A 29-year-old woman comes to the office for confirmation of pregnancy after a recent positive home pregnancy test. The patient has mild fatigue and nausea but no vomiting, vaginal bleeding, or pelvic pain. She has no chronic medical conditions, and her only medications are a daily probiotic and prenatal vitamin. The patient does not use tobacco, alcohol, or illicit drugs. She exercises daily, alternating between running and weight training. The patient avoids processed foods and red meat, preferring a diet rich in vegetables and fish. She drinks decaffeinated coffee with breakfast and has ginger tea throughout the day to help relieve nausea. BMI is 21 kg/m². Vital signs are normal. Physical examination is unremarkable. Ultrasound shows a 7-week intrauterine fetal pole with cardiac motion. Which of the following part of this patient's history requires further evaluation?

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11ec25c8_d237_2960_bc81_c51e1df615c6_MD0003_00 During the initial prenatal visit, maternal nutrition should be discussed because certain foods and beverages may be harmful for fetal development. In addition, this provides a time to discuss optimal nutrition and common diet concerns, appropriate weight gain, and exercise. This patient's fish consumption should be further evaluated because certain types of seafood and improper cooking technique can pose significant risks to the mother and fetus. Seafood is a healthy source of protein; it is low in saturated fat and high in beneficial omega-3 fatty acids (eg, docosahexaenoic acid [DHA]), which help in fetal neurocognitive development. However, it is recommended that pregnant women consume only cooked seafood because raw seafood can transmit parasites or bacteria. Pregnant women should also avoid fish with potentially high mercury levels (eg, swordfish, shark, bigeye tuna, king mackerel) because mercury can be toxic to fetal neurodevelopment. However, patients may eat 2-3 servings/week of fish (eg, salmon, flounder) or shellfish (eg, crab, shrimp) with low mercury levels. (Choice A) High caffeine doses can be harmful in pregnancy, but moderate intake (ie, 1 or 2 cups of coffee daily) is acceptable. This patient drinks decaffeinated coffee and ginger tea, which do not contain high levels of caffeine. (Choice B) Most types of exercise (eg, running, weight training) can be continued during pregnancy as tolerated. Pregnant patients are counseled to avoid exercise that increases the risk of abdominal trauma (eg, contact sports, downhill skiing) due to the increased risk of placental abruption. (Choice D) Ginger (eg, ginger ale, tea) is commonly used as a natural remedy for nausea and vomiting. Although ginger is safe in pregnancy, other herbal supplements (eg, saw palmetto) should be avoided due to risk of adverse obstetric outcomes (eg, preterm delivery). (Choice E) Probiotic (eg, Lactobacillus) intake during pregnancy may have some maternal benefits (eg, anti-inflammation, improved glucose metabolism), but data are limited. However, most studies show no increased risk in adverse fetal outcomes, and patients may continue probiotic use if desired. Educational objective: Pregnant patients are advised to eat 2-3 servings of fish per week for intake of beneficial omega-3 fatty acids. However, pregnant patients should consume only cooked seafood and avoid fish with high mercury levels (eg, swordfish, bigeye tuna). References: A review of guidance on fish consumption in pregnancy: is it fit for purpose? (http://www.ncbi.nlm.nih.gov/pubmed/29576029) Pregnancy outcomes in women taking probiotics or prebiotics: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/29310610)

A 29-Year-Old Woman Comes to the Office for Confirmation of Pregnancy