10 Things to Know in Early Pregnancy

Yay! Can you believe it? You made it out of the Infertility Club, and you are now part of the Pregnant Club. We knew you could do it! So, no worries, right? Well, maybe not so much. You may have just replaced one set of worries with another. No sweat! In this list, we offer some help as you “graduate” from your fertility clinic to your obstetrician’s office.

Good pregnancy or not?

So, the pregnancy test is positive — now what? The hormone that is measured for pregnancy is human chorionic gonadotropin. Specifically, it’s one of the components of the beta chain and is thus called beta hCG. For the most part, only the pregnancy — the trophectoderm, specifically — makes hCG, so any amount of hCG is a sign of an implantation of an embryo and shows in the blood roughly ten days after ovulation. As the pregnancy grows, more hCG is produced. A normal pregnancy will secrete a normal amount of hCG, which is a rise of more than 60 percent in 48 hours. Frequently, the rise is said to double every 48 hours, but that’s not always true, and a normal pregnancy may not have a doubling of the hCG every 48 hours.

What does low progesterone mean if you are pregnant? The issue of low progesterone when you are pregnant is whether the low progesterone is a sign of an abnormal pregnancy or whether the low progesterone is causing an abnormal pregnancy. With very few exceptions, an abnormal pregnancy will cause low progesterone. This is especially true if the pregnancy has an abnormal number of chromosomes. Considering that this is the cause of the low progesterone, treating a low progesterone with progesterone makes little sense. That having been said, many physicians prescribe progesterone and there seems to be no adverse effects of doing so.

What is a biochemical pregnancy? Somewhat aggravatingly, the term “biochemical” has crept into the lexicon of infertility. It implies that somehow a biochemical pregnancy is unique. The reality is that a biochemical pregnancy is a pregnancy that fails to grow to a size that can be seen on ultrasound or diagnosed if the pregnancy tissue is passed vaginally and assayed by pathology. Most biochemical pregnancies fail to progress because they are genetically abnormal with an abnormal number of chromosomes.

What is a pregnancy of unknown location?

A normal pregnancy will grow to a size where it can be seen on ultrasound somewhere in the fifth week of pregnancy (calculated from the first day of the last menstrual period). By the sixth week, a normal pregnancy will be seen on ultrasound as a gestational sac (GS) — the pregnancy unit. If the GS is in the uterus, it is termed a clinical pregnancy even if it is not normal and ends as a miscarriage. If the pregnancy is in the tubes and can be seen on ultrasound, it is called an ectopic pregnancy. Sometimes there is a pregnancy that is developing abnormally in the uterus or in the tube and cannot be seen. This is a pregnancy of unknown location and is usually treated as an ectopic pregnancy.

Bleeding is bad, right?

What about first trimester bleeding? Bleeding early in a pregnancy is a scary and concerning problem. Sometimes, it is the first sign that something is terribly wrong with the pregnancy and the pregnancy will end as a first trimester loss. Other times the bleeding has no significant correlation to the outcome of the pregnancy.

First trimester bleeding is common. Over 25 percent of pregnant patients experience vaginal bleeding sometime before week twelve of a pregnancy. Of those women who bleed in the first trimester, a little over half miscarry. However, not all bleeding is the same. Some women will have a small amount of bleeding with no cramping while other women will experience heavy bleeding and cramping. Women who have heavy bleeding are three times more likely to miscarry. Those women with light bleeding, no cramping, and bleeding less than two days have no increased chance of miscarriage when compared to women without bleeding.

If you are spotting or bleeding, contact your physician. Most probably, she will draw blood to measure the hCG and or perform an ultrasound. The thing to remember is that no amount of measuring the pregnancy by the hCG or ultrasound will alter the course of the pregnancy. At best, the information can distinguish a normal pregnancy from an abnormal pregnancy and help determine what action to take.

What about exercise?

Regular exercise has been associated with a number of health benefits. ACOG recommends that a pregnant woman, at a minimum, should maintain her pre-pregnancy level of exercise. So, if you are one of those fortunate people who have a healthy lifestyle, being pregnant is no excuse to stop. However, for the rest of the world, the pre-pregnant and pregnant period are a good time to develop a healthy lifestyle incorporating sound eating habits and exercise.

In 2008, the U.S. Department of Health and Human Services issued guidelines for physical activity. The guidelines suggest that healthy pregnant and postpartum women should do at least 150 minutes of moderate-intensity exercise, such as brisk walking, spread over the week. If a woman has a very high prepregnant level of activity, it is okay to continue that when pregnant after a discussion with your obstetrician to make sure there are no reasons for reducing her exercise level.

There are obvious pre-pregnant conditions that are absolute contraindications when pregnant, such as significant heart disease, severe lung disease, incompetent cervix, abnormal placement of placenta (previa), multiple gestations, or severe anemia. But most women are aware of these conditions and should be under the care of their OB prior to conceiving. A number of less severe conditions may suggest the need to restrict a woman’s level of aerobic exercise, but these can be discussed with the OB. Not all types of exercise carry the same risk, so the type of exercise matters. For example, walking, swimming, stationary cycling, and yoga are safe. Exercises such as contact sports, those activities with a high risk of falling, sky or scuba diving, or “Hot Yoga” should be avoided. If you are exercising and you feel anything unusual that suggests you should stop exercising (think bleeding or significant pain), then stop exercising. This is definitely not a no pain, no gain situation.

Can I fly when I’m pregnant?

Coauthor Dr. R recalls, “Once when I was a young, mouthy adolescent, my mother asked if she could fly somewhere and I asked if she had a broom — only once did I make that mistake.” So, can you fly when pregnant? Yes — just use an airplane. Air travel is safe when a woman is pregnant, especially in early pregnancy. Turbulence can’t be predicted, so the seatbelt should be used at all times. Most people do not fly frequently enough to be harmed by the increased cosmic radiation, but flight attendants and pilots may be. Pilots and flight attendants need to contact their employer for further information and company policy regarding flying when pregnant.

Should I quit my job?

According to the ACOG practice bulletin, working during pregnancy is generally safe. As of 2015, 70 percent of women with children under the age of 18 were in the labor force. Of these, 56 percent of pregnant women worked full time during the pregnancy.

Jobs where it may not be safe to work while pregnant require individual investigation. For example, what about jobs where there are toxic chemicals? While thousands of chemicals are used in industry today, very few have been documented to be harmful to a pregnant woman. However, some chemicals are considered to increase risks for fetal anomalies and miscarriage. These include heavy metals like lead, mercury, or arsenic; some pesticides and herbicides; some solvents; ionizing radiation; and chemotherapeutic medicines. OSHA regulates exposure to some of these potential hazards, but if you are concerned about the risk, you can consult the chemical’s data safety sheet, CDC-NIOSH, and your employer. Sometimes, accommodations can be made to make sure you are comfortable with any potential risk.

The information available on night shift work or extensive occupational lifting is mixed, but there may be a slight increased risk for miscarriage. Studies did show a slight increase in the risk for preterm birth for some work conditions, such as work where the person was standing for more than three hours or carrying more than 11 pounds. Physically demanding work has been shown to increase low back pain and musculoskeletal problems. For these conditions, accommodations have been shown to reduce the risk. For example, where the work involves standing for prolonged periods of time, things like floor mats, sit-stand workstations, support hose, and appropriate shoes have been shown to help. Jobs requiring lifting do pose a risk of back pain and musculoskeletal injuries. The National Institute of Occupational Safety and Health has made recommendations for pregnant women for weight limits. An excellent summary of these recommendations is published by ACOG.

Should I get a flu shot?

The answer to this is easy: Yes! Unfortunately, vaccination has become a hot topic with fears of risks like autism from being vaccinated. These undue fears have already needlessly cost lives.

In recent years, there have been 24,000 deaths in the United States per year due to influenza. In the 2009 influenza pandemic (an infection that is prevalent over an entire nation or worldwide), pregnant women between the ages of 18 and 29 accounted for 16 percent of deaths from the influenza infection. A study done by the FDA’s Vaccine Adverse Event Reporting System reported no or mild adverse outcomes in over 2 million people vaccinated. There were no adverse effects on the infants. This is one example of how bad science, fake news, and conspiracy theories have caused needless deaths.

When should I see my ob/gyn?

You have a positive pregnancy test. Yay! Then another one. Double-yay! But you are still at the fertility clinic. There will come a time when you need to move from the care of your REI to the care of an obstetrician (OB). There is no set standard. Some REIs like to monitor patients and manage their early obstetric care. Other REIs do a single ultrasound to document that the pregnancy is in the uterus and that the fetus has fetal heart motion. When your REI tells you it’s time to move on, as coauthor Lisa likes to say, “You have now graduated!”

It is a very good idea to have chosen an obstetrician, the physician who will manage your pregnancy and deliver your baby, prior to treatment for infertility so that when the good news comes, the OB is already on the team. Occasionally, there may be a question or problem that is more appropriately handled by your OB rather than by the REI. So, having an established relationship with an OB will avoid the problem of whose patient you are. Also, OBs differ in how they handle certain problems, and since that is the person who will manage you to the finish line, it is helpful to already have that doctor on board.

Do I have to stay on my medication?

Sometimes women feel that they are not pregnant and will stop their medications. Whether this can cause a pregnancy to fail is up for debate, but a good rule of thumb is to stay on your medications until your REI has told you exactly what to do with your meds. Also, this is probably not the best time to start meds that you were not on unless you clear this with your REI.

On the other end of the spectrum, if the pregnancy test was positive, you may figure you are pregnant so, what the heck, you can stop all those injections and other meds from the fertility office. No! There was a reason that the fertility clinic prescribed the medications, and you are most often sent on to see your OB with a list of instructions on what meds to stay on and when to stop. Even though you are an IVF “glad grad,” you still need the drugs. So, don’t change anything until you talk to your OB.

Dealing with a UTI

Urinary tract infections (UTIs) are the second most common problem for pregnant women behind anemia. Left unattended to, they can cause severe infections of the kidneys (pyelonephritis), which can be harmful to the pregnancy. So, do you start by downing a gallon of cranberry juice and hope that cures the problem, or is it time to consult your physician? The most common treatment for UTIs is oral antibiotics, which. properly prescribed and taken, are safe in early pregnancy. When in doubt, consult your physician.

What is happening to my skin?

Skin changes are common in pregnancy. Common changes include dark spots on the breasts, nipples, or inner thighs and sometimes brown patches on the face (melasma). Other changes include linea nigra (a dark line running from the belly button to the pubic hair line, stretch marks, acne, varicose veins, and changes in hair and nail growth.

Some of these changes are due to the hormones that are present during pregnancy, and some, such as varicose veins, are due to the physical presence of the fetus as it gets bigger. Over-the-counter medications that can be used during pregnancy include topical benzoyl peroxide, azelaic acid, and glycolic acid. Some prescription medications should not be used during pregnancy, and these include isotretinoin, oral tetracyclines, and topical retinoids.

Many women experience increased hair growth, perhaps in places where there had been very little hair. These changes usually return to normal by six months postpartum (after the child’s birth), but many women experience hair loss in the first three months postpartum.

Varicose veins are common in pregnancy due to the weight of the pregnancy as it grows and places pressure upon the veins that return the blood from the legs. Varicose veins are almost impossible to prevent, but certain physical accommodations can be made to lessen swelling and discomfort. These include not sitting with your legs crossed, moving around, elevating your legs as often as you can, considering support hose (consult your OB first), and avoiding (good luck) constipation by eating high-fiber foods and adequate liquids.