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written by Pam Becker, CNM

So you are planning to have a baby!
Congratulations!
During an annual physical exam it is not unusual for our patients to tell us they are planning to become pregnant. It is important to inquire about what steps you should take before you conceive to ensure a healthy baby. There are many things for you to think about before becoming pregnant and we have developed a list of things to consider prior to conceiving.

HEALTH HABITS: Before your pregnancy, it is a good time to overhaul your health habits.

How is your nutrition? Do you rely frequently on fast foods for meals? Do you eat at least 3 servings of fruits and 5 servings of vegetables (other than french fries) a day? The food you ingest provides the building blocks of your baby’s body, cell by cell. Recent research has shown that the quality of your diet throughout your pregnancy food pyramid

can affect your child’s weight, blood pressure, and predisposition to diabetes and heart disease when he/she is an adult. Get in the habit of eating healthy foods such as whole grains, low fat dairy products, fruits, vegetables, and limit junk foods, sweets and fats.

Do you exercise and maintain a healthy weight? If you are significantly overweight, consider increasing your exercise and losing some pounds. It is known that obese women do suffer more complications in pregnancy such as diabetes, high blood pressure and pre-eclampsia. Pregnancy is never a time to diet, so if you do need to lose a few pounds do so now.

A simple yet essential step you can start before pregnancy is to take a multivitamin daily starting at least one month prior to conception. The vitamin should contain a minimum of 400 mcg of folic acid. Folic acid may prevent some birth defects such as spina bifida, cleft lip and palate and may even reduce the chances of having a baby with Downs Syndrome. Another benefit of supplementing with folic acid is that it may reduce the risk of childhood leukemia. While we are on the topic of vitamins, check the label of your brand and make sure that it contains less than 5000 units of vitamin A in the form of retinol. Vitamin A in amounts more than this has been shown to cause facial birth defects, and central nervous system and cardiac abnormalities in exposed babies. Beta-carotene, however, is a safe form of vitamin A and will not cause birth defects.

EXERCISE: Do you exercise? As you consider pregnancy, this may be a good time to revise that old couch potato life style. Moderate exercise is known to benefit the pregnant woman and fetus. Walking or swimming for 20-30 minutes at least three times a week will improve your fitness, help relieve stress and some common pregnancy discomforts such as constipation and insomnia. There is some evidence that exercise in pregnancy may be protective against complications in labor such as abnormal fetal heart rate patterns, meconium stained fluid, low apgar scores and cesarean births. Exercising throughout your pregnancy may prevent you from going

significantly over your due date.

It is very important to remember, however, that you must not get over heated when you exercise. An elevated maternal temperature of 102 F or greater has been linked to neuro tube defects in the baby. Avoid exercising in hot, humid weather and skip the temptation to relax in the Jacuzzi, hot tub, sauna or even hot bath water. It is a good idea to discuss your exercise habits with your health care provider so that specific recommendations and modifications can be tailored to your program and level of fitness.

PRE PREGNANCY PHYSICAL: Prior to conceiving you should go for your annual physical and pap. Treat any vaginal and uterine infections before pregnancy because they can impair your fertility and some are linked to miscarriages and prematurity. Likewise, you will want to discuss with your health care provider any history of sexually transmitted infections such as genital herpes, chlamydia, gonorrhea, syphilis, HIV, trichomoniasis and genital warts.

Do you have any chronic health issues such as diabetes or thyroid disease, lupus, hypertension, asthma, heart disease, a blood clotting disorder, renal disease, viral hepatitis or cancer? Although these conditions do not necessarily preclude having a baby, it will take special planning and surveillance to ensure a healthy pregnancy when these underlying health problems are present. For example, it is very important to have excellent control of your blood sugar prior to pregnancy if you are diabetic to lessen the chance of some birth defects that are associated with poorly controlled diabetes.

Believe it or not, even dental problems can affect your pregnancy. If you haven’t been to your dentist within the year, do so now. Gum disease, which affects 60-75% dental

of all pregnant women, has been linked to prematurity. Women with untreated periodontal disease have a 3-5 times greater risk of delivering a premature baby. This is because the bacteria in your mouth enters your bloodstream and travels to your uterus triggering the production of prostaglandins, which cause uterine contractions. If possible, take care of any dental problems before you are pregnant.

What medications are you taking? Please review your prescriptions and over-the-counter medications with your health care provider before you are pregnant. If you are on a medication that may be harmful in pregnancy, they will prescribe a safer drug for you. Many people do not realize that their acne medication or seizure medicine may cause birth defects. Even Ibuprofen, if taken around the time of conception, can cause woman to have a 60-80% greater risk of miscarrying later because nonsteroidal anti-inflammatory drugs can interfere with the implantation of the embryo.

Are your immunizations up to date? Ideally you have already been immunized against rubella, measles mumps and chicken pox (if you did not have the disease as a child). Because these are “live” vaccines, you should postpone pregnancy for at least needle

one month after you receive them to prevent the virus from potentially attacking the embryo. If you are susceptible to these diseases, you must be very cautious in pregnancy to avoid coming in contact with carriers as they have can harm the fetus. Women who work in occupations where they are exposed to blood and body fluids should have completed their Hepatitis B series. Hepatitis B can infect a baby at the time of birth unless the baby is vaccinated immediately in the nursery.

Unfortunately, there are many other contagious diseases that we do not have vaccinations against, so you must do your best to avoid infection at the time you conceive and throughout your pregnancy. Listerioris, a bacteria that can lurk in hot dogs, deli meats, soft cheeses, refrigerated meat spreads, refrigerated smoked seafood like lox and unpasteurized milk can cause miscarriages, and prematurity. Fifth’s Disease, a common childhood virus, can cause a fatal anemia in the fetus. The most common congenital infection is cytomegalovirus (CMV), although many people have never heard of it. Teachers and caregivers of children under the age of three are most at risk for contracting CMV. Protect yourself by wearing disposable gloves or careful hand washing when changing diapers, and wash your hands after wiping runny noses. Since there is no treatment for CMV (which can cause mental retardation and deafness) the only way to prevent it is by avoiding exposure.

Now take an inventory of your unhealthy habits and exposures to harmful substances. Thanks to massive public awareness campaigns, you are probably aware that you should avoid alcohol, cigarette smoking and recreational drug use in pregnancy. Development of the embryo’s organs starts just 17 days after conception well before many women realize that they are pregnant. Rather than waiting until you already conceive, it is better to address your harmful habits now and clean up your lifestyle before you risk exposing your baby to these substances. If you are having trouble stopping the use of drugs or alcohol, please discuss this with your health care provider. You may benefit from a referral to a counselor or treatment programs.

SMOKING: About 22% of women in the USA smoke. It is no secret that quitting smoking is one of the most difficult things you may ever do in your life. But if you quit before you are pregnant, you can make use of such devices as the nicotine no smoking

patch or gum which are not recommended in pregnancy. (Zyban, a prescription medication, is also available to help you quit smoking and may be safe to use while pregnant as well). If you need a referral to a smoking cessation program, your provider can direct you to these services.

Why exactly should you quit smoking before pregnancy? Women who smoke are up to 40% less likely to conceive. Furthermore, smokers are also more at risk for tubal pregnancy, a life threatening condition in which the embryo implants in the fallopian tube instead of the uterus. Smoking cigarettes in pregnancy reduces the amount of oxygen that the baby receives and also exposes the fetus to up to 4000 different chemical compounds whose effects on the fetus’s developing brain and body are not known. Babies of smokers are more at risk for miscarriage, low birth weight, strabismus (crossed eyes), crib death, attention deficit hyperactivity disorder (ADHD), learning difficulties and lower IQ.

ALCOHOL: It is believed that 20% of women who drink alcoholic beverages do not stop during pregnancy. Alcohol increases your risk of miscarriage, especially a late miscarriage after 4 months. Fetuses exposed to alcohol in the womb are affected to various degrees. The worst-case scenario is Fetal Alcohol syndrome (FAS). These infants are born with facial defects, microcephaly and mental retardation. A less severe form of FAS is Fetal Alcohol Effect (FAE). Babies with FAE also have a small head size, tremors, poor feeding and less noticeable birth defects such as crooked toes or protruding ears. They also may have lower IQs and poor attention spans and learning difficulties. The March of Dimes states that in the USA, 1 out of every 750-1000 babies has full blown Fetal Alcohol Syndrome, This is about the same number of infants born every year with Down’s Syndrome.

Laboratory studies in animals have shown that even a single drinking binge in your pregnancy may cause irreparable harm. During the time of maximal fetal brain growth from six months of gestation onwards, drinking several alcoholic beverages within a 4-hour period can kill millions of brain cells. FAS and FAE are entirely preventable. Since it is not known exactly how much alcohol will cause these deficits, you should avoid alcohol entirely in your pregnancy.

DRUGS: All recreational drugs such as marijuana, cocaine, heroin, speed, etc. should be avoided. Cocaine exposure during the first trimester can cause congenital medicines

malformations of the heart, limbs, face, or genitourinary structures. Later in pregnancy cocaine can cause placental abruption, a life threatening shearing of the placenta away from the uterine wall. Babies exposed to heroin and methadone in utero undergo lengthy withdrawal. Neonatal withdrawal syndrome is characterized by a high-pitched cry, tremors, vomiting, diarrhea, disturbed sleep and appetite. Many women are not aware that even marijuana use is not safe in pregnancy. Studies report that babies exposed to marijuana also show reduced growth in the womb.

CAFFEINE: Caffeine may reduce a women’s fertility. Some studies have shown that among women having difficulty getting pregnant, caffeine consumption was higher compared to women who did not have fertility issues. Very high doses of caffeine may increase the risk of miscarriage although this has not been proven conclusively. Caffeine crosses the placenta and reaches the same concentration in the fetus as in the mother’s blood stream. Two studies have shown that high consumption of caffeine by the mother can induce transitory cardiac arrhythmias in the fetus. Remember caffeine is a powerful stimulant; so try to limit yourself to one serving a day of caffeine at the most.

SEAFOOD: Once thought of as a health food, many types of fish may now be too polluted to eat. Fish caught in freshwater lakes and streams may be dangerously high in PCB, which is linked to lower IQ in children exposed prenatally. High levels of mercury, a neurotoxin, have been found in many types of seafood: shark, swordfish, fish

northern pike, tile fish, king mackerel, wall eye, striped bass, eels, and tuna steaks. Pregnant women should avoid these fish entirely. Shrimp, Pacific salmon, pollock and catfish appear to be safe in pregnancy while canned tuna is intermediate as it does contain some mercury. If you are going to eat canned tuna, then purchase light tuna rather than albacore tuna which has a greater amount of mercury and eat only 1-2 servings of this a week. Mercury has been linked to lower IQ in children. If a fetus is exposed to very high doses it can develop microcephaly, cerebral palsy, cerebral atrophy and retardation.

LEAD: Another worrisome metal that pollutes our environment is lead. Have you had your water checked for lead? Recently many families who live within Washington, DC found that their tap water contained dangerously high levels of this metal. You can also be exposed to lead if you live in an older house built before 1960 when lead paint was commonly used. Peeling or chipped paint releases toxic lead dust. Friction and wear tend to release lead dust in areas around painted doors and window frames. Some serious cases of lead poisoning have occurred after an older home is renovated to make room for the growing family, releasing massive quantities of lead laden paint dust. Some women are exposed to lead through their jobs or hobbies such as working with stained glass. During pregnancy high levels of lead in the maternal blood stream are linked to central nervous system problems and congenital cardiac anomalies. If you are concerned about lead exposure, a simple blood test will let you know the actual levels present in your blood stream.

WATER: We often urge our patients to drink at least 8 glasses of water a day when water

they are pregnant but is your water safe to drink? If you are unsure about the quality of your water you may want to have your water tested for contaminants through a professional company or home testing kit. Many things besides lead can pollute your tap water. Well water can be contaminated with pesticides and herbicides, nitrates and bacteria. Chlorinated water has also been linked to miscarriages. A study in California showed that women who daily drank 5 or more glasses of chlorinated water contaminated by at least 75 micrograms of trihalomethane (TTHM) per liter had a 16% increase risk of miscarriage. The municipal water consumed in this study met all state and federal standards for safety. Most American cities have chlorinated water, and to be safe, some women elect to consume only bottled water.

CHEMICAL EXPOSURES: While we are on the rather depressing topic of environment pollutants and contaminants, you should consider if you have any toxic exposures in your place of employment or your hobbies. Paint thinners, cleaners, solvents, pollutants such as polychlorinated biphenyl (PCB) and polybrominated biphenyl (PBB), pesticides, radiation, antineoplastic medications, carbon monoxide and formaldehyde may increase your chances of miscarriage or birth defects. Fetal Solvent Syndrome is caused by exposure to solvents such as organic hydrocarbons, phenols, trichloroethylene, vinyl chloride, acetone, and xylene among others. Children prenatally exposed to these industrial chemicals have a higher risk of being born with CNS and cardiac malformations. Other studies have suggested a link between parental exposures to chlorinated hydrocarbon solvents and pesticides with an increased risk of leukemia and brain cancer in their children.

If your job requires you to work around chemicals, investigate what these are and their toxicity. Employers are required to post MSDS sheets (Material Safety Data Sheets) listing the toxicity of chemicals in the work place. Always work in a well-ventilated area, wear protective gear and practice good hand washing. Never eat, drink or smoke in your workplace if you work with chemicals since you can ingest microscopic particles of the toxic substance without your awareness. In some circumstances, you may need to ask your boss to modify your job responsibilities to minimize risks during your pregnancy or you may have to stop work altogether. If you have concerns about hazards in your work environment, please discuss them with your health care provider, who may refer you a specialist in Occupational Medicine.

CATS: Many people are familiar with the advice to avoid raw or undercooked meat in pregnancy and to stop changing the kitty litter. This is because these are both sources cat

of infection with the toxoplasmosis parasite. Toxoplasmosis can cause microcephaly, hydrocephaly and blindness. It is transmitted to humans through undercooked meat or by exposure to the cat feces of infected pets. Remember that cats also use sand boxes as their litter boxes, so keep yours covered when not in use. Along these same lines, remember that you can be exposed to cat feces when gardening; always wear gloves and wash your hands carefully.

YOUR FAMILY TREE: Do you have any genetic problems in your family? A few of the more common genetic diseases that you would want to discuss with your health care provider are PKU, Cystic Fibrosis, Sickle Cell Anemia, Thalassemia, Muscular Dystrophy, Hemophilia, Tay Sachs Disease, and Huntington’s Disease. PKU is an inborn error of metabolism that will cause mental retardation if the person does not avoid all foods containing phenylalanine during infancy and childhood. Adult women with PKU dna

who become pregnant must again restrict their intake of phenylalanine or risk mental retardation in their babies. It is best to restrict all phenlyalanine prior to conceiving to avoid risks of miscarriage and cardiac anomalies.

Women who carry the genes for Sickle Cell Anemia and Thalassemia are at risk for delivering severely affected children if their partners also carry these genes. Carrier testing is available and can be done on yourself and your partner before you conceive. 1 in 12 African Americans in the USA carry the gene for sickle cell and 1 in 600 have full blown Sickle Cell Anemia themselves. Women of Asian, Mediterranean or African American descent may carry the genes for Thalassemia. Children who inherit genes from both parents for thalassemia will have life threatening anemias, which are often transfusion dependent.

Tay Sachs is a fatal neurological disease that affects 1 out of every 3600 children born of Eastern European Jewish descent. Cystic Fibrosis is common in Caucasians of northern European ancestry. 1 in 29 white Americans will be a carrier for this disease. Less commonly it can also be carried by 1:60 African Americans and rarely in Asians. It is possible to be tested to see if you are a carrier for Tay Sachs and Cystic Fibrosis before you plan a pregnancy.

Duchennes Muscular Dystrophy, Hemophilia and G6PD Deficiency affect male infants born to mothers who are carriers. Fragile X Syndrome, the most common form of inherited mental retardation, affects boys twice as frequently than girls.

Genetic counseling is recommended if there is a family history of any of these conditions. You may be aware that regardless of family history, women who conceive at age 35 or older do have a higher risk for carrying a child with a chromosomal abnormality. The most common of these is Down’s syndrome, which will affect 1/384 infants born to women age 35 and up and 1/112 infants of women at age 40 and beyond. Fathers who are older than age 40 also can contribute to genetic defects in children such as Marfan syndrome and achondroplasia.

STRESS: What is your stress level like? Do you live in an environment where there is physical or mental abuse? Studies show that physical abuse and battering in a relationship actually increases in pregnancy and can injure both you and the baby. If you are in an abusive relationship please tell your health care provider as he/she can refer you to resources in the community for domestic abuse victims.

It is known that very high levels of stress in pregnancy can contribute to prematurity or low birth weight infants. New research, however, suggests that even moderate but chronic levels of stress can be problematic. The amount of stress you must manage on a daily basis in your pregnancy during the second and third trimesters, may actually affect how your child reacts to stress in the future. It is believed that if the fetus is constantly subjected to high levels of your stress hormone, cortisol, the fetal brain develops a relative insensitivity to this powerful hormone. In later life, even minimal stress can cause his or her brain to overreact and send messages that cause cortisol to shoot up to higher harmful levels in the body with the least provocation.

Unfortunately we cannot always control the amount of stress in our lives but you can take a stress inventory now before you conceive and try to decrease what sources of stress that are within your power. A healthy pregnancy lays down the foundation of your child’s life. As this article has discussed, there are many things for you to investigate before you get pregnant. However, if your pregnancy is a surprise, you can still make many of these lifestyle changes as soon as you know you are pregnant. A healthy pregnancy is a lifelong gift to your child!

FINAL THOUGHTS: Please feel free to contact us here at The Adler Center if you would like to set up an appointment to further discuss preconception. Keep in mind that it often takes 6 months to a year to get pregnant when trying, so if you become discouraged or need some medical advice we are here to assist you. We look forward to taking care of you in pregnancy and hope that you call on us when you get the exciting news of a positive pregnancy test.

Now that you have been educated on the serious side of preparing yourself for becoming pregnant here is some humor on the subject of preconception.

joke

HOW TO TELL IF YOU ARE READY TO HAVE A CHILD

MESS TEST: Smear peanut butter on the sofa and curtains. Place a fish stick behind the couch and leave it there all summer.

TOY TEST: Obtain a 55 gallon box of Legos (or you may substitute roofing tacks). Have a friend spread them all over the house. Put on a blindfold. Try to walk to he bathroom or kitchen in the middle of the night. Do not scream.

GROCERY STORE TEST: Borrow one or two small animals (goats are best) and take them with you as you shop. Always keep them in sight and pay for anything they eat or damage.

DRESSING TEST: Obtain one large, unhappy, live octopus. Stuff into a small net bag making sure that all the arms stay inside.

FEEDING TEST: Obtain a large plastic milk jug. Fill halfway with water. Suspend from the ceiling with a cord. Start the jug swinging. Try to insert spoonfuls of soggy cereal into the mouth of the jug, while pretending to be an airplane. Then dump the contents of the jug on the floor.

NIGHT TEST: Prepare by obtaining a small cloth bag and fill it with 8-12 pounds of sand. Soak it thoroughly in water. At 3:00 p.m., begin to waltz and hum with the bag until 9:00 p.m. Lay down your bag and set your alarm for 10:00 p.m. Get up, pick up your bag, and sing every song you have ever heard. Make up about a dozen more and sing these too until 4:00 a.m. Set alarm for 5:00 a.m. Get up and make breakfast. Keep this up for 5 years. Look cheerful.

INGENUITY TEST: Take an egg carton. Using a pair of scissors and pot of paint, turn it into an alligator. Now take a toilet paper tube and turn it into an attractive Christmas candle. Use only scotch tape and a piece of foil. Last take a milk carton , a Ping-Pong ball, and an empty box of Coca Puffs. Make an exact replica of the Eiffel Tower.

AUTOMOBILE TEST: Forget the BMW and buy a station wagon. Buy a chocolate ice cream cone and put it in the glove compartment. Leave it there. Get a dime. Stick it into the cassette player. Take a family size package of chocolate chip cookies. Mash them into the back seat. Run a garden rake along both sides of the car. There. Perfect.

PHYSICAL TEST (women): Obtain a large beanbag chair and attach it to the front of your clothes. Leave it there for 9 months. Now remove 10 of the beans. Try not to notice your closet full of clothes. You won’t be wearing them for a while.

PHYSICAL TEST (men): Go to the nearest drug store. Set your wallet on the counter. Ask the clerk to help himself. Now proceed to the nearest food store. Go to the head office and arrange for your paycheck to be directly deposited to the store. Purchase a newspaper. Go home and read it quietly for the last time.

FINAL ASSIGNMENT: Find a couple who already have a small child. Lecture them on how they can improve their discipline, patience, tolerance, toilet training and child’s table manners. Suggest many ways they can improve. Emphasize that they should never allow their children to run wild. Enjoy this experience. It will be the last time you will have all the answers.