38 and Pregnant... Key advice

Question:  "I am 38 years old and pregnant with my second child.  I have heard there are extra screening tests for me such as amniocentesis.  But I've also heard that it can be risky.  Do I need to have one?"

Whether or not to have prenatal diagnostic testing is a personal decision that all pregnant women, regardless of their age, need to make for themselves. 

The older our ovaries get, the greater the likelihood of a chromosomal abnormality.   (The egg and sperm each carry 23 chromosomes,  giving each cell in the fetus 46 chromosomes altogether.) The majority of  pregnancies  with an atypical number of chromosomes will end in miscarriage.  However a few, most commonly Trisomy 21 (otherwise known as Down Syndrome in which there is an extra chromosome number 21), will continue to term.  Women age 35 and older are considered “advanced maternal age”.  35 was chosen as the "threshold" age because the risk of having a baby with Trisomy 21 at age 35 is equal to the risk of miscarriage from an amniocentesis - approximately one in 250.  But otherwise, there is nothing magical about age 35.  Our risk of having a chromosomally abnormal fetus increases as we age but fortunately there are screening and diagnostic tests we can use to find out if the baby is healthy.

Each state has its own prenatal diagnostic program to screen for birth defects. For instance, in California you can elect to have a blood test done between 10 and 14 weeks of the pregnancy.  The results of this blood test can be combined with a measurement of the fetus’ neck thickness (nuchal translucency) which gives a screening risk for both Trisomy 21 and Trisomy 18.  Between fifteen and twenty weeks, another blood test is performed which is combined with the other two measurements to give a final screening number (Sequential Integrated Screening).  This test will pick up pregnancies affected by one of these age related chromosomal abnormalities in about 90 percent of cases.  One can also choose to have only the first and second trimester blood tests (Serum Integrated Screening) or only the second trimester blood test (Quad Marker Screening)  though the test will be less sensitive.  Screening tests will let you know if there is an increased or decreased risk.  They will not give you a final answer but they also do not have complications associated with diagnostic tests. 

A new type of screening called "Noninvasive Prenatal Testing" or NIPT was introduced recently and is offered by several commercial companies.  Essentially a sample of the mother's blood is taken after the 10th week of pregnancy.  Chromosomes reside in the cell nucleus but when cells break apart, fragments of the DNA can be found in the bloodstream. With NIPT,  fragments of the fetus' DNA are separated out from fragments of the mother's DNA and analyzed. The test looks for abnormal amounts of fetal chromosome 21 as well as 18, 13, and gender chromosomes.  (In other words, you can find out the sex of the baby along with the results if you wish.) It is extremely sensitive in picking up these chromosomal abnormalities.  At this point, this screening option is only recommended for women in a high risk group -- age over 35, state screening or nuchal translucency results in the high risk category, or another factor such as a previously affected pregnancy.  

If any of these screening tests return with an increased risk or if you are in a high risk category (over 35, for example) and would feel more comfortable with definitive results, you can elect to have a diagnostic test which will give you the actual chromosomes of the baby.   Chorionic villus sampling (CVS) is performed between nine and fourteen weeks and involves taking a tiny sample of cells from between the baby and the placenta.  An amniocentesis is another diagnostic test and is done between sixteen and twenty weeks .  A needle is carefully placed into the uterus under ultrasound guidance and amniotic fluid with cells the baby has shed is withdrawn.  In both of these procedures, the cells are then grown and the chromosomes analyzed with results available in two weeks.  Neither of them hurt - they feel like a pinch or a shot.  While they offer more conclusive results than the screening tests, they also incur a small amount of risk such as bleeding, infection, or miscarriage of the pregnancy.  It is also routine to have an ultrasound to check the baby’s anatomy sometime between eighteen and twenty weeks.  

Ultimately, you and your partner should discuss your feelings about screening and diagnostic tests to check for birth defects.  Some couples will choose not to have any screening done while others will strongly desire early tests.  Even if you do not feel that knowing of a chromosomal irregularity will change how you proceed with your pregnancy, the information may help you prepare for your baby.  All of these options should be discussed with your obstetrician.  The decision of how to proceed is yours.

Running while pregnant

Question:  "I love running and I usually run three to five miles a day.  Can I continue to run throughout my pregnancy?  Do I need to stop at some point?"

It is wonderful that you want to continue exercising during your pregnancy - you go!

If you have been running consistently prior to becoming pregnant, you can certainly continue running your three to five miles a day as long as it feels comfortable.  Exercising at least thirty minutes, most days of the week helps build  muscle tone, strength and endurance.  Additionally, regular physical activity helps with sleep, digestion, and, so importantly, mood.  Keeping your weight gain reasonable (twenty five to thirty five pounds overall if you start off at average weight) is much easier with consistent exercise and you decrease your chance of ending up with gestational diabetes.  Plus, maintaining your strength throughout your pregnancy will make the delivery and recovery that much more of a breeze!  

Pregnancy, however, is not the time to train for a marathon or start a vigorous exercise campaign if you’ve been a couch potato up until now.  Start slowly with walking, swimming, and low impact aerobics for cardio.  Prenatal yoga is a fabulous way to build your strength and flexibility.  After the first three months, avoid lying flat on your back - it decreases blood flow and oxygenation to the uterus.  Stop exercising if you feel tired, faint, or short of breath.  Make sure you drink plenty of water to avoid dehydration and wear appropriate layers so you do not overheat.  Of course, any bleeding or regular contractions is a sign to quit and check in with your obstetrician.  And contact sports, skiing, and scuba diving are off limits for now.

Over the course of the next nine months, you may notice changes in your posture and balance.  You may experience lower back discomfort, sciatic nerve pain down the back of your leg  and pelvic pressure as the pregnancy advances. In addition, your pregnant body makes more hormone called relaxin which loosens joints.  While this is fabulously important in helping prepare the pelvis for labor, it can increase risk of injury by relaxing other joints in the body.  Exercises that were once easy may become uncomfortable as you grow.  As always, listen to your body and don’t overdo it.  Modify your routine as your body changes and have fun with it.  Start a pregnant women walking club at your local mall or park or meet other mommies-to-be at a prenatal yoga class.  Many women are able to exercise all the way through their pregnancies... Brava!

Restless Leg Syndrome and Pregnancy

Question:  "This restless leg syndrome is driving me crazy - how do I deal with it? I can't get a good night sleep and I have't even had the baby yet!"

Restless Leg Syndrome (RLS) is characterized by prickly, tingly, painful sensations in the legs.

Those affected can have an irresistible urge to move the legs and can even have uncontrolled jerks. It is a movement disorder that affects five to ten percent of the population but can temporarily affect up to forty percent of pregnant women!

The symptoms tend to worsen at night and can be relieved by moving, shaking or massaging the legs. Of course, with all that moving around, RLS interferes with sleep and those affected often complain of insomnia and sleepiness. While the condition is most commonly seen in the third trimester of pregnancy, the good news is that it usually resolves soon after delivery.  Anemia has been suggested as a possible cause, and should certainly be checked for and treated, but its increase during pregnancy is more likely hormonal.  

So, what are you to do when those “pins and needles” are keeping you up at night? 

First of all, try to exercise daily. In addition, stretch those lower extremity muscles morning and evening and massage your legs before bed. Avoid caffeine and, of course, smoking. And try to maintain healthy sleep habits. Go to bed and wake up at the same time each day. Not napping during the day is helpful. Stay away from heavy meals and sugar close to bed time. And avoid activities that can make it hard to fall asleep like television or reading right before you doze off. 

Try to turn any LED alarm lights away from you and put electronics away. And since stress only increases the symptoms, keep your bedroom a worry-free, work-free zone reserved only for sleep and sex. Here’s a suggestion:  about half an hour before your scheduled sleep time, put away your smart phone and the computer. Shut off the TV. Take a warm bath. In your bedroom, stretch out your body and give your legs a good massage. Consider turning on relaxing music or putting in ear plugs to block out any outside noise. Hopefully you and your baby will finally get some much deserved rest.

Best Prenatal Vitamins

Question: "Which are the best prenatal vitamins? And when should I start taking them if I want to try to get pregnant?"

There are so many prenatal vitamins on the market, available both by prescription and over-the-counter, that choosing one to take during your pregnancy can be quite overwhelming. 

Prenatal vitamins are a multivitamin intended for women who are trying to conceive, are pregnant, or are nursing.  They are meant to supplement a healthy diet with daily additional minerals and vitamins and are important for the well being of both the mother and the developing baby.  Prenatal vitamins are specifically formulated to primarily ensure adequate intake of folic acid, iron, and calcium.  Folic acid is important in the prevention of defects in the spinal cord or brain.   Spina bifida is the most common example of a neural tube defect.  Since the development of the baby’s  central nervous system starts before many women even know they are pregnant, adequate intake of folic acid, at least 400 mcg a day, is recommended at least a month prior to conceiving.  Some prescription prenatal vitamins have a special type of folic acid that is more bioavailable branded as Metafolin.  Iron, at least 27 mg a day, is recommended to help prevent anemia, low blood count,  which is very common as the pregnancy progresses. Iron, however, can also lead to constipation and for some women, upset stomach, so there are varying doses of iron in different prenatal vitamins depending on need and side effects.  Calcium is important for the bone health of both the mother and baby.  While 1,000 mg a day is recommended, most prenatal vitamins have between 200 and 300 mg with the rest of the daily requirement meant to be from dietary sources.  

Prenatal vitamins generally also contain vitamin B 12, C, and D, as well as thiamine, riboflavin, niacin and zinc.  Vitamin A, in high doses, can have serious consequences for a developing baby and should therefore be limited to less than 4,000 IU a day.  

Many prenatal vitamins are now incorporating Docosahexaenoic acid (DHA) an omega-3 fatty acid, either into their supplement or as an additional softgel capsule because of reports of improved brain and eye development in the baby.  

Prenatal vitamins come in many different sizes and forms such as gel tabs or solid tablets. There are even chewable and liquid forms for those who have difficulty swallowing a pill. Some are meant to be taken just once a day while others spread the daily dosages across several pills.  Be sure you understand the daily dose you are receiving from the number of vitamins per day you are recommended to take.  It is possible to have too much of a good thing so do not go over the daily recommended allowance by taking additional vitamins or supplements without checking with your obstetrician.  Also, some prenatal vitamins have a stool softener to help with constipation.  If you switch from one brand of vitamins to another, you may notice changes in your digestion, your bowel movements and even the color of your urine. The bottom line is that you should choose a prenatal vitamin that has enough of what you need, and not too much of what you don’t need, and is easy for you to take and tolerate during your pregnancy and the months that follow.