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PRENATAL CARE
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- 2. INITIAL PRENATAL EVALUATION •GOALS: 1) Define the health status of the mother and fetus 2) Estimate the gestational age 3) Initiate a plan for continuing obstetrical care
- 3. PREGNANCY DURATION • Themean duration of pregnancy calculated from the first day of the last normal menstrual period is very close to 280 days or 40 weeks • EDD = adding 7 days to the date of the first day of the last normal menstrual period and counting back 3 months—Naegele rule
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- 5. PREVIOUS AND CURRENTHEALTH STATUS • Past Medical History • Menstrual history • Psychosocial Screening • Smoking cessation • Alcohol • Illicit Drugs • Intimate Partner Violence
- 6. SMOKING • Twofold riskof placenta previa, placental abruption and premature membrane rupture compared with nonsmokers • Neonates born to women who smoke are more likely to be preterm and have lower birthweights than infants born to nonsmokers
- 7. ALCOHOL • Ethyl alcoholor ethanol is a potent teratogen that causes a fetal syndrome characterized by growth restriction, facial abnormalities, and central nervous system dysfunction
- 8. ILLICIT DRUG USE •Include heroin and other opiates, cocaine, amphetamines, barbiturates and marijuana • Well-documented sequelae include fetal- growth restriction, low birthweight and drug withdrawal soon after birth
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- 10. CLINICAL EVALUATION • Thoroughgeneral physical examination should be completed at the initial prenatal encounter • Pelvic examination • Pap smear • Specimens for identification of Chlamydia trachomatis and Neisseria gonorrhoeae are also obtained when indicated
- 11. PREGNANCY RISK ASSESSMENT •factors exist that can adversely affect maternal and/or fetal well-being • - Diabetes Mellitus • - Cardiac Disease • - Genetic Abnormalities • - Chronic Hypertension • - Pulmonary Disease • - HIV infection • - Cancer • - Autoimmune Condition
- 12. PRENATAL VISITS • 4-weekintervals until 28 weeks, • then every 2 weeks until 36 weeks, • then weekly thereafter • Women with complicated pregnancies often require return visits at 1 to 2 week intervals.
- 13. PRENATAL SURVEILLANCE • Eachreturn visit - the well-being of mother and fetus are assessed - Fetal heart rate, growth, amnionic fluid volume, and activity are evaluated • - Maternal blood pressure, weight and their extent of change are assessed
- 14. PRENATAL SURVEILLANCE • DangerSigns in Pregnancy - severe or persistent headache - altered/disturbed vision - abdominal pain - severe nausea and vomiting - bleeding/ vaginal fluid leakage - decline on baby’s activity level
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- 17. FOLIC ACID • Dailyintake of 400 μg throughout the periconceptional period • 4 mg folic acid supplements the month before conception and during the first trimester if with previous child with NTD (reduce 2-5% recurrence risk by 70%)
- 18. PROTEIN • Second halfof pregnancy, approximately 1000 g of protein are deposited, amounting to 5 to 6 g/day • Sources: Meat, milk, eggs, cheese, poultry, and fish
- 19. IRON • 300 mgof transferred to the fetus and placenta • 500 mg incorporated into the expanding maternal hemoglobin mass • Requirements imposed by pregnancy and maternal excretion total approximately 27 mg of elemental iron supplement daily
- 20. IODINE AND ZINC IODINE •recommended daily allowance is 220 μg ZINC • recommended daily allowance is 12 mg/day
- 21. CALCIUM • In onerecent metaanalysis, Patrelli and coworkers (2012) reported that increased calcium intake lowered the risk for preeclampsia in high-risk women • In aggregate, most of these trials have shown that unless women are calcium deficient, supplementation has no salutary effects (Staff, 2014)
- 22. OTHER MINERALS ANDVITAMINS • Magnesium • Trace metals (Copper, selenium, chromium, and manganese) • Potassium • Fluoride • Vitamins A, B6, B12, C • Vitamin D- 15 μg per day or 600 IU per day
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- 24. EXERCISE • Regular, moderate-intensityphysical activity for 30 minutes or more • Refrain from activities with a high risk of falling or abdominal trauma
- 25. EMPLOYMENT • Physically-demanding work:20 to 60% increase in rates of preterm birth, fetal-growth restriction or gestational hypertension • Work is associated with fivefold risk of preeclampsia • Occupational fatigue—estimated by the number of hours standing, intensity of physical and mental demands, and environmental stressors—was associated with an increased risk of PPROM
- 26. AIR TRAVEL • Pregnantwomen can safely fly up to 36 weeks • Include seatbelt use while seated and periodic lower extremity movement and at least hourly ambulation to lower venous thrombo-embolism risks
- 27. COITUS • AVOIDED ifwith threat of abortion, placenta previa, or preterm labor
- 28. DENTAL CARE • Dentalevaluation should be included in prenatal care • Periodontal disease has been linked to preterm labor • Pregnancy is not a contraindication to dental treatment including dental radiographs
- 29. IMMUNIZATION • One doseof Tdap be given to women during each pregnancy, optimally between 27 and 36 weeks (CDC, ACOG) - 3 doses of Td should be received by pregnant patient 1 month apart. 3rd dose can be given postpartum
- 30. CAFFEINE INTAKE • Moderateconsumption of caffeine—less than 200 mg per day—does not appear to be associated with miscarriage or preterm birth, but that the relationship between caffeine consumption and fetal-growth restriction remains unsettled (ACOG) • Recommendation: Less than 300 mg daily, or approximately three 5-oz cups
- 31. NAUSEA AND VOMITING •Eating small meals at more frequent intervals but stopping short of satiation is valuable
- 32. BACKACHE • Reported bynearly 70% of pregnant women • Reduced by squatting rather than bending when reaching down, by using a pillow back support when sitting, and by avoiding high-heeled shoes.
- 33. VARICOSITIES • Venous legvaricosities have a congenital predisposition and accrue with advancing age • Treatment is generally limited to periodic rest with leg elevation, elastic stockings, or both
- 34. HEMORRHOIDS • Hemorrhoids: rectalvein varicosities, may first appear during pregnancy as pelvic venous pressures increase • Pain and swelling usually are relieved by topically applied anesthetics, warm soaks, and stool-softening agents
- 35. HEARTBURN • Upward displacementand compression of the stomach by the uterus, combined with relaxation of the lower esophageal sphincter • May give Aluminum hydroxide, magnesium trisilicate, or magnesium hydroxide alone or in combination
- 36. SLEEPING AND FATIGUE •Soporific effect of progesterone • Sleep efficiency appears to progressively diminish as pregnancy advances • Daytime naps and mild sedatives at bedtime such as diphenhydramine (Benadryl) can be helpful
- 37. LEUKORRHEA • Increased mucussecretion by cervical glands in response to hyper-estrogenemia is undoubtedly a contributing factor • Rule out vulvovaginal infection
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Editor's Notes
- #6 PSYCHOSOCIAL SCREEN: American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2012) define psychosocial issues as nonbiomedical factors that affect mental and physical well-beinG; barriers to care, communication obstacles, nutritional status, unstable housing, desire for pregnancy, safety concerns that include intimate partner violence, depression, stress, and use of substances such as tobacco, alcohol, and illicit drugs. This screening should be performed on a regular basis, at least once per trimester, to identify important issues and reduce adverse pregnancy outcomes