Health

We’re in the home stretch now, almost ready to start trying for a baby. You’ve quit the bad stuff and attained a healthy weight. You’ve gotten pre-existing conditions under control. And you’ve gotten immunizations and dental care out of the way. Now, all you need to do is head down to the supplement aisle of your nearest drugstore and…

…and stare blankly at the thousands of options that meet your eye.

What on earth should you be taking before you try to conceive?

6. Start taking a vitamin

There are lots of opinions on the value of vitamin supplementation or the lack thereof. The standard professional response to the question of “should I be taking a vitamin?” is that “the best source of vitamins and minerals is a healthy diet.” And that’s absolutely right.

Unfortunately, a lot of us don’t eat a healthy diet. Which is why a whole spate of other professionals respond with “a good multivitamin is good nutritional insurance.”

So what’s a hoping-to-become-pregnant woman to do?

Well, there is one nutrient for which we know supplementation is absolutely beneficial. All women who are capable of becoming pregnant (whether they’re actively trying or not) should ensure that they are getting 400 mcg of folic acid, either from fortified foods or from supplements.

Folic acid is essential for a baby’s brain or spinal cord development, but the most important weeks for this development are before you miss your first period – which means you need to make sure you’re getting enough folic acid BEFORE you get pregnant.

It’s possible that you don’t need a supplement to get even this – if you religiously eat breakfast cereal or a sandwich daily and your daily intake from fortified foods equals 100% of the Daily Value (check the nutrition facts panel on your cereal and bread), you can breathe a sigh of relief. But if you don’t currently eat 100% every single day, you should be taking a supplement that contains 400-800 mcg of folic acid.

That’s all you really need for the prepregnancy period, unless you have reason to suspect that you have a nutritional deficiency. (For my part, I knew that I should probably take my known Vitamin D deficiency more seriously since I’d be hurting not just myself but potentially a growing baby by staying deficient.)

But it might be worthwhile to also look into what your increasing needs will be during pregnancy and incorporate those supplements in now.

The three nutrients that are worth looking at are 1) iodine, 2) iron, and 3) calcium.

Iodine is a mineral that is very important for thyroid function – and thyroid controls our rate of metabolism and therefore baby’s rate of growth. Iodine needs are increased during pregnancy from 150 mcg to 220 mcg per day. The majority of the iodine in our diets (especially for those of us who live far from the sea and don’t eat seaweed :-P) comes from iodized salt. During pregnancy, you would need to be eating 3/4 tsp of iodized salt daily to get enough. If you’re a really liberal salter, you might be okay – but if, like me, you use little salt in your cooking and don’t usually salt at the table, you’re probably not getting enough. While I do recommend making sure that the salt you DO use is iodized (I had to switch mine since Daniel and I somehow managed to end up with some non-iodized salt that I’d been trying fruitlessly to use up), I don’t recommend that you start salting things more. While a small portion of the population could handle additional salt, the majority of us get way too much sodium from the processed foods we eat – but this salt generally doesn’t contain any iodine. So, to make sure you’ll be getting enough iodine during pregnancy, I recommend looking for a multivitamin that contains both that 400-800 mcg of folic acid AND 100% of the daily value for iodine (that’ll be 150 mcg).

Iron is a tricky one. The research is mixed regarding the benefits or drawbacks of iron supplementation during pregnancy – and the evidence is currently insufficient to recommend that all pregnant women take an iron supplement. On the other hand, iron-deficiency during pregnancy is one of the most common preventable pregnancy complications. If you have been diagnosed with anemia in the past, it might be a good idea to ask your doctor about checking your hemoglobin before you conceive and treating anemia now. If you suspect that your iron intake is low, you could do a three day food diary and check out how close your current intake comes to the daily value. Check labels to see if your daily intake comes up to 100% of the Daily Value. If you’re usually getting 100%, don’t fret unless your doctor tells you otherwise. But if you’re generally getting less than 75% of the Daily Value, it might be worthwhile to include iron in your supplement.

Calcium is the third nutrient that some women may not get quite enough of during pregnancy. If you’re a milk drinker who currently drinks 3 cups (24 oz, not 3 glasses) of milk a day, you probably don’t need to worry. But if you only have milk in your cereal, you may not be getting enough calcium. Like iron and folic acid, though, calcium values are listed on the nutrition facts labels. So, do that three day food diary, count up your calcium intake. If you’re usually getting less than 75% of the daily value, you might want to consider supplementing some calcium as well.

Now that you know what your supplement should contain, it’s time to choose your supplements.

I generally recommend starting with a multivitamin that contains at least 400 mcg folic acid and 150 mcg iodine. If your daily intake of iron and calcium is less than 75% of the daily value, go ahead and look for a supplement that contains 100% of the daily value for iron and at least 20% of the daily value for calcium. If you already have anemia or if your calcium intake is less than 50% of the daily value, it’s probably better than you choose a multivitamin without extra calcium and iron and choose to supplement those separately instead. It’s also important to note what the multivitamin should NOT contain. It should NOT have any more than 100% of Vitamins A, D, E, and K (the four fat soluble vitamins can build up in your body and lead to toxicity – and Vitamin A, in particular, can be very dangerous for a growing baby) and it should NOT have any herbal additives.

If you’re most women, that one multivitamin should be all you need for the preconception period and during pregnancy. You should NOT take any additional vitamin, mineral, or herbal supplements unless they are prescribed by your doctor.

If you were anemic before pregnancy, your doctor will likely give you directions for how to supplement. Generally, iron-deficiency anemia is treated with a ferrous sulfate supplement containing 65 mg iron once or twice a day. You should take these as the doctor recommends, keeping in mind that “twice a day” does not mean “two pills a day.” Your body can only absorb a certain amount of iron at a time, so taking two pills at a time means one will probably just go right through. Take the iron pill with a little bit of 100% fruit juice (which contains extra vitamin C) to help you absorb the iron better.

If your intake of calcium is very low (less than 50%), you should probably be taking a separate calcium supplement. Choose calcium carbonate or calcium citrate (NOT oyster shell calcium, which can be contaminated) in a dose that will bring you up to 100% of the daily value for calcium. The calcium in the supplement will be best absorbed if it contains no more than 500 mg of calcium in each dose, and if it is accompanied by some vitamin D. I do recommend trying to keep your daily intake of Vitamin D from supplements below 2000 IU daily unless you have a documented Vitamin D deficiency and are taking Vitamin D under the supervision of a doctor – so check the labels of both the multivitamin and the calcium and make sure your daily intake will be less than 2000 IU.

In my case, I ended up with a generic men’s over 60 one-a-day multivitamin (which contains 400 mcg folic acid and 150 mcg iodine), a iron supplement (65 mg iron), and a calcium supplement (600 mg calcium and 500 IU vitamin D-yep, I know I’m losing 100 mg worth of calcium, but it’s actually cheaper for me to flush that extra 100 mg than to buy a smaller dose). I’m taking the iron primarily because the men’s one-a-day doesn’t contain iron, not because I have preexisting anemia. If I were having constipation with the iron supplement (as many women do, but I am not so far), I would take it only every other day (since it contains a little over double the daily requirement.) I take the multivitamin with breakfast, the calcium at lunch, the iron at supper, and a second calcium (actually used to correct my vitamin D deficiency, not so much for the extra calcium) right before bed.

Most of you should be able to get away with just a multivitamin – so you can breathe a sigh of relief!

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And now, at last we’re done planning and ready to START TRYING!!!

Even if you’ve done the three steps in Part 1 and Part 2, you’ve still got more you can do before you conceive to improve your pregnancy’s health.

4. Get immunized

Did you get all your shots as a child? Are you up-to-date on all your boosters? If you haven’t gotten or aren’t sure if you’ve gotten the MMR (measles, mumps, and rubella) vaccine and the Hepatitis B vaccine, now’s the time to get it done. If you didn’t get chickenpox as a child, you need the varicella vaccine too. And if you haven’t gotten a tetanus booster in the past ten years, you need one of those.

Play it safe and take your shot records along with you to your preconception appointment with your doctor and have him make sure you’re up-to-date. He may want to do some blood tests to make sure you’ve still got immunity to some of the things you were vaccinated against as a child.

Additionally, if it’s flu season when you’re thinking of trying, go ahead and get the flu vaccine. If it’s not yet flu season, don’t freak out yet, you can (and should) get your flu shot while you’re pregnant if you happen to be pregnant when the next flu shot becomes available.

I got all my shots as a child (including the MMR) and got the Hepatitis B vaccine when I first started working in healthcare. I had chickenpox three times, the last time of which rendered me immune (and allows me to experience shingles as an adult). I get a flu shot every year, this one no exception… and I cut myself badly enough that I got a Tdap (Tetanus, Diphtheria, and acellular pertusis) booster earlier this year. So no shots for me until next flu season (and another Tdap in my third trimester, since pertussis or “whooping cough” is not something I want to mess with and getting a shot myself is the best way to protect my newborn).

5. Take care of your teeth

Does this seem a weird one to you? It kinda does to me.

But it’s true. Having healthy teeth and gums can make a big difference in your pregnancy. Gum disease prior to pregnancy increases adverse pregnancy outcomes. It’s wild but true. And while you can try to get your teeth healthy during pregnancy, there isn’t really much evidence that this helps prevent those adverse pregnancy outcomes. You’ve got to get to it beforehand. So, if you haven’t had a dental cleaning in the past 6 months, get one scheduled. If you don’t already brush your teeth twice a day with fluoride toothpaste, get started. And if you aren’t flossing every single day? Find a floss or an interdental cleaner that you will use and start using it. (Flossing is the single best way to prevent or solve the gum disease that increases pregnancy risk.)

And if you’ve been putting off some dental work that needs to be done? Get it done before you start trying to get pregnant. If you have teeth that need extracted (like my wisdom teeth!), it’s tons nicer to be able to be OUT for the procedure – and they won’t do that if you’re pregnant. Maybe you just need a cavity filled? While you can get that done during pregnancy, it’s best to avoid silver-amalgam (aka mercury amalgam) fillings during pregnancy – and it’s also a good idea to avoid doing anything in the mouth that might release some of the mercury from your existing fillings into your bloodstream. So get that dental work done now!

Up-to-date on your cleanings and don’t have any work that needs done? Don’t worry about it. Keep practicing good oral hygiene; you can keep your next 6-month check up even if you’re pregnant when that comes around.

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We’re on the home stretch now – I’ll be talking next about how to choose the right vitamin(s) to start taking to prepare your body for pregnancy and then we’ll be READY TO START TRYING!

So you’ve been working through my prepregnancy list. You’ve got all those bad habits squashed and you’ve reached a healthy weight.

Or maybe, like me, you don’t have any bad habits to quit and your BMI is already between 20 and 30.

You’re (We’re) not off the hook yet. There’s more.

3. Get any pre-existing medical conditions under control

Are you currently on any medications? If so, it’s worthwhile to talk to your doctor and make sure they’re safe for use during pregnancy. If possible, it’s nice to switch to pregnancy-safe medications prior to trying to become pregnant–it can save you the grief of struggling to figure out how to get things under control while your hormones are swinging in early pregnancy (and reduce the chances of your baby being exposed to something potentially harmful while in utero.)

What if you’re not on any medications at present? That’s great, as long as that means that you’re healthy. But if you have asthma, depression, diabetes, epilepsy, lupus, phenylketonurea, polycystic ovarian syndrome, or thyroid conditions that aren’t being treated (or not being treated optimally), you could be putting your pregnancy at risk. If you have any of these conditions (or suspect that you have any of these conditions), it’s best to schedule a preconception appointment with your doctor to make sure everything’s under control.

Additionally, if you or your partner have ever had sex with anyone other than each other, you should have a gynecological exam and get tested for sexually transmitted infections. Getting evaluated and treated prior to pregnancy can make a big difference in the health of your pregnancy.

For my part, I have a thyroid condition, so I knew I wanted to make sure I was taking an optimum dose of replacement hormones. I scheduled an appointment with my doctor to get a TSH (thyroid stimulating hormone) and free T4 test done to check on the adequacy of my thyroid hormones. It looks like I’m doing well now, but I also know that I need to go in for another test as soon as I find out I’m pregnant as dose-changes during pregnancy are very common and can make a big difference to baby’s health.

I’m also on an antidepressant, so I knew I needed to take a look at that too. Depression during pregnancy can be dangerous to mom and baby’s health since depression often leads to a host of unhealthy behaviors, so it’s important that depression be under control. At the same time, antidepressant medications may pose some risk to the baby. For that reason, it’s important to balance the cost and benefits of medicating for depression during pregnancy. If counseling or behavioral techniques are sufficient to manage your depression, that’s fantastic. Otherwise, you want to be on the lowest dose of the safest type of medication that will manage your depression. In general, the safest types of antidepressants are SSRIs (selective serotonin reuptake inhibitors), medications like Prozac and Zoloft. Since my medication is an SSRI, I can stay with my current medication, but I want to find the lowest effective dose. The thing with psychoactive medications, though, is that they can’t just be cut off cold turkey. You need to talk with your doctor about the best way to taper your dose. The plan my doctor and I came up with was that I’d take a full pill every other day with a half pill on the opposite day for two weeks. At the end of two weeks, if my depression was still under control, I could move to a half pill every day, and so on and so forth. Depending on which medication you’re taking and the severity of your symptoms, your doctor may recommend another regimen.

My final medical condition that needed to be checked out was allergies. Grrr. Allergies.

About a third of women experience an increase in allergy symptoms during pregnancy. Another third see no difference in allergy symptoms. The final fortunate third experience a decrease in allergy symptoms. Since my allergies are currently awful, I have a 67% chance that I’ll still have awful allergies during pregnancy. Which means that it would do me well to get them under control (in a pregnancy-safe way) now.

The first step was evaluating what I was already taking and determining whether those medications were pregnancy-safe.

• Guaifenesin (Mucinex)-an expectorant, safety in pregnancy unknown. This is nice but not absolutely required to control my allergy symptoms. I can just drink lots of water or hot tea to keep my fluids running. I chose to discontinue this and use those non-drug options.
• Pseudoephedrine (Sudafed)-a decongestant, generally considered safe during pregnancy but not recommended for breastfeeding. Decongestants dry up body fluids, including cervical mucous (which is helpful when you’re trying to get pregnant) and breastmilk. Which means I could benefit from going off the psuedoephedrine now. To manage nasal congestion, I’m now taking an inhaled corticosteroid, which doesn’t have systemic effects (and therefore isn’t as risky for either pregnancy or breastfeeding.)
• Fexofenadine (Allegra)-an antihistamine, safety in pregnancy unknown. I tried going without and just using the inhaled corticosteroid–but my eyes itch and my sinuses plug, so I have to stay on some sort of antihistamine. The doctor recommended cetirizine (Zyrtec) or loratadine (Claritan), two better studied antihistamines. For now, I’m experimenting with cetirizine, trying to see if I can manage the drowsy side effect by adjusting what time I take it. If that doesn’t work, I may have to go with Claritan (less safe and, at least when I used it back in high school, not very effective for me).

Your process, depending on what sort of medications you’re on or what conditions you’re treating, may be a little different. But the general steps you and your doctor will want to take will be:

1. Evaluate the risks associated with a poorly controlled condition
   For example, uncontrolled hypothyroidism or diabetes can be horrible for the baby. Uncontrolled respiratory allergies? Not so much unless they’re accompanied by uncontrolled asthma. In my case, I’m going without a lot of my allergy meds because the only risk is decreased quality of life for me. If I start having more asthma episodes once I’m pregnant? I’ll probably be ramping back on to some more serious allergy meds
2. Evaluate the risks associated with your current medication regimen
   Depending on the risks of your current medication regimen and the process you went through to get to your current regimen (for example, if you tried multiple medications before you found one that adequately controlled your condition), your doctor may decide that no changes to your medications are needed. On the other hand, your doctor may want to try some lower-risk alternatives to your current regimen.
3. Adjust medications to maximize benefits and minimize risks
   Especially if you’re taking a high risk medication and haven’t tried a lower risk one, your doctor will probably try either switching to a lower risk one or adjusting your dose down to find the lowest possible risk (from medication) while still maintaining adequate control (to avoid risk from an uncontrolled medical condition.)

This step can be a long one, depending on what kind of medical conditions you have and what kind of medicines you’re on. That’s why it’s worthwhile to set up a preconception appointment as soon as you start thinking about trying to become pregnant.

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And yes, I’m still not done. I’m guessing there’ll be one or two more installments in the planning section–and then, who knows, maybe I’ll be able to talk a bit about post-planning pregnancy health :-)

By the time I see a pregnant woman, there’s only a very limited amount we can do.

We can manage nausea and try to have appropriate weight gain. We can make sure she doesn’t get listeriosis. We can treat her anemia. We can try to get her blood sugars back under control. But generally, we’re too far behind to make a significant difference.

If we really wanted as healthy a pregnancy as possible, we’d have needed to start before she got pregnant–not at 20 weeks along.

So, say you’re thinking about having a baby…what are the first steps you should take to plan for a healthy pregnancy?

1. Quit bad habits

If you smoke, you’re currently starving your body’s organs of oxygen. If you get pregnant while you’re smoking, you’ll be starving baby of oxygen. Womb-asphyxiated babies don’t grow as well–they are more likely to be born prematurely and more likely to be born small, both of which increase the risk for a whole slew of problems in infancy and beyond. Stop smoking before you start trying.

If you use illegal drugs, cut it out. Cocaine, meth, and narcotics all increase the risk of low birthweight and preterm birth. Think that’s not so bad? Low birthweight and preterm birth are the single leading cause of infant death. Furthermore, your baby can get addicted to those drugs in utero–and when they start going through withdrawal in the delivery room? You’re going to get your baby taken away.

Think marijuana’s okay? It’s legal in two states, so it’s fine, right? Think again. Marijuana use increases risk of at least two different types of congenital heart disease–and there’s plenty we don’t know about how marijuana affects pregnancy. It’s not worth the risk.

What about alcohol? If you’re drinking under the recommended amount for women (no more than once a day with no more than one drink on any given occasion), you don’t need to worry too much about this one in the preconception period. But if you’re dependent on alcohol or are used to consuming more than one drink at a time, now’s the time to rein this in to within the recommended amount for women. Since you’re going to be quitting drinking entirely once you start trying, it wouldn’t hurt if you were to cut back beyond the recommendations at this point.

I know that a lot of you are breathing a sigh of relief at this point. You’re good to start trying, you might be thinking.

But there’s more.

2. Attain a healthy weight

There are plenty of people who have their personal tiffs with BMI (myself included), but it does have some value. When we look at BMI as a predictor of pregnancy outcome, we do see an increased risk with both high and low BMIs. The risk of miscarriage is more than doubled in women with BMIs over 30, while women who have BMIs between 25 and 30 are at only slightly increased risk of having a miscarriage. Obesity (defined as a BMI above 30) also increases risk of having an infant born with a neural tube defect. Furthermore, obesity is frequently associated with a host of metabolic and cardiovascular abberations that can cause complications during pregnancy (predisposition to diabetes and hypertension among them). On the other hand, having too low a BMI has problems of its own. Women whose prepregnancy BMIs were below 20 have an increased risk of delivering a baby prematurely (which I’ve already mentioned leads to a whole host of other complications).

The good news is that you can do something about these risks. By attaining a healthy weight prior to pregnancy, you can improve your chances of having a healthy, uncomplicated pregnancy and delivery.

So, check out your BMI. If you’re under 20, start working on gaining weight. If you’re over 30, start working on losing weight.

I know, that last bit isn’t as easy as it sounds. If readers are interested, I’m willing to go into a bit more depth on the best approaches for losing or gaining weight prepregnancy–but this information isn’t dramatically different than normal healthy weight gain/weight loss strategies, so I was thinking to focus more specifically on the items that are more specific to pregnancy in this particular series.

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And I’m now up to over 600 words with a bazilliondy things left to mention, so we’ve got ourselves a series :-)