Next Steps - Pregnancy Care

Next steps Pregnancy care

Contents Congratulations

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Next steps

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What next Making appointments

Early pregnancy

Common complaints in early pregnancy

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General care

Pregnancy in women over 35 years

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Pregnancy loss

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Antenatal tests

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Ultrasound scan Maternal seruym screening

Congratulations Pregnancy following fertility treatment Congratulations on your positive pregnancy test.

Having a pregnancy confirmed is generally a happy and exciting time. However, when pregnancy follows fertility treatment, it is also natural to feel other emotions such as caution, anxiety, and maybe fears about the pregnancy outcome.

Pregnancy support and counselling Fertility Associates offers support during early pregnancy. You may also want to use our counselling services, to explore: • Feelings and concerns • How and when to tell others about your pregnancy • The transition from fertility treatment to pregnancy • Developing strategies for adjusting to changes to your life with pregnancy and later parenting • How to find support and resources in the community If you have the misfortune to lose your pregnancy, our counsellors can help with the feelings that loss releases. Counselling appointments (including phone consultations) can be made by contacting reception staff.

It is important, even though it is early, to think about what happens next.

Have a look at the section “What Happens Now” on page 89 in our Pathway to a Child magazine.

Please contact a nurse at the clinic if you do not have a copy of the magazine.

Next steps What next?

Appointments At the time of your positive pregnancy test you will be four weeks pregnant using the usual way of calculating gestation. Pregnancy is traditionally counted from the date of the last menstrual period, which for many treatments is the same as the day 1 of your cycle.

Blood tests Most people will have two blood tests for the pregnancy hormone hCG, usually 14 and 18 days after treatment. We may ask for further tests if the day 14 and 18 results are outside the usual range, if you have previously had a pregnancy loss, or if there are other reasons for following your pregnancy more closely. Your nurse will discuss tests with you.

Pregnancy scan Fertility Associates will arrange a pregnancy scan when you are around 7–8 weeks pregnant. This is a vaginal scan, just like those done during treatment. Most women bring their partner to the scan. It is good idea to have someone you know well as a support person at the time of the scan.

Antenatal appointment After the scan result, Fertility Associates or your GP can help you find a Lead Maternity Care (LMC) provider to look after the rest of your pregnancy. Your LMC can be a midwife or an obstetrician. Your Fertility Associates doctor will send a referral letter including scan results to your LMC. It is a good idea to contact your preferred LMC early to make your first antenatal appointment, since LMCs do get booked up.

Pregnancy timeline 6–8 weeks 1st scan

4 weeks

Pregnancy blood test

15 weeks

Amniocentesis test

10–12 weeks

18–20 weeks

1st Antenatal appointment & Nuchal Translucency (NT) scans, Harmony blood test

Anatomy scan

26–28 weeks

Diabetes screen

Moving on from Fertility Associates care Your LMC will look after the rest of your pregnancy. She or he will manage your antenatal care, any referrals for extra care during pregnancy, and your delivery and post-natal follow up.

Keeping in touch We are always pleased to hear from people during their pregnancy and of course we are always delighted to receive photos, emails and visits after the birth of your baby. You can also ‘like us’ on Facebook; Good News stories are a source of encouragement for others going through treatment.

If we have not heard from you about the outcome of your pregnancy, one of our nurses will be in touch. As mentioned in our patient information and consents forms, we have an obligation to collect key information about each pregnancy from most types of fertility treatment. One of our nurses or embryologists will write to your LMC or you soon after the expected date of delivery to collect information about gender, date of delivery, birth weight, and any complications.

Early pregnancy Common complaints in early pregnancy Tiredness It is common to feel very tired in the first 12 weeks of pregnancy. If possible, allow some time for an afternoon rest and go to bed early.

Sore breasts This varies between individual women, but can be helped by wearing a well-supporting bra.

Nausea Many women have some degree of morning sickness. Morning sickness doesn’t not just occur in the morning; many women feel nauseated at other times of the day too.

Although most women experience “morning sickness” for just a few weeks, others are unwell for the first three months of pregnancy.

A few people feel unwell for the majority of their pregnancy. Feeling sick to the point of vomiting is quite common.

Practical suggestions for dealing with morning sickness Step 1 Sipping dry ginger ale or flat lemonade slowly and frequently in small amounts may help settle your stomach. This is a good first step.

Step 2 As nausea and vomiting become more controlled, take sips of more nourishing fluids such as chilled, diluted fruit juice, vegetable juices or a light soup.

Step 3 Introduce small amounts of solid food.

• If you are nauseous and vomit first thing in the morning, keep some dry biscuits or fruit next to your bed so that you can eat something when you wake but before you get up. This can help relieve the nausea. Try to have a light breakfast, for example, cereal and low fat milk or toast and honey.

• Eat small amounts frequently, such as every one or two hours. Do not let your stomach get too full or too empty. Try to have at least six small meals spread out through the day rather than three large meals.

• Eat carbohydrate-containing foods that you find easy to digest and provide energy, such as plain biscuits, toast with honey or Vegemite, jelly, dry cereal, or stewed fruit.

• Eat and drink slowly. Rushing around can cause vomiting. Continue to sip dry ginger ale or flat lemonade if you still feel nauseous.

• Avoid drinking liquids with meals.

Step 4 Introduce light, low fat meals.

• Cold foods and drinks are often easier to tolerate than hot foods or drink.

• Omelettes, milkshakes, custard and fruit are nourishing. Low fat varieties may be easier to tolerate than full fat.

• Continue to eat six small meals a day rather than two or three larger meals.

• Try to have a nourishing snack before bedtime.

The best way to manage morning sickness is with the appropriate diet.

Drugs should only be sought as a last resort.

Helpful tips • Try ginger taken in the form of ginger beer, ginger ale or tablets • Some people find acupuncture helpful for treating morning sickness.

If you are interested, discuss this option with your doctor.

• Vitamin B6 50mg morning and evening may help Remember that the baby will take all the nutrients it needs from your body. Don’t not worry if you cannot follow the diet recommended in pregnancy. Eat what you fancy and can keep down, and move to a healthy well balanced diet as soon as you can. There is little evidence to suggest that vomiting and weight loss affects the outcome of your pregnancy.

Urinary frequency It is common to go to the toilet more often than usual in early pregnancy. Don’t cut back on your fluid intake. If urination is associated with a burning or stinging sensation or if there is any sign of blood in your urine, then tell your doctor promptly and increase your fluid intake. Urinary infections are more common in pregnancy.

Constipation Constipation is very common in pregnancy due to high hormone levels. Increase your fluid intake and ensure your diet includes plenty of fruit and vegetables, whole grain foods and cereals. Your doctor may need to prescribe medication if the problem is persistent, but do not use strong laxatives.

Dizzy spells Dizzy spells are also quite common, but persistent fainting needs to be reported to your doctor.

Aches and pains It is not uncommon to experience some abdominal discomfort due to enlarged ovaries and the stretching of the ligaments supporting the growing uterus. However, you should call your doctor and report any symptoms of abdominal pain – initially this will be Fertility Associates and then your LMC. While we recommend not taking any drugs during pregnancy, you can take Paracetamol for fevers and headaches. It is quite safe when used according to directions.

Heartburn The muscles at the top of the stomach can relax due to hormonal changes and combined with the pressure of the uterus this can lead to heartburn. Try elevating the head of your bed and avoid large meals at night. Simple antacids such as Mylanta may help.

Bleeding Some vaginal bleeding is not uncommon in early pregnancy and in most instances does not mean you are going to miscarry. However, it is important to report any bleeding so your doctor can follow it up.

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General care Smoking If you are still a smoker, please stop. See us if you need help with stopping. Carbon monoxide in cigarette smoke displaces oxygen from the red blood cells and restricts blood flow to the uterus, which reduce the nutrients the baby receives. Women who smoke while pregnant have a higher risk of miscarriage, stillbirth, neonatal death and their babies have on average a lower weight. The more you smoke, the greater the risk. Babies and children exposed to cigarette smoke are more likely to suffer bronchitis, pneumonia, chest infections and cot death than babies who breathe clean air.

Alcohol It is ideal for women not to drink alcohol from before conception until after breastfeeding. A large and constant intake of alcohol must definitely be avoided as it may result in a child having foetal alcohol syndrome. This permanently affects the child’s intelligence and physical skills.

Medication It is ideal not to take any medications all during pregnancy. However, in some situations medication is necessary. For example, high fever can be detrimental in pregnancy and should be treated, in this case by Paracetamol.

Whether you obtain medicine from a pharmacy, supermarket, health food shop or elsewhere, check with your doctor that is safe to use in your pregnancy.

Sex Pregnancy is a very special time and an intimate relationship is part of the experience. You can enjoy a normal sexual relationship whenever you choose. Intercourse cannot hurt the baby – it is well protected by the uterus and a closed cervix. However, if you have bleeding in early pregnancy, it is best to check with your doctor when you can resume having sex.

Some women find intercourse uncomfortable in early pregnancy because of tender breasts and enlarged ovaries. The vagina can also become more sensitive due to extra blood flow triggered by hormone changes.

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Exercise Moderate exercise during pregnancy can be beneficial for you and your baby.

However, remember to: • Avoid overheating.

• Avoid saunas and steam baths.

Pregnant women should limit how long they are exposured to high temperature.

• Drink plenty of water.

• Do pelvic floor exercises later in pregnancy. There are many ante-natal exercise programs run in the community that help you prepare for birth.

Diet Eat a well balanced diet with plenty of fresh fruits, vegetables, milk and dairy foods. If your intake of dairy foods is low, calcium supplements are suggested.

Try to reduce your intake of caffeine as much as possible since the effects of caffeine on pregnancy are uncertain. Remember that coffee, tea, green tea, most energy drinks and some sift drinks all contain caffeine.

The Ministry of Health booklet “Food Safety in Pregnancy” is a useful source of advice. Please call the clinic to get a copy if you do not have one.

Vitamins & minerals Folate (800mcg or 5mgs if advised by your specialist) and Iodine supplements should be continued for the first 12 weeks of pregnancy.

If your diet is low in iron or your blood count is found to be low, then iron supplements may be needed.

In general, pregnant women only need vitamin supplements if their diet is inadequate or if they have a medical condition that affects the absorption of nutrients.

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Listeriosis Listeria infection is a rare but serious illness that can cause miscarriage. It is transmitted by food contaminated by the Listeria bacteria. . To reduce the risks of Listeriosis, it is recommended that everyone in the household follows these basic guidelines when preparing food: 1. Thoroughly cook raw food from animal sources (e.g. meat, fish, poultry and eggs); 2. Thoroughly wash raw vegetables before eating; 3. Keep uncooked meats separate from cooked foods, vegetables, and ready-to-eat foods; 4. Avoid raw (unpasteurised) milk or foods made from raw milk; and 5. Wash hands, knives, and cutting boards after handling uncooked food to avoid cross contamination of cooked and ready-to-eat food.

For more details, see the Ministry of Health’s booklet “Food Safety in Pregnancy”.

Foods to avoid In addition, pregnant women should also avoid the following foods because they carry an increased risk for Listeriosis.

• Soft cheeses such as feta, brie, camembert, ricotta and blue vein.

There is no need to avoid hard cheeses, cream cheese, cottage cheese, or yoghurt.

• Paté.

• Cooked, diced chicken and sliced processed meats.

• Pre-prepared salads with sauces or mayonnaise obtained from delicatessens and supermarket refrigerators.

Leftover food should be reheated thoroughly before use.

Other precautions in pregnancy There are other infections that can sometimes be harmful in pregnancy. For this reason, scrupulous hygiene should be observed when handling pets, their droppings or litter trays.

If you want to know more or have concerns about infections during pregnancy, please talk to your LMC.

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Pregnancy in women over 35 years Pregnancy for mothers aged 35+ Women aged 35 and older are at a higher risk of a pregnancy having a chromosomal imbalance, and therefore have a higher chance of miscarriage. Most chromosomal imbalances lead to miscarriage, but some are compatible with the child being born, the most common examples being Down Syndrome and Fragile X. It is possible to test the fetus for chromosome imbalances using Chorionic Villus Sampling (CVS) or Amniocentesis. If you want to consider these tests, you will need to discuss them with your LMC early in pregnancy since some need to be performed as early as 11 weeks. There is more on testing later in this booklet.

Older women are also more likely to have pre-existing medical conditions which may affect their pregnancy, and are more at risk of the medical conditions that arise from pregnancy, such as preeclampsia. Some studies suggest that woman aged 40 and older are more at risk of particular obstetric problems, such as early delivery and smaller babies. They may also be at more risk of problems in labour, which may lead to a Caesarean section. Most risks can be well managed through good antenatal and obstetric care.

Ideally pre-existing conditions will have been well controlled before pregnancy, but you may need to see your physician to make some alterations to your medication or lifestyle.

Congenital abnormalities About 4% of children have some type of congenital abnormality, which can range from mild conditions to rare severe birth defects.

Most are apparent soon after birth.

The rate of congenital abnormalities is slightly higher at around 6% for children conceived from IVF, and also a little higher for children conceived after other types of fertility treatment. The increase seems to be partly associated with fertility technology itself, and partly associated with the experience of infertility.

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Pregnancy loss Early pregnancy loss The first three months of a pregnancy can be an uncertain time.

Pregnancy loss occurs in about one in four pregnancies, no matter how conception took place. The chance increases with a woman’s age, especially in the late 30’s and early 40’s. Pregnancy loss is probably no higher after fertility treatment than after natural conception, but may seem that way because of the pregnancy tests that are part of fertility treatment.

Nearly all early pregnancy loss is believed to be due to a chromosomal imbalance in the embryo. The chance of a miscarriage can be higher than average if you have had previous pregnancy losses, although usually the chance is not much increased unless you have had three recurrent losses or more.

It is sometimes hard to know whether a miscarriage is happening, because many of the early symptoms such as mild period like pain, twinges and a pulling sensation are common in continuing pregnancies, and they are often noticed by women who have had fertility treatment to achieve their pregnancy.

If a fetal heart is seen and the fetus is of a normal size at the early pregnancy scan at 7-8 weeks, then there is a 95% chance that you will deliver a live baby.

Definitions There are a few definitions which are worth understanding.

Biochemical pregnancy This term is used for a very early pregnancy loss that occurs before the stage of having an ultrasound scan.

Anembryonic Pregnancy This means there is sac seen at ultrasound but no fetal heartbeat. At some stage fetus has stopped developing and a miscarriage is inevitable. It is also commonly called an ‘empty sac’.

Ectopic Pregnancy This is a pregnancy that implants outside the uterus, usually in one of the Fallopian tubes.

Ectopic pregnancy occurs in 1-2% of pregnancies following fertility treatment, and is more common when the cause of infertility is damaged or blocked Fallopian tubes.

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Miscarriage Because miscarriages in the first trimester are nearly all caused by developmental problems of the fetus or the placenta, they cannot be prevented by medical management or intervention during the pregnancy. Stress and daily activities do not cause miscarriage, and trying to avoid stress or changing your daily routine are very unlikely to protect you against miscarriage.

It is import to follow up each miscarriage because a few women will be found to have conditions that make miscarriage more likely.

Trying to prevent recurrent miscarriage is difficult, but for some conditions there are interventions that may help staying pregnant more likely.

Nearly all women who have a miscarriage will be able to have a successful pregnancy in the future.

Although it is common, miscarriage after treatment is a disappointment, and the depth of the experience and the range of emotions can bewildering and unexpected. For some people, a miscarriage brings a deep sense of grief. If you find yourself in this position, please seek support from our staff and counsellors – they can help you through this difficult time.

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Contact us (or your obstetrician or hospital) as soon as possible if you have any concerns.

Warning signs of a miscarriage Fertility Associates’ early pregnancy monitoring of blood tests and one or two ultrasound scans often pick the early signs of a possible pregnancy loss. We will always tell you what we have found, and what we expect. Although it is seldom possible to be certain from blood tests alone, the blood test results can help prepare you for possible bad news.

Sometimes people experience the symptoms of pregnancy loss before we have an opportunity to prepare them for what might happen.

Please contact your nurse if you have: - Severe pain in the lower abdomen - Cramping - Vaginal bleeding These symptoms are typical of miscarriage but do not necessarily mean that you are miscarrying. If you experience these symptoms, we will arrange further investigations at the clinic or locally.

Treatment of miscarriage Most instances of early pregnancy loss do not require any medical intervention, and the pregnancy will end with a heavy period.

Fertility Associates may ask for more blood tests to check that all the placental tissue has been shed or has stopped functioning, especially if an ectopic pregnancy was suspected.

Losses that occur slightly later in pregnancy may require medical intervention, such as a dilatation and curettage of the uterus (D and C). This would usually be performed at a public hospital or by a private gynaecologist, and would be arranged by your Fertility Associates doctor if you were still under our care, or your GP or LMC if care had been transferred. Your doctor may order chromosome testing on the products of conception – however it is often not always possible to find the reason for a miscarriage.

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Ectopic pregnancy Ectopic pregnancies can be dangerous because the growing placenta tissue can cause blood vessels to rupture, leading to internal bleeding.

By using a combination of blood tests for the pregnancy hormone hCG and ultraosund scans, most ectopic pregnancies can be detected and treated before they cause any problems.

Ectopic pregnancy can be associated with some bleeding, and occasionally sharp lower pelvic pain, but often there are no symptoms.

It is important to contact Fertility Associates, your obstetrician, GP or a local emergency department immediately if your have a severe, sharp lower pelvic pain, because this may be a sign of internal bleeding.

Management of ectopic pregnancy An ectopic pregnancy cannot continue and some type of intervention is nearly always needed. There are two broad approaches – surgical or using the drug methotrexate. Which is appropriate will depend to the duration of pregnancy, hormone levels, and what the ultrasound scan shows. Surgical intervention is nearly always done by laparoscopy at a public hospital.

Starting treatment after miscarriage Your doctor will recommend how long to wait for before starting treatment again. It is generally a good idea to wait for at least one normal period to occur; otherwise it can difficult to know when to start the drugs used for IVF or other treatment.

Resuming treatment after a pregnancy loss can be stressful and we recommend seeing one of our counsellors.

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Antenatal tests Blood tests Blood and urine tests are usually arranged during your first antenatal visit as a check of routine health.

Ultrasound 1. A nuchal translucency scan is performed at 12 weeks. When this scan is combined with a blood test for two pregnancyrelated proteins, the results can better predict the chance of chromosomal abnormalities such as Down Syndrome.

2. A detailed anatomy scan is routinely performed at 18-20 weeks to screen for congenital abnormalities.

Amniocentesis or Chorionic Villus Sampling (CVS) These are tests that look at cells from the placenta. They screen for common chromosomal abnormalities, such as Down Syndrome. They are usually performed when the risk of an abnormality is higher, such as indicated by the results of a nuchal translucency test or when a woman is older. Fertility Associates has a separate Fertility Fact sheet on amniocentesis and CVS which covers both techniques, benefits and risks.

Non-Invasive Antenatal Diagnosis There is a new alternative to amniocentesis or CVS which uses fetal cells isolated from the mother’s blood, instead of cells being taken from the placenta or the amniotic fluid as is done in CVS or amniocentesis. It is sometimes known as the ‘Harmony test’. The mother’s blood sample is couriered to the USA for analysis. Please discuss this test with your specialist if you would like to know more.

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References

Available in the community •F ertility NZ 0800 333 306 •P arents Centre New Zealand Ltd www.parentscentre.org.nz •P regnancy Counselling Services 0800 PREGNANT •S ANDS www.sands.org.nz •S MOKECHANGE www.smokechange.co.nz Contact your General Practitioner for further references.

My information

For my Lead Maternity Carer IVF

ICSI

IUI

Other

Date of egg collection or insemination: ________________________________________ Date of embryo transfer: __________________________________________________________ Other important dates:

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Notes

Notes

Notes

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