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

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

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

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

5. 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

6. 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

7. 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

8. Smoking ,alcohol (not have safe borderline) Remember LMP

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

17. 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…

18. 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

19. Most guidelines recommend that pregnant women with a normal body mass index gain approximately 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

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

21. 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).

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

23. 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

24. 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 beats/min

25. 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.

26. 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

27. 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

28. 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 w to the end of pregnancy.

29. 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

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

31. 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

32. 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

33. 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)

34. 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

35. 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.

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

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

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

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

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

41. 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.

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

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

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

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

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

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

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

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

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

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

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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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