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

Definition of Antenatal care comprehensive health supervision of a woman want to be pregnant@ pregnant woman before delivery

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

Preconceptional care FH:familial marriage (increase risk thallassemia in some families,…=> do Genetic consult if needed ) Obstetrition HX:in recurrent Abortion =>do some tests

PMH/PAST MEDICAL HX pulmonary HTN(50% mortality) IDDM(increased risk of malformation=>good control of BS before pregnancy &in organogenesis period is very preventive Rubella:vaccinate ,pregnancy suggested after 3 months

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

Folic Acid Supplementation with 0.4 mg of folic acid (4 mg for secondary prevention:hx 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 suggest=> 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

Smoking ,alcohol (not have safe borderline) Remember LMP

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

EDC (Estimated Date of Delivery) EDC should be calculated by accurate determination of the last menstrual period (LMP)=>(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

Schedule for Antenatal Visits FIRST VISIT The first visit or initial visit should be made as early is pregnancy as possible. Lab tests:CBC,BG,Rh,IDC,FBS,BUN/Cr,HBSAg.VDR L,HIV Ab ,Rubela ab (IgG,IgM),U/A,U/C,TSH lately?,PAP SMEAR

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

8 TO 18 WEEKS Sonography early sono ;best for GA NT,NB,CL:11 TO 14 W(Best:13w) R/O anomaly:18 w to 20 w Fetal growth:32-34w Lab&procedure(Cvs,amniocentesis,cordocentesis) double test (PAPP-A,FREE HCG) Tripple test (UE3,HCG,AFP) Quadripple test (plus inhibin) 26 TO 28 WEEKS=>>CBC,GCT,U/A 28 WEEKS=>>IDC,RHOGAM 32 WEEKS=>>CBC,Sopnography

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

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)

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…

Physical Examinations Height of over 150 cm indication of an average-sized statue =>may be not have good pelvic) BMI(20-26=>OK) 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 BW=>less weight gain 7 to 18 Kg can be nl dependent to BMI

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

FUNDAL HEIGHT Determine FH & check with GA(bladder must be empty) 12 W =>SP 20 w=>umblicus 18-32 w =>(cm equal with week)

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).

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

Edema occurs in 80 percent of pregnant women 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

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

Fetal kick count In primi =>20 to 22 w as kick at first In MP =>16 W Ask in each visit The pregnant woman reports at least 10 movements in 12 hours. In decreased FM =>eat sweet food then left lat position &palp abd &count FM Absence of fetal movements precedes intrauterine fetal death by 48 hours.

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

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

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.

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

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

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

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

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 =>use abd shield)

Influenza vaccine suggestable 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

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.

Fatigue RELIEF MEASURES: Rest frequency. Go to bed earlier.

Sleep difficulties Rest frequency RELIEF MEASURES: Decrease fluid intake at night

Breast enlargement and sensitivity RELIEF MEASURES: Wear a good supporting bra. Assess for other conditions.

Nasal stuffiness and epistaxis ETIOLGY: Elevated estrogen levels RELIEF MEASURES : Avoid decongestants. Use humidifiers, and normal saline drops.

Ptyalism (excessive salivation) ETIOLGY: Unknown RELIEF MEASURES: Perform frequent mouth care. Chew gum. Decrease fluid intake at night. Maintain fluid intake during day.

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.

Shortness of breath RELIEF MEASURES: Use extra pillows at night to keep more upright. Limit activity during day

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

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

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

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

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

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

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

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

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

Counseling Issues in Pregnancy Air travel? Hair dye? Exercise? Alcohol? Hot tubs? Sex? Smoking?

Safe for pregnant women until 4 weeks before the EDC 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

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

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

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

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

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