Pregnancy is a great time, an exciting time, but it’s also a time of endless questions. Women have access through social media, television, print media, Internet searches, and their friends to much information about pregnancy, but sometimes it can be confusing or wrong. There are many questions about all facets of life including eating, drinking, sleeping, working, travel, exercise and having sex.  We are often asked these questions by our patients, and in the recent issue of our professional publication, Obstetrics and Gynecology (April 2018, p713), Dr. Fox wrote a nice summary about current, science-based recommendations regarding these topics. I’m going to summarize them for you in this article.

Prenatal Vitamins

Prenatal vitamins are designed to meet the needs of pregnant women. However, except for folic acid, iron and Vitamin D, it’s unknown if taking them makes a difference in outcome. For women with well-balanced nutritious diets, they are probably not required. Folic acid deficiency is associated with fetal birth defects, so women who don’t have it in their diet should be on 400-800 micrograms a day. Women who have had a history of a previous pregnancy complicated with a neural tube defect should be on 4,000 micrograms a day. Iron supplementation is advised to increase the mother’s blood count to avoid becoming anemic at birth.  It is more needed if the mother’s blood count is low to begin with. Vitamin D deficiency is associated with pregnancy problems including pre-eclampsia and premature birth. While testing for Vitamin D levels is not routinely recommended, taking Vitamin D (usually 200-600 IUs) daily is. Calcium supplementation has been shown to decrease high blood pressure in pregnancy. Women should be sure to consume through diet or supplements at least 1,000 mg of calcium per day. Some prenatal vitamins don’t have that much.

Nutrition and Weight Gain

Pregnant women should eat a healthy, well-balanced diet and usually should increase their calorie intake in the second and third trimesters by only a small amount, about 350-450 calories per day. A good nutrition resource is a website run by the U.S. Department of Agriculture at www.chooosemyplate.gov. Women with higher pre-pregnancy weight should not gain as much as women with normal or low weight.

Alcohol

High alcohol intake in pregnancy has been associated with fetal malformations. Studies in Denmark and Australia have found no association between a low level of maternal drinking (less than one drink per day) and developmental cognitive abilities in children. However, the threshold for safe drinking is not known, and it can’t be concluded that a small amount of drinking is safe. All major health organizations recommend abstaining from alcohol completely during pregnancy.

Artificial Sweeteners

There is no evidence that aspartame (NutraSweet), sucralose (Splenda), acesulfame potassium (Sunett), stevioside (Stevia) or saccharin (Sweet N Low) cause birth defects.

Caffeine

Most studies in humans show that low to moderate caffeine use is not associated with any adverse outcomes. Some animal studies suggest that high caffeine intake (greater than 10 cups per day) slightly increases the risk of miscarriage.

Fish

Eating fish conveys both benefits and potential risks. Benefits are that studies have shown eating fish in pregnancy resulted in improved neurodevelopment in children, and also lowered the risk of premature birth. However, fish is also a potential source of mercury exposure and mercury can cause harm. Therefore pregnant women should try to consume 2 to 3 portions weekly of fish that are high in long chain polyunsaturated fatty acids and low in mercury, such as anchovies, Atlantic herring, Atlantic mackerel, mussels, oysters, farmed and wild salmon, sardines, snapper, and trout. Other safe fish which have less fatty acids include shrimp, pollock, tilapia, cod and catfish. Women should avoid fish with higher mercury content such as king mackerel, shark, swordfish, marlin, and tilefish. For women who do not consume 2 to 3 servings of fish a week, there is no clear evidence that supplementation with omega-3 fatty acids improves outcome in children, but they are unlikely to be harmful.

Most health organizations advise women to avoid raw fish in pregnancy. However, the fish that typically makes up sushi (tuna, salmon, yellow tail, snapper, flounder) rarely carries parasites. Therefore, the risk of infection from eating well-prepared sushi in a clean and reputable establishment is not significant.

Other Foods to Avoid

Food restrictions in pregnancy are designed to minimize exposure to harmful infections such as toxoplasmosis and Listeria.  To lower the risk of toxoplasmosis, avoid eating raw and undercooked meat, and wash all fruits and vegetables before eating them. To lower the risk of Listeria, avoid unpasteurized dairy products, raw sprouts, unwashed vegetables, and unheated deli meats. While Listeria outbreaks were linked to deli meats in the 1990s, recently outbreaks were caused by ice cream, cantaloupes, hummus, and unpasteurized dairy products, so it’s difficult to make a list of safe foods without becoming overly restrictive.

Smoking and Nicotine

Smoking in pregnancy is harmful to both maternal health and to fetal health, causing many possible pregnancy complications. Although some of the adverse effects of smoking are due to nicotine, nicotine products designed to aid in smoking cessation are acceptable as part of a smoking cessation program, since nicotine in gum or a patch would reduce exposure to other toxins in cigarettes and in second hand smoke.  Other interventions such as bupropion and varenicline are thought to be effective and safe, but data is limited. Electronic nicotine delivery systems such as electronic cigarettes and vaporizers deliver high amounts of nicotine and could potentially be harmful, but less is known about them.

Marijuana

Marijuana is the most common illicit substance used in pregnancy. Current evidence shows that marijuana use in pregnancy is not associated with premature birth, low birth weight, or an increased risk of birth defects. Doses of it are not regulated and could vary significantly. Current recommendations are to avoid marijuana in pregnancy due to concerns about fetal neurodevelopment.

Exercise and Bedrest

Women with normal pregnancies should engage in regular aerobic and strength conditioning exercise. It is prudent to avoid exercise with a higher risk of injury such as contact sports, downhill skiing, and horseback riding. Women should try to moderately exercise 20-30 minutes four to five times a week. Moderate exercise is at the level at which women can still talk while exercising.

Bedrest, or activity restriction, is associated with several risks and has not been shown to be beneficial in pregnancy. Activity restriction has not been shown to be beneficial for women with high blood pressure, premature rupture of membranes, fetal growth restriction, or placenta previa.

Avoiding Injury in the Car

Pregnant women should continue to use three-point seatbelts in pregnancy. The lap belt should be placed across the hips and below the uterus. While airbags can also reduce the risk of injury, deployment of an airbag itself can also cause injury. It’s unclear if they are beneficial or harmful.

Oral Health

Oral health and routine dental procedures should continue as scheduled during pregnancy, including cleanings, extraction, root canal and fillings. X-rays can be done if the abdomen and thyroid are shielded.

Hot Tubs and Swimming

Hot tubs have the potential to increase body temperature, which is considered a risk for miscarriage and birth defects. It is thought to be more potentially harmful if it is done within the first 4 weeks from the last menstrual period, or if it is done more often.

Swimming pools are typically maintained below normal body temperature, and their use is not associated with harmful outcomes.

Insect Repellents

Topical insect repellants can be used in pregnancy because they are not associated with adverse fetal effects. As a result of the risk of mosquito-borne illnesses including Zika virus, their use in high risk areas is recommended.

Hair Dyes

Most studies on exposure to hair dye relate to the profession of cosmetology, and studies are mixed as to whether or not there is increased risk of pregnancy loss in that setting. Data on safety is limited, but for an individual pregnant woman, exposure to hair dye results in minimal systemic absorption, so hair dyes are presumed safe in pregnancy.

Travel

Airline travel is considered safe in pregnancy, but it is prudent to take precautions to lower the risk of a blood clot by periodic walking.  Pregnant women may go through security metal detectors. The radiation exposure from the newer backscatter units is also safe. In regard to travel destinations, women should be aware of the potential infection exposures (including Zika virus) as well as the availability of medical care at their destination. As the length of the pregnancy advances, the risk of travel increases, but there is no exact gestational age at which women cannot travel. In our office, it’s our policy to not allow distant travel in the last two months.

Sexual Intercourse

Sex and orgasm are not associated with an increased risk of pregnancy complications or premature birth. For women with vaginal bleeding or ruptured membranes, the risks of bleeding or infection may increase. Although there is little data to support it, most authorities recommend avoiding sexual intercourse after 20 weeks of pregnancy if a placenta previa is present.

Sleeping Position

Women are frequently advised to sleep on their sides, especially the left side. Several retrospective studies (limited by recall bias) have shown an increased risk of stillbirth when sleeping flat on one’s back. Considering the limitations of these studies as well as not knowing more about the benefits of side sleeping, it’s unclear if side sleeping conveys a benefit, how much it reduces risk and when. It’s our recommendation to not sleep flat on your back in the last 2 months of pregnancy. Sleeping on your side or on your back being tilted up by additional pillows should be safe.

by Bailey K. Cannon, MD

We get this question a lot. You may have heard about birth plans from your friends, the internet, or even the hospital. What is a birth plan? It is a document that states your wishes for delivery. That sounds like a nice idea but when it comes to labor and delivery the only person who is in charge is the baby. Have you ever planned a family vacation and you have the great plan of how things will go, what restaurants you’ll eat at, and the sights you will see? Then only to find the roads are under construction, the restaurant you really want is closed, and the parks are closed for maintenance. You may still have had a great time but feel a little let down because “not every went as planned.” The same is true with birth and plans for it.

In our office we do not encourage birth plans. Our ONLY plan is for a healthy mom and a healthy baby. Additionally, a vaginal delivery is also always our first wish for you. We certainly care about your preferences and will discuss any ideas you may have. You are welcome to bring any music, scents, clothes, etc. that you would like. Additionally, during labor if there is a choice: we will always give you that choice. Such as: Would you like an epidural or not? That choice is 100% up to you – we are happy either way. We may use our medical education and training to suggest an intervention that we feel will help you, but as long as it is safe – you are welcome to decline. If ever you or the baby are in danger we will immediately make a medical decision and we hope you will agree.

While we do not encourage birth plans, should you desire a birth plan we will be happy to review it in the office and discuss what is reasonable or what things may be unsafe. There are many unsafe recommendations on the internet. We have included a birth plan from the March of Dimes that we think is a good choice in birth plans.

Our only plan for you is a healthy baby and healthy mom. We look forward to achieving this goal together.

Click on the following to see a sample birth plan:

 

One in eight women in the United States will be diagnosed with breast cancer. The longer someone has breast cancer before it is detected, the more difficult the treatment becomes and the worse the odds of survival. One of the best ways to find breast cancer earlier is by self-exam.

The Worldwide Breast Cancer organization has come out with a nice campaign using photos designed by a breast cancer survivor to help increase awareness of how to find breast cancer.

This campaign gets the point across effectively and can be used in social media posts to help spread the word. The original photo has been shared nearly 35,000 times and seen by more than 3 million people. Just think about how many lives can be saved!

If you find anything like this in your breast self exam, please let your doctor know about it!

A study was just released which will be coming out soon in the American Journal of Obstetrics & Gynecology ( http://dx.doi.org/10.1016/j.ajog.2016.08.033 ). It looks at two different groups of reversible birth control methods, long acting and short acting. Long acting methods of birth control include the Nexplanon implant, the Mirena IUD and the Paraguard IUD. Short acting methods include the pill, the patch and the ring.

To see if there is a difference in success rate based on which women choose long versus short acting methods, the women who chose to participate in the study were assigned one of these groups randomly and received their contraceptives for free. Women who did not agree to randomization still submitted their results but did not receive the medication for free.

The results were striking. Of 916 participants the study, after 12 months there was an unintended pregnancy rate of 6.4% in those who were not randomized and instead chose a short term method, 7.7% in those who agreed to randomization and were assigned to the short term method group, and 0.7% for those who were randomized to the long term contraception group.

The study shows, comparing the two different classes of methods, women who use short acting birth control methods such as the pill have a ten times greater chance of becoming pregnant by accident compared with longer acting methods such as the implant or the IUD. This is true whether a person prefers one type of method or is randomly assigned to it. This may be related to the greater requirements of being on short term methods, with many more opportunities for failure to take it every day and on time. Longer acting methods have less opportunities to make mistakes.

It appears that most women are not aware of the large difference in effectiveness between these two types of birth control methods. If this information were more widely known, more women would choose the type of method with a less than 1 percent failure rate in a year rate compared with one that fails 6 to 7 percent over the same amount of time.

Zika was reported in May 2015 in South America and since then has spread throughout the Americas. The CDC and Pan American Health Organization (PAHO) websites maintain and update the list of areas where Zika virus transmission has been identified.

The virus spreads to humans primarily through infected Aedes aegypti mosquitoes. Once a person is infected, the incubation period for the virus is approximately 3-12 days. Symptoms of the disease are non-specific but may include fever, rash, aching in joints, and eye inflammation. It appears that only about 1 in 5 infected people will have these symptoms and most will have mild symptoms. It is not known if pregnant women are at greater risk of infection than non-pregnant.

Zika during pregnancy has been associated with birth defects, specifically significant microcephaly (small fetal head). Transmission of Zika to the fetus has been documented in all trimesters; Zika virus RNA has been detected in fetal tissue from early miscarriages, amniotic fluid, babies and the placenta. However, much is not yet known about Zika virus in pregnancy. Uncertainties include the incidence of Zika virus infection among pregnant women in areas of Zika virus transmission, the rate of transmission to the fetus, and the rate with which infected fetuses have complications such as microcephaly or demise. The absence of this important information makes management in the setting of potential Zika virus exposure (i.e. travel to active areas) or maternal infection, difficult. Currently, there is no vaccine or treatment for this infection.

Prevention Guidance:

• Avoiding exposure is best. Pregnant women should delay travel to areas where Zika outbreaks are ongoing when possible. Women considering pregnancy should discuss with their obstetricians the advisability of travel. See the CDC and PAHO websites for updated lists of affected countries.
• When traveling to areas where Zika has been reported, women should take all precautions to avoid mosquito bites including the use of EPA-approved bug spray with DEET, covering exposed skin, staying in air-conditioned or screened-in areas, and treating clothing with permethrin.
• Sexual transmission of Zika virus has been reported in a few cases but the frequency and efficiency of this route of infection is uncertain. Based on limited data, there is a theoretical risk of sexual transmission through exposure to semen of males with Zika virus disease. Given the potential risks of maternal Zika virus infection, pregnant women whose male partners have traveled to countries in which Zika is reported or have Zika virus infection should consider using condoms or abstaining from sexual intercourse.

Summary of Updated Guidance:

• Antibody testing for Zika virus is now recommended for all pregnant women who have traveled to or lived in affected area regardless of the presence of clinical illness.
• Physicians should discuss reproductive plans, including pregnancy planning and timing, with women of reproductive age considering the potential risks associated with Zika virus infection.
• Women of reproductive age with current or previous laboratory-confirmed Zika virus infection should be aware that there currently is no evidence that prior Zika virus infection poses a risk of birth defects in future pregnancies.
• Although the presence of Zika in breast milk has been reported, it is in very small amounts and unlikely to be harmful for the neonate. The benefits of breastfeeding likely outweigh the potential neonatal risks. Therefore, the recommendation is that women should continue to breastfeed.

If you are pregnant or planning for pregnancy check with us before traveling to areas of the American tropics and strictly follow steps to avoid mosquito bites during your trip.

The field of medicine is changing rapidly through the advances made by genomic technology. We are on the verge of an exciting era where we will be able to have personalized medical care and treat each person based on his or her individual risks. For example, every woman fits into one of three risk categories for breast cancer. A person may face only a sporadic risk with the same risk as the general population, or their risk may be increased due to a positive family history, or increased even more if they are discovered to have an inherited genetic risk.  Focusing on a person’s family history gives us the opportunity to detect those people who face a significantly increased danger of developing cancer and then use proven successful strategies to reduce that risk.

Cancer screening depends on risk. Women who face only the sporadic risk of breast cancer do not need additional screening beyond that for the general population: regular mammography starting at age 40. Those who have an increased risk due to family history or who have dense breasts would benefit from more frequent screening with mammography, breast ultrasound or breast magnetic resonance imaging starting at least 10 years prior to the age of cancer diagnosed in their youngest affected relative. A small number of women carry the highest risk for gynecologic cancer due to having a defective gene. BRCA gene carriers, for example, should have testing started 15 years earlier than average, and usually benefit from oral contraceptives to decrease the risk of ovarian cancer. They also benefit from surgery to reduce their risk such as preventative removal of the ovaries, as otherwise the risk of ovarian cancer can be as high as 44% by age 70.

There are about 1 million people in the United States carrying genes for the most common hereditary gynecologic cancers: BRCA and Lynch syndrome. Hereditary Breast and Ovarian Cancer syndrome (HBOC) is seen in approximately 10% of breast and ovarian cancer patients. This autosomal dominant genetic disorder is caused by mutations in tumor suppressor genes BRCA1 and BRCA2. Red flags for HBOC syndrome include a three generation family history positive for breast cancer prior to age 50, bilateral, triple negative or male breast cancer, ovarian cancer at any age, prostate, pancreatic or melanoma cancer under age 50, Ashkenazi Jewish population, or a known BRCA mutation in the family.

About 20% of colon and endometrial cancers are associated with a strong family history of cancer. 5% occur in autosomal dominant genetically defined high-risk syndromes such as Lynch syndrome. Risk factors for Lynch syndrome include colorectal or endometrial cancer before age 50, colorectal cancer in 2 generations on the same side of the family, ovarian or gastric cancer at any age, and 2 or more individuals with colon, endometrial, ovarian, gastric, brain, biliary, pancreatic, or small bowel cancers.

Cancer risk assessment is one of the key parts of the annual well woman exam. Standard pap testing has been successful in reducing cervical cancer, and so too can screening for hereditary cancers result in cancer prevention and early detection. Knowing one’s cancer risk can guide lifestyle choices and the choice of medications that can safely decrease cancer risk. 10% of people carry increased cancer risk, and approximately 6% of people have increased genetic family risk that makes them eligible for testing to determine if their risk is greatly higher than was previously thought. If positive, this result can have a positive impact on not only the patient, but also their relatives and their descendants.

With our understanding of cancer genetics progressing rapidly, knowing one’s detailed family history and then determining who is at increased cancer risk can be of great value in having a safer, healthier life.