoiding the sun between 10 a.m. and 4 p.m.; using a sun hat, sunglasses and sun-protective clothing; and reapplying your sunscreen every two hours.”
And if you have melasma, adds Baumann, you can try a UV protector with a skin lightener.
On the label:
Titanium dioxide
Zinc oxide
Avobenzone (Parsol 1789)
Oxybenzone
Dioxybenzone
Benzophenone
Octyl methoxycinnamate (OMC)
Para-aminobenzoic acid (PABA)
Octocrylene
Bottom line:
Safe to use
Makeup
You may not give a second thought to the kind of makeup you use, but even cosmetics are something to consider when pregnant, says dermatologist Johnson.
Many makeup products are marked “noncomedogenic” or “nonacnegenic” — meaning they’re oil-free and don’t clog pores. These are safe and will not affect the health of your baby.
Avoid cosmetics that contain retinol or salicylic acid (found in some makeup for acne-prone skin).
If you want to be super careful during pregnancy, try some of the minerals-only makeup lines. These products use ingredients that primarily sit on top of the skin and don’t cause irritation for most people.
On the label:
Differin (adapelene)
Retin-A, Renova (tretinoin)
Retinoic acid
Retinol
Retinyl linoleate
Retinyl palmitate
Tazorac and avage (Tazarotene)
Tretinoin
Bottom line:
Avoid cosmetics that contain retinoids or salicylic acids. Otherwise, safe to use.
The final word
When you’re pregnant, it’s important to discuss any product you use on your skin with your healthcare provider.
But if you realize you have used a product that contains one of the potentially harmful ingredients noted above, don’t panic, says Johnson. Simply stop using the product now and pick one with known-to-be-safe ingredients.
“Most over-the-counter products by reputable brands are safe,” she says. “And if you are applying these products to less than 10 percent of your total skin surface, the risks of systemic effects are very low.”
Dental Care During Pregnancy:
It’s vitally important for you to take good care of your oral health while you are pregnant. This is because pregnancy causes hormonal changes that increase your risk of developing gum disease, and because your oral health can affect the health of your developing baby.
Below are some suggestions for maintaining good oral health – as well as your baby’s health and safety — before, during, and after your pregnancy.
Before you get pregnant
Make a dental appointment before getting pregnant (if possible). In this way, your teeth can be professionally cleaned, your gum tissue can be carefully examined, and any oral health problems identified can be treated in advance of your pregnancy.
While you are pregnant
· Tell your dentist (and doctor) if you know you are pregnant or are planning to become pregnant. This will help your health care providers plan for any treatments or procedures. It’s always best to complete any major dental treatment prior to pregnancy. Routine dental care, on the other hand, can be received during the second trimester. As a precautionary measure, dental treatments during the first trimester and second half of the third trimester should be avoided as much as possible. These are critical times in the baby’s growth and development, and it’s simply wise to avoid exposing the mother to procedures that could in any way “influence” the baby’s growth and development. All elective dental procedures should be postponed until after the delivery.
Tell your dentist the names and dosages of all medicines you are taking – including medicines and prenatal vitamins prescribed by your doctor – as well as any specific medical advice your doctor has given you to follow. Your dentist might need to alter your dental treatment plan based on this information. Certain drugs — such as tetracycline can affect the development of your child’s teeth and should not be given during pregnancy.
Avoid dental X-rays during pregnancy. If X-rays are essential (such as in a dental emergency), your dentist will use extreme caution to safeguard you and your baby. Advances in dentistry have made X-rays much safer today than in past decades.
Don’t skip your dental checkup appointment simply because you are pregnant and believe this appointment is not important. Now more than any other time, regular periodontal examinations are very important. Pregnancy causes hormonal changes that put you at increased risk for periodontal disease and for tender gums that bleed easily – a condition called pregnancy gingivitis. To remove irritants, control plaque, and maintain optimum oral health, you might actually benefit from more frequent professional cleanings during your second trimester or early third trimester rather than fewer dental visits. Pay particular attention to any changes in your gums during pregnancy. If tenderness, bleeding, or gum swelling occurs at any time during your pregnancy, talk with your dentist or periodontist as soon as possible.
Follow good oral hygiene practices to prevent and/or reduce gingival problems, including brushing your teeth at least twice a day and flossing at least once a day. Use a good-quality, soft-bristled toothbrush. Use a toothpaste that contains fluoride, and brush for at least two minutes to remove the plaque that forms on your teeth.
If morning sickness is keeping you from brushing your teeth, change to a bland-tasting toothpaste during your pregnancy. Ask your dentist or hygienist to recommend brands.
Rinse your mouth out with water or a mouth rinse if you suffer from morning sickness and have bouts of frequent vomiting.
Ask your dentist about the need for fluoride supplements. Since fluoride is found in water and almost all brands of toothpaste, fluoride supplementation might not be necessary.
Avoid sugary snacks. Sweet cravings are common during pregnancy. However, keep in mind that the more frequently you snack, the greater the chance of developing tooth decay. Additionally, some studies have shown that the bacteria responsible for tooth decay are passed from the mother to the child. So be careful of what you eat.
Eat a healthy, balanced diet. Your baby’s first teeth begin to develop about three months into your pregnancy. Healthy diets containing dairy products, cheese, and yogurt are good sources of these essential minerals and are good for your baby’s developing teeth, gums, and bones.
Consult with your dentist or doctor about the need for anesthesia or other medicines should a dental emergency arise. Make sure you tell all health care providers that you come into contact with that you are pregnant. This information could change their treatment plans. Dental treatments that could be considered “emergency” are those that are necessary to ease your pain, prevent an infection, or decrease stress on you or your fetus.
Care during pregnancy for women with type 1 or 2 diabetes:
INTRODUCTION — Prior to the development of insulin in 1922, pregnancy in women with diabetes mellitus posed very high risks to both mother and fetus. Today, most women with diabetes can expect an excellent pregnancy outcome, similar to that of nondiabetic women. This improvement is largely due to tight blood glucose control, which can be achieved with frequent daily glucose monitoring and insulin adjustment.
This topic review discusses care of women with type 1 or 2 diabetes during pregnancy, as well as fetal and newborn issues. It does not address gestational diabetes, which develops during pregnancy.
Type 1 diabetes is thought to be an autoimmune disease and requires insulin treatment because the pancreas has lost its ability to produce insulin. Type 2 diabetes , previously referred to as adult-onset diabetes, is usually caused by insulin resistance, and can be managed with insulin or other drugs that increase the body’s sensitivity to insulin or increase the pancreas’ production of insulin.
IMPORTANCE OF BLOOD GLUCOSE CONTROL — Glucose in the mother’s blood crosses the placenta and enters the baby’s bloodstream to help provide energy for it; thus, maternal hyperglycemia (high blood glucose levels) leads to high blood glucose levels in the developing baby as well.
High blood glucose levels can cause several problems:
Early in pregnancy, high glucose increases the risk of miscarriage and birth defects. These risks are highest when the A1C is >8 percent or the average blood glucose >180 mg/dL (10 mmol/L).
In the last half of pregnancy and near delivery, high glucose can cause the infant’s size and weight to be larger than normal (see “Ultrasound” below) and have a higher risk of complications during and after delivery (see “Newborn issues” below).
In particular, women with large infants are more likely to have difficulty delivering vaginally or require cesarean delivery.
These complications occur less frequently when blood glucose levels are carefully controlled.
General measures to control blood glucose
Most women with type 1 diabetes will require two to four insulin injections per day to optimally control blood glucose levels. An alternate option is to use an insulin pump.
Women with type 2 diabetes who have been controlled with diet or oral medications may require insulin during pregnancy
Women with diabetes need more insulin during pregnancy, especially during the last one-third of pregnancy (approximately 26 to 40 weeks of pregnancy) because the body becomes resistant to insulin as the pregnancy progresses. (See “Patient information: Diabetes type 1: Insulin treatment”).
Frequent contact with health care providers is important for managing blood glucose levels and monitoring the health of the woman and her baby. The healthcare provider may want to review blood glucose levels and insulin doses one or more times per week; this can usually be done via telephone, e-mail, or fax.
Oral diabetes medications, (eg, glyburide, metformin) have been used to manage gestational or type 2 diabetes in some cases. These medications adequately control blood glucose levels, but large studies of their safety have not been performed. As a result, the American College of Obstetricians and Gynecologists and American Diabetes Association do not recommended these medications during pregnancy. Women who are taking these drugs when they become pregnant should speak with their healthcare provider.
A nutritionist can help to plan a diet that provides the optimal number of calories, carbohydrate, and distribution of snacks/meals throughout the day. The optimal calorie intake depends upon the woman’s prepregnancy weight and activity level.
Exercise is an excellent way to control weight and blood glucose levels. Most women who exercised before pregnancy can continue to do so during pregnancy at the same or a slightly reduced pace. Moderate intensity exercise, such as brisk walking, is recommended. Women who did not exercise previously may begin to exercise during pregnancy after consulting with their healthcare provider. Exercise intensity, type, and duration may need to be modified as the pregnancy progresses or if complications develop.
Target blood glucose levels — Frequent glucose monitoring is recommended during pregnancy, including testing before breakfast (fasting) and before and after each meal. (See “Patient information: Self-blood glucose monitoring”). Target blood glucose levels during pregnancy are slightly lower.
The American College of Obstetricians and Gynecologists recommends the following goals:
Fasting: 60 to 90 mg/dL (3.3 to 5 mmol/L)
Preprandial (before meals): less than 100 mg/dL (5.6 mmol/L)
One-hour postprandial (after meals): less than 130 to 140 mg/dL (7.2 to 7.7 mmol/L)
Two-hour postprandial: less than 120 mg/dL (6.7 mmol/L)
A1C is a blood test that represents the average blood glucose level over the previous three months. This test is usually done once per month during pregnancy. The goal is for the A1C to be at or near normal (6 percent or an average blood glucose of 120 mg/dL [6.7 mmol/L]), (show figure 1). However, attempting to maintain this level can cause frequent episodes of hypoglycemia (low blood glucose), so A1C goals should be determined individually.
CARE DURING PREGNANCY — Ideally, a woman with diabetes who is planning pregnancy should consult her health care provider well before she becomes pregnant. This provides an opportunity to make sure her blood glucoses are in optimal control, adjust her medication, evaluate and treat any medical complications related to diabetes, and start folic acid supplementation (at least 400 mcg per day is recommended, starting at least one month before conception). It is also an opportunity to discuss how pregnancy may affect diabetes and vice versa.
The care of diabetic women during pregnancy is a team effort involving an obstetrician and an endocrinologist or internist who oversees insulin management and medical care. Some family practitioners may perform all of these functions.
Eye examination — Retinopathy refers to abnormal, leaky blood vessels in the light sensitive tissue lining the back of the eye (the retinas). Retinopathy can lead to vision problems, and even blindness in severe cases. Pregnancy can worsen diabetic retinopathy, although the reasons are not entirely clear. It is known that the risk of worsening retinopathy during pregnancy is increased in those with the highest initial A1C values and in women whose A1C is significantly reduced (usually as a result of tight blood glucose control).
The impact of pregnancy on diabetic retinopathy is mild and temporary for most women; the retina usually returns to its prepregnancy condition within several months postpartum. Nevertheless, all women with type 1 or 2 diabetes should have an eye examination by an ophthalmologist or optometrist before pregnancy and during the first trimester (three months). In most cases, a follow up examination is recommended every three months until delivery, depending upon the results of the initial examination.
Women with severe retinopathy are more likely to experience progression and complications. Eye examinations before and during pregnancy, along with close monitoring and treatment (as needed) of retinopathy can minimize the risk of vision loss. Some experts have recommended cesarean delivery for women with retinopathy, although this is controversial; most women can attempt a vaginal delivery.
Blood pressure monitoring — Blood pressure may become elevated during pregnancy and should be measured at every appointment. High blood pressure often improves during the first half of pregnancy, but returns to baseline or worsens in the second half.
Medications to treat high blood pressure during pregnancy may include methyldopa, calcium channel blocking agents (nifedipine, diltiazem), hydralazine, or beta blockers (atenolol, propranolol). Beta blockers can mask some symptoms of low blood glucose and should be used with caution.
Angiotensin converting enzyme (ACE) inhibitors (captopril, lisinopril, enalapril) and angiotensin II receptor blockers (ARBs, losartan, valsartan) are not safe during pregnancy, and should be discontinued in any woman planning pregnancy.
Gestational hypertension (high blood pressure during pregnancy) and preeclampsia are more common in women with diabetes. Preeclampsia is a condition that can occur in pregnancy that causes hypertension (blood pressure greater than 140/90) and proteinuria (protein in the urine). Fortunately, most cases are mild. In severe cases (eclampsia), seizure, stroke, heart failure, kidney damage, and rarely, maternal death can occur.
Preeclampsia cannot be prevented; the only treatment is to deliver. Women with moderately elevated blood pressure may be monitored for days or even weeks if preeclampsia develops prematurely; this may require hospitalization. Steroids may be given to encourage the fetus’s lungs to mature more rapidly. However, steroids significantly increase the woman’s blood glucose levels, and usually require a temporary increase in the insulin dose.
Kidney function monitoring — Pregnancy does not cause diabetes-related kidney disease (nephropathy), but it can worsen existing disease. Kidney function is monitored during pregnancy by urine dipstick testing for protein, which is usually performed at every visit. Other urine or blood tests may be ordered depending upon the individual’s situation.
Nephropathy is associated with other pregnancy complications, such as preeclampsia, preterm delivery, babies who are small for their age (intrauterine growth restriction (IUGR)), and a higher frequency of maternal hospitalization and cesarean delivery (show table 3). Women with retinopathy and kidney disease are at increased risk of having a small infant because blood flow to the placenta may be reduced.
If a woman develops worsening nephropathy during pregnancy, it is usually temporary and reverts to the prepregnancy condition within several months of delivery. Nephropathy probably worsens because blood flow through the kidney increases by 50 percent during pregnancy, which increases the kidneys’ workload. In addition, some women develop high blood pressure or new pregnancy-induced high blood pressure, which further stresses the kidney.
Permanent kidney damage, including kidney failure, can occur in women who already have significant nephropathy before becoming pregnant. These women may require dialysis or kidney transplant sooner than a woman with severe chronic kidney disease who never becomes pregnant. (See “Patient information: Renal replacement therapy” and see “Patient information: Hemodialysis”).
Ultrasound — An ultrasound examination of the baby is recommended during the first trimester of pregnancy (before 13 weeks) if there is any uncertainty about the date of the last menstrual period or estimated due date. It is important that the due date is accurate because decisions about when to begin fetal testing and when to deliver the baby are based upon this date.
Ultrasound examination is recommended at 18 to 20 weeks gestation to screen for birth defects. The examination should pay particular attention to the spine because these infants may be at increased risk for neural tube defects. Some experts recommend a fetal echocardiogram (an ultrasound of the fetus’s heart) because of the increased incidence of heart defects among infants of diabetic women who have uncontrolled high glucose levels in early pregnancy.
Ultrasound is also used to monitor the amount of amniotic fluid around the fetus; polyhydramnios is an abnormal increase in the amount of amniotic fluid. This condition is more common in women with diabetes than in women without diabetes. Polyhydramnios related to diabetes is usually mild and does not cause problems. If it becomes severe, maternal discomfort, uterine contractions, premature rupture of the membranes (“breaking the water”), and preterm delivery can occur.
Ultrasound is also used to monitor the baby’s growth and development throughout the pregnancy, although ultrasound estimates of the baby’s weight can be off by as much as 15 percent. Macrosomia is a condition in which an infant weighs more than nine pounds (4000 grams) at or beyond 37 weeks of pregnancy, and is more common in women with diabetes. High fetal insulin levels, which can develop in response to elevated maternal blood glucose levels, are one potential cause of increased birth weight since insulin stimulates fetal growth.
Macrosomia occurs in 15 to 45 percent of diabetic pregnancies, compared to 10 percent in the nondiabetic population. Cesarean delivery may be needed if labor does not progress normally because of the large size or position of the baby. In addition, macrosomic infants are at higher risk of being injured during delivery and may be delivered by cesarean delivery before labor if there is a concern that the infant’s shoulders may be difficult to deliver through a woman’s pelvis (called shoulder dystocia).
Screening for birth defects — Birth defects are more common in infants of women with elevated blood glucose levels before and during the early weeks of pregnancy; most birth defects develops by the 10th week of pregnancy. There is no particular birth defect caused by maternal diabetes. Recent studies have demonstrated that tight blood glucose control before becoming pregnant reduces the risk of birth defects to a level that is similar to that in women who do not have diabetes.
Screening for birth defects such as spina bifida and Down syndrome is recommended to all pregnant women, not just those with diabetes. Women with diabetes are not at increased risk for having a baby with a chromosomal abnormality, such as Down’s syndrome, but they are at increased risk of having a baby with a neural tube defect (eg, spina bifida).
Screening may be performed in the first or early second trimester, depending upon the type of screening test. Screening tests are used to identify pregnancies at increased risk of a birth defect, and cannot determine with certainty if a baby actually has the birth defect. If the test is abnormal, an ultrasound examination and/or amniocentesis may be performed to determine if the abnormality is actually present.
Fetal testing — Close monitoring of the fetus is recommended during the third trimester, usually starting at 32 to 38 weeks of pregnancy. This usually includes weekly to twice-weekly nonstress testing. This is done by monitoring the baby’s heart rate with a small device that is placed on the mother’s abdomen. The device uses sound waves (ultrasound) to measure the baby’s heart rate over time, usually for 20 to 30 minutes. Normally, the baby’s baseline heart rate should be between 110 and 160 beats per minute and should increase above its baseline by at least 15 beats per minute for 15 seconds when the baby moves.
The test is considered reassuring (called “reactive”) if two or more fetal heart rate increases are seen within a 20 minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes.
PLANNING FOR DELIVERY — A woman and her obstetrician may decide to schedule the date of her delivery (either an induction of labor or cesarean delivery), especially if there are risk factors, such as increased blood glucose levels, nephropathy, worsening retinopathy, hypertension or preeclampsia, or limited or excessive fetal growth. If delivery before the due date is planned, an amniocentesis to determine fetal lung maturity may be needed, depending on the individual’s situation and the fetus’s gestational age.
If the fetus appears to be very large (based upon ultrasound measurements), a woman and her obstetrician may consider cesarean delivery to avoid possible trauma from shoulder dystocia. The American College of Obstetricians and Gynecologists suggests that a woman and her physician consider a planned cesarean delivery if the estimated fetal weight (by ultrasound measurement) is greater than 4500 grams (9 lbs, 14 oz).
Waiting for labor to start on its own is reasonable if blood glucose levels are well-controlled and the mother and fetus are without problems. However, extending pregnancy beyond 40 to 41 weeks of gestation is generally not recommended; some practitioners routinely induce labor between 39 and 40 weeks in all women with type 1 or 2 diabetes.
The risk of stillbirth for pregnant women with carefully controlled diabetes is very low and is about the same as women without diabetes (less than 1 percent). The newborn mortality (death) rate in infants of diabetic women is slightly higher than in nondiabetics (2 versus 1 percent). This is mostly due to a higher rate of serious birth defects in infants of diabetic mothers.
INFANT CARE
Newborn issues — The infant of the diabetic mother is at risk for several problems in the newborn period, such as low blood glucose levels, jaundice, breathing problems, excessive red blood cells (polycythemia), low calcium level, and heart problems. These problems are more common when the mother’s blood glucose levels have been elevated during the pregnancy. Most of these problems resolve within a few hours or days after delivery. Infants of diabetic mothers are often evaluated in a special care nursery to monitor for these potential problems.
Infants of mothers with diabetes are at higher risk of having difficulties with breathing, especially if the infant is born earlier than 39 weeks of gestation. This is because the lungs appear to develop more slowly in infants of women with diabetes. The risk of respiratory problems is highest when maternal blood glucose levels have been elevated near the time of delivery.
Inheritance of diabetes — The children of parents with diabetes are at increased risk of developing the same type of diabetes. According to the American Diabetes Association:
Children of a father with type 1 diabetes have a 1 in 17 risk of developing type 1 diabetes. Children of a mother with type 1 diabetes have a 1 in 25 risk if, at the time of pregnancy, the mother is less than 25 years of age but a 1 in 100 risk if the mother is 25 years of age or older. These risks are doubled if the affected parent developed diabetes before age 11. If both parents have type 1 diabetes, the risk to the child is between 1 in 10 and 1 in 4.
The risk of diabetes in children of a parent with type 2 diabetes is 1 in 7 if the parent was diagnosed before age 50 and 1 in 13 if the parent was diagnosed after age 50. There is some evidence that the child’s risk is greater when the parent with type 2 diabetes is the mother. If both parents have type 2 diabetes, the risk to the child is about 1 in 2. (See “Patient information: Diabetes mellitus, type 1” and see “Patient information: Diabetes mellitus, type 2”).
AFTER DELIVERY CARE — Postpartum (after delivery) care for a woman with diabetes is similar to that for women without diabetes. However, it is important to pay close attention to blood glucose levels because insulin requirements change significantly in the first few days after delivery; some women require little or no insulin. Insulin requirements usually return to near-prepregnancy levels within 48 hours.
Breastfeeding — In all women (with and without diabetes), breastfeeding is strongly encouraged because it benefits both the infant and the mother. Insulin requirements may be lower while breastfeeding, and frequent blood glucose monitoring is important to prevent severe hypoglycemia. (See “Patient information: Breastfeeding”).
SUMMARY
Most women with diabetes can expect an excellent pregnancy outcome as a result of improvements in blood glucose control, as well as obstetrical and neonatal care. This requires adherence to diet, frequent daily glucose testing, and insulin adjustment, as needed.
Women with diabetes who have elevated blood glucose levels before or during pregnancy are more likely to have complications, including miscarriage, an infant with birth defects, or a large baby that requires cesarean delivery. Pre-existing nephropathy or retinopathy may worsen.
Frequent visits with a healthcare provider are recommended to monitor blood glucose levels and blood pressure, eye and kidney health, and also to monitor the health of the developing baby.
Target blood glucose levels during pregnancy are as follows: A!C level: less than 6 (show figure 1), fasting blood glucose: 60 to 90 mg/dL (3.3 to 5 mmol/L), before meals: less than 100 mg/dL (5.5 mmol/L), one hour after meals: less than 130 to 140 mg/dL (7.2 to 7.7 mmol/L), two-hours after meals: less than 120 mg/dL (6.7 mmol/L).
A woman and her obstetrician may decide to schedule the date of her delivery (either an induction of labor or cesarean delivery), especially if there are risk factors, such as poor blood glucose levels, nephropathy, worsening retinopathy, high blood pressure or preeclampsia, or limited or excessive fetal growth. Waiting for labor to start on its own is reasonable if blood glucose levels are well-controlled and the mother and baby do not have problems. However, extending pregnancy beyond 40 to 41 weeks of gestation is generally not recommended
If the baby appears to be very large (based upon ultrasound measurements), cesarean delivery should be considered to avoid possible trauma from shoulder dystocia.
The infant of the diabetic mother is at risk for several problems in the newborn period. These problems are more common when the mother’s blood glucose levels have been elevated during the pregnancy. Most of these problems resolve within a few hours or days of delivery. Infants of diabetic mothers are often evaluated in a special care nursery to monitor for these potential problems.
Postpartum (after delivery) care for a woman with diabetes is similar to that for women without diabetes. However, insulin requirements change significantly in the first few days after delivery; some women require little or no insulin. Insulin requirements usually return to near-prepregnancy levels within 48 hours.
Breastfeeding is strongly encouraged, and benefits both the infant and the mother. Insulin requirements may be lower while breastfeeding, and frequent blood glucose monitoring is important to prevent severe hypoglycemia.
After you’ve had your baby
If you experienced any gum problems (including pregnancy gingivitis or a pregnancy tumor) during your pregnancy, see your dentist soon after delivery to have your entire mouth examined and your periodontal health evaluated.
Family Entertaintment 