Pre-pregnancy Considerations

“A woman’s health prior to conception is critical to the outcome of her pregnancy and may have a lifelong impact on her baby’s health. There is a lot that women can do prior to pregnancy to optimise their health including lifestyle changes such as a healthy diet and appropriate supplementation. Pre-pregnancy care helps find issues that may affect a woman’s pregnancy, so that steps can be taken to manage potential problems prior to pregnancy.”
RANZCOG Guideline Pre-Pregnancy Counselling”C-Obs 3(a) (July 2017)

For each of the following pre-pregnancy considerations, your GP is key to providing advice, guidance and is the link to future pregnancy care.

Medical Conditions and Medications

Some medical conditions may impact on your fertility, your health during pregnancy and the well-being of your baby during and after birth. Before you consider trying to fall pregnant it is important to visit your GP to discuss how your medical conditions and medications may affect your pregnancy, and vica versa, how any pregnancy may affect your medical conditions.

Medications may need changing, stopping, increasing or decreasing. Some medications may be risky to the baby, others innocuous, and some extremely important to continue and perhaps increase once a pregnancy is conceived.

It may be important to delay conception so that a medical condition can be optimised, in which case contraception is paramount as part of a healthy and safe short to medium-term plan to prepare for pregnancy.

Vaccinations

Prior to pregnancy you may need to consider vaccinations that protect you and your baby during the pregnancy period. These include the measles, mumps and rubella (MMR) vaccine, the chicken pox vaccine and hepatitis A/B vaccine. If you have had chicken pox in the past, you will be protected. However, if you have had a vaccination in the past for the above viruses, your immunity status should be checked, and a vaccination recommended if this is sub-optimal.

There are other vaccines important for your general health that should not be administered during pregnancy, but may be considered prior to pregnancy, including the meningococcal vaccine, and the HPV vaccine. A recently released vaccine protects you against nine of the most common HPV viruses that cause 90% of cervical cancers and genital warts. Your GP can advise you of your suitability for these vaccines.

Genetic Carrier Screening

You, your partner, children or relatives may have a heritable condition, or come from a racial background where particular conditions are common and can be passed from one generation to the next. Some genetically heritable conditions can also skip generations. It is reasonable to discuss the susceptibility of your unborn children to heritable conditions with your practitioner prior to pregnancy. You can expect to be provided advice about screening for conditions for which your children may be at increased risk, and the potential implications of conceiving a pregnancy and having a baby with the condition in question. In some cases referral to a genetic counselor may be required.

Lifestyle, diet and weight

A healthy weight is important not just from a general health point of view, but can have an important impact on the health of a woman and her baby in pregnancy, at delivery and for the lifetime of the child. Infants born to women of a healthy weight have a reduced risk of high blood pressure, metabolic, vascular and weight problems later in life.

A long-term plan for healthy eating and exercise can help contribute to a healthy pre-pregnancy weight and reduce risks of infertility, early pregnancy failure, blood pressure problems, diabetes in pregnancy, and birthing risks. There are a multitude of treatments for weight loss, and your GP is in a good position to discuss these with you.

Early review where there may be concerns about body weight or other risks for diabetes in pregnancy can make a huge difference to the health of your pregnancy. Your GP will discuss screening for diabetes earlier in your pregnancy and healthy eating and exercise to optimize the health of your pregnancy.

Alcohol, smoking and other illicit drugs have a negative impact on your baby during pregnancy and later in life. It is recommended to raise these concerns with your doctor before pregnancy so that you give yourself and any future children the best chance of good outcomes. There are many effective support and treatment programs available to help deal with addictions. Your GP is the best first person of contact to help point you in the right direction.

Supplements

0.4mg of folic acid, daily, at least four weeks prior to conception and during the first trimester of pregnancy has been proven to reduce the incidence of neural tube defects in early pregnancy. The neural tube is the structure that develops into the babies brain and spinal cord and is highly dependent on folate for normal development.

Some women will require a much larger supplement of folic acid. Nutritional deficiencies, some medical conditions and some medications can impair your folate levels. Furthermore a personal history of previous pregnancies affected by neural tube defects increases the risks in future pregnancies. In such cases women are recommended to increase this supplementation to 5mg of folic acid per day for one to three months prior to conception and for the entire pregnancy.

Your doctor can help to guide you where such an increase in the dose of folic acid is appropriate.

Women should consider taking a 150mcg daily of iodine supplementation in order to ensure there are the building blocks for adequate thyroid function in early pregnancy.

A reputable multivitamin for pregnancy will have the above constituents. Where an increase in folic acid supplementation is required, an additional preparation is needed.

Cervical screening

Routine cervical screening is considered good practice for the early detection of cervical disease to reduce the risk of cervical cancer. Unfortunately 80% of all cervical cancers in Australia are diagnosed in women who do not participate in, or have fallen out of, the cervical screening program.

For the majority of people, current recommendations for cervical cancer screening have recently changed from a 2-yearly PAP smear test where cervical cells are examined under a microscope, to a 5-yearly cervical screening test based on the detection of cancer-causing HPV viruses collected by using a cervical brush. Abnormal screening tests may require an earlier repeat cervical screening test or may need a colposcopy, where their cervix is examined under a microscope.

Women who have abnormal symptoms, such as abnormal vaginal bleeding or discharge, should see their doctor immediately and not wait for their next screening test.

Early Pregnancy

Congratulations, you are pregnant!
Below are some of the important issues and concerns that should be considered in early pregnancy.

Lifestyle

A healthy but moderated exercise regime bears no significant risk to you or your pregnancy provided there are no medical or obstetric reasons that preclude such activity. The Royal Australian College of Obstetricians and Gynaecologists Guideline [PDF Download] endorses and details general advice about what would be considered a healthy exercise regimen to help regulate your metabolism and encourage a healthy weight during pregnancy.

Diet and food preparation

There are foods that are encouraged and discouraged in pregnancy, but the general advice is to ensure your diet is well balanced, healthy, is safely stored and prepared and does not include potentially dangerous foods.

Fresh foods (mainly fruit and vegetables) should be handled with washed hands, kept separate from meats when prepared and stored in the fridge, and washed well before consumption.

Use gloves when gardening and handling kitty litter and cat faeces. This is to avoid contamination of foods and food-borne infections.

Food types that should be avoided in pregnancy include unpasteurized dairy products such as soft cheeses, smoked salmon, cold meats, pates and fresh ciders. Undercooked meat should also be avoided, while meat that has been cooked through well is safe to eat. Likewise food that has been refrigerated should be re-heated till piping hot before consumption. Foods that have not undergone a heating or pasteurizing process may harbor potentially dangerous microorganisms that can cause infections that affect your unborn child.

Foods very rich in Vitamin A, such as liver, should be avoided during pregnancy due to concerns about Vitamin A teratogenicity, especially in the first trimester.

Seafoods such as clams, oysters, muscles, abalone, other sea-living crustaceans, and shark, swordfish, king mackereal, marlin, orange roughy and big eye tuna (other tuna’s are ok) may be high in heavy metals, such as mercury and can affect your child’s neurological development. Most other fish may be consumed but no more one to two servings per week for the same reasons.

When to book in to see the GP

Once you have found out that you are pregnant it is important to book an early appointment with your GP. Your GP will usually recommend early pregnancy blood tests that confirm the pregnancy hormone level in your blood (bHCG), and will recommend an early pregnancy ultrasound to date and locate your pregnancy. This is to ensure that your pregnancy is viable with a heartbeat and is safe and sound inside your uterus.

1-2% of pregnancies are ectopic, meaning they fall outside the womb and pose a significant risk to the mother. This risk increases for women who have had a previous ectopic pregnancy, pelvic infections in the past (most commonly sexually transmitted infections that have infected the fallopian tubes), endometriosis, previous pelvic surgery, cystic fibrosis sufferers, pregnancies conceived by IVF and smokers.

Pregnancy Dating

Accurately dating the gestational age of your pregnancy with an early pregnancy ultrasound allows for a true assessment of your babies growth and wellbeing throughout pregnancy. In turn it enables you and your doctor to help make good decisions about the safe planning and timing of delivery and can help to reduce unnecessary intervention. An optimal gestation to date your pregnancy with a specialist pelvic ultrasound is between 8-12 weeks of pregnancy.

The “expected due date” (EDD) of delivery is the date at which you would be 40 weeks pregnant. This has traditionally been thought of as the median gestational age at which babies will deliver spontaneously. The EDD is used as a yardstick to calculate the gestational age of your pregnancy. It is important to note that the EDD may not necessarily be the optimal time for your baby to be delivered. In fact the optimal time for your baby to deliver may be earlier, may be later or when the “baby decides” depending on your specific circumstances.

Special tests in early pregnancy

Blood tests
When you visit your GP in early pregnancy, they will order a host of blood tests to check on your health and fitness for your pregnancy. This will include a check on your immune status for important infections, type of blood group, liver kidney and blood health and fasting blood sugar levels.

Urine checks
Your GP will check to make sure your urine contains no infection. Infections in your urine can cause early pregnancy loss and can cause your baby to be born prematurely. If infection in your urine is found your doctor will treat it with antibiotics. Sometimes it is recommended to check that the infection has been cleared.

Screening for Down’s syndrome and other chromosomal disorders
There are two common tests that your doctor will offer if you wish to screen your pregnancy for common chromosomal disorders including Down’s syndrome.

1. The “First Trimester Screen” includes blood tests, best done at 10 weeks, and an early ultrasound at 12-13 weeks. These results are combined to calculate a risk of your baby being affected with some of the most common chromosomal disorders including Down’s syndrome. It is not a diagnostic test, so a “high risk” result means the pregnancy needs further assessment. Apart from screening for chromosomal disorders, the purpose of this ultrasound is to get an early look at your babies basic anatomy, investigate the placenta(s) of twins/multiple pregnancies, and date the pregnancy, should this have not been done previously.

Non-Invasive Prenatal Testing (NIPT) is another screening test for common chromosomal disorders such as Down’s syndrome. Some pathology laboratories also offer specific tests for chromosome aneuploidies and other genetic mutations. They all can detect whether your baby is a male or female, but you have the option as to whether or not this information is disclosed. NIPT is a much more accurate screening test than the first trimester screen. It involves a maternal blood test after 10 weeks of pregnancy. A very small fraction, less than 5%, of tests will fail. Unfortunately at this time NIPT is not Medicare subsidized and the patient bears the cost of this test. The cost however is continuing to decrease as the technology becomes less expensive.

Like the first trimester screening test, NIPT is not a diagnostic test, so if it comes back as high risk, the pregnancy will need further diagnostic testing. At this point it is best to discuss what this means for your pregnancy and where to from here with your doctor.

Bleeding in early pregnancy

Reassuringly most bleeding in early pregnancy will resolve and your pregnancy will continue on to be normal. However bleeding should never be ignored and must be investigated as soon as possible. If your doctor is accessible they will request an urgent ultrasound to ensure your pregnancy is safe and sound within your uterus. If there are delays you should attend a hospital emergency centre to investigate.

After the first trimester of pregnancy

Anatomy Ultrasound (18-20 week Ultrasound)

The ultrasound at 18-20 weeks of pregnancy is really important. It is where we check that your placenta is located in a safe position, your babies anatomy again appears normal, and that your babies growth are in the normal range. Benchmarking the babies growth at this point also allows for later comparisons. The length of your cervix is now routinely recommended at the time of your anatomy scan to identify pregnancies that may be a risk of preterm birth.

Growth of baby during pregnancy

The symphysio-fundal height is the measurement between your pubic bone and the top of your uterus. It is used to estimate appropriate growth of your baby where the length measured in centimetres is supposed to approximate the gestational age of your pregnancy in weeks. It is notoriously inaccurate as a measure of your baby’s size, as maternal tissues, amniotic fluid around the baby and a large variation in observer measurements results in inconsistencies. The change in this measurement over a period of time can be more helpful in assessing the appropriate growth of your baby, but is still associated with significant error.

If your practitioner has been trained in obstetric ultrasound, this allows for the most accurate predictor of your babies growth. Changes in your babies measured growth over time help us to ensure your placenta is working well and your baby is continuing to grow appropriately.

Foetal movements

By 23 weeks of pregnancy you should have started to feel your baby moving. If you have an anterior placenta (on the front wall of your uterus) this can affect the sensation of your babies movements. There are no good quality studies indicating an acceptable frequency of fetal movements. However, it is a common story that women who have experienced poor outcomes in pregnancy commonly remember reduced or absent fetal movements. It is therefore recommended if you feel your babies movements are reduced, to take action and seek obstetric advice.

Some well-regarded professional organisations recommend to take a lie down and concentrate on feeling your baby move for a 30 to 45 minute period. If you are still worried that your baby is still quiet, make no hesitation in contacting your health provider, and certainly do not leave your concerns till the next day. You should never feel, or be made to feel, that your concerns are unwarranted, and you should be supported to seek out appropriate care from your health provider to ensure that your baby is healthy and well.

Diabetes screening in pregnancy

It is normal for your blood sugar levels to rise in response to pregnancy hormones. However, excessive increases in your blood sugar levels (gestational diabetes), or high blood sugar levels to start with (pre-existing diabetes), can increase the risks to you and your baby during pregnancy, birth and can have a lasting impact on your child’s health into adulthood. This is why we recommend screening for diabetes in pregnancy. The standard time to screen is between 26-28 weeks. However, women who are at high risk of pre-existing or gestational diabetes will be recommended screening much earlier in pregnancy. The earlier we detect abnormal blood sugar levels, the sooner we can correct it and improve the health of you and your baby.

Routine antenatal visits

Much of your pregnancy care is about screening for problems that commonly arise in pregnancy so that we can prevent poor outcomes.

Occasionally I am asked why we always check your blood pressure, urine protein or tissue swelling. This is to check that you are not developing high blood pressure and/or preeclampsia (pregnancy toxaemia). These are high-risk conditions that arise in 5-7% of pregnancies that can have catastrophic consequences for mother and child. By screening frequently we can help to detect these problems early, prevent poor outcomes and optimize the valuable time that your baby can spend in your womb.
Symptoms that often arise with preeclampsia include headaches, changes to your vision (commonly described as spotty vision), abdominal pain, chest pain, nausea, vomiting, recent onset excessive tissue swelling (especially facial swelling) and just feeling generally unwell. If you develop these symptoms it is very important you check in to be assessed by your doctor.

Intimacy in pregnancy

During pregnancy your sex drive may increase, decrease or stay the same. Not surprisingly your partner may feel scared about hurting the baby during intercourse. These are very common concerns in pregnancy that you may not have the confidence to ask your practitioner about.

Your baby will not get “hurt” as a result of sexual intimacy as it is well protected inside the womb. However, there are some circumstances in which intercourse should be avoided, one of which includes a low-lying placenta. This is where your placenta lies in close proximity to, or covers, the cervix. Your doctor can discuss more about these and other circumstances where sexual intimacy requires careful consideration in pregnancy.

Most importantly however, open communication with your partner about how you feel toward physical intimacy can really help strengthen your relationship and avoid frustration and misunderstandings.

Whooping cough and Influenza vaccines

It is recommended to be vaccinated every pregnancy for whooping cough and influenza, unless you have an allergy to these preparations.

Whooping cough is relatively common infection in the community, across all ages, and it is easily passed by droplet spread from infected individuals. It can cause a nasty respiratory infection to your newborn requiring hospitalization, and cause long-term lung disease in your child. In severe cases a newborn may not survive the infection.

The good news is that your newborn can be protected by having a whooping cough vaccination, optimally given between 28-32 weeks of pregnancy. The antibodies you produce against this vaccine cross the placenta, enter the babies circulation and protect your baby for the first 3-4 critical months until your child has begun its own vaccinations (the DTTP vaccine). Your partner and any other close contacts with your newborn are also encouraged to have a booster every 5 years in order to create “herd immunity” around your child.

The “flu” is a particularly nasty infection to acquire during pregnancy and pregnant women are considered high risk. Pregnant women have an altered immune system and later in pregnancy have compromised respiratory capacity. If you are pregnant, you should take the “flu” very seriously and check in with your GP or obstetrician.

Fortunately, the flu vaccine is available in Autumn every year and is recommended by Australian medical authorities. Pregnant women may consider receiving the flu vaccine at any gestation during their pregnancy and it bears no harm to you or your baby as it only contains the “dead” influenza virus. Like the whooping cough vaccine, the antibodies you produce against the influenza viral strains will cross the placenta and protect your baby at birth.

Other important precautions that you can take to reduce the risk of acquiring a nasty respiratory infection are regular washing of hands before touching your own, or your child’s, face. Others who clearly have signs of the flu or a respiratory tract infection should ideally not handle the child.

Anti-D

If your blood type is rhesus negative you may need to have anti-D protection during pregnancy. Anti-D is a purified antibody harvested from human blood donors. It may be required when there are risks of blood mixing between you and your baby. For example, as a result of abdominal trauma, bleeding in pregnancy, amniocentesis and after delivery of your baby. It may also be given as a preventative medication at 28 and 34 weeks of pregnancy for further protection. There are some circumstances in which anti-D may not be recommended for a rhesus negative woman, however these exceptions are best discussed with your medical practitioner.

Bleeding and vaginal loss in pregnancy

Bleeding in pregnancy should never be considered normal and a medical opinion should be sought as a matter of urgency. All vaginal bleeding in pregnancy must be fully investigated as some causes may be dangerous for mum and baby. Important information your doctor will require are previous ultrasounds you have had this pregnancy.

The well-being of your baby should be determined as soon as possible with either a cardiotocograph (CTG; a heart beat trace of your baby) and an ultrasound.

Divarication

This is where the muscles of your abdominal wall become spread apart in the midline of your abdomen. It is noticed when you lift your head off your pillow, or sit up from a lying position. If it is associated with pain you should seek a medical opinion as soon as possible, however this is rarely the case. Divarication may get worse with each successive pregnancy.

During and after pregnancy you may wish to help with divarication by wearing an elastic-tube abdominal support. However, there is little evidence it limits the process. After delivery, most cases of divarication repair spontaneously, however if it persists and you are concerned by the appearance, there are conservative and surgical measures that can help.

Optimising iron and haemoglobin before delivery

During pregnancy your haemoglobin (the protein that carries oxygen to your tissues) level naturally decreases in concentration due to the large increases in your blood volume. However, your haemoglobin level must be maintained in the normal range for your health and for the growth of your baby. Your haemoglobin level should also be optimized leading up to delivery.

Iron is a key building block for the synthesis of haemoglobin. If your iron stores are low, your haemoglobin stores will not reach their full potential. Anaemia (low haemoglobin) and low iron stores are best corrected earlier on in pregnancy.

Red meat is the richest source of iron in your diet. If you are vegetarian, leafy green vegetables are also a good source, but they need to be consumed in large quantities to meet daily requirements. An iron supplement is often the simplest method of increasing iron levels and should be taken with vitamin C to optimize uptake of iron. Iron supplements can disturb your bowels, and you may find yourself either constipated of getting diarrhoea. If your iron stores are severely deficient, you cannot take iron supplements or you do not respond to supplements, an iron infusion may be recommended. This would require discussion with your doctor.

GBS screening

Australian guidelines support screening for Group B Streptococcus (GBS) after 34 weeks of pregnancy. This microorganism naturally lives in the bowel and vaginal environment of about 20-25% of women at any one particular time. Its presence should in no way be considered an “infection”. However, where it is present in sufficient abundance, GBS can cause a nasty infection in your newborn after a vaginal delivery or prolonged rupture of your membranes. By treating you with antibiotics during labour we can help to prevent most newborn infections that may otherwise have occurred within the first week of delivery.