Healthy Woman: The 12 Months of Pregnancy

Most women are careful about leading a healthy and safe lifestyle during pregnancy, but it usually takes at least a few weeks for a woman to realize that she's pregnant. Because so much development occurs in those first few weeks, experts say that women who are planning a pregnancy should begin preparing for it at least three months prior to actively trying to conceive.

"The greatest risk to the fetus for congenital anomalies and birth defects happens between the first two and eight weeks of pregnancy," says Ginger Breedlove, the program director of the Nurse Midwifery Education Program at the University of Kansas School of Nursing and a board member of the American College of Nurse Midwives.

"If most of the risk is happening before health professionals see or even talk to the women on the phone, by and large, we've lost the window of opportunity for education," explains Breedlove.

Below, Breedlove discusses how preconception medical visits and lifestyle adjustments can help women prepare for pregnancy to help ensure they have the healthiest possible pregnancy and baby.

Why is it important to prepare for pregnancy? I think the most important thing that we can do in America is reframe the duration of pregnancy and not think of it as nine months but as 12 months. Many of the risks that women have are relevant before they ever conceive.

For example, research that was primarily funded by the March of Dimes has shown that women who took appropriate levels of folic acid prior to conception significantly reduced the rate of neural tube defects, primarily spina bifida.

One of the things that we want women to continue to understand is that taking at least 0.4 mg of folic acid in a daily multivitamin anytime during the childbearing years is important because about 70 percent of pregnancies are unplanned.

Why are preconception visits important? I think it's important that women and families understand that a preconception visit, in my opinion, is probably more important than a routine obstetric appointment. So many things happen before you ever get to that first prenatal visit. An average woman, even with private health-care insurance, isn't in that obstetric office until about 10 weeks of pregnancy.

What sort of vaccinations should women have prior to conception? Oftentimes, after we get out of the secondary school system, people don't pay attention to vaccinations. But a tetanus/diphtheria booster every 10 years is important.

Women who are in high-risk groups — women with asthma, cardiac problems, HIV or other conditions that might increase their risk of bacterial or viral infections —should probably have a hepatitis B vaccine, an influenza vaccine and maybe even a pneumonia vaccine annually.

Whenever possible, preconception immunizations are preferred to vaccinations of pregnant women. For example, women should have their rubella status identified prior to conception and, if necessary, have an MMR vaccination three months prior to conception.

When is genetic testing appropriate? Screening is considered in people with a family history of certain conditions, such as a neural tube or congenital heart defects.

Other candidates for genetic screening would those with a family history of Down's syndrome, Tay-Sach's disease, particularly in Jewish and French-Canadian families, sickle cell disease, which primarily affects African-American populations and thalassemia, a type of anemia common in people with Mediterranean and some Asian backgrounds. Hemophilia is also genetically predisposed, as is muscular dystrophy and cystic fibrosis.

People with any history of mental retardation and the thousands of other rare chromosomal and genetic disorders are also candidates.

I would encourage anybody who is in those categories to see a genetic counselor prior to pregnancy. This kind of specialist can talk to both future parents about all the risks and percentages of them carrying a genetic trait onto their baby.

What medical conditions might affect pregnancy? There are medical conditions that women have prior to conception that can worsen during pregnancy and that, if not monitored closely, especially in the first trimester, can lead to birth defects. For example, if diabetes is not controlled well in the first month of pregnancy (and again, most of us don't know until a couple weeks after we expect a period), it can lead to abnormalities with the fetus due to glucose levels that are out of control.

We also encourage women with pre-existing heart disease to have preconception visits. This includes women with hypertension and women who have had major cardiac anomalies when they were born that were surgically corrected. Women who have epilepsy, lupus, renal disease or genetic disorders should discuss their conditions with a health professional prior to pregnancy.

Women with asthma should talk about how asthma will affect their pregnancy. The good thing is that if these moms are given medication to control the asthma, the pregnancy is probably not going to cause any increased problems.

Are there medications that are known to be detrimental to the fetus? The medications for epilepsy that women take to prevent seizures are potentially harmful to the fetus. The preconception period is the best time to think about the best medications that a woman with epilepsy can use so that when she does become pregnant, seizure control is normalized with minimal effects to the fetus. These moms really need maternal fetal medicine specialists taking care of them.

In women taking mood stabilizers for a psychiatric condition, you weigh the risks and benefits. Is it healthier for the mom to be able to maintain a healthy state of well-being than the very vague potential risk to the fetus that we haven't identified as being harmful to the fetus, at least at this point?

It's important for women planning a pregnancy to stay away from tetracycline and Accutane, which some women take for acne control.

We also want to make sure women know that over-the-counter medications can be as powerful as prescriptive drugs. We really don't know what long-term risks might be associated with any drug because we can't do studies on pregnant women to find those answers. That is why we say, "Don't take anything, unless you seek medical advice," particularly in the preconception period.

What lifestyle changes should women make? Smoking cessation programs that are preconception-based, not introduced when the woman is pregnant, are very important. We know that smoking has a high correlation with first trimester spontaneous loss, preterm birth, stillbirth and growth-restricted infants during pregnancy.

Of course, we encourage women who are considering pregnancy not to drink. We don't know how many drinks will affect the fetus or if one weekend of binging at a particular gestational age of the fetus is going to compromise it. If a woman doesn't have a planned pregnancy, but she's of childbearing age, we encourage her to either have effective birth control or not drink excessively.

Women who are using illegal drugs are certainly affecting their potential of having a healthy first trimester and a healthy baby. Women who are addicted need to be identified and assisted into social-service programs that help them either deal with their addictions prior to pregnancy or once they're pregnant.

How can women best improve their diets? There are so many recommendations out there about the healthiest way to eat. I would suggest that eating a healthy variety of foods from all the food groups is important.

If one is a self-identified vegetarian, and there are so many subcategories of vegetarianism, one should be aware of getting adequate protein, adequate folic acid, adequate calcium and adequate iron. If women can focus on those areas in whatever diet that they have adopted, they're going to be healthy when they go into pregnancy.

It's advisable for women who are overweight to try to lose weight prior to pregnancy. But if women are trying to lose weight in a period when they also want to conceive, I would suggest they seek medical advice and guidance. Fad dieting or extreme dieting in the preconception period is not a good idea.

Is exercise recommended? In terms of exercise and activity, if American women could be more mobile, that would be wonderful. We do discourage women who have never exercised in their life from all of a sudden deciding that they're going to be a long-distance runner or a downhill skier when they're planning to get pregnant or already pregnant. If they're not used to that kind of activity, it's not a good idea to introduce it at a point where they're much more vulnerable to potential risks, either to the fetus or to themselves, which is more likely.

We tell women athletes who have had a thorough health history and exam that they don't necessarily have to change an active lifestyle when they are pregnant because their body is used to it.

If women are unsure about their state of pregnancy, they should avoid excessive heat exposure. That's not going to happen in your home bathtub. It is going to happen in commercial hot tubs and saunas.

How can fathers prepare for their partner's pregnancy? On thing we often leave out is that men have babies, too. There's really a need for more importance on the male role in relationship to his occupational exposures, his use of alcohol or drugs, whether there's any genetic history in his family, in addition to risks such as HIV and sexually transmitted infections.

When should a woman meet with a health-care provider about pregnancy? I would suggest that if a woman is considering pregnancy she seek health-care advice before she goes off birth control or at least three months prior to actively trying to be pregnant. Then you're truly making informed decisions about what kind of provider might be best for you and what choices you might need to think about in terms of genetic testing or early prenatal testing, or maybe earlier access into health care because you have medical risks that put your pregnancy in a higher category.

What kinds of providers are available to women? We have many health-care providers in the women's health field and maternity care that could help women preconceptually. All the way from maternal fetal medicine specialists who take care of the most-ill women to reproductive infertility specialists who help women who have reproductive problems conceive. OB/GYNs, family practice physicians, certified nurse midwives, women's health nurse practitioners, physician's assistants, Planned Parenthood and health departments are other providers.

What should women be looking for when trying to choose a provider? I think what's important is thinking about what kind of pregnancy and birth experience they're looking for. They also need to consider their choices based on their insurance and where they live.

There's variation in the philosophy of care among different providers. A certified nurse midwife's expertise is in caring for healthy pregnant women, which is about 80 percent to 85 percent of all pregnancies. Their foundation of care is based on health promotion and disease prevention and seeing pregnancy as a healthy, natural function. In medical communities, there may be more of a slant on seeing pregnancy as a potential disease and perhaps being more interventionist.

I encourage women to think of pregnancy and childbirth as something that is truly a life-changing event and to try to take the time to think about how this can be an emotionally positive experience that's shared by all the people she wants to share it with. And I encourage women to invest in a provider that will give her that experience.