Pregnancy Planning

Pregnancy Planning Facts

• Pregnancy planning can address issues of nutrition, vitamins, body weight, exercise, and potentially harmful medications and illnesses as well as immunizations and genetic counseling.
  
• Women who take folic acid at least four weeks prior to conception can reduce their baby's risk of birth defects of the spinal cord and skull by 70%.
  
• Alcohol has been implicated in infertility, early miscarriage, and birth defects.
  
• Certain acne medications and other prescription and OTC medications can cause birth defects.
  
• Babies of older women have an increased risk of having chromosomal abnormalities.
  
• The timing of sexual intercourse in relation to ovulation does not influence the gender of the baby.

What is pregnancy planning and why is it important?

Having a baby is one of the most important events in a woman's life. Women considering pregnancy are encouraged to start planning for the pregnancy with their doctors early. This early planning process is called pregnancy planning. The goals of pregnancy planning are to create a healthy environment for the fetus and to prevent birth defects and other pregnancy related problems to the greatest extent possible. The issues addressed during pregnancy planning include nutrition, vitamins, body weight, exercise, avoidance of certain medications and alcohol, immunizations, and genetic counseling. Even though many women will have normal pregnancies without any planning, pregnancy planning improves the chances of a smooth pregnancy and a healthy baby. Unfortunately, many more women who are anticipating conceiving do not seek prior medical consultation.
Pregnancy planning can help prevent exposure of the mother to potentially harmful medications or substances during the early days of pregnancy. The baby's organs begin developing as early as 17 days after conception, and the fertilized egg begins to grow even before the first day of the missed period. Some women continue to have light bleeding that may be mistaken for a menstrual period during the first few months of pregnancy and may not even realize that they are pregnant. Others may not recognize that they are pregnant until they experience weight gain or abdominal enlargement. By then, they may have already been exposed to medications or substances potentially harmful to the fetus.
In addition to avoiding medications and substances that are potentially harmful to the fetus, other important health issues are addressed during pre-pregnancy planning.

• Conditions such as diabetes, high blood pressure, kidney disease, thyroid disease, and heart disease in the mother are controlled to optimize pregnancy outcome.
  
• The status of the woman's immunity against German measles (rubella) and varicella (chickenpox) is also determined. Women lacking rubella antibodies are immunized before conceiving (see medical issues below). Women who are not immune to varicella (chickenpox) can be vaccinated, but should wait 30 days after vaccination before becoming pregnant.
  
• Women who are carriers of the hepatitis B virus can be identified by blood tests, and their infants can be protected from hepatitis B infection by immunizations at the time of delivery. Women with HIV (human immunodeficiency virus) infection should take certain medications during pregnancy to decrease not only their risks but those of the fetus as well.

The effects of diet, exercise, and each of the medical conditions previously discussed will be reviewed below.

What are pregnancy symptoms?

There are both symptoms and signs of pregnancy. These symptoms and signs depend upon the time in pregnancy. In the first trimester of pregnancy, the first sign of pregnancy is most often a missed menstrual period. If a sexually active woman's periods are generally regular, missing a period for a week or more is presumptive evidence of pregnancy.
Early symptoms of pregnancy also include feelings of breast swelling and tenderness, and nausea sometimes with vomiting. "Morning sickness" does not always occur in the morning, and the nausea of pregnancy can occur at any time of day. Many women become fatigued early in pregnancy, and some may feel abdominal enlargement (bloating).
Early in pregnancy, the woman may feel she has to urinate frequently, especially at nighttime, and she may leak urine when coughing, sneezing or laughing. This is also normal later in pregnancy and is not a problem.
Other changes characteristic of pregnancy include the deepening color of the areola (area surrounding the nipple), increased body temperature, the so-called "mask of pregnancy" (darkening of skin on the forehead, bridge of the nose, or cheekbones), and a dark line going down from the middle of the central abdomen area to the pubic area. Eventually, enlargement of the abdomen is a normal feature of the growing fetus.

What is a pregnancy calculator and calendar?

A pregnancy calendar or calculator can allow a pregnant woman to understand what is happening to her body and to the developing embryo or fetus at each stage of pregnancy. Most pregnancy calendars explain the changes of pregnancy on a week-to-week level and can be found online or in print form. In many cases, pregnancy calendars contain photos or diagrams to illustrate the appearance of the fetus at each stage.

How effective are home pregnancy tests?

At-home pregnancy tests, first introduced in 1975, are very accurate and reliable when used correctly. These tests measure the presence of the hormone human chorionic gonadotropin in the urine, which, when present, is indicative of pregnancy. The same hormone is measured in blood and urine pregnancy tests available at clinics and doctors' offices. Currently, the blood test is the most specific and sensitive pregnancy test available, although urine tests have become increasingly sensitive. For example, home urine tests may be able to detect the pregnancy hormone at 8 to 9 days after conception, or a few days before the missed menstrual period.
While many manufacturers claim that their home pregnancy tests are 99% accurate, a number of factors influence the accuracy of these kits. Studies have shown that false negative results may occur when very low levels of the pregnancy hormone are present, and that home test kits from different manufacturers differ in their sensitivity for detection of the very low levels of the pregnancy hormone in the early days of pregnancy. If a woman takes a home pregnancy test too soon, the result may be negative even though she is in the first stages of pregnancy. A repeat test should always be performed a week later if a home test is negative and a woman suspects that she might be pregnant.

How can diet and nutrition affect early pregnancy?

The developing fetus receives its nutrition from the mother's blood. Therefore high fat diets and some vegetarian diets are discouraged during pregnancy because they may not provide all the nutrition needed for the developing fetus. Bulimia, anorexia nervosa and other eating disorders in the mother are addressed and treated. Weight reduction diets are avoided during pregnancy. Excess intake of sugar, alcohol, megavitamins, and caffeine are also avoided Because a "safe" amount of caffeine has never been confirmed to date, it is best to avoid caffeine entirely. Women who feel strongly that they need some coffee are advised to drink no more than one cup per day. There is no proof that 1 to 2 cups of coffee daily cause pregnancy complications.
Listeria is a type of bacteria found in contaminated food that can cause miscarriage and other problems in a fetus. Because of the danger of getting a listeria infection, pregnant women should avoid unpasteurized milk, soft cheeses, cold cuts, and undercooked or raw animal foods. In addition, fruits and vegetables should be washed completely prior to consumption.
Phenylketonuria is an inherited disease that affects the utilization of a certain protein component in foods. This disorder can be detected by a blood test. Mothers with phenylketonuria may give birth to developmentally disabled children unless their diets are strictly controlled to exclude phenylalanine.
Megavitamins contain double or even triple the recommended daily allowances of vitamins and minerals. High doses of vitamin A have been implicated in producing birth defects. The better idea is to avoid megavitamins and instead follow the recommendation that has proven benefit: take a prenatal vitamin containing folic acid.
Folic acid intake in the mother prior to, and during pregnancy has been shown to reduce the risk of birth defects involving the brain and spinal cord. The United States Public Health Service recommends folic acid for all women of child-bearing capacity. Studies have shown that if folic acid is begun at least 4 weeks prior to conception, the risk of birth defects of the spinal cord and skull can be reduced by more than 70%. In women with or even without a history of having infants with birth defects of the spinal cord or skull, folic acid should be taken one month before conception and continued through the 12th week of pregnancy. In fact, continuing prenatal vitamins through pregnancy and even through nursing is probably wise. These prenatal vitamins are available over-the-counter. If a particular brand makes you feel nauseated, simply switch to another brand or try taking the vitamin at night.
Because of the risks of mercury poisoning and nervous system damage in the fetus from contaminated fish, pregnant women are advised to eliminate consumption of certain types of fish that are known to be high in mercury, including shark, swordfish, tilefish, and king mackerel. Tuna steaks, made from large tuna, may also have high mercury levels. Canned tuna is made from smaller fish that typically have lower levels of mercury than larger fish.

How does alcohol affect pregnancy?

Alcohol has been implicated in infertility, early miscarriage, as well as in birth defects. The amount of alcohol consumption necessary to cause these problems is not known, and varies among women. Some women can drink excessively and have normal infants. Others consume considerably less alcohol but still give birth to babies with cognitive disabilities and/or other birth defects. It is generally believed that the greater the amount of alcohol consumed during pregnancy, the greater the risk of pregnancy-related problems and birth defects.
It is recommended that pregnant women avoid all consumption of alcohol. Fetal alcohol spectrum disorders are a group of conditions reflecting the possible effects of prenatal exposure to alcohol. The FASDs include fetal alcohol syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disabilities (ARND). Fetal alcohol syndrome (FAS) is the extreme end of the fetal alcohol spectrum disorders and is a leading cause of cognitive disabilities.

How do high blood pressure and diabetes affect pregnancy?

Elevated blood pressure (hypertension) that is present before pregnancy can interfere with growth of the fetus and increase the risk of fetal death. Therefore, controlling blood pressure with carefully chosen blood pressure medications is important during pregnancy and before conception.
In addition, underlying hypertension can increase the risk for a condition called preeclampsia, a potentially very dangerous complication of pregnancy. It is sometimes difficult for doctors to distinguish between high blood pressure alone and high blood pressure occurring from preeclampsia. For those reasons, and given the risk of birth defects from many of the blood pressure medications, women with high blood pressure who become pregnant should be followed very carefully by a medical expert who is familiar with this type of situation. Ideally, medication would be switched to a relatively safe medication before the woman even becomes pregnant.
Poorly controlled diabetes can lead to high blood sugar levels. High blood sugar levels during early pregnancy can lead to miscarriages and birth defects. Therefore, controlling diabetes is important for a good pregnancy outcome, and the blood sugar should ideally be controlled before becoming pregnant. It is important to consider that control of blood sugar during pregnancy is important, but control prior to pregnancy may be just as important.
Oral diabetes medications may be dangerous to the fetus, but insulin is not dangerous to the fetus. Insulin is the key treatment for diabetes during pregnancy. Not only is insulin safe to the baby and mother, but it also helps prevent the complications that the baby could have suffered from the mother's sugar being uncontrolled. Insulin is usually substituted for pills as soon as a woman with diabetes is considering pregnancy. The ideal time to control blood sugar is before pregnancy, because control of sugar levels even in early pregnancy (when the mother does not yet

What are examples of commonly-used medications that are dangerous in pregnancy?

Many women do not know that over-the-counter medications can be dangerous. In fact, many prescription and over-the-counter medications harm the fetus very early in pregnancy at a time that the mother does not even know she is pregnant. Even aspirin use by the mother can cause defects in the fetus. For this reason, as soon as pregnancy is being contemplated, women should avoid all over-the-counter and prescription medications until reviewed with their doctor.
Acne medications, such as isotretinoin (Accutane) can cause birth defects, and should be discontinued before conception. Since many medications and substances can affect fetal growth and development, pregnancy planning is important so that potentially harmful substances can be stopped before conceiving.
Unplanned pregnancy during oral contraceptive use is not felt to pose a significant danger to the fetus, although deliberate use of oral contraceptives during pregnancy is not advisable. Women who become pregnant during oral contraceptive use have the same risk of birth defects in their newborns as the general population of women, in the range of 2% to 3%.

How do kidney and heart disease affect pregnancy?

Because pregnancy is associated with an increase in blood volume and an increase in cardiac output as well as other changes in the circulatory system, many types of heart disease may worsen or be associated with poor outcome during pregnancy. While many mild chronic heart conditions may be well tolerated during pregnancy, other conditions pose a significant risk to mother and fetus. Women with preexisting heart disease should always consult an expert when planning a pregnancy to examine their own degree of risk, potential outcomes, and treatment options. know she is pregnant) is important for the developing baby's health.

What infections affect pregnancy?

Certain infections during early pregnancy can cause birth defects in the fetus. Rubella (German measles) virus infection during early pregnancy can cause birth defects and even miscarriages. Therefore, women of child bearing age are tested for blood antibodies against this virus. Women lacking rubella virus antibodies are susceptible to rubella infection, and should be vaccinated against this virus. Pregnancy should be avoided for one month after vaccination, due to the theoretical concern that the vaccine virus itself may cause fetal damage.
Toxoplasmosis is a small parasite that is transmitted through cat feces and raw meats, especially pork. Toxoplasmosis, like the rubella virus, can cause severe birth defects if the infection occurs during early pregnancy. Women planning pregnancy should avoid raw meat and avoid handling the cat litter box. Many people have been exposed to toxoplasmosis without even knowing it. As a result, they develop a protective immunity from the "silent" infection. Women who have a blood test that is positive for toxoplasmosis immunity can be reassured that they will not develop toxoplasmosis complications during pregnancy.
Hepatitis B is the only type of hepatitis that is known to affect the newborn infant.
Female healthcare workers, dental assistants, and others exposed to hepatitis B should receive hepatitis B vaccination to avoid chronic infection by this virus. The majority of hepatitis B virus infections resolve spontaneously without treatment. Patients whose disease resolves completely are no longer contagious. Approximately 10% of hepatitis B virus infections do not resolve, and become chronic. Patients chronically infected with hepatitis B virus may have no symptoms of liver disease early on, but they remain contagious. Over time, chronic hepatitis B infection can lead to liver cirrhosis and/or liver cancer.
Women with chronic hepatitis B infection can transmit the virus to their babies at birth. Babies infected are at risk of developing chronic liver disease, liver cirrhosis, and liver cancer in later life. Currently, infants born to mothers infected with the hepatitis B virus are given both the hepatitis B antibodies and hepatitis B vaccinations at birth for protection. Therefore, pregnant women are often tested for signs of hepatitis B infection, even if they do not have any symptoms or knowledge of past infection. The babies of infected mothers detected in this manner would receive special care at (and after) delivery.
Cytomegalovirus (CMV) is a common viral infection worldwide that often does not produce any symptoms. Women who become infected or have a reactivation of a previous infection during pregnancy may pass the infection along to their babies. Congenital CMV infection is the most common congenital viral infection. Although the majority of infected infants will not have any symptoms, up to 20% will have symptoms that may include an enlarged spleen, jaundice, or rash. Rarely, involvement of many organs may occur resulting in severe illness or disability.
Genital herpes may also result in the passage of the infection to the infant at the time of delivery. The risk of transmission is increased if the genital lesions are from a herpesvirus (HSV) infection acquired during the pregnancy, rather than simply a reactivation of previous disease. HSV infection can have multiple effects in the newborn. Disease may be limited to the eyes, skin and mouth; may be localized to the central nervous system; or may be widespread and involve many organs. Treatment involves administration of antiviral medications to the newborn and supportive care.
Parvovirus B19 is a virus that causes the condition known as Fifth disease, a common mild disease of childhood. Transmission is by droplets in the air (respiratory secretions) or through blood. Pregnant women who have not previously had fifth disease should avoid contact with those who have it because parvovirus B-19 can infect a fetus prior to birth. Although no birth defects have been reported as a result of fifth disease, it can cause the death of an unborn fetus. This occurs in less than 5% of pregnant women who become infected with the virus.
When traveling to a foreign country, it is important to determine what diseases are common, whether vaccines are needed, and whether they are safe during pregnancy. Human immunodeficiency virus (HIV) infection can be passed from a mother to her baby. The chances of this happening are decreased substantially with certain medication programs during pregnancy. Pregnant women are routinely offered testing for HIV infection. Women with previously undetected infection who are found to have HIV infection can be given special medication to try to protect the baby. At the same time, the medication may benefit the health of the mother herself.
Varicella, or chickenpox, can cause pneumonia or even death in older adults and in pregnant women. Varicella vaccine is available for women who are not immune to chickenpox. Women who had chickenpox in the past do not need a vaccine because they are immune. Women who are not sure if they are immune can receive a blood test to determine immunity status. A vaccine would be given if the blood test showed they were not immune.

What inherited (genetic) diseases can play a role in pregnancy planning?

Certain diseases, such as Tay-Sachs, sickle cell anemia, hemophilia, cystic fibrosis, and certain neurological diseases are genetically inherited. Healthy couples with family histories of these conditions may themselves be carriers of these genetic traits. Blood tests can be performed to screen for certain genetic traits prior to conceiving. Genetic counseling is given to couples who may carry genetic diseases as part of pregnancy planning.
Older women have an increased risk of having babies with chromosome abnormalities, leading to cognitive disabilities and other birth defects. Chromosomal abnormalities (like Downs syndrome ) can lead to birth defects and cognitive disabilities. Pregnant women older than 35 years may consider amniocentesis to detect these chromosomal abnormalities. During amniocentesis, amniotic fluid samples are aspirated from the womb. Chromosome analysis can be performed on fetal cells within the amniotic fluid.
Phenylketonuria is an inherited disease that affects the utilization of a certain protein component in foods. This disorder can be detected by a blood test. Mothers with phenylketonuria may give birth to developmentally disabled children unless their diets are strictly controlled to exclude phenylalanine.

Is it safe to exercise during pregnancy?

Recommendations from the American College of Obstetrics and Gynecology say that pregnant women who have an uncomplicated pregnancy should participate in at least 30 minutes of moderate exercise on most, if not all, days of the week. A few exceptions are noted: ice hockey, kickboxing, soccer, and horseback riding probably should be avoided because they are activities with higher risk of trauma to the abdomen. Also, scuba diving poses a risk of decompression sickness ("the bends") to the fetus and should be avoided. Exercise programs should be discussed with the monitoring health care professional.
Elevated temperatures can have adverse effects on the development of the fetus. Therefore, hot tubs and sauna baths should be avoided when trying to conceive and during pregnancy.

Can I travel by air during pregnancy?

The American College of Obstetrics and Gynecology guidelines say that air travel is safe for most pregnant women up to 36 weeks gestation, as long as there are no obstetric or maternal complications already diagnosed. Examples of special situations would be women with hypertension, poorly-controlled diabetes, or sickle cell disease, or women diagnosed with increased risk of premature labor. Support stockings during flight, and intermittent walking to move the legs around are recommended to minimize the chance of blood clots in the legs during prolonged flights. Travel plans should be discussed with the monitoring health care professional in high-risk pregnancies.

Can I have intercourse during pregnancy?

Intercourse during pregnancy is safe for most women. Special situations in which women might be advised to avoid intercourse include prior preterm labor, multiple miscarriages, infection, bleeding, amniotic fluid leak, and a condition called placenta previa or low placenta. (A placenta previa is when the placenta is implanted near the outlet of the uterus, so that at the time of delivery the placenta precedes the baby. Placenta previa can cause painless bleeding in the last trimester of pregnancy, and may be a reason for a C-section.)
All women are advised to avoid sexual intercourse that could put them at risk to exposure to sexually transmitted diseases.

How soon after stopping birth control can I become pregnant?

There is no evidence that there is increased risk of spontaneous abortion increases if a woman becomes pregnant in the first cycles after stopping oral contraceptive pills. Intrauterine devices (IUD's) are not harmful to the fetus. Women who get pregnant with an IUD that is still in place do not have higher change of congenital abnormalities in the fetus compared to other women. If the IUD of a woman in her 1st trimester is carefully removed by a doctor, or if it is expelled on its own in the 1st trimester, the chance of spontaneous miscarriage is not increased compared to other women.
When barrier methods such as condoms, diaphragms, cervical caps, and sponges are used, pregnancy can occur by simply discontinuing their use during a regular cycle. The same can be said for spermicidal gels and suppositories.
Medroxyprogesterone (Depo-Provera) is an injectable hormone used for contraception. The contraceptive effect of Depo-Provera may last as long as 18 months after the last injection. Normal menstrual cycles and pregnancy cannot occur until after the contraceptive effect wears off.

How do we maximize our chances of becoming pregnant?

For most couples, becoming pregnant occurs naturally. Some couples have difficulty conceiving, and ways to maximize chances of conception become important. Other parents may want to time the delivery of their babies during particular times of the year or space the birth of their babies according to a desired schedule.
The first step in maximizing the chances of conception is by estimating the time of ovulation. Ovulation is that time of the menstrual cycle wherein the egg is released from the ovary and travels towards the Fallopian tube. In women with regular menstrual cycles, ovulation usually occurs 12-14 days prior to the onset of the next menstrual flow. Simply counting back fourteen days from the expected date of the onset of next period should be the time of ovulation. The couple should have intercourse for several days before, day of, and day after the expected time of ovulation. There is usually some variation in the time of ovulation even in women with regular cycles, so a few extra days of intercourse before and after expected ovulation is advised.
If the cycles are irregular and unpredictable, estimating the time of ovulation becomes difficult, and professional assistance may be helpful. Another option for a woman with irregular cycles is the use of ovulation predictor kits available over-the-counter at most drug and grocery stores. These kits can be used to determine the approximate time of ovulation by detecting urinary hormone elevations that precede ovulation. Another approach is to have intercourse every other day throughout the menstrual cycle. This approach will take out the stress or anxiety involved in timing intercourse.
Basal body temperature timing is a technique of checking the body temperature every morning and charting the results. If the temperature rises by a certain amount and stays elevated, it can be assumed that ovulation occurred. Difficulties with this method are that it is tedious and only provides the woman with information about ovulation after it has occurred.
Ultrasound images of the ovaries can be performed to monitor the growth and collapse of the ovarian follicle during the cycle. The follicle is the fluid-filled structure that surrounds the egg, and it can easily be seen on ultrasound. This method is probably the most accurate in timing ovulation. It is also the most expensive and is usually reserved for selected couples who are experiencing difficulty in becoming pregnant.
It is important to remember that even though intercourse and ovulation coincide, pregnancy may still not be achieved in any given menstrual cycle or even after several consecutive menstrual cycles. In many situations, the failure to conceive after multiple attempts is not a reason for alarm. It is not uncommon for pregnancy to occur only after several months of consistent attempts. Couples who have experienced an inability to conceive after several cycles may consider seeking professional advice to determine if an infertility evaluation is necessary.

Can I do something to help my chances of conceiving a boy or a girl?

• The ancient Greeks tied off the left testicle when attempting to conceive a boy.
  
• French noblemen in the 18th century went one step further and actually removed the left testicle, believing that this would guarantee a male infant.
  
• In the 19th century, the man would stand on the right bedpost and the woman would lie on her right side after intercourse in order to assure a boy!
  
• The 20th century brought on the ideas of deep penetration, adjustment of vaginal acidity, consumption of certain foods, position, and other various methods to enhance the chances of bearing either a girl or a boy.

None of these various approaches has ever been scientifically tested. Therefore, no definite statement can be given regarding the success of these techniques, but they probably have no impact on the gender of the baby. Currently there have been a few proven laboratory techniques of increasing the percentage of male or female sperm, but these are not routinely used. These techniques either use electrical charges, or special "gels" through which the sperm have to swim. Even with these techniques, there is no guarantee that a child of the desired gender will be born. Research has refuted any relationship between the timing of sexual intercourse in relation to ovulation and the gender of the baby.

REFERENCES:

eMedicine.com. Pregnancy Diagnosis.

eMedicine.com. Common Pregnancy Complaints and Questions.

Previous contributing authors: Leon J. Baginski, MD, FACOG and Carolyn Janet Crandall, MD 

Medical Author:

Melissa Conrad Stöppler, MD

Medical Editor:

William C. Shiel Jr., MD, FACP, FACR
Source:Medicinenet.com.