Everything You Need to Know About Pregnancy

Everything You Need To Know About Pregnancy With Dr. Nada Megally

Welcome to the show. This episode is going to be all about pregnancy hot topics. Our guest is Dr. Megally, a board-certified OB-GYN, here to unpack some of the biggest questions in pregnancy. I’m excited to have you here. Thanks for joining.

Thank you for having me. This is very exciting.

I do not know if you want to give a little intro about yourself and your background.

As you said, my name is Nada Megally. I am a board-certified OB-GYN in Atlanta, Georgia. I have been practicing for six years now. I was in private practice for about five years, and then I recently transitioned to a hospitalist role. It is nice that I have gotten a little bit of a mix of different populations. It has been great, and I love my job, and I get to help women of all different ages and walks of life. It has been great.

On a side note, which is fun, Dr. Megally and I went to residency together. When I was pregnant, she got bombarded with all of my pregnancy questions.

Which I do not mind at all.

Most Common Pregnancy Myths

Basically, that's what we're going to get into because I feel like it's very common. I think one thing that we can kind of start with, because there's almost information overload now, especially with social media. What are some common pregnancy myths that you hear now?

The first thing is, yes, we are bombarded with information on TikTok, Instagram, ChatGPT, and online. That is a huge shift that we've seen over the past couple of years, where I think it makes it almost worse for some people. When I try to look something up, and now I'm like, there's way more information, and you really do not know which sources to trust.

That is a very important thing to acknowledge is that we do have information overload, and not everything is wrong, and not everything is right, and two things could be correct. It is very important to take everything that you see with a grain of salt and look at the background of where that information is coming from, and it can be correct for one person, but incorrect for another person, depending on your situation. That is just one thing I always tell my patients.

In terms of myths, I would say that the big thing that we get a lot is "People did this for years, and people had natural births, and they didn't have medicine, and everything was okay." That is true to a certain extent, but I do think there is a role in medicine and there is a role in decreasing the maternal morbidity and mortality that comes with pregnancy, which used to be very high, and we have done a really good job of decreasing it. That is one big myth that we see a lot, and we hear.

I feel like I have heard that all the time. Again, yes, women were created to have babies, and like our body was created that way, but there was a very high rate, meaning like people dying in delivery. That was like very common.

I do not think we have the statistics for it.

Most Popular Yet Concerning Wellness Trends

People forget that aspect of it, that it is dangerous, too. There are a lot of positives in terms of modern medicine and helping with that. What are popular wellness trends that concern you?

We end up being able to pick up on what's trending on TikTok based on the questions that we get from patients. For a little while, it was the RhoGAM shot. I can talk about that a little bit, but right now it is vitamin K. That is a big thing where we're seeing a huge movement where people are declining the vitamin K shot. It's very important. I fully support patient autonomy. I fully want my patients to always ask the questions and know what they're putting into their bodies and what they're giving to their babies.

It's very important to understand why some of these things are given and their importance. At that point, you can make whatever informed decision you feel is best for your family. One of the things right now is vitamin K, and what people do not realize, and maybe they do, again, that's completely their decision at that point, is that babies are not born with vitamin K. Vitamin K is a fat-soluble vitamin that we get from food, we get from gut bacteria as we eat and as we grow. What that is, it is a byproduct or a protein that helps your clotting factors clot. What that means is that it's what keeps you from bleeding out.

A lot of these clotting factors do not work if you do not have vitamin K. If a baby is born, they do not have vitamin K. Breast milk does not have very high levels of vitamin K. They can have a spontaneous brain bleed. That can be absolutely catastrophic. That is something that modern medicine has brought, which is great. It's a very small thing that has made a huge impact on the overall well-being of these babies that were having spontaneous bleeds, especially premature babies, who can have that very easily.

I have had a lot of friends ask me about that. That's when I go over. It's important when people are making these decisions to also know the dangers of not doing something like that. It would be bleeding. It can be fatal, or it can be where the baby survives, but they have a mental disability that is severely debilitating for the rest of their life. People understanding that, and the risks of not having it, I think, is also very important because that comes up a bunch. 

Everything in medicine is risk and benefit, and just understanding why you're doing it. At the end of the day, you decide to decide if it's worth it for you.

Tweet: Everything in medicine is risk and benefit. At the end of the day, you decide if it is worth it for you.

I also like what you talked about earlier in terms of everything is not black and white. I think that especially on TikTok and Instagram, that's what I feel like I always see is, "You need to do this, but you cannot do this. You have to do this." This aspect could be true for this patient, but this patient is in a completely different category. This completely changes how they would respond to that. It's amazing that it is individualized. We're all different, and we have different risk factors. Anyway, it's just something for. When people are listening to all of these TikToks and Instagram, to remember, like, they do not know all of my personal information. It's important to actually see your doctor and talk to them and everything.

We all get sucked into it. Even me, sometimes I'll watch something, and then I'm like, "Wait, that has nothing to do with my situation." It is very important to remind everyone to just take everything online with a grain of salt.

The Right Balanced Diet During Pregnancy

Something else that is important is diet in pregnancy. I feel like that is talked about a lot. What would you say a healthy, balanced diet should be in pregnancy?

Another myth, just to go back to your first question, is that people think pregnancy requires this complete change from what you're doing at baseline. For everyone, whether you're pregnant or not, the recommendations are essentially the same. There are some supplements and vitamins that I'll talk about in a second. They're a little bit more critical, obviously, when you're trying to conceive or when you're getting pregnant. The goal is always to have a well-balanced, nutrition-dense diet.

In pregnancy in particular, you want to focus a little bit more on protein because you're essentially making an entire human. You need those basic building blocks for building a placenta, building blood vessels, or building your blood supply, or making an entire human. Focusing on eating a protein-rich diet, you also need carbohydrates just as much as any other nutrient because you need the energy. You need good, healthy carbohydrates to give you energy, not from processed foods.

You need your leafy greens, you need your iron, you need your folate, you need all of that stuff. You also need your fruits for your antioxidants and all of those things. The goal is to just have a well-balanced diet. ACOG does recommend approximately 70 to 100 grams of protein per day for a pregnant patient. You can also do 1.1 grams per kilogram of body weight. 

I got distracted because I was thinking, I do not think I ate that much protein.

That is the recommendation. 

I am not good with that.

It is very difficult. Unless you're a bodybuilder, you're tracking your macros, it is very hard to get that much protein. That is just one of the things that I talk about in the first visit with patients, whether it's a preconception visit or a positive pregnancy visit, especially for my vegetarian patients who really need to be very cognizant and very intentional with their protein intake because of their tissue healing, whether they end up having a vaginal delivery or whether they have a C-section, you really need all those proteins to help with your healing process as well as like the development of your fetus. Just having a well-balanced diet is very important. The other thing with nutrition is you really only need about 300 more calories per day, actually, per baby. 

Which is wild because everybody's like, "You're eating for two," and it's like, “You are not.”

Yeah, you're not. If you have twins, you can say it's 300 calories per baby. For pregnancy, you can say 600 calories if you're having twins, and if you've got triplets, you can just do the math and go from there. You really only need about 300 more calories per day to supplement. Of course, I tell everyone, again, whether you're pregnant or you're not pregnant, to try to get those sources of protein from natural foods.

Of course, if you need to supplement because it is obviously really hard to get that much protein. A lot of the protein shakes and the protein bars can have a lot of filler in them in terms of processed foods, sugars, and fats. Of course, if it's your only option, absolutely. To try to really get those first, and then you can add on as needed. 

That makes sense. It's good for me to know because I think that I definitely struggled with that.

Again, I tell people you have to just look at the whole picture. If you are nauseous and you cannot eat anything, your whole first trimester and all you can eat are crackers, eat crackers. You do not need to be so worried that "I need to get my protein" because babies are resilient. They will get what they need from you, but then you're a little bit more depleted. It's better to be supplementing those things so you have the energy, and your body is able to recover better. Again, if one day you're craving ice cream, absolutely eat ice cream, like, everything is in moderation. Just prioritize the nutrients, and then you go from there.

What would you say the biggest nutrition mistake is that you see people making in pregnancy?

I think overall is the mentality of, "I'm eating for two. I'm going to just give in to my cravings. I'm going to eat whatever I want." People do not realize that significant weight gain in pregnancy can have negative impacts on your growing baby, on your recovery, and on possible complications in your pregnancy. It's really not just about "Do not eat, do not gain weight," but it does have an impact on the overall well-being of your pregnancy and your baby. 

Tweet: People do not realize that significant weight gain in pregnancy can have negative impacts on the growing baby and cause possible complications in the pregnancy.

I can see that. I do think that's still so common. Everybody they're always like, even when I was pregnant, people would tell me, "You're eating for two."

You are because you are growing as a human, but you're making everything from scratch. You want to have good ingredients, essentially, if you think about it that way. If you want to make something that you're going to be lifelong, you want to use the best basic foundational ingredients. You do not want to be eating sugary processed snacks. You want to be eating like the best, putting the best things in your body because that's the building block of your baby. 

I feel like there's like a whole list in terms of pregnancy. It's like you find out you're pregnant and you're like, "Wait, I can't have all this stuff." I think how strict do people need to be about, I think like deli meat is something that people always talk about. There are certain cheeses and sushi. What is your usual recommendation for patients on those?

Again, back to vitamin K, I think transparency and education are very important. Explaining why we say no to these things, not because we're just being mean or saying you cannot have sushi, but understanding why we say no to deli meats? Why do we say no to sushi? We do say to try to avoid them. For deli meat, specifically, Listeria is the main thing that we worry about. That can grow if it's processed wrong, it lives on cold cuts, and it can be packaged wrong.

If you feel like you have to eat deli meat, and sometimes that's all you can afford, and that's all you have, and you just need to heat it up. You just need to heat it up until it's steaming. I believe it's 165 degrees where you need to get your deli meat, and then it's safe because that will be able to kill the Listeria. In terms of sushi and unpasteurized dairy products, you can also have Listeria, you can have bacterial growth, and so all of those things can be harmful to your growing fetus. Again, there's nothing that's black and white.

It's just informed decision-making, and even though the risks are really low, I believe the rate of Listeria in the US is one in 25,000 pregnancies. It's fairly low, but the consequences can be very detrimental. It is again, a decision that, do you have to eat this turkey sandwich? Do you have other options? If you do not have other options or if you accidentally eat a turkey sandwich, I would not get scared or concerned. The risk is very low, but again, if it does occur, it can have some detrimental consequences. Making those choices for yourself is what's important.

Also, like for sushi, too, do you need to have the raw sushi? It is like a higher risk versus, like, you can get a cooked sushi. You can get it cooked. You can get it there. I think sometimes people do not realize why it's like that. It's not why there is no sushi, because I feel like sometimes you have these cravings, and it's like, you could have like an avocado sushi that doesn't have the raw fish in it. You can kind of still feel like maybe you're having it.

If you just put soy sauce on something, it tastes like sushi. You're exactly right. You can go to a sushi restaurant, absolutely like a tempura roll, or like a cooked roll, or they have the baked rolls. As long as they're cooked, you absolutely cannot have them, but fish can be, especially since most fish eaten raw are significantly undercooked. It does increase that risk. Again, as we see in the news, there's been a Listeria outbreak in spinach, and there's been a Listeria outbreak in eggs. You just have to do the best that you can. We know which items are the highest risk, so we tell people to avoid them. If you, even if you do eat something, it does not automatically mean something bad is going to happen, but something to notify your OB-GYN about. 

How Much Water You Should Drink During Pregnancy

I feel like hydration is something that always comes up. People are like, "Drink your water." Is that really as important as we say? If so, how much water do people need to be like drinking water in pregnancy?

Hydration is very important. It's not just because we want you to drink a bunch of water, but because you're already going to the bathroom a lot. Hydration is actually very important for your developing baby. You are expanding your blood volume, and so you have to think about the water that you're taking in to supplement your circulation. It also supplements the amniotic fluid that surrounds the baby. If you are dehydrated, that fluid does decrease, and amniotic fluid is good for the baby's lung development.

If you do not have enough fluid around your baby, it can actually impact their development as well, which that's an extremely rare case, but just overall. Especially if you're somebody who is prone to UTIs, it's very important that you're hydrating to help decrease the risk of UTIs. Your cardiac output does go up. You do need that hydration to help with that as well. There's a significant benefit to staying hydrated.

The recommendation is about 80, 60 to 80 ounces of water per day, which is a lot. It helps decrease Braxton Hicks contractions. Think of your uterus as a muscle. If you're dehydrated, you're going to get a leg cramp. Your uterus will start to cramp up as well. All of those things are beneficial. Hydration is very important for that reason, and especially if you exercise too, and it's hot, and you live somewhere that's hot, that recommendation may actually be higher than that. 

I remember being pregnant, and obviously, you're tired. There's all that, but it's a lot on your body. I think being hydrated does help with that.

You go to the bathroom more, but it is important, not just for our normal hydration. There is actually physiological importance to being hydrated in pregnancy.

Now what about the coffee? I love my cup of coffee. That's always hard for me in terms of caffeine intake. There are tea drinkers, too, but caffeine is also something I remember being told that we have to limit. What do you think in terms of how much caffeine somebody can actually have?

ACOG, which is the American College of Obstetricians and Gynecologists, does say that you can have about 200 milligrams of coffee per day, which is I think that, I think that comes out to about 12 ounces or so.

I remember it was like two cups, maybe like three small cups max, but it also depends on the milligrams of caffeine. It's how strong your coffee is. It's different if you're doing like a super strong espresso shot.

Espresso was like I've looked it up before. It's like 65 milligrams of caffeine. It really just depends on it. Are you brewing your coffee at home? How strong are you making it? Again, if you need one day, an extra cup of coffee that is not going to be detrimental, but you have to just think about chronic caffeine use, like what does caffeine do that causes vasoconstriction? If you have vasoconstriction, that's going to decrease the blood flow through your placenta, which will decrease the blood flow to your baby. That's where you can absolutely have a cup of coffee a day. If one day you need an extra one, that's okay. In extreme cases, we'll see babies detoxing from caffeine when someone is drinking an excessive amount of caffeine. After birth, they're actually withdrawing from caffeine.

I did not know that. I knew about the baby being smaller, because that being one of the risks because of the decreased flow. I didn't know about the baby withdrawing from caffeine.

That's like in extreme cases. In those situations, I think people have to be careful with caffeinated drinks, especially with Starbucks and Dunkin' Donuts. There's a ton of sugar as well. You have to also be careful where your source of caffeine is. If you're drinking Cokes and sodas and those fun coffee drinks that you get at the store, they have tons of fats, tons of processed sugar. Not only are you getting caffeine, but you're also getting a lot of other things in there as well.

I feel like people do not realize that sometimes they're drinking those all throughout the day. I mean, yeah, you're getting all the sugar and all the other stuff that's also bad for you. It could be way more caffeine than you realize. You're having tea out here and then this Coke here.

This chocolate has caffeine in it. Caffeine is not all bad in pregnancy. If someone is having a headache, we do recommend having a little bit of caffeine, a little bit of magnesium, and a little bit of Tylenol. Those actually synergistically work together. Everything is in moderation. Again, just talk to your OB-GYN, figure out if you know that you're a very heavy caffeine drinker, a very heavy coffee drinker, you know you're going to conceive in the next couple of months, you know that is a great time to start to cut back, so you're not fatigued from the pregnancy. Plus if you suddenly went from four cups of coffee a day to one cup of coffee a day, you're not going to feel very good.

I missed coffee a lot. What I did was I had this blend that was like it had a third of the caffeine amount of what a regular cup would have.

I could have a coffee version too.

In the first trimester, then around halfway, then I'm feeling back to myself, then I'm like, “My coffee.” The first time I was, “Could I have it even if I wanted it?”

You can even smell it. I feel like I remember that. Most women nowadays work, so we cannot just be like, “You are not, and you're exhausted in the first trimester.” Just being cognizant of everything that you're putting in your body, and like, how much your cup is, and just these, “I'm going to go to Starbucks here, do this, do that.” It does tend to add up.

I feel like cravings are something that everybody talks about in pregnancy in terms of craving different foods. Are there any certain cravings you're like, "Wait a minute, maybe we need to do some labs, check out some things that's a little bit concerning for something else"? Is there anything like that or not really?

Two days ago, we had someone come in who was eating two bars of Dove soap a day for her pregnancy. I have not heard of that one before, actually, but everyone hears of ice chips and eating ice and cornstarch and dirt, and some of these, it's called pica. Some people call it pica. I'm not really actually sure how to say it. The important thing is food aversions. Typically, there's nothing overly concerning. That's just a normal part of pregnancy. Food aversions, I would not be concerned. Of course, food cravings. When it gets problematic is when you're having cravings for non-food items. 

That is actually the definition of pica, that you are craving and eating things that are not meant to be eaten, even though ice technically is. If you're having excessive ice eating, that is typically a sign of anemia or an iron deficiency. Typically, in most OB-GYN offices, at your first visit, a panel is done to determine where your baseline is. You should be getting another set of labs around the midpoint at 28 weeks. If you're coming in and you're noticing that you're craving these things, you should definitely let your OB-GYN know so they can check your anemia or check your iron levels and see if they need to give you an iron infusion or possibly even blood.

I've heard ice chips are always what I think of, but soap, I have not.

That was my first for me and two bars of soap a day throughout the past, an entire pregnancy. She hadn't told anybody, but eventually came in. 

That's just, that's rough. I have tasted soap before, but that was because I was a kid and I got in trouble, and my mom washed my mouth out with soap. 

She came in for abdominal pain, and I was like, “I'm sure your stomach hurts. I cannot feel good,” but we got some iron, and hopefully she's feeling better. 

Recommended Supplements To Take During Pregnancy

Getting into the next topic would be more supplements and medications, because I think a lot of people know about prenatal vitamins. Maybe touching a little bit on like prenatal vitamins, what's in them that's so important, and then are there any other supplements that you also would recommend? 

Again, prenatal vitamins are very important because, unfortunately, most people do not have a fully balanced diet in our day and age. There are some supplements that you do need a little bit more of than you can have in your daily diet. That's where prenatals come into play and are very important. What people do not know is that not all prenatal vitamins are created equal. Depending on your medical history, potentially your prior pregnancies, or just overall what you're looking for, it is important to take a look at your prenatal vitamins and determine what's in them.

Tweet: Not all prenatal vitamins are created equal. It depends on your medical history, your prior pregnancy, and whatever you may need.

Not all prenatal vitamins have iron. Some have more than others. If you have sickle cell disease or sickle cell trait or beta thalassemia or alpha thalassemia, any condition where you are baseline anemic, it'd be important to take a look at your prenatal vitamin or even take an additional iron supplement throughout your pregnancy. The other thing is folate, which most prenatal vitamins do have folate, but that's another thing that you would need to talk to your OB-GYN about, is certain conditions and certain things that have possibly occurred in your prior pregnancy, such as a neural tube defect.

If you've had a child with a neural tube defect or you're on any seizure medications, those tend to have side effects. They deplete your folate stores. You do need to be taking higher doses of folate, and you need to take them before conception. That's where it's most important. A big thing that people do not talk about is choline. Choline is actually not in a lot of prenatal vitamins. 

It’s really not fine. It's typically not in them. 

I think of the ones I've seen just a very minimal amount, if any.

Like 2% or 5%, and you're like, you put that in there just to list it.

You need I think 450 milligrams is like your daily recommendation for it. For people who do not know, it is important for fetal brain development. 

A new study came out, and it showed it was even higher than what ACOG has, which I think is 550 milligrams.

I have to go back and look.

It was like 900 milligrams. That is what they gave. They did a study, and basically, they looked kind of like an IQ equivalent. The babies whose moms took the higher amount, closer to 900 milligrams of choline, the babies scored a lot higher in terms of their IQ. Anyway, I found that really interesting. Especially for vegan people, because I think like eggs, it's eggs, and the egg yolks, but a lot of people do not eat eggs as much, or they think they're being healthier eating egg whites, and it's like, no, actually the egg yolks. 

The yolks are actually very nutritionally dense. You actually want to eat them. 

I wish prenatal vitamins had them, but a lot of them do not have them.

You really cannot find any with choline. Those are really the main ones, and then DHA, but it depends on your diet. You can get DHA and omega-3s from fish, and everybody's a little bit different in terms of fish and their tolerance of fish. There's always a little controversy regarding fish in pregnancy, which we can talk about in a second. If you do get a lot of that from your diet, then you do not necessarily need a supplement. For people who are vegetarian or vegan, I think those patients would be the most important to really get your supplements, take them prior to conception, because that's really the most critical time to have them.

I feel like an aversion, like I had in my first trimester. That was the other thing where it's helpful to take it ahead of time, because it was so hard for me to take anything in my first trimester. It's like, then at least you've gotten your stores up. Obviously, not everybody can. That's like, ideally, I think they say you start all these three months before. 

Three months ago, yeah. One thing with prenatals and iron. Iron can make you really nauseous, like iron, zinc, and all those things. What I do tell people who are nauseous and cannot tolerate them, you're not as likely to be anemic in the first trimester. That typically happens later on. Start with a gummy. I think most gummy prenatal vitamins do not have iron in them. You do not necessarily need to be taking the iron as much in the first trimester. 

At least you're getting the folic acid down.

Start with the gummies, and then later on, once you feel a little bit better, you can transition over to an iron supplement or one that has iron in it.

That's helpful because I know I get asked all the time in terms of when people are trying to pick out their prenatals. What do they need to look for? What's in them?

People do not realize it. 

No, they do not. They're not all equal, or they get kind of overloaded in terms of there are so many choices, they seem all the same, but they're not. How do I tell the difference?

Some can be very expensive. I think the problem with social media is once you look one thing up, the algorithm just starts flooding you with ads and things, and you're like, "Why is this one good? Why is the influencer I follow using this one?" Maybe they're being paid to market that one. Talk to your OB-GYN. I support people doing their research. I support people understanding why they're doing certain things and why they're putting things in their bodies. There's nothing wrong if you're like, "I eat five eggs a day." You do not need choline. "I eat a head of kale and spinach every day," maybe I do not need that. You can tailor everything to yourself. 

Which is important. The other question is what medications? I feel like there's always a list you have to avoid a lot of medications. There's just so much because again, there's only so many things that are safe when you're pregnant for the baby's growth and everything. How would you say someone should evaluate whether a medication is safe to take during pregnancy?

The issue with pregnancy is that you just never know, and you cannot run studies on people to see, "Is this medication going to be safe or not?" Typically, most people err on the side of caution. I would say that if you are someone with multiple conditions and you do take a lot of medications prior to pregnancy, I do think a preconception visit is very important. These are the patients where it's very critical to go in and see your OB-GYN, whether it's a year or six months before you're going to try to conceive, because for most conditions, there is an alternative medication that is potentially safe.

It may not be 100%, but you have to weigh that risk versus benefit in terms of, “Do you have a severe seizure disorder?” If you come off your medications, are you going to be seizing throughout your pregnancy? That's not ideal. Do you have severe hypertension? Some blood pressure medications are not safe in pregnancy, but the risk of uncontrolled hypertension is way more dangerous in your pregnancy than taking medication. We can switch you to a different medication. Same with diabetic medications, same with a list of conditions.

These are the patients for whom it's especially anti-anxiety, anti-depressive medication, or bipolar medications. These are all conditions that are very important to control in pregnancy because they can get worse. We never want to just take someone completely off of them and say, "We do not know the safety profile," or, "It's not 100% safe." These are very risk versus benefit to determine.

For those patients, a preconception visit is absolutely critical and communication between your OB-GYN and your neurologist or your primary care doctor, or whoever, or your endocrinologist, whoever is managing these medications, to switch you and make sure that they're working well before you conceive. There's that. In terms of just basic over-the-counter medications, most OB-GYN practices will provide you with a list of medications that are safe.

Most women choose to try not to take anything as much as possible, which is completely reasonable and understandable because nothing is going to be 100% safe. Of course, nothing is better than something. Again, the risk of an uncontrolled condition or uncontrolled symptom can actually have a detrimental effect. A very high fever, for instance, can have a significant impact on a growing baby, especially in the first trimester, as it can have neurological effects on the baby.

Your neural tube cannot close. Taking one Tylenol to decrease that fever is going to be significantly better than having a high fever, versus chronic use of medications, of course, can have a negative effect. Again, very important to talk to your OB-GYN in terms of what my symptom is, what it is that's going on, the risk versus benefit of what's going on, and determining what's best for you.

Is It Safe To Continue Exercising During Pregnancy?

Maybe the next subject would be exercise. That's something I know, even for me, it was like, there was a time period where I was like, "Am I exercising too much? Am I not exercising enough?" It's like, I feel like you hear both sides of the spectrum. Is it, I think first off, safe to continue exercising in pregnancy, and then are there any limits if it is safe?

That's honestly a great question because I do encourage everyone to exercise. However, there are a couple of caveats in there. Exercise has a lot of great physiological benefits, and I'll go over that. It also depends on someone's medical history and their mental status. If I have a patient who has unfortunately had multiple miscarriages, even though the evidence does not support that exercise causes miscarriages or is going to make your body do anything.

Tweet: Exercise has a lot of great physiological benefits, and it depends on your medical history and mental status.

That mental aspect of it, if something did happen, if you're exercising, could have a significant toll on someone. You kind of have that conversation. You say, "There's no evidence, but I understand that this may impact you if something did happen." You have them scale back. You have them just do some walking, just walk around the neighborhood, just walk around your house, just to still get that benefit. There's that subset of patients.

Some patients are very active and are like, "I have to go to the gym every day, and I'm a marathon runner," and you absolutely can continue to do all the exercises that you want, but listen to your body. There are certain things that you should not do when you're pregnant. Contact sports, horseback riding, scuba diving, anything where you might fall, rugby, football, all those things, definitely avoid. You can absolutely continue running if you were a runner before, you can continue to CrossFit if you were CrossFitting before, you can do yoga.

We do recommend against hot yoga and like saunas and things of extreme temperatures, especially in the first trimester. If someone has never exercised before and wants to, then yeah, absolutely. Swimming is a great exercise to do because it's really great for your joints. Walking is great to just start off with, small walks a day increase as you go, listening to your body. The more you're active in your pregnancy, the better your recovery is going to be. It's also going to help with your glycemic control throughout your pregnancy.

It's so helpful, I feel like, in every aspect. Also, something, it's like, I remember this was a little bit silly. I do not recommend this, but I worked it out. The morning I went in, I ended up having to be induced, and I was like, "I'm going to get my workout in." That was very silly.

It's not, though.

Delivering is like the workout that I had the day before. That day, I needed all that energy. 

I do always wonder how many calories it burns and all this. Did you have your Apple Watch on? How many calories does pushing a baby out require? 

It is intense. I have to say, I mean, that's where I think exercising is so important throughout your pregnancy, because the delivery process helps if you're in better shape. Not only does it help decrease all these other risks, too, that I'm sure you'll talk about.

I do actually notice a difference with my laboring patients who have exercised throughout their pregnancy and have been active. They tend to have a smoother labor curve, and they also tend to recover more quickly. There are a lot of benefits from that aspect as well.

Do you find that any exercise is better than another type? Is there any specific exercise that you recommend, or just that somebody enjoys, that they should do?

What somebody enjoys is what they should do because, for me, I hate yoga. I hate Pilates. You know this very well. If somebody told me all I can do is yoga and Pilates, I probably would not be exercising because I hate it. I enjoy different things, and someone might hate workouts, and they may hate running. Whatever you were doing before, you can absolutely continue to do. Obviously, tailor and also just, I did not mention there are certain things in pregnancy that you are not supposed to exercise. It is very important to just check with your doctor before you continue on if you do get diagnosed with anything in the pregnancy, to see if it is okay to exercise.

What are some big things that would kind of make you tell a patient that you cannot exercise?

The biggest ones are going to be threatened by preterm labor. If somebody has a short cervix, someone is dilated early on in their pregnancy with their membranes bulging, that's of course fairly obvious. Typically, these patients are in the hospital, but some patients will be if they're pre-viable. We'll go home. If your water is broken and you're at home, absolutely. If someone has an abnormal placenta, something called a placenta previa or a vasa previa, where the blood vessels are close to the cervix, or the placenta is covering the cervix, these are things that you do not want to cause any friction or irritation to the placenta, because you could have significant bleeding. 

When would you see that? That probably wouldn't be in your first ultrasound, or would you see it already in the first ultrasound when you're checking for a heartbeat?

Which one? The placenta? 

Yes.

Typically, you wouldn't see it in the first trimester most of the time. In terms of the placenta, yeah, typically most placentas are pretty low in the first trimester, with that, like first anatomy, or not anatomy, the first ultrasound. Nothing to worry about. Once you get to your anatomy ultrasound, which is typically about twenty weeks, at that point, your placenta should have moved. If it is covering the cervix or if it's within two centimeters of the cervical os, it's considered a low-lying placenta, or there's something called a vasa previa, in which the blood vessels of the baby are exposed, and they're not covered.

Those are fairly high-risk pregnancies. In those situations, do pelvic rest, so no intercourse. In those situations, you can walk around, you can do walking, but depending on the severity of it, we may put some people on bed rest, or if you bleed, you actually get admitted to the hospital for the remainder of your pregnancy. Some will resolve, and some do not. Those patients will get frequent scans throughout the pregnancy to see.

In terms of like, I guess somebody has like a relatively healthy pregnancy, they do not have one of those contraindications, and they're working out, where do you tell people like, should they be monitoring their heart rate or checking anything when they're working out, and like not going past a certain exertional level?

I do not know if there are particular guidelines regarding that. I would say that the most important thing is listening to your body. Everyone's baseline heart rate is a little bit different. If someone were a marathon runner, their heart rate would be a little bit lower than someone who's really never been walking frequently. I would say your recovery is very important.

If you get done exercising, if you get done walking and it's taking a really long time for your heart rate to come down, you're feeling excessively fatigued afterwards, you're really struggling through a workout that you were doing before, then that's something that you should be concerned about and just talk to your OB-GYN, maybe scale back a little bit and see how you feel.

If you're still not, maybe scale back a little bit more. Just listening to your body and just kind of determining how fast my heart rate recovers? “I just did a workout. It took me 30 minutes, maybe a little bit longer, to just feel normal the rest of the day,” then I would say that's okay. If you did a workout and you really just cannot recover, I would say that's probably not normal. 

Biggest Benefits Of Staying Active During Pregnancy

We kind of talked about it a little bit, but what would you say are the biggest benefits of being active during pregnancy?

Mental health is a huge benefit to exercising during pregnancy, getting outside, seeing the sun, and getting your body moving. As we talked about, stamina in labor is a huge thing. The more active you are, the better your recovery is, and the better you're going to do during the labor process because it has a huge impact on your body, pregnancy, and delivery.

One of the biggest benefits is preventing excessive weight gain in pregnancy because with excess weight gain, you can develop gestational diabetes, and you can develop hypertension. It does help with glycemic control. It does help with weight gain, and with all those things come complications. The other thing is that pregnancy is a hypercoagulable state. We are physiologically built to clot more in pregnancy to prevent bleeding.

Even though that's amazing, the more sedentary you are, the higher the risk you're going to have of developing a blood clot. Getting out and moving, even our patients that are admitted to the hospital and are on bed rest, we're like, "Get up and do a lap in the room, get up and do a lap in the hallway." If they absolutely cannot, we do have to put what we call SCDs on their legs to help with their circulation. These are all benefits. 

Especially for glucose control, that's like, it helps so much because the more muscle you have, that's going to help pull in that sugar and everything and help regulate insulin and everything. It’s very important. That helps if you're diabetic already. 

If you develop it, you get it, you've had it, it's very helpful.

Why Sleep Will Always Be An Issue During Pregnancy

Sleep, I think, is something else that is always an issue in pregnancy. Everybody's like, "First there's the whole first trimester, which is unreal.” You get into the “Now I cannot sleep. I cannot sleep." Maybe starting with, why is pregnancy fatigue so intense? 

There are a lot of factors, actually, but the main thing is progesterone. Every woman who's had a cycle and has had a progesterone surge understands that fatigue, like when you get your cycle, and you're like, "Oh my God." Imagine that times 1000 is essentially what's happening. Your progesterone levels skyrocket at the beginning of the pregnancy. Progesterone actually has a way we call a sleeping, calming effect on your body. It's not that you're being dramatic.

It's not that you're anything, but it truly does make you feel very tired and very sleepy. That's one thing. The second thing is you're creating a human, you're building a placenta. Your body is physically making an organ from scratch. Your heart rate goes up, your cardiac output goes up. Your body is increasing its blood volume. You are just on the go, and your cellular growth and your cellular turnover are double, triple what it is at baseline.

Tweet: A pregnant woman is creating a human, building a placenta, and physically making an organ from scratch. Your heart rate will go up, and the body will increase its blood volume.

On top of that, you may be nauseous. You may not be eating, so you are almost in a calorie deficit. You're not getting the nutrients that you need. You can get insomnia from hormonal changes. You are getting up to go to the bathroom a little bit more. All of these things together in the first trimester can make you, and if you were someone who's drinking a lot of coffee and suddenly stopped drinking. You have all these factors in the first trimester that make you very exhausted.

You feel great in the second trimester, and that's when they say that's because you're out of your nausea state, you're not pregnant enough where you cannot sleep. It's the sweet spot. You get to your third trimester, and then you go back to now you're uncomfortable, you cannot get into a comfortable sleep position. There are recommendations on how to sleep, and people subconsciously are worried.

I feel like that has gone from like, "You can only sleep in these certain positions," to like, "No, it's fine." To then back to no, actually, you have to, once you hit the third trimester, only sleep in certain positions. What is the reasoning behind that? What is the recommended sleep position that is recommended? Does it matter?

It doesn't matter, but it's nothing to freak out about either if you end up waking up on your back or on your right side. The reasoning behind it is that you have your inferior vena cava, which is the big blood vessel that takes all the blood from your body and shunts it back to your heart, and then that gets pumped back out to the placenta. When your uterus gets bigger, if you lie on your right side, it can obstruct your inferior vena cava and decrease the blood flow to your heart, which gets pumped to the placenta.

That is a theoretical reason why you should not be sleeping on your right side. Most people will tell them to put a wedge or a pillow, just to elevate their body off the right side. With that being said, it is not detrimental if you end up waking up and you happen to be on your right side or if you lie completely flat on your back. It is a recommendation that you should try to follow, but it's not something that you should absolutely stay up at night because you cannot get comfortable or worried that you might roll over. There are wedges that you can buy so you cannot accidentally roll over. Some people just use a pillow or roll up a towel. You just need to elevate yourself a little bit off your right side. 

I feel like I've heard of some people who cannot lie down at all. I think because they'll get more like sleep apnea symptoms, and to fall asleep in a chair. 

If you think about your diaphragm, it is right here, right above where your uterus is. As your uterus gets bigger, when you take a deep breath in, your diaphragm expands, and your lungs expand, so you really do not have much room anymore to expand. When you lie down, that can also move up, and so it makes it very hard to breathe. We do see that more towards the end of the third trimester, where people are just like, "I have to sleep sitting up." As you lie down, the uterus comes up, and that decreases the volume of your lungs even more. 

Is it okay in terms of like positioning to like sleeping sitting up?

Yeah. Honestly, any position that you can sleep in is a good position towards the end because you really need to be getting as much sleep as you can. The main big thing is not to sleep completely on your right side, everything else, and obviously not directly on your stomach. Not that I think anybody is doing that, but I do not think you physically can. I do not think you can, even if you wanted to, but the main one is the right side. I see so many women, they're just like, "The only way I can get comfortable is sitting up in a chair at night," and they start sleeping in a rocking chair or one of those La-Z-Boy. If you're sleeping, that's what's important.

Tweet: Any position that you can sleep in is a good position for a pregnant woman. You need to get as much sleep as you can.

Why Fatigue And Symptoms Are Typically Linear

Is there any time when you would like be worried that fatigue is more than pregnancy fatigue, like where it's more than you're just pregnant?

The main thing I tell my patients is that fatigue and symptoms that are normal are typically linear. First trimester, that makes sense. You're tired, or if you have leg swelling and it goes away and it's progressively getting worse, and you're like, "Okay." Something that's more acute or severe or overnight is going to be more concerning. Shortness of breath with walking, but then you sit down, and you recover. That's okay.

If you were just short of breath sitting, not even able to talk, that's not so normal. If you have been exercising every day and suddenly you wake up and say, "I cannot even walk up a flight of stairs, when yesterday I ran three miles.” That's not normal. Anything that you would say is acute and sudden and severe, it's definitely something that you want to tell your OB-GYN or even go to the ER if it's sudden enough, like sudden chest pain, sudden shortness of breath.

Ten minutes ago, you were fine, concerning. Like, “My third trimester, I’m really having a hard time going up the stairs. When I lie down, I go back to normal.” Those things you should mention to your OB-GYN. Those typically just normal physical changes. The great things with aura rings and Apple Watch is most people can now see their heart rate reading. If you’re sitting down and your heart rate is 130, that’s typically abnormal. We do have a lot of data now, which is great to be like, “I’m 140.”

The wearables, I think, do help with that a lot. We even have people come into the hospital, not in terms of pregnancy, but just other, other issues, and they will come in because their watch or whatever wearable device was telling them to. 

It is great.

We talked a little bit about anxiety and exercise, helping with that. I think postpartum gets a lot of focus in terms of postpartum depression. I feel like it is not talked about all that much, anxiety and depression that occur in pregnancy. How common are those? Do you see that?

It’s so common. I do think we are seeing it more and more. I do not know if societal stressors are significantly higher than they used to be, which I do think they are, and I think that makes a huge impact. Most OB-GYN practices, and I would say all, should be screening patients for anxiety and depression when they first come in for their first OB appointment. There is a screening questionnaire that they should be given, and then, depending on how they score, that will tailor the rest of their screening.

If you have less than a ten score, then you are not at high risk, but you should still be screened in the third trimester and postpartum. If someone's score is very high and there are certain questions that are considered, I do not want to say red flags, but to make you more aware, that you should be having that patient come in more frequently, you always need to look at those specific questions and how they answered them.

Those patients in particular, we will have them come in a lot more frequently, provide them with resources early on, even offer medications, and talk about the risks and benefits of those medications. Again, this is one of these situations where you may not want to take a medication, but the risk associated with severe depression or severe anxiety in pregnancy outways that risk associated with that medication. 

When would you say what things that a patient should be looking out for in themselves? I think some anxiety and a little bit of mood changes are probably normal. Where should they be thinking, if they have not done the screening or if it was missed or whatever, when should they be asking, "I think I need a little extra support"? 

I would say loss of interest in things that you were previously interested in, especially if you have a family and a partner and other children, if you are noticing that you are dissociating and not as engaged with your family, pulling back, sleeping more or sleeping less significantly. Those are also things that you need to be looking out for. Excessive crying, or lack of appetite, or just other family members making comments and noticing that, "You're not yourself anymore."

Those are things for a patient to be aware of. It is very hard for people to notice these things because a lot of times they creep up and they are very slow, and a lot of people make excuses of, "I'm just tired. I'm just overwhelmed." Even though patients need to be cognizant, I think the role of the family is very important to recognize these things, but also the OB, your provider. There are certain things that we notice, certain wording, certain verbiage, certain affect when patients come in that your provider should also be picking up on, especially if they have been a long-term patient. It is easier to pick up, but it can be very difficult.

Especially if it's like the first time you're meeting them is when you're coming in, and you're pregnant, and then it's hard to know, is that like their normal or is that new? 

Things can happen in life. Some people might be going through a divorce, or something happened to a family member.

There are a lot of stressors that are there that are not necessarily from the pregnancy. It is hard. I remember just, I think the whole not having as much control in pregnancy is hard. That was a little bit for me.

I cannot imagine. 

I realized, and I feel like I'm baseline not an anxious person, which I think is a blessing, like for pregnancy, for me, especially with my first pregnancy, more anxious than I expected, so it was a surprise to me.

For people who are baseline anxious, that can really start to interfere with their lives. We do have a lot of patients who, again, we always encourage people to call if they have questions, but there are some people where it's a trend of, "Your anxiety is actually interfering with you going to work, with socializing with your friends and family. You really cannot function." Those patients, definitely we will have them come in, and you never want to be accusatory, but you start having these conversations with them like, "How are you feeling? What's going on?" It can get worse before it gets better.

Simple Habits To Support Your Mental Well-Being

You want to start giving support early. No, it makes sense. We talked a little bit about exercise, which I think would play a role in this for sure. What are some simple habits that can help people support their mental well-being?

I do not think we have great mental health support for women, and especially pregnant women. It is very difficult. I think recognition is the first thing. We do see women who are on anti-anxiety and anti-depression medication. Again, I keep talking about it, but that preconception visit is very important, coming in and recognizing, "I have bipolar disorder," or, "I really struggle," or, "I had really bad postpartum depression in my prior pregnancy that really affected me," or any of those things. Being honest with yourself and not being embarrassed, because it is not anything embarrassing.

We just want to get you the proper help or get you on the right track so you do not have to worry about these things again, is coming in for that preconception visit and saying, "I probably need to get on something prior," or, "This is what I've been on," because a lot of these medications do need to be adjusted in pregnancy because your metabolism changes. Some of them, you need to go up in the dosing, so that's also very important.

Having a good support system, but of course, not everybody is able to have that, unfortunately, but there are support groups online, which is a good thing about social media. The good and bad thing about social media is that there are a lot of support groups out there that you do not even have to leave your house. There are therapy sessions or counseling sessions that you can go to via telehealth. The biggest thing is not being embarrassed about it because it is not anything to be embarrassed about. It is a disease, it is a condition just like everything else, just like hypertension, it should be treated exactly the same. Just being honest and telling your provider and speaking to those around you and letting them know what's going on is going to be the best thing you can do. 

Why You Do Not Want To Gain Too Little Or Too Much

Asking for help, and I think definitely getting support where you can. Of course, eating healthy, trying to sleep, which is again difficult in pregnancy, as we just talked about. Eating healthy, sleeping, and exercising all of that helps support too, but it can be hard because sometimes you can feel like you're paralyzed in this, especially for some people in terms of how bad their anxiety and depression can be. Go and get help, talk to your provider. One of the other questions that comes up commonly is weight gain, which we talked about a little bit in body changes. What would you say is like the average amount of weight gain that is recommended? You do not want to gain too little, but then again, we also talked about you do not want to gain too much.

There is actually not one number that is given out to everyone. It actually has to do with your pre-pregnancy weight in terms of how much you should be gaining. If you are starting out at an underweight level, so say your BMI, I believe, is like 18.9, which is considered underweight, I think the recommendation is up to 40 pounds of weight gain. 

That is even more than I would have expected. 

It really has a lot to do with where you start. If you start off considered obese, your recommendation is only about 11 pounds of weight gain. 

Much less. Your body is like, "I already have the stores. You do not have to build it up."

I do not like to talk about pregnancy weight as if it were like weight. It's like nutritional needs, because that's really what weight is. As women, that can be a very sensitive subject, and in pregnancy, body image is huge. Some women who struggle with that before can have a really hard time seeing the number, talking about the number, and feeling a certain way about their body image. Those things are very important because you do not want to have excessive weight gain, and you do not want to have very minimal weight gain either.

Reframing it as, yeah, it's a nutritional need, because the baby will get what they need. The baby will get what they need. If someone is overweight, they do not have to provide as many nutritional needs from the outside as someone who may come into the pregnancy underweight and already requiring a little bit more nutrition. There are guidelines in terms of exactly per your BMI, per your weight, how much you should be gaining, but yeah, it really depends on your pre-pregnancy BMI. 

What would you say are the usual body changes that happen in terms of, like, with this weight gain and everything in pregnancy, versus like somebody should be concerned and get it checked out?

Excessive weight gain is a big one. That unfortunately plays into one of the first questions, which is like, "What is normal? How much should I be eating?" A lot of women are like that, and I feel like I will also potentially be like that, like, " I cannot wait to eat whatever I want." That excess weight gain, eating for two. That can make it very difficult to mobilize because you are already having difficulty mobilizing with just the pregnancy. If you have that excess weight gain, it can be really difficult on your joints. 

Remember, progesterone does make your joints and ligaments more lax, so it also makes it more difficult to get up and do things, and it's very painful. Those are some major pregnancy changes. Even if it is the healthy amount of weight for someone whose BMI is 18 starting out to gain 40 pounds, that's a significant difference for them, so that's a big thing. Water retention, progesterone, and your hormones can make you retain a lot more water.

You may not be gaining fat specifically, but you are still gaining weight just by retaining a lot more water, so that can also be very difficult. Your fingers will get more swollen, your legs will get more swollen, and your face may be a little bit more swollen. Those are all normal, but these could also be signs of preeclampsia. These can be signs of things that are abnormal. It is important to monitor those things and determine, "Does my swelling go down at the end of the night? Do my feet get better when I elevate them? Is it linear? Am I slowly getting a little bit more swollen, or did I just wake up 10 pounds heavier today with water?"

That's not normal. That's something to look out for. Those are some of the changes. Your center of gravity changes a lot. Someone who does yoga or Pilates or is into skating, which I would not recommend in pregnancy, your center of gravity does change, and you do have more back pain and things like that, which again are normal, but they will definitely affect you during the pregnancy. 

What do you tell patients who are worried about bouncing back, like, "I want to bounce back"?

That's a hard one. I try to shift the mentality as much as I can, because as a woman myself, I cannot lie that that would be something I am worried about too. I try to shift it into, "Let's focus on how amazing your body's doing right now. What your body is building is a human. You're building a miracle of life, and how amazing that your body can sustain this. Once the baby comes, it's a recovery journey. You will get there, but every part of it is beautiful in its own way.”

You do not want to minimize their concerns, and you do not want to minimize their fears, because it's very real to some people and can be very debilitating to them. You want to recognize that, like, there will be some changes, and you will get back there. You may not, but just setting realistic expectations in terms of shifting their focus to try to focus on the positive. 

That's a hard one. That's just as females, I think that can be something that we can struggle with easily. I think it could be a common thing. I also love that it is actually becoming a trend. One of the trends that I do like is that people are focusing less on bouncing back and more on the "This is amazing that like I was able to like grow a human and that now there's like this new life and that my body was able to go through all of those changes." 

Why Seeing A Professional Pelvic Floor Physical Therapist Is Always A Good Idea

It can be difficult, but like also such a beautiful process. Celebrating that is so important, and having that mind shift is a good way to look at it. When do you recommend people see a pelvic floor physical therapist? I saw them both times during my pregnancy. I found it was very helpful, but I think a lot of people do not realize that's an option. I do not think it's talked about enough. 

To me, it's like exercise. It is your pelvic floor, which is a muscle. Your rectus abdominal wall muscles. I do not think there is ever a bad time to go. If you want to start going before you get pregnant, great. If you want to go throughout your pregnancy, amazing. It is probably most helpful to go after a pregnancy, or specifically if you unfortunately had a traumatic birth, or some of those risk factors that increase your risk of pelvic floor prolapse.

Think about it like exercise. If you have already trained your muscles to do something, it's going to be a lot easier for you to get there postpartum, versus "I've never worked these muscles before. They're already so weak." It's a lot harder to get you there, so I do not think there's ever a bad time unless you have a contraindication, which again, that's something to talk to your doctor about. Overall, I think it's good for everyone, anytime to go.

I know I went both during my pregnancy and after, I found it so helpful, even in terms of like some of the things that we would go over, like how to relax and the different muscles and everything. It's just something that even as a doctor, I wasn't aware of. It's not something that I get training on.

It's hard because it's not cheap. That's considered more of an elective, which I do not think it should be. It's something that insurance is not going to cover it. You have to go out and seek it on your own, and you can look up some stuff online. People do not realize that pelvic floor physical therapy is not just Kegel exercises.

There's so much more. I do think there's more now online. Not obviously everybody has this, but there are places where sometimes they have these virtual physical therapists where they're cheaper, and they can at least go through some of the basics. Some jobs they'll have that include, which is also a resource, I think, that people sometimes forget to look into. How often in terms of appointments, because I feel like people are on the spectrum, either they see their OB-GYN way too much, and they're like, "I can't believe I'm going to all these appointments," or they're like, "I never see them and all of a sudden I'm having a baby." 

Which is not a bad thing, I tell people, because I work with midwives and I joke, I'm like, "If you do not see me, you're having a great pregnancy." Not that others are bad, but it means you're having a low-risk pregnancy because we're not going to let you just fly under the radar, because we do not feel like seeing you. It just means that you're good. 

Tweet: If you are not seeing your OB-GYNE, you are having a low-risk pregnancy.

How often should they expect to see you?

I will tell you that for a healthy, uncomplicated pregnancy, I can only speak from the private practice that I worked in. I'll tell you the actual guidelines, but we would have a positive pregnancy visit just to confirm that you are pregnant, because sometimes you come in and you're not pregnant or whatever happens. We determine how many weeks you are based on your cycle at that visit. We do see a lot of people get upset, "I'm not getting an ultrasound today," but you're really not going to see anything if you're anything less than about six weeks or so.

We will have them come back. You do not always see a heartbeat that early, either, so we will have them come back at typically eight weeks, and you should definitely be seeing something at that point. Again, that can really change if you come into your positive pregnancy visit and you're bleeding, that changes the whole trajectory of how often we're seeing you, what we're doing, whether we're getting blood work, whether we're doing an ultrasound the same day, what happened in your prior pregnancy.

That's very different, but if everything's okay, "I'm pregnant," "Great, come back at eight weeks, you'll get an ultrasound, you confirm the pregnancy," and then typically you would come back at about ten weeks for your first OB visit. At that visit, you'll get blood work, which is like your basic prenatal labs to check your iron levels, your immunization status, hepatitis, and rubella. You'll check your thyroid level, which can change a little bit at the beginning of the pregnancy, and determine if you need to take medication or not.

You'll get a Pap smear if you haven't had one. They should be looking at your cervix at that first visit to make sure there's no concern or anything that would cause them to need to check on it more frequently. If you are a candidate, they'll offer you genetic testing at that visit. That's the NIPT screen that checks for Down syndrome, trisomy 18, and 13. After that, you really come back once a month for a while, so up until 28 weeks, you just go in every four weeks.

Once you hit 28 weeks, which is your third trimester, you're going to be coming in anywhere between once every 2 to 3 weeks until about 36 weeks. After 36 weeks, you'll come in once a week until delivery. If there's any complication or you have any new diagnosis, if your provider is concerned about anything, whether it's anxiety, "I need to see you more frequently, and I just want to check on you," whether it's anemia, whether it's hypertension, whether your baby's not growing appropriately, whether we saw something on the ultrasound we didn't like.

I would say very few people have that perfect pregnancy, which is great. I think it makes people more anxious than not to say, "You're good. Do not come back till later." It is a great thing not to need to come back. I would say as more and more women are having babies later and at an older age, those patients do need to get screened a little bit more frequently, so I would say for the most part, most people come in a lot more frequently than that. 

I know for me, for my first pregnancy, I had to go in way more because the anatomy ultrasound picked up something that was a little bit abnormal. I was there, it felt like all the time. My second, I didn't have that. I remember being like, "Wait, this is all that I go? What's going on?" It feels weird. 

People get stressed. They're like, "Can I see?" It's like ultrasound is safe, but you also do not want to keep just doing ultrasounds. It causes some anxiety, but I try to reassure them that means nothing is wrong, which is great.

Which Pregnancy Screening Tests Are The Most Important

It's a good sign. It's a good thing. What screening tests are the most important? We talked about ultrasounds, how often they're done, and when they're done. For people who haven't been pregnant, I think one thing that can be surprising is that it's not always an abdominal ultrasound. That's what's shown on TV, that's what's shown in the movies.  That's why you're actually doing a transvaginal ultrasound. Maybe also going through, like when you switch over in the types of ultrasounds that you're doing. 

Early on in the pregnancy, a couple of things that make a difference are body habitus. If your BMI is higher, it makes it a little bit more difficult to see your uterus because the uterus is really not as big as people think at the beginning. Probably about this big, and it's very low in the pelvis. For someone who has a bigger body habitus, sometimes earlier on in the pregnancy, you would need to do a transvaginal ultrasound because it gives you a more direct image of the uterus, and you can see really well.

I would say that most people in their first ultrasound visit will get a transvaginal ultrasound because we want to see really clearly. Very few people, I would say, can see abdominally like a yolk sac or a crown-rump length or a baby that barely has a heartbeat, so I would usually expect a transvaginal ultrasound at your first visit. The second ultrasound that most people get will be a nuchal translucency ultrasound, which can be anywhere between 11 and 13 weeks.

Most people can get that abdominally. Again, if your body habitus is a little bit bigger, that can make it more difficult to see, so that's when you would do a transvaginal ultrasound. By the anatomy ultrasound, most people, I would say about 100% of patients, you can see everything abdominally, so you do not need to do a transvaginal ultrasound. However, if someone has risk factors for preterm labor or a short cervix or an incompetent cervix or has had a history of a LEEP procedure, those are all risk factors for a short cervix.

The only way to be able to accurately see that, especially early on, is to do a transvaginal ultrasound, where they can measure the length of your cervix. For instance, have a history of a LEEP procedure, you will be getting your cervix measured every two weeks because that can increase the risk of a preterm delivery or a short cervix.

If you've had a preterm delivery in a prior pregnancy, they will also be looking at your cervix every two weeks until you get to about 24 to 28 weeks to make sure that your cervix is not shortening. Typically, you will get a transvaginal ultrasound, or if they're also looking at your placenta, especially if it's a placenta previa or vasa previa, which is what we talked about earlier, you'll also get a transvaginal ultrasound.

Screening tests, what would you say are the really important screening tests for people to get? 

Again, preconception is the best way to determine a lot of things. If you know that you are a carrier of a specific gene, a bunch of people in your family have it, or for some reason you know that you're a carrier, it's very important, depending on what that is, to get your partner tested because some diseases can be detrimental. Some diseases are recessive in nature, and some are dominant in nature. That's one thing, to go through genetic screening if you know. Most people do not know, and I would not recommend routine genetic screening for anybody, but that would be one thing.

In terms of blood work, most people do not need any excessive screening. You just get your regular routine blood work. Your thyroid is very important because if it's too high or too low, that can have negative consequences in the pregnancy, increased risk of miscarriage or stillbirth, so it's important to get checked out. Anemia screening that's very important. One of the things I didn't mention in terms of body changes that are not normal is if you're bruising a lot, some people can get thrombocytopenia in pregnancy, which is low platelets.

If you're noticing that you're having a lot of bruising or a lot of things like that, that's also very important too, and that's part of your routine screening, so you do not need to be asking specifically. Risk factors for genetic abnormalities, which is your NIPT, which is what most people like to call it, the gender reveal test, because you do get to find out the gender. What it's really there for is to screen for Down syndrome, which is trisomy 21, trisomy 18, and trisomy 13.

Unfortunately, those are the only three that it screens for, so that it does not take away everything else. You get the nuchal translucency ultrasound, which is between 11 and 13 weeks, to see if there are any obvious anatomical structural abnormalities, which would then reflect on maybe going to high-risk doctors to get a sample. I do not know if you've heard of an amniocentesis, where they go in and actually extract fetal genetic material to test and see if there's something outside of those routine screenings. 

Which used to be the only way they could even do like the Down syndrome test, all of that. It's so cool now that they have the blood test, even if it's not for everything. I've had people ask me, "Should I get this done?" It's a very different discussion than it was 30 years ago or 20 years.

It's not without risk. 

Back then, the only way you could get those tests was actually doing that amniocentesis, which was a higher-risk procedure. It's like now that it's just a blood test, that's a very different scenario.

Some people elect not to have the genetic screening. If you get to your anatomy ultrasound and there are some concerning features that we're seeing, we'll say, "There's something called soft markers that are concerning to us that maybe these are phenotypically more consistent with a genetic disorder," then we can go back and get that genetic screening done. The amniocentesis does have a time cap to it.

It was also really cool to be able to find out the gender so early. It's wild that you can do that even before the anatomy scan.

It is. I do like to always be like, it's also for genetic screening. It is fun to find out, open your envelope, and see all that.

Why Vaginal Bleeding Must Never Be Ignored

I guess something else that's probably important are warning signs, because I feel like, especially in pregnancy, it's very easy to be like, "This is different, and it's like something to worry about," or it's like, "Now you actually do not have to worry about that." What symptoms would you say, "If this is going on, you should be giving us a call like ASAP, this should not be ignored"? Vaginal bleeding.

Any vaginal bleeding in pregnancy is not normal. It really just depends on where you are in terms of gestational age. If you're having a little bit of bleeding, a little bit of spotting, and you're in your first trimester, I would not fully panic. You can just call your OB-GYN and go in when they have something available. If you're having significant bleeding, then you could just go to the ER at that point. Once you're viable, which is 24, some will say 22, 22 to 24, depending on the hospital that you're at, those are things that you should promptly go to the hospital. Any vaginal bleeding is not normal.

Severe abdominal pain, the abdomen is hard, very concerning, that's something you should go straight to the hospital. In terms of fetal kick counts, your OB will tell you certain things that you do if you do not feel your baby move, like ice water, chocolate, something a little caffeinated, or go to a quiet room. You really still cannot feel your baby move, then absolutely. We're never upset that you came in because you couldn't feel your baby move. We'd rather reassure you and make sure that everything is okay, cause it could be a sign of low fluid, could be a sign of something's going on with the baby.

Sometimes the baby has to be delivered right away, so that's the whole reason why they say to do the kick count. 

Exactly. Of course, there are different anxiety levels, but we would always rather you err on the safe side in terms of checking on your baby to make sure everything is okay. In terms of not directly uterus pregnancy related, but any neurological changes. I suddenly have a severe headache," facial droop, because seizures and strokes and things like that are all, I wouldn't say common, but can happen in pregnancy, especially with preeclampsia. Any kind of seizure-like symptoms or neurological symptoms, headaches, chest pain, shortness of breath, difficulty breathing, feeling like you're drowning, you can definitely have heart failure in pregnancy, and those are all signs of preeclampsia. They can happen very quickly.

This is a question because it happened to me. I became a klutz in pregnancy, and I fell. If somebody does happen to have a trip and fall during pregnancy, the first trimester is different from the third trimester. What would you say, depending on where they're at in their pregnancy, that somebody needs to do if they tripped and fell?

If you trip and fall and you land directly on your abdomen, I would potentially call an ambulance and go straight to the hospital because you need to be checked out immediately. If you trip and fall and you land on your butt or you catch yourself, I would still go get evaluated because even though you did not have a direct fall, that shearing shift, or if you get in a car accident and you get that jolt, that can still potentially cause placental abruption, which is what we worry about, where the placenta separates.

You should absolutely still go in or still call your OB-GYN because you do need to be monitored for a certain amount of time. Tripping, falling, anything that would have caused a sudden movement, you need to go get evaluated. If you directly fall on your abdomen, that's obviously more concerning, and you need to go in very quickly. If you're in any trauma, whether it's unfortunately domestic abuse or a car accident or someone shaking, anything like that, you need to be evaluated. 

I know where you are, like a crazy toddler, there are so many things. 

All that to say, I've had patients where my dog stepped on my belly. The baby is contracted. There is amniotic fluid. Again, you should not be staying up all night freaking out, being like, "My doctor said, do not call about this.” If it is a significant trauma to your abdomen. If the dog did something or if your toddler pushed on you a little bit, typically not something to be overly concerned about.

Looking For Signs Of Gestational Diabetes

You mentioned some of the signs of preeclampsia. What about gestational diabetes? I feel like typically that's caught, like in screenings, but not always. What do you look for? 

It's hard for people to specifically look for those symptoms themselves because you're already peeing a lot in pregnancy. Typically, if you're not pregnant and then you're suddenly very thirsty, and you're peeing a lot, those are the things that we tell someone to look out for. Unfortunately, those things are happening already during pregnancy. You're not really picking up on that. A lot of times, especially since I'm a hospitalist now, and we do see a lot of patients with no prenatal care, as they come in, and they give a urine sample, and they've got a crazy amount of sugar in their urine.

That typically is our first telltale sign. Other things with ultrasound, which again, you would not be able to tell, are polyhydramnios, which is an excessive amount of amniotic fluid around the baby, or a baby who's measuring really big, above the 95th percentile. These are typically side effects of untreated diabetes. For someone, most people do not know that they're diabetic until they come in and deliver, especially where I work now, you're like, “That's a big baby.” We do not like being surprised with big babies. Typically, it's hard to tell on yourself.

Tweet: Most people do not know they are diabetic until they deliver a big baby.

Having Sex During Pregnancy: Should You Do It?

The other questions that people always ask me are, “Can I have sex during pregnancy? Is that safe?” When should it be avoided? Which you talked about before, with like, depending on where the placenta and everything, but.

It is safe. Again, it is up to your comfort level. If someone, your partner, is going to be freaking out that whatever they think is going on, like they're not hitting the baby's head, they are protected. It is good for you and your partner to talk about and see because you should not feel like, “My partner doesn't want to have sex with me, and I want it.”There's this tension regarding it. It's something, and it's great for partners to also come in during the OBGY. The partners need to come in and listen. They might have questions like themselves in terms of what I should be doing to support her.

It’s actually safe to have sex and pregnancy at all times throughout every trimester. Things may feel different, and that's okay. You may be doing different positions for comfort level, especially later on. As I mentioned, there are certain contraindications, such as if you're prematurely dilated, if your water is broken, if you have an abnormal placenta, certain things. If you ever get diagnosed with something in a pregnancy, always ask. Your provider should be telling you, but not always. If there's any concern, always ask, and they'll be able to tell you if it's okay or not. 

Traveling During Pregnancy: Is It Safe?

What about travel? That's also something you probably did a little bit too late. Is it safe to travel in pregnancy? I guess also like ideal times, what should people be considering when they're making travel plans? 

It's safe. The problem is that we say it's probably not a good idea to travel after 36 weeks. It's not because it's not safe to get on an airplane, but you do have a higher risk of going into labor. You probably do not want to have a baby on an airplane. You do not want to be somewhere international, having a baby, and you do not have your doctors or your provider, or you're in a different city or town without your family. It's not that it's not necessarily safe, but after 36 weeks, I highly recommend that. I do not believe most airlines. I do not know the answer to this, but I know that people will say airlines will require documentation, but I do not know at what point they will ask.

Tweet: It is safe to have sex during pregnancy throughout every trimester. Things may feel different, and that’s okay.

I'm not sure either. I could see them asking because I'm sure they're like, we also do not want you delivering on 100.

I do not know if they see you.

A minute, “I'm concerned.” 

I've always meant to look into that, but I really do not know how they do that. I've heard most airlines won't let you travel past 36 weeks, but I do not know how they go about that process. The other thing with traveling long distances is the hypercoagulable state that we were talking about. Even if you're traveling in a car or an airplane at any part of your pregnancy, I do recommend getting up and walking every one to two hours, whether it's in a car, stopping, doing some laps, wearing compression socks, or maybe even taking baby aspirin.

Again, ask your doctor if that's okay. Those are my recommendations. If you are traveling, the second trimester is your sweet spot because you're finally feeling better. You're finally not nauseous and having all these food aversions. You're like, “I'm pregnant.” You're sleeping again. Second trimester is your good sweet spot for travel, but with these compression socks, get up and walk, do all those things. In the third trimester, you really want to stop around 36 weeks.

Again, it depends on your pregnancy and your risk factors. Some people were like, absolutely do not leave anywhere. You've got to stay within a radius. Some patients were actually discharged from the hospital, but were like, how far from the hospital are you? Some people really need to be in a very close vicinity to the hospital. Always check with your doctor. 

The common sense part of it, too. You do not want to deliver on an airplane. You want somebody delivering who knows you, who knows your pregnancy, even in an uncomplicated pregnancy, right? There's always like, as you get further along, it's like, the closer you are to your due date, the closer you should stay.

There are going to be two people who are 36 weeks old at my wedding. I did say, “We will have twenty OBGYNs there.”

I feel like they're more than covered. A little bit different.

Typically, I say no traveling, but they should be covered there.

I feel like that would be safe. It's a little different from what I wanted to do, which was to go camping on Cumberland Island, which is an island that you can only get to by boat. 

That's a no.

That's an appropriate thing.

That would be “Absolutely not.” Every pregnancy is different. Even with your own pregnancies, as you said, the two were completely different. Always check with your doctor because it might be something that you do not know.

Everyday Things Pregnant Women Should Stay Away from

People are more aware of this, but like every day, like cleaning products, household products, things like that. Are there things that people should be cautious about, like handling and having around? 

Really, the main big one is cat litter. That's one that I think most people know about the risk of toxoplasmosis. If you have a cat and you're pregnant or trying to get pregnant, you really should not be handling cat litter. I would say that's the main one in terms of household, of course, with all the chemicals. I know not everybody is doing this, but some people are switching to more natural products.

Overall, I think there's a big shift in society now to doing that, but just like with everything else, you do not want to be inhaling, like in a closed, not circulated, you do not want to be cleaning with corrosive chemicals in the closed garage. Nobody really should be doing that. I would say there's no chemical that I can think of, like in terms of home cleaning products, that I would absolutely not use other than cleaning cat litter. Overall, just use caution in terms of not inhaling. It's not good for anyone. 

If it's how I was and for both of my pregnancies, I felt like I was so sensitive to all that stuff. Almost any smell that was strong would be a major trigger for me. 

Hopefully, your partner is doing all the cleaning anyway. 

I feel like there's a lot of like with those changes, sometimes it's probably protective.

No, it is.

You cannot handle it.

Actually, it is interesting. I do not remember what I was reading about smells and things, and they're saying it's likely a physiological thing because your aversions to meats, fish, and eggs back in the day, these were the things most likely to have bacterial overgrowth. It is the body's physiological mechanism of having aversions to things that might be bad for you. Nowadays, obviously, meat is handled differently. 

No, and now we can, like, you can actually check the temperature, and you can cook it right away. It's not like you had a cow, kill it. Now a lot of it's like, been out for a while and all that stuff, so it's a little bit different. Modern advances it's amazing. Look at that. 

The body still tries.

Navigating The World Of Social Media And Information Overload

Anything else that you can think of that you would want patients to know? We hit all the big things. Those are all the ones that I feel like I had questions about, or all my friends have questions about. 

The biggest thing is I think there's a huge shift with social media, and like information overload. It's most providers, at least most of the providers I know, it is okay. You should absolutely go ask the questions, understand why we're doing certain things, and understand why certain products, not products, medications, are offered or certain things, because there's a reason behind it, and informed consent is very important.

You shouldn't ever feel like your provider is forcing something on you without explaining to you the reasoning behind it. Taking all the internet information with a grain of salt, but asking the right questions and being able to get that, and then you can make your informed decision based on that, is the new thing that we're all having to navigate.

It's important. That's why things like this are helpful because it goes over so much. I feel like I have so many questions that I know I had when I was pregnant. 

Ask your provider about every pregnancy. Do not compare to the internet and this mom, who was this way at this gestational age, or every pregnancy is so different. Even for every patient that walks in the door, we tailor our care to them. Nobody is the same between your two pregnancies, so do not compare. That's the big thing.

Tweet: Do not compare two mothers together. Every pregnancy is different.

Thank you so much. This was awesome.

You're welcome. I hope this was informative.

It was very informative. I am sure that all of our audiences enjoyed everything and learned a lot. As always, this is not intended as medical advice. This is for educational purposes only. Of course, thank you so much for joining us, Dr. Megally. This was awesome.

You're welcome.

We'll have you back soon.

Thank you for having me on. This was so fun. 

Bye.

Important Links

• Dr. Nada Megally on LinkedIn

About Dr. Nada Megally

Dr. Megally is a board-certified obstetrician and gynecologist with years of dedicated experience providing comprehensive women’s healthcare. Known for a compassionate, patient-centered approach, Dr. Megally specializes in preventive care, prenatal and postpartum management, and the diagnosis and treatment of a wide range of gynecologic conditions.

Throughout a distinguished medical career, Dr. Megally has built a reputation for clinical excellence, clear communication, and a commitment to empowering patients to make informed decisions about their health. By staying at the forefront of advancements in obstetrics and gynecology, Dr. Megally ensures that patients receive the most up-to-date, evidence-based care in a supportive and respectful environment.

Whether guiding patients through pregnancy, addressing complex health concerns, or promoting long-term wellness, Dr. Megally is dedicated to improving the lives of women at every stage.

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FASEB Journal: Official Publication of the Federation of American Societies for Experimental Biology. 2018. Caudill MA, Strupp BJ, Muscalu L, Nevins JEH, Canfield RL.

1. Choline Intake During Pregnancy and Child Cognition at Age 7 Years.

              American Journal of Epidemiology. 2013. Boeke CE, Gillman MW, Hughes MD, et al.

1. Early Second Trimester Maternal Plasma Choline and Betaine Are Related to Measures of Early Cognitive Development in Term Infants.

PloS One. 2012. Wu BT, Dyer RA, King DJ, Richardson KJ, Innis SM.

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European Journal of Nutrition. 2026. Weng Y, Liu Y, Qin Y, et al.