Legacy Obstetrics and Gynecology

Pregnancy Information

Congratulations on your pregnancy! We appreciate your confidence in us for your prenatal care. We want you to have a comfortable pregnancy free of complications, easy labor and delivery, and a healthy mother and baby when all is over. The majority of our patients achieve such an outcome. Please be aware that complications can occur, and bad things can happen to good people. The goals of prenatal care are to prevent complications whenever possible, identify complications if they develop, and manage them to minimize their effect on you and your baby. You can help achieve these goals by keeping to your scheduled appointments, avoiding unsafe substances or activities, and following your doctors’ recommendations.

***This is a group practice made up of three providers, both male and female. Your prenatal visits will be scheduled with ALL providers to develop a professional relationship with all healthcare providers. We do have call coverage by a few other physicians for some weekends and holidays. Expect to be delivered at Corewell Health- Dearborn.

The frequency of your prenatal visits will depend on how far along you are in the pregnancy and your conditions. A pelvic examination is not performed at every visit unless your condition mandates it. You will have the opportunity to ask any questions during each visit, and you will also be asked questions about how you are doing. You will receive recommendations and instructions regarding your care and are expected to follow them.

EXPECTANT MOTHER

Most women tolerate pregnancy very well. In general, a pregnant woman should be able to continue to attend school and/or work up until the onset of labor. Your activities may have to be modified if medically necessary. Please be aware that maternity leave starts once you deliver. If you choose to stop working early, this is your choice if there is not a medical reason to be off of work. You are responsible for all of your paperwork for your employer, there is a charge for initial request of paperwork completion and may be a charge if multiple updates or copies are needed. Maternal death is extremely rare but can still occur in a mother with a serious preexisting condition, or from rare obstetrical complications. In some instances, your care may be transferred to a High-Risk service. During delivery, you may run the risk of injury to your vagina, cervix, rectum or bladder. You may require a cesarean delivery or a forceps- or vacuums-assisted delivery. A blood transfusion may be needed, with the risks of HIV and Hepatitis being very low. Please inform us if you have religious, cultural, or any other objections to receiving blood or blood products.

FETUS

Babies are the healthiest if they are born full term and appropriately grown, and not exposed to dangerous substances such as cigarette smoking, alcohol, THC, and street drugs. Warning signs of pregnancy are spotting, bleeding, cramping, intermittent backache, leaking of fluid, or pelvic pressure. If you develop any of these symptoms, call the office or answering service. The on-call physician will direct you what to do. If you do not reach us within 30 minutes, please proceed immediately to the Emergency Room. In the latter part of pregnancy, decreased or absent fetal movements need immediate attention. Callus or go directly to the emergency room. Do not wait for your next appointment. Miscarriage (a loss of pregnancy in the first 20 weeks) is common, especially in the first 12-14 weeks, and is a part of the usual pregnancy risk. If this does occur, we will assist you in taking the appropriate steps in getting you through it. Pregnancy loss during the second half of pregnancy is about 1-2%. The majority of these are believed to be the result of umbilical cord accidents and premature placental detachments or tears. Often, the cause of pregnancy loss cannot be determined. The risk of birth defects is less than 4% in the general population. The majority of them are minor and can be corrected. Some can be detected prior to birth, but some cannot be detected at all. Therefore, a normal ultrasound cannot guarantee the absence of a birth defect. You can expect 1-3 ultrasounds during your prenatal care.
The purpose of these paragraphs is not to frighten you, but to introduce you to some of the things you can expect during your prenatal care and that sometimes complications can occur. I have read and understood the above information and have had the opportunity to have my questions answered. I realize the practice of obstetrics is not an exact science and that no guarantees have been made. I understand that my choices can have an impact on the outcome of this pregnancy and my care.
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Prenatal Questionnaire

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Please help us get to know you better and identify any areas of concern regarding your pregnancy. Check the appropriate answer, to the best of your knowledge.
1. Have you ever been pregnant before?
2. Will you be 35 years old, or older, when the baby is due?
3. Do you, or father of the baby, or any relatives have a genetic condition?
a. Neural tube defect (ex. Spina bifida, anencephaly, etc.)
b. Down syndrome
c. Cystic fibrosis
d. Spinal Muscular Atrophy
e. Other chromosomal abnormalities
4. Do any birth defects run in your family or the father of the baby?
5. Does mental disability run in your family or father of the baby?
6. Do you have a history of previous miscarriages or still births?
7. Have you or the baby’s father been screened for Sickle Cell trait?
a. Mother screened?
Results
b. Father screened?
Results
9. Have you or the baby’s father been screened for Tay Sachs disease?
a. Mother screened?
Results
b. Father screened?
Results
8. Have you or the baby’s father been screened for Tay Sachs disease?
a. Mother screened?
Results
b. Father screened?
Results
11. Do you smoke cigarettes/hookah/vape/other?
12. Do you drink alcoholic beverages?
13. Do you use any recreational/illicit drugs or substances?
14. Are you employed/homemaker/disabled?
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CONSENT TO OBTAIN A SPECIMEN FOR GENETIC TESTING

Name
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The intended purpose is:
*Carrier status (Cystic Fibrosis)
* Spinal Muscular Atrophy (SMA)

1. I have been informed about the nature and purpose of this genetic test.
2. I have received an explanation of the effectiveness and limitations of this genetic test.
3. I have discussed the benefits and risks of this genetic test with my provider. I understand some genetic tests can involve possible medical, psychological or insurance issues for my family and me.
4. I understand the meaning of possible test results and have been informed how I will receive the result.
5. I have been informed that genetic testing can sometimes reveal secondary finding-results that are not related to the purpose of testing. I have discussed with my provider if and/or how such results will be shared with me. I understand that it is up to me to decide whether I want secondary results reported back to me and what secondary results I want reported.
6. I have been informed who may have access to my biological sample, and that any leftover samples may be retained by the laboratory.
7. I have been informed who may have access to my genetic test result, which is part of my confidential medical record.
8. My questions have been answered to my satisfaction.
9. I understand that this consent form is intended to be used together with the patient information booklet that contains important information explaining the above eight items. I have read both this consent form and the booklet. I receive d a copy of the form and booklet for my records.

I consent to have a sample taken for genetic testing on the above-named patient for the condition(s) listed above:
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Check one
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This consent form was developed by the Michigan Department of Health and Human Services in compliance with PA 29 of 2000 and must be distributed with “Informed Consent for Genetic Testing” patient booklet. Neither may be altered or deleted to change the meaning of specific statements above or the consent of the informed consent process.

MICHIGAN DEPARTMENT OF COMMUNITY HEALTH CONSENT FORM FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV) ANTIBODY TEST

I have been informed that my blood obtained from a finger stick or vein, a urine sample, or an oral sample from my mouth, will be tested for antibodies to the Human Immunodeficiency Virus, the virus that causes AIDS. I acknowledge that I have been given an explanation of the test, including its uses, benefits, limitations and the meaning of test results. I have been informed that the HIV test results are confidential and shall not be released without my written permission, except to: _JURE GRAHOVAC MD PC *and as permitted under state law. I understand that I have a right to have this test done without the use of my name. If my private physician does not provide anonymous testing, I understand that I may obtain anonymous testing at any Michigan Department of Community Health-approved HIV counseling and testing site. I understand that have the right to withdraw my consent for the test at any time before the test is complete. I acknowledge that I have been given a copy of the pamphlet, “What You Need to Know about HIV testing.: I have been given the opportunity to ask questions concerning the test for HIV antibodies, and I acknowledge that my questions have been answered to my satisfaction.

By my signature below, I consent to be tested for HIV.
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AT THIS TIME, I DO NOT WANT TO BE TESTED FOR THE HUMAN IMMUNODEFICIENCY VIRUS

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* Please write in the physician or health facility name who will receive the HIV test results

HIV and Pregnancy

Why should I be tested for HIV during pregnancy?
If you are pregnant and have HIV, the virus can be passed to your fetus. Getting treatment during pregnancy and treating the baby after birth can greatly reduce the risk of this happening. Getting treatment during pregnancy can also help you stay healthy.
When should I be tested for HIV during pregnancy?
If you are pregnant, you should have a routine test for HIV during your first prenatal care visit. If you are at an increased risk of HIV infection, you should be retested in the third trimester of pregnancy, ideally before 36 weeks of pregnancy. You are at increased risk if you have any of the following risk factors:
  • Have had a diagnosis of another sexually transmitted infection (STI) in the past year
  • Inject drugs or have a sex partner who injects drugs
  • Exchange sex for money or drugs
  • Have a new sex partner or more than one sex partner during this pregnancy
  • Have a sex partner who is HIV positive or at high risk of being HIV positive

You should also be retested in the third trimester if you have signs and symptoms of an HIV infection, including:
  • Fever
  • Swollen lymph nodes
  • Skin rash
  • Muscle or joint pain
  • Headache
  • Mouth ulcers (canker sores)
  • Problems with your blood cells or liver

Retesting may also be recommended if you:
  • Are in jail or prison
  • Live or receive health care in an area that has a high number of people who are HIV positive
    •
    What should I do if I’m pregnant and have HIV? If you have HIV, the following steps can help prevent passing the virus to your fetus:
    • Take anti-HIV medications during your pregnancy as prescribed.
    • Have a cesarean birth if lab tests show that your level of HIV is high.
    • Take anti-HIV medications during labor and delivery as needed.
    • Give an anti-HIV medication to your baby after birth.
    • Do not breastfeed.

    By following these guidelines, 99 percent of people with HIV will not pass HIV to their babies.

    Obtained from: https://www.acog.org/womens-health/faqs/testing-for-hiv
    Learn more about pregnancy, labor, birth and after birth at:

    https://www.beaumont.org/services/womens-services/maternity

    • Watch free labor and support videos
    • Breastfeeding information and support
    • Breathing techniques for labor and birth
    • Develop your birth plan
    • Guided imagery during labor and delivery including a free relaxation download
    • How Beaumont is preparing for your safety during labor and delivery
    • Sleep strategies for new parents
    Pregnancy

    Some of your decisions before and during childbirth may affect your risk of cesarean. These decisions are best made in collaboration with your provider during your prenatal visits, well in advance of labor beginning. Here are some common decision points:

    • Whether to wait for labor to begin on its own (induction of labor may increase your risk of cesarean)
    • Whether to be admitted to the hospital in early labor or to wait until active labor (being admitted in active labor improves your chances of having a vaginal birth)
    • How to monitor your baby's heart rate during labor (low-risk women who are continuously monitored may be more likely to have a cesarean)
    • Whether to have continuous labor support by a trained caregiver like a doula (continuous labor support improves your chance of having a vaginal birth)
    • How to help manage labor pain and labor progress.
    • How to stay hydrated and maintain strength during labor.
    • Whether to remain mobile and upright during labor
    • How to push around the time of birth
    • What practices to engage in shortly after your baby is born and before you go home
    Labor & Birth
    • Understanding birth
    • Natural birth class
    • Hypnobirthing class
    • Cesarean birth class
    After Pregnancy
    • Understanding your newborn class
    • Understanding breastfeeding class
    • Understanding and supporting the postpartum parent class
    • Baby care and safety class
    Beaumont Podcasts
    • The fourth trimester episode
    • Safe care: the labor and delivery episode
    Infant Care and Development Postpartum Adjustment and Mood Disorders Breastfeeding Support Services Postpartum Adjustment and Support
    • Beaumont Parenting Education and Support (248) 551-4232
      Email: parentingeducationandsupport@beaumont.org
    • Beaumont Virtual Postpartum Adjustment Support Group Classes.beaumont.org
    • Postpartum Support International Virtual Support postpartum.net
      Offers specialized online support groups for: Mood support, Dads, Spanish-speakers, South-Asian moms, Black moms, NICU parents, Birth moms, Military moms, Queer Parents, Pregnancy and Infant Loss, Fertility Challenges, Termination for Medical Reasons and Postpartum Psychosis.
    • Postpartum Support International HelpLine (800) 944-4773
    • Postpartum Dads Postpartummen.com / postpartumdads.org
    Pregnancy Lab Tests

    Several tests are required during each pregnancy. Below is a list of recommended tests that you should have throughout the pregnancy. Some tests may be repeated as necessary. Some tests may be required that are specific to each pregnancy. Optional tests are listed as well.

    First Trimester

    • Blood type, antibody screen
    • Complete blood count
    • Rubella titer
    • Syphilis
    • HIV
    • Hepatitis B & C
    • Genetic testing/Carrier screening (if necessary)
    • Blood sugar (if necessary)
    • Urine drug screen
    • Urine culture
    • Vaginal/cervical culture (gonorrhea, chlamydia)

    Second Trimester

    • Genetic testing (if necessary/optional)
    • Blood sugar

    Third Trimester

    • Complete blood count
    • HIV, Syphilis
    • Vaginal/cervical culture (GBS, gonorrhea, chlamydia)
    • Genetic testing/Carrier screening (if necessary)

    Vaccination Recommendations

    Various vaccinations are recommended during pregnancy depending on the time of year, gestational age and those with at risk pregnancies.

    • Covid-19
    • Tdap (Whooping cough)
    • Influenza
    • RSV

    Other vaccines: Hepatitis B, Hepatitis A, vaccines for travel

    Also see the following recommendations:
    https://www.cdc.gov/vaccines/pregnancy/vacc-safety.html
    https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2022/10/maternal-immunization

    *Please see the immunizations handout in your OB folder.

    Weight in Pregnancy, Week by Week

    Concerned about pregnancy and obesity? Understand the risks of obesity during pregnancy plus steps to promote a healthy pregnancy. By Mayo Clinic Staff

    Having a high body mass index (BMI) during pregnancy can have a major impact on your health and your baby's health. Find out about the possible complications, recommendations for weight gain and what you can do to promote a healthy pregnancy.

    Obesity is diagnosed when a person's BMI is 30 or higher. To determine your BMI, divide your weight in pounds by your height in inches squared and multiply by 703. Or divide your weight in kilograms by your height in meters squared.

    BMIWeight status
    Below 18.5Underweight
    18.5 – 24.9Standard range
    25.0 – 29.9Overweight
    30.0 and higherObesity

    Source: Centers for Disease Control and Prevention

    Having a high BMI can harm fertility by inhibiting regular ovulation. Even in women who regularly ovulate, the higher the BMI, the longer it may take to become pregnant. Some research also suggests that a higher BMI is associated with an increased risk of unsuccessful in vitro fertilization (IVF).

    Having a high BMI during pregnancy increases the risk of various pregnancy complications, including:

    • Miscarriage, stillbirth and recurrent miscarriage
    • Gestational diabetes
    • A pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys (preeclampsia)
    • Heart problems
    • Sleep apnea
    • The need for a C-section and the risk of C-section complications, such as wound infections

    Having a high BMI during pregnancy has been linked to an increased risk of various health problems for a baby, including:

    • Congenital disorders
    • Being significantly larger than average at birth (fetal macrosomia)
    • Growth problems
    • Childhood asthma
    • Childhood obesity
    • Cognitive problems and developmental delay

    However, other factors also might play a role in these outcomes.

    It's important to consider your pre-pregnancy weight and BMI when determining how much weight you need to gain during pregnancy. Work with your health care provider to find out what's best for you and to manage your weight throughout pregnancy.

    Start by considering these guidelines for pregnancy weight gain and obesity:

    • Single pregnancy. If you have a BMI of 30 or higher and are carrying one baby, the recommended weight gain is 11 to 20 pounds (about 5 to 9 kilograms).
    • Multiple pregnancy. If you have a BMI of 30 or higher and are carrying twins or multiples, the recommended weight gain is 25 to 42 pounds (about 11 to 19 kilograms).

    Rather than recommending that you gain a specific amount of weight, your health care provider might encourage you to focus on avoiding excessive weight gain during pregnancy.

    If you have a BMI of 30 or higher, your health care provider will closely monitor your pregnancy. Your provider might recommend:

    • Early testing for gestational diabetes. For women at average risk of gestational diabetes, a screening test called the glucose challenge test is often done between weeks 24 and 28 of pregnancy. If you have a BMI of 30 or higher, your health care provider might recommend the screening test at your first prenatal visit. If your test results show that your glucose levels are within the standard range, you'll likely repeat the screening test between weeks 24 and 28 of pregnancy. If the results show that your blood glucose levels are high, you'll need further testing. Your health care provider can advise you on blood sugar monitoring and control.
    • Changes to your fetal ultrasound. A standard fetal ultrasound is typically done between weeks 18 and 20 of pregnancy to evaluate a baby's anatomy. But ultrasound waves don't easily penetrate abdominal fat tissue. This can interfere with the effectiveness of fetal ultrasound. Talk to your health care provider about the best approach for getting an accurate ultrasound.
    • Screening for obstructive sleep apnea. Sleep apnea is a potentially serious sleep disorder that causes breathing to repeatedly stop and start during sleep. Women who have obstructive sleep apnea during pregnancy are at increased risk of preeclampsia and other complications. You'll likely be screened at your first prenatal visit. If obstructive sleep apnea is suspected, your health care provider may refer you to a sleep medicine specialist for evaluation and possible treatment.

    You can limit the impact of having a high BMI on your health and your baby's health. For example:

    • Schedule a preconception appointment. If you have a BMI of 30 or higher and you're considering getting pregnant, talk to your health care provider. Your provider might recommend a daily prenatal vitamin and refer you to other health care providers such as a registered dietitian who can help you reach a healthy weight before you conceive.
    • Seek regular prenatal care. Prenatal visits can help your health care provider monitor your health and your baby's health. Tell your provider about any medical conditions you have such as diabetes, high blood pressure or sleep apnea and discuss what you can do to manage them.
    • Eat a healthy diet. Work with your health care provider or a registered dietitian to maintain a healthy diet and avoid excessive weight gain. Keep in mind that during pregnancy, you'll need more folic acid, protein, calcium, iron and other essential nutrients.
    • Be physically active. Consult your health care provider about safe ways to stay physically active during your pregnancy, such as walking, swimming or doing low-impact aerobics.
    • Avoid risky substances. If you smoke, ask your health care provider to help you quit. Alcohol and illicit drugs are off-limits, too. Get your health care provider's OK before you start or stop taking any medications or supplements.

    Having a BMI of 30 or higher during pregnancy can increase the risk of complications for you and your baby. Working with your health care provider can help you manage your risks and promote a healthy pregnancy.

    Original article: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/pregnancy-and-obesity/art-20044409

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    Breastfeeding Benefits

    Breastfeeding provides many benefits to you and your baby. Realize that it takes time to feel fully confident, as breastfeeding is more than an instinct — it is a learned art. Be gentle on yourself, try to limit your activities, take good care of yourself, and ask for help and support. Remember that Beaumont lactation consultants are always here if you have any questions or concerns.

    Benefits of Breastfeeding for Baby

    There are many benefits of breastfeeding for baby that can boost his or her overall health during infancy. Some studies also show that breastfeeding can have a positive impact on baby's health as he or she grows and develops.

    The benefits of breastfeeding include:

    • Breast milk is the most complete form of nutrition for infants.
    • The first milk, called colostrum, is a gentle and natural laxative that helps clean your baby's intestine, which reduces the chance of jaundice occurring.
    • A mother's milk has just the right amount of fat, sugar, water and protein needed for a baby's growth and development.
    • Babies find it easier to digest breast milk than they do formula.
    • Breastfed infants grow exactly the way they should; they tend to gain less unnecessary weight and be leaner, which may result in having fewer weight problems later in life.
    • Breastfed infants experience fewer illnesses as children and are less likely to develop chronic diseases, such as asthma, diabetes, Crohn's disease and different cancers.
    • Breast milk can increase the effectiveness of immunizations and increase your baby's protection against diphtheria, tetanus and polio (DTaP) vaccines.
    • Some studies have shown that the activity of sucking at the breast improves the development of your baby's muscles, facial bones and teeth.
    • Premature babies tend to do better when breastfed compared to premature babies who are fed formula.

    Benefits of Breastfeeding for Mom

    The benefits of breastfeeding don't end with baby. Moms may benefit from choosing to breastfeed, especially exclusively, both in the near and long term. Mom's breastfeeding benefits include:

    • Nursing uses up extra calories, making it easier to lose the pounds of pregnancy. It also helps the uterus get back to its original size and lessens any bleeding a woman may experience after giving birth.
    • Breastfeeding, especially exclusive breastfeeding (no supplementing with formula), delays the return of normal ovulation and menstrual cycles. However, you should still talk with your doctor or nurse about birth control choices.
    • Breastfeeding your children lowers the risk of breast and ovarian cancers, and it may also reduce the risk of hip fractures and osteoporosis after menopause.
    • Breastfeeding can save time and money; you do not have to purchase, measure and mix formula, and there are no bottles to warm, which is especially convenient in the middle of the night.
    • A mother can give her baby immediate satisfaction by providing her breast milk whenever and wherever her baby is hungry.
    • Breastfeeding requires a mother to take some quiet relaxed time for herself and her baby.
    • Breastfeeding can help a mother bond with her baby. The skin-to-skin contact increases mothering hormones, such as prolactin and oxytocin, leaving breastfeeding mothers with increased feelings of closeness and bonding, as well as greater self-confidence. This physical contact is important to newborns and also helps them feel more secure, warm and comforted.

    So You Want to Breastfeed Successfully and Get Connected With Local Resources!

    Download your free App to get the most up to date, evidence-based information to start you down the right path.

    Coffective: "Helping families get a great start." Search "Coffective" in the App Store.

    Attention OB Patients

    You can expect to have an ultrasound at your first OB visit, at 18–22 weeks for anatomy, and around 37 weeks to check fluid, position, and estimate weight.

    All other ultrasounds are done for other medical reasons that will be determined by your provider.

    If you have any questions, please ask your provider.

    Thank you!

    Safe Medications in Pregnancy

    Allergy Symptoms

    Cetirizine (Zyrtec®) • Diphenhydramine (Benadryl®) • Fexofenadine (Allegra®) • Fluticasone (Flonase®) • Loratadine (Claritin®)

    Cough and Cold

    Pseudoephedrine (Sudafed®) for nasal congestion — Don't take this medication during the first trimester (the first 12 weeks of pregnancy). If you have high blood pressure, talk with your health care provider before taking this medication. • Guaifenesin (Mucinex®) for congestion • Dextromethorphan (Robitussin®) for cough • Benzocaine (Chloraseptic®, Cepacol®, Halls®) lozenges for sore throat.

    NOT SAFE: cold remedies that contain alcohol (most liquid suspensions).

    Acetaminophen (Tylenol®) for aches, pains, and a temperature over 100.6°F (38.1°C) • Do not take aspirin, ibuprofen, or naproxen. If headache persists despite Tylenol and rest; and if you have any other symptoms like vision changes, or if you have blood pressure issues, notify your doctor.

    Constipation and Gas

    Polyethylene glycol (Miralax®) • Docusate sodium (Colace®) stool softener • Fiber (Metamucil® or FiberCon®) • Simethicone (Mylicon® or Gas-X®) for gas

    Diarrhea

    Loperamide (Imodium®) for diarrhea lasting longer than 24 hours

    Heartburn

    Calcium (Tums®, Mylanta®, Maalox®) • Famotidine (Pepcid®)

    Hemorrhoids

    Topical phenylephrine hemorrhoidal gel (Preparation H® or Anusol®) • Witch hazel pads

    Nausea and Vomiting

    Ginger and Peppermint. Vitamin B6 (take 25 mg 3 times per day) plus doxylamine succinate (Unisom®) (take 25 mg up to 3 times per day)

    Vaginal Yeast Infection

    Miconazole (Monistat®) or You can use the 1 day, 3 day, or 7 day treatment

    Dr. Marija Grahovac Dr. Al Lore Dr. Madhura Mahapatra Laura Mills DNP, CNM, IBCLC
    7445 Allen Road Suite 190, Allen Park, MI 48101
    Ph. (313) 382-0244 / Fax (313) 271-1427
    Answering Service (248)222-1204