Patient and Family Education in Pregnancy Marzena Slater, MD PGY-3

Objectives To discuss the following in the context of patient education: Guidelines for Exercise in Pregnancy Nutrition and Dietary changes in Pregnancy Discomforts and Physical Changes Commonly Found in Pregnancy & Treatments available for each.

A Reminder: Levels Of Evidence Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweighs the potential risks. --consistent, good-quality patient-oriented evidence (i.e RCT) Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. --inconsistent or limited-quality patient-oriented evidence (i.e meta analysis) Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. --consensus, disease-oriented evidence (i.e usual practice, opinion, or case series) Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients. Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service. Most recommendations in OB/GYN fall into the B or C category

Exercise in Pregnancy Physical activity is essential to the health of women in their childbearing years. Pregnancy is a normal condition for women, and exercise can be part of a normal pregnancy. The research studies dealing with exercise in pregnancy have shown no harmful effects to the mother and fetus.

Exercise in Pregnancy For most pregnant women, exercise is not only safe but also beneficial to the health of the mother and the infant. Pregnant women who exercise have: reduced weight gain more rapid weight loss after pregnancy improved mood and sleep patterns Some studies have also shown faster labors and less need for induction with pitocin.

Exercise in Pregnancy Precautions that patients should take to ensure that their exercise program does not lead to pregnancy complications: An exercise routine prior to the pregnancy should be able to be maintained to some extent throughout pregnancy. If patients are just starting an exercise program, they should start very slowly and be careful not to over exert themselves. Regular activity (ex. 3 times/week) is preferable to intermittent activity Special care should be taken to: drink plenty of fluids wear comfortable clothing/shoes not to exercise in hot environments to prevent overheating & dehydration. Weight training exercises should emphasize improving tone, especially in the upper body and abdominal area. Heavy lifting or lifting weight above the head and using weights that strain the lower back should be avoided. Pregnancy requires an additional 300 kcal/day, make sure your patients are getting adequate nutrition

Exercises Not Recommended Any type of exercise that has risks of fall/injury to the abdomen should be avoided. These include contact sports. (Level C evidence) Sports considered unsafe in pregnancy include: Horseback riding Skiing/snowboarding Water Skiing Scuba diving (Level C) Kick boxing Soccer/basketball/baseball or any other contact sports where patient could collide with another player Cycling- other than a stationary bike During the second and third trimester patients should avoid exercises that involve laying flat on the back, since this decreases blood flow to the uterus and baby. In general counsel patients to stop exercising if they are fatigued and to not exercise to exhaustion. They should be able to talk while exercising. Pregnant women should avoid activities that put them at risk for falls or abdominal injuries. C At least 30 minutes of moderate exercise on most days of the week is a reasonable activity level for most pregnant women. Scuba diving during pregnancy is not recommended.C

When to avoid exercise during pregnancy High blood pressure/Pre-eclampsia Placenta Previa/Vaginal Bleeding Preterm labor or history of preterm labor Intrauterine Growth Restriction (IUGR) Twin pregnancy Heart Disease Other conditions Uncontrolled kidney disease Anemia Uncontrolled diabetes Thyroid disease Extreme obesity. ----Preterm labor or history of preterm labor--Women who have delivered a baby prior to 36 weeks of pregnancy should be cautious about exercising during pregnancy. Weight bearing exercises should generally be avoided. Light or non-weight bearing exercises such as stretching, yoga & walking are preferred. Also women with preterm contractions should avoid exercises that increase uterine contractions. ---IUGR-- The baby may in turn not tolerate activity that shifts blood supply and oxygen away from the uterus ---Twin pregnancy---Involves a higher risk of complications and preterm labor. Exercise should be limited to non-weight bearing and should focus on toning and stretching.

The Exercise Prescription Sedentary women Mode Walking, stair climbing, biking, swimming, aerobic dance Intensity 65-75% max heart rate; perceived exertion= moderate hard Duration 30 min Frequency 3 times/week Recreational athletes/regular Fitness Exercises Same as above plus running/jogging, dance, tennis 65-85% max heart rate; perceived exertion= moderate to hard 30-60 min 3-5 times/week Elite Athletes Same as above plus some competitive activities- depends on pregnancy trimester 75-85% max heart rate; perceived exertion= hard 60-90 min 4-6 times/week

Nutrition and Dietary Changes in Pregnancy On average pregnant women should be eating 300 calories more per day than usual. Weight Gain (lbs) Maternal classification Total (lbs) Rate (lbs/4wk)* Pre-pregnant BMI Underweight (<19.8) 28-40 5.0 Normal Weight (19.8-28) 25-35 4.0 Overweight (28.1-29.0) 15-25 2.6 Obese (>29.0) 15 2.0 Twin Gestation 35-45 6.0

Calcium 1200 mg of calcium is required-- an additional 400 mg over non-pregnant amount. Three to four milk servings per day are sufficient to achieve this additional need. Sources of calcium other than milk include yogurt, cheese, ice cream, broccoli, spinach. Calcium ---Recommended daily intake is 1,000 to 1,300 mg per day ----level A evidence Routine supplementation with calcium to prevent pre-eclampsia is not recommended However, calcium supplementation may be beneficial for women at high risk for gestational hypertension or in communities with low dietary calcium intake. Calcium supplementation has been shown to decrease blood pressure and pre-eclampsia, but not perinatal mortality

Iron Iron is needed in larger doses, especially in the later stages of pregnancy. In healthy, well nourished women, routine iron supplementation is not necessary. Select iron supplementation may be necessary depending on patient’s blood counts (Hb < 10.5 g/dL) . Some iron rich foods include iron fortified cereals, certain beans, red meats, spinach & eggs. Educate patients that if they are started on an iron supplementation to not take it with milk, antacids, or anything containing calcium (including prenatal vitamins) since calcium blocks absorption of iron. Warn patients about constipation associated with iron use. Iron-----Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary. Level B Iron-deficiency anemia is associated with preterm delivery and low birth weight. Pregnant women should supplement with 30 mg of iron per day. Level C

Folic Acid Women of reproductive age should take a multivitamin with 0.4 mg to 0.8 mg of folic acid before trying to conceive. This vitamin can be found in many food sources: Dark, leafy green vegetables (spinach, collard, turnip green, romaine lettuce, broccoli, asparagus) Whole grain breads & cereals Citrus fruits & juices (strawberries, oranges) Dried peas & beans (pinto, black, navy & lima beans) Folic acid Supplementation with 0.4 to 0.8 mg of folic acid (4 mg for secondary prevention) should begin at least one month before conception. Level A----Supplementation prevents neural tube defects. RDA (in addition to supplements) is 600 mcg of dietary folate equivalents (e.g., legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread) per day. Level B Folate deficiency is associated with low birth weight, congenital cardiac and orofacial cleft anomalies, abruptio placentae, and spontaneous abortion.

Foods To Avoid In Pregnancy Raw meat Uncooked seafood, beef or poultry should be avoided, because it may be contaminated with salmonella, E. coli and toxoplasmosis. Listeriosis Bacteria that can occur in un-pasteurized milk and soft cheese and prepared and uncooked meats, poultry, and shellfish. It can cause miscarriage. May be found in: Deli Meat- Counsel patients that if they choose to eat deli meat, to buy it from a reputable source and eat within 48 hours of purchase. They may also consider heating it up in the microwave until it is steaming. Soft Cheeses- brie, feta, gorgonzola, Mexican style cheeses such as queso blancho and queso fresco. Soft non-imported cheeses made with pasteurized milk are safe to eat. Unpasteurized Milk Pate All Level C evidence

Foods To Avoid In Pregnancy Fish Fish containing mercury- shark, swordfish, king mackerel, fresh tuna, sea bass, and tilefish. (Level B evidence) Canned tuna is safe, but patients should not eat more than 12 oz. in a week. Mercury consumed during pregnancy has been linked to developmental delays Fish exposed to Industrial Pollutants- Fish from contaminated lakes & rivers that may be exposed to high levels of polychlorinated biphenyls. These fish include: blue fish, striped bass, salmon, pike, trout & walleye. This is regarding fish caught in local waters and not fish from local grocery store. Raw Shellfish- The majority of seafood related illnesses are caused by undercooked shellfish, which include oysters, clams & mussels. They should be avoided in pregnancy. All recommendations except listed above for shark etc. is level C evidence

Foods To Avoid In Pregnancy Caffeine There has been some controversy in linking maternal caffeine use and pregnancy complications, with some studies suggesting excess intake increasing the risk for miscarriage, low birth weight. General rules of thumb: Counsel to avoid caffeine during the first trimester to reduce the likelihood of miscarriage. In later stages of pregnancy, caffeine should be limited to less than 300 mg/day (which is about 2 beverages/day). Caffeine is a diuretic. Make sure your patients are drinking plenty of fluids. Caffeine- containing drinks----Moderate amounts probably are safe. Some guidelines recommend limiting consumption to 150 to 300 mg per day.Level B Observational studies show an association between high caffeine consumption and spontaneous abortion and low-birth-weight infants. However, confounding factors such as smoking, alcohol use, nausea, and age cannot be ruled out.

Foods To Avoid In Pregnancy Alcohol Safe levels of alcohol in pregnancy have not been established. Counsel your patients to AVOID alcohol during pregnancy. Alcohol depletes the body of zinc and magnesium, which are necessary for fetal development. Alcohol consumption during pregnancy can lead to Fetal Alcohol Syndrome or other developmental disorders. Alcohol should continue to be avoided during breastfeeding. All pregnant women should be screened for alcohol misuse. Level B evidence There is good evidence that counseling is an effective intervention in decreasing alcohol consumption in pregnant women and morbidity in their infants. There is no known safe amount of alcohol consumption during pregnancy. Abstinence is recommended. Level B

Common Discomforts Of Pregnancy & Treatments

A Word on Medications in Pregnancy Counsel patients that risks and benefits of any drug therapy taken during pregnancy should be discussed with physician. The effect a medication has on the fetus depends on the medicine itself and the trimester of pregnancy it is taken in: First trimester- the period of greatest risk for the fetus. Up till 12 weeks is the period of organogenesis Second trimester- in general is the “safest” period to take medications. However, medications may still affect the fetal nervous system or the growth of the fetus, resulting in low birth weight. Third trimester- Medications taken during this time can stick around in the fetal bloodstream after birth, causing problems such as breathing difficulties. Clinical trials/actual studies on the safety of medications are rarely or never done on pregnant women, for obvious reasons – Most medications are level C evidence

Nausea & Vomiting Up to 70 % of pregnancies. Usually begins early 6-8 weeks and continues up to 13-16 weeks. Caused by hormonal changes (higher level of circulating Estrogen) that decrease the motility of the intestines. Behavioral Rx: Eating small, frequent meals, avoiding spicy and fried foods. A protein snack before bedtime and keeping dry crackers at the bedside to eat before rising in the morning. Medical Rx: Vitamin B6 (100 mg twice a day) Doxylamine (Unisom), ½ tab at bedtime (Antihistamine) or Benadryl Emetrol liquid as directed Ginger (250mg cap po qid) If patient is unable to tolerate prenatal vitamin in the morning, they may try taking it in the evening or taking 2 chewable Flinstone vitamins daily Things we can perscribe: Category B: Meclizine, Reglan, Zofran Category C: Phenergan, Compazine Emetrol is an OTC antiemetic=mixture of glucose, fructose, and phosphoric acid

Heartburn Delayed emptying from the stomach due to hormonal changes and pressure from an enlarging uterus commonly cause reflux in pregnancy. Behavioral Rx: Eating smaller, more frequent meals and taking antacids. Avoiding spicy, fatty and gas producing foods, such as cabbage. Avoiding eating close to bedtime. Medical Rx: Antacids are generally safe Gaviscon is safe to take as directed Tums, Maalox, Mylanta, Rolaids, Milk of Magnesia as directed for minor discomfort. Pepcid AC or over the counter Zantac are safe. Mylicon (simethicone) as directed for gas Early Pregnancy Heartburn—due to reduced smooth muscle motility 2/2 to relaxation on Lower esophageal sphincter (Progesterone mediated) Gaviscon==alginic acid and bicarbonate In general—antacids containing magnesium hydroxide or magnesium trisalicylate are safe for use, but counsel to avoid use of baking soda and antacids with high sodium content, which can cause water retention and alkalosis. Aluminum-containing antacids can worsen constipation.

Constipation Due to slowed motility of the gastrointestinal tract and growing size of the uterus. Behavioral Rx: Increasing fluid intake (2 quarts/day), fiber intake. Regular exercise. Medical Rx: 1st line: Bulking agents- Fibercon, Benefiber, or Metamucil. Stool softeners - Colace as directed. 2nd line: (Have patients consult you 1st) Stimulant laxatives - Senekot If no relief after the above measures, patients may try a glycerin suppository as directed If no relief after above, patients may use as Ducolax suppository as directed If no relief after above, patients may use Fleet enema as directed --Progesterone mediated decreased bowel transit time (first trimester) -Iron supplementation may exacerbate it.

Hemorrhoids/Varicose Veins Occur due to the pressure of the growing uterus as well as inactivity, prolonged standing and constipation. Behavioral Rx: Avoid constipation with stool softeners and with increased fluid and fiber intake. Sitz baths- warm water for 20 minutes, 3-4 times per day Prevention of varicose veins from occurring by resting the feet up, wearing support hose and proper shoes. Increasing water and decreasing salt intake. Kegel exercises Medical Rx: Anusol cream or Preparation H as directed Tucks pads as directed Tell patients to alert you if hemmorrhoids become tender (indicating possible thrombosis) or bleed.

Urinary frequency/ incontinence Due to the growing uterus pushing down on the bladder. Incontinence is usually of the stress type- i.e. occurring with coughing, sneezing or laughing increases pressure on the bladder. Behavioral Rx: Educate patients to continue to drink plenty of fluids during the day, less so at night. Educate patients regarding sx’s of urinary tract infection. Symptoms of urinary incontinence can be improved by regular Kegel exercises --Urinary frequency and stress incontinence occur most commonly during the first and third trimester. 1st trimester—Uterus places increased pressure on the bladder. Improves in 2nd trimester as uterus rises out of the bladder. 3rd trimester- sx return when engagement of the presenting part exerts pressure on the bladder. --Also glomerular filtration rate increases throughout pregnancy, contributing to urinary frequency. --Incontinence is a common problem of late pregnancy and may be confused with premature rupture of membranes.

Round Ligament Pain Pain on the sides of the abdomen that can extend into the groin. Caused by stretching of the ligaments that support the uterus as the uterus grows. Behavioral Rx: Applying heat, Tylenol and lying with a pillow between the knees at night.

Backache As the uterus enlarges during pregnancy, the center of gravity will be shifted, putting more strain on the lower back. It may be prevented by avoiding excessive weight gain, improving posture, proper bending with a straight back and wearing flat shoes. Behavioral Rx: Tylenol as needed Heating pads At night sleeping with a pillow between the legs to improve hip/knee alignment. --To maintain balance, a pregnant woman’s shoulders are shifted backward and her head angled forward, causing a compensatory lumbar lordosis that predisposes to lower back pain. --During the latter ½ of the pregnancy a woman’s ligaments and joints of the back and pelvis become more lax, further promoting back injury or pain. -Women with poor abdominal muscle tone and poor posture are more prone to this

Headaches Are common during pregnancy. May be related to tension, increased sinus congestion head colds/allergies, increased blood flow and nasal edema or high blood pressure. Women who suffer from headaches or migraines prior to pregnancy, will often find their headaches become more frequent & severe while pregnant. Behavioral Rx: Tylenol & rest may help. Headaches/edema- always warn women about pre-eclampsia warning signs

Pain (Ligament pain, Backaches, Headaches) Medical Rx: Tylenol is safe in all three trimesters. Educate patients not exceed recommended doses. Aspirin is not acceptable. Advil, Motrin or Ibuprofen should be avoided, particularly in the third trimester. Codeine and hydrocodone: Found in most narcotics Can affect the baby’s breathing if taken in the last trimester or during labor in large amounts. Chronic use may cause withdrawal symptoms in the newborn. In general try to avoid prescribing these medications if possible They may be taken for short periods of time to treat specific pain conditions in the second and third trimester. Studies have linked aspirin to various pregnancy complications. --A few studies show that taking aspirin around the time of conception and in early pregnancy is associated with an increased risk of miscarriage. -- And some researchers believe that taking aspirin at adult doses during pregnancy might affect the baby's growth and may slightly increase the risk of a placental abruption. --Finally, taking full-dose aspirin later in pregnancy might delay labor and increase the risk of heart and related lung problems (as with all NSAIDS) in your newborn and bleeding complications for you and your baby. -Obviously ASA may be taken for specific conditions at low doses (ex. Preeclampsia prevention and Antiphospholipid syndrome)

Shortness of Breath Due to hormonal changes and upward pressure of the growing uterus. Behavioral Rx: Sleeping with head elevated on pillows. Pacing self when it comes to daily activities. In early pregnancy increase in circulating progesterone contributes to increased minute ventilation—referred to as pregnancy induced hyperventilation, Late in pregnancy—mechanical limitation in excursion of the diaphragm– leads to reduced residual volume and functional residual capacity.

Nasal Congestion Due to increased blood volume & hormonal changes of pregnancy. Pre-existing allergies may make it worst. Behavioral Rx: Using of a room humidifier. Saline nose drops Medical Rx: Tylenol cold & sinus, Sudafed (caution if high blood pressure) - may be taken in limited quantities for short amounts of time. Afrin and other nasal decongestants, such as phenylephrine are NOT acceptable & should be avoided. --Increased perivascular edema and enlargement of nasal turbinates occurs in early pregnancy (estrogen and progesterone mediated).

Colds, Cough & Allergies- RX Behavioral Rx: Educate patients to stay well hydrated, eat plenty of protein, and get extra rest Steam inhalation/humidifiers also help Have patients call you if Temp>100.5 Medical Rx: Allergies: Claritin or benadryl are safe. Nasal steroid sprays such as Flonase, with long term use can be absorbed in sufficient amounts to impair the growth of the fetus. They may be used short term Coughs: Cough medicines often contain several ingredients- educate patients to check the safety of each one before use. Cough expectorants, such as guaifenesin, are safe to use. Educate patients to AVOID cough medicines containing iodine Cough suppressants, such as codeine or dextromethorphan, can be used in the second and third trimester for short periods of time. Educate patients to avoid them in the first trimester. Lozenges are the safest option. codeine or dextromethorphan—theoretical risk of fetal malformations when used in 1st trimester– not well proven

Edema Swelling of the ankles and feet commonly occur during pregnancy due to decreased circulation and pressure from enlarging uterus. Behavioral RX: Avoidance of sitting and standing for long periods of time Sleeping on side & elevating the legs Increasing fluid intake, decreasing salt intake and wearing support stockings. Slowed venous return from the pressure on the vena cava contributes to lower extremity edema commonly seen in the third trimester. -Educate patients about warning signs for pre-ecclampsia.

Skin changes Chloasma- “Mask of pregnancy”. Increased pigmentation over the face/neck. Hormonal- patients may try to avoid direct sun exposure/wear sun screen. Will fade after delivery. Areola- area around nipple becomes darker Linea Nigra- dark line between the belly button and pubic region. Normal in pregnancy. Will eventually fade after delivery. Stretch Marks- Develop over the abdomen, hips, and breasts in over 50% of pregnant women. They will fade in color after delivery. Behavioral Rx: There are no proven methods for preventing stretch marks- likely genetically determined. Cocoa butter and vitamin E creams may help with the itching that often accompanies striae formation Most skin changes mainly due to stimulation of melanocytes by estrogen and progesterone. -All these changes benign and reversible and can be minimized by sunscreen use and minimizing sun exposure.

Skin conditions (Eczema, dermatitis & skin allergies) Medical Rx: Moisturizers and soothing products are completely safe and should be the first line rx. Steroid creams can be used in pregnancy, but should be avoided on large areas of skin, for long periods of time or under dressings since they can be absorbed into the bloodstream.

Recommended Vaccinations Flu vaccine. Tetanus vaccine if patient hasn’t had one in > 10 years (Td not Tdap) NO LIVE VACCINES are allowed during and up to 3 months before pregnancy.

REFERENCES Ratcliffe, S.D. et al; Family Practice Obstetrics, 2nd ed.. Philadelphia:Hanley & Belfus Inc. 2001 Kirkham, C., Harris, S. & Grzybowski, S.; Evidence Based Prenatal Care: Part 1. General Prenatal Care and counseling issues. American Family Physician, April 1, 2005. Kirkham, C., Harris, S. & Grzybowski, S.; Evidence Based Prenatal Care: Part 2. Third Trimester Care and prevention of infectious diseases. American Family Physician, April 15, 2005. Choby; Pregnancy Care: FP essentials 292. AAFP home study. September 2003. Lu, M.C. Recommendations for preconception care. American Family Physician, August 1, 2007 Cunningham, G. et al; Williams Obstetrics. McGraw-Hill Companies, March 2005. http://www.acog.org/publications/patient_education http://www.perinatology.com/Reference/RDApregnancy.htm