Perplexities of Pregnancy

There's a new baby boom in the United States. Last year more than 4 million babies were born, according to the U.S. Department of Vital Statistics.

Accompanying this steadily increasing birth rate (up 250,000 from 1985) is an abundance of continually updated information for mothers-to-be, on everything from nutrition to the use of aspirin. Keeping current with this information can often leave the expectant mother perplexed.

The ideal time to begin learning about pregnancy is before becoming pregnant. However, if this is not possible, once pregnant, a woman should consult a health-care professional trained in obstetrics.

HOME PREGNANCY TESTS

Many women use home pregnancy tests if they suspect they're pregnant. Regulated by the Food and Drug Administration, pregnancy tests have come far since the early to mid-1900's when toads, rats and rabbits were used in testing. Now, over-the-counter home pregnancy kits provide privacy and fast results, and can detect pregnancy as early as six days after conception, or one day after a missed menstrual period. This gives an early advantage for vital prenatal care.

All pregnancy tests are based on the presence of a hormone, human chorionic gonadotropin (HCG), that the pregnant woman produces after conception. The first self tests of the 1970's used ring, or "tube agglutination," tests consisting of prepackaged red blood cells to detect HCG in urine. A ring at the bottom of the tube indicated a positive result. Sensitive to movement and human error, ring tests are now rarely used.

Today's brands, such as e.p.t. and First Response, contain monoclonal antibodies that detect minute traces of HCG. These antibodies are molecules coated with a substance that bonds to the pregnancy hormone, if it's present, to produce either a positive or negative result. (Each test manufacturer uses a different "trade secret" chemical formula for the bonding substance.) The user collects urine and combines it with the antibodies provided in the package. The test is timed, and a color change indicates the result.

Although most manufacturers claim 99 percent accuracy in laboratory tests, inaccurate results may be more frequent in actual use, due to such factors as improper use of the test, using a product past its expiration date, exposure of the test to the sun, and cancers. The procedures outlined in the instructions must be followed exactly for results to be accurate.

Whitehall Laboratories markets the newest one-step brand, Clearblue Easy. It gives results in three minutes and informs the user when the test hasn't been done properly. This new testing method, called rapid assay delivery system, combines a biochemical process with monoclonal antibodies in one pen-like instrument.

Whatever the result or the brand used, most manufacturers recommend repeating the process a few days later to confirm the results. After conception, a woman produces a minimal amount of HCG. The strength of each test varies, and although a woman may be pregnant, the test may not pick up the amount of HCG hormone present the first time.

NUTRITION AND SUPPLEMENTS

Even before pregnancy begins, nutrition is a primary factor in the health of mother and baby. A well-balanced diet before conception contributes to a healthy pregnancy and will probably need few changes.

According to the American College of Obstetricians and Gynecologists, pregnant women should increase their usual servings of a variety of foods from the four basic food groups to include a total of four or more servings of fruits and vegetables, four or more servings of whole-grain or enriched bread and cereal, four or more servings of milk and milk products, and three or more servings of meat, poultry, fish, eggs, nuts, and dried beans and peas.

These additional servings will help meet the recommended daily allowances (RDAs) of nutrients required to maintain good health. These RDAs from the National Research Council were updated in 1989. The accompanying chart outlines the requirements of vitamins and minerals during pregnancy.

Often, nutritional supplements are provided for pregnant women, but according to a June 1990 report released by the Institute of Medicine (IOM) studies found these supplements to be of little or no value. Most physicians agree that RDAs, except those for iron, can be obtained through a proper diet. Check with your physician for latest information.

Iron is needed in larger doses, especially in the later stages of pregnancy, and cannot be met by diet alone, according to the National Research Council. This mineral is essential to the formation of healthy red blood cells, and it is difficult for a woman to consume enough of it from foods to maintain an adequate supply for herself and her fetus. Without enough iron, the fetus will draw its supply from the mother, often leaving her anemic and exhausted. An iron supplement can alleviate this condition.

In certain studies, the vitamin folacin has been shown to be important in preventing neural tube defects, such as spina bifida. The need for folacin is essential to the formation of red blood cells. For more information on folacin see this article: How Folate Can Help Prevent Birth Defects

Other research questions whether there may be some benefit from multivitamins in preventing neural tube defects. The U.S. Centers for Disease Control reported a study of women who took multivitamin pills three months before and three months after conception. Researchers found a slightly higher incidence of birth defects in babies of women who were not multivitamin users. However, it is unclear whether the increase of defects was due to a lack of vitamins or to other factors that were not measured.

Although some subsequent studies showed that taking a daily multivitamin helped decrease birth defects, other studies showed multivitamin intake had no relationship to the incidence of birth defects. However, it is known that very high intakes of vitamins, such as vitamin A, may increase the occurrence of birth defects.

While research continues, the IOM recommends supplements only for pregnant women who are smokers, drug users, alcohol drinkers, or strict vegetarians. Obstetricians will continue to make the decision to recommend supplements based on individual requirements and will not recommend multivitamin supplements without a specific medical reason.

WHAT ABOUT WEIGHT GAIN?

Thirty years ago, the National Research Council's Food and Nutrition Board advised women to gain 20 to 25 pounds during pregnancy. Studies have since shown that underweight women, or those who gain fewer than 20 pounds during pregnancy, are at an increased risk of delivering low-birth-weight babies. Based on a 1990 study, IOM now recommends a weight gain of 25 to 35 pounds during a normal pregnancy to decrease this risk. Adolescents and black women, who often have smaller babies, are now strongly advised to gain a greater amount. Check with your physician for latest information.

The recommended increase in weight gain does not give a green light for mothers-to-be to overeat. Although the extra nutrients are required, an increase of only 300 calories per day is recommended. Weight gain during pregnancy should be gradual. The American College of Obstetricians and Gynecologists recommends 3 to 4 pounds in the first three months and 3 to 4 pounds per month during the rest of the pregnancy. Approximately 6 to 8 pounds of the total weight is the baby, and the remaining weight consists of an increased fluid volume, larger breasts and uterus, amniotic fluid, and placenta.

Contrary to popular belief, sodium, which helps to regulate water in the body, is needed in larger quantities during pregnancy. Larger than normal amounts of this electrolyte are needed because of increased fluid volume in the mother, the requirements of the fetus, and the level of sodium in the amniotic fluid. For those who do not have high blood pressure, salt restriction is not recommended. Those with medical problems that require salt restriction should consult their physicians. Trace minerals, such as iodine, usually needed in small amounts, are needed in greater quantities during pregnancy. Iodine can be obtained in iodized salt and spinach.

IS CAFFEINE OKAY?

Caffeine--a stimulant found in colas, coffee, tea, soft candies, chocolate, cocoa, and over-the-counter and prescription drugs--has been a controversial topic in pregnancy nutrition for more than a decade. A 1980 study by FDA found that caffeine, when fed to pregnant rats, caused birth defects and delayed skeletal development in their offspring. At that time, although the human implications were unknown, FDA advised pregnant women to eliminate caffeine from their diets.

Since then, more studies have been done to determine the effects of caffeine on the fetus. A study of women in Costa Rica, where coffee consumption is high, showed a significantly lower birth weight for infants and a lower concentration of iron in mothers who were coffee drinkers. This report indicated that maternal coffee intake may also contribute to maternal and infant anemia.

Consumed in large quantities, caffeine can cause irritability, nervousness and insomnia. In addition to crossing the placenta and affecting the fetus, it is also a diuretic, dehydrating the mother's body of valuable water. After the baby is born, caffeine can also be transmitted through breast milk.

As mentioned, caffeine is an ingredient in some over-the-counter (OTC) and prescription drugs. Before taking any drugs, a pregnant woman should consult her physician.

DECIDING ABOUT DRUGS

Drugs may pose dangers to the embryo or fetus throughout pregnancy, but they are especially of concern during the first trimester, when the vital organs and systems are developing, and the last trimester, when excessive bleeding can occur during labor.

According to the New England Journal of Medicine, an estimated 10 to 45 percent of pregnant women in the first trimester, unaware of their condition, reach for the most common OTC drug, aspirin. Aspirin and other drugs containing salicylate are not recommended throughout pregnancy, especially during the last three months, except under a doctor's supervision. Acetylsalicylate, a common ingredient in many OTC painkillers, may prolong pregnancy and cause excessive bleeding before and after delivery.

Overall, according to Debbie Limkins of FDA's division of OTC drug evaluation, most other OTC drugs can be used during pregnancy with the supervision of a physician. Although scientists do not know the effects on the fetus of all OTC and prescriptions drugs, some are known to cause birth defects and should be avoided.

Since 1984, all OTC drug products have carried the following warning: "As with any other drug, if you are pregnant or nursing, seek the advice of a health professional before using this product." In July 1990, FDA issued a regulation requiring all oral and rectal nonprescription aspirin and drugs that contain aspirin to include the additional warning "It is especially important not to use aspirin during the last three months of pregnancy unless specifically directed to do so by a doctor because it may cause problems in the unborn child or complications during delivery."

One drug that can cause severe birth defects is Accutane, or isotretinoin. Accutane, a derivative of vitamin A, is a powerful prescription drug that can clear severe cystic acne, but can cause birth defects (such as heart defects, small jaw, cleft palate, and skull and facial disfigurements) in about 1 out of every 4 exposed fetuses. Accutane can also cause miscarriages.

Since its approval, Accutane has been labeled as being in pregnancy category X, meaning it should not be used during pregnancy. However, due to persistent reports of birth defects associated with the use of the drug in 1988, the manufacturer, Hoffman-La Roche, began including additional patient information in the packaging, including a drawing of a baby with birth defects associated with the drug. Before being permitted to take Accutane, a woman of childbearing age must sign a consent form stating that she has been fully informed of the drug's side effects. (See "Acne: Taming That Age-Old Adolescent Affliction" in the October 1990 FDA Consumer.)

Another derivative of vitamin A, etretinate (or Tegison), was approved in the mid-1980's to treat psoriasis. This drug is also forbidden for use by women who are pregnant or who are likely to become pregnant either while taking it or for a certain period after they have stopped taking it.

A Nonalcoholic Toast

While pregnancy is a time for celebration, toasting with champagne, a few beers, or any alcoholic beverage is not healthy for the fetus or the mother-to-be. Alcohol can cross the placenta and in the case of heavy drinking (at least four standard drinks per day) can cause a condition known as "fetal alcohol syndrome," or FAS.

The American College of Obstetricians and Gynecologists describes babies with FAS as being shorter and lighter in weight and having the following characteristics:

• smaller heads
• abnormal features of the face, head, joints and limbs
• heart defects
• poor control of movements.

• Mental retardation is common, as is hyperactivity, extreme nervousness, and poor attention span.

According to a report, "Alcohol and Health," released by the Department of Health and Human Services in January 1990, some studies suggest that the more alcohol a mother drinks during pregnancy, the greater the danger to the fetus, especially in the first trimester. Because it's difficult to determine how much alcohol puts a fetus at risk and at what stages of pregnancy the fetus is affected, it is not known whether drinking any amount of alcohol is safe. The safest course at present, therefore, is for pregnant women to abstain from drinking alcoholic beverages.

Safety of Tests

X-rays may pose dangers to the fetus. While x-ray examinations of the teeth or extremities do not generally expose the fetus to significant levels of radiation, x-rays of the abdomen, lower back, or hip areas place the fetus in the direct x-ray beam and can be hazardous. It is particularly important for a pregnant woman--or a woman who thinks she may be pregnant--to inform the doctor or technician before having an x-ray performed on these body areas.

Certain tests are routinely done to check the well-being of the fetus during pregnancy and labor. The most common of these, ultrasound, uses sound waves that bounce off internal organs to project images of the organs and the fetus on scanners. There have been no reports of harmful effects associated with ultrasound, which has been used for more than 20 years. Ultrasound does not use radiation, drugs, dyes or chemicals and is beneficial in providing valuable information. For example, it can reveal the number of fetuses and age, size, fetal position, some birth defects, and other information vital to the health care of the pregnant woman and her baby.

There are three types of ultrasound, each used during pregnancy for different purposes. The most common is real-time ultrasound, which takes still pictures in rapid succession and detects the heart-beat, placenta, movement of the arms and legs, and the number and position of the fetus(es).

The second is the Doppler ultrasound, used before and during labor to provide electrical signals that are converted to audible signals of the fetal heartbeat. The third, vaginal ultrasound, can help diagnose the cause of bleeding and pain or an ectopic pregnancy, in which the fertilized egg grows outside the uterus. It can also detect some birth defects early in the pregnancy.

Prenatal care is vital to the health of both mother and baby. Mothers-to-be will find it worthwhile to educate themselves about all aspects of pregnancy and consult an obstetrics specialist to guide them through a successful pregnancy.

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