Prenatal Care

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Prenatal Care

• Kommerien Daling

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• History
• Goals
• Statistics
• Effects
• Current recommendations
• evidence

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After Dr. Delee's slander campaign against the
midwives and his successful campaign to scare our
grandmothers to the hospital so that resident
physicians might learn and have women to
experiment upon during birth, Mary Breckenridge
became the first American nurse midwife
Convinced that prolonged pounding of the fetal
head against a rigid perineum caused brain
injury, DeLee proposed his "prophylactic forceps"
operation in 1922
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History of PNC its goals

• 1901 Prevention of fetal abnormalities
• Reduction fetal/maternal/neonatal
• Physicians vs midwives
• Concerns about eclampsia
• Reduce low BW, PTL, infant
• 1985 Expanded Medicaid. Improve populations
  birth weight distribution.
• Counseling, education

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Statistics

• 4.3 million American babies/2006
• 440.000 to teenage mothers
• 75 receive adequate PNC
• 7-11 visits/ pregnancy

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• Studies until mid 70s no clear criteria
• for adequate care
• Most early studies uncorrected for confounding
• factors
• Kessner index of adequate PNC
• - EGA month of first visit
• - total of visits adjusted for EGA at
  delivery
• - site of prenatal care private vs public
• Shifting Demographics

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• Tuesdays 13,000, Sundays 7,000
• Increasing induction rates
• CS 2006 31
• breech gt 40yo 65/1000
• lt 20yo 30/1000

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• Medical risk factors for maternal infant
• morbidity/mortality HTN, DM
• gestational DM 1990 21/1000 births
• 2004 36/1000
• chronic DM gt 40 81/1000
• lt 20 11/1000
  
• gestational HTN 2004 38/1000 steady
  ? 1990-2000
• chronic HTN 1990 6.5/1000
• 2004 9.6/1000
• gt 40 27 /1000
• lt 20 3.5/1000

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Effects

• Decreased infant mortality rates attributed to BW
  specific mortality
• No improved weight distribution
• Succes of high tech advances vs prevention
• Decreased maternal mortality
• Meta-analysis reducing to 4-5 visits equal
  outcome, less satisfaction
• PN Caregiver contituity -gt
• ? labor intervention, ? satisfaction
• Care by FP -gt? cesarean section rate

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A consistent, good-quality
patient-oriented evidence B
inconsistent or limited-quality patient-oriented
evidence C consensus,
disease-oriented evidence, usual practice, or
case series
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Food supplements
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Recommended examinations
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Third trimester care
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FGR / IUGR

• condition in which a fetus is unable to achieve
  its genetically determined potential size
• SGA growth at the 10th or less percentile
• 40 at risk of perinatal death
• 40 are constitutionally small
• 20 2-ndary (eg. Trisomy 18, CMV, FAS)
• Screening fundal Ht _at_ 20wks. if ltgt 3cm -gt US
• Diagnosis US
• Further eval MFM

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IUGR. Maternal causes

• Chronic hypertension
• Pregnancy-associated hypertension
• Cyanotic heart disease
• Class F or higher diabetes
• Hemoglobinopathies
• Autoimmune disease
• Protein-calorie malnutrition
• Smoking
• Substance abuse
• Uterine malformations
• Thrombophilias
• Prolonged high-altitude exposure

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Pregnancy causes

• Twin-to-twin transfusion syndrome
• Placental abnormalities
• Chronic abruption
• Placenta previa
• Abnormal cord insertion
• Cord anomalies
• Multiple gestations

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IUGR. Interventions

• Quit Smoking
• Thrombophilia anticoagulation next pregnancy
• Select the right time for delivery
• if at all possible gt32wk
• No evidence for benefit
• nutritional suppl maternal O2
• ASA ß mimetic
• heparin CCB
• bedrest anti-HTN treatment
• corticosteroids

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Early US
Might decrease need for labor induction
PAP Might be less reliable in pregnancy
Domestic violence Screening improves
identification, No evidence for improved outcome
Genetic screening Counsel about ltd sens/spec of
tests What to do with POS Risks of
amniocentesis/CVS
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GBS screening/tx
Goal reduce EONS, chorioamnionitis CDC
guidelines screen everyone, treat all positives.
Penicillin. Canadian gdl screen everyone,
treat only high risk 2001 2/1000 EONS
cases 2004 0.34/1000 Fatality 4-23
(8-46/10.000) Saved 0.5-3/10.000 births
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• RF EONS PROM gt18h chorioamnionitis sustained
  fetal tachycardia temp in labor gt 38 prior
  GBS
• Concerns increase of ampi R non GBS
• ampi R GBS
• R to 6 of 12 alternative Abx
• (cetriaxone, clinda,
  Azithr)
• Racial disparity 70 increase of EONS in AA
  infants
• Vaccins on the way

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GBS bacteriuria

• What is the definition of bacteriuria
• Risk pyelonephritis
• chorioamnionitis OR 7.2
• First line of tx nitrofurantoin

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BV screening
Amsel criteria
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NVP / hyperemesis

• Weight loss gt 5, ketonuria
• factors psychological? Hormonal?
• HCG related?
• Abn gastric motility?
• RF migraine, motion sickness,
• N/V after estrogen/taste
• Anosmia -gt low risk
• Labs Ht ?, K ?, met. alk, LE ?,
• amylase/lipase x5, TSH ?,
• fT4 ?.

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treatment

• Avoid triggers
• Dietary change low fat, high carb
• Meds pyridoxine, phenergan,
• reglan, meclizine, (zofran)
• IVF, gut rest
• corticosteroids ?

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Gestational DM

• Incidence 2-5
• Screen all, except low risk (lt25yo)
• 2-step test 1h 50gm glucola
• 3h 100g GTT
• Has not shown to predict
• adverse perinatal outcomes
• RTC on the way.

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Post-term

• Stillbirth 1/3000 _at_ 37
• 3/3000 _at_ 42
• 6/3000 _at_ 43
• 1 meta-analysis routine induction at 41
• weeks reduces perinatal death, no ? CS
• EGA gt42 NST, US, AFI
• Sweeping of membranes NNT 8 to prevent
• 1 labor
  induction

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