Folic Acid Supplementations
Evidence from well conducted trials have shown that Folic Acid Supplementation at periconception period will reduce the risk of having a baby with neural tube defect by 70%. High risk women, such as those who have been previously affected, have a family history, have diabetes or are on anti-epileptic medication, should take 5 mg/day from at least one month before pregnancy till 10 weeks of gestation. For low risk women, the dosage is 0.5 mg/day but most obstetricians recommend the higher dose even for low risk group.

Smoking / Substance Abuse
Anti-smoking interventions are strongly indicated before and during pregnancy. Maternal cigarette smoking is associated with an increased risk of microcephaly (small head), facial clefts and low birth weight. There is a long-term relation between smoking in pregnancy and the intellectual development of the offspring. Partners also need support too, to stop smoking or to at least smoke outside so as not to expose the mother and fetus to the negative effects of passive smoking.

Heavy maternal alcohol consumption (defined as more than 80 gm/day, equivalent to at least ten small glasses of wine or units of alcohol) is associated with a group of fetal problems - the "fetal alcohol syndrome". The effects include fetal growth retardation, central nervous system involvement including intellectual impairment and facial deformities.

It is recommended that women should be careful about alcohol consumption in pregnancy and limit this to no more than one standard drink per day. Heavy alcohol consumers should be referred to specialist treatment to stop alcohol consumption.

Ultrasound in Antenatal Care
Ultrasound scan is very safe for mother, baby and operator. It is now common practice for a woman to have ultrasound scan at booking visit and at 18 - 20 weeks' of gestation for detailed fetal anomaly scan. Ultrasonic examinations is also most useful in the following situations:

1. Vaginal bleeding and abdominal pain in early pregnancy.
2. Confirmation of gestational size - up to 45% of women are uncertain of their last menstrual period
3. Examination fetus when risk of congenital anomaly is high and before invasive procedures like amniocentesis and chorionic villus sampling.
4. To check fetal size and liquor volume when the uterus is small or large for dates
5. Monitoring of fetal growth in high risk pregnancies.

Sport and Exercise in Pregnancy
The one sport clearly contra-indicated is scuba diving, especially beyond 30m. Experiments with pregnant sheeps taken to significant depths have shown serious problems in fetuses of these animals. Sports that require balance and those in which injury could result (e.g. horse riding) should also be avoided.

Physical activity in moderation is acceptable and desirable during pregnancy. Aerobic exercise have been extensively studied and good outcomes / in terms of birth weight and delivery at term, were found among women who were participating in 1 to 4 aerobic sessions a week at 25 weeks' gestation. Swimming is safe for pregnant women.

Sex and Pregnancy
There is no evidence that sex during pregnancy does any harm. Many women reported a heightened libido. There is no proof that frequent intercourse bring on labour. However, in early pregnancy, if abdominal cramps or vaginal bleeding follow coitus, sexual intercourse should be avoided, as there has always been a suspicion that sexual intercourse may be responsible for early miscarriage.

Later in pregnancy, intercourse should be avoided in women with spontaneous ruptures of membranes (leaking liquor) or antepartum haemorrhage (bleeding before onset of labour pains).

Ultrasound examination on a pregnant mother

Hyperemesis (Vomiting)
This is a common problem that is worse with twin pregnancy. Treatment is symptomatic with dietary modification. Avoidance of fatty and highly spiced foods is advised. Intakes of 4 to 6 small meals are preferable. Other treatment methods include Vitamin B6, reassurance and sometimes anti-emetics like metoclopramide. In severe cases, admission to hospital for intravenous hydration is required.

Nutritional Requirements
The general advice is that the diet should contain less fatty meats, sugar and salt and more proteins (meat, fish, cheese), calcium (milk), vegetables, fruits, cereals and fibre. It is important that the pregnant women do not overindulge in her meals.

The more weight she gains during her pregnancy, the more difficult it is for her to lose it after delivery. The average weight gain during the whole pregnancy is 12kg with increments of 0.3 to 0.4kg per week.

Dietary Supplements
Only extremes of diet adversely affect pregnancy outcome. Famine leads to low birth weight and obesity predisposes to large babies and difficult labours. For a woman in good health and of normal weight for height and with a good, well balanced mixed diet, she does not need supplements from other sources of protein, calories, iron and calcium.

Iron supplementation should be guided by the results of screening blood counts at booking and at 28 weeks. If the haemoglobin level is below 11.0g/dl. then iron supplementation is advised. Indeed, harm might be done by increased red blood cell size and blood viscosity that reduces blood flow to the placenta.

Travel in Pregnancy
Patients often ask about travel during pregnancy, most often about aeroplane travel. The main issues are the length of time spent in the air on long distance flights and the (often) exotic destinations, when medical care may be hard to find. The more recent issue is travellers' thrombosis (blood clot) of the "economy class syndrome" which refers to blood clot formation in the legs due to prolonged immobility.

Generally, international flights are fine up to about 32 weeks' gestation and domestic flights fine at any time. However, she should not fly if she has had bleeding in pregnancy or any other complication likely to recur as an emergency.

Studies have suggested that the risk of deep venous Thrombosis (DVT) may be increased two or three folds by long distance flight. The blood clot may get dislodged from the calf veins and ends up in the lungs resulting in pulmonary embolism which is potentially fatal. The incidence of symptomatic venous thrombosis after a long-hour flight ha been estimated as around one in 4,000 - 10,000 and a symptomatic venous thrombosis is about ten times this figure. The risk is mainly due to immobility, although other factors such as low oxygen tension, low humidity, low cabin pressure and excessive consumption of coffee and alcohol also contribute through venous stasis ad dehydration. This thrombosis also occurs in business class and in association with long-distance car, bus and rail travel.

Preventive measures include calf exercise, walking around the aircraft cabin every 2 hours where possible and avoiding dehydration by drinking plenty of water/ juice/ soft drinks and by minimising alcohol and caffeine intake. If the flight is more than 4 hours, wearing of well-fitting elastic below-knee compression stockings is recommended. However, for the pregnant woman with additional risk factors, she is advised to seek her doctor's advice before travelling.

These additional risk factors include body weight of 100kg or more, twin pregnancy, strong family history, medical disorders with increased DVT risk and thrombophilias. In this high risk group, prophylactic anti-thrombotic drugs have been recommended. These include (1) low molecular weight herapin (40mg enoxaparin) on day of travel (preflight) and day after and (2) low dose aspirin, 75mg per day for 3 days before travel and on day of travel.