A positive pregnancy test: What now? Melbourne IVF’s guide to early pregnancy

A Guide to Early Pregnancy This booklet aims to provide relevant information relating to the first twelve weeks of your pregnancy.

You can obtain additional information from your Fertility Specialist, the Early Pregnancy Management Nurse at Melbourne IVF or from various external sources such as antenatal clinics, your General Practitioner, The Royal Women’s Hospital Health Information Centre or the obstetrician of your choice.

Dr Lyndon Hale Medical Director, Melbourne IVF

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Important dates to remember Date

Commencement of last menstrual cycle

Date of embryo transfer

First pregnancy Ultrasound

Expected date of birth

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First Pregnancy Ultrasound

Following your positive pregnancy test result, an ultrasound (vaginal or abdominal) is recommended at approximately 6-7 weeks gestation or earlier if requested by your Fertility Specialist.

This ultrasound is necessary to identify the following;

• A pregnancy within the uterus • Exclude an ectopic pregnancy

(pregnancy located outside of the uterus)

• The number of gestational sacs• A fetal pole• Measure the size of the fetus(s)• Detect a heartbeat(s)

Possible outcomes of your first pregnancy ultrasound

• Viable clinical pregnancy A pregnancy is visualised within the uterus and a heartbeat is detected.

• Ectopic pregnancy A pregnancy located outside the uterus. The most common location for an ectopic pregnancy is the fallopian tube; however it may be located in the cervix, ovary or abdomen. Ectopic pregnancies occur in approximately 1-2% of all IVF pregnancies. The clinical signs of an ectopic pregnancy may include: slowly rising pregnancy hormone levels, vaginal bleeding and/or left or right sided lower abdominal pain.

Please contact your Fertility Specialist or the Early Pregnancy Management Nurse at Melbourne IVF immediately if you have any concerns.

If you have severe pain, you should attend your nearest Emergency department or an Emergency department of your Fertility Specialist’s choice. An ectopic pregnancy cannot continue and surgery may be required.

Early diagnosis will help to minimize any tubal damage and the ectopic pregnancy may be removed surgically by laparoscopy (keyhole surgery). This is usually a surgical day procedure. Alternatively, a drug called Methotrexate may be used to avoid surgery. Your Fertility Specialist will advise the most appropriate treatment option for you.

• Blighted ovum A blighted ovum occurs when a fertilised egg implants into the uterus but an embryo does not develop. This is most commonly due to a chromosomal abnormality in the embryo. A blighted ovum will eventually result in a miscarriage, however this may not occur for several weeks. Your Fertility Specialist will discuss the most appropriate treatment for you.

• Missed abortion The pregnancy sac and fetus are visualised but no fetal heartbeat is detected. A missed abortion is most commonly due to a chromosomal abnormality in the embryo.

This will eventually result in a miscarriage, however may not occur for several weeks. Your Fertility Specialist will discuss the most appropriate treatment for you.

• Early failed pregnancy/biochemical pregnancy A biochemical pregnancy occurs when hCG (pregnancy hormone) is detected in the blood but fails to rise at the appropriate rate over a period of time. It indicates that early implantation has occurred, however the embryo has not continued to develop. This outcome is most commonly due to a chromosomal abnormality in the embryo. Your Fertility Specialist will discuss the best treatment for you.

Further information is available at www.thewomens.org.au/health-information/pregnancy-and-birth/pregnancy-problems/early-pregnancy-problems/

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• Counselling support following pregnancy loss Our experienced counsellors are available to support you during this difficult time. You can make a counselling appointment by contacting Melbourne IVF and speaking to a Patient Liaison Administrator on (03) 9473 4444.

Your antenatal pathway

At this early stage, you are advised to make your first antenatal appointment. Choosing a hospital or obstetrician is an important decision.

In order to schedule your first antenatal appointment you will require a referral from your General Practitioner. At this appointment you may wish to discuss any lifestyle factors that may affect you or your baby throughout the pregnancy.

Your Fertility Specialist is available to discuss appropriate antenatal care options for you.

Common symptoms of early pregnancy

Common symptoms in early pregnancy include:

• Tiredness It is common to feel tired during the first twelve weeks of pregnancy. At this time, your body is going through significant hormonal and physiological changes.

• Breast Changes Due to hormonal changes that are occurring at this time, you may experience the following: tender, swollen and enlarged breasts, darkened nipples and breast veins may become more visible. These symptoms may vary and fluctuate between individuals.

• Nausea & vomiting Nausea and vomiting may be experienced at any time of the day or night and the severity varies between individuals.

Strategies for managing nausea and vomiting during pregnancy:

1. Maintain fluid intake It is important to maintain adequate

hydration. Water, ginger ale/tea or soups may assist with symptoms of nausea. It is recommended to avoid caffeinated and sweet carbonated beverages which can be dehydrating.

2. Regular small meals If you experience nausea and vomiting in the morning, you may wish to keep dry biscuits at your bedside to eat prior to getting up. Eating small, regular, healthy meals throughout the day may also help overcome nausea. Ginger or Vitamin B6 tablets can be beneficial to treat nausea.

You can consult your pharmacist for further advice on non-prescription preparations. If symptoms persist please consult your General Practitioner or Obstetrician.

• Urinary frequency As the uterus enlarges it compresses the bladder increasing the urge to pass urine. It is important not to decrease your fluid intake. Urinary tract infections are more common in pregnancy. If you experience any burning or stinging when passing urine, or if there is any visible blood in your urine, please consult your General Practitioner.

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• Constipation Constipation is common during pregnancy. To avoid constipation, increase your fluid intake and consume a diet high in fibre which includes fresh fruit and vegetables, whole grain foods and cereals. If constipation persists, please discuss this with your Pharmacist or General Practitioner.

• Dizziness/fainting Dizziness and fainting is commonly experienced in pregnancy. Avoid standing for prolonged periods of time as this may increase the risk of this occurring. Persistent fainting should be discussed with your General Practitioner or Obstetrician.

• Back aches & pains Abdominal discomfort and back pain are common symptoms in pregnancy. Paracetamol or paracetamol with codeine (remember that codeine increases the risk of constipation) may be taken in pregnancy in accordance with manufacturer’s instructions. If symptoms persist discuss your concerns with your General Practitioner or Obstetrician.

• Heartburn Heartburn is common in pregnancy. To help alleviate these symptoms you can avoid foods that cause discomfort, elevate the head of your bed and avoid consuming large meals at night. If symptoms persist please consult your pharmacist, General Practitioner or Obstetrician.

• Vaginal bleeding Bleeding is common in early pregnancy and does not always result in miscarriage. Therefore it is important not to cease any of your prescribed medications and to notify the Melbourne IVF Early Pregnancy Management Nurse, your Fertility Specialist or Obstetrician.

If you experience bleeding and severe abdominal pain, you should immediately report this to the Melbourne IVF Early Pregnancy Management Nurse, your Fertility Specialist, Obstetrician or General Practitioner. If your concern is after hours, please attend your nearest Emergency department.

For further information regarding common concerns in pregnancy please refer to www.thewomens.org.au/healthinformation/pregnancy-and-birth/a-healthy-pregnancy/common-concerns-in-early-pregnancy/

General health and Lifestyle factors

• Medications It is important to discuss with your Obstetrician or General Practitioner the safety of any medication (including natural supplements) that you take during your pregnancy.

For more information regarding medications during pregnancy or lactation call The Medicines Information Service at the Royal Women’s Hospital, Monday to Friday 9.00am to 5.00pm on (03) 8345 3190.

• Alcohol There is no known safe level of alcohol use in pregnancy.

For further information and support regarding alcohol and pregnancy, please contact The Women’s Alcohol and Drug Service at the Royal Women’s Hospital on (03) 8345 2000 or visit: www.thewomens.org.au/health.../womens-alcohol-and-drug-service.

• Smoking It is strongly recommended that you do not smoke during pregnancy or lactation.

For further support and information call Quitline on 13 78 48 or visit: www.quit.org.au.

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• Sex Unless your Obstetrician or General Practitioner advises you otherwise, sex is safe during pregnancy.

• Exercise Regular and moderate exercise is recommended as part of a healthy lifestyle. Good exercise patterns developed prior to pregnancy will assist your body in coping with the pregnancy, childbirth and postnatal period. Moderate, low impact exercise during pregnancy can be beneficial for you and your baby. Some women find meditation, yoga, pilates, swimming and relaxation classes helpful. Certain contact sports eg: weightlifting, boxing, judo may be unsuitable for pregnant women. Check with your General Practitioner or Obstetrician if you are unsure of any aspect of exercise during pregnancy.

Important points to remember when exercising:

• Avoid overheating • Avoid spas, saunas and steam baths • Maintain adequate hydration – water is the best choice • Perform regular pelvic floor exercises

There are many antenatal exercise programs available in the community. Prior to undertaking any new exercise program, please advise your General Practitioner or Obstetrician.

• Diet It is recommended to eat a well-balanced diet.

For further information visit: www.thewomens.org.au/health-information/pregnancy-and-birth/a-healthy-pregnancy/food-nutrition-in-pregnancy.

• Folate Folate, also known as folic acid, is important during pre-conception and for the first three months of pregnancy. It must be taken as a supplement for the entire pregnancy as it reduces a baby’s risk of developing neural tube defects such as spina bifida. The recommended dose of Folic Acid is 500mcg daily. However, if you have a family history of spina bifida, or you have epilepsy and are taking antiepileptic medication, please consult your General Practitioner or Obstetrician for further advice on your required dose of Folic Acid.

• Air travel If you are planning a flight during your pregnancy, please consult your General Practitioner or Obstetrician to discuss.

• Listeria Listeria infection is relatively uncommon however, pregnant women are at risk of this infection. It is caused by ingesting food contaminated with Listeria Monocytogenes. Prevention is better than cure, therefore it is best to avoid high risk foods and always handle and store food safety. If you have concerns please consult your General Practitioner.

Listeria can be treated with antibiotics if treatment is commenced promptly.

For further information please email infectious.diseases@health.vic.gov.au or refer to www.foodstandards.gov.au.

• Animals Toxoplasmosis is an infection caused by a parasite found in some animal faeces (most commonly cats). A blood test can identify if you have immunity to toxoplasmosis. This infection can affect a developing baby if contracted during pregnancy. There are several food sanitation and safety steps you can take to prevent becoming infected.

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Please note, it is safe to have animals during your pregnancy as long as you follow the guidelines below.

These include:

• Wash hands after handling raw meat • Cook meat thoroughly until juices run clear • Do not eat rare or medium rare meats • Wash vegetables to remove any traces of soil • Wash hands thoroughly before eating • Avoid unpasteurised milk or dairy products • Wash cooking utensils follow contact with raw meat • Wear gloves when gardening • Avoid contact with cat faeces or soil • Ask someone else to handle kitty litter trays • Ensure litter trays are cleaned daily

Miscarriage

A miscarriage is a pregnancy loss before 20 weeks. Most miscarriages occur within the first twelve weeks of pregnancy, approximately 20% of all pregnancies result in miscarriage. The chance of miscarriage increases with maternal age, as follows:

• Under 35 years of age – 15-20%• 35 – 45 years of age 20-40%• Over 45 years of age 50%

There is no significant difference in miscarriage rates between assisted conception and naturally conceived pregnancies. There is no way to prevent an impending miscarriage from happening. It is not a result of too much exercise, lifting, having sex, eating the wrong foods or drinking alcohol. The main cause of a miscarriage is a random chromosomal error causing abnormal development in the fetus.

Your doctor will discuss the most appropriate management for you. This management will depend on how many weeks pregnant you are and the type of pregnancy loss you have had. In some cases, testing the products of conception for possible chromosomal abnormalities may be beneficial for your ongoing management and you may wish to discuss this with your doctor.

After a miscarriage you may be required to have regular blood tests to ensure your pregnancy hormone (beta hCG) levels are decreasing. The blood test will usually be ordered weekly until there is a negative result. Further IVF treatment cannot be commenced until this has occurred. For further information visit www.thewomens.org.au/health-information/pregnancy-and-birth/pregnancy-problems/early-pregnancy-problems/miscarriage/

Our experienced counsellors are available to support you during this time. You can make a counselling appointment by contacting Melbourne IVF and speaking to a Patient Liaision Administrator on (03) 9473 4444.

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Anti D

In a pregnancy where the mother is a Rhesus negative blood group and the father is Rhesus positive blood group, it is possible that the fetus will also be a Rhesus positive blood group. If this is the case, the mother’s immune system can recognise the fetal cells as foreign and may develop Rhesus D antibodies. Although there are limited issues with this scenario in the first pregnancy, if these antibodies remain in the woman’s system, they can cause problems in subsequent pregnancies. To prevent this from occurring, Anti D is administered (as an injection) within 72 hours of the following circumstances occurring:

• vaginal bleeding during your pregnancy• miscarriage• termination of pregnancy• a medical procedure such as chorionic

villious sampling (CVS), amniocentesis, or external cephalic version

Your fertility specialist or obstetrician will advise you whether you require Anti D.

Special considerations with advanced maternal age

Complications increase with advanced maternal age. Older women are at a higher risk of spontaneous miscarriage as well as a higher risk of carrying a baby with chromosomal abnormalities. Women over 35 years of age are more likely to have a pre-existing medical condition such as diabetes and hypertension and are at greater risk of developing obstetric complications, such as preterm delivery, gestational diabetes, pre-eclampsia, placenta praevia and small for gestational age babies.

Antenatal screening

If you decide to undertake prenatal testing you will need to see your General Practitioner, Fertility Specialist or Obstetrician early in your pregnancy to discuss the most appropriate test and risk factors.

For further information please refer to the Murdoch Children’s Research Institute website www.mcri.edu.au/Downloads/PrenatalTestingDecisionAid.pdf.

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References

• Preparing for Pregnancy The Women’s Hospital, Victoria

• Early Pregnancy Loss Support Sands, Victoria

• Listeria – The Facts Department of Health Services, Victoria

• Medications in Pregnancy The Royal Women’s Hospital Medication Information, Victoria

• Ultrasound Screen for Down syndrome Chorionic Villus Sampling & Amniocentesis Women’s Imaging Centre, Victoria

• Smoking & Pregnancy Quitline, Victoria

Resources

• Australian Breastfeeding Association www.breastfeeding.asn.au/breastfeeding-helpline

• Family Planning Victoria Website: www.fpv.org.au/

• National Perinatal Depression Hotline Telephone Support: 1300 726 306 www.panda.org.au/

• Royal Women’s Hospital Medication Information Service Telephone: (03) 8345 3190

• SANDS (Stillborn and Neonatal Death Support) www.sands.org.au/

• Women’s Health Information Centre (RWH) Telephone: (03) 8345 3045 Toll Free: 1800 442 007

• Vic Health www.health.vic.gov.au/maternity

• Quitline Telephone: 13 78 48 www.quit.org.au

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