During your first obstetrical visit, which is relatively long and comprehensive, we will engage in extensive discussion and perform multiple tests. You undoubtedly have many questions for me about pregnancy, testing, delivery and my approaches to them. Similarly, I want to get to know you, your medical history, and your philosophy on medical care.

We review your medical, surgical, obstetrical history and family history in detail to ascertain any factors which might change your care in this pregnancy.

I perform a complete physical examination which includes your baseline blood pressure, height and weight, checking your uterine size and obtaining a PAP smear (if you have not had one in the past year) and cervical cultures to screen for organisms which might affect the pregnancy and other things. A vaginal sonogram will also be performed.

One very important aspect of the first visit is establishing the “dating” of your pregnancy: when is the baby due? Pregnancies are traditionally dated from the first day of your last menstrual period. Forty weeks from that day is taken as your “due date.” If your periods are irregular or you have been through IVF, dating by last menstrual period may not be accurate, and your date of conception, insemination, retrieval and early sonogram is used for the calculation. Early, accurate estimation of gestational age is essential.

The due date derived from this information can then be compared to the size of the fetus on vaginal sonogram, which will be completed in my office. Unless there is a large discrepancy, we will use the dating based on your estimated last menstrual period.

Be aware that your “due date” is only approximate, and that considering a two-week period around that day as a “delivery window” is more appropriate. Indeed, up to 10% of normal pregnancies last 42 weeks.

Patients undergoing any screening tests should understand the difference between screening and diagnostic tests. This is particularly important in genetic screening where couples need to understand what is and is not being screened for, the interpretation of positive and negative results, the possibility of false positive and negative results, follow up invasive or noninvasive testing and possible reproductive choices.

We will discuss available screening and testing for genetic abnormalities. At the conclusion of the visit, you will be directed to the lab to complete a standard panel of tests required for pregnancy evaluation. These tests include blood type and antibody screen, blood count, documentation of certain immunities, infectious disease, carrier status for multiple genetic abnormalities, hemoglobinopathies, HIV testing and several other tests. Additional blood tests in women at risk for specific conditions will be added.

Subsequent visits monitor your health as well as the growth and well-being of the baby. I monitor weight and blood pressure. I measure baby growth and heart rate, as well as other indicators of good health, such as fluid amount and baby movement.

We will discuss the changes you are undergoing and any problems you may be having. Write down your questions. It is too easy to forget them in the bustle of the visit.

In the third trimester, at approximately 26-28 weeks, a few of the blood tests are repeated to check for anemia or the development of antibodies to blood cells. If your blood type is “negative,” you will receive an injection, “Rhogam,” around 28 weeks to prevent your making antibodies against the baby’s blood. You would also get the injection after CVS, amnio, or an episode of vaginal bleeding.

All pregnancies are screened for the development of gestational diabetes which can delay fetal maturity and increase the rate of stillbirths. If anyone in your immediate family has diabetes, you are considered at increased risk and will be tested three times; 18, 26 and 32 weeks. Low- risk patients are only screened once, at 26-28 weeks. The test involves drinking, on an empty stomach, a very sweet drink followed by a blood sugar draw one hour later. If the level is elevated, a three-hour test will be done involving double the amount of sweet drink, and four blood tests, the results of which determine if treatment is needed.

Although our ability to screen for congenital conditions has grown dramatically over the past few years, no one test or combination of tests can predict all fetal abnormalities and problems. Between 2 and 4% of all newborns have some anomaly, many minor, but others severe. If you, the baby’s father, sperm donor, or anyone in your families has an inherited disease or birth defect, your baby may be at a higher risk. We will discuss these issues at your first visit to determine the testing appropriate for your pregnancy.

NUCHAL SCAN is performed between 10 ½ and 13 ½ weeks gestation. It is a sonogram that measures the thickness of the back of the fetal neck. The results of this scan are combined with the results of five blood markers to provide a risk of Down Syndrome specific to each patient. This combined test detects approximately 85% of Down Syndrome with a false positive of 5%. It can also detect Trisomy 18 and 13. Abnormal combined test results will prompt further testing with cell free DNA testing and/or invasive testing such as amniocentesis. AFP is a fetal specific protein produced by the baby. Maternal serum AFP (MSAFP) is a screening test performed on your blood between 15 ½ and 20 weeks. An elevated level may indicate an anatomical fetal problem, such as a neural tube defect. A decreased level may indicate a chromosomal abnormality such as Down Syndrome. Either result would prompt further investigation and testing. Even so, most babies whose mothers have abnormal AFP levels are found to be normal.

CELL FREE DNA TESTING or non-invasive prenatal testing (NIPT) is a maternal blood test performed in my office after 10 ½ weeks. This is a screening test that has a reported sensitivity of 99% for Down Syndrome, Trisomy 18, Trisomy 13 and several microdeletion abnormalities. This test also predicts gender relatively accurately.

MATERNAL/PATERNAL CARRIER SCREENING is a blood test that tests for 502 different diseases for which you may be a carrier. A carrier does not necessarily display the disease but has the potential to pass the disease to the child if the partner is also a carrier for the same disease. Partners can be tested at the same time or only if the maternal blood test returns with a positive carrier status.

SONOGRAMS use high frequency sound waves to create a picture of internal organs, including the baby. X-rays are not used and no harmful effects from ultrasound have ever been substantiated. I perform a vaginal sonogram at your first visit to confirm the size and location of the pregnancy. Most subsequent visits will incorporate a sonogram to check position, amniotic fluid and heartbeat. Later, around 16-21 weeks, more detailed sonograms will examine your baby’s anatomy. This scan is used for many purposes including confirmation of gestational age, identification of congenital abnormalities and evaluation of the placenta, amniotic fluid and growth. Many, but not all, structural abnormalities can be seen on sonogram. Although many parts of the sonogram will be unrecognizable to you during the anatomy scan, the technician can show you pictures of specific sites of interest to you.

The sonogram may be able to tell the gender of your baby, depending mostly on the position of the legs. If you do not want to know, be sure to tell the sonographer, who may then ask you to look away during parts of the scan. Only genetic studies (see below) can definitively identify a baby’s gender.

Eating a normal healthy diet is all pregnancy requires, though I suggest the added restrictions below. You need extra calcium and protein later in pregnancy, 300-500 extra calories a day. Drinking three to four glasses of skim milk per day will meet these needs, but if this quantity of dairy products is intolerable, you can take Os Cal 500mg (or equivalent) a day and obtain more protein from other sources (fish, poultry, lean meat.) Pre-natal vitamins and DHA (omega 3) supply the other minerals and trace elements you and your baby need, though if nausea prevents you from stomaching them for the first couple of months, no harm is done. Extra vitamin supplements, as with any medication whether prescribed by a doctor or not, should not be taken without speaking to me first. Even vitamins, A especially, has been known to cause birth defects.

During the first few months of pregnancy, all this advice may be beside the point. Just finding a single food that does not make you feel nauseated may be the week’s highlight. Don’t despair. This phase passes, usually by the 12-14th week. The pregnancy is small enough during this period that it can derive all its requirements from your reserves even if your weight drops slightly. By week 20, most women have gained a few pounds. From then on, the average gain is ½ lb pound per week for a total of around 25lbs. This figure varies widely and within the range of 15-35 lbs. and there is rarely cause for concern. Remember though: pregnancy is NOT a time to lose weight, or to gain as little as possible so as to have less to lose at the end. New elements and proteins are needed for normal fetal development.

Even after the early nausea dies down, your digestive system may not seem “normal.” Some of the hormones present in your body slow and relax the intestinal muscle, leading to heartburn, early fullness and constipation. Small frequent meals, antacids (Tums, Maalox, Mylanta, etc.), and lots of fiber and water are the solutions here. You should be drinking 4-6 glasses of water a day.

The following list of suggested prohibitions is neither complete nor absolute. Relatively few substances have been proven to cause birth defects. Many more, sometimes it feels like all others, have been suspected. It seems prudent to avoid as many chemical additives and exposures as possible, recognizing that complete purity is not to be found in the Tri-State area.

• No medications, prescriptions, or over-the-counter, except an occasional Tylenol, without
• speaking to me first.
• No sushi or raw meat (These may contain parasites.)
• No caffeine (The data is not all in, but best to be avoided, if possible. If you need that cup
• of coffee in the morning, make it your only one.)
• No artificial sweeteners.
• No alcohol.
• No smoked foods or pork (may contain nitrates.)
• No oysters, mussels or clams unless well-cooked (hepatitis A contamination.)
• No unwashed fruits or vegetables (Unless organically grown, these may have pesticide
• residues.)
• No smoking or vaping (Linked to inadequate fetal growth and premature delivery.)
• A maximum of 12oz. of fish per week. The following fish should be avoided: swordfish,
• shark, king mackerel.
• No deli meats.
• No soft or unpasteurized cheeses.

As long as your pregnancy is uncomplicated, you should continue to exercise regularly. You may need to alter your chosen activity as your body changes and your balance becomes less sure.

Sports, which might lead to abdominal injury, primarily from falling, are best avoided after the first few months.

You should scale back your activity to avoid over-exhaustion and dehydration. Be sure to keep your pulse under than 120. Please avoid saunas and hot-tubs.

Continued sexual activity, including intercourse, poses no danger to you or the baby in an uncomplicated pregnancy. As your body grows, you may find certain positions awkward or uncomfortable. Similarly, your desire for sex may increase or decrease at different times during the pregnancy, as may your partner’s (and not always in sync.) These changes are a normal part of the emotional adjustment you both are making to your pregnancy and impending parenthood. Talk with each other about these changes and feel free to discuss any concerns or questions with me.

For emergencies and deliveries, I can be reached 24 hours a day via my secretary, Michelle or answering service (both can be reached via 212-734-1893.) They will take your information, number and I will call you back as soon as possible. For other problems or questions that need to be addressed before your next visit, call my office during working hours and I will get back to you. Please provide as much information as possible about the situation. This allows me not only to respond most rapidly to serious emergencies, but also to be better prepared to answer your questions when I call.

If, for some reason, in an emergency situation only, you feel the need to speak to someone before I have gotten back to you, call Lenox Hill Hospital Labor and Delivery and ask to speak with one of the doctors or nurses at 212-434-2760.

ANY OF THE FOLLOWING SHOULD PROMPT AN IMMEDIATE CALL TO MY OFFICE:

• A decrease in the baby’s movement.
• Vaginal bleeding.
• Persistent leaking of fluid from the vagina.
• Fever and chills.
• Persistent lower abdominal cramping or pain, menstrual-like cramps, or increased pelvic pressure prior to 36 weeks.
• Severe headache or blurred vision.