Obstetric Topic 60. Advices during pregnancy

I. General Counseling

Goals

• Advice during pregnancy: maternal self-care, fetal protection and early recognition of danger signs.
• Main areas: nutrition/supplements, teratogen avoidance, medication safety, vaccines, exercise, travel and psychosocial risks.
• Individualize by gestational age, BMI, medical disease, medications, obstetric history and social/work risks.

Danger Signs Requiring Review

• Bleeding, severe abdominal pain, regular painful contractions, rupture of membranes.
• Severe headache, visual symptoms, epigastric/RUQ pain, sudden swelling, dyspnea or chest pain.
• Fever, dysuria/flank pain, persistent vomiting/dehydration or reduced fetal movements after viability.

II. Nutrition and Supplements

Diet

• Balanced diet: protein, complex carbohydrates, vegetables/fruit, dairy/calcium source, iron-rich foods and healthy fats.
• Protein: supports maternal plasma proteins, fetal growth and tissue repair; severe protein deficiency worsens edema risk.
• Water intake: maintain circulation, urine output and lower dehydration/VTE risk; do not use diuretics or fluid restriction for physiologic edema.
• Weight gain: individualize by pre-pregnancy BMI; avoid both restriction and excessive gain.

Food Safety

• Avoid raw/undercooked meat, fish, eggs; unpasteurized milk/cheese; unwashed vegetables/fruit.
• Prevent listeria/toxoplasmosis: safe dairy/meat handling, wash produce, hand hygiene and avoid cat-litter exposure if possible.
• Mercury: avoid high-mercury predatory fish; choose low-mercury fish in moderate amounts.
• Limit caffeine and avoid energy-drink excess.

Supplements

• Folic acid: start before conception and continue through early pregnancy; prevents neural tube defects.
• Typical dose: 400 mcg/day for low-risk women; higher dose for previous neural tube defect or high-risk medication/history.
• Iron/iodine: often needed according to Hb/ferritin, diet and local prenatal protocol; iodine supports fetal brain/thyroid development.
• Calcium + vitamin D: fetal ossification and maternal bone health; calcium also helps if dietary intake is low.
• Magnesium ± vitamin B6: may help leg cramps; calcium and iron can reduce magnesium absorption → separate doses.
• Vitamin A: normal dietary/prenatal amount is needed; avoid high-dose retinol/isotretinoin because teratogenic.

III. Teratogens, Drugs and Infections

Avoid Teratogen Exposure

• Radiation: avoid unnecessary ionizing radiation, especially in 1st trimester; urgent indicated imaging should not be withheld but use shielding/lowest dose.
• Heat/hyperthermia: avoid sauna, hot tubs and hot yoga; fever should be treated with safe antipyretic and hydration.
• Alcohol: no safe amount; risk of fetal alcohol spectrum disorder → growth restriction, facial abnormalities, CNS dysfunction.
• Smoking/nicotine: hypoxia + vasoconstriction → miscarriage, placenta previa/abruption, PROM, FGR, low birth weight, stillbirth and SIDS risk.
• Illicit drugs and teratogenic medications: avoid; use necessary drugs only after pregnancy-safety review.
• Infections: use food safety, hand hygiene, STI prevention and seek care after rubella/varicella exposure if non-immune.

Medication Principles

• Use drugs only with clear indication; avoid self-medication and unnecessary polypharmacy.
• Preferred analgesic/antipyretic: paracetamol/acetaminophen at appropriate dose.
• NSAIDs: avoid especially after 20 weeks unless specifically indicated; avoid late pregnancy because ductus arteriosus constriction/oligohydramnios risk.
• Low-dose aspirin is an exception when indicated for preeclampsia prevention.
• Generally safe antibiotics: penicillins, cephalosporins and selected macrolides according to protocol.

IV. Immunization

Before Pregnancy

• Check immunity/vaccination status before conception when possible.
• Give needed live vaccines before pregnancy: MMR and varicella; avoid conception for about 1 month after live vaccine.
• HBV/COVID-19 and Tdap may be updated according to risk and national schedule.

During Pregnancy

• Inactivated influenza vaccine: recommended during flu season.
• Tdap: recommended in each pregnancy, usually 27-36 weeks, to protect newborn from pertussis.
• COVID-19/HBV/RSV: follow current national recommendations when indicated.
• Contraindicated: live vaccines such as MMR, varicella and live nasal influenza vaccine.

V. Physical Activity, Travel and Lifestyle

Exercise

• Uncomplicated pregnancy: moderate exercise is safe and beneficial.
• Recommended: walking, swimming/water exercise, stationary cycling, prenatal yoga/pilates, pelvic-floor/Kegel and back exercises.
• Avoid: abdominal strain, contact sports, high fall-risk activity, weight-lifting/anaerobic overexertion, scuba diving, hot yoga/pilates and prolonged supine exercise after 1st trimester.
• Stop exercise if bleeding, dizziness, chest pain, dyspnea before exertion, contractions, fluid leakage or severe headache.

Travel

• Travel is usually safe in uncomplicated pregnancy; avoid long-distance travel after about GW36 or earlier if high risk.
• Long trips: hydration, walking/leg exercises, loose clothing and compression stockings if VTE risk factors.
• Avoid travel with threatened preterm labor, PPROM, significant bleeding, severe preeclampsia or unstable medical disease.
• Seat belt: lap belt under abdomen across hips + shoulder belt between breasts.

Work, Sex and Psychosocial Care

• Work: avoid heavy lifting, toxic chemicals, radiation, extreme heat and prolonged standing if symptomatic/high risk.
• Sex is usually safe in uncomplicated pregnancy; avoid with bleeding, placenta previa, PPROM or preterm labor risk.
• Screen for depression/anxiety, intimate partner violence, substance use and poor social support.

VI. Common Symptoms

Symptom Relief

• Nausea/GERD: small frequent meals, avoid triggers, do not lie down immediately after meals; vitamin B6 or antacids if needed.
• Constipation/hemorrhoids: fiber, fluids, exercise and local treatment if symptomatic.
• Leg cramps/back pain: stretching, hydration, magnesium if useful, posture/back exercises; unilateral calf pain needs DVT review.