Pregnancy Planning (Tips)

Picture of a fetus at 12 weeks

• Many women choose to start pregnancy planning prior to conception so that they may minimize possible toxic exposures to the fetus.
• Women or couples with an increased risk or family history of genetic (inherited) diseases may undergo genetic counseling as a step in pregnancy planning.
• For the best outcomes, chronic medical conditions should be treated and under good control prior to attempting pregnancy.
• Smoking cessation and avoiding alcohol or illicit drug use strongly improve a woman's chances of having a healthy pregnancy and baby.
• The amount of weight that a woman should gain during pregnancy depends partially on her pre-pregnancy weight.
• As soon as a woman stops using birth control, she is able to become pregnant. Some long-term hormonal contraceptives may require a period of time for the hormonal effects to wear off.
• Women who are planning to become pregnant should take folic acid supplements to reduce the likelihood of neural tube defects in the fetus.
• Some types of fish may be high in mercury or other toxins and are not recommended for pregnant women.
• Exercise is part of a healthy lifestyle and is recommended for most pregnant women with uncomplicated pregnancies.
• It is important to review all medications, whether prescription or over-the-counter (OTC), with your health-care professional if you are planning to become pregnant.
• Sexual activity is safe for most pregnant women.
• Certain infections, including Zika virus, rubella, toxoplasmosis, and parvovirus B19 can pose risks for the fetus.
• Women who do not have immunity to the rubella virus should be vaccinated before trying to conceive.
• Women who have been infected with the HIV or hepatitis B viruses can receive medications during pregnancy or at delivery to reduce the likelihood of transmitting these infections to their newborn.

Pregnancy planning begins even before conception for many women. Others choose to start planning when they are aware of a pregnancy. While it is possible to have a healthy pregnancy and baby without a pregnancy plan, developing a pregnancy plan is one way to help ensure that your baby has the greatest chances of having good health and that you have a healthy pregnancy. Planning for pregnancy typically involves:

• Discussions with a woman's partner and her health-care team, and includes discussions about nutrition and vitamins, exercise, genetic counseling, weight gain, and the need to avoid certain medications and alcohol.
• Sometimes, planning for pregnancy includes fertility planning and scheduling sexual intercourse for the time of the month when the woman is most fertile. Couples who are having regular sexual intercourse and who still do not conceive typically consult a fertility specialist. Doctors generally recommend that healthy couples in which the woman is under 35 try to get pregnant for a year before consulting a fertility specialist. Women over 35 may want to consult a fertility specialist after 6 months of trying to conceive.
• Because some women experience light bleeding known as implantation bleeding around the time of the expected menstrual period, or because of irregular menstrual cycles, some women may not realize they are pregnant until specific symptoms of pregnancy start to develop. By this time, the woman may have unknowingly exposed herself to substances that may be harmful for the pregnancy. Women who choose to begin pregnancy planning before conception can take steps to ensure that potentially harmful exposures are avoided.

Before a woman becomes pregnant, she can discuss her medical history with a doctor, focusing on the following:

• Chronic medical conditions like diabetes, thyroid disease, kidney disease, or heart disease should be monitored and well controlled prior to conception for the greatest chances of a healthy pregnancy.
• Women may be tested to determine if they have been infected with the HIV or hepatitis B viruses, so that appropriate treatment during pregnancy or at delivery can help prevent transmission of the infections to the baby.
• Immunization history and immune response to varicella (chickenpox) and rubella (German measles): the status of a woman's immunity to these two infections, which can cause harm to the developing fetus can be determined by a blood test. If a woman is not immune to these infections, vaccinations can be given before trying to conceive. After receiving the varicella vaccine, women should wait 30 days before attempting conception. Precautions against developing certain other infections should also be taken.
• Couples who have a history of inherited diseases, have other children with genetic diseases, or who have family histories of certain conditions may choose to undergo genetic counseling prior to conception. Your doctor can help you determine whether genetic counseling is appropriate for you.
• Smoking cessation dramatically improves the chances of a healthy pregnancy, and women planning pregnancy should abstain from alcohol use. Those with substance abuse problems should ideally be identified and treated prior to planning a pregnancy.

A pregnancy calendar or calculator is a tool that helps a woman determine precisely which changes are taking place in her body and in the fetus at a given week of pregnancy. Calculators are also available to predict a woman's due date. Many versions of pregnancy calendars and calculators can be found online.

A woman is physiologically able to become pregnant as soon as she is no longer using birth control. For certain hormonal methods designed for longer-term contraception, the effects can take some time to wear off so pregnancy is possible when the hormonal effects wear off. There is no evidence to suggest that waiting a few cycles after stopping oral contraceptives "the pill" will lead to better pregnancy outcomes.

A healthy diet that provides all the necessary nutrients for the developing fetus increases the chances of a healthy pregnancy. For this reason, it is best to avoid certain diets in pregnancy. In particular, high-fat diets, some vegetarian diets, and weight loss diets should generally be avoided by pregnant women. A healthy diet also means limiting sugar intake. Many women also choose to start eating a healthy diet in the stage prior to conception to maximize their chances of delivering a healthy baby. In general, a healthy diet is the same for both pregnant women and non-pregnant women, with a few special exceptions that will be discussed below.

Evidence about whether consumption of caffeine in pregnancy is detrimental has been inconclusive. However, it is known that the fetus metabolizes caffeine very slowly, so maternal consumption of caffeine results in a prolonged exposure for the fetus. Consumption of typical levels of caffeine has not been associated with any adverse pregnancy outcomes, yet individual studies have shown that caffeine can lead to changes in fetal arousal and heart rate. According to many experts, including the American Academy of Nutrition and Dietetics, caffeine intake in pregnant women should be limited to 200 mg per day (equivalent to one 12 oz. cup).

Women who are planning to become pregnant are advised to take folic acid supplements to reduce the likelihood of neural tube defects in the fetus. The neural tube closes early in pregnancy (18 to 26 days after conception) so supplementation with folic acid is most critical during the early days of pregnancy. Often, supplementation after the diagnosis of pregnancy is too late to reduce the risk of neural tube defects. Vitamins containing 400 to 800 mcg of folic acid, taken daily, are recommended.

Due to the presence of certain environmental toxins (such as mercury), the kinds and amount of fish (and shellfish) that are eaten during pregnancy should be regulated. The US FDA has issued guidance for pregnant women and those planning a pregnancy regarding the types and amount of fish that should be eaten.

• In general, 2-3 servings of fish that are low in mercury are recommended per week.
• Seafood that is lower in mercury includes salmon, shrimp, pollock, tuna (light canned), tilapia, catfish, and cod.
• Tilefish from the Gulf of Mexico, shark, swordfish, and king mackerel are typically high in mercury and should be avoided.
• Pregnant women should not consume raw fish.

Megavitamins may not be safe for pregnant women, since excessive doses of vitamins can be harmful and their effects on the fetus have not been fully studied. Megadoses of vitamin A in early pregnancy have been linked to birth defects. Women planning pregnancy and who are pregnant also are advised not to consume nonessential dietary supplements or herbal preparations, since their effects on the developing fetus are unknown. The safest choice for women planning a pregnancy is to take a prenatal vitamin supplement that contains folic acid and iron.

Pregnant women also should try to avoid unpasteurized milk, soft cheeses, deli and luncheon meats, and undercooked or raw animal foods. This is due to the risk of exposure to Listeria monocytogenes, common bacteria that can cause miscarriages and other problems. Fruits and vegetables should be washed well before consumption.

The mother's pre-pregnancy weight should be taken into account when estimating how much weight gain is appropriate for a healthy pregnancy. Women with multiple gestation pregnancies will need to gain more weight to maintain a healthy pregnancy than those with singleton pregnancies. The Institute of Medicine (IOM) has issued guidelines for recommended weight gain in women who have a singleton pregnancy. They are as follows:

• Underweight women (BMI < 18.5) should gain 28-40 pounds.
• Normal-weight women (BMI, 18.5-24.9) should gain 25-35 pounds.
• Overweight women (BMI, 25-29.9) should gain 15-25 pounds
• Obese women (BMI, 30 or higher) should gain 11-20 pounds.

Fetal alcohol spectrum disorders (FASDs) are a group of conditions reflecting the possible effects of prenatal exposure to alcohol. These include fetal alcohol syndrome (FAS), alcohol-related birth defects (ARBD), and alcohol-related neurodevelopmental disabilities (ARND). Fetal alcohol syndrome is a leading cause of cognitive disabilities in children. The exact amount of alcohol exposure that is associated with these disorders has not been determined, so there is no known limit for safe alcohol consumption in pregnancy. For this reason, women planning to conceive and pregnant women are advised not to drink alcohol.

Exercise is part of a healthy lifestyle and is recommended for healthy pregnant women who have uncomplicated pregnancies, with a few exceptions. You should always discuss your exercise program with your doctor. Recommendations from the American College of Obstetrics and Gynecology state that pregnant women who have an uncomplicated pregnancy should participate in at least 30 minutes of moderate exercise on most, if not all, days of the week. However, there are some sports with an increased risk of trauma to the abdomen that should be avoided. These include ice hockey, kickboxing, soccer, and horseback riding. Scuba diving should also be avoided in pregnancy since it poses a risk of decompression sickness ("the bends") to the fetus.

For most women, sex during pregnancy is safe. Your doctor may recommend avoiding sexual intercourse if you have certain conditions or risk factors. These include prior preterm labor, multiple miscarriages, infection, bleeding, amniotic fluid leak, and placenta previa (low placenta). Pregnant women should not have sexual activity that would put them at risk for contracting a sexually transmitted disease (STD).

Pregnant women should always follow a healthy nutrition plan that is optimized for both mother and baby (see previous sections on dietary considerations and weight gain). A weight reduction diet is not appropriate for pregnant women. Even women who are overweight or obese prior to the pregnancy will need to gain weight during pregnancy, although some may need to gain slightly less weight than normal-weight women. Women who are overweight or obese should discuss with their doctor the best amount of weight gain weight gain for the pregnancy.

According to the American College of Obstetricians and Gynecologists, occasional air travel in pregnancy is considered safe, and there are no data to show that air travel adversely affects pregnancy outcomes for occasional travelers. Most airlines allow women to fly up to the 36th week of gestation. Women who have high-risk pregnancies and are at risk for preterm labor or who may require emergency care should avoid air travel. It is generally recommended that pregnant women traveling by air take precaution to decrease their risk of developing blood clots (thrombi) in the extremities. The use of support stockings, frequent ambulation, and remaining well hydrated can help reduce the risks of developing a blood clot in the legs during long flights.

Part of pregnancy planning involves attention to underlying or pre-existing medical conditions that may affect a woman's pregnancy. Women who take regular medications should review their medication schedule (including any over-the-counter medications or supplements) with their doctor when planning to conceive. Some medications may be harmful to the fetus, while other drugs are safe for pregnant women. It may be necessary to discontinue certain medications or change to alternate medications in some cases. For example, the acne medication isotretinoin (Accutane) has been shown to cause birth defects in the fetus.

In some cases, the effects of a particular medication may be unclear in pregnant women. In these cases, a decision must be made regarding the necessity of the medication for the mother's health versus possible or unknown risks to the fetus.

Women taking oral contraceptives who become pregnant are not believed to be at any increased risk for poor outcomes, although the oral contraceptives should be discontinued immediately.

It is safe for women who become ill during pregnancy to be treated with many medications; however, some medications, including some antibiotics and pain relief medicines, may not be recommended for pregnant women. It is important if you require medication to tell your doctor that you may be pregnant or are trying to conceive.

Viral infections that can cause problems for the mother and/or the fetus include the following:

• Rubella (German measles)
• Varicella (chickenpox)
• HIV
• Hepatitis B
• Genital herpes (herpes simplex virus (HSV)
• Cytomegalovirus (CMV)
• Parvovirus B19

Infection with the parasite Toxoplasma is a risk for pregnant women.

Rubella viral infection

Rubella viral infection in early pregnancy can cause miscarriage or birth defects. Therefore, women of childbearing age are tested for immunity to this virus, and those lacking antibodies to the rubella virus should be vaccinated against this virus.

Genital herpes

If a pregnant woman has genital herpes infection, it is possible to transmit the virus to the baby at the time of delivery. Herpes simplex virus (HSV) infection can have multiple effects in the newborn. The infection may be limited to the eyes, skin and mouth. It may be localized to the central nervous system or may be widespread. Antiviral medications are given to the newborn after delivery. Cesarean delivery (C-section) is recommended for most women with an active outbreak of genital HSV infection at the time of labor to prevent transmission of the infection to the baby.

Parvovirus B19

Parvovirus B19 causes fifth disease, a common mild disease of childhood that is spread by respiratory secretions or blood. Pregnant women who have not previously had fifth disease should avoid contact with people with the condition since parvovirus B-19 can infect the fetus. About 65% of pregnant women in North America have evidence of previous infection with parvovirus B-19, while acute parvovirus B-19 infection occurs in up to 2% of pregnant women in endemic periods. About 30% of women who develop parvovirus B19 infection in pregnancy will transmit the infection across the placenta to the fetus. Although no birth defects have been reported as a result of fifth disease, the infection can cause fetal death. For women who contract parvovirus in the first trimester, the rate of fetal loss can be as high as 10%. Avoiding people with fifth disease can greatly reduce the chances of becoming infected.

Hepatitis viruses B and C in newborns

Hepatitis viruses B and C can affect newborns, but hepatitis B is much more commonly passed from a pregnant woman to her baby. Only about 4% of fetuses exposed to maternal hepatitis C become infected while that percentage is much higher for those with Hepatitis B (90%).

Infants born to mothers infected with the hepatitis B virus are given both hepatitis B antibodies and hepatitis B vaccinations at birth for protection. Currently there is no effective way to prevent transmission of hepatitis C in newborns, and the medications used to treat hepatitis C in adults are not recommended for pregnant woman or infants.

HIV infection

HIV infection can be passed from a mother to the baby. The chances of this happening can be greatly reduced by treating the mother with certain medication regimens during pregnancy.

Varicella and chickenpox infection

Varicella, or chickenpox, infection can cause pneumonia or even death in older adults and in pregnant women. Varicella vaccine is available for women who are not immune to chickenpox. After receiving the varicella vaccine, women should wait 30 days before attempting conception.

Toxoplasma

Toxoplasma is a parasite that is transmitted through cat feces and raw meats, especially pork. As with infection with the rubella virus, toxoplasmosis can cause birth defects if the infection occurs during early pregnancy. Women planning pregnancy can decrease the risk of contracting toxoplasmosis by avoiding raw meat and avoid handling cat litter boxes. It is possible to have been exposed to toxoplasmosis and have immunity to the infection without being aware of it. Women can have a blood test to determine if they have immunity to toxoplasmosis; if the test is positive for toxoplasmosis immunity, the woman will not develop toxoplasmosis complications during pregnancy. There is no vaccine available to prevent toxoplasmosis.

Zika virus

Zika virus is a Flavivirus that is transmitted by the bite of a mosquito that carries the virus. The illness that follows may last for a few days to a week and causes signs and symptoms like conjunctivitis (redness of the eyes), rash, fever, and joint pain. The virus has been traditionally reported in Indonesia and Africa, but it has continued to spread through North and South America including the U.S. The viral infection has been associated with to birth defects (mainly small brain size and small head, known as microcephaly, as well as certain eye defects that can cause vision loss) in babies whose mothers contracted Zika virus infections during pregnancy. While mosquito-borne transmission is the usual route of spread, the virus may less commonly be spread through sexual intercourse, through blood transfusions, or from mother to fetus.

The US Centers for Disease Control and Prevention (CDC) maintains a web site with up-to-date information on the risks of contracting Zika virus in specific areas of the world. Pregnant women should avoid travel to an area where Zika virus transmission is occurring. An updated list of areas that should be avoided by pregnant women can be found at the CDC web site (http://wwwnc.cdc.gov/travel/notices). Also, pregnant women with a male partner who lives in or has traveled to an area with an active Zika infection should use condoms during sex or abstain from sex until the pregnancy is over.