General pregnancy supplements

General pregnancy supplements such as Blackmores I-Folic, Blackmores Pregnancy & Breast-Feeding Gold or Elevit, provided they contain folate and iodine, are recommended for pregnancy.

It is possible to achieve the dietary requirements of most essential vitamins and minerals in a normal balanced diet. Unfortunately, this is not always easy in pregnancy when nausea, vomiting or dietary preferences may interfere. 

I recommend at least 400 micrograms of folate per day, ideally for one month prior to conceiving and throughout the first trimester, to prevent neural tube defects. Additionally, iodine deficiency is a significant concern during pregnancy. These are both included in sufficient doses in these supplements.

I may recommend additional iron, folic acid, calcium, magnesium or vitamin D depending on your circumstances.

Iron

Iron is used by the body to help red blood cells carry oxygen to your organs and tissues, and your body’s requirement in pregnancy doubles. A sufficient daily dose is found in most pregnancy multivitamins, but you can also eat iron-rich foods such as red meat, poultry, fish, beans and peas, iron-fortified cereals and prune juice. Iron is more easily absorbed if it is eaten with vitamin C-rich foods such as citrus fruits, berries and tomatoes.

Calcium

Calcium is used to build your baby’s bones and teeth. It is found in milk, cheese, yoghurt, broccoli, and dark leafy greens. In some patients, I will recommend a calcium supplement.

Manicures, pedicures and massages

Nail polish and nail polish remover are not harmful to your baby, however I recommend applying them in a well-ventilated area to minimise the inhalation of toxins. Less is known about the safety of gel manicures, so they are best avoided. 

If you are having a pedicure, it is important to ensure the tubs where you soak your feet are cleaned after every use or have disposable linings. This will reduce the risk of a bacterial infection.

With respect to massages, I advise visiting only therapists who specialise in pregnancy massage. They will optimise your position during the massage to maintain placental blood flow and avoid strain on your back and belly, as well as knowing which pressure point triggers to avoid.

Hair colour

Although safety data on hair colouring in pregnancy is limited, the amount of hair dye absorbed through your scalp is negligible, meaning that adverse effects for your baby are extremely unlikely. I suggest avoiding unnecessary exposure during the first trimester while your baby’s organs are developing. Furthermore, if you have any breaks in your scalp avoid hair treatments until they have resolved.

Laser hair removal 

While laser hair removal is unsuitable during the first trimester of pregnancy, it can be continued during the second and third trimesters. Many clinics will request mandatory medical clearance prior to proceeding. As an alternative, shaving and waxing are entirely safe methods of removing unwanted hair whilst you are pregnant.

Fake tan

Fake tan contains a chemical called dihydroxyacetone (DHA). When applied to the skin directly it is not absorbed into the body and therefore cannot affect your baby. Fake tan creams and lotions are therefore safe during pregnancy. However, I suggest that you avoid spray tans as the DHA can be accidentally inhaled. If you are getting a spray tan, you should ensure that you wear a face mask during the process. During pregnancy, your skin may be more sensitive than usual, so I recommend testing any fake tan on a small area of skin first to ensure you do not have an allergic reaction to the product.

Epworth Freemasons Hospital conducts childbirth education and early parenting classes. Information will be provided by the hospital when you receive your hospital registration. Fees for private classes may be covered by your health fund, although there is often an out of pocket expense. I encourage both you and your partner to attend these classes, as they will prepare you better for birth, delivery, breast/chest feeding and early parenting. Further information can be found here with bookings made online.

Most people first feel fetal movements at 18 to 22 weeks gestation. With your first baby, this often occurs after 20 weeks, however with subsequent babies it may be as early as 16 weeks. Importantly, movements are different for every person, and you will become aware of what is normal for your baby. Movements tend to increase in frequency until 32 weeks and then plateau. Although the type of movement may change from kicks to more subtle rolls as your pregnancy progresses, the movements should not reduce in frequency, including up until the onset of labour.

Reduced movements may be the first sign that your baby is unwell. Each time you feel the movements are reduced, no matter how often this occurs, you should contact me immediately for advice. Call my rooms during business hours and Labour Ward outside of these hours. I will arrange for your baby’s heart beat to be monitored, and I may also organise an ultrasound scan to assess the growth and well-being of your baby. If you are at term, and experience reduced movements, I may advise that the safest thing to do is to move towards delivering your baby. Reassuringly, most patients with reduced movements will have a normal pregnancy outcome.

Fish

Omega-3 fatty acids, which are found in many kinds of fish, are important in the development of the brain both before and after birth. While you are pregnant it is safe and healthy to eat two to three serves of fish per week, but the consumption of certain species needs to be limited because of the mercury content. You should limit your intake of shark (flake), marlin or swordfish to no more than one serve per fortnight with no other fish to be consumed during that fortnight. For orange roughy (also known as sea perch) and catfish you should consume no more than one serve per week with no other fish being consumed during that week. Smoked fish, sushi and sashimi should be avoided.

Caffeine

Studies on caffeine and the risk of miscarriage are inconclusive. Most obstetricians agree that consuming 200mg of caffeine per day (one cup of coffee) is safe.

Food hygiene

Listeria infection or Listeriosis is an illness caused by food contaminated with a bacteria known as Listeria monocytogenes. Infection with Listeria is exceptionally rare but the complications are quite serious and pregnant women are more susceptible to infection. During pregnancy you should reduce your risk of contracting Listeria by eating only freshly prepared foods, reheating left over foods until piping hot and avoiding ready to eat foods which have been refrigerated for more than a day. You should also avoid the following foods: raw seafood, smoked fish, smoked mussels, soft service ice-creams, soft cheeses (camembert, brie, ricotta), unpasteurised milk or foods made from unpasteurised milk, coleslaw and precooked meat products which are eaten without further cooking or heating (pate, sliced deli meat, cooked diced chicken from sandwich bars).

Toxoplasmosis is an uncommon infection carried by cats and transmitted in their faeces. You should not handle cat litter during pregnancy. Gloves should be worn when gardening and your hands washed carefully following any contact with cats.

Salmonella is a bacterial infection that although unlikely to harm your baby can cause you to have severe diarrhoea and vomiting. To prevent transmission:

• Avoid raw or partially cooked eggs or foods that may contain them eg. mayonnaise

• Avoid raw or partially cooked meat, especially poultry

If you are sharing a household with pets during your pregnancy, there are a few important risk factors to keep in mind:

Cats 

The main risk with cats is the parasite toxoplasmosis, which can cause significant birth defects or stillbirth. Toxoplasmosis is spread via feline faeces, so avoid touching the litter box and garden beds, and wash your hands carefully with soap and water after petting your cat. Avoid touching stray or unfamiliar cats while pregnant. 

Dogs

The main advice here is to limit rough play with your dog once your bump ‘pops’ — this is to avoid your dog jumping on or striking your belly.

Hamsters, Guinea pigs & rodents

These animals can carry a virus called lymphocytic choriomeningitis which is an infection that can cause severe birth defects and miscarriage. While pregnant, avoid cleaning the cage and touching any bodily fluids from these animals - consider moving the cage to a room you do not have to enter on a regular basis.

Reptiles

These animals can carry salmonella — avoid touching them, and clean any surfaces they touch (outside of their enclosure).

Exercise

During your pregnancy, aim to be active on most, if not all days of the week. Do moderate intensity activities for 2.5–5 hours each week or vigorous intensity activities for 1.25–2.5 hours each week. The benefits of exercise during pregnancy include:

• Reduced back pain

• Decreased constipation

• Promotion of healthy weight gain in pregnancy

• Improved overall general fitness and improved mental heath

• Possibly shorter and less complicated labour

• Easier loss of baby weight after the baby is born

Good options include:

• Walking

• Swimming and water workouts — avoid prolonged immersion in heated spas and hydrotherapy pools

• Stationary bicycling 

• Modified yoga and modified Pilates

Avoid:

• Strenuous exercise, especially if repeated or prolonged, as this may affect fetal growth

• Contact sports

• Vigorous racquet sports that may involve the risk of abdominal trauma

• Activities that may result in a fall, such as snow skiing and water skiing

• Scuba diving

• Skydiving, bungee jumping and parachuting

• “Hot yoga” or “hot Pilates”

• Heavy weight-lifting

• Sit-ups after the first trimester

When exercising, ensure that you drink plenty of water and avoid becoming overheated. You should wear a sports bra that gives adequate support.

If you experience any of the following symptoms, you should stop exercise and seek medical attention immediately:

• Chest pain or shortness of breath

• Faintness or dizziness

• Uterine contractions or abdominopelvic pain

• Decreased fetal movements

• Calf pain, swelling or redness

• Vaginal bleeding or amniotic fluid loss

Alcohol

There is no safe amount of alcohol consumption during pregnancy. Alcohol is best avoided whilst trying to conceive and throughout pregnancy. 

Smoking

Cigarette smoking is associated with a number of pregnancy complications including miscarriage, fetal growth restriction and stillbirth, as well as being detrimental to your health. I recommend that you stop smoking during pregnancy. 

Sexual activity

Sexual activity and orgasm are safe during pregnancy. It is not unusual to have a small amount of bleeding after sexual intercourse. This is not cause for concern unless the bleeding is either heavy or recurrent. If you have a history of miscarriage you may prefer to abstain in the first trimester. You may be advised to avoid penetrative intercourse if you have a condition called placenta praevia, where your placenta lies low down in your uterus (near the cervix).

Sleeping positions

There are many myths about sleeping positions for pregnancy. You may sleep on either your left or right side at all stages of pregnancy. It is best to avoid lying on your back from 20 weeks so that you avoid compressing the major blood vessels in your abdomen. This can lead to low blood pressure and fainting.

In practice, the risks to your baby are very small. If you wake up and find that you have been lying on back do not panic. You will have done no harm; your body has done exactly what it should have and woken you to allow a position change.

It is important to understand how drugs are classified according to their safety in pregnancy. In Australia drugs are categorised as A, B, C, D or X according to their safety in pregnancy:

• Category A drugs have been taken by a large number of pregnant people for many years with no evidence of any adverse effects on the fetus ever having been reported.

• Category B drugs, likewise, have never been shown to have any adverse effects but have only been taken by a limited number of pregnant people.

• Category C drugs have been known to have or are suspected of having harmful effects on the fetus but these are not necessarily effects that may be relevant during the first trimester. They do not cause malformations.

• Category D drugs have caused or may be expected to cause fetal malformations or irreversable damage.

• Category X drugs are known to cause fetal malformations with such a high risk of permenant damage that they must never be taken in pregnancy.

You can be assured that if I ever prescribe a drug for the treatment of any condition in pregnancy that I am perfectly comfortable with its safety. I will never prescribe a Category X medication; almost always I will prescribe Category A and Category B drugs. If I ever prescribe a Category C or Category D drug it is because I believe the benefits of you taking the medication outweigh the potential risks. Nevertheless, I appreciate that there is a great reluctance for many patients to take any medication in pregnancy and this is completely understandable.

Please see our full list of drugs and categories here.

Newborn infants have a relative vitamin K deficiency at birth. I recommend that all newborn infants should receive vitamin K prophylaxis at birth. This is usually given as a single injection just after your baby is born, however it can be given orally to full term babies who then require three doses. These are given at birth, on day 3-5 and again in the fourth week of life (this dose can be omitted in predominantly formula-fed infants).

Car travel

Always wear a three-point seatbelt above and below your pregnant belly, not over it. Make frequent breaks to stretch your legs and visit the toilet. Keep a water bottle filled with cool water in your car.

Flying

There is no evidence that air travel has a harmful effect on you or your baby, with no increased risk of miscarriage, preterm labour or rupture of the membranes. The primary concern I have for pregnant patients who wish to travel is that, if you deliver away from Melbourne, the risks to you and your baby are greater:

• You will need to find a new hospital and a new doctor, neither of whom will have a record of your history

• If you deliver even slightly prematurely, you are not permitted to travel until the newborn is the equivalent of 40 weeks gestation

• It is very difficult to get travel insurance to cover you for pregnancy after around 26 weeks internationally or 36 weeks domestically

• The costs for an international delivery can be as high as one million dollars, and are rarely covered by insurance. It is for these reasons that I do not recommend pregnant women fly internationally from around 26 weeks and domestically after around 36 weeks. If you do need to fly, the airlines will require a letter from me authorising you to fly (either internationally or interstate) after 20 weeks gestation. Please contact my rooms to request your letter.

When flying, I suggest that you do the following to reduce the risk of deep vein thrombosis:

• Wear compression stockings

• Wear loose clothing and comfortable shoes

• Try to get an aisle seat

• Take regular walks around the plane

• Do in-seat exercises every 30 minutes or so

• Have cups of water at regular intervals throughout the flight

• Cut down/avoid drinks that have alcohol or caffeine

I also recommed wearing your seatbelt at all times – it should be belted below your belly

Travel and illness

In some countries, hygiene standards may not be as stringent as they are in Australia, and the risk of infection (and thus complications) is substantially higher. When travelling, avoid salads, ice, water (including bottled water unless you can be certain you are the one who broke the seal) or anything else that may have been rinsed in tap water. Also, try not to eat food of which you cannot guarantee the safety.

Zika virus

Zika virus can potentially pose serious risks to your baby, including:

• Microcephaly (an abnormally small head) — this can cause long-term problems such as seizures, feeding problems, hearing problems, visual problems and learning difficulties

• Other brain abnormalities

Zika virus is spread via the following methods:

• Mosquito bites

• From a pregnant patient to their fetus

• During sex

Unfortunately there is no vaccine, and avoiding infection is therefore best. My recommendations for pregnant people are as follows:

• Avoid countries that are high or moderate risk for Zika virus

• If you travel to a high or moderate risk country, avoid mosquito bites – use pregnancy-safe bug sprays, wear long-sleeved shirts and long pants, wear clothing that has been treated with permethrin and stay in air-conditioned or screened-in areas

• Avoid unprotected sex with a male/person with XY chromosomes partner who has been to a high or moderate risk country for the duration of the pregnancy or for 6 months, whichever is longer

• Avoid unprotected sex with a female/person with XX chromosomes partner who has been to a high or moderate risk country for 8 weeks.

I recommend Zika virus testing in pregnant women with Zika virus exposure whether or not you have symptoms of infection. Symptoms of infection are usually mild and include fever, rash, joint pain and itchy red eyes. Usually, two blood tests will be taken, with the second blood test at least 2 weeks after the first sample and at least 4 weeks after your last potential exposure to Zika virus.

If you are not yet pregnant, and have been to a high or moderate risk Zika-affected country, you should avoid pregnancy and unprotected sex for at least 8 weeks. If your male partner has also been potentially exposed to the Zika virus, pregnancy and unprotected sex should be avoided for 6 months. If you are unable to wait 6 months, I can arrange a blood test for your male partner 4 weeks after the last potential exposure to exclude infection.

Influenza Vaccine

Pregnant people are particularly susceptible to Influenza infection. It can be a very serious illness that can cause severe pneumonia in pregnancy and rarely, the early delivery or loss of an unborn baby. Newborns are also at high risk. Having the Fluvax during pregnancy protects you for 12 months and your baby for the first six months of its life. As there are multiple strains of this virus that change annually, it is necessary to have an Influenza vaccination on an annual basis. The vaccine is safe at all stages of pregnancy, including the first trimester.

Whooping Cough Vaccination

Whooping cough is a highly contagious respiratory infection that is particularly serious in babies under 6 months of age. If they contract the virus, they are at risk of significant complications and usually need to be hospitalised. Pregnant people should be vaccinated against whooping cough in every pregnancy to help protect their newborn via transfer of antibodies across the placenta. This should be done between 20 and 32 weeks gestation. Babies usually receive their first vaccination against whooping cough between 6 weeks and 2 months of age, with the next two doses given at 4 and 6 months (babies remain especially vulnerable until after the third injection has been given). The optimal way to protect babies from whooping cough is ensuring up to date immunity in all adults who will be in contact with the baby. If an adult will have close contact with a newborn baby, they should check that they have had a whooping cough vaccine booster within the preceding five years. Ideally, this should be given at least two weeks before they have contact with your baby.

I will also check your immunity to Rubella (German Measles) and Varicella (Chicken Pox) during pregnancy. If you are found to be non-immune, I will suggest a postnatal vaccination for you – please do not have these vaccinations while you are pregnant. If you are inadvertently vaccinated against either of these infections in pregnancy (or within 28 days of becoming pregnant) please do not panic as no adverse reactions have ever been reported.

Vaginal seeding can be undertaken by patients whose babies have been born by caesarean section. A gauze swab is used to transfer the patient's vaginal fluid, and hence vaginal microbiota, to the baby’s mouth, face and body shortly after birth.

The theory behind this is that vaginal birth exposes the baby to vaginal microbiota, which reduces the risk of autoimmune diseases, asthma, and allergic diseases seen in children delivered by caesarean section in patients who did not have a labour. 

However, newborns may develop severe infections from exposure to vaginal bacteria and viruses, which could also be transferred on a vaginal swab. This includes group B streptococcus, chlamydia, gonorrhoea and herpes.

In the absence of proven benefit or safety, vaginal seeding cannot be recommended. However, as long as you are fully informed about the theoretical risks, I will respect your decision to perform vaginal seeding should you choose to do so.

Miscarriage can be a devastating outcome for a wanted pregnancy, yet it is a relatively common phenomenon as approximately 1 in 5 pregnancies will result in miscarriage. Happily, for most patients, the next pregnancy will bring a happier outcome. Unfortunately, in a small proportion of cases the subsequent pregnancy will not have the desired result, with approximately 2% of patinets experiencing two consecutive miscarriages and less than 1% suffering three consecutive miscarriages. The definition of recurrent miscarriage varies - traditionally it has referred to three or more consecutive failed pregnancies, however many guidelines now define it as two or more consecutive pregnancy losses.

What causes recurrent miscarriage?

I too often see couples despairing after a second consecutive pregnancy loss. It is natural for people to blame themselves for their miscarriages — I commonly get asked “Was it something I ate?” or “Was it because I pushed myself too far at the gym?” or “Did this happen because we had sex after finding out we were pregnant?” Well I can reassure these people with absolute confidence that this outcome has not been self-inflicted. Somewhat frustratingly for those going through recurrent miscarriage, in 50% of cases no cause will be found.

However, the other 50% of cases of recurrent miscarriage are due to underlying pathology. Possible recognised pathologies include:

• Genetic problems in one or both parents — 3–5% of cases

• Abnormalities in the shape of the uterus, due to either congenital factors (including uterine septum or bicornuate / ‘heart-shaped’ uterus) or acquired factors (such as fibroids) — 10–50% of cases

• Hormonal issues such as poorly controlled thyroid disease or diabetes — 15-60% of cases

• Autoimmune disorders such as antiphospholipid syndrome — 5-15% of cases

In order to determine whether or not an underlying abnormality exists, all patients with recurrent miscarriage should ideally see an obstetrician who can begin performing investigations. Finding a cause allows for appropriate, targeted interventions personalised to your circumstances, with the aim of reducing the risk of subsequent miscarriages. 

What will I do to help reduce your risk of recurrent miscarriage?

A thorough medical history will be taken, along with a history of each your pregnancies including your miscarriages. From this, I may also arrange for a number of relevant medical investigations to be performed. These may include:

• Specialist pelvic ultrasound to assess for abnormalities of the uterus

• Bloods tests, including tests for thyroid disease and antiphospholipid syndrome

• Genetic testing of the parents where indicated

I may also suggest commencing Asprin peri-conceptually.

If a pathological cause for recurrent miscarriage is found, what happens next?

Where identified, any underlying condition should be treated — the exact treatment will depend on what the cause is, and what approaches the patient or couple is comfortable exploring. Some examples include:

• For couples where a genetic issue is identified, genetic counselling should be arranged. IVF with pre-implantation genetic testing for monogentic conditions (PGT-M) may be used to avoid implantation of an affected embryo

• Uterine abnormalities may require surgery 

• Thyroid disease and antiphospholipid syndrome require medications prior to and/or after conception to reduce the risk of a subsequent miscarriage - these will often be prescribed in consultation with another specialist, such as an endocrinologist or haematologist respectively

Pregnancy after recurrent miscarriage

Along with the correct medical support that I provide as your obstetrician (such as frequent blood tests, weekly scans and progesterone supplementation where indicated), it is essential to have adequate psychological support as well. Patients with a history of recurrent miscarriage often experience significant anxiety in each subsequent pregnancy, and frequent appointments with me to ensure the well-being of the pregnancy can be incredibly reassuring. I may also refer you also to my practice psychologist for support during this time.

Key points:

• Recurrent miscarriage is where a patient has experienced two or more consecutive pregnancy losses.

• 50% of the time, the cause of recurrent miscarriage is unknown; 50% of the time there is an underlying medical pathology. 

• There are are a number of possible medical interventions that can be applied to optimise the chance of future successful pregnancies (dependent on individual cases). 

• People who experience recurrent miscarriage are at a high risk for anxiety, and psychological support is important during the preconception, antenatal and postnatal periods.

Cytomegalovirus (CMV) is a common virus that can be passed from person-to-person without their knowledge, usually via close contact. The most common source of CMV infection is young children, as they are more likely to shed high levels of virus in their saliva, urine or nasal secretions for long periods. Women who catch CMV infection while pregnant may pass the virus to their unborn child. If infected, some of these children may have health problems such as hearing loss, developmental delay and learning problems. Pregnant women can reduce their risk of being infected with CMV by aiming to adhere to the following advice:

• Do not share food, drinks, or utensils used by young children (less than 3 years of age)

• Do not put a child’s dummy in your mouth

• Avoid contact with saliva when kissing a child

• Pay attention to hand hygiene, when changing nappies or when in contact with urine. Thoroughly wash hands with soap and water for 15–20 seconds, especially after changing nappies, feeding a young child, or wiping a young child’s nose or saliva

• Clean toys, countertops, and other surfaces that come into contact with children’s urine or saliva

• Do not share a toothbrush with a young child

I will check your CMV immunity during the first trimester, as this further allows me to quantify your risk during pregnancy.