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Preconception checklist
Patient Preference for Permanent Contraception Met

This information applies to non-complicated pregnancies only.  If you have a high-risk pregnancy (high blood pressure, diabetes, bleeding, preterm labor, twins or any other complications) contact the doctor's office before doing any of the things listed.

Over-the-counter medications for obstetrical patients with upper respiratory infection symptoms (regardless of trimester):

  • Tylenol (ES, Cold/Sinus, PM, Theraflu etc)
  • Sudafed
  • Robitussin
  • If fever greater than 100.6 F or symptoms persisting more than 4-5 days despite treatment, need visit
Other over-the-counter drugs that are safe:

  • Benadryl (sinus allergies or rash)
  • Pepcid/Zantac (Heartburn, gas)
  • Claritin D (NOT Clarinex)
  • Milk of Magnesia (for constipation)
  • Immodium (for nonbloody diarrhea)
  • Colace or Surfak (constipation)
  • Maalox, Rolaids or Tums (Heartburn, gas)
  • Short term hydrocortisone creams/Cortaid (Insect bites, rashes)
DO NOT take Ibuprofen, Motrin, Alleve or Pepto Bismol

Medications for obstetrical patients with yeast infections

  • Recommend visit unless absolutely sure of diagnosis
  • Monistat (any trimester)
  • Diflucan (after 12 weeks)

Things to Avoid During Pregnancy:

  • Cat litter and cat feces
  • Raw meat
  • Digging in dirt/soil (use gloves)
  • Children with unexplained rash or fever
  • Radioactive materials
  • Horseback riding or contact sports
  • Heating pads to abdomen
  • Alcohol

Vaccinations/Shots OK Anytime in Pregnancy

  • PPD (Tuberculin Skin Test)
  • Flu Shot
  • Hepatitis Vaccination
  • Meningococcal Vaccine
  • Hib Vaccine
  • Pneumovax

OK to Use AFTER 16 Weeks Gestation

  • Sunless Tanning Products
  • Hair Color & Permanents
  • Tanning Beds with Adequate Ventilation & Hydration
  • Hot Tubs ONLY if Water Temperature is Less Than 99 Degrees Farenheit
  • House Painting With Adequate Ventilation (Odor may cause nausea!)

Exercise During Pregnancy:

  • Most exercises are safe during pregnancy.  If you have not been exercising regularly before your pregnancy do not start a rigorous routine at this time.  Walking, yoga, Pilates and aerobic activities are safe.  You may continue light weight training but avoid heavy weight training utilizing the abdominal muscles since this may cause cramping.  If you experience cramping or bleeding, stop exercise until you see your doctor.

24-28 Weeks Gestational Age Screening/Testing

  • Diabetes Screening (blood test) is Performed Between 24-28 Weeks for MOST patients
  • Prior to the one hour glucose test, try not to eat anything sweet or high in carbohydrates, and try not to drink soda or juice
  • Obstetrical patients with Rh factor negative blood type will have RhoGAM workup at 28 Weeks Gestation
  • Patient has 72 hours after blood draw to pick up RhoGAM then take it to the office where one of our nurses will give the injection

Notes on Travel

  • Travel is permitted up to 32 weeks gestation age for uncomplicated pregnancies
  • After 32 weeks, plans must be individualized
  • Discuss contingencies plans such as "where do I go if I start to contract or have bleeding?"
  • Be sure to request a copy of your prenatal records to keep with you when you travel
  • There is no difference between flying or driving
  • On long trips (>1 hour) get up and stretch or walk every 60-90 minutes
  • Some airlines have stricter limits on pregnant women, be sure to check with your airline FIRST!

Working During Pregnancy:

  • You may work up until you go into labor, in fact, most women do.  If you fall into a high-risk category, begin bleeding or cramping, then temporary leave of absence may be granted.  This is at the discretion of the physician.

Alcohol and Pregnancy: Know the Facts

The recent news story "Can Pregnant Women Drink Alcohol in Moderation?", which aired on ABC's Good Morning America Weekend, has created tremendous confusion among women about the safety of drinking alcohol during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) strongly urges women not to ignore the public health warnings associated with consuming alcohol while pregnant.

ACOG is concerned that this television segment disseminated a potentially dangerous and mixed message to pregnant women. According to ACOG, patients who saw the show are asking their ob-gyns for clarification about whether moderate—or even light—drinking will impact the health of their baby. Therefore, ACOG reiterates its long-standing position that no amount of alcohol consumption can be considered safe during pregnancy.

Maternal alcohol use is the leading known cause of mental retardation and is a preventable cause of birth defects. Children exposed to alcohol in utero are at risk for growth deficiencies, facial deformities, central nervous impairment, behavioral disorders, and impaired intellectual development. Consuming alcohol during pregnancy also increases the risk of miscarriage, low birth weight, and stillbirth.

The bottom line according to ACOG: Women should avoid alcohol entirely while pregnant or trying to conceive because damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.

The Normal Menstrual Cycle

Why do women have periods?  I get asked this very often.  Beyond the explanation of menstruation being outward "proof that a girl is becoming a woman," having a period is your body's way of saying it’s functioning properly.  Every month, one egg leaves one of the ovaries on its way to the uterus via the fallopian tubes. Meanwhile, in preparation for the egg, the uterus starts to develop a thicker lining and it’s walls become cushiony (the endometrial lining). If the egg reaches the uterus and is fertilized by a sperm cell, it attaches to this cushiony wall.

Most of the time the egg just passes right through without fertilization. Since the uterus no longer needs the extra blood and tissue which made up the walls thick, it sheds them by way of the vagina. This cycle will happen nearly every month until the ovaries stop releasing eggs, usually several decades later. (Menopause).  If you're a teenage girl you probably have started having a period. If you have not, you might be anxious about the subject or a bit concerned. This whole menstruation thing might seem a bit mysterious, it is to many young women. It's actually very complex, but interesting too.

Hormone release and control in the normal menstrual cycle is as precise as a Mozart symphony.  If one aspect is faulty, everything crashes.  Without a clear understanding of the normal menstrual cycle, diagnosis and treatment of bleeding abnormalities becomes significantly more difficult.  Luckily, one must understand only a few key points.

Remember—THE HYPOTHALAMUS CONTROLS EVERYTHING.  Gonadotropin releasing hormone (GnRH) is secreted by the arcuate nucleus.  These cells originate from the olfactory area and have both neuronal and endocrine activity.  The half-life of GnRH is 2-4 minutes and is secreted in a pulsatile fashion.  Once per hour (equating to a concentration of 2 ng/mL) leads to maximum stimulatory effect.  Increasing the frequency (say, 2-5 pulses/hour) or amplitude (amount) leads to loss of the stimulatory effect.  <1 pulse/hour decreases LH secretion & increases FSH secretion.  Norepinephrine stimulates GnRH release (stress), and dopamine inhibits GnRH release (hyperprolactinemia).

The Gonadotropins, Follicle stimulating hormone (FSH) and Luteinizing hormone (LH) are secreted by basal and chromophobe gonadotrope cells of the anterior pituitary.  These are also secreted in a pulsatile fashion.  FSH is stimulated by GnRH and inhibited by estradiol.  LH is stimulated by GnRH and estrogens, and is inhibited by progesterone.

In the ovary, the follicle consists of not only the developing ovum, but also cells that form a biochemical factory.  In the “two cell theory,” LH stimulates theca cells to produce the androgens androstenedione and testosterone.  These androgens are aromatized in the granulosa cells, under control of FSH, to Estrone and 17 beta-Estradiol.  Remember, estrogen is good for follicular growth and development; androgens are bad for follicular growth and development. Other estrogen effects include:

1. Pubertal growth spurt

2. Breast development

a. Stimulates ductal formation

b. Increases breast size

3. Increases bone density

4. Proliferation of the endometrium

5. Cervical mucus changes

a. Copious

b. Thin

c. Clear

6. Lower genital tract changes

a. Increased epithelial thickness

b. Pliability and moisture increased

7. Skin

a. Increased water and hyaluronic acid

b. Reduced collagen breakdown

c. Decreased sebum

d. Decreased epithelial proliferation

8. Lipids

a. Decreased LDL

b. Increased HDL

9. Liver

a. Increased plasma proteins

i. Thyroid-binding globulin

ii. SHBG

10. Coagulation

a. Increased factor VII, VIII, IX and Prothrombin

b. Decreased antithrombin III

There are three types of estrogen—estrone, 17-beta estradiol, and estriol.  Estrone, a weak estrogen, is produced in the ovary (and adipose tissue) from the aromatization of androstenedione.  The most potent of the estrogens, 17-beta estradiol, is aromatized from testosterone in the ovary.  Estriol is the least potent of the estrogens and is produced by the placenta.

Progesterone is a 21-carbon steroid with antiestrogen effects.  It induces glandular (alveolar) development in the breast, blocks estrogen receptors in the endometrium (leading to secretory endometrium), thickens cervical mucus making it relatively impenetrable to sperm, blocks androgen receptors in hair, reduces bone resorption, decreases HDL and has no effect on coagulation.

Androgens (in this case testosterone and androstenedione) cause follicular atresia (androgens bad!), inhibit endometrial growth, cause terminal hair growth, block estrogen receptors, lower HDL and increase LDL.

If you've ever seen this graph you likely remember how much you hated it.  Most physicians have seen it and hate it.  All those lines which seem to make no sense whatsoever.  By understanding a few simple principles and focusing on each event, we CAN make sense of this chart.

Let’s start in the early follicular/proliferative phase.  Follicular recruitment begins PRIOR to the previous menstrual cycle and is independent of FSH.  Up to 1,000 follicles are recruited with the goal being to select the BEST follicle for ovulation.  Our little follicular biochemical factories are immature and estrogen levels are low.  LH is low so there is low androgen production.  Since FSH is relatively high due to relatively low negative feedback secondary to low estrogen levels, virtually all of the androgens are converted to estrogens.  This is an excellent environment.

By the mid-follicular/proliferative phase follicles are maturing thus estrogen levels are rising, stimulating LH (leading to more androgens), inhibiting FSH (reducing the ability to convert androgens to estrogens), and stimulating the local production of FSH receptors.  The BEST follicles do what they do best, that is, produce more estrogens, again, stimulating more local FSH receptors in an environment of low FSH (thus no local androgenic build up).  In the mean time POOR follicles produce less estrogen, have fewer FSH receptors and have less ability to convert androgens to estrogens.  This local androgen build-up leads to follicular atresia.  The vast majority of follicles are lost in this fashion.

In the late follicular phase, progesterone now begins to rise.  This causes an FSH surge that promotes granulosa cell LH receptor formation (aiding in the formation of the corpus luteum), expansion and dispersion of the cumulous cells causing the oocyte to become free floating, and converts plasminogen to the proteolytic enzyme plasmin, in preparation for ovulation.  As the last surviving follicles mature, they produce a surge of estrogens that is sensed by the pituitary.  When estradiol levels rise above 200 pg/mL it signals the follicles are nearly mature and a super positive feedback of LH is initiated, the LH surge.

LH levels peak 24-36 hours after estrogen peaks.  The rising LH causes androgen levels to rise, knocking off all but the queen of all follicles.  The rising androgen levels also increase libido.  The LH surge also initiates the resumption of meiosis, increases prostaglandin production (essential for follicle rupture and ovulation), and luteinization of the granulosa cells, leading to corpus luteum formation.  Ovulation occurs 10-12 hours after peak LH.

After ovulation LH RAPIDLY falls.  This is certainly facilitated by rising progesterone (from the corpus luteum) and decreasing estrogen, but the exact mechanism of the rapid fall of LH levels is unknown.

Now the luteal/secretory phase begins.  Progesterone levels continue to rise and will peak on cycle day 23 (in a non-pregnant cycle).  The female basal temperature will also rise.  Progesterone blocks estrogen receptors and converts the proliferative endometrium to secretory endometrium.  This proceeds in a PREDICTABLE and orderly fashion.  Endometrial dating is accurate within ? 2 days.  The corpus luteum lasts 14 days with progesterone beginning to decline 9-11 days post-ovulation.  Embryo derived hCG maintains luteal function.

Here’s the short version of the menstrual cycle:

1. Estrogen levels are low initially but rise as follicles develop

2. LH rises, increasing androgens, helping to select the best follicle

3. FSH falls as estrogen rises

4. Estrogens surge stimulating the LH surge and ovulation

5. Progesterone blocks estrogen receptors and converts the proliferative endometrium to secretory

6. Corpus luteum survives only 14 days, progesterone levels fall, and menstruation begins

7. hCG maintains corpus luteum and menses does not occur

Knowledge of the menstrual cycle is crucial in the diagnosis and management of many gynecologic conditions, ESPECIALLY abnormal or "dysfunctional" uterine bleeding.  Luckily, only a few key points need to be remembered.

Starting the Good Life in the Womb


Pregnant women who eat right, watch their weight and stay active can actually improve their unborn babies’ chances of growing into healthy adults



Most pregnant women know they can hurt their babies by smoking, drinking alcohol and taking drugs that can cause birth defects. But they also may be able to "program" the baby in the womb to be a healthier adult. New research suggests that mothers-to-be can reduce the risk that their babies will develop obesity, high blood pressure, heart disease and diabetes by monitoring their own diet, exercise and weight. The science behind this is relatively new and still somewhat controversial. In the late 1980s, a British physician and epidemiologist named David Barker noticed that a group of Englishmen who were born small had a higher incidence of heart disease. Studies showed that rates of obesity, high blood pressure and diabetes illnesses that often are associated with heart disease are higher in men born small. Barker proposed that poor nutrition in the womb may have "programmed" the men to develop illness 50 years or more later.


The "Barker Hypothesis" is still hotly debated, but it is gaining acceptance as the evidence builds. Because organs develop at different times, it appears that the effects of too little food during pregnancy vary by trimester. One example comes from study of the Dutch Hunger Winter, a brief but severe famine that occurred during World War II. Pregnant women who didn't get enough to eat in their first trimester had babies who were more likely to develop heart disease. If they were in their second trimester, their babies were at risk for kidney disease. A poor diet in the last three months led to babies who had problems with insulin regulation, a precursor of diabetes.

More-recent research has focused on the negative effects of too much food during pregnancy. Women who gain excessive weight during pregnancy are more likely to have babies who are born large for their age and who become overweight in childhood. A recent study from the National Birth Defect Prevention Study found that obesity in pregnancy also increases a baby's risk for birth defects, including those of the spinal cord, heart and limbs.


A mother's nutrition and exercise patterns during pregnancy influence the long-term health of the baby by shaping her baby's metabolism. "Metabolism" includes everything that allows your body to turn food into energy from the organ systems that process food and waste to the energy-producing chemical reactions that take place inside every cell. It is the collective engine that keeps you alive.

A mother's body may influence her baby's metabolism on many levels: the way organs develop, how appetite signals get released in the brain, how genes are activated, even the metabolic chemistry inside the baby's cells. Research now shows that the environment of the womb helps determine how a baby's metabolism is put together, or "programs" it for later health. The science of fetal programming is still new; it will be a long time before we have all the answers, since these health effects emerge over a lifetime. But several principles already are clear for a pregnant woman.


The first is to get healthy before pregnancy. Weighing too little or too much not only hampers fertility but can set the stage for metabolic problems in pregnancy. Doctors used to think of body fat as nothing more than inert insulation, but they know now that fat is an active tissue that releases hormones and plays a key role in keeping the metabolism running. Women should also eat a balanced diet and take prenatal vitamins before pregnancy to ensure that their bodies provide a good environment from the beginning.

The amount of weight gain is also critical. Women who gain too little weight during pregnancy are more likely to give birth to small babies, while women who gain too much weight are likely to have large babies. Paradoxically, both situations can predispose a child to metabolic disease. The weight gain should come slowly at first about two to eight pounds in the first trimester, and one pound per week after that for normal-weight women. Obese women (with a body-mass index, or BMI, higher than 29) should gain no more than 15 pounds.


During pregnancy, women are already more susceptible to metabolic problems such as gestational diabetes and preeclampsia (high blood pressure), so choosing foods that help your metabolism run smoothly is important. Eating whole grains and foods rich in protein and fiber while avoiding foods high in sugar can help even out rises and falls in blood sugar. Pregnant women should eat about 300 extra calories per day while they're pregnant. But, as always, the quality of the calories matters even more. It's important to eat a diet rich in nutrients, since a lack of specific nutrients in the womb can hamper a baby's long-term health. A clear example is folic acid, without which the brain and spinal cord do not develop properly. But new research is uncovering other nutrients that may have subtler but long-lasting effects on health.

Studies suggest that women could benefit from taking omega-3 fatty-acid supplements, particularly those that contain docosahexaenoic acid (DHA, for short), a type of fat that has been shown to help prevent prematurity and contribute to healthy brain development. A recent study found that women with more vitamin D in their bodies have children with stronger bones; adequate vitamin D is also needed for organ development.


Women may have different nutrient needs because of genetic differences, but to be safe every woman should take a daily prenatal vitamin before and during pregnancy. But supplements, whether in the form of a pill, a fortified shake or energy bar, don't replace the nutrients found in fruits, vegetables, low-fat meats, whole grains and other foods.

The energy you expend is as important as what you take in. Regular activity helps keep a woman's metabolism running smoothly and offsets problems of pregnancy like varicose veins, leg cramps and lower back pain. Pregnant women should avoid high-impact activities, especially late in their pregnancies.

All this may sound daunting, but most of the changes are simple ones that will improve a mother's long-term health as well as her children's.




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