Pre Pregnancy-101


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In this multimedia presentation Dr. Melissa Stoffel, D.O. provides valuable insight on preconception counseling, the practice of getting a woman as healthy as they can be prior to pregnancy, and describes what women should expect during pregnancy.

Stoffel describes what to expect from preconception counseling, how to prepare for counseling sessions and how she manages special conditions like asthma management, diabetes management, smoking cessation and heart conditions before a pregnancy.

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  • More important than prenatal care for prevention of congenital anomalies since 30% of women begin prenatal care in the second trimester (>14wks) after which organogenisis is complete. (3-10wks).
  • Benefits of identifying and treating medical conditions before pregnancy occurs.
  • Infertility, fetal aneupoloidy (chromosomal risks), GDM, preeclampsia, stillbirth Preeclampsia increases at extremes of ages
  • Prior miscarriage, surgeries, pregnancy outcomes.
  • Immunizations – live –attenuated viral vaccines not given in pregnancy Flu – ok after first trimester If recent vaccination – wait one month before conceiving
  • NTDs, heart defects, cleft palate/lip, Downs Syndrome, cystic fibrosis, PKU, Hemophilia, kidney disease,
  • Community support available – badger care, WIC, public health nurses
  • Gestational HTN, preeclampsia, GDM, Preterm premature ROM, preterm/post-term delivery, macrosomia, operative vaginal delivery, congenital anomalies, c-section, stillbirth, increased childhood obesity and DM
  • Toxo – avoid changing cat litter, don’t eat under cooked meat, wear gloves gardening, when preparing food – frequent hand washing Mercury – bottom feeder fish, once weekly Increased levels can lead to CNS damage, intellectual/motor/psychosocial impairement OSHA – organization that enforces work places to provide workplace free from recognized hazards, frequent audits
  • Nutrasweet = aspartame Splenda = sucralose Sweet N Low = sucharin
  • Oral disease increases preterm labor/delivery
  • Glucose screen – hx macrosomic infant >9#), personal hx of GDM, overwt, family hx of DM CMV- work in child care area
  • Increase glucose it the most important determinent of increase fetal risk in pregnancy. Decrease glucose levels decreases spont AB, congenital malformations. (heart/limbs.etc) BP meds = aldomet/methyldopa
  • Medication list.
  • Iron containing foods – liver, red meat, egg, dried beans, leafy green veggies, dried fruit, whole-grain bread
  • Edema in legs is normal as pregnancy advances = venous compression by wt of uterus
  • Increase fiber in diet. May take fiber supplement.
  • Breastfeeding support class Childbirth preparation class Fathers in training Happiest baby on the block Infant care basics/infant safety Sibling celebration Early pregnancy fair Mommy mondays…move it, make it, manage it Mommy café Infant massage and nurturing touch
  • Pre Pregnancy-101

    1. 1. Pre-pregnancy 101 Melissa Stoffel D.O. Marshfield Clinic OB/GYN May 26, 2009
    2. 2. Preconceptual Counseling <ul><li>Definition: Identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management. </li></ul><ul><li>Goal: Help the mother maintain her well-being and achieve a healthy outcome not only for herself, but for her unborn child. </li></ul>
    3. 3. Preconceptual Counseling <ul><li>Optimal time to assess, manage and treat many conditions/complications before conception. </li></ul><ul><li>Improves pregnancy outcomes. </li></ul><ul><li>Reduced maternal/neonatal morbidity and mortality. </li></ul>
    4. 4. Components <ul><li>Identification of pregnancy related risks </li></ul><ul><li>Pt education regarding pregnancy risks, management options, and reproductive alternatives </li></ul><ul><li>Initiation of interventions, when possible, to provide optimum pregnancy outcome </li></ul>
    5. 5. What to Expect <ul><li>Complete medical/family history </li></ul><ul><li>Physical exam </li></ul><ul><li>laboratory </li></ul>
    6. 6. Comprehensive History <ul><li>Age </li></ul><ul><ul><li>Teens – nutritional/emotional needs, STD’s </li></ul></ul><ul><ul><li>>35 yrs – increase pregnancy risks </li></ul></ul><ul><ul><li>Father >age of 55 </li></ul></ul>
    7. 7. Comprehensive History <ul><li>Reproductive history (obstetrical/gynecologic) </li></ul><ul><ul><li>May identify factors that may contribute to infertility or pregnancy complications </li></ul></ul><ul><ul><li>Menstrual calendar (accurate dating is critical for obstetric decision making) </li></ul></ul>
    8. 9. Personal Medical History <ul><li>Medications </li></ul><ul><li>STI hx </li></ul><ul><li>Chronic medical conditions </li></ul><ul><li>Immunization hx – up to date </li></ul><ul><li>Surgeries </li></ul><ul><li>Mental Health </li></ul>
    9. 11. Family History <ul><li>Helps identify genetic risks to fetus and maternal medical risks </li></ul><ul><li>Ethnicity </li></ul>
    10. 12. Psychosocial Issues <ul><li>Stress, financial issues, mental health </li></ul><ul><li>Maternal suffering can lead to poor compliance, nutrition, substance abuse, or disturbed relationship between mom and baby </li></ul>
    11. 13. Weight and pregnancy <ul><li>Obesity is associated with decreased fertility </li></ul><ul><li>Normal Pre-pregnancy BMI 19.8 – 26.0 </li></ul><ul><li>Increased pregnancy complications with extremes of BMI </li></ul><ul><li>Weight reduction attempted prior to pregnancy </li></ul>
    12. 14. Exercise <ul><li>Mild – moderate exercise while pregnant is not harmful if done on a regular basis prior to pregnancy </li></ul><ul><li>Do not initiate a strenuous exercise regime during pregnancy </li></ul><ul><li>Low impact routine </li></ul>
    13. 15. Substance Use <ul><li>Tobacco </li></ul><ul><ul><li>Increase miscarriage, prematurity, and low-birth weight infants, IUGR, placenta abruption, </li></ul></ul><ul><ul><li>Smoking cessation/decreased amount during pregnancy improves pregnancy outcomes </li></ul></ul><ul><ul><li>Chantix not used in pregnancy </li></ul></ul>
    14. 16. Substance Use <ul><li>Alcohol and Illicit Drugs </li></ul><ul><ul><li>Increase preterm delivery, IUGR, FAS, neonatal withdrawal </li></ul></ul><ul><ul><li>Avoidance of all = better pregnancy outcomes </li></ul></ul><ul><ul><li>Methadone Clinic </li></ul></ul>
    15. 17. Substance Use <ul><li>Caffeine </li></ul><ul><ul><li>Limit 300mg/d </li></ul></ul><ul><ul><li>Consumption of >250mg/d can decrease fertility </li></ul></ul><ul><ul><li>>500mg/d increase miscarriage, stillbirth, low-birth weight infants </li></ul></ul>
    16. 19. Environmental Exposures <ul><li>Avoid organic solvents </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>Mercury </li></ul><ul><li>Lead (paint, arts/crafts) </li></ul><ul><li>No harm from computer monitors, electric blankets, heated water beds, microwave </li></ul><ul><li>Work place (OSHA) </li></ul>
    17. 20. Nutrition <ul><li>The fetal environment affects infant and childhood development. </li></ul><ul><li>Dietary changes that optimize growth and development have life long health benefits. </li></ul><ul><li>Vegetarian diets lack adequate amts of amino acids and iron, vitamin B12 and complex lipids. </li></ul>
    18. 21. Nutrition <ul><li>Discontinue megavitamins, non-essential dietary supplements, and herbal preparations. (not studied to evaluate fetal risk) </li></ul><ul><li>No evidence that Nutrasweet, Splenda, Sweet N’ Low increase risk of birth defects above the general population. </li></ul><ul><li>Multivitamin/prenatal vitamin with 400mcg (0.4mg) of folic acid needed </li></ul>
    19. 22. Physical Exam <ul><li>General head/toe exam </li></ul><ul><ul><li>Thyroid/dental carries </li></ul></ul><ul><li>Pelvic exam </li></ul><ul><li>Pap </li></ul><ul><li>Gonorrhea/chlamydia cultures </li></ul>
    20. 23. Laboratory <ul><li>Rubella titer </li></ul><ul><li>Varicella titer </li></ul><ul><li>Hepatitis B </li></ul><ul><li>CBC (anemia) </li></ul><ul><li>Blood type and RH factor </li></ul><ul><li>HIV </li></ul><ul><li>Glucose screen </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>CMV </li></ul>
    21. 24. Maternal Medical Conditions <ul><li>-Optimal management </li></ul><ul><li>-Change in medications that are safer in pregnancy prior to conception </li></ul>
    22. 25. Maternal Medical Conditions <ul><li>Diabetes </li></ul><ul><ul><li>Referral to endocrinology </li></ul></ul><ul><ul><li>Achieve tight glycemic control prior to conception </li></ul></ul><ul><ul><li>Dietary consultation </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>BP control prior to pregnancy </li></ul></ul><ul><ul><li>Safer meds (no ACE inhibitors) </li></ul></ul>
    23. 26. Maternal Medical Conditions <ul><li>Asthma </li></ul><ul><ul><li>Good control prior to pregnancy </li></ul></ul><ul><ul><li>Most meds safe in pregnancy </li></ul></ul><ul><li>Thyroid disease </li></ul><ul><ul><li>Close monitoring of thyroid function </li></ul></ul><ul><ul><li>Adjusting medication dose common </li></ul></ul><ul><ul><li>Neuropsychological impairment </li></ul></ul>
    24. 27. Maternal Medical Conditions <ul><li>Epilepsy </li></ul><ul><ul><li>Neurology referral for drug adjustments </li></ul></ul><ul><ul><li>Frequent blood levels </li></ul></ul><ul><ul><li>Extra folic acid 1gram </li></ul></ul><ul><ul><li>Vitamin K (36wks – delivery) </li></ul></ul><ul><li>Lupus </li></ul><ul><ul><li>Better prognosis for both mom and baby is quiescent for 6 mos before conception </li></ul></ul><ul><ul><li>Better prognosis if normal renal function </li></ul></ul>
    25. 28. Maternal Medical Conditions <ul><li>Anemia </li></ul><ul><ul><li>HGB 6g/dl (decreased AFI, abnormal FHT, increase fetal death) </li></ul></ul><ul><li>Depression </li></ul><ul><ul><li>If controlled and doing well on medication = continue taking drug </li></ul></ul>
    26. 29. Prenatal Education <ul><li>Pt education leads to better self-care and pregnancy outcomes. </li></ul><ul><li>Radiologic studies (dental/radiologic) </li></ul><ul><ul><li>Can be performed when indicated </li></ul></ul><ul><ul><li>Delay if elective </li></ul></ul><ul><li>Medications </li></ul><ul><ul><li>Take only medications approved or prescribed by your doctor. When in doubt…ask! </li></ul></ul>
    27. 30. Prenatal Education <ul><li>Nutrition </li></ul><ul><ul><li>Iron 30mg/d (take between meals, empty stomach) </li></ul></ul><ul><ul><ul><li>Necessary for fetal/placenta development and to expand the maternal RBC mass </li></ul></ul></ul><ul><ul><li>Calories: increase by 340 – 450 kcal/d </li></ul></ul><ul><ul><li>Calcium 1000mg/d </li></ul></ul><ul><ul><li>Three servings of dairy daily </li></ul></ul>
    28. 33. Weight Gain <ul><li>3-6# wt gain in first trimester </li></ul><ul><li>0.5 – 1#/wk in last 2 trimesters </li></ul><ul><li>Inadequate wt gain during pregnancy is associated with increase low-birth-weight infants, and preterm delivery. </li></ul>
    29. 34. Weight Gain <ul><li>Underweight women </li></ul><ul><ul><li>BMI <19.8 kg/m2 </li></ul></ul><ul><ul><li>26-40# </li></ul></ul><ul><li>Normal weight women </li></ul><ul><ul><li>BMI 19.9-26.0 kg/m2 </li></ul></ul><ul><ul><li>26-35# </li></ul></ul><ul><li>Overweight women </li></ul><ul><ul><li>BMI 26-29 kg/m2 </li></ul></ul><ul><ul><li>15-26# </li></ul></ul><ul><li>Obese women </li></ul><ul><ul><li>BMI >29 </li></ul></ul><ul><ul><li>15# </li></ul></ul>
    30. 35. Weight Gain <ul><li>2-3# = increased fluid volume </li></ul><ul><li>3-4# = increased blood volume </li></ul><ul><li>1-2# = breast enlargement </li></ul><ul><li>2# = enlarged uterus </li></ul><ul><li>2# = amniotic fluid </li></ul><ul><li>6-8# = baby </li></ul><ul><li>1-2# = placenta </li></ul><ul><li>4-6# = maternal stores of fat and protein (lactation) </li></ul>
    31. 36. Prenatal Education <ul><li>Activity and Employment </li></ul><ul><ul><li>Avoid heavy lifting (25-30#) </li></ul></ul><ul><ul><li>Most are able to maintain normal activity level </li></ul></ul><ul><li>Travel </li></ul><ul><ul><li>Avoid prolonged sitting in car/plane (clotting risk) </li></ul></ul><ul><ul><li>Support hose </li></ul></ul><ul><ul><li>Seat belt </li></ul></ul><ul><ul><li>Driving 6 hours/d (stop every 2 hours for 10 min) </li></ul></ul>
    32. 37. Prenatal Education <ul><li>Nausea and vomiting </li></ul><ul><ul><li>Avoid greasy/spicy foods </li></ul></ul><ul><ul><li>Frequent small meals </li></ul></ul><ul><ul><li>Crackers at bedside </li></ul></ul><ul><ul><li>Protein snack at night </li></ul></ul><ul><li>GERD </li></ul><ul><ul><li>Relaxation of esophogeal sphincter </li></ul></ul><ul><ul><li>Don’t eat before lying down </li></ul></ul><ul><ul><li>Worse with overeating and spicy foods </li></ul></ul><ul><li>Hemorrhoids </li></ul><ul><ul><li>Varicose veins of rectum </li></ul></ul><ul><ul><li>Avoid constipation/straining/prolonged sitting </li></ul></ul><ul><ul><li>Regress after delivery (not go away completely) </li></ul></ul>
    33. 38. Prenatal Education <ul><li>Constipation </li></ul><ul><ul><li>Decrease bowel transit time </li></ul></ul><ul><ul><li>Fresh fruit/veggies/water </li></ul></ul><ul><ul><li>Metamucil/colace </li></ul></ul><ul><li>Urinary frequency </li></ul><ul><ul><li>Growing uterus and fetal head increase pressure on the bladder. </li></ul></ul><ul><li>Round ligament pain </li></ul><ul><ul><li>Sharp groin pains = spasm of round ligament associated with movement </li></ul></ul><ul><ul><li>Right > left </li></ul></ul><ul><ul><li>Local heat, gradual rising/sitting, avoid sudden movement </li></ul></ul>
    34. 39. Prenatal Education <ul><li>Syncope </li></ul><ul><ul><li>Compression of veins in legs from the growing uterus causes venous pooling with prolonged standing = faint </li></ul></ul><ul><ul><li>Compression stockings </li></ul></ul><ul><li>Back ache </li></ul><ul><ul><li>Prevented by excessive weight gain </li></ul></ul><ul><ul><li>Exercises to strengthen back muscles </li></ul></ul><ul><ul><li>Posture, sensible shoes </li></ul></ul><ul><li>Intercourse </li></ul><ul><ul><li>Usually no restrictions </li></ul></ul><ul><ul><li>May cause increase uterine activity and spotting </li></ul></ul>
    35. 40. Prenatal Education <ul><li>Breast feeding </li></ul><ul><ul><li>Avoid soap/lotions on breasts </li></ul></ul><ul><li>Preparation for childbirth </li></ul><ul><ul><li>Studies have shown that prepared childbirth can have a beneficial effect on performance in labor and delivery </li></ul></ul>
    36. 41. Questions <ul><li>How long after a miscarriage should I wait before trying to get pregnant again? </li></ul>
    37. 42. Questions <ul><li>Are there any cosmetics or body lotions that should be avoided if I’m trying to get pregnant? </li></ul>
    38. 43. Questions <ul><li>When in the menstrual cycle would I most likely get pregnant? </li></ul>
    39. 44. Questions <ul><li>How long after a person stops taking oral contraception do recommend waiting before trying to get pregnant? </li></ul>
    40. 45. Questions <ul><li>Do women who have had abnormal pap smears and a colposcopy have problems getting pregnant or delivering a baby? </li></ul>
    41. 46. Questions <ul><li>How often during the menstrual cycle should I have intercourse? </li></ul>
    42. 47. Questions <ul><li>Can I use natural planning to help get pregnant? </li></ul>
    43. 48. Questions <ul><li>If you are considering getting pregnant or are already pregnant and you need to choose a doctor what are the reasons to choose an OB versus choosing a family practitioner, what things should a person think about when making that decision? </li></ul>
    44. 49. Questions <ul><li>If you had a pre-term delivery in the past would there be something you would recommend to do differently during the pre-pregnancy planning stage or during the first trimester? </li></ul>
    45. 50. Questions <ul><li>Hot tubs in pregnancy? </li></ul>
    46. 51. Questions <ul><li>How much fish can I eat during pregnancy? </li></ul>
    47. 52. Questions <ul><li>What about using sunscreen when you’re pregnant? </li></ul>
    48. 53. Questions <ul><li>Is there anything out there to help prevent stretch marks? </li></ul>
    49. 54. Questions <ul><li>I’ve seen some women where a belt during pregnancy, what is that for? </li></ul>
    50. 55. Questions <ul><li>What about chiropractic care or messages during pregnancy? </li></ul>
    51. 56. Questions <ul><li>When can I begin to slim down post pregnancy? </li></ul>