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Lifestyle in Pregnancy

Article in Canadian family Médecin de famille canadien · October 1984 Source: PubMed Central

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Robert Bryce Murray Enkin Flinders University McMaster University

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The user has requested enhancement of the downloaded file. Robert L. Bryce Murray W. Enkin Lifestyle in Pregnancy SUMMARY SOMMAIRE While there is little doubt about the Bien qu'il ne subsiste que peu de doute quant a la relation entre le mode de vie et son influence sur le association of lifestyle and pregnancy resultat de la grossesse, on questionne enormement outcome, there is considerable doubt about la valeur nette, pendant la grossesse, des the net value of lifestyle adjustments during changements au niveau du mode de vie. On n'a pas pregnancy. Advice alone on nutrition, sexual demontre qu'a eux seuls, les conseils sur la activity, alcohol and smoking in pregnancy nutrition, l'activite sexuelle, la consommation has not been demonstrated to improve d'alcool et le tabagisme pendant la grossesse ont ameliore la situation et qu'ils pr'sentent en soi des outcome, and may, in itself, have adverse effets adverses. Certains effets benefiques peuvent effects. Beneficial effects may occur when se manifester lorsque les conseils s'accompagnent advice is accompanied by a program of social d'un programme de support social. support. (Can Fam Physician 1984; 30:2127-2130).

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Dr. Bryce, who has completed a our advice is encouraging; on other oc- woman looks after herself, no one else fellowship in Maternal Fetal casions, the results fall far short of our can look after her. However, we must and a master's degree in expectations. be careful to avoid the simplistic belief Design, Measurement and The pregnant woman is a particu- that advising a woman to look after Evaluation at McMaster University, larly favored and susceptible target for herself is the solution to further im- is on the staff of the Departments of that advice. She is specially concerned proving the outcome of pregnancy. and Gynecology and not only for her own wellbeing, but for Advice on lifestyle, to be appro- Epidemiology in Perth, Western that of her unborn child. She is rela- priate, must satisfy three fundamental Australia. Dr. Enkin is professor of tively young, perhaps not yet fixed in criteria. First, that if the advice is fol- Obstetrics and Gynecology at her habits, and thus capable of change. lowed, it will lead to benefit. Second, McMaster University, with an In addition, because she is generally that it is likely to be followed. Third, associate appointment in clinical well, we often have little else to offer and most important, that whether our epidemiology and biostatistics. her at antenatal visits. patients comply with our advice or Reprint requests to: Dr. M. W. A large part of antenatal care is not, the giving of that advice in gen- Enkin, Department of Obstetrics made up of advice-on diet, hygiene, eral will do more good than harm. and Gynecology, McMaster activities and habits. We tell the preg- University, 1200 Main St. West, nant woman to get plenty of rest, and In this paper we review some of the Hamilton, ON. L8N 3Z5. plenty of exercise; what to eat and lifestyle prescriptions and proscrip- what not to eat; how much weight she tions that have been used in the past should or should not gain. We tell her and are used today for pregnant "The most common form of remedy of- when she can have coitus, orgasm, women. On what evidence are these fered to pregnant women comes in the both, either or neither, and which of prescriptions and proscriptions based? guise of 'advice'. However, this is no life's other pleasures she may continue What side effects may they have? As ordinary advice, there being no option or must abjure for the duration of her examples, we will look at four areas to of refusal." 1 pregnancy. We have no shortage of which a great deal of attention has advice for her. Unfortunately much of been paid in recent years; diet and T HE ASSOCIATION between poor that advice is inconsistent, based on weight control, sexual activity, alco- health outcomes and undesirable unsupported opinion or conflicting ev- hol intake and smoking. lifestyles generally leads well-meaning idence, and potentially capable of to 'improve' these out- causing harm as well as good. comes by advice to alter lifestyle for The importance of health habits can Nutrition the better. At times, the response to scarcely be denied. Unless a pregnant Despite the fact that diet is clearly a

CAN. FAM. PHYSICIAN Vol. 30: OCTOBER 1984 2127 major determinant of postnatal to the physiologic changes in her me- The adverse effects of advice about growth, little is known about how, or tabolism which make her more resil- coitus during pregnancy have not been how much, the mother's diet during ient to deprivation, and her fetus less investigated. Williams 14th edition14 pregnancy affects the growth and well- vulnerable than hitherto has been be- comments bluntly about one such ef- being of the fetus. This lack of knowl- lieved". Except in situations where fect: "It has long been the custom of edge has not prevented professionals there are specific indications for inter- many obstetricians to recommend ab- from giving specific advice throughout vention, perhaps her appetite may well stinence from intercourse during the the centuries. Hippocrates advised that be the best guide to her requirements. last four to six weeks of pregnancy, a "dry foods are more adapted to the recommendation undoubtedly not car- softness of woman's flesh, and are bet- ried out in many instances. On occa- ter for the womb and pregnancy". He Sexual Activity sion the couples' drive in the face of also suggested that "food and drinks "Marital relations are to be re- the admonishment against intercourse that are not quite so good are to be pre- stricted, particularly near the men- late in pregnancy has led to sexual ferred' ' .2 On the other hand, some strual dates, and are strictly interdicted practices with disastrous conse- professionals advocated a more liberal where there is a tendence to abortion. quences. Aaronson and Nelson, for in- approach. Magnus, a 13th century All relations should be positively for- stance, describe fatal cases of air em- monk, cautioned that "to deny the bidden during the last months of gesta- bolism late in pregnancy as a result of pregnant woman any food she may de- tion. Non-observance of these rules air blown into the vagina during cunni- sire might cause the unborn child to may cause abortion, premature labor lingus." Less dramatic, but more die of weakness".2 and puerperal infection' .6 common, may be cases of marital fric- Obstetricians in the 19th century ad- Advice about sexual activity in tion and disharmony caused either by vised restriction of weight gain during pregnancy has softened somewhat sexual abstinence or guilt. pregnancy in the hope of making over the years. Williams' classic text smaller babies and achieving vaginal in its sixth and tenth editions suggest delivery in cases of contracted pelvis.2 that "in healthy persons sexual inter- Alcohol In the 1920s, observations of the course in moderation usually does no The association between alcohol weight gain seen in toxemia led obste- harm . . . but should be forbidden in and suboptimal mental development tricians to advise weight restriction to the last months of pregnancy". By the has been known for a long time. Aris- prevent eclampsia. An era of dietary 12th edition it admits that "even in the totle stated that "foolish drinking and restriction, especially of protein and last weeks it probably exerts less dele- hare-brained women for the most part salt, began, extending to the 1960s and terious effects than was formerly bring forth children like them- even to some degree today. More re- feared". 7, 8, 9 selves". 15 cently, many nutritionists have ad- Retrospective studies have shown Controlled experiments have estab- vised a high calorie, high protein diet an association between frequency of lished that heavy maternal alcohol to achieve maximal increase in fetal coitus,10 orgasm11 and preterm labor. consumption during pregnancy causes weight and development.3 It is difficult to argue that this associa- reduction in birthweight and an in- At least 17 controlled trials of die- tion is more than coincidental. Sexual creased incidence of congenital abnor- tary supplementation in pregnancy activity -generally declines in the last malities.16 Similarly, in humans con- have been undertaken.4 Eight of these weeks of pregnancy, making it more sistent association has been seen showed a decrease rather than an in- likely that a woman in preterm labor between heavy alcohol consumption crease in birthweight in the supple- will have had recent intercourse than and increased rates of spontaneous mented group compared to the con- one who gives birth at term. abortion, fetal growth retardation, and trols. Seven of the eight studies in Naeye,12 analyzing the data of the mental retardation, as well as a spe- which over 20% of the dietary calories NICDS collaborative perinatal project, cific dysmorphic syndrome. 17 were protein showed a decrease in found an increase in chorioamnionitis The risks of adverse outcomes with birth weight in the supplemented in women who had more frequent in- alcohol consumption in pregnancy are group. tercourse before labor. Postulating that dose related. Heavy drinkers who re- The only real conclusion we can this infection may be caused by orga- duce intake in pregnancy reduce their come to from these studies is that the nisms carried in the semen, Naeye and risks.18 Ingestion of as little as one relationship of pregnancy outcome to Ross 13 prospectively studied two ounce of alcohol per day carries some diet is a complex one. Contrary to groups of couples, one who agreed to danger.19 Whether smaller amounts much current opinion, it appears that use condoms during coitus in preg- carry any risk remains to be deter- excessive dietary protein may be nancy, another who did not. Preterm mined. No harmful effects have as yet harmful and should be avoided. No labor and inflammation of the mem- been reported. Only with total abstin- consistent benefit from dietary advice, branes was less common in the group ence can a woman be sure to be free of restriction or supplementation has using condoms. The results of this any possible hazard of harmful effects been observed, and the possible ad- prospective study are of great interest, of alcohol ingestion. The present state verse effects of such dietary con- but the differences in outcome ob- of our knowledge does not justify giv- straints have not been investigated. served may be due to inherent dif- ing such advice. Hytten5 wisely observed that the "the ferences between those who chose to . Abstinence is certainly easy to obvious ability of the pregnant woman comply with the advice to use con- preach, but for some it may not be and her fetus to weather the gamut of doms and those who did not, rather easy to practice. No controlled studies nutritional hazards, from crop failure than an effect of the condom use per of the risks or benefits of alcohol ad- to obstetrical advice may well be due se. vice in pregnancy have as yet been un- 2128 CAN. FAM. PHYSICIAN Vol. 30: OCTOBER 1984 dertaken. Until this is established, likely to be of lower socioeconomic cessful social support manifested by women have the right to complete and class, to be an urban dweller, and to be Sexton and Hebel. current information to aid their per- lighter in weight than the non-smoker. sonal decision making. Smithell's ad- She also drinks more coffee, beer Adverse Effects vice of 197920 is perhaps still valid: and whisky, has had less schooling, "For the fantasiacs who demand guar- and received less prenatal care.27, 28 Apart from the physical side effects antees, total abstinence throughout Studies which correct for these con- of weight loss from high protein diets, pregnancy probably combines scien- founding factors still show an indepen- the possible adverse effects of lifestyle tific with poetic justice. For the real- dent (although much weaker) associa- advice remain largely unaddressed. ists, who recognize that life is a series tion with smoking, but the differences There is some evidence, however, that of subconscious computings of bene- in outcome may be attributable to anti-smoking advice may increase fit/risk ratios (crossing the road, eating those and other known or unknown stress and anxiety in pregnant women, out, getting married) a little of what differences between the smoking and particularly if it is unusccessful.33 It is they fancy will do them good, and is non-smoking subjects.29' 30 naive and wrong to assume that a preg- very unlikely to do their fetuses any Randomized controlled trials will be nant woman who fails to comply with harm". needed to find out whether anti-smok- our advice is either ignorant of the sup- ing intervention can ward off adverse posed consequences of her actions, or outcomes. Two such trials have been selfish and irresponsible. Smoking reported, with conflicting results. Actions contrary to medical advice The fact that women who smoke Donovan28 was unable to show a sig- may derive from a different assess- cigarets during pregnancy have lighter nificant effect on birthweight between ment of the evidence, with reliance on babies than similar women who do not controls having routine care and personal experience rather than the smoke has been consistently seen in women receiving individual anti- wisdom of so-called experts. ("My over 50 studies, including over half a smoking advice, despite the fact that cousin smoked all her pregnancy and million births.21 The difference in the number of cigarets smoked in the had a nine pound healthy baby"). weights was found to be from 150-300 intervention group was only 56% of Sometimes apparently unhealthy be- grams, and the risk of having a low that in the control group. However, havior may be important to a woman's birthweight (less than 2500 g) baby Sexton and Hebel32 were able to ability to cope with the stress of preg- achieve a statistically significant dif- nancy. For us to seize on the vulnera- was twice as great for smoking as for as a non-smoking mothers. The incidence ference of 92 g in birthweight in favor ble time of pregnancy moment to of their intervention group. induce lifetime changes at the expense of low birthweight increases with of lifetime seems cruel numbers of cigarets smoked22 and is The intervention used by Sexton and possible guilt the same in those who stop smoking in Hebel was a massive one, perhaps im- indeed. pregnancy as in non-smokers.23 practical to implement on a major Smoking is also associated with scale. Each woman received at least The Future other adverse reproductive outcomes. one home visit and often more, supple- The studies presented suggest that Case control studies have shown that mented by frequent telephone and mail mere advice about lifestyle in preg- the risk of spontaneous abortion for contacts. It was conducted by two nancy is seldom effective in altering smokers was 1.8 times that for non- women, both with master's level edu- behavior, and not effective in altering smokers,24 and of preterm birth 1.1 to cation. One had experience in preg- the outcome of pregnancy. However, 1.5 times as great.25 Some large series nancy counselling, the other in smok- studies of anti-smoking advice32 and have shown an increased risk of perin- ing intervention. In addition to enhanced antenatal care34 35 which atal mortality in the offspring of smok- assistance to stop smoking through en- were accompanied by social support ers, although many other series fail to couragement, information, practical have shown significant effects on out- show this association.21 guidance and behavioral strategies, it come, particularly birthweight. Although there seems to be no dif- provided personal attention and indi- Later this year, one of us (RLB) will ference in immediate morbidity (as vidual support. It would be reasonable begin a randomized controlled trial ex- evidenced by Apgar scores) between to argue that the key factor in the im- amining the effectiveness of lifestyle the newborns of smokers and non- proved outcome demonstrated in this advice (smoking and alcohol), given in smokers, later morbidity seems to be study may have been the intensity of the home and accompanied by social much higher for the children of smok- the interaction between the pregnant support from midwives, on the inci- ers. This includes risk of sudden infant woman and the therapist, and the non- dence of preterm birth. The relative death syndrome, increased hospital ad- specific benefit the pregnant woman contributions of changes in smoking, missions and more diagnosis of bron- would get from this support and inter- alcohol consumption and social sup- chitis, pneumonia, injuries and poi- est in her welfare, rather than the port to the observed effect will be mea- soning.12 Long term deficits in stature smoking reduction per se. sured. This study may shed some light and mental functioning of smokers' It is clear from this study that a suc- to the question of what is the important children have been reported.26 cessful anti-smoking program can im- aspect of lifestyle advice in preg- These adverse effects, however, prove health outcomes during preg- nancy. cannot be attributed solely to smoking. nancy. It is not clear whether the Smokers differ from non-smokers in improvement is sufficient to outweigh many environmental, behavioral and the possible adverse effect of anti- Condusions biological variables. The woman who smoking advice, particularly if that ad- There is considerable doubt about smokes during pregnancy is more vice is not accompanied by the suc- the net value of lifestyle adjustments in

CAN. FAM. PHYSICIAN Vol. 30: OCTOBER 1984 2129 ACTIFED* Tablets/Syrup pregnancy-enough doubt to preclude the year of the child. Courrier 1980; (triprolidine HCI-pseudoephedrine HCI) 30:225-230. Antihistamine-Decongestant vehement exhortations for any particu- 16. Tze WJ, Lee M: Adverse effects of ma- lar adjustment. Women in pregnancy ternal alcohol consumption on pregnancy Indications: The prophylaxis and treatment deserve to be informed of what is and fetal growth in rats. Nature 1975; of symptoms associated with the common known about the possible adverse ef- 257:479480. cold, acute and subacute sinusitis, acute eu- fects poor 17. Newman NM, Correy JF: Effects ofal- stachian salpingitis, serous otitis media with of nutrition, sexual activity, cohol in pregnancy; Clinical review. Med J alcohol and smoking during preg- Aust 1980; 2:5-10. eustachian tube congestion, aerotitis media, They also croup and similar lower respiratory tract dis- nancy. should be allowed to 18. Oullette EM, Rossett HL, Rosman NP, eases, in allergic conditions which respond to share our doubts about the value of at- et al: Adverse effects on offspring ofmater- antihistamines, including hay fever, pollenosis, tempting to change these practices. nal alcohol abuse during pregnancy. N Engl J Med 1977; 297:528-530. allergic and vasomotor rhinitis, allergic . We must be conscious that advice is an 19. Little RE: Moderate alcohol use during intervention in itself, and is potentially Precautions: Use with caution in hyperten- pregnancy and decreased infant birth sive patients and in patients receiving MAO harmful. Should a physician feel con- weight. Am J 1977; inhibitors. Patients should be cautioned not to fident that the three criteria mentioned 67:1154-1156. operate vehicles or hazardous machinery until in our are an 20. Smithells RW: Fetal alcohol syndrome. introduction fulfilled by Dev Med Child Neurol 1979; 21:224-248. their response to the drug has been deter- aspect of advice, then that advice is 21. The Health Consequences of Smoking mined. Since the depressant effects of antihis- warranted. Should the criteria not be tamines are additive to those of other drugs for Women; A Report of the Surgeon Gen- affecting the central nervous system, patients fulfilled, a non-judgmental informa- eral. Washington, DC., Public Health Ser- should be cautioned against drinking alco- tive discussion may leave a pregnant vice, US Dept. of Health Education and Welfare, 1982. holic beverages or taking hypnotics, sedatives, woman in a position to better decide 22. Yerushalmy J: Mother's cigarette psychotherapeutic agents or other drugs with what is best for herself. smoking and survival of infant. Am J Ob- CNS depressant effects during antihistaminic stet Gynecol 1964; 88:505-518. . Rarely, prolonged therapy with anti- 23. Butler NR, Goldstein H, Ross EM: histamines can produce blood dyscrasias. References Cigarette smoking in pregnancy: Its influ- 1. Lumley J, Astbury J: Advice in preg- ence on birth weight and perinatal mortal- Adverse Effects: None serious. Some nancy: Perfect remedies, imperfect ity. Br Med J 1972; 2:127-130. patients may exhibit mild sedation or mild science, in Enkin M, Chalmers I: Effective- 24. Kline J, Stein ZA, Susser M, et al: stimulation. ness and Satisfaction in Antenatal Care. Smoking: A risk factor for spontaneous Philadelphia, J. B. Lippincott Co., 1982, abortion. N Engl J Med 1977; 297:793- Overdose: Symptoms: , , pp 132-150. 796. . 2. Mussey RD: Nutrition and human repro- 25. Meyer MB, Jonas BS, Tonascia JA: duction: An historic review. Am J Obstet Perinatal events associated with maternal Treatment: (1) For antihistaminic action: If Gynecol 1949; 57:1037-1048. smoking during pregnancy. Am J Epide- respiratory depression is severe, intubation 3. Hytten FE: Restriction of weight gain in miol 1976; 103:464-476. and artificial respiration is better than using pregnancy: Is it justified? J Hum Nutr 26. Butler NR, Goldstein H: Smoking in analeptic drugs. Convulsions should be 1979; 33:461-463. pregnancy and subsequent child develop- treated with alcohol sponges or paraldehyde. 4. Rush D: Effect ofchanges in protein and ment. Br Med J 1973; 4:573-575. (2) Pseudoephedrine: Adverse effects due to calorie intake during pregnancy on the 27. Yerushalmy J: The relationship of central action are reversed by the barbitu- growth of the human fetus, in Enkin M, parents' cigaret smoking to outcome of rates. Methamphetamine to maintain blood Chalmers I: Effectiveness and Satisfaction pregnancy-Implications as to the problem pressure. in Antenatal Care. Philadelphia, J. B. Lip- of inferring causation from observed asso- pincott Co., 1982, pp 92-113. ciations. Am J Epidemiol 1971; 93:443- Dosage: Children over 6 years and adults: 5. Hytten FE: Nutrition in pregnancy. 456. 10 mL (2 tsp.) of syrup or 1 tablet 3 times Postgrad Med J 1979; 55:295-302. 28. Rantakallio P: Social background of daily. Children 1-6 years: 1/2 tablet 3 times daily. 6. Polak JO: Manual of Obstetrics. New mothers who smoke during pregnancy and Children 4 months to 6 years: 5 mL (1 tsp.) of York, Physicians and Surgeons Book Co., influence of these factors on the offspring. syrup 3 times daily. Infants up to 4 months: 1928. Soc Sci Med 1979; 13A:423-429. 2.5 mL (½12 tsp.) of syrup 3 times daily. 7. Williams JW: Williams Obstetrics, ed 6. 29. Cardozo LD, Gibb DMF, Studd JWW, New York, NY, Appelton-Century-Crofts, et al: Social and obstetric features asso- Supplied: Tablets: Each white, biconvex 1950. ciated with smoking in pregnancy. Br J tablet 7.4 mm in diameter with code number 8. Eastman NJ (ed): Williams Obstetrics, Obstet Gynecol 1982; 89:622-627. ACTIFED M2A on same side as diagonal score ed 10. New York, NY, Appleton-Century- 30. Rantakallio P: Social background of mark contains triprolidine HCI 2.5 mg and Crofts, 1950. mothers who smoke during pregnancy and pseudoephedrine HCI 60 mg. Available in 9. Eastman NJ, Hellman LM (eds): Wil- influence of these factors on the offspring. packages of 12 and 24 tablets, bottles of 100 liams Obstetrics, ed 12. New York, NY, Soc Sci Med 1979; 13A:423-439. and 500 tablets. Appleton-Century-Crofts, 1961. 31. Donovan JW: Randomized controlled 10. Rayburn WF, Wilson EA: Coital activ- trial of anti-smoking advice in pregnancy. Syrup: Each 5 mL of clear, lemon-yellow syrup ity and premature delivery. Am J Obstet Br J Prev Soc Med 1977; 31:6-12. contains: triprolidine HCI 1.25 mg and pseu- Gynecol 1980; 137:972-974. 32. Sexton M, Hebel R: A clinical trial of doephedrine HCI 30 mg. Available in 100 mL 11. Goodlin RC, Keller DW, Raffin M: Or- change in maternal smoking and its effect and 250 mL bottles. gasm during late pregnancy. Possible dele- on birth weight. JAMA 1984; 251:911- terious effects. Obstet Gynecol 1971; 915. Additional prescribing information available 38:916-920. 33. Graham H: Smoking in pregnancy: The on request. 12. Naeye R:: Coitus and associated am- attitudes of expectant mothers. Soc Sci niotic-fluid infections. N Engl J Med 1979; Med 1977; 10:399-405. *Trade Mark W-1056 301:1198-1200. 34. Sokol RJ, WoolfRB, Rosen MG, et al: |PAAB| 13. Naeye RL, Ross S: Coitus and Risk, antepartum care, and outcome: Im- chorioamnionitis; A prospective study. pact ofa maternity and infant care project. Early Hum Dev 1982; 6.91-97. Obstet Gynecol 1980; 56:150-156. 14. Hellman MN, Pritchard JA: Williams 35. Scott KE: Reduction of LBW with en- Obstetrics, ed 14. New York, NY, Apple- hanced antenatal care. Read before the So- ton-Century-Crofts, 1971. ciety for Pediatric Research, San Fran- 15. Seixus FA: Fetal alcohol syndrome and cisco, CA., 1984. s WELLCOME MEDICAL DIVISION BURROUGHS WELLCOME INC. KIRKLAND, 2130 OUE.

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