From the first moment you see the test turn positive until you sit down with your doctor for the initial appointment, the waiting can sometimes feel like an eternity. Some of you will spend those weeks worrying if you really are pregnant since you feel so normal.  For others, the pregnancy symptoms will be so severe that you will be desperate for some relief. The following is a list of common concerns that I get asked about at the first pregnancy appointment as well as some helpful hints for common symptoms.

Vitamins
If you are not already on a prenatal vitamin, then please start one as soon as you find out you are pregnant. Folic acid is the most important ingredient in a prenatal vitamin. We recommend 1 milligram of folic acid per day during pregnancy. Taking folic acid can significantly reduce the risk of birth defects like spina bifida. If someone in your family has had a baby with spina bifida you may need to take higher doses of folic acid, so talk to your doctor.

One common question of expectant mothers is “Do I need a prescription prenatal vitamin?” The main difference in over the counter and prescription prenatal vitamins is a higher dose of the all-important folic acid that is included in a prescription vitamin. They have 1 mg, whereas most over the counter prenatals have 600 micrograms. Other “extras” that come with a prescription strength prenatal vitamin are stool softeners, special coatings to help you swallow, DHA (for brain development) and a special form of iron that causes less stomach upset. It’s usually easier to take the prescription prenatal because it has everything you need and it’s easier on your stomach. If it’s too expensive you can take the over the counter prenatal and simply add a folic acid and DHA supplement. It is important to note that folic acid is best absorbed as a supplement rather than its natural source.

You can take too many of some vitamins (like vitamin A) so you should not add additional supplements in pregnancy without talking to your doctor first. I’ve heard lots of women say that their prenatal vitamins upset their stomach so they took ‘a few’ Flintstone’s chewable vitamins instead. This is probably not a great idea because as I said, you can have too many of some vitamins. A better option would be to take one Flintstone chewable and then an additional folic acid supplement if you really can’t tolerate prescription prenatals. Here is link to a company that sells prenatals by mailorder for less than you can usually get them at the pharmacy: http://www.vitamedmd.com

Nutrition
Pregnancy should be a time of very purposeful, deliberate eating. Look at how many calories your body needs, and fill those calories with the most high yield nutritious foods. There are several websites that will tell you the amount of calories you need for your height and activity level. www.choosemyplate.gov is a good site that will give you a sample food pyramid based on your caloric needs. The best strategy is to plan ahead. Focus on getting 5 servings of fruits and vegetables a day with at least one of those vegetables being a dark green or leafy vegetable (sorry pickles don’t count). Drink lots of water. Around 8 glasses a day is ideal. Also make sure at least half of your grains are whole grains. You only need an additional 100 calories a day in the first trimester, so you not need to increase the amount of food eaten at this point.

Food Precautions:

Meat. All  meat should be well cooked. Raw sushi should be avoided as well as rare and medium-rare steak.

Alcohol. There is no known safe amount of alcohol during pregnancy so please discontinue all drinking.

Fish. Shark, swordfish, king mackerel, and tilefish contain high levels of mercury. It is recommended that they be avoided while pregnant. Salmon and tuna should be eaten in moderation. Please note that fish sticks and fast food fish sandwiches are in general made from low mercury fish. See the following link for a complete breakdown of fish safety. http://womenshealth.gov/publications/our-publications/fish-facts.pdf

Caffeine. Caffeine intake should be limited to 200 mg a day during pregnancy.

Unpasteurized food. Cheeses, milk and juices should all be fully pasteurized.  Soft cheeses such as feta and bleu cheese are some times sold in the unpasteurized form, so read labels.

Listeria associated foods. Several different foods have been associated with outbreaks of Listeria bacteria, which can be associated with miscarriage and bad pregnancy outcomes.  While the overall incidence of this bacteria is extremely low, precautions should be taken to make sure that all vegetables are thoroughly washed.  If a food cannot be well cleaned (such as fresh sprouts) it should probably not be eaten. Deli meats should be eaten only if fresh and for added precaution can heated in the microwave until sizzling to kill any possible contaminating bacteria.

Other precautions:

Smoking. Please stop smoking immediately when you find out you are pregnant. Smoking is associated with an increased risk of miscarriage, stillbirth, preterm delivery and fetal growth restriction. If you smoke more than a pack a day and are having difficulty quitting, talk to your doctor about whether the nicotine patch would be appropriate for you.

Cats. Toxoplasmosis is a parasite that can live in cat feces. If it is contracted during pregnancy it can cause severe pregnancy complications. You should avoid handling cat litter or being in the room when the cat litter is being changed. You can still pet your cat and be in the same room as the cat litter if needed.

Exercise. We recommend you stay active during pregnancy. This helps you maintain your overall stamina, avoid excess weight gain and decreases your risk for gestational diabetes. If you are not already active, then I recommend you start walking or swimming 30 minutes daily, or at least 5 times a week. As you exercise, you want to maintain your heart rate at under 150 beats per minute. This is an exertion level of about 6-7 (on a scale of 1-10). At this level you should still be able to talk.

If you are already active in an exercise routine such as running or aerobics, you can usually continue with the above modifications. Make sure to keep your heart rate under 150. It is also a good idea to maintain your flexibility and strength. A prenatal yoga or pilates class (or DVD) can help you maintain your core muscles to help reduce the back pain associated with mid-pregnancy. After 15 weeks, exercises that involve laying flat on your back should be avoided. Additionally weight lifting should be limited to under 40 pounds.

Heat. There are a few things that are known to cause malformations at this stage of development. One of them is extreme heat. This is a time when it is especially essential to avoid hot tubs or very hot baths (higher than body temperature). Having a high core temperature in early pregnancy has been shown to cause malformation of the spinal cord. If you have a fever at this time it is best to take acetaminophen (Tylenol) to help keep your temperature down. If that does not lower your temp, call your doctor.

Medications. Be cautious of taking any medications that might interfere with the development of the baby. Check with your doctor before taking any additional medication: prescription, over the counter, herbal supplements and/or additional vitamins. Thyroid medication and asthma medications are probably the most common medications that women can take in pregnancy. They are safe for the baby and can be harmful if discontinued suddenly.  If you care taking any other mediation, then notify your doctor’s office to determine if it is safe to continue.

Medications that are generally accepted as safe in pregnancy:

Tylenol

Benedryl

Guafenesin

Throat lozenges

Tums

Volace

Milk of magnesia

Immodium

Other things that are considered safe:

Hair dye has not been proven to cause malformations because it is minimally absorbed by the skin. Coloring your hair is considered safe, but if you want to be overly cautious you can wait until you are 12 weeks along.

Self-tanning lotions are also minimally absorbed and are considered safe to use. We always recommend you stay away from tanning beds and this applies during pregnancy as well.

Regular cleaning supplies are fine (sorry, I can’t give you an excuse to get out of your housekeeping). Just make sure you keep all areas well ventilated while cleaning. Avoid solvents such as paint thinner. Use common sense, if a chemical requires specialized disposal, you probably shouldn’t handle it while you are pregnant.

Most cosmetics and lotions are safe. If you use Retin-A, you should probably discontinue use during pregnancy. If you have questions about any prescription lotions, ask your doctor.

Sex is safe as long as you are not having any bleeding or complications.

Symptoms

Cravings. If you are craving a specific fruit, then go with it. If you need a Hershey’s bar every afternoon then you may need to slow down. I tell patients to give into their ‘bad’ cravings once or twice a week, just not once or twice a day!

There are weird cravings that could be a signal that something abnormal may be going on. For instance if you crave plain ice all the time, you could be anemic. Also some women will crave dirt or laundry soap, as well as other non-foods. This could be a signal of specific vitamin deficiencies. If this is the case inform your doctor. Needless to say, don’t give in to these ‘bad’ cravings!

Fatigue. I think fatigue is the least discussed early pregnancy symptom. Everybody knows about the “morning sickness,” but sometimes fatigue can be the most debilitating symptom in early pregnancy. The source is thought to be a combination of the high levels of HCG and Progesterone. But whatever causes it, from about 6 weeks to 12 weeks most pregnant women just want to sleep. Like 12 hours a night…and then take a nap later. If you can get away with it, go for it. The good news is that fatigue and nausea seem to get better after 12 weeks.

Links to discussions on other symptoms:

Nausea

Constipation

Vaginal Discharge

In our book I go into greater detail on all these issues and symptoms, with Jessica adding a faith based perspective on how to journey through pregnancy without fear. If you are looking for additional resources,  I also recommend the ACOG Pregnancy Guide.

Hopefully this post will help fill the information gap that may crop up during those weeks between peeing on the stick and your initial pregnancy appointment. As an obstetrician, I love seeing patients for their first pregnancy visit. The joy and excitement on their faces when they see that first tiny flicker of the heart beat on the sonogram, still melts my heart.  Thank you for letting us be a part of your journey and congratulations during this exciting time in your pregnancy.

The majority of women will experience at least occasional nausea during the first trimester, with about 2% experiencing severe daily vomiting. Symptoms usually peak at around 10 weeks as pregnancy hormone levels peak and then slowly improve over the next few weeks.

Because morning sickness is usually at the top of a mommy-to-be’s list of concerns, I wanted to offer my best advice for dealing with this unwelcome side effect of pregnancy.

As a starting strategy, eat small meals throughout the day. Stop before you are full, and try to eat again before you are hungry. High carbohydrate meals seem to be the most helpful. Sucking peppermint candy has been shown to reduce nausea after meals. Keep crackers beside your bed so you can eat them before you get up in the morning. Getting up very slowly can also be helpful.

Some women will have specific foods or smells that trigger the nausea. If you know what the troublesome foods are then you can plan ahead and avoid them. In general steer clear of spicy, rich or fried foods. Other women will experience nausea with brushing their teeth (but please don’t avoid this one!) or other activities like pumping gas.

Try to to take your prenatal vitamin at night with a small snack.  If the vitamin still causes nausea, then switch to one without iron.  It is very important to get adequate folic acid during the first trimester. So if you can’t hold down an entire vitamin, try a folic acid supplement.

If the nausea is not improving, the next option would be a combination of Vitamin B6 (10 mg) + doxylamine (10 mg…like Unisom) taken every 6 hours as needed. It is safe and is available over the counter. Obviously a sleeping pill may make you tired, but it does help the nausea. Natural ginger supplements have been shown in some studies to reduce nausea. A product that some of my patients have found helpful is  Tranquil Tummy Crackers. These are saltines with added ginger.

Another great option is the Prima Bella.  It is a medical device that is worn on your wrist that feeds an electrical impulse through the nerves in your arm that modulate the nausea centers of your brain and stomach. It is FDA approved and drug free. You do need a prescription from your provider.  Several of my patients have gotten significant improvement from this device.

If you’ve tried these tips and you’re still vomiting regularly or find your nausea incapacitating, then please call your doctor’s office. There are several prescription medications that can help reduce the nausea.

Reasons that you may need to be seen urgently are: vomiting blood, dehydration that results in decreased urination, or not being able to hold down anything for 24 hours.  Please let your provider know if you have these symptoms.

I found nausea to be the most challenging symptom in my own pregnancy. I found that keeping snacks close by during the day was helpful. At times, I took the anti-nausea medication in order to function and found it helpful. I would love to hear from our readers about any other helpful hints or products they found beneficial.

As always, we encourage you to discuss these remedies with your doctor so together you can determine what is best for you.

Dr. Rupe

WARNING: This post is not being written by the doctor. BUT, I am pulling from my current, personal experience AND the valuable information actually written by Dr. Rupe in our book. So read with confidence that there are accuracies (infused with a little personal story) here.

Many expectant moms consider entry into their 3rd trimester something to celebrate. Basically 6 months down, 3 to go. The reality of seeing baby in the flesh is so close. It truly is something to celebrate but for many (probably more for 2nd and 3rd time moms-to-be) there is some dread involved. . .because those moms know what’s coming.

3rd trimester symptoms.

Still, it’s not a terrible thing to be a little in the dark heading into the home stretch. Speaking of stretching. . .hang on a sec while I change positions. These leg cramps are killing me.

OK, that’s better. Now where was I? Oh, 3rd trimester symptoms. Actually, many 1st time moms-to-be will not experience the worst of these inconveniences. I know personally, I felt amazing during the last few months of my pregnancy. Although now that I am staring my last 3 months in the face for baby #2, I can honestly say I agree with my girlfriends – subsequent pregnancies are harder. It’s important to remember though that every pregnant woman is different. You may feel wonderful for every day of every pregnancy you have. You may feel great for one pregnancy and miserable the next. The important thing is to be familiar with what you may experience and be ready to do what you can to relieve your symptoms. Eating right and exercising throughout your entire pregnancy will make a huge difference right through delivery.

Give me a minute while I find my Tums, will ya? This heartburn is killing me. Be right back.

OK, much better. Where was I again? Right. Late pregnancy symptoms.

Our book covers symptoms all throughout pregnancy in detail and Dr. Rupe gives some great, simple advice on how to manage them. The more I talk to other moms-to-be the more it seems a few symptoms seem to really dominate the last few months of pregnancy.

Leg Cramps  //  Heartburn  //  Frequent Urination

Ah, man. Just typing the work urination made me have to pee. Hang on another minute while I take another trip to the loo.

OK, seriously that should be the last interruption.

There are probably several more prominent 3rd trimester symptoms but for the sake of your precious time and due to the fact that I’m obviously experiencing these symptoms right now, I will focus on those mentioned above.

Leg Cramps - This one came on a lot sooner for me in my 2nd pregnancy. Leg cramps can occur at any time during the day (especially if you are on your feet for long periods of time) but seem to plague most moms-to-be while they are trying to get their precious sleep. As if it weren’t hard enough to find a comfortable position, it’s miserable to be awakened by a severe charley horse at an ungodly hour. One night I woke up with one and after it passed, another one came and then another. I had to wake up my husband to rub my calf until the pain stopped. Leg cramps may come in the form of a charley horse (which usually follows a quick movement of the leg) or you may experience an aching pain in the hips or legs, even while lying still. Dr. Rupe suggested that I eat a banana before bed (sometime in the evening) as the potassium helps relieve this type of cramping. This simple remedy worked like a charm. I’ve not awakened in the night with a cramp in a couple of weeks.

Heartburn - Yet another symptom that entered the picture for me much earlier this time around. But heartburn always seems to intensify as pregnancy progresses. Simply explained (by Dr. Rupe in the book): your body releases high levels of the hormone progesterone during pregnancy. This brings a relaxing effect to the body and with that to the valve between your stomach and esophagus. This lets the acid in your stomach pass into the sensitive lower esophagus, causing the burning sensation in your chest. Heartburn is exacerbated by the growing uterus pushing up against the stomach. Awesome! The best ways to manage or even avoid heartburn are:

1. Avoid eating up to 2 hours before bedtime.
2. Cut back on fatty and fried foods.
3. Stay upright after eating.
4. If these tricks don’t work, it is safe to take chewable calcium carbonate (Tums, Rolaids) or even Pepcid if needed.

Tums are my best friend right now. I like the Smoothie kind. Yum.

Frequent Urination - You probably became acquainted with this friendly symptom during your 1st trimester. Surprise. He’s back! Did you miss him? 1st trimester frequent urination is caused by hormonal changes. While those changes may still contribute to it’s 3rd trimester return, later in your pregnancy it’s more about your growing baby pushing on your bladder. The frustrating thing about this symptom is that drinking water (which is vital throughout your pregnancy) does not help in the matter. There really is nothing you can do to avoid this symptom. The key is to manage it. Make sure you truly empty your bladder each time you visit the little girls room (gosh, sounds like something I just said to my 3 year old while potty training last week). Although peeing every 5-10 minutes is annoying for me throughout the day, it’s not as invasive as having to go every two hours during the night. To help with this inconvenience, my husband and I switched sides of the bed (his side is closer to the bathroom) during the last trimester of my 1st pregnancy. Last night after I had gotten up twice before 1am he asked, “Is it time to switch sides?” Almost!

I wish all of you mommies-to-be that are in or are entering your 3rd trimester lots of relief and comfort as you encounter these possible inconveniences. Just remember that you are that much closer to seeing the life that makes this all worth it. The frustration of peeing constantly and enduring heartburn will fade once you hold that sweet baby in your arms.

We’d love to hear from current moms-to-be and even you mommies that are past pregnancy out there on what symptoms you experienced most in your 3rd trimester and how you managed them.

Heading back to the bathroom,

Jessica

Williams Obstetrics and Gynecology is considered ‘The Bible’ of Obstetrics. It contains 1435 pages.  I’ve read it twice.  Yet only 2 paragraphs are devoted to constipation ,one of the most common and annoying symptoms of pregnancy. A prime example of how physicians and patients are often concerned about very different things in pregnancy. Although in our defense, we do focus most of our learning on the life threatening/saving issues.  Though constipation is not often a life threatening issue, over the years, I have heard from many women just how much added discomfort it can add to their pregnancy.

Constipation has been jokingly defined as having a bowel movement less often than your grandmother.  Perhaps a better definition would be hard, painful and less frequent stools.  Symptoms may include pain with bowel movements, rectal bleeding, hemorrhoids, bloating and cramping.  The cramping can be quite intense.  Due to the close proximity between the uterus and descending colon, it is often difficult to determine which organ is causing the cramping pain.   This can be upsetting to women, especially those with a history of miscarriage, who have to fight fear with each twinge and cramp.

The amount of the hormone progesterone is much higher during pregnancy and causes one’s stool to move through the colon at a slower rate.  The more time the stool is in the colon,  the greater the volume of  fluid that can be removed from it, leading to firmer stool.  The enlarging uterus physically pushes on the bowel which can further impede its exit.  First trimester nausea can lead to dehydration which causes the body to pull even more fluid from the stool.  Also, commonly used medications in pregnancy  such as zofran and iron supplements can also cause worsening constipation.

The key to treating constipation is prevention. In all pregnancies we recommend eating lots of fruits and vegetables (5-7 servings/day) as well as drinking 8-10 glasses of water per day.  Try to get 25 grams of fiber per day.  Often times prenatal vitamins will contain a small amount of stool softener, which can be helpful.  Fiber supplements can also be beneficial, but in some women they can cause excessive bloating.  Exercise like walking and yoga have also been shown to reduce constipation.

Joseph Schaffer, MD, chief of gynecology at the University of Texas Southwestern Medical Center in Dallas, presented an article in 2006 looking at a homemade fiber preparation that was found to be more effective than over the counter fiber supplements for treating constipation. I have had several patients find it beneficial:

Constipation Bowel Recipe

Mix together:

1 cup unprocessed wheat bran or miller’s bran

1 cup applesauce

1/4 cup prune juice

Take 2 tablespoons  twice a day

If these measures are not working, the the next step is to take a daily stool softener such as docusate sodium (colace) .  Colace works by  keeping moisture in the stool. It does not stimulate the bowel like a laxative and is not absorbed, therefore it is safe for continuous usage.

If constipation is still an issue, then discuss it with your provider. A common next step would be to add  Milk of Magnesia to the regimen.  If  MOM doesn’t work, then taking magnesium citrate or using an enema will most often result in relief.

Reasons to be concerned about constipation include: if it’ s associated with vomiting, abdominal pain or fever.

Again, the key is to NOT WAIT UNTIL IT IS SEVERE AND PAINFUL.  Keep hydrated, eat lots of fiber.  Stay on a stool softener if you are having issues, then add milk of magnesia as needed for breakthrough problems.

I am 10 weeks along in my pregnancy and all of a sudden I am hungry ALL THE TIME! Dr. Rupe talks about this symptom in the book. Hunger, with cravings and aversions.

I’m hungry all the time but not much sounds good to me. I am blessed in that I don’t suffer from extreme nausea or vomiting during my first trimester. Just a touch of queasiness from time to time. But I have lots of food aversions and honestly, they seem to come and go. One minute chicken sounds good, the next anything related to my feathered friends makes me want to puke. It makes it very challenging to eat healthy during these early stages of pregnancy.

My hope is that after I share my pregnant point of view on this symptom, Dr. Rupe will chime in with another entry that gives the facts and some good, doctorly advice on how to handle this early pregnancy dilemma.

Preparation is perhaps the most important action you can take when trying to eat healthy in your first trimester (and throughout your entire pregnancy for that matter). Since I know that chicken is hit or miss for me right now, I have to be ready with other options. What does sound good? Make a list of foods you have not been averse to and make sure you keep them around. Any kind of meat is tough for most women I talk to in their first trimester. What other forms of protein can you stomach at this stage?

I don’t hear much that fruits and vegetables bother women in pregnancy so focusing on those things is a good idea. I’ve eaten a lot of salads (the tangy vinegar helps the queasiness) along with citrus fruits (sour is great for nausea). When all else fails look to whole grains. Toast and whole wheat pasta are mild and will give you the carbs you need for energy. Try to find some form of protein to add to it though. Cheese is a good idea. Lastly, make sure you drink lots of water to keep you from dehydrating. Water is also just a great cleansing agent. It almost resets my system to drink a tall glass of cold water. Chicken might sound yucky but after downing 8 oz of agua, it might not be so bad.

We’d love to hear your pregnancy menu secrets. What worked for you?