So You're Thinking of Becoming Pregnant! What to Know, What to Do and What's New!

THE LOWDOWN ON PRE-CONCEPTIONAL CARE

Preparation means everything. Nobody would ever consider running a marathon without training for months before the big race, going into a college final without studying or not practicing a big speech before presenting it in front of a large crowd.

So why should you enter in to the most important venture of your life- (PREGNANCY!) a venture that will have implications for your entire life and that of your child without all of the preparation that you can have!! This article will address all aspects of planning your pregnancy. These issues are of paramount importance whether this is your first pregnancy or your fourth, pre-conceptual care plays a supreme role in the outcome of your child. Some of the things we talk about will be a review and you will be familiar with, while other topics are hot off the presses!

THE PLANNING PART

Don’t get annoyed or feel pressured when your Ob/Gyn asks you at every visit if you are thinking of becoming pregnant. On one hand, if pregnancy is not even on your radar, we want to make sure that you are using appropriate contraception to avoid an unintended pregnancy, and if you aren’t, we are here to share all of the contraceptive options with you!

We also want to be able to offer up the option of egg freezing if there is no partner on the horizon and you see yourself wanting children in the future. We start this discussion in the early 30s because we don't want to be freezing 40 year old eggs. This keeps all of the windows and options open.

If you are thinking of getting pregnant, we want to know when, so we can get you into great shape medically, physically and emotionally well in advance of getting pregnant. Take advantage of all that modern medicine has to offer and let your Ob/Gyn know at least 6 months in advance of your plans to conceive- even more lead time is preferable if you have any significant medical problems- especially those that require medications, and particularly pre-existing diabetes, hypertension, depression, asthma, seizure disorders and heart conditions.

ABOUT THOSE MEDICAL ISSUES…

Many women are getting pregnant later in life, and it is very common to see women in their late 30s and early 40s having their first baby. Along with age however, comes a higher incidence of pre-existing medical problems- many of which can have an impact on the outcome of a pregnancy, and the health of the unborn baby. Many of these medical issues can be optimized pre-conceptually, which can significantly alter the outcome in a very positive way. Below we will go over a few of the conditions that can impact pregnancy and that can be addressed and tweaked pre-conceptually.

1- OBESITY

Obesity is an epidemic in America, with 30-40% of the American population being overweight. Obesity, and particularly morbid obesity has many implications for the health and well-being of the mother and baby, and can be modified dramatically by pre-conceptual weight loss. We never want women who are already pregnant to diet during pregnancy- the optimal situation is to go into pregnancy at or close to your ideal weight.

Take a look right now at your BMI- body mass index. All you need to know is your height in inches and your weight. If you google BMI calculator you can easily calculate your BMI and it will tell you if you are underweight, overweight, obese or morbidly obese. If you are underweight it is important to optimize your diet, have a meal plan that has adequate fat and protein, and is well balanced.

Some women who are very underweight will not ovulate and will not get periods and they will not get pregnant. Meeting their ideal bodyweight by healthy weight gain and food intake can increase weight and critical body fat percentage and lead to regular ovulation and menses and ultimately pregnancy. Sometimes just gaining back a few critical pounds can make the difference.

If you are having difficulty with this, enlisting the help of a qualified nutritionist can make all the difference. If you are underweight when entering into a pregnancy we will also want you to gain more weight during the pregnancy than someone who is of average weight or who is overweight.

In those women who are overweight but not obese, now is the time pre-conceptually to get into shape with diet and exercise in preparation for pregnancy. Normal weight women should gain 25-35 pounds in the pregnancy, and if you are already starting out above the normal weight, you can have more issues in pregnancy, and more weight to lose after the baby is born, which most women find quite difficult. Starting out thinner is better.

Obese, and particularly morbidly obese women have much higher risk pregnancies. There is an increased risk of cesarean section, shoulder dystocia, diabetes, hypertension, pre-eclampsia and other obstetrical complications with obesity.

The sooner we know you want to get pregnant, the earlier we can get you involved with a plan of healthy eating and exercise. Regular exercise regimens along with a weight loss program such as weight watchers is an ideal place to start. Depending on how much weight you have to lose and what medical co-morbidities you have, bariatric surgery may also be an option. Weight loss programs and surgical options require months to over a year to produce ideal results, so again, get talking to your Ob/Gyn about your plans and allow ample time!

2- DIABETES

It is of paramount importance to have excellent control of your diabetes well before you conceive. An unintended pregnancy with poor glucose control dramatically increases the chances for birth defects in the baby as well as poor outcomes overall. It is mandatory to have your team set in place and communication is critical.

Your endocrinologist and your ObGyn have to work side by side in this venture. Multiple daily blood glucose values (fasting and an hour after each meal) are very important, as is your hemoglobin A1C value. This hemoglobin A1C value looks at glucose control over the last 6 weeks, and the higher the value is when you get pregnant, the higher the risk of birth defects. Let your endocrinologist know you are thinking about pregnancy so those sugars can be in better control. Sometimes this means altering your insulin regimen, and sometimes it means switching to an insulin pump for fine tuning your sugars.

Hold off on your plans for pregnancy until you get the all clear from endocrine and Ob/Gyn, so that you can have the healthiest pregnancy. Expect that your insulin requirements will increase in pregnancy and also expect to be followed as a high risk patient during the pregnancy. You may be seen every one to two weeks instead of monthly during the pregnancy, and in the last month or two of pregnancy more monitoring with non stress tests and sonograms will surely be important.

Pregnant women with a history of pre-existing diabetes have a long list of other doctors that they will need to see during pregnancy and tests that will have to be done such as Opthalmology and Podiatry visits, EKG, 24 hour urine collection and fetal echocardiogram to optimize the health and well being of both the mother and the fetus.

3- HYPERTENSION

If you have high blood pressure you will also be followed as a high risk pregnancy, with an important interplay between your Ob/Gyn and Internist/Cardiologist.

Getting your blood pressure into excellent control (and if relevant, weight loss, salt restriction and exercise may again play a vital role) prior to pregnancy is crucial. Certain medications for hypertension are not recommended in pregnancy, so make sure to talk to your Ob about what you are on now, and your Ob will speak to you and your medical doctor about potential alternatives. Beta blockers, aldomet, and calcium channel blockers are the mainstay of treatment in pregnancy, and ACE inhibitors are avoided.

Women with pre-existing hypertension have a higher chance of pre-eclampsia (also known colloquially as toxemia of pregnancy) and will be followed closely for this throughout the pregnancy, and particularly in the last trimester.

One of the newest interventions to prevent pre-eclampsia is the administration of a daily baby aspirin prophylactically throughout pregnancy in those women at high risk for pre-eclampsia. By giving a daily baby aspirin, we can significantly decrease the chance for those women who previously had pre-eclampsia in a prior pregnancy or in those women who have pre-existing hypertension or other significant risk factors.

Prevention is always better than cure- talk to your doctor about this!

Aside from checking your blood pressures in the office during the pregnancy you will also have more frequent sonograms to check the growth of the baby, especially if you are on certain blood pressure medications, as some of them can cause babies to be smaller.

4-DEPRESSION

If you have a history of depression and want to get pregnant, DON’T stop your anti-depressant medications. Talk to your psychiatrist and see if you are able to wean off the medications prior to getting pregnant. If you can’t, it is much better to have medications that are well studied in pregnancy (such as zoloft) than for you to be in a severe depression during pregnancy. This is not healthy or safe for you or the baby.

There are certain anti-depressants that are safer and better than others. Some medications should be avoided and if you are on some of these medications your OBGyn may speak to you and your psychiatrist about considering a change to a safer medication. These medication alterations may take months to tweak and to evaluate in terms of how well you are doing, so please give ample pre-conceptual notice to both your Ob and your psychiatrist. Women with a history of pre-existing depression prior to pregnancy have a higher chance of postpartum depression and should be watched and followed up closely after delivery.

5- SEIZURE DISORDERS

Women who have a history of seizure disorders are often on chronic medications to prevent recurrent seizures. Some of these medications are contra-indicated in pregnancy and should be changed well before pregnancy. It is also important for seizures to be well controlled prior to starting a pregnancy.

It is very important to speak with your neurologist and your OB prior to embarking on a pregnancy so all of the medications can be checked for safety in pregnancy, and fine tuned prior to getting pregnant. Women who have a seizure disorder, even if they are not on medications have a slightly higher risk for birth defects, so talk to your doctor before you get pregnant so you have all of the available information.

Due to the fact that there is a higher risk of neural tube defects in women taking medicine for seizure disorders, 4000 micrograms (4mg) of folic acid should be taken pre-conceptually instead of the usual 400 micrograms to decrease the chances of Neural tube defects.

6-CARDIAC ISSUES

There is a wide range of cardiac issues that women can have, with some being benign and of no consequence in pregnancy, while others can have a significant impact on mother and fetus. Some rare cardiac issues (such as Aortic stenosis and pulmonary hypertension) pose a very high risk of death to pregnant women, and in women with these issues pregnancy should be avoided all together. Surrogacy and adoption are alternatives in these circumstances.

Other cardiac issues depend on the type and severity of the lesion and it is of the utmost importance to discuss your particular issue with your cardiologist and your OB prior to contemplating a pregnancy.

PRE-CONCEPTUAL MULTIVITAMIN WITH FOLIC ACID

It is very important to initiate a multivitamin with at least 400 micrograms of folic acid daily for at least 3-6 months prior to conception. This will decrease the chances of the baby having a neural tube defect. Taking this vitamin is such an easy intervention and can make such a big difference.

ALCOHOL AND DRUGS

Tobacco cessation prior to pregnancy is ideal. Working with whatever modality gets you to stop prior to getting pregnant is critical for the health of your baby. Women who smoke during pregnancy have a higher chance of having a low birth weight baby and a higher risk of placental abruption (premature separation of the placenta from the uterine wall which can be catastrophic or fatal for the baby).

Babies of smokers also have a higher incidence of SIDS (sudden infant death syndrome). Starting your smoking cessation program months before trying to get pregnant is ideal and may involve hypnosis, acupuncture, medications by mouth or patch or gum. Talk to your medical doctor and Ob well in advance of pregnancy.

Alcohol should also be curtailed prior to pregnancy, as some women don’t find out that they are pregnant until weeks into their first trimester.

Binge drinking (5 or more drinks at a time) is particularly dangerous during pregnancy with regards to fetal alcohol syndrome, and there is no safe amount of drinking in pregnancy, so reduction in alcohol consumption should begin pre-conceptually. Addiction to illicit or prescription drugs can lead to serious and fatal complications in the mother and fetus. Getting help through drug counseling or rehabilitation programs are extremely effective and should start well in advance of trying to get pregnant to optimize the health of you and your baby.

GENETIC TESTING

In the past, pre-conceptual genetic testing was reserved to testing for genetic mutations based on ethnicity such as Sickle cell testing in African-Americans, Beta Thalassemia in Mediterranean populations, and Tay-Sachs testing in Ashkenazi Jewish populations.

Over the years, Jewish genetic screening has evolved to include 19 genetic mutations that are more common in this population. Specific genetic diseases that ran in families were tested for if the mutation was known and the testing was available.

Today, there is a much wider range of mutations that can be screened for. These tests are not based on family history or on ethnicity. They are global tests that screen for a wide variety of genetic mutations. The majority of them are autosomal recessive traits, which means that BOTH parents must carry the same gene mutation for there to be a chance that their child will be affected. Some are X-linked and are passed down through the maternal genes and are more likely to affect male offspring.

These simple blood tests can screen for HUNDREDS of genetic mutations.

RISKS & BENEFITS OF GENETIC TESTING...

Before we go into these tests, lets talk about risks and benefits. Having these tests BEFORE you get pregnant offers a couple that both carry the same mutation (giving each naturally conceived child a 25% chance of having the disease) the opportunity to conceive through IVF (in vitro fertilization) and have PGD (prenatal genetic diagnosis). After the eggs are stimulated and retrieved they are mixed with the partner’s sperm and fertilized. After the embryo grows a few cells, one cell of the embryo is removed and it is tested for the particular genetic disease that it is at risk for.

Only those embryos that do not have the disease are transferred to the woman’s uterus for pregnancy, virtually eliminating the possibility that the couple will have a child with the disease of concern.

What may seem seem to be an awesome option, however, may have drawbacks. Most of us would want to know if our potential child carries a genetic mutation that is incompatible with life or lethal with respect to cutting life short or providing a life that is fraught with life altering/limiting medical issues. However, some of the tests that are included in these panels do not meet the above criteria and are not life altering, but can cause significant anxiety in the parents. Talk to your doctor and decide what is best for you.

There are many global genetic test panels that are available, and two of the most commonly used panels are Horizon and Counsyl.

VACCINES- AM I UP TO DATE?

Check with your medical doctor to make sure that you have immunity to certain diseases before you get pregnant. Some vaccines are not safe in pregnancy, and should be administered at least 3 months before getting pregnant because they are live or attenuated virus vaccines. If you are not sure about your immunity have your doctor run blood tests to check.

Diseases such as Rubella (German measles) and Varicella (chicken pox) should be vaccinated for, as women who contract these diseases during pregnancy can give birth to children with severe birth defects. Theses vaccines are not to be given in pregnancy, and if your blood tests show that you are not immune to them, get vaccinated at least 3 months before pregnancy.

The HPV vaccine series that protects against genital warts and cervical cancers also should be given prior to pregnancy in women at or under 26 years of age. Vaccines that ARE recommended in pregnancy are the flu vaccine in any trimester and the Tdap (pertussus) vaccine between 28 and 36 weeks. These vaccines are completely safe in pregnancy and are strongly recommended.

YES- WE HAVE TO TALK ABOUT ZIKA AGAIN!

In previous articles we have talked about the travel restrictions in pregnancy with regard to Zika affected countries such as but not limited to (the country list changes so always check with the CDC website before you travel and take trip insurance if you are pregnant or planning to get pregnant!) The Caribbean, Miami, Central and South America. However- it is not just DURING pregnancy that you should be concerned. Women who have visited these countries should wait 2 months prior to conceiving and for men they should wait 6 months. Plan accordingly.

CONCLUSION

In conclusion, pregnancy is one of the most important marathons you will ever run in life, and it is a test that you can study for! Talk to your ObGyn well in advance (at least 6 months to a year) before you are thinking of getting pregnant so you can have an individualized plan set up for you to give you the best pregnancy and fetal outcome that you can. A healthy baby is the biggest investment in your life and the life of your baby!

Make sure your medical conditions are all tuned up and make sure all of your doctors are involved, become as fit as you can and get as close to your goal weight and have a great exercise regimen in place before you get pregnant. Stay away from Zika affected countries as directed, get those vitamins with folic acid on board, and get the vaccines you need well before you get pregnant. And then you can get started on baby making!

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THINKING ABOUT GETTING PREGNANT OR HAVE QUESTIONS ABOUT YOUR PREGNANCY?

Schedule an in-office appointment to chat with us. We'd love to meet you! Call us at 516-365-6100 to set up a convenient appointment. We're located right off the Northern State Parkway here in North Hills, Long Island, just a few minutes away from North Shore University Hospital & Northwell Health.

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