Nursing teaching for the woman who has hyperemesis gravidarum should include which of the following?

After nearly 20 years, the Institute of Medicine released guidelines for weight gain during pregnancy in 2009. The guidelines take into consideration the welfare of the infant and the health of the mother. Important variables to consider regarding weight gain recommendations include the presence of twin or triplet pregnancies, maternal age, and maternal prepregnancy weight. These variables can add to the burden of chronic disease for the mother and baby; excessive weight gain is associated with an increased risk for gestational diabetes, pregnancy-associated hypertension, and delivery of large-for-gestational-age (LGA) infants. [11]

Guidelines for weight gain during pregnancy* are as follows:

• Underweight women (BMI < 18.5) should gain 28-40 pounds.

• Normal-weight women (BMI, 18.5-24.9) should gain 25-35 pounds.

• Overweight women (BMI, 25-29.9) should gain 15-25 pounds.

• Obese women (BMI, 30 or higher) should gain 11-20 pounds.

*Weight gain guidelines are for singleton pregnancy; weight gain should be higher for multiple pregnancies but the ideal amounts are unknown.

Clinicians are urged to supplement these guidelines with individualized counseling about diet and exercise, and preconception counseling should emphasize the importance of conceiving when the mother is at a normal body mass index (BMI). To help mothers attain these goals, dietary, lifestyle, and exercise interventions have been shown to be safe and effective at reducing excessive weight gain in pregnancy. In an analysis of 44 studies that evaluated the efficacy of these 3 types of interventions, a balanced, low-glycemic diet with a maximum of 30% fat and 15-20% protein and an emphasis on unprocessed whole grains, fruits, beans and vegetables was the most effective. This dietary intervention decreased the incidence of gestational diabetes, gestational hypertension, preterm birth, and intrauterine fetal demise (IUFD). [12]

Dietz et al found that prepregnancy body mass index (BMI) modifies the relationship between pregnancy weight gain and newborn weight for gestational age. In a population-based cohort study of 104,980 singleton, term births from 2000-2005, women who gained 36 lb or more during pregnancy were more likely to bear an infant who was large for gestational age (birthweight >90th percentile) if the mother was lean before pregnancy than if she was overweight or obese. Compared with women who gained 15-25 lb, the adjusted odds ratio (aOR) for a gain of 26-35 lb was 1.5 (95% confidence interval [CI], 1.2-1.9); for a gain of 36-45 lb, the aOR was 2.1 (95% CI, 1.7-2.7); and for a gain of 46 lb or more, the aOR was 3.9 (95% CI, 3.0-5.0). The risk of macrosomia (birthweight 4500 g or more) was not modified by prepregnancy BMI. [13]

No medical information exists to support the hypothesis that increased paternal age causes increased numerical chromosomal abnormalities in the manner that increased maternal age does. However, as males age, structural spermatozoa abnormalities increase, and affected sperm usually cannot fertilize eggs.

The literature suggests a 0.3%-0.5% risk of autosomal dominant disease in offspring of fathers aged 40 years or older. [14, 15] Autosomal dominant disorders include neurofibromatosis, Marfan syndrome, achondroplasia, and polycystic kidney disease.

Paternal age has been identified as a significant predictor of schizophrenia. [16] Studies have also indicated a possible association between advanced paternal age and offspring with autism spectrum disorders. [17] The American Society of Reproductive Medicine recommends an age limit of 50 years for semen donors.

Any family with a history of birth defects should seek individual genetic counseling. To determine whether an individual has a family history of risk, patients should inform their clinician or genetic counselor about any birth defects that have occurred in the past 3 generations.

Seatbelts should absolutely be worn during pregnancy. [18] Trauma to the mother is more devastating to the child than any potential entrapment of the pregnant abdomen in the seatbelt. The seatbelt should be placed low, across the hip bones and under the pregnant abdomen. The shoulder strap should be placed to the side of the abdomen, between the breasts, and over the midportion of the clavicle. No information indicates that air bags are unsafe during pregnancy. Pregnant women should try to keep their abdomen 10 inches from the airbag. [19]

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The most recent guidelines primarily focus on the patient’s individual risks and the likelihood of acute problems during the travel segment. [20] The second trimester is considered the safest time to travel, because the risks of miscarriage and preterm labor are the lowest. Prolonged sitting in pregnancy is more restrictive, because the gravid uterus contributes to the risk of thrombosis and it can cause lower extremity venous stasis. Gravid women should promote circulation by ambulating or frequently flexing and extending the lower extremities at the ankles. Air travel can additionally increase the risks of travel in pregnancy because of factors that contribute to dehydration, such as low oxygen tension, low humidity, and recirculated air.

Being pregnant has been estimated to increase the risk of thrombosis about 10 times, to a rate of about 10:100,000; air travel further increases this rate between 2-4 times. Most planes are pressurized to around 8000 feet, so altitude is not an issue.

The International Commission on Radiological Protection recommends a maximum radiation exposure of 1 mSv per year for members of the general public; the same limit is recommended for a conceptus, but over a 40-week pregnancy. Air travel exposes passengers to less than 15% of this limit, even on the longest international flight. Occasional travelers are unlikely to exceed these limits, but frequent flyers should be informed of exposure to radiation and its health risks.

Maternal adaptions to altitude itself vary but could include elevated blood pressure, increased maternal heart rate, and lower oxygen saturation. A fetus can physiologically adapt to these conditions and is typically protected during these flights.

Drinking water and avoiding alcohol and caffeine is important to avoid dehydration. Additional risks may be due to communicable diseases, but those typically depend on to the destination. Traveler's diarrhea is common; pregnant women have an increased risk because of slower gastric and intestinal transit times. Pregnant women should be informed of travel risks and told to wear compression stockings. [21]

Many pregnant women have questions regarding TSA screening devices. TSA conducts a variety of tests to ensure the devices used are safe for all passengers, including pregnant women.  TSA’s Advanced Imaging Technology and walk through metal detector systems do not use X-rays to produce the image, but instead use non-ionizing electromagnetic waves that are reflected off the body.  According to research conducted by the Food and Drug Administration's Center for Devices and Radiological Health, it is safe for everyone, including pregnant women, to go through these machines. [22]

The Zika virus is transmitted by mosquito bites and through intercourse with individuals who have a Zika virus infection. The infection has been linked to severe birth defects including microcephaly. Current CDC recommendations include avoiding travel to countries with known Zika outbreaks and decreasing sexual transmission by avoiding intercourse when the partner has recently traveled to endemic areas. High risk areas include Africa, the Pacific Islands, Latin America, and the Caribbean, but it is a good idea to check the CDC website to see when additional areas are added. It is also important to avoid mosquito bites whenever possible as the mosquito that carries the virus is present in many portions of the USA and it is a matter of time before these mosquitos will become carriers. It is recommended to use an insect repellent that contains DEET, wear a hat, long-sleeved shirt, and long pants where possible, and stay in places that have air-conditioning or screens on windows and doors. Use a bug spray that has been registered with the Environmental Protection Agency.  Removing all sources of still water including flowerpots, animal water bowls, and children's pools can also be an important source of protection. [23]

It is uncertain whether there is a risk of vertical mother-to-infant transmission of coronavirus disease (COVID-19). Limited data suggest no evidence of intrauterine infection caused by vertical transmission in women who developed COVID-19 pneumonia in late pregnancy. No data are available on perinatal outcome when the infection is acquired in the first and early second trimesters of pregnancy; these pregnancies should be monitored carefully after recovery. Guidelines on COVID-19 infection control during pregnancy and the puerperium were released by the International Society of Ultrasound in Obstetrics and Gynecology. [24]

Dental care during pregnancy is an important part of overall healthcare. [25, 26] During pregnancy, the gums naturally become more edematous and may bleed after brushing. Epulis gravidarum, a type of gingivitis with violaceous pedunculated lesions, can occur. If treatment of cavities, surgery, or infection care is required, be sure the dentist is aware of the pregnancy. Most antibiotics and local anesthetics are safe to use during pregnancy. Radiographs can be obtained with abdominal shielding but are best avoided during pregnancy because a small, but statistically significant, increase in childhood malignancies exists in children exposed to in-utero radiographic irradiation.

See also Psychosocial and Environmental Pregnancy Risks.

Stomach emptying was thought to be retarded during pregnancy, but hormonal influences of increased progesterone and/or decreased levels of motilin may be more responsible for pyrosis (heartburn) than the actual mechanical obstruction in the third trimester. Some studies have also shown decreased lower esophageal sphincter tone, which can lead to an excess of gastric acid in the esophagus.

Half of women report having back pain at some point during pregnancy. The pain can be lumbar or sacroiliac. The pain may also be present only at night. Back pain is thought to be due to multiple factors, which include shifting of the center of gravity caused by the enlarging uterus, increased joint laxity due to an increase in relaxin, stretching of the ligaments (which are pain-sensitive structures), and pregnancy-related circulatory changes.

Treatment is heat and ice, acetaminophen, massage, proper posturing, good support shoes, and a good exercise program for strength and conditioning. Pregnant women may also relieve back pain by placing one foot on a stool when standing for long periods of time and placing a pillow between the legs when lying down.

In a randomized, placebo-controlled trial, Licciardone et al studied the effect of osteopathic manipulative treatment of back pain during pregnancy. No statistically significant differences were achieved between treatment and control groups; however, back pain decreased in the usual obstetric care and osteopathic manipulative treatment group, remained unchanged in the usual obstetric care and sham ultrasound treatment group, and increased in the usual obstetric care only group. [27]

Research indicates that sexual intercourse is safe in the absence of ruptured membranes, bleeding, or placenta previa, but pregnant women engage in sex less often as their pregnancy progresses. No studies have suggested that any particular position is unsafe, although a 1993 study demonstrated a 2-fold increased incidence of preterm membrane rupture with the male-superior position compared to other positions. [28] ACOG states that sexual activity during pregnancy is safe for most women right up until labor, unless there is a specific contraindication.

ACOG specifically cautions that a woman should limit or avoid sex if she has a history of preterm labor or birth, more than one miscarriage, placenta previa, infection, bleeding, and/or breaking of the amniotic sac or leaking amniotic fluid. ACOG discusses that, as part of natural sexuality, couples may need to try different positions as the woman's stomach grows. Vaginal penetration by the male is not as deep with the male facing the woman's back, and this may be more comfortable for the pregnant woman.

Varicose veins are more common as women age; weight gain, the pressure on major venous return from the legs, and familial predisposition increase the risk of developing varicose veins during pregnancy. These can occur in the vulvar area and be fairly painful. Rest, leg elevation, acetaminophen, topical heat, and support stockings are typically all that is necessary. Determining that the varicosities are not complicated by superficial thrombophlebitis is important. Having a venous thromboembolism in association with superficial thrombophlebitis is rare. Hemorrhoids, essentially varicosities of the anorectal veins, may first appear during pregnancy for the same reasons and are aggravated by constipation during pregnancy.

Pregnancy predisposes women with bacteriuria, which in the nonpregnant state is usually self-limiting, to developing urinary tract infections (UTIs). Normal pregnancy-related physiologic changes contribute to UTIs, including dilatation of the upper collecting systems, hypotonic renal pelvises, increases in urinary tract dead space and vesicoureteral reflux, and reductions in the natural antibacterial activity in the urine and in the phagocytic activity of leukocytes at the mucosal surfaces. UTIs in pregnant women usually do not present with typical symptoms, and they may be asymptomatic. All of these factors increase the likelihood for infections to ascend to the kidneys; pyelonephritis is a serious complication of UTIs.

Unfortunately, striae (stretch marks) cannot be prevented. The degree to which a woman experiences stretch marks is determined genetically. Stretch marks usually occur when weight is lost or gained quickly. Using creams and gels rarely make a difference. Fortunately, striae fade with time and marks become silvery white, but they do not tan. Striae managed early can be reduced with new medical laser technology. [29]