The Perplexities of Pregnancy 
by Lisa Iannucci

  There's a new baby boom in the United States. Last year more than 4 
million babies were born, according to the U.S. Department of Vital 
Statistics. 
  Accompanying this steadily increasing birth rate (up 250,000 from 1985) is
an abundance of continually updated information for mothers-to-be, on 
everything from nutrition to the use of aspirin. Keeping current with this
information can often leave the expectant mother perplexed. 
  The ideal time to begin learning about pregnancy is before becoming 
pregnant. However, if this is not possible, once pregnant, a woman should 
consult a health-care professional trained in obstetrics. 

Home Pregnancy Tests
  Many women use home pregnancy tests if they suspect they're pregnant. 
Regulated by the Food and Drug Administration, pregnancy tests have come far
since the early to mid-1900s when toads, rats and rabbits were used in
testing. Now, over-the-counter home pregnancy kits provide privacy and fast 
results, and can detect pregnancy as early as six days after conception, or 
one day after a missed menstrual period. This gives an early advantage for
vital prenatal care.
  All pregnancy tests are based on the presence of a hormone, human 
chorionic gonadotropin (HCG), that the pregnant woman produces after
conception. The first self tests of the 1970s used ring, or "tube 
agglutination," tests consisting of prepackaged red blood cells to detect 
HCG in urine. A ring at the bottom of the tube indicated a positive result. 
Sensitive to movement and human error, ring tests are now rarely used.
  Today's brands, such as e.p.t. and First Response, contain monoclonal 
antibodies that detect minute traces of HCG. These antibodies are molecules 
coated with a substance that bonds to the pregnancy hormone, if it's
present, to produce either a positive or negative result. (Each test
manufacturer uses a different "trade secret" chemical formula for the 
bonding substance.) The user collects urine and combines it with the
antibodies provided in the package. The test is timed, and a color change 
indicates the result. 
  Although most manufacturers claim 99 percent accuracy in laboratory tests,
inaccurate results may be more frequent in actual use, due to such factors
as improper use of the test, using a product past its expiration date,
exposure of the test to the sun, and cancers. The procedures outlined in the
instructions must be followed exactly for results to be accurate. 
  Whitehall Laboratories markets the newest one-step brand, Clearblue Easy. 
It gives results in three minutes and informs the user when the test hasn't 
been done properly. This new testing method, called rapid assay delivery
system, combines a biochemical process with monoclonal antibodies in one
pen-like instrument.
  Whatever the result or the brand used, most manufacturers recommend 
repeating the process a few days later to confirm the results. After
conception, a woman produces a minimal amount of HCG. The strength of each
test varies, and although a woman may be pregnant, the test may not pick up 
the amount of HCG hormone present the first time. 

Nutrition and Supplements 
  Even before pregnancy begins, nutrition is a primary factor in the health 
of mother and baby. A well-balanced diet before conception contributes to a 
healthy pregnancy and will probably need few changes. 
  According to the American College of Obstetricians and Gynecologists, 
pregnant women should increase their usual servings of a variety of foods 
from the four basic food groups to include a total of four or more servings 
of fruits and vegetables, four or more servings of whole-grain or enriched
bread and cereal, four or more servings of milk and milk products, and three
or more servings of meat, poultry, fish, eggs, nuts, and dried beans and
peas. 
  These additional servings will help meet the recommended daily allowances 
(RDAs) of nutrients required to maintain good health. These RDAs from the 
National Research Council were updated in 1989. The accompanying chart
outlines the requirements of vitamins and minerals during pregnancy.
  Often, nutritional supplements are provided for pregnant women, but 
according to a June 1990 report released by the Institute of Medicine (IOM),
studies found these supplements to be of little or no value. Most physicians
agree that RDAs, except those for iron, can be obtained through a proper
diet. 
  Iron is needed in larger doses, especially in the later stages of 
pregnancy, and cannot be met by diet alone, according to the National 
Research Council. This mineral is essential to the formation of healthy red 
blood cells, and it is difficult for a woman to consume enough of it from 
foods to maintain an adequate supply for herself and her fetus. Without 
enough iron, the fetus will draw its supply from the mother, often leaving
her anemic and exhausted. An iron supplement can alleviate this condition.
  In certain studies, the vitamin folacin has been shown to be important in 
preventing neural tube defects, such as spina bifida. The need for folacin
more than doubles during pregnancy, from 180 micrograms to 400 micrograms.
Like iron, folacin is essential to the formation of red blood cells.
However, the IOM panel found insufficient evidence to recommend that all
women take supplements containing folate, which can be found in liver,
kidneys, leafy green vegetables, and dried beans and peas.
  Other research questions whether there may be some benefit from 
multivitamins in preventing neural tube defects. The U.S. Centers for 
Disease Control reported a study of women who took multivitamin pills three 
months before and three months after conception. Researchers found a
slightly higher incidence of birth defects in babies of women who were not
multivitamin users. However, it is unclear whether the increase of defects
was due to a lack of vitamins or to other factors that were not measured. 
  Although some subsequent studies showed that taking a daily multivitamin
helped decrease birth defects, other studies showed multivitamin intake had 
no relationship to the incidence of birth defects. However, it is known that
very high intakes of vitamins, such as vitamin A, may increase the
occurrence of birth defects.
  While research continues, the IOM recommends supplements only for pregnant
women who are smokers, drug users, alcohol drinkers, or strict vegetarians. 
Obstetricians will continue to make the decision to recommend supplements 
based on individual requirements and will not recommend megavitamin 
supplements without a specific medical reason.

What About Weight Gain? 
  Thirty years ago, the National Research Council's Food and Nutrition Board
advised women to gain 20 to 25 pounds during pregnancy. Studies have since
shown that underweight women, or those who gain fewer than 20 pounds during 
pregnancy, are at an increased risk of delivering low-birth-weight babies.
Based on a 1990 study, IOM now recommends a weight gain of 25 to 35 pounds
during a normal pregnancy to decrease this risk. Adolescents and black
women, who often have smaller babies, are now strongly advised to gain a
greater amount. 
  The recommended increase in weight gain does not give a green light for 
mothers-to-be to overeat. Although the extra nutrients are required, an 
increase of only 300 calories per day is recommended. Weight gain during
pregnancy should be gradual. The American College of Obstetricians and
Gynecologists recommends 3 to 4 pounds in the first three months and 3 to 4 
pounds per month during the rest of the pregnancy. Approximately 6 to 8 
pounds of the total weight is the baby, and the remaining weight consists of
an increased fluid volume, larger breasts and uterus, amniotic fluid, and 
placenta. 
  Contrary to popular belief, sodium, which helps to regulate water in the
body, is needed in larger quantities during pregnancy. Larger than normal 
amounts of this electrolyte are needed because of increased fluid volume in 
the mother, the requirements of the fetus, and the level of sodium in the 
amniotic fluid. For those who do not have high blood pressure, salt 
restriction is not recommended. Those with medical problems that require
salt restriction should consult their physicians. Trace minerals, such as 
iodine, usually needed in small amounts, are needed in greater quantities 
during pregnancy. Iodine can be obtained in iodized salt and spinach. 

Is Caffeine Okay? 
  Caffeine--a stimulant found in colas, coffee, tea, soft candies,
chocolate, cocoa, and over-the-counter and prescription drugs--has been a 
controversial topic in pregnancy nutrition for more than a decade. A 1980 
study by FDA found that caffeine, when fed to pregnant rats, caused birth 
defects and delayed skeletal development in their offspring. At that time,
although the human implications were unknown, FDA advised pregnant women to 
eliminate caffeine from their diets.
  Since then, more studies have been done to determine the effects of 
caffeine on the fetus. A study of women in Costa Rica, where coffee 
consumption is high, showed a significantly lower birth weight for infants
and a lower concentration of iron in mothers who were coffee drinkers. This 
report indicated that maternal coffee intake may also contribute to maternal
and infant anemia.
  Consumed in large quantities, caffeine can cause irritability, nervousness
and insomnia. In addition to crossing the placenta and affecting the fetus, 
it is also a diuretic, dehydrating the mother's body of valuable water. 
After the baby is born, caffeine can also be transmitted through breast milk. 
  As mentioned, caffeine is an ingredient in some over-the-counter (OTC) and
prescription drugs. Before taking any drugs, a pregnant woman should consult
her physician.

Deciding About Drugs
  Drugs may pose dangers to the embryo or fetus throughout pregnancy, but 
they are especially of concern during the first trimester, when the vital 
organs and systems are developing, and the last trimester, when excessive 
bleeding can occur during labor.
  According to the New England Journal of Medicine, an estimated 10 to 45 
percent of pregnant women in the first trimester, unaware of their
condition, reach for the most common OTC drug, aspirin. Aspirin and other 
drugs containing salicylate are not recommended throughout pregnancy, 
especially during the last three months, except under a doctor's
supervision. Acetylsalicylate, a common ingredient in many OTC painkillers, 
may prolong pregnancy and cause excessive bleeding before and after delivery. 
  Overall, according to Debbie Limkins of FDA's division of OTC drug
evaluation, most other OTC drugs can be used during pregnancy with the
supervision of a physician. Although scientists do not know the effects on
the fetus of all OTC and prescription drugs, some drugs are known to cause
birth defects and should be avoided. (See "Drugs and Pregnancy: Often the 
Two Don't Mix" in the June 1989 FDA Consumer.)
  Since 1984, all OTC drug products have carried the following warning: "As 
with any drug, if you are pregnant or nursing, seek the advice of a health
professional before using this product." In July 1990, FDA issued a 
regulation requiring all oral and rectal nonprescription aspirin and drugs
that contain aspirin to include the additional warning "It is especially
important not to use aspirin during the last 3 months of pregnancy unless 
specifically directed to do so by a doctor because it may cause problems in 
the unborn child or complications during delivery." 
  One drug that can cause severe birth defects is Accutane, or isotretinoin.
Accutane, a derivative of vitamin A, is a powerful prescription drug that 
can clear severe cystic acne, but can cause birth defects (such as heart
defects, small jaw, cleft palate, and skull and facial disfigurements) in 
about 1 out of every 4 exposed fetuses. Accutane can also cause miscarriages. 
  Since its approval, Accutane has been labeled as being in pregnancy 
category X, meaning it should not be used during pregnancy. However, due to 
persistent reports of birth defects associated with use of the drug in 1988,
the manufacturer, Hoffmann-La Roche, began including additional patient 
information in the packaging, including a drawing of a baby with birth
defects associated with the drug. Before being permitted to take Accutane, a
woman of childbearing age must sign a consent form stating she has been 
fully informed of the drug's side effects. (See "Acne: Taming That Age-Old
Adolescent Affliction" in the October 1990 FDA Consumer.) 
  Another derivative of vitamin A, etretinate (or Tegison), was approved in 
the mid-1980s to treat psoriasis. This drug is also forbidden for use by
women who are pregnant or who are likely to become pregnant either while
taking it or for a certain period after they have stopped taking it.

A Nonalcoholic Toast
  While pregnancy is a time for celebration, toasting with champagne, a few 
beers, or any alcoholic beverage is not healthy for the fetus or the
mother-to-be. Alcohol can cross the placenta and in the case of heavy 
drinking (at least four standard drinks per day) can cause a condition known
as "fetal alcohol syndrome," or FAS.
  The American College of Obstetricians and Gynecologists describes babies
with FAS as being shorter and lighter in weight and having the following
characteristics:
* smaller heads 
* abnormal features of the face, head, joints and limbs 
* heart defects 
* poor control of movement. 
Mental retardation is common, as is hyperactivity, extreme nervousness, and 
poor attention span.
  According to a report, "Alcohol and Health," released by the Department of
Health and Human Services in January 1990, some studies suggest that the
more alcohol a mother drinks during pregnancy, the greater the danger to the
fetus, especially in the first trimester. Because it's difficult to 
determine how much alcohol puts a fetus at risk and at what stages of 
pregnancy the fetus is affected, it is not known whether drinking any amount
of alcohol is safe. The safest course at present, therefore, is for pregnant
women to abstain from drinking alcoholic beverages. 

Safety of Tests 
  X-rays may pose dangers to the fetus. While x-ray examinations of the 
teeth or extremities do not generally expose the fetus to significant levels
of radiation, x-rays of the abdomen, lower back, or hip areas place the 
fetus in the direct x-ray beam and can be hazardous. It is particularly 
important for a pregnant woman--or a woman who thinks she may be
pregnant--to inform the doctor or technician before having an x-ray 
performed on these body areas.
  Certain tests are routinely done to check the well-being of the fetus 
during pregnancy and labor. The most common of these, ultrasound, uses sound
waves that bounce off internal organs to project images of the organs and 
the fetus on scanners. There have been no reports of harmful effects
associated with ultrasound, which has been used for more than 20 years. 
Ultrasound does not use radiation, drugs, dyes or chemicals and is
beneficial in providing valuable information. For example, it can reveal the
number of fetuses and age, size, fetal position, some birth defects, and
other information vital to the health care of the pregnant woman and her
baby. 
  There are three types of ultrasound, each used during pregnancy for 
different purposes. The most common is real-time ultrasound, which takes
still pictures in rapid succession and detects the heartbeat, placenta, 
movement of the arms and legs, and the number and position of the fetus(es).
  The second is Doppler ultrasound, used before and during labor to provide 
electrical signals that are converted to audible signals of the fetal 
heartbeat. The third, vaginal ultrasound, can help diagnose the cause of
bleeding and pain or an ectopic pregnancy, in which the fertilized egg grows
outside the uterus. It can also detect some birth defects early in the
pregnancy.
  Prenatal care is vital to the health of both mother and baby. 
Mothers-to-be will find it worthwhile to educate themselves about all 
aspects of pregnancy and consult an obstetrics specialist to guide them 
through a successful pregnancy. 

Lisa Iannucci is a freelance writer in Yonkers, N.Y.