Patient Info

MORNING SICKNESS

Nausea and vomiting occurs commonly in the first trimester of pregnancy. It often occurs on an empty stomach and when your blood sugar levels are low. Tiredness can also exacerbate the symptoms. 

Some simple suggestions to help manage the symptoms:

• simple lifestyle changes such as avoiding any activities that make the nausea / vomiting worse (eg. cooking meat)
• try not to get overtired as the nausea is much worse then...curtail your activities where possible, earlier bedtimes and plan to do less on weekends
• eat small meals frequently (rather than 3 big meals) to keep your blood sugar level constant, remember that hunger pangs can also bring on the nausea
• eat what you can manage...don’t stress about the nutritional content of what you eat in the short term as most women have sufficient stores to see you through the first trimester
• concentrate on fluids and try to maintain an adequate fluid intake daily as dehydration can make the symptoms worse...take sips of fluid every 10-15 minutes or sucking ice-cubes / icy-poles may be better if you can’t tolerate drinking fluids easily, remember that water is not the only fluid...take fruit juice, sports drinks, flat lemonade / soda water
• ginger can be taken in any form (tablets, flat ginger ale, tea, ginger lollies) ...some women find them to be helpful and it’s worth a try (as long as you don’t hate ginger) 
• Vitamin B6 (Pyridoxine) supplements can be helpful in some women...25 mg tablets can be taken up to 3 times a day
• if these simple remedies are insufficient to control the symptoms, a variety of medication which is safe to be taken in pregnancy can be prescribed :
• eg. Maxolon - simple anti-nausea medication which can be taken 3 times  a day
• Zofran (Ondansetron) - anti-nausea medication, more effective than Maxolon but more expensive
• Sedating anti-histamines
• Corticosteroids

If you are unable to keep down any fluids and vomiting persists, please contact the rooms and we may need to admit you as a day patient for intravenous hydration and anti-nausea medication. This can also be repeated as often as you like if it makes you feel better.

It is important to keep in mind that morning sickness usually settles by 12-14 weeks gestation and is self-limiting.

GESTATIONAL DIABETES

Gestational Diabetes (GDM) is a condition where high blood sugars (also known as hyperglycaemia) is first diagnosed in pregnancy. It occurs in up to 10% of pregnant women  and is commonly diagnosed in the second trimester of pregnancy. This is due to an increase in pregnancy related hormones occurring around this time to help with the growth of the baby. This increase in the hormone levels can interfere with glucose metabolism in the mother and leads to gestational diabetes. Gestational diabetes usually goes away after the birth of the baby when the hormone levels return to non-pregnant levels.

As such, all pregnant women are screened for gestational diabetes during the second trimester of pregnancy. Screening for gestational diabetes involves taking a fasting blood test, then the ingestion of a sweet sugary drink before having another blood test one hour after the drink and then another blood test taken 2 hours after the drink. This is called a Glucose Tolerance Test.

Who is at risk of developing gestational diabetes?

• women over 30 years of age
• family history of type 2 diabetes (also known as adult onset diabetes or NIDDM)
• being overweight or obesity
• indigenous Australians
• certain ethnic groups including Chinese, Indian, South East Asian, Middle Eastern, Polynesian/Melanesian and African women
• previous gestational diabetes
• women having twins or triplets
• history of Polycystic Ovarian Syndrome

Management of gestational diabetes is centred around maintaining as near to normal blood sugars as possible. This is achieved by healthy eating (low GI foods and adjusting portion sizes), increased physical activity and then regular blood glucose monitoring to check blood sugar levels. Most women are able to maintain near normal blood sugar levels with these modifications alone, but if the blood sugar levels are persistently elevated, then a low dose of insulin may be required. The management and treatment of gestational diabetes is a team effort, involving you and your partner, the obstetrician, the diabetic educator and dietitian, as well as an endocrinologist if insulin is required.

The risks of poorly controlled gestational diabetes to the baby include excessive birth weight, pre-term birth and respiratory distress syndrome, low blood sugars after birth and the long term risk of developing type 2 diabetes, high blood pressure and obesity. A mother with poorly controlled gestational diabetes is also at higher risk of developing high blood pressure and pre-eclampsia in the pregnancy, as well as being more likely to need induction of labour or have a caesarean section. In later life, women who have had gestational diabetes are 50% more likely to develop type 2 diabetes. The good news however, is that if gestational diabetes is well managed, then the risks to both mother and baby are greatly reduced.

DIET IN PREGNANCY

It is recommended that pregnant women should have a broad diet covering the five main food groups. Multivitamins are not strictly necessary in pregnancy if you have a healthy diet covering the five main food groups. There are however several exceptions to this.

Folate is essential for the development of the baby’s brain and nervous system. Many modern diets do not contain adequate folate and as such folate supplementation is recommended to all pregnant women. Anyone planning a pregnancy should commence folate supplements (500mcg or 0.5mg) daily for 3 months pre-conception if possible , and then to continue in the first 3 months of the pregnancy. This significantly reduces the risk of neural tube defects such as spina bifida. Some women may require a higher dose of folate. Women who have had a baby with a neural tube defect in the past or women with epilepsy and diabetes should take 5mg of folate daily instead.

Iron is an essential component of haemoglobin which is the oxygen-carrying component in red blood cells. A woman’s blood volume is increased in pregnancy as is the number of red blood cells, hence the need for increased iron requirement in pregnancy. In addition, the developing fetus draws iron from the mother to last it through the first five or six months after birth. As such, anaemia is a common nutritional problem in pregnancy resulting from a lack of iron in the face of the increased iron requirements.

It is important for women to eat iron-rich foods every day. Dietary sources of iron include:

• red meat (beef, lamb, pork)
• whole grain cereals and breads, green vegetables (eg. broccoli, asparagus, spinach)
• dried fruits, nuts and iron-enriched breakfast cereals

Iron absorption from these foods are improved when taken at the same time as Vitamin C. We need to be aware that large quantities of antacids can also interfere with iron absorption, as can unprocessed bran, tea/coffee and excessive dairy intake.

Recommended daily intake of iron:

• pregnancy (27mg / day)
• breastfeeding (18mg /day)

Iron deficiency in pregnancy is common in Australia as a mother’s iron stores becomes depleted. Anaemia can make you feel breathless and lethargic and cause you to have palpitations (a racing heart). As such, iron supplements may be needed by some women in pregnancy.

Iodine is an important mineral needed for the production of thyroid hormone, which is important for growth and development of the baby. It is also essential for the development of the baby’s brain and nervous system. Inadequate iodine intake during pregnancy increases the risk of mental impairment and cretinism in the newborn baby. 

Good sources of dietary iodine include:

• seafood and seaweed
• eggs, milk and dairy products

 In Australia, pregnant women have been found to have insufficient iodine in the diet. As pregnant and breastfeeding women have increased iodine requirements,  iodine supplementation of 150mcgs per day is recommended for women planning a pregnancy, throughout pregnancy and whilst breastfeeding.

Calcium is essential to keep bones healthy and strong. During the third trimester of pregnancy, your baby needs a large amount of calcium as they develop and strengthen their bones. Insufficient dietary calcium in pregnancy can lead to osteoporosis in later life as the calcium needed by the baby is drawn from your bones.

The recommended daily intake of calcium in pregnancy is 1000mg daily. Each serve of dairy contains approximately 300mgs of calcium (eg. a glass of milk, a slice of cheese, a tub of yoghurt).  

LISTERIA

Listeria Monocytogenes is a bacteria present in the environment (found within the soil and vegetation) which can infect humans if ingested in contaminated food.

Certain foods, including soft cheeses (eg.camembert, brie, ricotta, cream cheese), pates, coleslaw, chilled meats and seafood, soft serve ice-cream and any food that has been refridgerated for a length of time may contain Listeria.

Infection with Listeria is exceptionally rare but the complications are quite serious particularly in pregnant women. Listeria can lead to miscarriages, preterm labour and babies that are born unwell. You can reduce your risk of Listeria by avoiding these “high risk” foods during pregnancy.

Listeria is a rare condition, so don’t panic if you have already eaten something you shouldn’t have. If you continue to be well, it is unlikely to have caused any problems to the pregnancy.
Listeria is destroyed by high heat and all the above foods are safe to eat freshly cooked (for example on a pizza or in a pie).
Leftover food should be stored in a sealed container and reheated until they are piping hot throughout.
Freshly prepared salads, hard cheeses, yoghurt are safe to consume in pregnancy. 

WEIGHT GAIN IN PREGNANCY 

Steady weight gain during pregnancy is normal and important for the health of the mother and baby. However, it al also important not to gain too much weight. 

The average weight gain for a healthy woman in pregnancy is approximately 12 -16 kgs. Being too underweight or too overweight can both have negative effects on the pregnancy and birth of the baby. Underweight women may need to gain more weight (between 12.5 - 18 kgs). Dieting is not recommended in pregnancy if overweight but the weight gain is less (between 5-12 kgs). If overweight at the start of pregnancy, weight loss during the pregnancy is not shown to be harmful and leads to improved outcomes for both the mother and baby. A dietitian review can be organised to review and modify diet /activity levels appropriately to help achieve this.

When pregnant, a good approach is to eat to satisfy your appetite and continue to monitor your weight. To maintain appropriate weight gain during pregnancy, it is important to choose healthy foods from the five food groups, and limit discretionary foods and drinks high in saturated fats, added sugars and added salt.

Some tips for a healthy diet in pregnancy:

• avoid high GI foods (eg. rice, bread, potatoes, chips)
• low GI options are recommended where possible
• drink 2-3 litres of fluid daily (avoid fruit juices and drinks high in sugar)
• excessive caffeine intake is not recommended, limit to one coffee daily
• dietary intake of large deep sea fish (eg. tuna, flake) should be limited due to the mercury and lead content which can be accumulated
• foods more likely to be contaminated by the Listeria bacteria should also not be ingested (eg. soft cheeses, pate, deli meats, soft serve ice-cream)
• processed foods and foods high in saturated fats should also be limited
• moderate portion sizes recommended 

COLD and FLU SYMPTOMS

Cold and flu symptoms are commonly due to an upper respiratory viral infection. Panadol can be taken every 4-6 hours to reduce the fever and alleviate the muscular aches and pains. No aspirin or Nurofen should be taken and over the counter flu medication (eg. Codral) must be avoided. Cough medicines (eg. Durotuss or Benadryl) may be taken if necessary. Nasal sprays such as Rhinocort or Seratide may be used. If the symptoms persist and you are not getting better, see your GP and if antibiotics are prescribed...most antibiotics can be taken safely during pregnancy (after checking with your obstetrician first). 

TRAVEL IN PREGNANCY

In general, if your pregnancy has been uncomplicated, most airlines will allow you to fly until 34 weeks gestation for international travel and until 36 weeks for domestic travel. It is always advisable to check with each airline for their policy prior to booking a flight. You will likely also require a medical certificate be issued prior to your travel date to be carried by you throughout the trip. Travel insurance for emergencies is also recommended and it may not always be possible to obtain cover beyond a certain gestation for particular destinations.

Other general recommendations with travel include:

• increased fluid intake to maintain adequate hydration
• avoid alcohol and coffee
• walk around the plane every few hours to improve circulation and when in your seat, do the recommended exercises to move your calves/feet to prevent DVTs
• low dose aspirin (1/2 a tablet) can be taken on the day of travel 

CHICKEN POX IN PREGNANCY

Infection with chicken pox in pregnancy is unusual as many of us have either had chicken pox as a child or have been vaccinated against the chicken pox virus (also known as Varicella Zoster Virus).

Chicken pox is however an extremely contagious disease and can be spread by respiratory droplets before the breakout of the classic chicken pox rash. It is typically an itchy rash of small, red bumps on the face and trunk spreading to other parts of the body. Blisters then form over 2-4 days and will crust over within 6 days of the rash first appearing. Once the blisters of the chicken pox rash forms, it is also possible to be infected by contact with the fluid in the blisters. Associated with the rash is fever, and a runny nose and eyes which can precede the rash by a week. Varicella is infectious for 2 days prior to the onset of the rash and until the final sore has crusted over. 

In certain people, the Varicella virus can remain dormant in a nerve root and may later be reactivated and expressed as a patch of Shingles. This is as equally infectious as the primary rash. 

If you have had chicken pox in the past or have been vaccinated, you then have immunity to the virus and cannot get chicken pox again. It is possible to check whether someone is immune to chicken pox by looking for the antibodies against chicken pox in the blood. If you don’t have immunity against chicken pox, you can be given an injection of VZIG (Varicella Zoster Immunoglobulin) within 72 hours of exposure to chicken pox.

The effect of chicken pox on the fetus depends on which trimester of pregnancy the infection occurs in. Infection is more of a problem in early and late pregnancy. If the infection occurs in the first trimester, damage to the baby can result. The commonest problem seen in intrauterine infection is skin scarring. In rare cases, the baby can be left with limb, eye and brain abnormalities. This syndrome occurs in less than 1% of babies whose mothers are infected in the first trimester of pregnancy, usually between 8 to 12 weeks gestation. Once the baby’s organs are formed, infections are not commonly a problem, especially after 20 weeks gestation.

If a pregnant woman develops chicken pox in the last few weeks of pregnancy, the baby could be born with an acute chicken pox infection as the maternal antibodies have not had a chance to cross the placenta to help the fetus deal with the infection. This is uncommon but if the baby develops chicken pox at birth, it can be treated with acyclovir following delivery.

Chicken pox infection is also usually much worse in adults than in children. Adults can become extremely unwell with the infection, particularly pregnant women who have a lowered immunity. In severe cases, pneumonitis and/or hepatitis can occur necessitating admission to hospital or else it could prove to be fatal. This is why we are concerned about  women developing chicken pox in pregnancy.

WHOOPING COUGH AND PREGNANCY

Whooping cough is a highly contagious disease caused by the bacteria Bordetella Pertussis. It is spread by droplets from coughing and sneezing to almost a 100% of susceptible household contacts and to 50-80% of susceptible school contacts. Susceptible people are those who are either unvaccinated or have waning immunity since childhood vaccination. 

The symptoms of a whooping cough infection may vary for different ages but the first symptoms are usually similar to a cold. It can then lead to a prolonged illness with severe bouts of sudden attacks of repetitive coughing, followed by a characteristic “whoop” as the person gasps for breath. Vomitting can then follow a coughing spasm.

Whooping cough is highly infectious. A person with whooping cough is most infectious in the early stages of the illness when their symptoms are mild and the diagnosis not obvious. They can then be infectious for up to three weeks after they start coughing. The cough itself can then last for months.Whooping cough is particularly serious in infants under 12 months of age, while older children and adults usually have a milder disease.

The Victorian Government provides the whooping cough vaccine free to all pregnant mothers. Whooping cough is most severe in very young babies who do not have any immunity. Babies are at greatest risk of the serious complications of Whooping cough including brain damage and death. The main purpose of the vaccine is to reduce the possibility of you getting Whooping cough and pass it along to the baby. In addition, you can also pass on some of the antibodies in your blood stream to the newborn via the placenta to provide the newborn baby with some immunity for the first few weeks of life until the baby is vaccinated at 6-8 weeks of age. Immunity to Whooping cough develops about 2 weeks after the vaccination is given. As such, it is recommended that all pregnant mothers should be vaccinated after 30 weeks of pregnancy to allow for immunity to develop and the maternal antibodies to cross the placenta to protect the newborn infant after birth. The vaccine is safe in pregnancy and it is not possible to catch Whooping cough from the vaccine. There are also no known complications from the Whooping Cough vaccination for your baby.

Husbands, partners and family members who will be in regular contact with the newborn (eg. grandparents and extended family) should be immunised during the pregnancy period as well. If you have been vaccinated before, you may still need to be given another booster as the protection is not found to be life long and tends to wane after about 5-10 years. 

VITAMIN K

Vitamin K is necessary for blood clotting to occur properly. Vitamin K deficiency can result in excessive bleeding and bruising, and in the worse cases lead to bleeding in the brain (ie. a stroke). Newborn babies are born with very little Vitamin K. It takes a baby several months to build up the bacteria in their gut which produces the Vitamin K for them. As such, newborn babies are at risk of a bleeding disorder called Haemorrhagic Disease of the Newborn (HDN). Without treatment, HDN is estimated to occur in approximately 1% of newborn babies. Bleeding into the brain can lead to brain damage or even death.

HDN can be prevented by giving newborn babies an injection of Vitamin K into a baby’s thigh after birth. This single dose of Vitamin K will provide enough Vitamin K to help the baby’s blood clot for several months, by which time the infant would have developed enough of the gut bacteria to make an ongoing supply of Vitamin K. It is a safe and harmless way of preventing a potentially serious disease (HDN).

HEARTBURN IN PREGNANCY

Heartburn is a common problem in pregnancy. There are several reasons for this. The pregnancy hormones which maintain the pregnancy also work as a smooth muscle relaxant which relaxes the sphincter between the stomach and the oesophagus, leading to regurgitation of the stomach contents into the lower part of the oesophagus. This can cause a discomfort or burning sensation in the chest/upper abdomen. In the third trimester of pregnancy, as the baby and uterus grows, they can press on the stomach to displace it upwards and push the acid contents of the stomach into the oesophagus as well. This also causes heartburn and that is why the symptoms are usually worse in the last 2-3 months of pregnancy.

As such, try and adjust your diet and avoid foods that may trigger heartburn (eg. acidic or spicy food). Coffee has also been found to irritate the stomach making heartburn worse. Drink plenty of fluids in between meals rather than with your meals. As your stomach capacity reduces due to its displacement in the third trimester, eat smaller meals more frequently rather than having 3 big meals. Eat slowly and chew the food thoroughly to ease digestion which can reduce heartburn. A small amount of milk or ice cream may also help to relieve the symptoms of acidity. Over the counter preparations (eg. Gaviscon, Mylanta or QuickEze) can also be taken which can help manage the symptoms. Try and sleep propped up on several pillows at night which often helps too. Should it be necessary, prescription medication such as Zantac can be used to reduce the acidity in the stomach. 

PRE-ECLAMPSIA IN PREGNANCY

Pre-eclampsia is a pregnancy-specific syndrome broadly defined as the presence of high blood pressure and increased amounts of protein in the urine. It can range from simple hypertension to the development of seizures and multi-organ disease. Pre-eclampsia complicates 5-9% of all pregnancies and can affect around 1 in 50 women. It is a leading cause of maternal and neonatal complications. The cause of pre-eclampsia has been associated with abnormal placentation (ie. how the placenta forms).

Risk factors for pre-eclampsia include:

• Maternal and paternal family history of pre-eclampsia
• Previous pregnancy with pre-eclampsia
• Multiple pregnancies (eg. Twins or triplets)
• Maternal age over 40y/o
• Increased BMI over 30
• Pre-existing high blood pressure, diabetes or kidney disease
• Smoking
• Systemic inflammation
• Ethnicity (more common in Caucasian women)

Prevention of pre-eclampsia includes low-dose aspirin started before 16 weeks gestation of pregnancy. Low dose aspirin (100mg) taken every night has been shown to reduce the risk of pre-eclampsia. It is thought to improve the way the placenta develops and prevent problems in the placenta. Aspirin can delay or even prevent the onset of early pre-eclampsia which can affect the normal growth of a baby.

Once pre-eclampsia is diagnosed, frequent follow-up is necessary to keep a close eye on both the mother and baby. This includes surveillance of fetal growth, antenatal testing of fetal well-being, regular blood tests to identify worsening disease, and close monitoring of the maternal symptoms and blood pressure.

The only way to cure pre-eclampsia is to deliver the baby and the placenta. Timing of delivery is based on balancing the gestational age, the disease severity and the fetal and maternal risks. If pre-eclampsia develops early, the complications of a pre-term birth needs to be weighed up against the risks of continuing the pregnancy. Untreated pre-eclampsia can lead to a condition known as eclampsia (where a woman can start fitting and have life-threatening seizures). As such, being able to delay pre-eclampsia gives the baby more time to grow and develop so as to reduce the risk of being born early / pre-maturely.

VITAMIN D DEFICIENCY

Vitamin D is necessary in calcium and bone metabolism. It plays an important role in forming and maintaining strong bones. In adults, a low level of vitamin D may contribute to osteoporosis which increases the risk of fractures. In children, Vitamin D deficiency can lead to a condition known as rickets, which is a bony deformity due to soft bones.

In Australia, Vitamin D is not routinely added to most foods. We make Vitamin D in our skin when we are exposed to sunlight. As such, mild to moderate Vitamin D deficiency is quite common, especially in winter when our sun exposure is reduced. In addition, skin cancer protection (such as cover ups and sun block) is vital in Australia due to our high UV rays and this blocks out the sun exposure necessary for us to make Vitamin D. 

As no one wants to develop melanoma / or any other skin cancers, it is good that we can protect our skin against the harmful rays of the sun AND if necessary we can also replace   Vitamin D with supplements if needed. Vitamin D can be taken as a tablet if you are found to be Vitamin D deficient on testing, and this works well to maintain our Vitamin D levels in a healthy range.