Medical Care During Pregnancy

G.A. Macones

Millions of women give birth every year. Nearly one third of them will have some kind of pregnancy-related complication. Those who don't get adequate prenatal care run the risk that such complications will go undetected or won't be dealt with soon enough. That, in turn, can lead to potentially serious consequences for both the mother and her baby.
These statistics aren't meant to alarm you, but rather to convey the importance of starting prenatal care as early as possible - ideally, before you even get pregnant. Of course, this isn't always possible or practical. But the sooner in your pregnancy you begin, the better your chances of ensuring your own health and that of your baby.

Prenatal Care Before Getting Pregnant
Ideally, prenatal care should start before you get pregnant. If you're planning a pregnancy, see your health care provider for a complete checkup. He or she can do routine testing to make sure you're in good health and that you don't have any illnesses or other conditions that could affect your pregnancy. If you've been experiencing any unusual symptoms, this is a good time to report them.
If you're already being treated for a chronic condition, such as diabetes, asthma, hypertension( high blood pressure), a heart problem, allergies, lupus (an inflammatory disorder that can affect several body systems), depression, or some other condition, you should talk to your doctor about how it could affect your pregnancy. In some cases, you may need to change or eliminate
medications - especially during the first trimester (12 weeks) - to reduce risk to the fetus. Or, you may need to be even more vigilant about managing your condition.
For example, women with diabetes must be especially careful about keeping their blood glucose levels under control, both before they begin trying to conceive and during their pregnancy. Abnormal levels increase the risk of birth defects and other complications.
This is also a good time to talk with your health care provider about other factors that can pose a risk to your baby, such as drinking alcohol or smoking. Ask about starting a prenatal vitamin that contains folic acid, calcium, and iron.
It's especially important for women who are planning to become pregnant to take vitamins with folic acid beforehand, because neural tube defects (problems with the normal development of the spine and nervous system) happen in the first 28 days of pregnancy, often before a woman even knows she's pregnant.
If you have or your partner has a family history of a significant genetic disorder and you suspect either of you may be a carrier, then genetic testing may be advisable. Talk this over with your health care provider, who can refer you to a genetic counselor if necessary. If you find out that you're pregnant before you do any of this, don't worry. It's not too late to get the care that will help to ensure your health and that of your baby.

Finding Medical Care
Pregnant women are typically cared for by:

• family physician/general practitioners (doctors who provide a range of services for patients of all ages - includes obstetrical care)
• certified nurse-midwife (an advanced practice nurse specializing in women's health care needs, including prenatal care, labor and delivery, and postpartum care for "normal" pregnancies)
• obstetricians/ gynecologists (doctors who specialize in pregnancy and childbirth, as well as women's health care)
  

Any of these care providers is a good choice if you're healthy and there's no reason to anticipate complications with your pregnancy and delivery. However, nurse-midwives do need to have a doctor available for the delivery in case a cesarean section has to be performed.
Your health care provider may refer you to a doctor with expertise in high-risk pregnancies if you:

• have a chronic condition like diabetes or heart problems
• have an increased risk of preterm labor
• are older than 35
• have some other complicating factor that might put you in a high-risk category
  

Even if your pregnancy isn't high risk, this may still be a good time to make a change in health care providers if you're not comfortable with your current doctor.

Your First Visit
Your first examination should take place during the first 6 to 8 weeks of your pregnancy, or when your menstrual period is 2 to 4 weeks late. Seeing your health care provider during this time will help him or her estimate the duration of your pregnancy and predict your delivery date. During your first visit, you can expect to have a full physical, including a pelvic and rectal examination. A blood sample will be taken and used for a series of tests:

• a complete blood cell count (CBC)
• blood typing and screening for Rh antibodies (antibodies against a substance found in the red blood cells of most people)
• for syphilis, hepatitis, gonorrhea, chlamydia, and other sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV)
• for evidence of previous exposure to chickenpox (varicella), measles (rubeola), mumps, or German measles (rubella)
• for cystic fibrosis (health care providers have just recently started to routinely offer this to individuals even if there's no family history of the disorder)
  

Women of African or Mediterranean descent are usually tested for sickle cell trait or disease because they're at higher risk for having sickle cell anemia - a chronic blood disease - or carrying the trait, which can be passed on to their children.
During the first visit, you also can expect to provide a urine sample for testing and to have a Pap test (or smear) for cervical cancer. To do a Pap smear, your health care provider uses what looks like a very long mascara wand or cotton swab to gently scrape the inside of the cervix (the opening to the uterus that's located at the very top of the vagina). This doesn't hurt at all; some women say they feel a little twinge, but it only lasts a second.

Routine Visits and Testing
If you're healthy and there are no complicating risk factors, you can expect to see your health care provider:

• every 4 weeks until the 28th week of pregnancy
• then every 2 weeks until 36 weeks
• then once a week until delivery
  

At each examination, your weight and blood pressure are usually recorded. The size and shape of your uterus may also be measured, starting at the 22nd week, to determine whether the fetus is growing and developing normally. During one or more of your visits, you'll be asked to provide a small urine sample to be tested for sugar and protein. Protein may indicate preeclampsia (a condition that develops in late pregnancy and is characterized by a sudden rise in blood pressure and excessive weight gain, with fluid retention and protein in the urine).
Screening for diabetes usually takes place at 12 weeks for women who are at higher risk of having gestational diabetes (diabetes that occurs during pregnancy). That includes women who:

• have previously had a baby that weighs more than 9 pounds (4.1 kilograms)
• have a family history of diabetes
• are obese
• aare older than 30
  

All other pregnant women are tested for diabetes at 28 weeks. This test involves drinking a sugary liquid and having a blood glucose test (which involves having blood drawn) after an hour. If the sugar level in the blood is high, it's tested again in 3 hours to determine if the woman has
gestational diabetes.
Many expectant parents also choose to have one or more of the following prenatal tests, which can help predict the likelihood, or even detect the presence, of certain developmental or chromosomal abnormalities in the fetus:

Alpha-fetoprotein screening (AFP):
Between 16 and 18 weeks, the level of alpha-fetoprotein, a protein produced by the fetus, can be measured in the woman's blood. If the level is high, she may be carrying more than one fetus or a fetus with spina bifida or other neural tube defects. A high level can also indicate that the date of conception was miscalculated. If the level is low, the fetus may have chromosomal abnormalities, such as Down syndrome.
It's important to keep in mind that low or high results don't automatically indicate a problem; rather, they indicate the need for further testing, which yields normal results in many cases. Multiple marker screening (also called a maternal serum screening, triple screen, triple marker, quadruple screen, quad screen, quadruple marker, or quad marker): Also between 16 and 18 weeks, your health care provider may measure the levels of certain hormones in your blood, along with AFP. For this screening, a sample of blood is drawn from the mother to measure the
level of AFP, as well as the levels of hCG (human chorionic gonadotropin) and estriol, which are produced by the placenta. The levels of these three substances (which is why the test is often called the triple screen or triple marker) in the blood can help doctors identify a fetus at risk for
certain birth defects or chromosomal abnormalities. The test is called a quadruple screen (or marker) when the level of an additional substance, called inhibin-A, is also measured.
Amniocentesis (also called an amnio): In this test, a needle is used to remove a sample of the amniotic fluid in the womb; it's generally performed between 16 and 20 weeks. Testing the fluid can identify certain fetal abnormalities such as Down syndrome or spina bifida. Typically, amniocentesis is recommended only if there is reason to believe that the risk for such conditions is higher than usual, perhaps due to maternal age (35 or older), abnormal AFP or multiple marker screening results, or family history. Although the test poses a small risk for causing preterm labor and inducing miscarriage, the large majority are performed without any problem.

Chorionic villus sampling (CVS):
This procedure is used during the first trimester for the same purposes as an amniocentesis. (Women usually have one or the other, but not both, if such testing is deemed necessary.) It involves taking a sample of the tissue that attaches the amniotic sac (the sac around the fetus) to the wall of the uterus. Like amniocentesis, CVS is typically done only when there are certain risk factors; its primary advantage is that results are available sooner. CVS also carries a slightly increased risk of miscarriage and other complications.

Ultrasound (also called a sonogram, sonograph, echogram, or ultrasonogram) :
You'll likely have at least one ultrasound examination to make sure the pregnancy is progressing normally and to verify the expected date of delivery. Usually, an ultrasound is performed at 18 to 20 weeks to look at the baby's anatomy, but can be done sooner or later and sometimes more than once. An ultrasound poses no risk to you or your baby. Some health care providers may have the equipment and trained personnel necessary to provide in-office ultrasounds, whereas others may have you go to a local hospital or radiology center.
Wherever the ultrasound is done, a technician will coat your abdomen with a gel and then run a wand-like instrument over it. High-frequency sound waves "echo" off your body and create a picture of the fetus inside on a computer screen.
Ultrasound scanning is used to:

• determine whether the fetus is growing at a normal rate
• record fetal heartbeat or breathing movements
• see whether you might be carrying more than one fetus
• identify a variety of abnormalities that might affect the remainder of the pregnancy or delivery
  

There are ultrasounds that are available at shopping malls as a way to have a "portrait" of your baby. However, the individuals using the equipment are not necessarily trained as ultrasound technicians. Before committing to having one of these done, it would be wise to discuss it with your health care provider first.

Common Concerns
Some women are concerned about preexisting medical conditions, such as diabetes, and how they could affect a pregnancy. It's important to discuss these concerns with your health care provider. He or she may recommend a change in medication or treatment approaches that could ease your concerns. Whether or not you have a preexisting condition, you may be concerned about some of the other conditions that can be associated with pregnancy including:

• gestational diabetes: Roughly 2% to 3% of women develop this condition during pregnancy, usually after the first trimester. During pregnancy, the placenta, which provides the fetus with nutrients and oxygen, also produces hormones that change the way insulin works. Insulin is a chemical that's made by the pancreas. It helps the body store the sugar in food so that later it can be converted to energy. Gestational diabetes can develop when the woman's pancreas can't make enough extra insulin.
• preeclampsia (also called toxemia of pregnancy): An abnormal condition that develops after the sixth month, it causes high blood pressure, edema (accumulation of fluid in body tissues resulting in swelling of the hands and face), and protein in the urine.
• Rh-negative mother/Rh-positive fetus: Rh factor is a substance found in the red blood cells of most people (a simple blood test can determine your Rh factor). If you don't have it, then you're considered Rh negative. If your baby does have the factor and is Rh positive, problems can result when the baby's blood cells enter your bloodstream. That's because your body may react by producing antibodies that can pass into the fetus' bloodstream and destroy red blood cells.
  

These conditions are serious but manageable, so it's important to educate yourself about them and discuss them with your health care provider. Pregnant women also frequently worry about weight gain. It's generally recommended that a woman of normal weight gain approximately 25 to 30 pounds during pregnancy - about 2 or 3 pounds each month. For individuals who start their pregnancy overweight, their total weight gain should be closer to 15 to 25 pounds. And those who are underweight should gain 28 to 40 pounds. Pregnancy is not a good time to start a diet, however, it can be a great time to start eating healthy food if you didn't before. It's also a good time to get regular, low-impact exercise.
Controlling weight gain is more difficult later in a pregnancy, so try to avoid gaining a lot of weight during the first few months. However, not gaining enough weight can cause problems too, such as inadequate fetal growth and premature labor.

Taking Care of Yourself
For your baby's sake and yours, it's important to take especially good care of yourself during your pregnancy. Follow the basics:

• Don't smoke, drink alcohol, or take drugs.
• Get enough rest.
• Eat a healthy diet.
  

Doctors generally recommend that women add about 300 calories to their daily intake to provide nourishment for the developing fetus. Although protein should supply most of these calories, your diet needs to be well-balanced, including fresh fruits, grains, and vegetables. Your health care provider will likely prescribe a prenatal vitamin to make sure you get enough folic
acid, iron, and calcium.
Over-the-counter medications are generally considered off-limits because of their potential effects on the fetus. Most doctors will recommend that you don't take any over-the-counter medications at all, but they might offer a list of those they think are safe to take. Be sure to discuss any questions about medications, including natural remedies, supplements, and vitamins, with your health care provider.
When you're pregnant, it's also important to avoid food-borne illnesses, such as listeriosis and toxoplasmosis, which can be life threatening to an unborn baby and may cause birth defects or miscarriage. Foods you'll want to steer clear of include:

• soft, unpasteurized cheeses (often advertised as "fresh") such as feta, goat, Brie, Camembert, and blue cheese
• unpasteurized milk, juices, and apple cider
• raw eggs or foods containing raw eggs, including mousse and tiramisu
• raw or undercooked meats, fish, or shellfish
• processed meats such as hot dogs and deli meats (these should be well cooked)
  

You should also avoid eating shark, swordfish, king mackerel, or tilefish, as well as limit the amount of other kinds of fish that you eat. Although fish and shellfish can be an extremely healthy part of your pregnancy diet (they contain beneficial omega-3 fatty acids and are high in protein and low in saturated fat), these types of fish may contain high levels of mercury, which can cause damage to the developing brain of a fetus.
Pregnancy also can cause a number of uncomfortable, although not necessarily serious, side effects, including:

• nausea and vomiting, especially early in the pregnancy
• leg swelling
• varicose veins in the legs and the area around the vaginal opening
• hemorrhoids
• heartburn and constipation
• backache
• fatigue
• sleep loss
  

If you experience one or more of these side effects, keep in mind that you're not alone! Talk to your doctor about strategies for alleviating any discomfort.

Talking to Your Health Care Provider
When your body is going through physical changes that may be completely new to you, it isn't always easy to talk to your health care provider. Maybe you're wondering whether you can have sex or what to do about hemorrhoids or constipation, or maybe you're feeling a great deal of anxiety about the delivery.
You might feel embarrassed to ask these or other questions, but it's important to do so - your health care provider has probably heard them all before. Keep a running list of questions between your appointments, and take that list with you to each visit.
It's also strongly recommended that you call your health care provider immediately if you experience:

• heavy bleeding
• a sudden loss of fluid
• a marked absence of movement by the baby once he or she has begun moving
• more than three contractions in an hour

(AAFP)