Folic acid supplements

You should take folic acid tablets (supplements). Ideally, do this from at least one month before you get pregnant, and continue taking them until at least the end of the 12th week of pregnancy - even if you are healthy and have a good diet. Folic acid is a vitamin which occurs naturally in certain foods. However, you need a good supply of folic acid when you are pregnant to help with the development of the baby. If you take folic acid tablets in early pregnancy you reduce the risk of having a baby born with a spinal cord problem such as spina bifida. There is evidence that folic acid also reduces the risk of having a baby born with a cleft lip and palate, a heart defect (congenital heart disease), and the risk of a premature (preterm or early) labour.

You can buy folic acid tablets from pharmacies. Also, the NHS Healthy Start scheme provides vitamin supplements that contain folic acid. These are free to many women who are on certain benefits - see: www.healthystart.nhs.uk

• For most women, the dose is 400 micrograms (0.4 mg) a day.
• If you have an increased risk of having a child with a spinal cord problem then the dose is 5 mg a day - you need a prescription for this higher dose. That is, if:
  • You have had a previously affected pregnancy.
  • You or your partner have a spinal cord defect.
  • You are taking medication for epilepsy.
  • You are obese - especially if your Body Mass Index (BMI) is 30 or more.
  • You have coeliac disease, diabetes, sickle cell anaemia, or thalassaemia.

When is the best time to start taking folic acid tablets?

Ideally, start taking folic acid tablets before becoming pregnant. The common advice is to start from the time you plan to become pregnant. If the pregnancy is unplanned then start taking folic acid tablets as soon as you know that you are pregnant. However, a recent study looked at the effect of taking folic acid for a year prior to becoming pregnant. This study looked at the effect folic acid had on reducing preterm labour and delivery of the baby (that is, of having a 'prem' baby). The study found a significant decrease in the rate of preterm delivery for women who took folic acid for one year prior to becoming pregnant. So, you may wish to consider taking folic acid tablets well before you plan to become pregnant.

Because of the substantial benefits of folic acid, some countries routinely fortify staple foods such as wheat, cornflour, or rice with folic acid. Currently there is debate as to whether the UK should follow suit and fortify certain common foods with folic acid. (See References at the end for details of this debate.)

Vitamin D supplements

Vitamin D is needed for growth. Vitamin D supplements are recommended for all pregnant women, breast-feeding women and breast-fed babies. The dose if you are pregnant or breast-feeding is 400 units (10 micrograms) daily. This can be either as a calcium/vitamin D tablet, or as a multivitamin tablet labelled as suitable for use in pregnancy. Some experts think that women who get little or no sunshine on their skin need a higher dose, such as 800 units (20 micrograms) daily. This is because, although there is a small amount of vitamin D in some foods, most of the vitamin D that we get is made in the skin with the help of sunlight. Your doctor will advise you. Pregnant women can get free prescriptions and vitamins.

Alcohol

Advice from the Department of Health is that you should not drink at all if you are pregnant or trying to become pregnant. It is known that if you drink heavily you have an increased risk of miscarriage, and it can cause serious harm to the baby's growth and brain development. A condition called fetal alcohol syndrome develops in some babies born to mothers who drink heavily. A baby with this syndrome can have severe physical and mental problems.

However, the exact amount of alcohol that is safe during pregnancy is not known. This is why the advice is not to drink at all. If you do chose to drink when pregnant then limit it to one or two units, once or twice a week. And never binge drink or get drunk. If you find it difficult to cut down or stop drinking alcohol, then seek help from your GP.

Smoking

If you smoke, you are strongly advised to stop before getting pregnant. Tobacco smoke contains poisonous chemicals which pass into the baby's blood and can slow the baby's growth. The risk of having a miscarriage, premature birth, or stillbirth are higher if you smoke. Babies born to mothers who smoked when pregnant also have an increased risk of developing behavioural problems and attention deficit hyperactivity disorder (ADHD) when they are older. Also, after the birth, children of smoking parents have an increased risk of having chest infections, asthma, glue ear, and sudden infant death syndrome (cot death).

For many women who smoke, planning to become pregnant is a good incentive to stop smoking. It is often a good time to persuade partners to give up too. If you find it difficult to stop smoking then seek advice and help from your practice nurse, GP, or pharmacist.

Street (illicit) drugs

If you take or inject street drugs, you are strongly advised to stop before getting pregnant. Their effects on pregnancy are not fully known. However, there is an increasing amount of evidence to suggest that they are likely to pose a risk of damage to the baby. If you cannot come off drugs easily, see your doctor for help. For example, an option if you inject heroin is to take prescribed methadone instead which is probably safer during pregnancy. A blood test for hepatitis C, hepatitis B, and HIV is advised if you take illicit drugs and plan to become pregnant, or are pregnant.

Overweight and obesity

If you are obese or overweight, try to lose some weight before becoming pregnant. Women who are overweight or obese have a greater risk of pregnancy complications such as pre-eclampsia, stillbirth and the need for a Caesarean section compared with women who are not overweight. Basically, the more obese you are, the greater the risk.

Food and diet

Eat a healthy balanced diet

Aim to eat a healthy diet (which everyone should be eating, not just pregnant women). Briefly, the bulk of most meals should be starch-based foods (such as bread, cereals, potatoes, rice, and pasta), with fruit and vegetables. Eat protein foods such as meat, fish, pulses, chicken, etc, in moderation.

Don't 'eat for two' by over-eating when you become pregnant. Too much weight gain increases your risk of developing problems later in the pregnancy. Also, extra weight is difficult to lose after the birth. According to the World Health Organization, for women with a normal pre-pregnancy weight, a weight gain of 10-14 kg over the pregnancy is associated with the lowest risk of pregnancy complications.

Include foods with plenty of iron, calcium and folic acid

A growing baby needs these nutrients right from the start of the pregnancy.

• Iron is mainly in red meat, pulses, dried fruit, green vegetables and fortified cereals.
• Calcium is mainly in dairy products such as milk, cheese, and yoghurt. (Low-fat milk, cheeses and yoghurts usually contain just as much calcium as the full-fat varieties.)
• Folic acid is mainly in green vegetables, brown rice, and fortified cereals.

What about supplements?

As mentioned, folic acid and vitamin D supplements are recommended for all pregnant women. Otherwise, apart from possibly iodine (see below) no other supplements are routinely advised if you have a normal diet. However, some women have low iron stores which puts them at risk of becoming anaemic during pregnancy. The routine blood tests that are done during pregnancy will detect anaemia and the need for iron supplements.

Iodine - a research study published in 2011 concluded that it is likely that many young women in the UK do not get enough iodine in their diet and are lacking in iodine. Iodine mainly comes from milk, yogurt, eggs and fish. Because iodine intake can be variable, some countries routinely fortify cereals and bread with iodine - but not the UK. Iodine is essential for the brain development of a baby in the womb. The author's concern is that many pregnant women will be lacking in iodine. This may cause their baby to have reduced brain development and be less intelligent than they would otherwise have been. Further research is needed in this area. But, in the meantime, you may wish to consider your diet - does it have enough iodine? And, if not, perhaps talk to your doctor about taking an iodine supplement. A link to the NHS Analysis on this study is given at the end.

What about fish?

In general, fish is a good source of protein and other nutrients. Aim to eat at least two portions of fish per week, with at least one portion being oily fish (see below). However, there are some important exceptions.

Some types of fish contain a high level of mercury which can damage the developing nervous system of an unborn baby. Because of this, the Food Standards Agency (FSA) advises:

• You should not eat any shark, marlin, or swordfish.
• Limit tuna. You should eat no more than four medium-sized cans (drained weight = 140 g per can), or two fresh tuna steaks per week (weighing about 140 g cooked or 170 g raw).

Also, do not eat raw fish or uncooked shellfish (which may contain bacteria, viruses or parasites).

Also, some types of fish may contain a small amount of dangerous chemicals from pollution, including dioxins and polychlorinated biphenyls (PCBs). If you eat a lot of these fish, these chemicals may build up in your body over time, which may be harmful. Because of this, the FSA advises that you should have no more than two portions a week of any of the following fish:

• Oily fish, including mackerel, sardines, salmon, trout and fresh tuna. (Tinned tuna doesn't count as oily fish.)
• Sea bream, sea bass, turbot, halibut, rock salmon (also known as dogfish, flake, huss, rigg or rock eel).
• Brown crabmeat.

However, the advice above (from the FSA) is controversial. Some experts think the advice to eat no more than two portions of oily fish per week during pregnancy is too restrictive, and may even be detrimental to a developing baby. For example, one study found that children of mothers who had eaten a reasonable amount of oily fish during pregnancy had, on average, better communication and social skills at age seven. Oily fish are rich in nutrients called omega-3 fatty acids. It is thought that omega-3 fatty acids are important to aid brain development and may be the reason for the results of this study.

Therefore, some experts argue that the concern over toxic chemicals in fish is over-cautious and that the benefits of eating three or more portions of oily fish per week outweigh other risks. Further research may help to clarify this.

Foods and drinks to avoid

You should not eat the following if you are pregnant or trying to become pregnant:

• Anything with a lot of vitamin A. You need a small amount of vitamin A to keep healthy. However, large amounts can harm an unborn baby. So, avoid:
  • Liver and liver products such as liver paté and cod liver oil supplements.
  • Vitamin tablets or supplements which contain vitamin A.
• Food which may have high levels of listeria. This bacterium (germ) does not usually cause problems in people who are not pregnant. However, pregnant women are more likely to become infected with listeria, and it sometimes causes miscarriage, stillbirth, or infections in the baby after birth. Foods which are most at risk of carrying listeria are:
  • Undercooked meats and eggs. This may occur in some pre-cooked meats and pre-prepared meals. Make sure all meat foods are cooked until piping hot. Eggs should be cooked until the white and yolk are solid. Avoid foods that may contain raw eggs, such as some types of mayonnaise and mousse.
  • Mould-ripened and soft cheeses such as brie, Camembert and blue-veined cheeses. (Hard cheeses and processed cottage cheese are safe.)
  • Patés - including vegetable patés.
  • Raw shellfish and raw fish.
  • Unpasteurised milk. Note: goat's milk is often unpasteurised, and goat's milk products such as cheeses are often made from unpasteurised milk.
• Certain fish (as described earlier).
• Limit the amount of caffeine to no more than 200 mg per day. Having a lot of caffeine increases your risk of having a miscarriage and a baby with low birthweight. The main sources of caffeine are coffee, tea, chocolate, and cola. It is also added to some energy drinks and to some cough and cold remedies. As a rough guide:
  • One mug of instant coffee has about 100 mg caffeine.
  • One mug of brewed coffee has about 140 mg caffeine.
  • One mug of tea has about 75 mg caffeine.
  • One 50 g plain chocolate bar has about 50 mg caffeine. Milk chocolate has about half the caffeine that plain chocolate has.
  • One can of cola or half a can of an energy drink has up to 40 mg caffeine.
• Liquorice may be important to avoid. A research study published in 2009 found that women who ate a lot of liquorice (which is common in some countries) were more likely to have children with lower intelligence levels and more behavioural problems. Further research is needed to clarify this issue.

A note about peanuts: until recently, the FSA advised that you may wish to avoid eating peanuts when you are pregnant if you have an atopic disease such as asthma, eczema, or hay fever, or if a close family member has one of these conditions. This was because there was a concern that children could develop a peanut allergy as a result of their mother eating peanuts during pregnancy. However, in light of new evidence, this advice was changed in December 2008. The FSA now advises that there is no need for women who are pregnant or breast-feeding, or who have children aged under three, to change their diets to exclude peanuts.

Animals

Avoid contact with sheep and lambs at lambing time. This is because some lambs are born carrying the germs that cause listeriosis, toxoplasmosis and chlamydia. These may be passed on to you and your unborn baby. See below about cats and kittens.

Medication

The effects of some prescribed drugs have been well studied and it is known that certain drugs are safe in pregnancy. For example, paracetamol at normal dose is safe and useful for headaches, backache and other aches and pains that may occur during pregnancy. However, some drugs are not safe, and may be harmful to a developing baby. In particular, if you take them in the early weeks of pregnancy.

Therefore, always tell a doctor or dentist who prescribes medication for you that you are pregnant, or intend to become pregnant. Also, don't take drugs that you can buy over the counter (including herbal remedies) unless they are known to be safe in pregnancy. The pharmacist will advise.

If you already take regular medication (for example, for epilepsy), it is important to discuss this with a doctor before becoming pregnant. If you have an unplanned pregnancy, discuss with your doctor as soon as possible any medication that you take.

Infections

Rubella (German measles)

If you plan to become pregnant for the first time, you should check that you are immune to rubella before becoming pregnant. See your practice nurse for a pre-pregnancy blood test. Most women are immune to rubella, as they have been immunised as a child. However, childhood immunisation does not work in every child and you may not be immune. If you are not immune, you can be immunised.

Note: you should not become pregnant for one month after the injection, and ideally until your immunity has been confirmed by a further blood test.

The rubella virus causes a mild illness, but can seriously damage an unborn baby, especially in the early stages of growth. So, until you know that you are immune (from the result of the blood test), you should avoid anyone who has rubella, especially in the first 16 weeks of pregnancy.

Toxoplasmosis

This germ is commonly found in raw meat, and sheep, lamb and cat faeces. It can sometimes cause serious harm to an unborn baby. To avoid it:

• Wash your hands after handling raw meat.
• Do not eat raw or undercooked (rare) meat.
• Wash salads and vegetables, as any dirt may have been contaminated by cat faeces.
• Wash your hands after handling pets or animals, especially cats and kittens.
• Get someone else to clean out any cat litter trays when you are pregnant.
• Always wear gloves when gardening.
• Avoid sheep, especially during the lambing season.

Food poisoning

Various bacteria and other germs can cause food poisoning - that is, a gut infection caused by eating food contaminated by germs. Two germs that are of particular importance to avoid during pregnancy have already been mentioned - listeria and toxoplasmosis. It is possible that other food poisoning bacteria may also cause complications during pregnancy. For example, gut infection with bacteria called salmonella and campylobacter may be associated with an increased risk of pregnancy complications. So, it is wise to be extra vigilant about avoiding food poisoning.

Therefore, be strict about food hygiene, always cook eggs, meat and poultry thoroughly, wash fruit and vegetables, and wash hands after going to the toilet, before handling food, before eating, and after handling raw meat or animals.

Chickenpox

Having chickenpox when pregnant can be a nasty illness, and there is some risk to the developing baby. A vaccine is offered to healthcare workers (doctors, nurses, etc) who have not previously had chickenpox and so are not immune and may catch chickenpox. (About 1 in 10 adults has not had chickenpox as a child.) Therefore, non-immune healthcare workers should consider having this vaccination before getting pregnant.

If you are not sure if you have had chickenpox, a blood test can check if you have previously had it.

Hepatitis B

A mother who is infected with hepatitis B has a high risk of passing it on to her newborn baby. If you are at high risk of catching hepatitis B you should be immunised against this virus before becoming pregnant. People at increased risk and who should be immunised include:

• Those whose job puts them at risk of contracting hepatitis B. For example, healthcare personnel and staff at daycare or residential centres.
• Those who inject street drugs.
• Those who change sexual partners frequently.
• Those who live in close contact with someone infected with hepatitis B.

Screening blood tests

Ideally, you should have a blood test before you become pregnant, to screen for hepatitis B, syphilis, and HIV. Ask your practice nurse for a pre-pregnancy blood test.

Consider your working environment

If you think that your job may pose a risk to a pregnancy, then ideally you should discuss this with your employer before becoming pregnant. For example, if you work with chemicals, fumes, solvents, etc, which may pose a risk, or if you work with animals such as cats or sheep which may be carrying germs (see above). You may wish to download information guides from the Health and Safety Executive website at www.hse.gov.uk

You may not wish to discuss your intention to become pregnant with your employer, but have a health and safety concern at work. One option then is to contact the Health and Safety Executive for advice on their Infoline - Tel 0845 345 0055.

Medical conditions

Women with certain medical conditions may benefit from advice before becoming pregnant. See your doctor if you have concerns about a medical condition which may affect pregnancy. For example:

• For some conditions, the medication or treatment may possibly affect the pregnancy or the unborn child. For example, epilepsy.
• For some conditions, the condition itself may require special attention during the pregnancy. For example, diabetes.
• If a hereditary condition runs in your family, you may benefit from genetic counselling.

If in doubt about any medical condition that you have or treatment that you take with regard to their effect on pregnancy, then see your doctor. Ideally, do this before you become pregnant. Or, if the pregnancy is unplanned, as soon as possible.

Screening tests

From October 2008, all pregnant women in England have been offered a screening test for sickle cell disease and thalassaemia. This is part of routine antenatal care. This is done by a blood test, together with a questionnaire about your family origins. Sickle cell disease and thalassaemia are blood diseases. Some people are carriers of the genes for these diseases but do not actually have the disease itself. If two carriers have a baby, then there is a risk that the baby will be born with the disease. Some women may wish to have the screening test before becoming pregnant, especially if their family origins make these diseases more likely. See your doctor to discuss this.

Genetic testing is a rapidly developing area of medicine. It may be possible that more tests will become available to detect carriers of various diseases. When they become available, these may be tests to consider before becoming pregnant.

Summary and checklist

Most pregnancies go well and without any major problems. But, it is wise to reduce any risks as much as possible. So, a reminder of things to consider before becoming pregnant, and as soon as you realise that you are pregnant ...

• Things you should do:
  • Take folic acid tablets before you get pregnant until 12 weeks of pregnancy.
  • Take vitamin D supplements when you become pregnant.
  • Have a blood test to check if you are immune against rubella, and to screen for hepatitis B, syphilis, and HIV. Ask your practice nurse to do this.
  • Eat a healthy diet. Include foods rich in iron, calcium and folic acid. Also, some oily fish.
  • Have strict food hygiene. In particular, wash your hands after handling raw meat, or handling cats and kittens, and before you prepare food.
  • Wear gloves when you are gardening.
• Things you should avoid:
  • Too much vitamin A - don't eat liver or liver products, or take vitamin A supplements.
  • Listeriosis - don't eat undercooked meat or eggs, soft cheese, paté, shellfish, raw fish, or unpasteurised milk.
  • Fish which may contain a lot of mercury - shark, marlin, swordfish, or excess tuna.
  • Sheep, lambs, cat faeces, cat litters, and raw meat which may carry certain infections.
• Things you should stop or cut down:
  • Caffeine in tea, coffee, cola, etc - have no more than 200 mg per day. For example, this is in about two mugs of instant coffee, or one mug of brewed coffee and a 50 g bar of plain chocolate, or two and a half mugs of tea.
  • Alcohol - you are strongly advised not to drink at all.
  • Smoking - you are strongly advised to stop completely.
  • Street drugs - you are strongly advised to stop completely.
  • Liquorice - reduce your intake if you eat lots of it.
• Other things to consider:
  • Your iodine intake and perhaps discuss with your doctor about iodine supplements.
  • Immunisation against hepatitis B if you are at increased risk of getting this infection.
  • Immunisation against chickenpox if you are a healthcare worker and have not previously had chickenpox and so are not immune.
  • Your medication - including herbal and 'over-the-counter' medicines. Are they safe?
  • Your work environment - is it safe?
  • Medical conditions in yourself, or conditions which run in your family.
  • Screening tests for sickle cell and thalassaemia.

Further information

Go Folic!

Encourages women to take folic acid before getting pregnant.
Web: www.gofolic.co.uk

National Childbirth Trust

Information on pre-pregnancy care and health of pregnant women.
Tel: 0300 330 0772 Web: www.nct.org.uk

The Pregnancy Book from the Department of Health

Go to their website - www.dh.gov.uk - and search for 'Pregnancy Book'.

Department of Health - Nutrition for pregnancy and the early years

Web: www.dh.gov.uk/en/Publichealth/Nutrition/Nutritionpregnancyearlyyears/index.htm

Food Standards Agency - Eating While you are Pregnant

Web: www.food.gov.uk/multimedia/pdfs/publication/eatingwhilepregnant1209.pdf
and their revised advise on peanuts.
Web: www.food.gov.uk/news/newsarchive/2008/dec/peanut08

FPA

Have a leaflet called 'Planning a Pregnancy'.
Web: www.fpa.org.uk/helpandadvice/planningapregnancy

NHS Sickle Cell & Thalassaemia Screening Programme

Web: http://sct.screening.nhs.uk

NHS - Behind the Headlines

Web: http://news.patient.co.uk/newspaper.asp?ss=15&id=15362
The NHS Analysis on the concern about iodine deficiency in UK women.

References

• Antenatal care: routine care for the healthy pregnant woman, NICE Clinical Guideline (March 2008)
• Langley K, Rice F, van den Bree MB, et al; Maternal smoking during pregnancy as an environmental risk factor for attention deficit hyperactivity disorder behaviour. A review. Minerva Pediatr. 2005 Dec;57(6):359-71. [abstract]
• Hutchinson J, Pickett KE, Green J, et al; Smoking in pregnancy and disruptive behaviour in 3-year-old boys and girls: an J Epidemiol Community Health. 2010 Jan;64(1):82-8. Epub . [abstract]
• No authors listed; Maternal caffeine intake during pregnancy and risk of fetal growth restriction: a large prospective observational study. BMJ. 2008 Nov 3;337:a2332. doi: 10.1136/bmj.a2332. [abstract]
• Weng X, Odouli R, Li DK; Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study. Am J Obstet Gynecol. 2008 Mar;198(3):279.e1-8. Epub 2008 Jan 25. [abstract]
• Hibbeln JR, Davis JM, Steer C, et al; Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study. Lancet. 2007 Feb 17;369(9561):578-85. [abstract]
• Preconceptional folate prevents preterm delivery - A report on proceedings from Society of Maternal-Fetal Medicine annual meeting 2008
• Bille C, Murray JC, Olsen SF; Folic acid and birth malformations. BMJ. 2007 Mar 3;334(7591):433-4.
• Alcohol consumption and the outcomes of pregnancy, Royal College of Obstetricians and Gynaecologists (2006)
• Ionescu-Ittu R, Marelli AJ, Mackie AS, et al; Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada. BMJ. 2009 May 12;338:b1673. doi: 10.1136/bmj.b1673. [abstract]
• Gardiner HM, Fouron JC; Folic acid fortification and congenital heart disease. BMJ. 2009 May 12;338:b1144. doi: 10.1136/bmj.b1144.
• Wald NJ, Oakley GP; Should folic acid fortification be mandatory? Yes. BMJ. 2007 Jun 16;334(7606):1252.
• Hubner RA, Houlston RD, Muir KR; Should folic acid fortification be mandatory? No. BMJ. 2007 Jun 16;334(7606):1253.
• Maternal Anthropometry and Pregnancy Outcomes, WHO Bulletin Supplement, Vol 73, 1995, World Health Organization
• Raikkonen K, Pesonen AK, Heinonen K, et al; Maternal licorice consumption and detrimental cognitive and psychiatric outcomes Am J Epidemiol. 2009 Nov 1;170(9):1137-46. Epub 2009 Oct 4. [abstract]
• Vanderpump MP, Lazarus JH, Smyth PP, et al; Iodine status of UK schoolgirls: a cross-sectional survey. Lancet. 2011 Jun 11;377(9782):2007-12. Epub 2011 Jun 2. [abstract]
• Management of women with obesity in pregnancy, Royal College of Obstetricians and Gynaecologists and Centre for Maternal and Child Enquiries (March 2010)