4. Counselling of the Pregnant Woman

Question 1

Canada’s Food Guide to Healthy Eating suggests what? (3)

Answer 1

• eating a varied diet with plenty of vegetables and fruits, whole grains, dairy products, and lean meats or plant proteins
• caloric increase of ~100 kCal/d in the T1, ~300 kCal/d in the T2 and T3, and ~450 kCal/d during lactation (less if BMI >25)
• daily multivitamin with folic acid should be continued during pregnancy

Question 2

Name: Nutrients in Pregnancy (5)

Answer 2

• folate: 0.4-1 mg/d for first 12 wk (5 mg/d if high risk)
  
  • supports increase in blood volume, growth of maternal and fetal tissue, and decrease in incidence of NTD
  • foods rich in folic acid include: spinach, lentils, chick peas, asparagus, broccoli, peas, brussels sprouts, corn, and oranges
• calcium: 1200-1500 mg/d
  
  • maintains integrity of maternal bones, skeletal development of fetus, and breast milk production
• vitamin D: 1000 IU
  
  • promotes calcium absorption
• iron: 0.8 mg/d in T1, 4-5 mg/d in T2, and >6 mg/d in T3
  
  • supports maternal increase in blood cell mass, supports fetal and placental tissue
  • required amounts exceed normal body stores and typical intake, and therefore need supplemental iron
  • iron is the only known nutrient for which requirements during pregnancy cannot be met by diet alone
• essential fatty acids – supports fetal neural and visual development
  
  • contained in vegetable oils, margarines, peanuts, and fatty fish

Question 3

Describe caffeine in pregnancy (4)

Answer 3

• diuretic and stimulant that readily crosses placenta
• less than 300 mg/d is considered safe
• relationship between caffeine and intrauterine growth restriction IUGR is unknown (ACOG)
• SOGC states 1-2 cups/d are safe during pregnancy

Question 4

Describe use of Herbal Teas and Preparations during pregnancy (4)

Answer 4

• not enough scientific information about safety of various herbs and herbal products to recommend their use during pregnancy
• some herbal teas can have toxic or pharmacological effects on the mother or fetus
• raspberry leaf tea often used at term to promote labour
• herbal teas considered safe in moderation (2-3 cups/d): citrus peel, ginger, lemon balm, linden flower (unless cardiac condition), orange peel, and rose hip

Question 5

Name microorganisms that are a concern during pregnancy

Answer 5

• listeriosis (Listeria monocytogenes)
• toxoplasmosis (Toxoplasma gondii)

Question 6

What food to avoid in pregnancy to avoid Foodborne Illnesses (4)

Answer 6

• avoid consumption of raw meats and fish, raw hotdogs, raw eggs, raw sprouts (especially alfalfa), and unpasteurized dairy products or juices
• avoid unpasteurized soft cheeses, deli meats, smoked salmon, and pâtés as they may be sources of Listeria
• current guideline for mercury of 0.5 ppm in fish is not considered harmful for the general population, including pregnant women
• Health Canada advises pregnant women to limit consumption of top predator fish such as shark, swordfish, king mackerel, and tilefish

Question 7

Describe exercise during pregnancy (2)

Answer 7

• exercise under physician guidance;
• “talk test” = should be able to speak while exercising

Question 8

Avoid supine position when?

Answer 8

after 20 wk GA

Question 9

Name absolute contraindications for exercise while pregnant? (12)

Answer 9

• ruptured membranes
• preterm labour
• hypertensive disorders of pregnancy
• incompetent cervix
• IUGR
• multiple gestations (>3)
• placenta previa after 28 wk
• persistent T2 or T3 bleeding
• uncontrolled type I DM
• uncontrolled thyroid disease
• serious cardiovascular or respiratory disease
• and other systemic disorders

Question 10

Name relative contraindications of exercise while pregnant (10)

Answer 10

• r
• recurrent pregnancy loss
• gestational hypertension
• history of spontaneous preterm birth
• mild/ moderate cardiovascular or respiratory disease
• symptomatic anemia
• malnutrition
• eating disorder
• twin pregnancy after 28 wk
• and other significant medical conditions

Question 11

Describe: Weight Gain in Pregnancy

Answer 11

Question 12

Strenuous work, extended hours and shift work during pregnancy may be associated with what? (3)

Answer 12

• greater risk of low birth weight
• prematurity
• spontaneous abortion

Question 13

Describe sexual intercourse while pregnant (2)

Answer 13

• may continue, except in patients at risk for: abortion, preterm labour, or placenta previa
• breast stimulation may induce uterine activity, and is discouraged in high-risk patients near term

Question 14

Smoking increases the risk of what? (5)

Answer 14

• decreased birth weight
• placenta previa/abruption
• spontaneous abortion
• preterm labour
• stillbirth

Question 15

When is alcohol safe in pregnancy? (3)

Answer 15

• no amount of alcohol is safe in pregnancy
• encourage abstinence from alcohol during pregnancy
• alcohol increases incidence of abortion, stillbirth, and congenital anomalies
  
  • fetal alcohol syndrome

Question 16

Name risks of cocaine while pregnant? (4)

Answer 16

• microcephaly
• growth retardation
• prematurity
• abruptio placentae

Question 17

Name risks of marijuana while pregnant? (1)

Answer 17

smoking associated with low birth weight infants

Question 18

Which analgesics for pregnancy? (1)

Answer 18

• acetaminophen preferable to ASA or ibuprofen

Question 19

Describe safety of immunization of intrapartum (4)

Answer 19

• administration is dependent on the risk of infection vs. risk of immunization complications
• safe: tetanus toxoid, diphtheria, influenza, hepatitis B, and pertussis
• avoid live vaccines (risk of placental and fetal infection): polio, measles/mumps/rubella, and varicella
• contraindicated: oral typhoid

Question 20

What does the Public Health Agency of Canada recommend for vaccination in pregnant women? (2)

Answer 20

• all pregnant women receive the influenza vaccine
• all pregnant women should be given Tdap every pregnancy irrespective of immunization history ideally between 27-32 weeks but can be given at 13-26 weeks if high risk of preterm labour. If Tdap was given in T1 (i.e. prior to pregnancy recognition), it does not need to be repeated

Question 21

Describe vaccines post-partum (3)

Answer 21

• rubella vaccine for all non-immune mothers. If they have had an adult booster and remain non- immune, they should not be revaccinated and pregnancy should be deferred for at least 1 mo following vaccination
• hepatitis B vaccine should be given to infant within 12 h of birth if maternal status unknown or positive
  
  • follow-up doses at 1 and 6 mo
• any vaccine required/recommended is generally safe postpartum

Question 22

Describe safety of radiation in pregnancy (4)

Answer 22

• ionizing radiation exposure is considered teratogenic at high doses
  
  • if indicated for maternal health, should be done
• imaging not involving direct abdominal/pelvic high dosage radiation is not associated with adverse effects
  
  • higher dosage to fetus: plain x-ray of lumbar spine/abdomen/pelvis, barium enema, CT abdomen/ pelvis/lumbar spine
• radioactive isotopes of iodine are contraindicated
• no known adverse effects from U/S or MRI (long-term effects of gadolinium unknown, avoid if possible)

Question 23

Name necessary amount of radiation to cause miscarriage (1)

Answer 23

>5 cGy

Question 24

Name necessary amount of radiation to cause malformations (1)

Answer 24

>20-30 cGy