Patient and Family Education in Pregnancy

1
Patient and Family Education in Pregnancy

• Marzena Slater, MD
• PGY-3

2
Objectives

• To discuss the following in the context of
  patient education
• Guidelines for Exercise in Pregnancy
• Nutrition and Dietary changes in Pregnancy
• Discomforts and Physical Changes Commonly Found
  in Pregnancy Treatments available for each.

3
A Reminder Levels Of Evidence

• Level A Good scientific evidence suggests that
  the benefits of the clinical service
  substantially outweighs the potential risks.
  --consistent, good-quality patient-oriented
  evidence (i.e RCT)
• Level B At least fair scientific evidence
  suggests that the benefits of the clinical
  service outweighs the potential risks.
  --inconsistent or limited-quality
  patient-oriented evidence (i.e meta analysis)
• Level C At least fair scientific evidence
  suggests that there are benefits provided by the
  clinical service, but the balance between
  benefits and risks are too close for making
  general recommendations. --consensus,
  disease-oriented evidence (i.e usual practice,
  opinion, or case series)
• Level D At least fair scientific evidence
  suggests that the risks of the clinical service
  outweighs potential benefits. Clinicians should
  not routinely offer the service to asymptomatic
  patients.
• Level I Scientific evidence is lacking, of poor
  quality, or conflicting, such that the risk
  versus benefit balance cannot be assessed.
  Clinicians should help patients understand the
  uncertainty surrounding the clinical service.

4
Exercise in Pregnancy

• Physical activity is essential to the health of
  women in their childbearing years.
• Pregnancy is a normal condition for women, and
  exercise can be part of a normal pregnancy.
• The research studies dealing with exercise in
  pregnancy have shown no harmful effects to the
  mother and fetus.

5
Exercise in Pregnancy

• For most pregnant women,
• exercise is not only safe but also beneficial to
  the health of the mother and the infant.
• Pregnant women who exercise have
• reduced weight gain
• more rapid weight loss after pregnancy
• improved mood and sleep patterns
• Some studies have also shown faster labors and
  less need for induction with pitocin.

6
Exercise in Pregnancy

• Precautions that patients should take to ensure
  that their exercise program
• does not lead to pregnancy complications
• An exercise routine prior to the pregnancy should
  be able to be maintained to some extent
  throughout pregnancy.
• If patients are just starting an exercise
  program, they should start very slowly and be
  careful not to over exert themselves.
• Regular activity (ex. 3 times/week) is preferable
  to intermittent activity
• Special care should be taken to
• drink plenty of fluids
• wear comfortable clothing/shoes
• not to exercise in hot environments to prevent
  overheating dehydration.
• Weight training exercises should emphasize
  improving tone, especially in the upper body and
  abdominal area. Heavy lifting or lifting weight
  above the head and using weights that strain the
  lower back should be avoided.
• Pregnancy requires an additional 300 kcal/day,
  make sure your patients are getting adequate
  nutrition

7
Exercises Not Recommended

• Any type of exercise that has risks of
  fall/injury
• to the abdomen should be avoided.
• These include contact sports. (Level C evidence)
• Sports considered unsafe in pregnancy include
• Horseback riding
• Skiing/snowboarding
• Water Skiing
• Scuba diving (Level C)
• Kick boxing
• Soccer/basketball/baseball or any other contact
  sports where patient could collide with another
  player
• Cycling- other than a stationary bike
• During the second and third trimester patients
  should avoid exercises that involve laying flat
  on the back, since this decreases blood flow to
  the uterus and baby.
• In general counsel patients to stop exercising if
  they are fatigued and to not exercise to
  exhaustion. They should be able to talk while
  exercising.

8
When to avoid exercise during pregnancy

• High blood pressure/Pre-eclampsia
• Placenta Previa/Vaginal Bleeding
• Preterm labor or history of preterm labor
• Intrauterine Growth Restriction (IUGR)
• Twin pregnancy
• Heart Disease
• Other conditions
• Uncontrolled kidney disease
• Anemia
• Uncontrolled diabetes
• Thyroid disease
• Extreme obesity.

9
The Exercise Prescription
10
Nutrition and Dietary Changes in Pregnancy

• On average pregnant women should be eating 300
  calories more per day
• than usual.

11
Calcium

• 1200 mg of calcium is required-- an additional
  400 mg over non-pregnant amount.
• Three to four milk servings per day are
  sufficient to achieve this additional need.
• Sources of calcium other than milk include
  yogurt, cheese, ice cream, broccoli, spinach.

12
Iron

• Iron is needed in larger doses, especially in the
  later stages of pregnancy. In healthy, well
  nourished women, routine iron supplementation is
  not necessary.
• Select iron supplementation may be necessary
  depending on patients blood counts (Hb lt 10.5
  g/dL) . Some iron rich foods include iron
  fortified cereals, certain beans, red meats,
  spinach eggs.
• Educate patients that if they are started on an
  iron supplementation to not take it with milk,
  antacids, or anything containing calcium
  (including prenatal vitamins) since calcium
  blocks absorption of iron.
• Warn patients about constipation associated with
  iron use.

13
Folic Acid

• Women of reproductive age should take a
  multivitamin with 0.4 mg to 0.8 mg of folic acid
  before trying to conceive. This vitamin can be
  found in many food sources
• Dark, leafy green vegetables (spinach, collard,
  turnip green, romaine lettuce, broccoli,
  asparagus)
• Whole grain breads cereals
• Citrus fruits juices (strawberries, oranges)
• Dried peas beans (pinto, black, navy lima
  beans)

14
Foods To Avoid In Pregnancy

• Raw meat
• Uncooked seafood, beef or poultry should be
  avoided, because it may be contaminated with
  salmonella, E. coli and toxoplasmosis.
• Listeriosis
• Bacteria that can occur in un-pasteurized milk
  and soft cheese and prepared and uncooked meats,
  poultry, and shellfish. It can cause miscarriage.
  May be found in
• Deli Meat- Counsel patients that if they choose
  to eat deli meat, to buy it from a reputable
  source and eat within 48 hours of purchase. They
  may also consider heating it up in the microwave
  until it is steaming.
• Soft Cheeses- brie, feta, gorgonzola, Mexican
  style cheeses such as queso blancho and queso
  fresco. Soft non-imported cheeses made with
  pasteurized milk are safe to eat.
• Unpasteurized Milk
• Pate

15
Foods To Avoid In Pregnancy

• Fish
• Fish containing mercury-
• shark, swordfish, king mackerel, fresh tuna, sea
  bass, and tilefish. (Level B evidence)
• Canned tuna is safe, but patients should not eat
  more than 12 oz. in a week. Mercury consumed
  during pregnancy has been linked to developmental
  delays
• Fish exposed to Industrial Pollutants-
• Fish from contaminated lakes rivers that may be
  exposed to high levels of polychlorinated
  biphenyls.
• These fish include blue fish, striped bass,
  salmon, pike, trout walleye.
• This is regarding fish caught in local waters and
  not fish from local grocery store.
• Raw Shellfish- The majority of seafood related
  illnesses are caused by undercooked shellfish,
  which include oysters, clams mussels. They
  should be avoided in pregnancy.

16
Foods To Avoid In Pregnancy

• Caffeine
• There has been some controversy in linking
  maternal caffeine use and pregnancy
  complications, with some studies suggesting
  excess intake increasing the risk for
  miscarriage, low birth weight.
• General rules of thumb
• Counsel to avoid caffeine during the first
  trimester to reduce the likelihood of
  miscarriage.
• In later stages of pregnancy, caffeine should be
  limited to less than 300 mg/day (which is about 2
  beverages/day).
• Caffeine is a diuretic. Make sure your patients
  are drinking plenty of fluids.

17
Foods To Avoid In Pregnancy

• Alcohol
• Safe levels of alcohol in pregnancy have not been
  established.
• Counsel your patients to AVOID alcohol during
  pregnancy.
• Alcohol depletes the body of zinc and magnesium,
  which are necessary for fetal development.
• Alcohol consumption during pregnancy can lead to
  Fetal Alcohol Syndrome or other developmental
  disorders.
• Alcohol should continue to be avoided during
  breastfeeding.

18
Common Discomforts Of Pregnancy Treatments
19
A Word on Medications in Pregnancy

• Counsel patients that risks and benefits of any
  drug therapy taken during pregnancy should be
  discussed with physician.
• The effect a medication has on the fetus depends
  on the medicine itself and the trimester of
  pregnancy it is taken in
• First trimester- the period of greatest risk for
  the fetus. Up till 12 weeks is the period of
  organogenesis
• Second trimester- in general is the safest
  period to take medications. However, medications
  may still affect the fetal nervous system or the
  growth of the fetus, resulting in low birth
  weight.
• Third trimester- Medications taken during this
  time can stick around in the fetal bloodstream
  after birth, causing problems such as breathing
  difficulties.
• Clinical trials/actual studies on the safety of
  medications are rarely or never done on pregnant
  women, for obvious reasons Most medications are
  level C evidence

20
Nausea Vomiting

• Up to 70 of pregnancies. Usually begins
• early 6-8 weeks and continues up to 13-16 weeks.
• Caused by hormonal changes (higher level
• of circulating Estrogen) that decrease the
  motility
• of the intestines.
• Behavioral Rx
• Eating small, frequent meals, avoiding spicy and
  fried foods.
• A protein snack before bedtime and keeping dry
  crackers at the bedside to eat before rising in
  the morning.
• Medical Rx
• Vitamin B6 (100 mg twice a day)
• Doxylamine (Unisom), ½ tab at bedtime
  (Antihistamine) or Benadryl
• Emetrol liquid as directed
• Ginger (250mg cap po qid)
• If patient is unable to tolerate prenatal vitamin
  in the morning, they may try taking it in the
  evening or taking 2 chewable Flinstone vitamins
  daily
• Things we can perscribe
• Category B Meclizine, Reglan, Zofran
• Category C Phenergan, Compazine

21
Heartburn

• Delayed emptying from the stomach due to hormonal
  changes and pressure from an enlarging uterus
  commonly cause reflux in pregnancy.
• Behavioral Rx
• Eating smaller, more frequent meals and taking
  antacids.
• Avoiding spicy, fatty and gas producing foods,
  such as cabbage.
• Avoiding eating close to bedtime.
• Medical Rx
• Antacids are generally safe
• Gaviscon is safe to take as directed
• Tums, Maalox, Mylanta, Rolaids, Milk of Magnesia
  as directed for minor discomfort.
• Pepcid AC or over the counter Zantac are safe.
• Mylicon (simethicone) as directed for gas

22
Constipation

• Due to slowed motility of the
• gastrointestinal tract and growing size of
• the uterus.
• Behavioral Rx
• Increasing fluid intake (2 quarts/day), fiber
  intake.
• Regular exercise.
• Medical Rx
• 1st line
• Bulking agents- Fibercon, Benefiber, or
  Metamucil.
• Stool softeners - Colace as directed.
• 2nd line (Have patients consult you 1st)
• Stimulant laxatives - Senekot
• If no relief after the above measures, patients
  may try a glycerin suppository as directed
• If no relief after above, patients may use as
  Ducolax suppository as directed
• If no relief after above, patients may use Fleet
  enema as directed

23
Hemorrhoids/Varicose Veins

• Occur due to the pressure of the growing uterus
  as well as inactivity, prolonged standing and
  constipation.
• Behavioral Rx
• Avoid constipation with stool softeners and with
  increased fluid and fiber intake.
• Sitz baths- warm water for 20 minutes, 3-4 times
  per day
• Prevention of varicose veins from occurring by
  resting the feet up, wearing support hose and
  proper shoes.
• Increasing water and decreasing salt intake.
• Kegel exercises
• Medical Rx
• Anusol cream or Preparation H as directed
• Tucks pads as directed

24
Urinary frequency/incontinence

• Due to the growing uterus
• pushing down on the bladder.
• Incontinence is usually of the
• stress type- i.e. occurring with
• coughing, sneezing or laughing
• increases pressure on the bladder.
• Behavioral Rx
• Educate patients to continue to drink plenty of
  fluids during the day, less so at night.
• Educate patients regarding sxs of urinary tract
  infection.
• Symptoms of urinary incontinence can be improved
  by regular Kegel exercises

25
Round Ligament Pain

• Pain on the sides of the
• abdomen that can extend into the groin.
• Caused by stretching of the ligaments that
  support the uterus as the uterus grows.
• Behavioral Rx
• Applying heat, Tylenol and lying with a pillow
  between the knees at night.

26
Backache

• As the uterus enlarges during pregnancy, the
  center of gravity will be shifted, putting more
  strain on the lower back.
• It may be prevented by avoiding excessive weight
  gain, improving posture, proper bending with a
  straight back and wearing flat shoes.
• Behavioral Rx
• Tylenol as needed
• Heating pads
• At night sleeping with a pillow between the legs
  to improve hip/knee alignment.

27
Headaches

• Are common during pregnancy.
• May be related to tension, increased sinus
  congestion head colds/allergies, increased blood
  flow and nasal edema or high blood pressure.
• Women who suffer from headaches or migraines
  prior to pregnancy, will often find their
  headaches become more frequent severe while
  pregnant.
• Behavioral Rx
• Tylenol rest may help.

28
Pain (Ligament pain, Backaches, Headaches)

• Medical Rx
• Tylenol is safe in all three trimesters. Educate
  patients not exceed recommended doses.
• Aspirin is not acceptable.
• Advil, Motrin or Ibuprofen should be avoided,
  particularly in the third trimester.
• Codeine and hydrocodone
• Found in most narcotics
• Can affect the babys breathing if taken in the
  last trimester or during labor in large amounts.
• Chronic use may cause withdrawal symptoms in the
  newborn.
• In general try to avoid prescribing these
  medications if possible
• They may be taken for short periods of time to
  treat specific pain conditions in the second and
  third trimester.

29
Shortness of Breath

• Due to hormonal changes and upward pressure of
  the growing uterus.
• Behavioral Rx
• Sleeping with head elevated on pillows.
• Pacing self when it comes to daily activities.

30
Nasal Congestion

• Due to increased blood volume hormonal changes
  of pregnancy.
• Pre-existing allergies may make it worst.
• Behavioral Rx
• Using of a room humidifier.
• Saline nose drops
• Medical Rx
• Tylenol cold sinus, Sudafed (caution if high
  blood pressure) - may be taken in limited
  quantities for short amounts of time.
• Afrin and other nasal decongestants, such as
  phenylephrine are NOT acceptable should be
  avoided.

31
Colds, Cough Allergies- RX

• Behavioral Rx
• Educate patients to stay well hydrated, eat
  plenty of protein, and get extra rest
• Steam inhalation/humidifiers also help
• Have patients call you if Tempgt100.5
• Medical Rx
• Allergies
• Claritin or benadryl are safe.
• Nasal steroid sprays such as Flonase, with long
  term use can be absorbed in sufficient amounts to
  impair the growth of the fetus. They may be used
  short term
• Coughs
• Cough medicines often contain several
  ingredients- educate patients to check the safety
  of each one before use.
• Cough expectorants, such as guaifenesin, are safe
  to use.
• Educate patients to AVOID cough medicines
  containing iodine
• Cough suppressants, such as codeine or
  dextromethorphan, can be used in the second and
  third trimester for short periods of time.
  Educate patients to avoid them in the first
  trimester.
• Lozenges are the safest option.

32
Edema

• Swelling of the ankles and feet commonly occur
  during pregnancy due to decreased circulation and
  pressure from enlarging uterus.
• Behavioral RX
• Avoidance of sitting and standing for long
  periods of time
• Sleeping on side elevating the legs
• Increasing fluid intake, decreasing salt intake
  and wearing support stockings.

33
Skin changes

• Chloasma- Mask of pregnancy. Increased
  pigmentation over the face/neck. Hormonal-
  patients may try to avoid direct sun
  exposure/wear sun screen. Will fade after
  delivery.
• Areola- area around nipple becomes darker
• Linea Nigra- dark line between the belly button
  and pubic region. Normal in pregnancy. Will
  eventually fade after delivery.
• Stretch Marks- Develop over the abdomen, hips,
  and breasts in over 50 of pregnant women. They
  will fade in color after delivery.
• Behavioral Rx There are no proven methods for
  preventing stretch marks- likely genetically
  determined. Cocoa butter and vitamin E creams may
  help with the itching that often accompanies
  striae formation

34
Skin conditions (Eczema, dermatitis skin
allergies)

• Medical Rx
• Moisturizers and soothing products are completely
  safe and should be the first line rx.
• Steroid creams can be used in pregnancy, but
  should be avoided on large areas of skin, for
  long periods of time or under dressings since
  they can be absorbed into the bloodstream.

35
Recommended Vaccinations

• Flu vaccine.
• Tetanus vaccine if patient hasnt had one in gt 10
  years (Td not Tdap)
• NO LIVE VACCINES are allowed during and up to 3
  months before pregnancy.

36
REFERENCES

• Ratcliffe, S.D. et al Family Practice
  Obstetrics, 2nd ed.. PhiladelphiaHanley Belfus
  Inc. 2001
• Kirkham, C., Harris, S. Grzybowski, S.
  Evidence Based Prenatal Care Part 1. General
  Prenatal Care and counseling issues. American
  Family Physician, April 1, 2005.
• Kirkham, C., Harris, S. Grzybowski, S.
  Evidence Based Prenatal Care Part 2. Third
  Trimester Care and prevention of infectious
  diseases. American Family Physician, April 15,
  2005.
• Choby Pregnancy Care FP essentials 292. AAFP
  home study. September 2003.
• Lu, M.C. Recommendations for preconception care.
  American Family Physician, August 1, 2007
• Cunningham, G. et al Williams Obstetrics.
  McGraw-Hill Companies, March 2005.
• http//www.acog.org/publications/patient_education
  
• http//www.perinatology.com/Reference/RDApregnancy
  .htm