Thursday, September 23, 2010

8.34 Good Pregnancy

Physician's Notebooks 8 - - See Homepage

34. Good Beginnings - Update 19 Feb. 2019

Here, I advise the reader who desires to make a good baby. It is an ideal model but in your life you may have to change some of my advice as a compromise with hospitals.

As soon as pregnancy test turns positive, get pelvic ultrasound scans, which are harmless. They can discover miscarriage, multiple or ectopic  and other abnormal pregnancy. It is important to know these possibilities early.

Expected date of birth (EDB)  Subtract 3 from the month number of your first day of last menstrual period (LMP) and add 7 to the calendar date day number, and, if LMP started 1 April or later move the year number ahead 1 year.  Example is LMP 4/2/2005, EDB 1/9/2006.

We divide pregnancy into thirds (trimesters). To calculate what is the week, count the days from LMP and divide by 7. Example: 120 days from 1st day LMP gives 17 with remainder 1, which gives 1st day of 18th week.

First trimester is from day 1 to 91; its symptom is nausea, worse in morning on empty stomach, starting after 4th week from LMP and going gone by 12th week. It is best not to use medicine because of the risk to fetus. Snacking between meals helps. Prolonged vomiting, more than a few hours, should quickly be treated by IV electrolyte fluid. The pregnancy may be causing the worsened vomiting and it risks fetal abnormality from the electrolyte imbalance of severe vomiting.
   During the first trimester, a fetus is maximally susceptible to the bad effect of medications or other chemicals, to radiation from x-ray and other materials (Radon gas in cellar dwelling) or to cosmic ray (worse in high altitude so do not fly and best not to live in Denver or higher altitude when pregnant); and to virus infection. Immunization of a pregnant or a person close to her with live virus vaccine (OPV, rubella, mumps, measles) should be No-No. Avoid risks of virus by avoiding crowds and persons with infection. A pregnant woman should avoid cats because the toxoplasmosis germ that cats carry may cause fetal malformation. A similar risk is cytomegalovirus infection which is one of the most frequent causes of fetal abnormalities and should be checked by antibody blood test before or in the very early stage of pregnancy.
   A pregnant person should avoid swimming or tub-bathing. Showers are okay.
   An X-ray (includes CT) is No-No except where urgently required to save life and then a leaded protective covering should be used to shield the pregnant part. Also avoid MRI, because the tremendous magnetic field increase may affect neurological development of the fetus. And do not forget: the video screen (TV, computer monitor) gives off small radiation so if you must watch, limit your watching time and do not get close-up.
   No pill, shot, spray should be taken unless urgently needed for medical reason. Avoid high intake of vitamins A or D as well as mineral supplements in first trimester; these have caused fetal malformation.

Second trimester is day 92 – 182, a time of rapid fetal growth when good nutrition is important. It is a pleasant part of pregnancy: discomforting symptoms go away, miscarriage worries fade and appetite improves. At 13 weeks weight gain starts; at 16 weeks, the pregnant abdomen shows; and at 20, a fetus begins to kick.

Third trimester is from day 183; a time of careful, watchful waiting because fetus could be kept alive if born. Close monitoring becomes important. Renal and cardiovascular complications rise as increasing blood volume stresses heart and kidneys.

The key to getting a good baby is healthy eating. Pregnancy is no time to worry about one’s figure or cholesterol. Eat well and gain healthy weight. Food should include daily good body-builder (a vegetarian needs iron, vitamin B12, and folic acid supplement, with egg for good protein and carbohydrate for calorie) and calcium and phosphorus in milk. And have green leafy vegetable for B vitamins especially folic acid, and carrot for vitamins A (but do not take vitamin A pills) and C for anti-oxudant effect. Fatty meat should be avoided and chicken skin removed before eating. Salt shaker, or adding salt to cook, and salty food are No-No. Also keep in mind that ketchup and all stimulating sauce, soda and regular milk, dairy, and processed and frozen food are high in salt; so select low-sodium food in market and avoid spicy processed food.
   And more about folic acid: A whole series of malformations of the newborn brain and spine are caused by minimal lack of folic acid and vitamin B12. Therefore every woman who is planning a pregnancy should start folic acid and vitamin B12 supplements before she gets pregnant or, if she has not, at the least, immediately on discovering her pregnancy.
   Each morning a liter of water and a serving of un-spiced or un-sugared high bran cereal with low-sodium milk helps easy stools.(But keep in mind, if you take daily calcium pills your stool will somewhat concretize into firm round balls which are easy for your digital removal from rectum but hard to expel naturally) In pregnancy, frequent small snacks may be most tolerable. Pregnancy slows stomach emptying and the enlarging uterus reduces abdomen capacity. Also the gastro-esophageal sphincter relaxes, leading to stomach acid reflux into esophagus with heartburn.
   Do not have cigarette (and stay far from the smoke of others), alcohol or recreational drug during pregnancy. Also no coffee. (Tea, or simply hot water, is good substitute for coffee) Studies show risk of fetus abnormality.
   A prenatal vitamin and mineral daily tablet should start at 13 weeks. For folic acid supplements the U.S. CDC has advised all women capable of becoming pregnant to eat at least 0.5 mg folic acid (folate) a day as soon as one plans or discovers one's pregnancy in order to prevent spina bifida and related abnormality in newborn. In addition to supplement (usually comes as 5 mg tablet) it is in green leafy vegetable.

Sexuality: The potential of trauma and infection from coitus and the decrease of placental blood supply to fetus during a pregnant woman's orgasm make advice for no sexual stimulation as soon as pregnancy is diagnosed and until after birth trauma heals.

Exercise and Relax: Artificial exercise serves no purpose when pregnant and draws away calories needed by the fetus. Normal chore is well tolerated and healthful until third trimester; then gradually reduce it and start quiet, meditative existence, with home chore taken over by mate or helper. The pregnant person should take mid-morning and afternoon rest, lying obliquely on right side in semi-dark room, with humble, peaceful thoughts. The tranquil interlude is an oasis from damaging effect of stress, for resting the over strained maternal heart and for improving the circulation of blood in placenta to the fetus.

Transportation: Ideally, the pregnant person should not travel because of accident, local air pollution, risk of viral infection from re-circulated air in jet, and increased radiation of high flying. The importance of altitude is shown by low birth weight and greater premature birth in Denver Colorado compared to sea level. Also to consider are the increased cosmic and UV radiation in high altitude and the x-ray airport search.

Prenatal Care and Self Monitoring should be to discover serious abnormality in fetus at a time the pregnancy can be terminated safely, and to detect and treat pregnancy complication before it harms mother or fetus, and to monitor growth and development of fetus in order to prevent stillbirth at a time when the endangered fetus can be removed safely from uterus and healthily survive. The prenatal caretaker should be able to arrange for necessary test and interpret result, able to do physical exam skillfully, should have access to UltraSound and be knowledgeable enough to know when to refer the pregnant person to a specialist who can expertly accomplish an amniocentesis, and can induced labor or cut a cesarean. The pregnant person herself can do most monitoring – regular observation on the course of pregnancy – which includes basal body weight (BBW), basal blood pressure and heart rate, urine protein and sugar test, fetal kick count per hour (FKH), fetal heart rate FHR, and measurements of increasing height of top of uterus above pubic bone.

BBW: Record body wake-up morning weight after emptying bladder, trying to empty rectum, and before food and drink. Normal pregnancy weight gain is 10 to 12 kg (22 – 26 lbs) almost all gained after the 1st trimester at average 0.4 kg (1 lb) a week. Between 13 and 37 weeks a gain of less than 1 kg (2 lb) a month is sign of poor eating or illness. Explosive weight gain (>2 kg or >4½ lb a wk) may be sign of pregnancy toxemia.

Basal Blood Pressure and Resting Heart Rate: Electronic digital BP and HR are convenient. Measurements should be made in bed or sitting quietly and recorded and be sure the measuring elastic cuff is at level of the heart. It is most healthy to enter pregnancy with BP lower than 120/75. At mid-pregnancy it may drop as low as 90/60, and as birth approaches rise back. A higher than 120/75 before 24th week suggests essential hypertension and the failure to drop to usual mid-pregnancy low or an elevation higher than 120/75 after 24th week may be a sign of toxemia of pregnancy. The Resting Heart Rate should normally not go above a weekly average 85 to 90 bpm (beats per minute). Higher suggests anemia, heart failure, hyperthyroidism or anxiety.

Urine Dipstick Testing for Protein (Albumin) and Sugar (Glucose) should be done weekly (if abnormal, every day) on 1st morning urine. A repeat finding 1+ protein suggests kidney disease or toxemia. Glucose in urine warns of pregnancy diabetes, and discovering it early may prevent stillbirth or predict a big baby birth complication of undetected pregnancy diabetes.

Height of top of uterus above top edge pubic bone  A measuring tape is applied mid line over pregnant abdominal curvature from center of top edge of pubic bone to top of uterus. (The point at upper body part of pregnant uterus where curvature tangents; the measure tape should gently press into abdomen skin) Measurement should be made just after bladder is emptied and before eating, by measuring tape applied to abdomen so that its markings are away from view. Between 20 and 34 weeks this measure in centimeters (cm) should roughly correspond to pregnancy week number. Three measures are made a week and averaged. Plus or minus 2 cm above the number of the pregnancy week is an indication for ultrasound check of the fetus. An average that is 2 cm less than the week number suggests small-for-dates fetus. Also it suggests oligohydramnios, an abnormally small volume of amniotic fluid almost always associated with severe fetal malformation.

Fetal Heart Rate: Normal range of FHR is 120 – 160/min. FHR below 120 or above 160 suggests fetal distress, and the more extreme the number and the longer it lasts, the more serious the distress. It should be brought to attention of midwife or the obstetrician immediately and treated by pure oxygen by mask or in nasal cannula. Best way to monitor FHR is by hand-held portable FHR monitor that is pressed against pregnant belly and can pick up fetal heartbeat early as 20 weeks. Monitoring FHR, one may mistakenly confuse it one’s own heartbeat, which should be between 70 and 100 bpm and will be synchronous with one’s wrist pulse.

Fetal Kick Count: A pregnant woman becomes aware of fetal kicks between 16 and 20 weeks (In first pregnancy it starts later than in later pregnancy). My FKC research showed weekly average FKC between 50 and 100 per hour is good predictor of baby that will show normal neuromuscular development. If one follows FKC in pregnancy, a normal fetus will be noted to start at low edge of that range in the first week (16th to 20th) that FKC can be noted, will be seen to peak at 34 weeks pregnancy, and then to drop back toward lower level after 37 weeks.
In one of my patients who had a baby that subsequently showed infantile hypotonia, the FKC weekly average ranged from 9 to 49 per hr and mother’s first perception of fetal kick was delayed to 23 weeks. This child could neither walk nor crawl at one year.
   All FKC referred to are weekly average per hour and based on personal research with several pregnant women. The FKC should be done after supper by an observant resting pregnant woman in reclining position and daily hour count averaged during 1 week.
   The pregnant should do FKC monitoring as follows: Start on 1st day of 16th week. Each day after supper (fetal movement most active after meal) lie down in quiet room, set timer for 1 hour and count by mark on paper all discrete fetal kicks perceived in the 60 min. At end of the week get daily FKC average of 7-day data and mark on weekly graph.

Monitoring that can’t be done at home: Ultrasound (US) gives image of uterus with pregnancy. Multiple pregnancy can be seen before 6 weeks, fetal heart can be detected by 6 weeks, and fetal sex may be determined by specialist as early as 12 weeks. Many malformations can be picked up in 1st trimester.
   In 3rd trimester, the US is used to monitor fetal development, maturity, size of parts, especially head, and to determine when time is ripe for birth in a case that needs planned induction of labor or cesarean section. The US scan has no side effect on mother or fetus. In early pregnancy, expert US should include both abdominal and inside-vagina scan. Routine office visit US gives guide to fetal development and abnormality but cannot be expected to be very accurate. When accuracy is needed, a referral to expert radiology US scanning is a must. Much US prenatal diagnosis needs serial US scans (consecutive repeat scans extending weeks).

Amniocentesis and Chorionic Villi Sampling: Amnio for prenatal diagnosis and sex determination is done at 15 weeks because that is the earliest for success. Under US scan, a needle punctures belly below navel, into uterine pregnancy cavity and 25 ml amniotic fluid is drawn, spun down in centrifuge and the sediment with concentrated amniotic cells cultured, and within the week the cultured cells are examined and reported for chromosome analysis which reveals fetal sex and various chromosomal abnormalities foremost of which is Down syndrome. And chemical tests can be done for enzymes whose lack signifies genetic abnormality. Alternatively, chorionic villus sampling may be done by early very suction technique with care not to disrupt the pregnancy. Sample of lower segment chorion is removed and same tests done. Advantage of the sampling is it is done early (5 weeks). Disadvantage is miscarriage risk. 
  END CHAPTER. To read next now, click 8.35 Birthing the Best Baby

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