- Nutrition in pregnancy
- Risk of Foodborne Infections
(Toxoplasmosis, Listeriosis, Hepatitis A, Salmonella infection)
- Risk of Infectious Diseases
(Parvovirus B19/Fifth Disease, Cytomegaly/CMV, HIV/Hepatitis, Zika Virus, GBS)
- Antenatal Fetal Testing
(Maternal Care Guideline Ultrasound Screenings, Additional Prenatal Screenings / Tests)
- Screening for Gestational Diabetes
- High-Risk Pregnancy
Nutrition in Pregnancy
Simply put: you will not require significantly more calories, but should take care to eat a healthy and well balanced diet. “Don’t ‘eat for two’ but keep meals ‘colorful and healthy’ as often as possible.” You should focus on wholefoods, seasonal fruits and vegetables (5 servings per day), protein-rich foods (cooked meat, poultry, sea fish ideally twice a week, eggs, beans, nuts) and milk / dairy products such as cheese, yoghurt and cottage cheese or “Quark”. Avoid high-fat and sugary foods wherever possible, take plenty of liquids (1,5 L/day). Unless otherwise advised by your doctor, you should also take an “over the counter” prenatal vitamin. It is most important to supplement folic acid and iodide, possibly also iron and vitamin D and certain B vitamins. From the second trimester on throughout the breastfeeding period, omega-3 fatty acids may be recommended to patients who do not consume 2 portions of sea fish per week.
The following foods and stimulants are harmful to the unborn child or can transmit dangerous pathogens, thus regard them as “off limits:”
- alcohol and nicotine
- unpasteurized milk and soft cheese made from unpasteurized milk
- unwashed raw or uncooked foods
- uncooked or semicooked meat / fish (such as tartar, mett, carpaccio,”bloody” steaks, sushi, graved lox)
- liver (high vitamin A content)
- foods containing raw eggs
Risk of Foodborne Infections
Toxoplasmosis, Listeriosis and Hepatitis A are infectious diseases potentially transmitted with food intake that may put your pregnancy at risk. They are not to be confused with typical “food-poisonings,” – gastrointestinal infections most commonly caused by coli bacteria (travel diarrhea) or salmonella. Generally remember that moldy foods – although not a direct danger to the unborn – may contain fungal toxins that are harmful to your own health.
Toxoplasmosis is caused by the parasite Toxoplasma gondii, which – once transmitted – leads to lifelong immunity. Although the infection generally causes a mild, symptomless illness in people with a healthy immune systems it does pose a risk during pregnancy because the parasite may infect the placenta and/or the fetus. Toxoplasmosis pathogens are found in cat feaces and are usually transmitted with food intake: Experts estimate that about half of toxoplasmosis infections are caused by the consumption of raw or undercooked infected meat- but the parasite is also transmitted via unwashed contaminated produce, contaminated water, or after handling contaminated soil, cat litter, or meat and then touching mouth, nose, or eyes (- be sure to wash your hands before eating after gardening or after handeling sand from a sandbox!).
Toxoplasmosis in adults will spread after a 1-3 week incubation period; often, the patient will not notice any clinical symptoms. If you have not yet acquired immunity against the pathogens, we recommend an antibody test every 8 weeks between the 16th and 32nd week of pregnancy. Should tests – and confirmation studies –suggest that you have recently been infected, antibiotic treatment will lower the risk of fetal infection. (back to top)
Listeriosis is a potentially serious infection acquired by eating food contaminated with the bacterium Listeria monocytogenes. Unless you have some underlying disease that affects your immune system, it’s unlikely that the infection will seriously affect your health. Symptoms of Listeriosis may show up 2-30 days after exposure. Symptoms in pregnant women include mild flu-like symptoms, headaches, muscle aches, fever, nausea, and vomiting. If the infection spreads to the nervous system it can cause stiff neck, disorientation, or convulsions. Listeria can infect the placenta, the amniotic fluid, and the baby, and can cause miscarriage or stillbirth. Therapeutically, antibiotics are available, and will prevent transmission of disease to the child if administered in time.
Listeria monocytogenes may be found in unpasteurized milk products, in uncooked meat and fish and in contaminated produce and sprouts. The bacteria thrive even in cold temperature, but need a humid environment to survive. Note that even refrigerated film-packed deli/supermarket salads, cheese produce and cold-cuts may be contaminated.
To avoid infection…
- pay close attention to everyday hygiene – always wash your hands before handling food
- clean your refrigerator regularly
- clean or replace dishtowels and sponges regularly
- avoid unpasteurized milk and soft cheeses made from unpasteurized milk
- avoid pre-cut deli meat, prefer freshly cut!
- no raw meats or eggs
- wash and scrub all produce carefully, avoid sprouts
Hepatitis translates to “inflammation of the liver”. The Hepatitis A virus is carried in stool and spreads easily from person to person or through contaminated water or food. It does not pose a direct threat to the pregnancy but can severely compromise a mother’s health. There is no need to take special precautions in Germany, as outbreaks are extremely rare. They do, however occur in Mediterranean European countries. (Hepatitis B and C do not spread as easily, they are only transmitted via direct contact to blood or bodily fluids). When in question while travelling, avoid raw foods, follow the “peel it or toss it” rule and generally use bottled water. Vaccinations are available against hepatitis A and B, and it is advised to vaccinate pregnant women planning to travel to high-risk countries.(back to top)
Salmonellosis (Salmonella GI-infection)
Salmonellosis is a gastrointestinal infection caused by contaminated food after 5-72 hours of incubation. People with an impaired immune system- as are pregnant women – are particularly susceptible. Headaches, vomiting, stomach and intestinal problems, chills and fever usually last only a few hours to days and generally do not compromise the fetus. The treatment of salmonellosis entails administering fluids and electrolytes, in severe cases i.v. fluids and antibiotics.
To avoid infection…
- avoid long storage, consume fresh produce quickly, mind the cooling chain
- always wash your hands before handling food
- handle raw meat carefully and separate from raw produce
- heat meats to 70°C for over 10 minutes
- Salmonella love protein:
eat eggs only hard-boiled and mind all meat and fish products, no matter what the expiry date says: anything that “smells” ever so slightly should be discarded!
- take frozen food out of the package, place it in a strainer and bowl to defrost in the refrigerator, dispose of any liquids immediately (back to top)
Risk of Infectious Diseases
Some of the diseases below are “clinically irrelevant” to a healthy adult, as they hardly cause symptoms – but all can have a negative effect on the course of a pregnancy. If in doubt, I advise checking an expectant mother’s immune status at the beginning of each pregnancy – this allows us to counsel all necessary prophylactic measures.
Parvovirus B19 (“slapped cheeks disease” or “5th disease”)
Fifth disease (it was the fifth red-rash childhood disease to be identified) is generally a mild illness that most commonly affects preschool and school-age children. It’s also sometimes referred to as “slapped cheeks disease” because of the red facial rash that children commonly develop when they’re infected. The disease is caused by parvovirus B19, which inhibits the production of red blood cells. For otherwise healthy adults and children, this isn’t a problem; it can however lead to serious anemia in an unborn child – necessitating treatment in a perinatal clinic. About 60-70% of all pregnant women are immune to the disease. Although there is no vaccine or treatment available, knowledge of an expecting mother’s immune status is particularly helpful for patients who are in frequent contact with younger children. (back to top)
Cytomegalovirus (a virus of the herpes family) is the virus most frequently transmitted from mother to child during pregnancy. CMV is spread by direct contact with an infected person’s bodily fluids, such as saliva, urine, feces, semen, vaginal secretions, blood, tears, and breast milk. You may catch the disease if, for example, you share eating utensils, kiss mouth to mouth, or have sex with an infected person. You can also get CMV if you touch infected fluid and then touch your mouth or nose.
About 50% of expecting mothers are believed to be immune to the disease. If infection occurs during pregnancy, a mother may not notice. The likelihood of transmission from mother to child is low and usually occurs in the third or fourth month of pregnancy via the placenta. This happens in a no more than 40% of maternal primary infections – and only about 10-20% of the infected children develop medical problems; the later in pregnancy, the less likely that a child will suffer serious impairments. The CDC estimates that only 1 of 750 of these children will develop disabilities as a result of congenital CMV.
Testing for CMV immunity allows for better pregnancy counseling- the following precautions are particularly important to expecting mothers who are at risk of primary infection.
To avoid infection…
- wash hands regularly with warm water and soap for a minimum of 15-20 seconds, especially after diaper changes, feeding, or contact with saliva
- do not share food, eating utensils, towels etc. and avoid licking pacifiers or feeding bottles
- avoid kissing young children on the mouth- most particularly if they are unwell
- carefully clean all objects and surfaces that have come into contact with urine and saliva
- practice safer sex and avoid oral sex if you do not live in a mutually monogamous relationship (back to top)
HIV, Hepatitis B and C
These viral infections are rare and can only be transmitted through blood or sexual contact. The Mutterschaftsrichtlinie recommend screening for HIV at the beginning, and for Hepatitis B towards the end of each pregnancy. Hepatitis C is only tested in mothers who may be at higher risk of infection.
With adequate therapy, it is possible to reduce the transmission of the HIV virus from mother to newborn to 1-2%. Hepatitis B and C may also be transmitted to the unborn child or cause a chronic pediatric infection if precautionary measures are neglected. Vaccination right after delivery will prevent transmission from mother to child if the mother is Hepatitis B positive. The recommended measures for Hepatitis C depend on the maternal viral load. Counseling will be coordinated by the specialized outpatient clinic at LMU University Hospital – Maistraße.(back to top)
The Zika virus is usually transmitted by a bite of the yellow fever mosquito (sexual transmission is also possible). Symptoms usually appear after 3-7 days and last for up to one week: they entail a rash, headaches, joint and muscle pains, conjunctivitis and fever. A maternal infection is particularly dangerous in the first trimester and can lead to severe fetal cerebral malformations. Women who have spent time in a Zika endemic area are advised to wait 6 months before attempting to become pregnant.
Currently, the risk of infection in Germany is considered to be extremely low. As a precaution, pregnant women are advised to practice safer sex with men who have been in a Zika endemic area. It is not yet clear how long the virus remains detectable in sperm – thus safer sex is recommended through the end of the pregnancy.
The Zika virus is spreading to more than 40 countries in Central and South America. Infections also occur in tropical Africa, Asia and the Pacific Islands. Current maps of countries with known transmission are provided by the World Health Organisation (WHO) and the European Centre for Disease Prevention and Control (ECDC).
The latest information on Zika virus infection can be found on the following pages of the CDC. (back to top)
Group B Strep Infection (GBS)
The colonization of the vaginal or rectal mucosa with B-streptococci occurs in 25% of all healthy adult women, is generally harmless and requires no treatment. GBS does become relevant during pregnancy if a vaginal delivery is intended. The bacteria can be passed on to the baby during childbirth and lead to severe neonatal infection. I therefore recommend performing a routine GBS test in the last trimester of pregnancy. If the smear is positive, an antibiotic will be administered to the mother during the delivery, thus preventing newborn infection. (Back to the top)
Antenatal Fetal Testing
After perinatal training at the Munich University Hospital Großhadern, this topic is particularly close to my heart. In principle, every expectant mother is free to decide how much she wants to find out about potential medical conditions of the unborn. As medical professionals, we are required to point out an increased risk of certain genetic disorders and provide adequate counseling to all mothers above age 35. In our office, we make an effort to offer detailed counseling to all expecting mothers if requested.
The maternal care guidelines call for certain blood-tests to determine blood-type and rule out certain infections; they also require 3 ultrasound screenings to ensure maternal and fetal wellbeing. Medical advances have brought forth other methods of antenatal testing that may be of interest to you even though your pregnancy is not officially considered at a “high risk” for genetic disorder. Although your insurance may not cover the cost, we will determine which tests “make sense” in your individual case and schedule them accordingly.(back to top)
Maternal Care Guideline Ultrasound Screenings
Our office is equipped with state-of-the-art 3D/4D ultrasound technology. In accordance with the maternal care guidelines (Mutterschaftsrichtlinie) and regardless of age, every woman is offered at least 3 ultrasound screening examinations. Individual assessment will determine if other scans are recommended:
The first screening (around 10 weeks) is devised to determine the location of the pregnancy, the number of embryos and to rule out early serious malformations.
The second screening (around 20 weeks) will focus more closely on the diagnosis of hard-to-detect malformations – the exam is therefore often referred to as “organ screening”.
The third screening (around 30 weeks) will entail a less detailed organ scan, and focus more precisely on fetal growth and development.(back to top)
Additional Prenatal Screening Techniques
NIPS – Non Invasive Prenatal Screening
Novel NIPS technology allows us to use a maternal blood sample when screening for the most common genetic disorders – from as early as 10 weeks of pregnancy. The test is particularly reliable in detecting trisomy 21, a little less precise in detecting trisomies 13 / 18 or maldistribution of sex chromosomes. Results are usually available within 5 working days. Negative results have to be confirmed via invasive testing. I will be happy to explain the scope of the test – as well as cost and limitations – in a detailed consulation.(back to top)
First Trimester Screening or Nuchal Translucency Measurement / NT screening
This screening method has been established for many years. It was developed to identify patients at significant risk of carrying a child with genetic abnormalities – and only expose these pregnancies to the more risky procedures of invasive diagnostics. The “nuchal translucency” itself is detectable in every pregnancy- visualized as a narrow black line at the back of the fetal neck which disappears with increasing gestational age.
The screening combines the following information:
- maternal age
- the results of a biochemical hormone analysis around the 11th week of pregnancy (PAPP-A and ß-HCG)
- the fetal NT-measurement taken between the 12th and 14th week of pregnancy.
These parameters are statistically combined to calculate an individual risk for fetal genetic disorder. If the result is unclear or “borderline,” NIPS may be recommended; in all obvious cases of increased risk, invasive diagnostics will be advised to rule out possible chromosomal defects.(back to top)
Screening for Preeclampsia
As part of the NT / First-Trimester-Screening, it has become possible to also test for a mother’s risk of developing preterm preeclamsia – a severe hypertensive complication that is difficult to treat once apparent. The screening test combines doppler-measurements of uterine vessles, maternal blood-pressure measurements and hormone levels. Early screening is key, since prophylactic administration of low-dose aspirin to women found at risk has been clinically proven to prevent severe preeclampsia – if the treatment is begun before 16 weeks of gestation.(back to top)
Invasive Prenatal Diagnostic Techniques
These methods are current “gold-standard” tests when exact analysis of the fetal chromosomes / genes is required, or an intrauterine infection needs to be ruled out. Chorionic villus sampling (CVS) can be performed as early as 11 weeks of gestation and entails the sampling of fetal cells from the early placenta (chorion) through the mother’s abdominal wall. From 16 weeks, amniocentesis (AC) becomes an alternative option; amniotic fluid can be used to examine fetal genes or test for infectious agents. Preliminary results are usually available within 24 hours, final results within 10-14 days. Both methods are not without risk – in 0.5-1%, miscarriages will occur as a consequence. This risk correlates directly with the routine of the examining physician – ideally, he/she should perform at least 100 interventions per year. Therefore, we do not carry out the above mentioned procedures in our office but cooperate with specialized clinics in Munich.(Back to top)(back to top)
Screening for Gestational Diabetes
About 5%-8% of all pregnant women will develop gestational diabetes. The disease may not become clinically apparent, but elevated blood-sugar levels are toxic to both mother and child. It is therefore important to detect changes in the mother’s glucose metabolism at an early stage- ideally by performing a glucose tolerance test between 24+0 and 28+0 weeks of pregnancy. The test begins with a fasting glucose check and is followed by 2 further blood samples taken 1 and 2 hours after the administration of a sugary drink that contains exactly 75g of glucose. Should we find metabolic problems, we will consult an endocrinologist as well as a dietitian to help you adapt your diet and monitor the blood-sugar levels at home. In our office, bi-monthly ultrasound and doppler exams will be scheduled to assure safe progess of the baby’s development.The goal is to aim for delivery at full term. In most cases, the mother’s metabolism will return to pre-pregnancy normal state within days after delivery.(back to top)
High-risk Pregnancy Care
Some pregnancies are considered “high-risk pregnancies”- particularly if a mother suffers a preexisting condition (i.e. diabetes, hypertension, coagulation disorder), has had serious complications in a previous pregnancy or is expecting multiples. Primary focus of my training at Großhadern Hospital was the care of these more complicated pregnancies. My patients benefit from my close ties to Munich’s specialists which we will consult whenever necessary to guarantee the best possible primary and secondary care. (back to top)