UPDATE I N MATERNITY CARE

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NUTRITION, EXERCISE, WORK, AND SEX IN PREGNANCY

Kathryn Reilly, MD

This article focuses on the effect of activities of daily living on pregnancy outcome. Although most patients can continue their everyday activities without any concern about effect on pregnancy outcome, all pregnant patients want and need their physicians advice about all of these areas.
NUTRITION

Optimal nutrition for pregnancy begins before conception. Folic acid taken for at least 1 month before conception and continued for 2 months afterward significantly decreases the risk for neural tube defects (NTDs). Although this malformation is rare in the United States, with 2500 affected infants born each year, it is one o f the most common congenital malformations, and its effects are devastating. Anencephaly is characterized by the absence of the cranial vault and cerebral hemispheres and is inevitably lethal, usually within a few hours of birth. Meningomelocele, which is characterized by neural tissue covered by meninges that extrudes through the vertebral column, causes varying degrees of paralysis and often a loss of bowel and bladder control. Folic acid is found in leafy green vegetables, beans, peas, citrus fruits and juices, liver, and whole-wheat bread. Despite the wide range of food items that contain folic acid, one report estimates that only 8%of adult women consume at least 0.4 mg of folic acid dailymStudies performed in England and the United States have shown that, although women have heard of folic acid, their practical knowledge about it is limited, and only 20% took supplements preconceptually.26,31 Also, the only prospective studies that have demonstrated the efficacy

From the Department of Family and Preventive Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

PRIMARY CARE
VOLUME 27 NUMBER 1 MARCH 2000

105

of folic acid on decreasing the prevalence of NTDs have been performed using supplements rather than increasing dietary intakes of natural folic acid. As a result of these studies, it has been recommended by the US PublicHealth Service,H,48 American College of Obstetricians and Gynecologists (ACOG); and the US Preventive ServicesTask that all women planning to become pregnant use 0.4 mg of folic acid at least 1 month prior to conception for primary prevention of NTDs and that women who have had an affected infant take 4 mg daily. Because an estimated 50%= of pregnancies are unplanned, all women of child-bearing age should take a multivitamin containing folic acid daily. In the future, fortification of cereal flour has been instituted to enhance the ability of the general population to achieve adequate folic acid levels. Multivitamin use before conception may lead to unexpected outcomes in the form on multiple births. Werler et a151reviewed five data sets from three studies and found that four of the five showed a 30% to 60% greater prevalence of periconceptual vitamin supplementation among the mothers of multiple infants. Multivitamin supplementation during pregnancy is much more common in the United States than in other developed counties. ACOGs Guidelines for Perinatal Care5 state that the increased amounts of vitamins and minerals recommended during pregnancy can usually be obtained through dietary intake and the routine use of a multivitamin supplement is not necessary. Despite this assertion, evidence shows that a sufficiently well-balanced diet is consumed by a relatively small proportion of US women.%Risk factors for inadequate nutrition include tobacco, alcohol, and other substance abuse; adolescence; and eating disorders, including frequent dieting and fasting, pica, and avoidance of certain foods. Short interpregnancy interval and certain drugs, such as phenytoin, can also predispose patients to deficiencies. Evidence shows that the use of prenatal vitamins in the first and second trimesters of pregnancy are associated with a decreased rate of preterm delivery and very low birth weight (VLBW), with the most benefit seen with use of vitamins in the first t r i m e ~ t e rEvidence .~~ also shows that the use of prenatal vitamins is associated with a decreased risk for brain tumors diagnosed up to the age of 5 years.% Iron supplementation to prevent anemia is generally recommended during the second and third trimesters of pregnancy, even by those who believe that supplements are unneeded. Thirty milligrams of elemental irGn per day is recommended. This should be taken at bedtime or between meals to facilitate absorption and should not be taken with milk, tea, or coffee.%Iron does not need to be taken during the first 4 months of pregnancy, especially if the vitamin intake seems to aggravate nausea or vomiting. Calcium requirements increase during the second and third trimesters of pregnancy. Compared with nonpregnant women, who need 800 mg/d of calcium, pregnant women must use at least 1200 mg to maintain homeostasis. This can be obtained from three servings of milk, cheese, or yogurt. Lactose-intolerant patients and adolescent patients benefit from calcium supplementation, which should be taken with meals and at a different time from iron. Calcium supplementation has been shown in some studies to reduce the risk for pregnancy-induced hypertension and pre-e~lampsia.2~ In a review of published studies, Kulier et aP7concluded that calcium supplementation in women at high risk for hypertension in pregnancy signhcantly decreased the risk for high blood pressure (RR, 0.35; 95% CI, 0.21-0.57) and pre-eclampsia (RR, 0.32; CI, 0.21-0.49).27It was also beneficial in women with low dietary calcium intake, giving similar decreases in relative risk. The amount of calcium supplement to achieve these benefits is 1500 to 2000 mg/d, taken in association with 400 IU of vitamin D.

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Zinc is involved in most major metabolic pathways that are essential for growth. The importance of zinc for fetuses is difficult to define because clinical assessment of zinc intake is difficult and plasma assays are unreliable, but one study has demonstrated that daily zinc supplementation in women with low plasma zinc values was associated with greater birth weights.I9Because iron intake may interfere with absorption of zinc, supplementation is recommended when more than 30 mg of iron is administered to treat anemia.33 Vitamin A supplementation during early pregnancy has been found to decrease the risk for congenital anomalies.'* This vitamin is teratogenic in high doses, so no more than 5000 IU/d should be consumed by pregnant women. Weight gain is important, even for the most obese women, in pregnancy. The amount of optimal gain depends on the prepregnancy body mass index (BMI). Underweight women with a BMI less than 19.8 should gain 12.6 to 18.0 kg, or 2.25 kg/mo in the last two trimesters. Women of normal weight (BMI, 19.8-26.0) should gain 11.25 to 15.75 kg, or 1.8 kg/mo in the second and third trimesters; overweight women (BMI, 26.1-29.0) should limit weight gain to 6.75 to 11.25 kg; and obese women (BMI, > 29.1) can gain up to 6.75 kg, although less weight gain is acceptable in these women.5 Twin gestations require a greater total weight gain of 15.75 to 20.25 kg, or 2.7 kg/mo, in the last two trimester^.^ Smaller amounts of weight gain increase the risk for intrauterine growth retardation (IUGR)and LBW. Larger amounts of weight gain increase the risk for perinatal mortality. During the first trimester, energy requirements increase minimally, with approximately 420 kJ/d more needed. A total of 1260 kJ more are needed in the last two trimesters. This extra energy intake should include additional protein (-15 g is recommended), together with a well-balanced intake of fruits, vegetables, grains, and dairy products. Women with excessive weight gain are frequently drinking large amounts of milk and fruit juices. Limiting milk intake to four glasses per day and juice to one or two glasses, as well as possibly diluting the juice, can help to moderate weight gain. Nausea and vomiting are common complications in the first trimester, with 70%of women reporting nausea and as many as 50%reporting vomiting. Small, frequent meals; low fat, bland foods; and ginger-containingfoods can be helpful. Eating crackers before getting out of bed in the morning is the traditional recommendation, as is sucking on hard candies. Supplementation with vitamin B, (25 mg, three times per day) is reported to be helpful.= This subject is discussed further in the article on medications during pregnancy and lactation elsewhere in this issue. Pica is common in pregnancy but is not typically disclosed by patients unless they are asked about it specifically. Clay, ice, laundry starch, and cigarette butts are the most common items consumed. Pica can lead to the consumption of empty calories, anemia, constipation, or infection with parasites. Pica can be a culturally mediated response to pwgnancy, and sensitivity to cultural beliefs must be maintained while discussing this issue. Caffeine intake is frequently curtailed by pregnant women because of concerns about possible effects on the fetus. The evidence for adverse effects in huA case-controlstudy from Brazil has evaluated the caffeine mans is inconsistent.40 intake of 1205 mothers and found no effect of caffeineon the risk for LBW, preterm birth, or IUGR.40 Alcoholic beverages should be avoided by pregnant women because no safe, lower limits of intake have been identified. Binge and excessive drinking results in fetal alcohol syndrome. Despite this, the risks of light alcohol intake should be overemphasized.

WORK DURING PREGNANCY

The number of employed women has increased dramatically during the past 40 years. In 1960,approximately 40% of women aged 20 to 34 years were employed; in 1994,the percentage was more than 70%." The increase in the number of pregnant women who continued to work during the last trimester of pregnancy is even more dramatic. In 1961,52%of employed, pregnant women continued to work during the last trimester, and 23% returned to work within 1 month of delivery.'8 In 1988, nearly 80% of employed, pregnant women continued work into the last trimester, and more than 50%returned to work to within 1 month of delivery.Is This increased participation in the workforce has led to increased focus on the possible effects of employment on pregnancy outcome. As is the case with diet, physicians should evaluate the possible iiffects of a woman's job on future pregnancy outcome before conception. Four substances to which exposure in the workplace is possible have been identified as teratogens. Lead, ionizing radiation, ethylene oxide, and dibromochloropropane are known to have potential adverse effects on fetuses. Blood levels of lead of more than 15 to 30 &dL are associated with spontaneous abortion, preterm birth, and delayed cognitive development. Ethylene oxide is used to sterilize hospital equipment; it is mutagenic and may be associated with spontaneous abortion. Ionizing radiation is mutagenic, can produce infertility, and can result in IUGR and spontaneous abortion. Dibromochloropropanewas formerly used as a pesticide and still is a groundwater contaminent in some agricultural areas. Video display terminals emit small amounts of ionizing radiation and were once suspected of increasing the risk for spontaneous abortion, but evidence for any effect of even long-term exposure to these devices is la~king.'~ Good evidence also shows that no increased risk for IUGR, preterm birth, or infant mortality with continued exposure to video display terminals during the pregnancy? Exposure to antineoplastic drugs is associated with an increased prevalence of fetal 10ss.'~Women using these drugs should be especially careful to follow the established handling techniques for these medications. Organic solvents are involved in many manufacturing processes. Evidence for adverse effects on pregnancy outcome caused by exposure to organic solvents is clear in animals; in humans, the risks are less clear. Exposure to high levels of aliphatic hydrocarbons in the shoe industry was found to increase the relative risk of spontaneous abortion to 3.85 (95%CI, 1.24 to 11.90) compared with no exposure.' These chemicals may also be associated with "fetal solvent syndrome," which resembles fetal alcohol syndrome with facial and limb malformations, IUGR, and CNS dysfunction.18Paternal exposure to many chemicals has been shown in many studies to be associated with a risk for stillbirth, preterm delivery, and small-for-gestational-age (SGA) infants.2," Health care workers may be exposed to biologic or infectious agents that could adversely affect the health of themselves and their fetuses. Appropriate vaccinations and the use of universal precautions can decrease the risks, but many viral risks exist against which no vaccine is available. Parvovirus B19, which c a m f i f t hdisease in children, is transmitted through respiratory secretions. Primary maternal infection with this virus can lead to hydrops fetalis or erythroblastosis fetalis, the fetal death rate of which is 9%.When serologic evidence of recent infection is present, patients should undergo serial sonograms for evidence of fetal hydrops because intrauterine fetal transfusion can be life saving.15 Cytomegalovirus is often acquired during childhood and adolescence, or through sexual contact. It can also be acquired by exposure to the respiratory and

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urinary tracts of affected children. Primary infection with cytomegalovirus in pregnant women can lead to microcephaly,sensorineuralhearing loss, and mental and motor disability. The risk for this infection is highest in women who work with children in diapers, including nurses and day-care workers, but women with non-toilet-trained children in day care are also at risk. Varicella infectionis common in childhood, and most adults, even those with no specific history of infection, are immune. Nonetheless, approximately 5% of adults have no antibodies to varicella. Infection during pregnancy does not typically constitute a risk to the fetus unless the outbreak occurs between 5 days before and 2 days after delivery. In this situation, infants should receive varicella immune Congenital manifestations of infection with varicella during pregnancy are rare. The care of a pregnant woman who has been exposed to varicella is discussed in the article devoted to maternal infections, elsewhere in this issue. Congenital infection with rubella is rare in the United States, with less than 10 cases per year.I5 Adherence to the guidelines for two measles-mumps-rubella vaccines before adolescence should decrease the risk for this devastating disease even further, as could screening for antibodies in preconception evaluations.23 Airborne substances common in some workplaces are also a risk factor for adverse pregnancy outcome. For example, proper venting of anesthetic gases is essential to protect operating-room personnel from an increased risk for spontaneous abortion.IsSecondhand smoke is a potential risk to those exposed in workplaces, such as restaurants and bars.15 f working conditions on pregnancy outcome are much less well The effects o understood than the results of workplace exposures. Results of studies from the United States and Europe have been inconsistent, although sighcant evidence shows that prolonged standing and long working hours may be associated with an increased risk for preterm birth or LBW.29,30,41,46 Many studies have been performed in the past 15 years in an attempt to understand the effect of working on pregnancy and to identify the specific risks of working during pregnancy. The general conclusions of these studies are that most women can continue to work without hazard well into the third trimester.18 The pioneering work of Mamelle et a P in the early 1980s defined an occupational fatigue score, which categorized occupations based on several components of activity, including posture, work on an industrial machine, physical exertion, mental stress (defined as low-control,high-monotony tasks), and working envir~nment.~~ After controlling for confoundingfactors, a significantrelationship was found between greater numbers of fatigue factors and increased rate of preterm birth. In a subsequent study, Mamelle and Munozjofound that work on an industrial machine and mental stress were the major risk factors for preterm deliver~.~~ Saurel-Cubizolles and Kaminski?l in a study of pregnant, French, working women, found that women exposed to more adverse conditions (e.g., standing during work, carrying heavy loads, working on an assembly line, and performing a physically demanding job) were more likely to deliver prematurely and to require increased sick leave from work.41 Teitleman et a1a found that women whose jobs required prolonged standing were at increased risk for preterm delivery compared with women who had sedentary jobs and those who alternated walking and sitting while working. In fact, women who sat and walked (e.g., registered nurses or veterinarians) had the lowest risk for preterm birth. Decreased birth weight has also been associated with employment in some studies. Naeye and Peters%reported that the birth weights of infants of women

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who worked outside of the home were significantly less than were those of infants of homemakers.3s The greatest differences were found in those who were underweight before pregnancy, who gained the least weight, who were hypertensive, and who stood at work. The investigators also found that women who stood at work in the third trimester had more large placental infarcts. The investigators speculated that women who stood at work had disruption of uteroplacentalblood flow, leading to lower birth weight and infarcts. Wergeland et almfound that strenuous work conditions (defined as influence on work pace, twisting and bending, lifting heavy loads, and standing or walking at work) did not predict LBW in the total population but did affect the risk for LBW in nonsmoking primiparas. Lack of influence on work pace was the strongest risk factor. Prolonged standing was also found to be a risk factor for LBW by Fortier et al.I7 Their study found that standing more than 6 hours per day significantly increased the odds ratio of delivering a SGA infant (RR, 1.42; 95%CI, 1.02-1.95). Women who stood more than 6 hours per day and who worked past 24 weeks' gestation had an odds ratio of 1.91 (95%CI, 1.12-3.25) for delivering a small infant. In women whose prepregnancy weight was less than 50 kg and who worked standing for more than 6 hours per day, the risk for an SGA infant was higher than that of an additive model, suggesting that women at high risk for SGA infants are more sensitive to the risks of prolonged standing at work.l7 In multiple studies, working conditions or hours were not associated with adverse perinatal Some of the differences in study outcomes may be related to recall bias. Many studies have not ascertained directly the details of each woman's job but have instead relied on generic job descriptions. In other studies, the week of pregnancy during which the woman stopped working was not identified or work modifications were not specified. In 1984, the AMA Council on Scientific Affairs published a list of guidelines for physical activity during pregnancy, which was not apparently based on research because little research of this issue had been done to that time. The guidelines limit activity based on exertion and loss of agility caused by the growth of the pregnancy. The guidelines are shown in Table 1 and serve as a reference for limiting work activities in women whose work seems to place them at risk for adverse pregnancy outcome.15 Stress associated with employment is also associated with poor pregnancy outcome in some studies. In one study16stressful work was associated with an increased risk for spontaneous abortion in older women, smokers, and primiparas, although no risk was found in the general population. Female lawyers who worked more than 45 hours per week were found to be more stressed at work than those who worked less than 35 hours per week. The more-stressed women In another had an odds ratio of 3.0 (95%CI, 1.4-6.6) for spontaneous abortion.@ study, work-related stress was found to be associated with preterm, LBW delivery only in women who did not want to be working." Other studies have not shown any effect of work-related stress on pregnancy o ~ t c o m e . ~ Advising , ~ ~ , ~ patients to stop working is not benign. Workman's compensation does not compensate women who cannot work because of personal problems, and employers are not required to alter job requirements based on pregnancy (although many do).39 Even if disability insurance is available to patients through their workplaces, the amount of money provided is sigruficantly less than their normal paychecks. Many women, especially those with blue-collar occupations, do not have disability insurance, and they also do not have much job security. The Family Medical Leave Act allows for 90 days off from work to care for medical problems, with a guaranteed ability to return to work afterward, but this does not help women

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Table 1. GUIDELINES FOR CONTINUATIONOF VARIOUS LEVELS OF WORK DURING PREGNANCY Job Function Week of Gestation

Secretarial and light clerical Professional and managerial Sitting with light tasks Prolonged (> 4 h) Intermittent Standing Prolonged (> 4 h) Intermittent (> 30 min/h) (< 30 min/h) Stooping and bending Below knee level Repetitive (> 10 timedh) Intermittent (< 10 > 2 times/h) (< 2 timeslh) Climbing Vertical ladders and poles Repetitive ( 2 4 times/d-hr shift) Intermittent (< 4 times/8-hr shift) Stairs Repetitive (2 4 times/&hr shift) Intermittent (< 4 times/d-hr shift) Lifting Repetitive > 23 kg < 23 > 11 kg

40 40
40 40 24 32 40

20 28 40

20 28 28 40 20 24 40 30 40 40

< 11 kg
Intermittent > 23 kg < 23 > 11 kg < 11 kg

Reprinted with permission from American Medical Association, Council on Scientific Affairs, Effects of pregnancy on work performance.JAMA 1984;251:1995-1997

who are advised to stop working at 24 weeks gestation.39 Some situationsrequire that pregnant women not work, such as severe hypertension or preterm labor, without regard to concerns about loss of income. Also, many women decide that they will stop working at some point during pregnancy. If modification of working conditions is advisable, direct contact between physicians and employers is most likely to effect such accommodations. In his summary of the evidence about the effects of work in pregnancy, Chamberlain9stated that it is probable that ordinary work done by a fit young woman has no serious effect on herself or a healthy fetus. This summary is still the state of the art in 1999.

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EXERCISE IN PREGNANCY

In contrast to the adverse effects that occur with employment in some circumstances, exercise in pregnancy has not been found to increase risks for preterm birth or LBW. Studies have reported that regular exercise is associated with more timely births, improved maternal weight gain, decreased fat mass of offspring at 5 years, and better performance on oral language and Wechsler tests at 5 yearS.11,12.20,24,37 The physiologic changes caused by pregnancy are dramatic. Pregnancy causes an increase in heart rate, stroke volume, and cardiac output. Pregnant women experiencemild increases in tidal volume and oxygen consumption.Fetal growth demands that mothers have a higher energy intake-as many-as 1260 kJ/d in the second and third trimesters. Some evidence shows that increased maternal temperatures to as high as 39.2"C are teratogenic in the first trimester." Enlargement of the uterus and breasts changes the maternal center of gravity. Ligaments become lax progressively during pregnancy. Theoreticconcerns about maternal ability to compensate for additional stresses on these systems and the results of animal studies have raised concerns about the safety of maternal exercise. Despite the theoretic concerns and the evidence about increased adverse outcomes from strenuous work activity, few cases of adverse effects of even elite class exercise during pregnancy have been reported. ClappIosuggests that occupation fatigue is the cause of pregnancy complications. This fatigue reflects a degree of cardiovascular compromise that results from an initial contraction of central blood volume caused by inadequate fluid intake. The additional stress of pooling of blood in the lower extremities progressively reduces venous return, cardiac output, and arterial pressure for prolonged periods of time, which decreases the availabilityof oxygen and nutrients to the fetus, placenta, and uterus; increases uterine contractility; and slows the rate of fetal growth. In contrast, recreational exercise does not produce severe fatigue, vascular stasis, or low blood pressure, and it is often a stress reliever rather than a stress generator.lO For some women with complicated pregnancies or chronic diseases, exercise during pregnancy could lead to adverse outcomes. Contraindicationsto exercise during pregnancy include pregnancy-induced hypertension, premature rupture of the membranes, history of preterm labor, incompetent cervix, persistent second-trimester or third-trimester bleeding, and IUGR.3 Careful evaluation of women with chronic hypertension or active thyroid, cardiac vascular, or pulmonary disease is important to determine whether exercise during pregnancy is appr~priate.~ Specific recommendations for appropriate types of exercise during pregnancy depend on a patient's prior experiences and desires. ACOG has recommended that women avoid supine exercise after the first trimester, modify the intensity of their exercise according to perceived exertion, take into account the changes in balance that occur as the pregnancy progresses, avoid abdominal trauma, drink adequate fluids, and monitor weight gain? Scuba diving and water skiing are specifically contraindicated during pregnancy, and contact sports are inadvisable after the first trimester. Non-weight-bearing sports, including stationary bicycling and swimming, are less affected by the physiologic changes of pregnancy and permit higher levels of activity later in pregnancy.
SEX IN PREGNANCY

Most women continue sexual activity during pregnancy, although the frequency of intercourse has been found to decrease in advanced pregnancy.52 Byrd et als found that 89%of couples reported intercourse during the second trimester.

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Intercourse during the last month of pregnancy has been associated with an increased risk for preterm delivery and amniotic fluid infection^.^^ Many physicians advise their patients to avoid sex after 36 weeks gestation, but this recommendation may not be followed in many cases. Air embolism as a result of air blown into the vagina during cunnilingus has been reportedj2Undiagnosed vaginal bleeding, placenta previa, and threatened preterm labor are the only specific contraindications to coitus during pregnancy.52

SUMMARY

Optimal weight gain in pregnancy is 11.25 to 15.75 kg for women with normal prepregnancy weights; underweight women should gain up to 18.0 kg; obese women should limit weight gain to not more than 6.75 kg. Weight loss is detrimental regardless of prepregnancy weight. A l l women of child-bearing age should consume at least 0.4 mg/d of folk acid to decrease the risk for NTDs. Women who have had one child with an NTD should take 4 mg/d during the month before conception through the first trimester. Iron supplementation decreases the risk for anemia. Calcium may decrease the risk for pregnancy-induced hypertension and pre-eclampsia. Adequate amounts of zinc are important for fetal growth, and supplementation may be advisable in women who are taking iron supplements. Although the Institute of Medicine does not recommend that all women take vitamins prenatally, evidence shows that these supplementsdecrease the risk for childhood brain tumors, preterm delivery, and very low birth weight. Most women can continue working during pregnancy, with modifications of strenuous activity in late pregnancy. Prolonged standing, repetitive lifting of heavy loads, and stress have been associated in some studies with preterm labor and decreased birth weight. Recreational activity has not been associated with adverse pregnancy outcomes may enhance pregnancy outcome. Sexual activity during pregnancy need not be limited except when unexplained vaginal bleeding, placenta previa, or preterm labor occur.

References
1. Agnesi R, Valentini F, Mastrangelo G Risk of spontaneous abortion and maternal exposure to organic solvents in the shoe industry. Int Arch Occup Environ Health 69:311631,1997 2. Alexander BH, Checkoway H, Faustman EM, et al: Paternal occupational lead exposure and pregnancy outcome. Int J &cup Environ Health 2280-285,1996 3. American College of Obstretricians and Gynecologists: Exercise During Pregnancy and the Postpartum Period. ACOG Technical Bulletin no. 189.Washington, DC, ACOG, 1994 4. American College of Obstetricians and Gynecologists: Folic Acid for the Prevention of Neural Tube Defects. ACOG CommitteeOpinion no. 120. Washington, DC, ACOG, 1993 5. American College of Obstetricians and Gynecologists: Nutrition during pregnancy. ACOG Technical Bulletin no. 179. Washington, DC,ACOG, 1993 6. Blanck PD, Butkowski CR Pregnancy-related impairments and the Americans with D i s abilities Act. Obstet Gynecol Clinics of North Am 25435445,1998 7. Brandt LPA, Nielsen CV: Job stress and adverse outcome of pregnancy: A causal link of recall bias? Am J Epidemioll35302-311,1992

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8. Byrd JE, Hyde JS, DeLameter JD, et al: Sexuality during pregnancy and the year post-

partum. J Fam Pract 47305-308,1998 9. Chamberlain GV Work in pregnancy. Am J Ind Med 23:559-575,1993 10. Clapp JF: Pregnancy Outcome: Physical activities inside versus outside the workplace. Semin Perinatol2070-76,1996 11. Clapp J F Morphometric and neurodeveloprnental outcome at age 5 years of the offspring of women who continued to exercise regularly throughout pregnancy. J Pediatr 129~856463,1996 12. Clapp JF, Simonian S, et al: The one-year morphometric and neurodevelopmental outf women who continued to exercise regularly throughout pregcome of the offspring o nancy. Am J Obstet Gynecol178:594-599,1998 13. Council o f Scientific Affairs, American Medical Association: Effects of pregnancy on work performance. JAMA 251:581-588,1984 14. Czeizel AE, Rockenbauer M Prevention of congenital abnormalities by vitamin A. Int J Vitam Nutr Res 68219-231,1998 15. Feinberg JS, Kelley C R Pregnant workers: A physicians guide to assessing safe employment. Western Journal of Medicine 168:87-91,1998 16. Fenster L, Schaefer C, Mathus A, et a 1 Psychologic stress in the workplace and spontaneous abortion. Am J Epidemiol142:1176-1183,1995 17. Fortier I, Marcoux S, Brisson J: Maternal work during pregnancy and the risks of delivering a small-for-gestational age or preterm infant. Scand J Work Environ Health 21:412418,1995 18. Gabbe SG, Turner LP: Reproductive hazards of the American lifestyle: Work during pregnancy. Am J Obstet Gynecol176826-832,1997 19. Goldenberg RL, Tamura T, Neggers Y The effect of zinc supplementations on pregnancy outcome. JAMA 2F463-468,1995 20. Hatch M, Levin B, Snu XO, et a1 Maternal leisure-time exercise and timely delivery. Am J Public Health 881528-1533,1998 21. Henriksen TB, Hedegaard M, Secher NJ: The relation between psychosocial job strain and preterm delivery and low birthweight for gestational age. Int J Epidemiol23:764774,1994 22. Homer CJ, James SA, Siege1E: Work-related psychosocial stress and risk of preterm, low birthweight delivery. Am J Public Health 80:173-177,1990 23. Jack BW, Culpepper L: Preconception care. In Taylor RB (ed): Family Medicine Principles and Practices, ed 4. New York, Springer Verlag, pp 61-68,1994 :Training in pregnant women: Effects on fetal development and birth. 24. Kardel KR, Kase T Am J Obstet Cynecol178:280-286,1998 25. Kolasa Kh4, Weismiller DG: Nutrition during pregnancy. Am Fam Phys 56:205-212,1997 26. Kleoblen AS: Folate knowledge, intake from fortified grain products and periconceptional supplementation patterns of a sample of low-income pregnant women according to the Health Belief Model. J Am Diet Assoc 99:33-38,1999 27. Kulier R, de Onis M, Gulmezoglu AM, et al: Nutrition interventions for the prevention of maternal morbidity. Int J Gynaecol Obstet 63231-246,1998 28. Locksmith GJ, Duff P: Preventing neural tube defects: The importance of periconceptional folic acid supplements. Obstet Gynecol91:1027-1034,1998 29. Mamelle N, Laumon B, Lazor P: Prematurity and occupational activity during pregnancy. Am J Epidemiol1119:309-322,1990 30. Mamelle N, Munoz F: Occupational working conditions and preterm birth: A reliable scoring system. Am J Epidemiol126:150-152,1987 31. Mathews F, Yudkin P, Neil A: Folates in the periconceptional period: Are women getting enough? Br J Obstet GynaecollO5954-959,1998 32. McDonald AD, McDonald JC, Armstrong B: Prematurity and work in pregnancy. Br J Ind Med 4556-62,1988 33. Menard MK Vitamin and mineral supplementation prior to and during pregnancy. Obstet Gynecol Clin North Am 24479-498,1997 34. Centers for Disease Control: Recommendations for the use of folic acid to reduce the number of cases of spina bifida and other neural tube defects. MMWR Morb Mortal Wkly Rep 41(RT-14):1-7, 1992

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