PRENATAL CARE Nazila karamy-MD gynechologist obstetritian www.doctor karamy .ir

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PRENATAL CARENazila karamy-MDgynechologist
obstetritian www.doctor karamy .ir
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Definition of Antenatal care

• comprehensive health supervision of a woman want
  to be pregnant_at_ pregnant woman before delivery

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History

• Personal history
• Family history
• Medical and surgical history
• Menstrual history
• Obstetrical history
• History of present pregnancy

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Preconceptional care

• FHfamilial marriage (increase risk thallassemia
  in some families,gt do Genetic consult if needed
  )
• Obstetrition HXin recurrent Abortion gtdo some
  tests

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PMH/PAST MEDICAL HX

• pulmonary HTN(50 mortality)
• IDDM(increased risk of malformationgtgood control
  of BS before pregnancy in organogenesis period
  is very preventive
• Rubellavaccinate ,pregnancy suggested after 3
  months

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• Hepatitis B In high risk cases vaccinate in
  contaminated husband ,hospital personnels if
  HBSAg is negative
• DX HIV ,VDRL positve
• DHteratogen(isotertinoin),Warfarrin ,some
  anticonvulsant drugs,ACEI
• X_raybetter not do esp in 3/1

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• Folic Acid
• Supplementation with 0.4 mg of folic acid (4 mg
  for secondary preventionhx NTD ,Anticonvulsant
  therapy ,thallassemia,) should begin at least
  one month before conception
• prevents neural tube defects
• Due to lack of folate in most women esp these
  days suggestgt more green leaf vegetables
  legumes, green leafy vegetables, liver, citrus
  fruits, whole wheat bread per day
• Folate deficiency is associated with low birth
  weight, congenital cardiac and orofacial cleft
  anomalies,NTD, abruptio placentae, and
  spontaneous abortion

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• Smoking ,alcohol (not have safe borderline)
• Remember LMP

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PRENATAL CARE
PNC

• Pregnancy is confirmed(U/A GT ,B HCG,)
• The initial visit should occur during the first
  trimester

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EDC (Estimated Date of Delivery)

• EDC should be calculated by accurate
  determination of the last menstrual period
  (LMP)gt(plus 7 days ,_3 months)
• Accurate dating is important for timing screening
  tests and interventions, and for optimal
  management of complications
• Some research indicates that early
  ultrasonography is more accurate than LMP at
  determining gestational age
• should be considered if LMP is uncertain

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Schedule for Antenatal VisitsFIRST VISIT

• The first visit or initial visit should be made
  as early is pregnancy as possible.
• Lab testsCBC,BG,Rh,IDC,FBS,BUN/Cr,HBSAg.VDRL,HIV
  Ab ,Rubela ab (IgG,IgM),U/A,U/C,TSH lately?,PAP
  SMEAR

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NEGATIVE BG

• Due to the risk of exposure and alloimmunization
• Rhogam should also be offered after
• spontaneous or induced abortion
• ectopic pregnancy termination
• chorionic villus sampling (CVS)
• amniocentesis
• cordocentesis
• external cephalic version
• abdominal trauma
• second- or third-trimester bleeding

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8 TO 18 WEEKS

• Sonography
• early sono best for GA
• NT,NB,CL11 TO 14 W(Best13w)
• R/O anomaly18 w to 20 w
• Fetal growth32-34w
• Labprocedure(Cvs,amniocentesis,cordocentesis)
• double test (PAPP-A,FREE HCG)
• Tripple test (UE3,HCG,AFP)
• Quadripple test (plus inhibin)
• 26 TO 28 WEEKSgtgtCBC,GCT,U/A
• 28 WEEKSgtgtIDC,RHOGAM
• 32 WEEKSgtgtCBC,Sopnography

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• Genetic Screening
• Family history of genetic disorders?
• Previous fetus or child who was affected by a
  genetic disorder?
• History of recurrent miscarriage?
• All women should be offered serum marker
  screening for neural tube defects and trisomies
  21 and 18
• Increased risk? amniocentesis or CVS may be
  offered
• Disease-specific screening should be offered to
  patients who belong to an ethnic group with an
  increased incidence of a recessive condition

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• Return Visits
• Once every month till 7th month(28 w)
• Once every 2 weeks till the 9th month(36 w)
• Once every week during the 9th month(36 to 40 w)

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Routine Prenatal Visits

• Fundal height
• Maternal weight
• Blood pressure measurements
• Fetal heart auscultation
• Urine testing for protein and glucose
• Questions about fetal movement
• Evidence supporting these practices is variable

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Physical Examinations

• Height of over 150 cm indication of an
  average-sized statue gtmay be not have good
  pelvic)
• BMI(20-26gtOK)
• In normal BMI the approximate weight gain during
  pregnancy is 12 kg. 2kg in the first 16 weeks
  and 10 kg in the remaining 20 weeks (1.5 kg per
  week until term).
• More BWgtless weight gain
• 7 to 18 Kg can be nl dependent to BMI

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• Most guidelines recommend that pregnant women
  with a normal body mass index gain approximately
  10- 12 Kg during pregnancy
• decreased weight gaingtlow birth weight and
  preterm birth
• Increased weight gain gt increased risk of
  macrosomia, cesarean delivery, and postpartum
  weight retention

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FUNDAL HEIGHT

• Determine FH check with GA(bladder must be
  empty)
• 12 W gtSP
• 20 wgtumblicus
• 18-32 w gt(cm equal with week)

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Local Examination

• The uterus may be higher than expected due to
  large fetus, multiple pregnancy, polyhydrammnios
  (PHA)or mistaken date of last menstrual period.
• The uterus may be lower than expected due to
  small fetus, intrauterine growth
  retardation(IUGR), oligohydramnios(OHA) or
  mistaken date of last menstrual period(LMP).

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• Blood pressure measurement
• It is not known how often blood pressure should
  be measured, but most guidelines recommend
  measurement at each antenatal visit

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• Evaluation for edema
• Edema occurs in 80 percent of pregnant women
• Edema is defined as greater than 1 pitting edema
  after 12 hours of bed rest, or weight gain of 2
  kg in one week
• Important esp in hand face
• It lacks specificity and sensitivity for the
  diagnosis of preeclampsia

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• Fetal heart sound is heard by sonicaid as early
  as 10thweek of pregnancy.
• Fetal heart sound is heard by Pinard' s fetal
  stethoscope after the 20thweek of pregnancy.
• The normal fetal heart rate is 120-160 beats/min

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Fetal kick count

• In primi gt20 to 22 w as kick at first
• In MP gt16 W
• Ask in each visit
• The pregnant woman reports at least 10 movements
  in 12 hours.
• In decreased FM gteat sweet food then left lat
  position palp abd count FM
• Absence of fetal movements precedes intrauterine
  fetal death by 48 hours.

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Health Teaching during the First Trimester

• Physiological changes during pregnancy
• Weight gain
• Fresh air and sunshine
• Rest and sleep
• Diet
• Daily activities
• Exercises and relaxation
• Hygiene
• Teeth
• Bladder and bowel
• Sexual counseling

• Smoking
• Medications
• Infection
• Irradiation
• Occupational and environmental hazards
• Travel
• Follow up
• Minor discomforts
• Signs of Potential Complications

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Nutrition

• Women should be counseled to eat a well-balanced,
  varied diet
• Caloric requirements increase by 400 kcal per
  day in the second and third trimesters

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• Iron
• Pregnant women should be screened for anemia
  (hemoglobin, hematocrit) and treated, if
  necessary
• IDA(Iron-deficiency anemia) is associated with
  preterm delivery(PTL) and low birth weight(LBW)
• Pregnant women should supplement with 30 mg of
  iron per day from 16-20 w to the end of
  pregnancy.

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• Vitamin A
• Pregnant women in industrialized countries should
  limit vitamin A intake to less than 5,000 IU per
  day
• High dietary intake of vitamin A (i.e., more than
  10,000 IU per day) is associated with
  cranial-neural crest defects
• High Liver eating not suggested in pregnancy
• Read dose of Vit A on each supplement drug

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Dietary Supplements

• Calcium
• RDI is 1,000 mg per day in women tht not take
• enough from nutrition

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• Vitamin D
• Vitamin D supplementation can be considered in
  women with limited exposure to sunlight (e.g.,
  northern locations)
• Evidence on the effects of supplementation is
  limited
• High doses of vitamin D can be toxic
• Article?more beautiful with ca-bicarbonate
  than ca-D

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• Caffeine-containing drinks
• Mild to Moderate amounts probably are safe
• Some guidelines recommend limiting consumption to
  150 to 300 mg per day
• Association between high caffeine consumption and
  spontaneous abortion and low-birth-weight infants

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• Exercise should be simple, mild exercise avoid
  lifting heavy weights
• A tooth can be extracted during pregnancy, but
  local analgesia is recommended (if x-ray needed
  gtuse abd shield)

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• Pregnant woman should avoid contact with
  infectious diseases especially rubella or (German
  measles) because it has deleterious effects on
  the fetus
• Influenza vaccine suggestable
• Pregnant woman should avoid exposure to x-ray or
  irradiation because of possible teratogenic
  effects on the fetus such as birth defects or
  childhood leukemia

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Common Discomforts of Pregnancy, Etiology, and
Relief Measures

• Urinary frequency
• RELIEF MEASURES
• Decrease fluid intake at night.
• Maintain fluid intake during day.
• Void when feel the urge.

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Fatigue

• RELIEF MEASURES
• Rest frequency.
• Go to bed earlier.

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Sleep difficulties

• RELIEF MEASURES
• Rest frequency
• Decrease fluid intake at night

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Breast enlargement and sensitivity

• RELIEF MEASURES
• Wear a good supporting bra.
• Assess for other conditions.

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Nasal stuffiness and epistaxis

• ETIOLGY Elevated estrogen levels
• RELIEF MEASURES
• Avoid decongestants.
• Use humidifiers, and normal saline drops.

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Ptyalism (excessive salivation)

• ETIOLGY Unknown
• RELIEF MEASURES
• Perform frequent mouth care.
• Chew gum.
• Decrease fluid intake at night.
• Maintain fluid intake during day.

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Nausea and vomiting

• RELIEF MEASURES
• Avoid food or smells that exacerbate condition.
• Eat dry crackers or toast before rising in
  morning.
• Eat small, frequent meals.
• Avoid sudden movements. Get out of bed slowly
• Breath fresh air to help relieve nausea.

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Shortness of breath

• RELIEF MEASURES
• Use extra pillows at night to keep more upright.
• Limit activity during day

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Heartburn

• RELIEF MEASURES
• Eat small, more frequent meals.
• Use antacids.
• Avoid overeating and spicy foods.

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Dependent edema

• Avoid standing for long periods.
• Elevate legs when laying or sitting.
• Avoid tight stockings.

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Varicosities

• Elevate legs regularly.
• Avoid crossing legs.
• Avoid tight stockings.
• Avoid long periods of standing

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Hemorrhoids

• RELIEF MEASURES
• Maintain regular bowel habits.
• Use prescribed stool softeners.
• Apply topical or anesthetic ointments to area.

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Constipation

• RELIEF MEASURES
• Maintain regular bowel habits.
• Increase fiber in diet.
• Increase fluids.
• Find iron preparation that is least constipating

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Leucorrhea

• RELIEF MEASURES
• Take a daily bath or shower.
• Wear cotton underwear.

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Backache

• RELIEF MEASURES
• Wear shoes with low heels.
• Walk with pelvis tilted forward.
• Use firmer mattress.
• Perform pelvic rocking or tilting

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Leg cramps

• RELIEF MEASURES
• Extend affected leg and dorsiflex the foot.
• Elevate lower legs frequently.
• Apply heat to muscles.
• Evaluate diet.

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Faintness

• Rise slowly from sitting to standing.
• Evaluate hemoglobin and hematocrit.
• Avoid hot environments

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Counseling Issues in Pregnancy

• Air travel?
• Hair dye?
• Exercise?
• Alcohol?
• Hot tubs?
• Sex? Smoking?

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• Air travel
• Safe for pregnant women until 4 weeks before the
  EDC
• Consider the availability of medical resources at
  the destination
• Lengthy trips are associated with increased risk
  of venous thrombosis

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• Exercise
• Pregnant women should avoid activities that put
  them at risk for falls or abdominal injuries
• At least 30 minutes of mild to moderate aerobic
  exercise on most days of the week is a reasonable
  activity level for most pregnant women

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• Hair Treatments
• Although hair dyes and treatments have not been
  associated clearly with fetal malformation,
  exposure to these treatments should be avoided
  during early pregnancy

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• Hot tubs and saunas
• Hot tubs and saunas probably should be avoided
  during the first trimester of pregnancy
• Maternal heat exposure during early pregnancy has
  been associated with neural tube defects and
  miscarriage

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• Labor and delivery
• All pregnant women should be counseled about what
  to do when their membranes rupture, what to
  expect when labor begins, strategies to manage
  pain, and the value of labor support

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• Breastfeeding
• Breastfeeding is the best feeding method for most
  infants
• Contraindications include galactosemia of
  neonate, breast cancer,maternal hepatitis
  C,breast abcess,post partum psychosis, HIV
  infection, chemical dependency(immune suppressive
  medication), and use of certain medications
• Structured behavior counseling and
  breastfeeding-education programs may increase
  breastfeeding success