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Initial Pregnancy InformationWe will go over this information at your 8 week New Pregnancy appointment, but in case you have questions now, you can refer to this. If you have nausea that you would like a prescription anti-nausea medicine for, please contact us and we will call one in to your pharmacy. ResourcesIf you have questions about what you can and can’t do in pregnancy, I strongly recommend buying a pregnancy book, such as “Expecting 411” by Dr. Michele Hakakha. or “Mayo Clinic Guide to a Healthy Pregnancy.” This website is very helpful: How to contact us:Our office is open Monday-Friday from 9am-5pm. Please call us at 425-454-5758 and my nurse can help you with your problem or question over the phone, or, if necessary, arrange for you to come in and see me. For urgent needs please press option #9; for non-urgent needs please leave a message for my nurse on her voicemail. For problems that aren’t addressed by the RN, or are more appropriate for me, email me at DrDvorak@Please reserve calls outside of office hours for emergencies. (Call the same number and you will be directed (via an answering service) to the doctor on call.) Please remember that we use paper charts; when we are at home we do not have access to your records. When calling our office and leaving a message, you MUST leave *the patient’s* first and last name and date of birth (not the father of baby’s), or we will not be able to call you back. And if you miss a call from us, please check your voicemail, as my nurse will leave you a detailed message and calling us back is often not necessary. Lastly, please make sure your voicemail is set up and not full. Concerning symptoms:Vaginal bleedingSevere abdominal pain (like menstrual cramps)Severe cough or sore throat AND fever (temperature>100.4 F)Visits:We will see you every month through 34 weeks, then every 2 weeks starting around 34 weeks, then weekly from 37 weeks onward. Of course, please call us for an urgent appointment if you have any problems. At each visit we will discuss warning signs for problems with your stage of pregnancy, so you will know what to look out for. At each visit we will check your weight and blood pressure, and check your urine for protein and sugar content. We will also listen to the baby’s heart rate, and measure your uterus. Due to the nature of private practice, it is sometimes necessary for us to go to the hospital to see or deliver a patient. We understand that you time is valuable, and we will try and call you before your appointment if I will be late to your appointment. Please feel free to call the office ahead of your appointment time to see if there is any delay in the schedule. Lab tests:Blood tests, urine cultures, some ultrasound exams, and pap smears are not included in your obstetrical fees. You will receive separate bills for these procedures. We do a set of routine blood and urine tests at the beginning of your pregnancy, and a blood test for diabetes and anemia at 28 weeks. You may also have prenatal screening for genetic diseases around 10-14 weeks (optional). You will also have an anatomy ultrasound around 20 weeks at an ultrasound facility. ExerciseIt is healthy to exercise in pregnancy. Please do at least 30 minutes of exercise dailyLink to Online Pregnancy workout: safety:-Practice good personal hygiene (frequent hand washing)-Consume only meats, fish, and poultry (including eggs) that are fully cooked-Avoid unpasteurized dairy products and fruit/vegetable juices-Avoid processed meats that contain nitrates-Avoid eating raw sprouts (including alfalfa, clover, radish, and mung bean). Bacteria can get into sprout seeds through cracks in the shell, these bacteria are nearly impossible to wash out.-Specific concerns in pregnancy: Listeria is a common low-level contaminant of both processed and unprocessed foods of plant and animal origin, but hot cooked foods are not a vehicle of Listeria transmission. It is most commonly associated with processed/delicatessen meats, hot dogs, soft cheeses, smoked seafood, meat spreads, and paté. I personally think you should use your common sense and eat good quality foods, and not avoid these foods.Seafood and Pregnancy:1. Do not eat Shark, Swordfish, King Mackerel, or Tilefish because they contain high levels of mercury (which is dangerous in pregnancy).2. Eat 9-12 ounces (2 average meals) a week of a variety of fish and shellfish that are lower in mercury. Some of the most commonly eaten fish that are low in mercury are shrimp, canned light tuna, salmon, pollock, catfish, herring, Atlantic mackerel, and sardines. Another commonly eaten fish, albacore ("white") tuna has more mercury than canned light tuna. So, when choosing your two meals of fish and shellfish, you may eat up to 6 ounces (one average meal) of albacore tuna per week.More info at: and at : Caffeine can increase the risks of miscarriage, preterm birth, and small babies. Don’t drink more than 200mg of caffeine daily. Artificial sweeteners: It is best to consume as little as possible. I advise you avoid saccharin. Prenatal vitamins: You need to take prenatal vitamin daily. You can buy one over the counter, or we can give a prescription. Also, you need to take a separate calcium supplement after 20 weeks (enough to get 1200mg total daily). Carrier Screening:Carrier screening is optional testing for rare genetic diseases called autosomal-recessive diseases. An example of this is Cystic Fibrosis. These recessive diseases can pass through families undetected until two carriers conceive a child, and then the disease “appears”. If you test positive for one of these diseases then we will test your husband, and if he also tests positive for the same disease then we will refer you to genetic counseling. About 1% of couples carry the same disease and are at risk for passing it on to their children. About 1 in 550 pregnancies are affected by one of these diseases. Some of these diseases have early interventions that can make a difference. Avoidance of infection while pregnant:-Please wash your hands frequently-Get the flu shot each year-CMV is a virus that is common in children, especially those in daycare. If a pregnant woman get infected it can cause severe birth defects. Pregnant women with young children or childcare workers or healthcare workers should Wash hands with warm, soapy water for 15-20 seconds after changing diapers, contact with oral or nasal secretionsAvoid kissing young children on the mouth or cheek- instead, give a hug or kiss them on the headDo not share food or utensils with childrenLet Dr. Dvorak know if you have symptoms of CMV (fever, sore throat, swollen lymph nodes, and fatigue). Iron supplementation: At some point in your pregnancy we may recommend you take iron supplements. You can buy these at the drugstore. Common varieties used are “Nature Made Iron 65mg”, “Megafood Blood Builder”, and “Garden of Life Vitamin Code Raw Iron”. If you cannot tolerate pills, “Novaferrum 125” is a liquid form. Try to take your iron with acidic foods (for example, vitamin C) and separate from basic foods (for example, milk or TUMs or calcium supplements). OK to take with your prenatals. Iron can cause constipation. To counteract this, make sure you are eating 20 to 35 g of fiber per day. In addition to consuming foods with high fiber, patients may add raw bran (two to six tablespoons with each meal) followed by a glass of water or another beverage to achieve the fiber intake goal. Fiber cereals like GoLean or All Bran can be a good source of fiber as well. You can also try Colace (over the counter stool softener)- use 100-400mg daily.Prenatal screeningOne of the first questions you will have to consider is what kind of prenatal screening, or if you will decline screening. Prenatal screening is a test that does not put the mother or baby at risk and determines the risk of genetic diseases. Why should you do prenatal screening? These syndromes can result in illness and even early death in children and high financial and psychosocial cost to their families.Diagnostic tests that detect chromosomal abnormalities are readily available.For couples who choose to prevent birth of an affected infant, safe and effective termination options are available. Even if termination is not something you would consider, early diagnosis allows you to plan for the birth of an affected child. Various associations offer support for families and individuals with these syndromes. Also, if your baby has a syndrome that is associated with physical malformations (such as heart problems), we might need to deliver your baby at a hospital that had pediatric surgery services. There are 2 main options for prenatal screening. One is a blood test and ultrasound (at Overlake Hospital or a maternal fetal medicine specialist’s office) between 11 and 14 weeks, and it is shown in the first column below. We recommend you check with your insurance about the cost; the CPT (procedure codes) are 76813 and 76801, and the ICD 10 code (diagnosis code) is Z34.02 if you will be under 35 years old when the baby is born, and O09.512 if you will be over 35. The other (“cell free fetal DNA”) is a blood test looking at the baby’s DNA in the mom’s blood, and we do this test shortly after 9 weeks. Ability of test to detect syndromeRisk of having syndromeNuchal translucency and Quad ScreenMaternity 21Down Syndrome (Trisomy 21)See chart82-87%99%Edwards Syndrome (Trisomy 18)1/550090%99%Patau Syndrome (Trisomy 13)Most babies die in uteroNo99%Turner's Syndome (Monosomy X)1/2500No92%Triploidy detection1/10000NoYesSex Chromosome- extra copy?NoYesGender determination?NoYesAge of mother at deliveryRisk of Down's251/1340301/939321/696351/353371/199401/85Nutrition in pregnancyIf your BMI is ____, you should gain ____ in the pregnancyBody mass index (BMI) <18.5 (underweight) – weight gain 28 to 40 lbs; 1 to 4 lbs over the first trimester and about 1 lb/week thereafterBMI 18.5 to 24.9 (normal weight) – weight gain 25 to 35 lbs; 1 to 4 lbs over the first trimester and about 1 lb/week thereafterBMI 25.0 to 29.9 (overweight) – weight gain 15 to 25 lbs; 1 to 4 lbs over the first trimester and about 0.5 lb/week thereafterBMI ≥30.0 (obese) – weight gain 11 to 20 lbs; 1 to 4 lbs over the first trimester and about 0.5 lb/week thereafterWomen who are pregnant should eat plenty of fruits and vegetables as well as whole grains, low-fat dairy, and a variety of proteins. The exact amount of foods from each food group needed by a woman depends on her pre-pregnancy body mass index (BMI), activity level, age, and trimester. It is important for pregnant women to choose foods that are nutrient-dense (foods that contain high levels of important nutrients compared with the amount of calories, such as fruits and vegetables, nuts/nut butters, yogurt) to meet the higher nutrient requirements in pregnancy without exceeding caloric needs. In the first trimester of pregnancy, women typically do not need to increase their caloric intake. It is common to be eating a lot of “comfort food” and carbs and fruit in the first trimester to help combat nausea, but once the nausea is over, you should get back to a healthy diet. In the second and third trimesters, most women will need to increase their caloric consumption to promote appropriate weight gain. On average, women need only approximately 340 and 450 additional kcal/day in the second and third trimesters, respectively.Most pregnant women in the second and third trimesters will require between 2200 and 2900 cal/day (on the lower range if you are shorter and less physically active, and on the higher end if you are taller and physically active).The ranges of number of servings for each food group needed to meet these caloric requirements (2200 to 2900 kcal/day) are:Fruits: 2 to 2.5 cupsVegetables: 3 to 3.5 cupsGrains: 6 to 10 ouncesProtein: 6 to 7 ouncesDairy: 3 cupsProtein - Pregnant women need 1.1 g/kg/day protein. For a 150lb woman, that is 75g protein per day. If you cannot get near this eating “real food”, you can use protein bars and shakes.Carbohydrate — Please aim for 150g-175g of carbohydrate (aka pasta, rice, bread, sugar) daily. The focus should be on whole foods (fruits, vegetables, and whole grains); minimize highly processed carbohydrates. Fiber intake of 28 g/day is recommended. Be sure to drink at least 2L of water per dayIt can be helpful to log all your food and exercise into a calorie tracker (My Fitness Pal, for example) for a few days- it will help you see if you are eating the correct amount of caloriesVegetarian diets that are well-balanced are similar to well-balanced omnivore diets in that they meet most nutrient goals except for iron, vitamin D, vitamin E, and choline. Additional potential nutrients of concern, particularly for vegans, are calcium, vitamin B12, and essential n-3 fatty acids. Dietary deficiencies can usually be resolved with minor dietary alterations or supplements. For example, fortified vegetarian/vegan food products are now widely available and include some nondairy milks (such as fortified soy beverages), meat analogs, and breakfast cereals. Great website about protein in vegetation and vegan diet: 1: Sample Menus Showing How Easy It Is To Meet Protein NeedsProtein (grams)Breakfast:1 cup Oatmeal6?1 cup Soy Milk7?1 medium Bagel10Lunch:2 slices Whole Wheat Bread7?1 cup Vegetarian Baked Beans12Dinner:5 oz firm Tofu12?1 cup cooked Broccoli4?1 cup cooked Brown Rice5?2 Tbsp Almonds4Snack:2 Tbsp Peanut Butter8?6 Crackers2TOTAL?77 grams ................
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