Tag Archive | first trimester

ZIKA VIRUS and PREGNANCY

mosquitoZika Virus: Answers for Pregnant Women

What is Zika virus?

Zika is a virus that’s been around for actually dozens of years; it generally causes a mild viral syndrome and is prevalent in the Tropics—South America, the Caribbean islands, and Pacific islands.

Zika virus is a mosquito-borne illness.  Most people who are infected with Zika virus have no symptoms. If they have symptoms, they are usually very mild such as fever, rash, red eyes, muscle pain or joint pain. People usually do not get sick enough to be hospitalized and they very rarely die.

Is there a link between the Zika virus and birth defects? Infection during pregnancy can be harmful to the fetus or the newborn. Zika virus has been associated with microcephaly, a birth defect in which the size of a baby’s head and brain is smaller than expected. This birth defect is associated with developmental delays including trouble speaking, problems with movement and balance, hearing loss, and vision problems.

How is Zika virus transmitted? Women can be infected with the Zika virus directly by mosquito bite in an area where there is active Zika transmission or by sexual transmission from an infected male partner.

How can I prevent catching the Zika virus? The Centers for Disease Control and Prevention (CDC) has recommended that pregnant women, or women who may potentially become pregnant, avoid travel to countries that have been affected by the virus, including a large number of countries in South America, the Caribbean and the Pacific Islands. Check the CDC website http://www.cdc.gov/travel/page/zika-travel-information for a complete list of affected countries. Both pregnant women and their partners should avoid mosquito bites, particularly if traveling to a country that has been affected by Zika. If your sexual partner has recently visited an area with the Zika virus or is infected with the Zika virus, abstain from sex or use condoms throughout the pregnancy.

 If I am going to travel to an affected area, what should I do to prevent catching the virus? Travel to an affected area is not recommended for pregnant women. If travel is completely unavoidable, talk to your healthcare provider and take precautions to avoid mosquito bites. This should include use of EPA-registered insect repellents, wearing long-sleeved shirts, long pants, and hats to cover exposed skin, and maximizing time spent indoors in air-conditioned or screened rooms.

The recommendations for people contemplating pregnancy are a little bit different. If the woman has been exposed to Zika and gotten sick—meaning she has flu-like symptoms, runny nose, sore throat, low-grade fever, red or itchy eyes—it is possible that it is due to the Zika virus and, currently for people who have symptoms that have been exposed, they can be tested to see if that is true.

For a woman who has been exposed and been sick from Zika, it is recommended  waiting 8 weeks before tyring to conceive. There’s concern for men that the virus can remain in their bodies and be spread through sexual contact. And so for a man who has been sick from Zika, again, been exposed, been in an area and had a viral syndrome, the man can now be tested and, if he’s been sick or tested positive, the current recommendation is that he not have unprotected intercourse with a pregnant woman or try to conceive for 6 months.

If I catch the Zika virus before my pregnancy, is my baby at risk? We do not yet have recommendations about the safe period between infection and conception. However, once the virus is cleared from the blood, prior Zika infection is not thought to affect future pregnancies.

For more information about Zika virus, visit www.ChildrensNational.org/Zika

If you are concerned that you have been exposed to the Zika virus, please talk to your doctor. The Fetal Medicine Institute at Children’s National can work with your doctors directly.

http://childrensnational.org/departments/fetal-medicine-institute

Phone number:  202-476-7409

*SOURCES: Information provided by Children’s National Health System Centers for Disease Control and Prevention

*Excerpts from The Zika Virus and Getting Pregnant, Eric A. Widra, Medical Director,  Shady Grove Fertility

The Benefits of Red Raspberry Tea

Red Raspberry leaf tea is one of the safest and commonly used tonic herbs for women wanting to get pregnant or for women who are already pregnant. Red Raspberry Leaf (Rubus idaeus) tones the uterus, improves contractions and decreases constipation. Most tonics need to be used regularly, for a tonic is to the cells much like exercise is to the muscles; it is not much help when done irregularly . But you will still  benefit even from occasional use of tonics during pregnancy, since they contain nourishing factors. The herb comes in forms of leaves to make teas or tonics as well as pill like capsules you can swallow. Most of the benefits given to regular use of Red Raspberry leaf tea throughout pregnancy can be traced to the strengthening power of fragrine, an alkaloid which gives tone to the muscles of the pelvic region, including the uterus itself; and to the nourishing power of the vitamins and minerals found in this plant. There is rich concentration of Vitamin C, the presence of Vitamin E and the easily assimilated calcium and iron. Raspberry leaves also contain vitamins A and B complex and many minerals, including phosphorus and potassium.

When to use: There are two basic points of view on the subject. There is agreement among many
clinicians that in the 3rd trimester frequent (2- 3 cups per day of tea or 1 – 2 cups per day of infusion) isred raspberry leaf tea
beneficial to the uterine and pelvic muscles.

The more radical point of view is that drinking one cup of tea per day in the 1st trimester and 2 cups in the 2nd trimester and switching to the infusion in the 3rd trimester ensures a strong uterus, is good for you nutritionally and prevents miscarriage. Some say it is advised to not use it in the first trimester, particularly if you have a history of miscarriage. If a mother is prone to miscarriages she may feel safer avoiding raspberry until the third trimester. This is an herb with centuries of safe use behind it, there is usually little cause for concern, but check with your healthcare provider before using.

According to Susun Weed, author of “Wise Woman, Herbal for the Childbearing Year,” the benefits
listed below for drinking a Raspberry leaf brew before and throughout pregnancy are as follows:

  • Increasing fertility in both men and women. Red Raspberry leaf is an excellent fertility herb when
    combined with Red Clover.
  •  Preventing miscarriage and hemorrhage. Raspberry leaf tones the uterus and helps prevent
    miscarriage and postpartum hemorrhage from a relaxed or atonic uterus.
  • Use raspberry leaf infusion to help facilitate placenta delivery. Chips of frozen raspberry leaf infusion
    sucked throughout labor help keep the uterus working strongly and smoothly.
  •  Easing of morning sickness. Many women attest to raspberry leaves’ gentle relief of nausea and
    stomach distress throughout pregnancy. Drink a cup or two of raspberry leaf tea or infusion each day.
    Sipping the infusion before getting up or sucking on ice cubes made from the infusion increases the
    strength of this remedy.
  •  Reducing pain during labor and after birth. By toning the muscles used during labor and birth,
    Raspberry leaf eliminates many of the reasons for a painful birth and prolonged recovery. It does not
    counter the pain of dilation of the cervix.
  • Red Raspberry Leaves do not start or encourage labor. It can help the contractions to be productive
    once true labor has begun because it strengthens the uterine and pelvic muscles but it is not an oxytonic
    herb (one that would induce labor). That being said, it’s important to talk with your midwife,
    obstetrician or herbalist before beginning drinking red raspberry leaf tea or taking a supplement. Some
    will recommend you wait until you are 36 weeks along before incorporating the tea into your health
    regime while others may encourage you to begin right away. Each situation and pregnancy is different
    so it’s best to get other’s opinions before beginning red raspberry leaf tea.

Tea recipe: To make a tea, pour 1 cup boiling water over 2 teaspoons of herb and steep for ten minutes. Strain. During the first two trimesters, drink 1 cup per day. During the final trimester, drink 2-3 cups per day.

Excerpts from Weed, Susun. “Wise Woman Herbal Childbearing Year.”http://www.motherandchildhealth.com/Prenatal/raspberry.html

Presented by Angel J. Miller, MSN, CNM

www.midwiferycareassociates.com

https://www.linkedin.com/in/angeljmiller

The Importance of Healthy Nutrition Throughout Your Pregnancy

Adequate nutrition during your preconception and prenatal periods is important for a healthy pregnancy and healthy baby. Achieving a normal body mass index (BMI) prior to your pregnancy as well as improving your nutritional status prior to and during your pregnancy can lower your risk of pregnancy complications such as gestational diabetes and pre-eclampsia. Remember, you are not eating for two; you only need to increase your calorie intake by 300-500 calories. You should gain weight gradually during your pregnancy, with most of the weight gained in the last trimester.

Read your food labels! What are you consuming to help with your baby’s growth?  Food labels will tell you what nutrients are in the foods you eat. The letters RDA, which you find on food labeling, stand for recommended daily allowance, or the amount of a nutrient recommended for your daily diet. When you’re pregnant, the RDAs for most nutrients are higher.

Pregnant women need a balanced diet including:

  • Whole grains: Breads, cereals, pastas and brown rice.
  • Fruits: All types of fruits, fresh, frozen or canned without added sugar.
  • Vegetables: Eat a variety of colorful vegetables, fresh, frozen or canned with no added salt. Raw sprouts should be avoided.
  • Lean protein: Choose lean protein from meat, poultry, fish, eggs, beans and peas, peanut butter, soy products and nuts. Pregnant women should avoid eating tilefish, shark, swordfish and king mackerel, and limit white (albacore) tuna to 6 ounces per week. Deli, luncheon meats and hot dogs should be reheated if consumed.
  • Low-fat or fat-free dairy: This includes milk, cheese and yogurt. Unpasteurized milk and some soft cheeses that are made from unpasteurized milk should also be avoided.
  • Healthful fats: Vegetable oils including canola, corn, peanut and olive oil are good choices.

Avoid extra calories from added sugar and fats, which can lead to unhealthy weight gain. Cut down on foods such as regular soda, sweets and fried snacks. These are empty calories and of no nutritional value.

Key Nutrients for Healthy Pregnancy

  • Folate/Folic Acid: Folic acid reduces the risk of birth defects that affect the spinal cord. All women of childbearing age and pregnant women should consume 800 micrograms of folic acid each day. Sources include fortified foods such as cereals, pastas and breads, supplements and natural food sources of folate, including legumes, green leafy vegetables and citrus fruits.
  • Iron: Maternal iron deficiency is the most common nutritional deficiency during pregnancy.  A pregnant woman needs 27 milligrams a day. Your body uses iron to make hemoglobin, a protein in the red blood cells that carries oxygen to your tissues. During pregnancy your blood volume expands to accommodate changes in your body and help your baby make his or her entire blood supply, doubling your need for iron.

If you don’t get enough iron, you may become fatigued and more susceptible to infections. The risk of preterm delivery and low birth weight also might be higher.

Foods with high and moderate amounts of iron include red meat, chicken and fish, fortified cereals, spinach, some leafy greens and beans. For vegetarians and women who do not eat a lot of meat, increase iron absorption by combining plant-based sources of iron with vitamin C-rich foods. For example, try spinach salad with mandarin oranges or cereal with strawberries.

  • Calcium: During pregnancy, calcium is needed for the healthy development of a baby’s teeth, bones, heart, nerves and muscles. When a pregnant woman does not consume enough calcium, it is taken from her bones for the baby. It is important to consume adequate amounts of calcium daily before, during and after pregnancy. The recommended amount of calcium during pregnancy is 1,000 milligrams per day for adolescents 14 to 18 years old and 1,300 milligrams per day for women aged 19 to 50. That means at least three daily servings of calcium-rich foods such as low-fat or fat-free milk, yogurt or cheese or calcium-fortified cereals and juices.

Vitamin D Promotes bone strength and helps build your baby’s bones and teeth.  Fatty fish, such as salmon, is a great source of vitamin D.  Other options include fortified milk and orange juice.

There has been many studies recently revealing how common it is women of childbearing age are either insufficient or deficient in their levels of Vitamin D. This can cause an adverse outcome in pregnancy if not addressed.  Your vitamin D3 level should be > 40 ng/ml for a healthy pregnancy and for breastfeeding. Ask your healthcare provider to include your 25-OH-D concentrations of your Vitamin D level in your initial prenatal lab work.

Prenatal vitamins currently contain only 400 IU of Vitamin D3 which is inadequate.

 Protein is crucial for your baby’s growth, especially during the second and third trimesters. You need 71 grams/day. Good sources of protein include: Lean meat, poultry, fish and eggs are great sources of protein. Other options include dried beans and peas, tofu, dairy products, and peanut butter.

When you look at your food choices on your plate, you should have a variety of color!

Fine-tuning your eating habits to ensure you are receiving adequate nutrition for the health of you and your baby is key. Healthy eating during pregnancy is critical for a healthy pregnancy, healthy mom and baby!

Shelia L. Kirkbride,  MS, NC, VE.

 

colorfulplate

References:

Mayo clinic.org-Nutrients in pregnancy

maternal vitamin D supplementation reduces the risk of premature birth

http://tinyurl.com/q83koe6

https://www.vitamindcouncil.org/newsletter/newsletter-pregnancy-and-gestational-vitamin-d-deficiency/

Building a Strong Foundation for Your Pregnancy

Contemplating pregnancy?  Nutritional and optimal health should be priority number one!  Women contemplating pregnancy must keep in mind that healthy eating habits and healthy lifestyle behaviors should be established before pregnancy to make sure proper nutrient levels for early embryo development and growth.

Eating a balanced diet that includes the proper amount servings of protein, grains, fruit, and vegetables is key. Protein is essential to the very foundation of your baby’s growth. Eating enough protein ensures that your little one, from the very beginning, is getting adequate food stores to support cell growth and blood production.  Regular exercise should also be incorporated in your daily routine to prepare your body for the demands of pregnancy. Habits such as drinking or smoking must be avoided to allow for optimal health and development of the child during pregnancy and after birth.  Good habits should  include taking a daily multivitamin or a daily prenatal vitamin.  Even if you are consuming healthy foods daily, you can miss out on key nutrients.  A daily prenatal vitamin — ideally starting three months before conception — can help fill any gaps.  A quality, fast absorbing prenatal vitamin is necessary for all the basic micronutrients needed during pregnancy.eat-well-teaser

Through the course of pregnancy there is an increased need for nutrients and calories to make sure proper fetal growth. The increased need for vitamins and minerals such as folate, calcium and iron is necessary to prevent birth defects, ensure proper bone formation/retention, and to reduce the risks of preeclampsia or anemia. Folic acid intake increases to a daily amount of 800 mcg, calcium to 1200 mg, and iron to 30 mg. Your Vitamin D levels should be checked with your initial prenatal labs to be sure you levels are not insufficient or deficient.  Fetal needs for vitamin D increase during the latter half of pregnancy, when bone growth and ossification are most prominent. Vitamin D travels to the fetus by passive transfer, and the fetus is entirely dependent on maternal stores. Your body needs vitamin D to maintain proper levels of calcium and phosphorus, which help build your baby’s bones and teeth. A vitamin D deficiency during pregnancy can cause growth retardation and skeletal deformities. It may also have an impact on birth weight.  Therefore, maternal status is a direct reflection of fetal nutritional status.

Researchers believe that a vitamin D deficiency during pregnancy can affect bone development and immune function from birth through adulthood.

Blog by Shelia Kirkbride

The Benefits of Red Raspberry Leaf Tea in Pregnancy

Red Raspberry leaf tea is one of the safest and commonly used tonic herbs for women wanting to get pregnant or for women who are already pregnant. Red Raspberry Leaf (Rubus idaeus) tones the uterus, improves contractions and decreases constipation. Most tonics need to be used regularly, for a tonic is to the cells much like exercise is to the muscles; not much help when done irregularly . But you will still benefit even from occasional use of tonics during pregnancy, since they contain nourishing factors. The herb comes in forms of leaves to make teas or tonics as well as pill like capsules you can swallow.
Most of the benefits given to regular use of Raspberry lea tea throughout pregnancy can be traced to the strengthening power of fragrine, an alkaloid which gives tone to the muscles of the pelvic region, including the uterus itself; and to the nourishing power of the vitamins and minerals found in this plant. There is rich concentration of Vitamin C, the presence of Vitamin E and the easily assimilated calcium and iron. Raspberry leaves also contain vitamins A and B complex and many minerals, including phosphorus and potassium.
When to use: There are two basic points of view on the subject. There is agreement among many clinicians that in the 3rd trimester frequent (2- 3 cups per day of tea or 1 – 2 cups per day of infusion) is beneficial to the uterine and pelvic muscles.
The more radical point of view is that drinking one cup of tea per day in the 1st trimester and 2 cups in the 2nd trimester and switching to the infusion in the 3rd trimester ensures a strong uterus, is good for you nutritionally and prevents miscarriage. Some say it is advised to not use it in the first trimester, particularly if you have a history of miscarriage. If a mother is prone to miscarriages she may feel safer avoiding raspberry until the third trimester. This is an herb with centuries of safe use behind it, there is usually little cause for concern, but check with your healthcare provider before using.
According to Susun Weed, author of “Wise Woman, Herbal for the Childbearing Year,” the benefits listed below for drinking a Raspberry leaf brew before and throughout pregnancy are as follows:
• Increasing fertility in both men and women. Red Raspberry leaf is an excellent fertility herb when combined with Red Clover.
• Preventing miscarriage and hemorrhage. Raspberry leaf tones the uterus and helps prevent miscarriage and postpartum hemorrhage from a relaxed or atonic uterus.
o Use raspberry leaf infusion to help facilitate placenta delivery. Chips of frozen raspberry leaf infusion sucked throughout labor help keep the uterus working strongly and smoothly.

• Easing of morning sickness. Many women attest to raspberry leaves’ gentle relief of nausea and stomach distress throughout pregnancy. Drink a cup or two of raspberry leaf tea or infusion each day. Sipping the infusion before getting up or sucking on ice cubes made from the infusion increases the strength of this remedy.

• Reducing pain during labor and after birth. By toning the muscles used during labor and birth, Raspberry leaf eliminates many of the reasons for a painful birth and prolonged recovery. It does not counter the pain of dilation of the cervix.

Red Raspberry Leaves do not start or encourage labor. It can help the contractions to be productive once true labor has begun because it strengthens the uterine and pelvic muscles but it is not an oxytonic herb (one that would induce labor). That being said, it’s important to talk with your midwife, obstetrician or herbalist before beginning drinking red raspberry leaf tea or taking a supplement. Some will recommend you wait until you are 36 weeks along before incorporating the tea into your health regime while others may encourage you to begin right away. Each situation and pregnancy is different so it’s best to get other’s opinions before beginning red raspberry leaf tea.

Tea recipe: To make a tea, pour 1 cup boiling water over 2 teaspoons of herb and steep for ten minutes. Strain. During the first two trimesters, drink 1 cup per day. During the final trimester, drink 2-3 cups per day.

Excerpts from Weed, Susun. “Wise Woman Herbal Childbearing Year.”
http://www.motherandchildhealth.com/Prenatal/raspberry.html

Preconceptional Counseling and Care

Becoming a parent is a major commitment in life. It can be met with challenges, rewards and informed choices. Before you conceive, be sure to incorporate a healthy life-style to ensure optimal health for mom and baby. Receiving pre-conceptional counseling and care can lay the ground work for a healthy lifestyle and healthy pregnancy. Good health before pregnancy can help you cope with the stress of pregnancy, labor and birth. Obtaining good health care before you conceive will help you throughout your pregnancy. It also provides you with the opportunity to find out your risks, treat any medical problems that may affect the outcome of your pregnancy and adopt or continue a healthy lifestyle.

If you are planning to conceive, schedule a pre-conceptional visit with your healthcare provider. Included in your visit is a comprehensive history of your health including: Family history and risk factors, your medical history, surgical history, medications that you are presently taking including vitamins, supplements, OTC (over-the-counter) meds; your diet and lifetstyle and any past pregnancies.

Your preconception visit is a time for you to ask questions. Do not hesitate to seek advice, discuss your concerns and your options. Your healthcare provider is there to provide information and guidance to help you make informed choices in your healthcare to help you obtain and maintain a healthy pregnancy.

Women who are planning to conceive should stop their form of birth control several months in advance. Even though methods vary in use, it may affect when your menses resumes and becomes regular. During this time you may also want to start taking a prenatal vitamin daily to ensure you are getting added vitamins and increased folic acid.

Your lifestyle includes diet, exercise, weight, substance use, living/working environment and infection history. Current immunizations are important to prevent any infections during your pregnancy that can harm you and your baby, even if you were vaccinated as a child (measles, mumps, rubella, polio, tetanus), you may not be immune now. If you are vaccinated prior to conceiving, you will be protected. The vaccine for mumps, measles and especially rubella should be given at least 3 months
prior to conceiving. During this period of time, you should use a reliable method birth control.

Optimal health at any time during your lifetime involves a healthy diet and the proper amount of exercise. Ideally, you should be in good physical shape and follow a regular exercise regimen before your conceive. If you are not used to being active, you should start an exercise program gradually.

Tobacco, alcohol and recreational (illegal) drug use is addictive and can harm you and your baby that can last a lifetime or even result in death. They can have detrimental affects on the organ formation, causing damage. The misuse of prescription medication can also harm the fetus. For the sake of your own health and that of your baby, now is a good time to cut back on smoking and alcohol and quit all recreational drugs. It takes time and patience to quit a habit, especially if you have had that particular habit for a long time. Ask your healthcare provider to suggest ways to get through the withdrawal state or quitting and to refer you to support groups. Your decision to quit may be one of the hardest things you have ever done, but it will be one of the most worthwhile.

Does your work environment impose any hazards? If you are trying to conceive, it is a good idea to look closely at your work place and surroundings. Are you exposed to toxic substances, chemicals, or radiation? Discuss your level of exposure to specific substances with your employee health division, personnel office or union representative.

Exposure to lead or certain solvents, pesticides or other chemicals can reduce your partner’s fertility by killing or damaging sperm. Unlike women, who are born with a complete supply of eggs for their entire lifespan, men make new sperm on a daily basis for most of their lives. Unless the damage to a man’s reproductive system is very serious, he will probably be able to make healthy sperm against a short time span after his exposure to the harmful material stops.

Questions to Consider…
• Do I or a member of my family have a disorder that could be inherited?
• Do I need to gain or lose weight to prepare for pregnancy?
• Should I make any changes in my lifestyle?
• Could any medications I am taking cause problems during my pregnancy?
• Can I continue my present exercise program?
• Does my work expose me to things that could be harmful during pregnancy?
• Do I need to be vaccinated for any infectious diseases before I try to conceive?

Tips for Morning Sickness

by Angel J. Miller, MSN, CNM

Nausea, with or without vomiting, is known as “morning sickness” but may occur any time of the day or night. Although we do not know exactly why women experience morning sickness, some thoughts are:

• hormonal changes during pregnancy
• low blood sugar
• gastric overload
• slowed movement of the intestines
• enlarged uterus
• emotional factors

Take heart! In most cases morning sickness goes away by the 14th week of pregnancy.

Try the following comfort measures to ease the symptoms:

 Eat small, frequent meals (5-6 a day or on the average of every 2 hours)
• Avoid foods that do not have an appealing smell or taste to you at the time. Eat whatever sounds good. Let someone else do the cooking!
• Avoid strong or offensive odors, spicy, fried or greasy foods
• Restrict fat intake

 Dry crackers, cereal or bread—every time you are up to pee at night and first thing in the morning.
• On bad days, have crackers at the bedside even before getting/sitting up

 Drink or sip ice cold beverages. Some women do better just sucking on ice, and some do better when they add a splash of lemon juice to their cold water.
• Do not drink fluids with meals, do so after
• Do not drink large amounts of fluids at one time; sip on small amounts frequently between meals

 Eat a protein snack just before going to bed, such as cheese & crackers, or peanut butter & toast.

Stop your vitamins and iron supplements (temporarily) if you think they are adding to your morning sickness problem, or try taking the vitamin at bedtime with a snack.

Take a vitamin B6 (pyridoxine) tablet-30-50mg, 3 to 4 times a day-every day initially, then 1-2 times per day until problem has subsided
• Ovaltine is enriched with vitamin B6
• Another suggestion is to take Unisom (doxylamine) 1 tablet
(25 mg) at bedtime-with the vitamin B6. In the morning take ½ a tablet (with the B6). At 2 pm, ½ tablet with vitamin B6. Ask your pharmacist to help you find this medication. It is available over-the-counter and some brands are less expensive that others. In order for this to help, you need to take it regularly not just when you feel sick.

• Or you can take Vitamin B6, 100mg, po, three times a day with Magnesium 500mg, po, twice a day

Sea-Bands (seasickness prevention wrist bands) which are available at most drug stores help many women. Some women swear by them, and others do not find them helpful

• Take ginger. You can find this spice in the health food or vitamin stores. Get the 250 mg capsules. Take one capsule 4 times each day, or try nibbling on ginger snap cookies, sip on ginger tea
• Papaya or papaya tablets, as directed on the bottle
• Suck on fireballs or lemon balls; chewing cinnamon gum
• Alfalfa tablets—2 at bedtime, 2 late in day
• Basil, chamomile, spearmint, or peppermint tea

DO NOT SKIP MEALS EVEN IF YOU ARE NAUSEATED OR HAVE NO APPETITE! Graze…

If these suggestions do not work ask your health care provider about prescription medications that are available. They can make you sleepy; therefore it is wise to try the other remedies first.

**If you ever find that you are among the very few who are unable to keep anything down for 48 hours (even liquids) give us a call. In these extreme cases we recommend that you come into the hospital for IV fluid therapy.