Healthy Pregnancy 101


Uploaded by PackardChildrensHosp on 19.01.2012

Transcript:
I want to welcome you all to our presentation this evening
under Your Child's Heath University here at Packard
Children's Hospital.
I'm Nancy Sanchez, from Community Relations, and we're very
excited about this evening, this Healthy Pregnancy 101 class
that's being presented to you.
It's a great pleasure for me to introduce Dr. Natali Aziz
to you, she's a Clinical Assistant Professor in Obstetrics
and Gynecology and Maternal Fetal Medicine at the Stanford
School of Medicine and Lucile Packard Children's Hospital.
Dr. Aziz actually
attended Stanford School of Medicine and she did her
internship and residency at Stanford, as well as a
fellowship at UCSF.
She's board certified in both OB-GYN and maternal fetal
medicine.
Dr. Aziz has published research on many pregnancy related
topics, and has developed the curriculum for this Healthy
Pregnancy 101 class, which you are about to enjoy.
And I will want to mention to you that, because we're
videotaping, and we will have this posted on, on the web, we
will not be recording your
questions, we'd like to save your questions for the end.
If you would, there are little cards if you want to jot down
things to remember to ask Dr.
Aziz so that we don't catch you or your questions for
privacy reasons in, during the, during the lecture.
So it's my great pleasure, as I mentioned, to introduce
tonight Dr. Natali Aziz.
Thanks for coming and sharing with us.
>> Thank you so much for that kind introduction.
And thank you.
Thank you so much for coming, and good evening.
It is an absolute
Joy and pleasure to be here today to discuss with you what a
patient along with her physician can do and steps that she
can take to help ensure a very optimal prenatal care both
prior to and during her pregnancy.
And this is a philosophy that's deeply embedded in our
Lucile Packard Children's Hospital philosophy and mission
and as we strive every single day to provide the best
obstetric and pediatric care for our patients.
So with that being said, thank you and we'll get started.
And as a reminder, I will be happy to stay and answer any
and
all questions you have at the end of the program, so thanks.
So today we'll be discussing a wide variety of topics
pertaining to pregnancy.
We're going to first start off with preconception issues and
then move forward to discussing what to expect at your first
prenatal visit, followed by what to expect during the first,
second, and third trimesters, and then specifically address
counseling issues pertaining to nutrition and weight gain,
work, exercise, travel, and some other issues associated
with pregnancy.
So, preconception is a very important time.
And preparing for pregnancy has many things to consider.
To start off with, optimizing one's pre-existing medical
conditions is extremely important.
So that means things such as medical complications like
diabetes, high blood pressure, hypertension, seizure
disorder.
All of those are very much aimed at helping to optimize them
prior to initiation of your pregnancy.
Next, we
Hope to aim for an ideal bodyweight, or close to it, with a
normal body mass index.
And then, finally, promoting a really healthy lifestyle, not
only with diet, but also avoiding substances such as
tobacco, drugs, and alcohol, is always helpful, especially
in the
organogenesis or organ development period during
pregnancy.
And finally, consulting with your physician is very
important regarding a variety of issues including medication
safety.
So there are many medications that we try to avoid in
pregnancy including things like Accutane, ace inhibitors
which are used to treat high blood pressure, lithium which
may be used to treat seizure disorders for example.
You also want to avoid multi-vitamins with a high dosage of,
vitamin A, especially over 10,000 international units per
day in that these levels have been associated with birth
defects in particular neural tube defects or spina bifida
for example.
Next, choosing a prenatal vitamin obviously is very
important for many couples.
In all reality many prenatal vitamins are wonderfully
sufficient.
Things to keep in mind would be folic acid.
Generally we need about 400 to 800 micrograms of folic acid
daily.
And you generally want to initiate that a month prior to
your conception attempts.
And certainly, to continue during this, two to three months
into the pregnancy, and after conception.
Thereafter, about 600 micrograms daily is needed.
And many of that, or much of that can be attained through
nutrition.
But supplementing it will always ensure that you have the
sufficient amount.
Next, you know, DHA has played a big role lately in the
news.
And patients seem to ask, you know, why is it so important?
So, DHA is one of the Omega 3 long chain fatty acids.
And there has been some studies
That show that there's some modest benefit to the promotion
of visual as well as cognitive development in the fetus.
So generally a recommendation of about two to three hundred
milligrams daily is made.
Now you can obtain that through consumption of fish that is
low in mercury and we will discuss that a little bit later
or supplement it through your prenatal vitamins as well.
So generally you want about two to three hundred milligrams
daily.
Now next would be to track your menstrual period and to
arrange your preconception appointment with your provider
and that may be anyone such as a primary
care physician, OB-GYN, nurse practitioner, or a
certified nurse midwife.
And in that appointment you can certainly talk about not
only your pre-existing medical conditions, preparing
yourself
for pregnancy, but also things such as updating your
immunizations which is very important during the pregnancy
period as well.
Things like your measles, mumps, and rubella vaccine and
your varicella vaccine are important to obtain prior to your
prenatal care in case you are not immune and that generally
if you are going to be vaccinated you want to avoid
pregnancy for about a month thereafter.
Other things that you want to update your immunizations on
would be the influenza, the Tdap, or the tetanus,
diphtheria, and acellular pertussis which is pretty big
right now in, given the pertussis outbreaks in California
that occurred about a year to two years ago,
and Hepatitis B as needed.
Now these vaccines are safe in pregnancy, but during a
preconception period if you want to start the series it's
always beneficial to begin and become immunized prior to
conceiving.
And so finally you know why is it so important to keep track
of that last menstrual period?
Well that's one of the first ways we actually date and give
you a due date for your pregnancy, so a lot of people, you
know, it doesn't,
it's not very intuitive. However the first day of your last
menstrual period is the day that your cycle begins
basically.
And generally so we use that as the first day of your cycle
and two weeks thereafter most women who have 28 day cycles
will then ovulate and that'll be the time of conception.
And thereafter we use those dates to give you an estimated
due date.
So your first prenatal visit can be actually conducted with
a variety of healthcare providers.
You know, you can start off with a general OB-GYN or if your
family practice physician conducts obstetric care, you can
also continue with your family care provider.
Other people who may provide OB care include certified
nurse midwives, as well as nurse practitioners.
And we do have certain providers and a variety of providers
in this area meeting all of these requirements.
Of course
a perinatologist or maternal fetal medicine physician is
also a person who is
a specialist for complicated pregnancies.
And at our center we have an MFM service that not only
serves as a consultant, but also as your primary care
obstetrician.
So if you do have any high risk complications you can either
be referred for a one time consult and thereafter the doctor
will help care for your pregnancy along with your general
OB-GYN, or people may choose to be transferred completely to
our care.
And so that's an option as well here.
Other things to think about are the type of practice.
So we have private practice, which generally is a multi-
person group as well as university service or HMO.
And in terms of the university service, the thing to keep in
mind is that it is a teaching institution so there are
groups of people that will help provide care for you.
I think they're all wonderful including the attendings,
fellows, residents, but additionally there's also the
medical student component too that's involved, and all
through excellent supervision.
So you get to be a part of a multidisciplinary team.
And generally what we aim for is to help establish your care
with your OB clinic by
about eight to ten weeks. So that means you call, you set up
your appointment.
Generally you go in and have your laboratory values drawn
and meet with the nurse for your first time visit.
And then by ten to twelve weeks you want to have your first
visit with your doctor or your clinician.
So as this little guy will show you here, who doesn't look
too excited, the first prenatal visit can take a little bit
of time.
It is an extensive period where you get to find out about
your prenatal care and your physician gets to find out about
your healthcare history.
So although it is long, it is certainly worth it as it
establishes the course for your medical care thereafter.
So things that we review during this first visit include
your medical history, you know again, diabetes, hypertension
or high blood pressure, anemia, history of seizure disorder,
your surgical
history, which may actually pertain to your care
during your delivery if a c-section is needed, for example,
your family medical history.
And particularly your obstetric and gynecological history.
We really want to know about past pregnancies, you know
stillbirths, miscarriages, deliveries, or terminations, your
last menstrual period, the duration of your cycles for
example, and other details pertaining to your gynecological
history as well such as abnormal pap smears, or history of
sexually transmitted infections.
Medications are always so important, and we like to review
them
in great detail.
So prescription, but also over the counter including
vitamins and supplements.
Allergies to both drugs or other substances.
And then, it's a nice period of time during that prenatal
visit to review some basic educational aspects of prenatal
care, including your nutrition, exercise, substances to
avoid and, as well as kind of bring up the issue of domestic
violence.
Now sometimes people are alarmed when we ask about domestic
violence at the first visit.
This should not be a stigma; it is something that we ask
every woman, every woman who is pregnant.
It is a very important time in prenatal care to establish
that rapport and to question patients about any
situations that may be harmful to them whether it's at home
or in other environments.
So the prenatal exam in the first visit is also very
exciting, not only because of the physical exam but also
because you, generally have a first time ultrasound
performed, where we actually look at the embryo, and we
determine if the confirmation of the pregnancy as well as
the dating of the pregnancy, so that's where it's important
that we keep track of your last menstrual period and
determine if our ultrasound measurement, actually
correlates.
Now this, embryo here is about seven weeks along and about
perhaps almost the finger breadth of my index finger here.
So very small, and we are able to demonstrate heartbeat at
this point, which is very exciting, and a great time.
So, you know, if partners want to come in for that first
prenatal
visit
it's always very rewarding.
We also perform the pelvic exam and breast exam in addition
to the traditional, you know, lung, heart, abdominal exam.
And then studies that we do at that time include a pap
smear, studies for infections, as well as urine analysis and
culture.
And some additional prenatal labs if they haven't been done
already, you know, with your nurse visit, include a complete
blood count,
again check for the level of
hematocrit and hemoglobin, and assess if someone has
anemia, your blood type, the RH status.
We have a panel of infections that we check for including
HIV, syphilis, rubella, Hepatitis B, as well as varicella,
or the causative organism for chicken pox.
Things also, which we bring up, are genetic disorders,
including cystic fibrosis, and others, as they apply to
specific ethnic backgrounds.
So the prenatal visit is also a wonderful time for you to
become more informed about your care.
And a time for you to learn about the type of practice that
your physician has for you.
So it's important to review the scope of care. You know you
can ask how many partners does that physician have, who
covers when they are gone on vacation for example, what kind
of call schedule they have perhaps. Additionally, you know,
you can discuss what tests will be done not only at this
visit but future visits to come, your expected course of
pregnancy and of course it's always important to always ask
what should I
be concerned about, what things should I report to you.
You know, signs and symptoms to report to your provider.
And those include vaginal bleeding, leakage of amniotic
fluid from the vagina or abnormal vaginal discharge, uterine
contractions, pelvic pain.
And once you feel the baby moving, fetal movement as well,
which generally happens after the middle of the pregnancy,
after twenty weeks in general.
And any unexpected fevers, for example.
It's also important to discuss the type of scheduled visits
you'll be having and we'll go over exactly how that is
distributed.
And then again physician coverage on labor and delivery
because who you may see in the clinic, you know, may not be
on call in the evening that you come in, in labor, so it's
also nice to be aware of the partners that are available and
hopefully will be providing care for you in some capacity.
And finally, just to summarize things, you know it's also a
good time at that point to explore the, you know, cost of
prenatal care if you want.
If you're interested in your insurance coverage or your
copays, that's a good time at the first visit to review that
with the front desk staff.
As well as, practices that promote safe health for pregnancy
but also just throughout, including use of seatbelts and in
particular dental care for pregnant woman is very important
in that poor dentition has been associated with preterm
birth so it's also important to become aware of that
component of preventive health that can be employed during
pregnancy.
And then what type of educational programs are available
and additional services.
For example, do you have a nutritionist or a dietician?
Is there an exercise program?
Are there available studies that you know patients may
participate in if they're interested?
For exercise, for example or for different variety of
things.
So a typical pregnancy is generally 280 days or 40 weeks and
just to be aware that, that does count from the first day of
your last menstrual period.
So that goes all of the way back there, again another reason
why the LMP is important to track.
And it's divided into three trimesters and the first
trimester is about from zero to thirteen weeks, second
trimester from fourteen to 27 weeks and third trimester from
28 to term.
So, the frequency of prenatal visits, obviously is dependent
upon the trimester that you are in.
So, generally, in the first trimester, until the twenty-
eighth week, we see usually patients every four weeks, so
unless there's a complication that needs more detailed or
additional attention.
And then from 28weeks to 36 weeks, we generally see patients
every two weeks and then weekly after 36 to 37 weeks.
So, I'd love to go over some of the things that are
routinely experienced in the first trimester.
Although these are mentioned here, we still want you to
report them to your physician but this is a bit of a
reassurance to let you know that these things are common.
So if you are experiencing them it is not atypical.
So in the first trimester generally there is nausea and
vomiting.
Fatigue may be experienced, definitely breast tenderness or
constipation and as the second trimester comes along there's
possibly skin changes, hyper-pigmentation or darkening of
certain moles or other skin areas especially in the face or
a vertical line down the abdomen, in the mid-line, which is
called a Linea nigra.
Stretch marks obviously increase, sense of shortness of
breath due to the physiologic changes that are going on with
the gravity uterus increasing.
There's also that, infamous broad ligament pain where women
will have a stretching sensation on the lateral aspecst of
their abdomen or uterus.
And it really is the suspensory ligaments that are holding
up the uterus, that are starting to stretch as the uterus is
becoming larger.
And of course, and unfortunately, varicose veins also may be
more prominent during this time, as progesterone does
relax muscles, and therefore, varicosities may be more
prominent.
In the third trimester, you may start to feel contractions
and, you know up to three or four per hour are actually
within
normal physiologic range, so that's something to be
reassured about.
Obviously, we want you to report your contractions to your
physician.
But, again it's nice to know that a few is, is appropriate.
Back pain can definitely be problematic during this time, as
the weight gain of the pregnancy and the uterus can place
strain on the back, for example.
Lower extremity pain and swelling is certainly very common
as well.
Breast discharge may be common as lactation is starting to
progress, increased vaginal discharge and gastric reflux.
And gastric reflux seems to be a very, very common and very
common symptom during pregnancy.
So if, if you do have that please let your doctor know.
There are many things that we can do to help treat whether
it's from lifestyle modification of the way that you sleep,
or smaller meals, less spicy meals to additionally where we
can actually treat you with medications.
So, fetal development is this amazing
[laugh] period where from about twelve weeks, the fetus
actually goes from a, about a two inch
fetus basically, and to about twenty weeks where the length
is
about 6.5 inches and the weight is about half a pound or so.
And then finally, this development goes on to 40 weeks
to where the infant is at approximately 7.5 pounds and
twenty inches when he or she is born.
So there's a dramatic evolution of fetal development during
that
short 40 weeks of gestation.
And just to show you what your uterus looks like at twelve
weeks, it's about the size of a grapefruit.
So at twelve weeks, this is the size of your uterus, and
this is the adorable size and look of your baby.
So as you can see, at about twelve weeks or so, it ranges
anywhere between six to seven centimeters.
And it's amazing
With newer advances in ultrasound technology, we are able
to capture some really beautiful images of the fetus, even
at this very early stage.
And it's always a lovely event to share with our families
and parents and
to again when undergoing your first trimester ultrasound
nuchal-translucency, it's always nice if you do want to have
a
partner come in to share this lovely picture with them.
So first trimester also is an important time to review the
genetic counseling considerations for specific families.
There are many families such as African American or
Mediterranean
that may need counseling in Sickle Cell Anemia or
Thalassemias, for example,
Tay-Sachs disease, Cystic Fibrosis, Canavans, and Familial
Disautonomia is again...
Are considerations of genetic disorders for specific ethnic
backgrounds.
Of course inheritable diseases are also important to
consider.
So if your prior child for example, had a heart defect for
example, we'd definitely want to know with subsequent
pregnancies for further evaluation.
And then finally, for screening and testing of chromosomal
abnormalities, there are a variety of screens,
Diagnostic procedures that you can be offered. So to start
off with the screening includes a nuchal-translucency, which
is generally performed between about eleven to fourteen
weeks and that is combined with the first and second
trimester blood screens and it's a very, high sensitivity,
mode of screening patients for chromosomal abnormalities of
the fetus.
And then finally for diagnostic evaluation, which includes
testing that is invasive though either a chorionic villus
sampling, which is actually sampling of the placental tissue
in the first
trimester or an amniocentesis can be performed in the second
trimester where we actually sample the amniotic fluid.
So nuchal-translucency and the analyte or hormonal screening
is done between about ten to thirteen weeks for the blood
work and the nuchal-translucency is about eleven to fourteen
weeks.
Chorionic villus sampling is performed about ten to thirteen
weeks, so very early on you will be offered the option of
deciding whether you want screening or diagnostic testing.
And this is a picture of what our nuchal-translucencies look
like for babies that are very well behaved.
If you've ever gone to an ultrasound, sometimes the fetuses
won't exactly, you know, have that perfect mid, mid-line
profile, and we have to, you know, be very patient with
them, but ultimately, they usually come around.
So, the nuchal-translucency is this area here of fluid that
we measure behind the baby's back of the neck, and this has
actually been associated with chromosomal abnormalities when
it's beyond a certain point and we combine that with the
maternal
hormones to actually give patients a screening number. So,
common things that may occur in the first trimester.
This is, again, something that you should always report to
your physician.
But I just want to bring about how common it is, so that
when,
if it does happen, that we can hopefully continue to keep
you reassured.
But vaginal spotting is extremely common
and can occur in up to twenty to 25% of early pregnancies.
And not all of those pregnancies end in miscarriages.
For example, most of those pregnancies will actually
continue to be a viable pregnancy which is the reassuring
aspect of this.
Additionally, nausea and vomiting is very common in
pregnancy, particularly in the first trimester.
It can affect as many as, you know, at various degrees up to
70% of pregnant women.
Generally we recommend lifestyle and diet changes.
Again, potentially eating smaller meals, avoiding spicy
foods.
Things that you can use include ginger, vitamin B-6, Unisom
which is a sleeping agent and has actually been used to
treat nausea and vomiting associated with pregnancy as well.
We can also provide prescription medications that have
really been very safe for use in pregnancy and unfortunately
in about two percent of pregnancies this will be
hyperemesis, meaning severe
nausea and vomiting and some of those patients may actually
require hospitalization and IV fluids or other type of
medications and IV nutrition, but that is a rarity.
So, in the second trimester fetal development occurs where
all the major organs and systems have actually formed.
And then thereafter they just develop and grow further.
The remainder of the time after the second trimester is
really devoted to increase in weight.
And the fetus will actually increase its weight by seven
times over the next few months.
So there's a dramatic period of growth in the fetus in the
third trimester.
Fetal movement generally is felt at about twenty weeks for
first time pregnant women.
And as early as eighteen weeks or so for recurrent
pregnancies as moms get to know a little bit more about how
a fetal movement may be and are able to recognize it a
little bit earlier.
So no matter how many ultrasounds I've done in my life you
know every one of these is a very special moment as, as we
perform the anatomy ultrasound at about twenty weeks or so.
This is the time where we get to introduce you to your baby
and all of his or her parts.
And that's when we do a very detailed survey of the fetal
anatomy where we look at the head, the heart, the
gastrointestinal tract.
We look at the genitourinary areas.
We look at the limbs and assess also the pelvic organs
including the uterus and the cervix, which is the lower
portion of the uterus in the ovaries.
So this is always a very exciting time.
And with the advent of, and use of 3-D imaging as well
it's amazing what pictures you can capture during these
ultrasound assessments.
In the second trimester we also do the quad marker.
Which assesses for the some common genetic abnormalities,
including trisomy 21 and eighteen.
And for neural tube defects such as Spina Bifida or
abdominal wall defects.
We also perform amniocentesis if desired.
And, again this is an invasive testing where we actually
sample the amniotic fluid.
And this occurs anywhere between fifteen to twenty weeks.
And
then in the late second trimester which is up to 28 weeks or
so
we do our gestational diabetes screen and then check the
blood
count again because there's a component of physiologic
anemia or lower blood count that is very common in pregnancy
due to hemo dilution and we just want to assess and make
sure
that we have a, a good account and marker of the current
blood count status.
So third trimester, you know we'll see you more frequently.
After 28 weeks we generally see you every two weeks and then
in the last four weeks or so, we see you weekly.
Those times again, we are measuring your weight, measuring
your blood pressure, measuring the uterus to check for
proper growth of the fetus.
We perform physical exams if there is any discomfort, again
if people are having discomfort with their hands or
swelling.
Something that commonly occurs in pregnancy is carpal tunnel
syndrome, where the median nerve is actually compressed due
to the swelling that occurs in pregnancy.
Many moms will have potential symptoms of that, that
we assess. And then obviously swelling of the feet and lower
extremities as well.
We assess the urine to make sure that we check for sugar and
protein levels as those are markers for diabetes and
preeclampsia respectively, and obviously every time you come
in we will check the baby's heart rate and make sure that
it's in an appropriate range.
And then at 35 to 37 weeks we also perform a
Group B streptococcal culture.
This is a transient organism that generally lives in our
gastrointestinal tract, and sometimes it colonizes the
vagina or bladder, and at 35 to 37 weeks we'll check with a
rectal vaginal swab, and if mom has colonization, then we
will administer antibiotics during labor to help prevent
baby from acquiring the infection at the time of birth.
So, it's amazing.
I don't know how nature did this, but it did.
After twenty weeks, fundal height mysteriously correlates to
the gestational age which is very interesting.
So at twenty weeks, fundal height is about at the umbilicus
or so
or belly button.
And then thereafter, it actually progresses to increase
along with your gestational age.
So, at 24 weeks of gestational age, typically from the pubic
symphysis to the tip of the fundus of the uterus is about 24
centimeters plus or minus a few centimeters.
So, that's a way of us assessing if the fundal
height is appropriate or if it's too large which could be an
indication that the baby's growing very largely or has
extra fluid.
Or if it's too small which would be an indication that
perhaps growth isn't
appropriately progressing or that there may be low fluid.
Now, most of the times, though, reassuringly when we do have
ultrasounds to assess for size greater than dates or size
less than dates on a fundal height, most of the times it is
reassuring and there's appropriate growth.
It's just that not every body is going to adhere to this
tight rule but it's always nice to have as a way of a
screening.
So, in your subsequent prenatal visits, very importantly,
it's a great idea to discuss with your physician the options
for labor.
And you know, some families have preferences and it's nice
to let your physician know what your preferences may be, for
example.
And it can be as small as I want my partner or my
partner wants to cut the cord for example.
But those are all nice things to discuss and to review and
how feasible they may be at the time of labor.
Pain control in labor is very important, to assess if there'
s
an obstetrician at all times, on labor and delivery for
example.
Or if they have to be called in.
At our institution we actually have a 24 hour obstetric,
Obstetric anesthesiology service, which we're very, very
fortunate.
We have one of the leading programs in the nation and so we
have our doctors there readily available to provide pain
control for moms who may be interested in that.
Again, planning for delivery, postpartum child care, asking
about, you know hospital tours, car seat fittings, for
example are important things and usually your office will
have that information.
Breastfeeding benefits are always great to discuss with
your provider as well and choosing a child's physician.
And we may not know exactly who to send you to but I think
it's nice to discuss it with your obstetrician and they can
guide you for specific referrals.
So some of the things also in the subsequent visits or to
begin with to discuss with your doc are your nutritional
counseling. So what is healthy and perhaps what do we need
to avoid during pregnancy?
So one of the things that's important is generally to limit
your caffeine intake to less than 200 milligrams per day.
Now that being said it sounds like it's quite restraining,
it's actually not.
You know roasted ground drip has about a 100 milligrams per
cup, tea about 30 to 35.
A Starbucks coffee though has just about that limit, about
250 and then a Coke or Pepsi is about 50 or so.
So as you can see you don't have to cut out caffeine
completely but drinking in moderation is an appropriate
consideration.
As we reviewed before, limiting your Vitamin A intake is
always very important to consider.
And for those who have an exclusively vegetarian diet, it's
really important to make sure that you take in the
appropriate amino acids, iron, minerals, Vitamin B12,
Vitamin D, and calcium and complex lipids.
These minerals and vitamins are all
really essential for normal embryonic development, and so
it's important to incorporate them in your diet.
And I think consultation with a registered dietitian or a
nutritionist is very helpful to help you prepare and to
continue to provide appropriate nutrition during your
pregnancy.
So another nutritional counseling matter that comes up is
fish and how much can I eat and what form can I eat.
So this is a very excellent topic to discuss with your
obstetrician.
Methyl mercury exposure definitely is something that causes
severe central nervous damage and it can on a milder level
cause intellectual motor or psychosocial impairment.
So it's very important to be aware of the levels of mercury
in the fish that you may be eating and to gauge your
consumption accordingly.
Things that you want to avoid, fish specific
types are shark, swordfish, king mackerel, tilefish, because
they have really high levels of mercury.
Otherwise, eating about up to twelve ounces.
So, on average, one to two average meals of either shrimp,
canned light tuna, salmon,
pollock, or catfish, are actually appropriate, and very
reasonable.
And, one of the things to keep in mind, also, is the
albacore white tuna actually has more mercury than the
canned light tuna.
So avoiding the albacore might be a good idea
or limiting its consumption to only about half, or six
ounces.
And it's very helpful, the FDA has a website where you can
actually click on and look at the fish mercury levels so
that if you particularly have a craving for some type of
fish you can have you can actually see mercury levels that
are noted by the FDA. And obviously always checking local
advisories is a good idea.
For example our west coast specifics may be a little bit
different than east coast.
Additionally for nutritional counseling a very important
thing to remember is to avoid undercooked or raw foods. You
know there is a risk of food poisoning, whether it's
bacteria or parasites.
And food poisoning not only causes dehydration of the mother
and deprives the fetus of nutrition, but it can also cause,
you know significant and severe maternal disease. And in the
fetus there's a variety of possible adverse risks, including
congenital disease, which may be associated with
toxoplasmosis that can be associated with eating raw foods,
for example, raw meats or undercooked meats.
Premature labor, if there is significant infection,
miscarriage, meningitis, which is inflammation and infection
of the lining of the brain and spinal cord, pneumonia, and
even death for fetuses.
So it's important to avoid these, especially bacterial and
parasitic food-bourne illnesses.
You know, things to do.
Really thoroughly cook your food, from animal sources,
including beef, pork, poultry, and fish.
So, no sushi.
[laugh].
Wash your raw vegetables thoroughly as well.
And keep your uncooked meat separate from your vegetables,
and from cooked foods, and ready to eat food, so that they
don't cross contaminate.
Obviously, avoiding unpasteurized milk, cheese, and foods
made from raw milk is very important.
And that, for prevention of listeria or listeriosis.
And although, generally, it's in unpasteurized products, as
you may all be aware, there was a recent outbreak in
cantaloupes, for example.
So, it can also be in fruits and vegetables, but usually,
advisories are given for those types of situations and
those are uncommon
in, in, in the grand scheme of things.
And finally washing hands, knives and cutting boards after
handling uncooked food is also sanitary.
And not only for pregnancy but for all cooking practices.
So you may ask what's an appropriate weight gain now that
we've talked about all the foods that I can and cannot eat?
Well, our weight gain is generally based on our body mass
index.
And body mass index we calculate using your weight divided
by two
times the height, basically your height squared, I should
say.
So for lower body mass indexes, there is more generous
recommendation for weight gain anywhere between about 28
to 40 pounds.
For normal BMI which on average is about eighteen to 25 or
so general weight gain is about 25 to 35 pounds and for high
BMI's, so between 25 to almost 30 is about fifteen to twenty
and obviously the higher the BMI such as obese which is
greater than 30 the lower the recommended weight gain.
An average weight gain per trimester, and this is just
average because in all reality, it very, not many people may
fit this standard.
However, generally we quote about three to four pounds in
the first trimester twelve to fourteen pounds in the second
trimester, and about eight to, eight to ten pounds in the
third trimester.
And in terms of all the weight, and what components make up
this weight.
Well, at term, your baby is about, approximately seven and a
half pounds or so.
Your extra maternal energy sources, including fat, protein,
and other nutrients make up another seven pounds that you
have stored.
Fluid volume that also, we store, in third space, the lovely
swelling that may come about, for example, is an additional
four pounds, breast enlargement is two pounds.
The uterus, itself, becomes very large and
engorged with vessels.
And it, itself, weighs two pounds.
Amniotic fluid is another two pounds, and then the placenta
is approximately one and a half pounds.
And the thing to remember is that, generally, for pregnancy,
an increase of about 300 calories per day is recommended for
a goal of 2,500 for singleton pregnancies.
Now, this goal is a little bit higher for twin pregnancies,
as moms need additional nutrients.
So, additionally, the specialized counseling that we talk
about during pregnancy.
If, Vaccinations were perhaps not updated prior to
pregnancy.
reassuringly things like the flu vaccine, Hepatitis B,
Hepatitis A, T-Dap, Pneumococcal and Meningococcal vaccines
can all be administered safely during your prenatal care.
We try to avoid the measles, mumps, rubella and varicella
vaccine in pregnancy.
However, this is for theoretic concern so if one does
inadvertently get the vaccine during pregnancy please
consult your physician, and hopefully they'll reassure you
as to, that it's just a theoretical risk, and not
significant severe outcomes have been demonstrated when
people do get these vaccines inadvertently.
Additionally, whenever you go to a physician that may not be
an OB-GYN, and that there's need for x-rays, please always
consult your physician of your prenatal care.
Generally, dental and chest x-rays are permitted during
pregnancy.
Other types of imaging, we consider, but only if they're
needed for significant maternal management issues.
So it's always a good idea to talk about any x-rays with
your OB-GYN before proceeding with them.
Additionally, I think pregnancy is a great time for
specialized counseling for individuals that may need
assistance in terms of tobacco, substance abuse, domestic
violence or medication use whether it's prescription or over
the counter.
It's an amazing period of time when the inspiration and
motivation for healthy, wellbeing and prenatal care can
really motivate individuals to lead healthier lifestyles.
So I think it's a great time to modify one's lifestyles to
benefit
not only one's long term outcomes but also your prenatal
care.
So, in addition, pregnancy brings to the conversation of
what to do during everyday activities.
You know, this includes work, exercise, sex, sleep, travel,
air travel, car travel.
So I'm going to just go over, very briefly, some
considerations for each of these topics.
So during pregnancy, many or most women will actually
continue to work without complications.
You know it really does depend on the type of work and your
medical condition.
But for most low-risk or uncomplicated pregnancies, a
pregnant woman can continue until her third trimester, until
she's ready to take her time off basically.
So physical job demands that though include prolonged
standing or walking,
heavy lifting, working at various shifts for example, or job
stress, may affect pregnancy.
And so if that's the case it, I really encourage you to
discuss these things with your physician so that you can
kind of modify your perhaps work environment to best benefit
a optimized prenatal course.
Things that you want to watch out for in the workplace
include metals like mercury and lead, solvents in the house
cleaning industry for example, cleaning agents and
pesticides, exposure to pharmaceutical agents, in particular
for example, those medical personnel that work with
chemotherapy.
It's very important to remember chemotherapy can be
associated with miscarriage, low birth weight or
malformations.
And so being aware of your environment is very important.
Infections are another, common Work place adverse event that
we deal with quite often.
So whether you're a school teacher, or a nurse, or a
physician, or just a plain mom who is at home with her two
year old, there's things that can happen such as hepatitis
or chicken pox, rubella, CMV, parvovirus or toxomoplasmosis
and
other infections that may actually influence pregnancy and
so those types of infections not only need to be reported to
your physician but it's good to kind of access your work
environment to see what you may be exposed to and discuss
that with your OB. And then finally physical agents like
radiation and radioactive waste are definitely need to be
avoided as they can actually lead to birth defects,
miscarriage and development issues and extreme heat
especially in the first trimester, has been
associated with birth defects.
So if you have a really high fever, especially in your first
trimester, or you just love the jacuzzi and sauna, those are
things to actually discuss with your OB-GYN
because you really want to avoid high heat environments.
So the AMA, or American Medical Association recommends these
lovely things for pregnant women.
And I really emplore you to bring them up at your workplace.
You need to take a break every few hours.
You need to take a longer meal break if possible, every four
hours.
Drink plenty of fluids on the job if possible.
And you want to vary your work positions you know,
continuously, from sitting to standing to walking.
And you really want to minimize heavy lifting and bending.
I had a patient who you know, is an employee at Costco, and
had to go up on really high ladders.
And that was just something that was not very safe for her
during her pregnancy.
So we modified her work activity, and that's something that
your OB-GYN will be happy to do, depending on the certain
situation.
So, people may also ask, are video display terminals
dangerous for me and for my baby?
Actually, fortunately video display
terminals do not emit X-rays, and so, and there has been
no link to exposure of the electromagnetic field and the
risk to pregnant women.
So, fortunately, you don't have to worry about that.
Now computers, just as in non-pregnant individuals, can be
associated with neck, wrist, hand, shoulder, and back pain.
And this may be exaggerated in pregnancy.
So, prolonged sitting at a computer terminal may not be the
best for these symptoms.
So, if that happens, just bring it up with your physician,
and I'm sure that they can work something out with your
boss, basically, to help relieve some of those symptoms.
And, just like in non-pregnant patients, you definitely want
to take frequent work breaks.
You want to use detachable keyboards, and adjustable chairs,
and use non-reflective glass on the screen to basically
adjust the lighting and contrast.
Now, exercise in pregnancy.
It's very important to stay healthy throughout your life,
but additionally during your pregnancy course.
So pregnancy and exercise is actually a wonderfully
symbiotic relationship, and we've definitely determined that
exercise has many benefits during pregnancy.
It can minimize the physical discomforts of pregnancy
itself.
It's beneficial for women with diabetes and can help keep
both gestational diabetes and preconception or pre-
gestational diabetes in better control.
It actually has been proved to improve mood, energy, sleep
patterns.
It can increase your endurance and strength and muscle
tone and it can improve or help with the recovery after the
birth of your baby as well.
So if someone is healthy and has been exercising and
physically fit before the pregnancy, they can safely
continue to exercise throughout their pregnancy course.
Obviously, you want to let your physician know, throughout
your pregnancy but generally continuation is very
appropriate.
However, women who have not had an exercise regimen prior to
pregnancy, we highly encourage you to really speak to your
physician before starting one.
It's very important to discuss this in consultation with
your doctor so you can set up a reasonable regimen to begin
you gradually.
So your target heart rate in terms of how hard can I
exercise.
So we usually like to say keep it below about the one
forties or so.
And really, this is a level where you can conduct a normal
conversation with an individual.
So if you're able to talk without taking deep breaths, and
huffing and puffing, that's generally a very appropriate
exercise level and correlates to less than one hundred and
forty beats per minute.
Your goal is up to about thirty minutes per day and you know
again for those individuals who have never started an
exercise program, you want to start this gradually and
discuss it with your physician first.
You want to drink plenty of fluids.
You want to avoid extreme exhaustion, excessive heat, and
lying flat on your back as well.
And, of course, if any of the following things occur in your
pregnancy, we do ask for potentially modifying your exercise
regimen.
So, whether it's preterm labor in the current or past
pregnancies, if there's active vaginal bleeding or cervical
issues, if there's leakage of amniotic fluid, if you ever
experience shortness of breath you should stop and discuss
it with your physician and probably obtain some additional
studies.
Dizziness or fainting is another period of time where
exercise may not be safe.
Decrease fetal activity or other complications.
If your heart rate is greater than the 140 and you're not
able to exercise at a level where you can sustain it below
that
level, and then obviously certain health problems, such as
high blood pressure for example, may not make you an ideal
candidate for the exercise regimen that we discussed.
However again, these things are all done in consultation
with your physician and bringing these up to your physician
is important.
So exercises to avoid in a healthy individual.
Things that obviously could potentially be unsafe, if there
was an accident, or a fall, so including horseback riding,
water skiing, scuba diving, contact sports, high altitude
skiing.
So virtually any exercise that can cause a serious fall.
Things to also consider for exercises that are not within
this group.
So exercising on your back for the first trimester may,
after the first trimester, may actually reduce blood flow to
your uterus so we generally say avoid exercise on the back
in the second and third trimesters.
Exercising in a vigorous, hot, humid environment or weather
conditions is also not recommended in that you have less of
an ability to have efficient exchange of heat at that time
and so we don't want to dehydrate you or cause a
hyperthermia situation. And then finally exercise, which
consists of the
valsalva maneuver, which is holding a breath during some
type of exertion, can cause increased abdominal pressure so
we recommend avoiding those types of valsalva maneuvers.
So although some people seem to water ski we do
recommend that pregnant women do not.
But it seems like it's very tempting right here is that it's
so easy for so many people.
So sex during pregnancy?
That's a question that comes up often and it is a very
appropriate question.
In most cases sex during pregnancy is completely safe and,
is appropriate.
Intercourse, however may be avoided in special
circumstances.
Again those need to be discussed with your OB.
So when there's vaginal bleeding.
If there's any discomfort that is atypical for you, leakage
of amniotic fluid or significantly different discharge and
contractions.
And in terms of sleep positions, most of you may be aware
that we do recommend not lying flat on your back,
especially in late pregnancy,
in that, this places, when you're flat on your back, it
actually places pressure on the blood vessels that return
blood back to your lower body from your heart, including
your uterus.
So it actually may prevent the appropriate and sufficient
amount of blood getting back to your uterus, and to
profusing the placenta, and reaching the fetus.
So that's why we recommend you to sleep on your side.
Sleeping on the stomach, again, also, is not recommended
late in pregnancy
as it applies pressure on the fetus that may be not
completely safe for the fetal environment.
And finally, on the side is the best sleeping position.
Usually we say left, but sometimes you just can't stay on
the left and you do need to change your positions and that's
completely appropriate.
It does allow for maximum blood flow to the fetus. It
improves the kidney function of the mother. And it may
actually reduce the swelling as it allows for better
profusion and return of blood from the lower
extremities to the heart.
One of the things that is really challenging for pregnant
women is to sleep on their sides, and so that's why we
recommend placing a pillow between the knees.
It actually really helps improve the side position and
makes it more tolerable and many women find it much more
comfortable.
So travel during pregnancy.
Fortunately, traveling during a pregnancy is actually, it is
appropriate and maybe performed but always remember to
consult your physician.
You want to make sure that you've been recently seen by your
OB-GYN before you take a big trip.
You want to have a copy of your prenatal records.
Hopefully nothing adverse will occur, but if you needed to
go to a hospital, it's always very nice to have a clear
record
of your documented pregnancy course, when you are being
evaluated by a physician that may not be familiar with your
case.
During long airplane or car rides, we definitely recommend
you ambulating, if possible.
You want to wear compression stockings, especially on long
trips,
for example, airline trips or car trips.
And travel, usually after 36 weeks thereafter, is not
recommended.
And that's either by car or plane, where you are going
significant distances, is that, that's the time where most
labor will occur, and we really want you to avoid having to
present to an unfamiliar area and
in labor, for example. And then always using a seatbelt
either in a car or plane. And this little schematic here
demonstrates. So a seatbelt should be placed underneath the
belly and not over or across the belly.
So the green area here is the appropriate way or place of
placement of the safety belt.
And then finally just as a reminder you know, the most
pivotal and important time for organogenesis and organ
development of the fetus is in that first trimester,
generally before you even find out that you're pregnant.
So in that preconception period where you are thinking about
pregnancy it's very important to keep your medications in
mind.
The period of organogenesis is between four to eight weeks
of gestation and this is the time when the fetus is most
vulnerable to birth defects from prescription medications or
nonprescription medications even, and so that's an important
time to always keep that in the back in your mind as
especially even before you are pregnant to think ahead and
see
what types of medications would be safe if I were to become
pregnant.
That being said, it's very important also to balance mom's
health and maternal wellbeing with
pregnancy and prenatal wellbeing. So it's very important
that we discuss the medications that are needed.
We don't want to penalize or, you know make it a stigma for
moms who do have to take medications.
So there's usually a general safe medication alternative
that you can discuss with your physician and usually we can
transition patients very safely.
And then finally we, you know use the medication that's
least likely to cause birth defects and least teratogenic,
and fortunately most drug classes will have medications that
Do not cause birth defects that we can safely transition
moms to.
And finally just keeping the risks of alcohol and drugs,
cigarettes, infectious diseases, medications, uncooked or
unpasteurized food and then medical conditions as well in
mind, including diabetes, high blood pressure, sexually
transmitted infections. And kind of wrap it all up and to
think of these things as being
potential situations or environments or substances to
avoid during pregnancy is always a good, healthy rule.
And finally when to call your doctor. We reviewed things,
signs and symptoms to report to your physician but
additionally, you know, any vaginal bleeding, pelvic cramps,
or pressure should be reported.
Fevers that are greater than approximately one hundred and
one degrees should be reported.
Leg swelling, especially asymmetric leg swelling which
pregnant women are more at risk for blood clots in their
lower extremities. So we always, we never take this lightly.
It's always a serious situation and we definitely want to
evaluate you as soon as possible.
Severe headaches as well, pain or burning with which could
be the sign of a bladder or kidney infection.
Severe vomiting or inability to keep anything down
because it can lead to dehydration for the mom and that's
something that we definitely want to avoid and can treat
with IV fluids.
Abnormal vaginal discharge or symptoms and especially of
abdominal trauma. Whether it's through a motor vehicle
accident or fall we always want to know if they, if there
has
been an abdominal trauma and then especially in the late
second and third trimesters.
We like to monitor the fetus so it's always better for you
to call us as soon as possible.
And finally, thank you.
I want to thank everyone for your time and attention,
especially in this late evening.
And I want to thank Mrs. Sanchez and
Stonestrom for the office of Community Relations and
Community Programs for helping us establish this evening.
And thanks for the opportunity to allow me to come in and,
and talk about things that may, hopefully, be of value to
you in your prenatal care and help lead to a very happy,
healthy, and informed pregnancy.
And on a personal note, I just want to thank you all for
potentially choosing or considering Lucile Packard
Children's Hospital
as the medical facility to have your prenatal care.
We really believe and value the fact that pregnancy is not
only one of the most important healthcare periods, but also,
one
of the most important personal life events for an individual
and her family. And we're honored to be a part of that for
you.
And with that, I'll take any questions that you may have,
and thanks for your attention.