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

1. PRENATAL CARENazilakaramy-MDgynechologistobstetritianwww.doctorkaramy .ir

2. Definition of Antenatal care comprehensive health supervision of a woman want to be pregnant@ 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 VisitsFIRST 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.VDRL,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 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

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. 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 120-160 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 &palpabd &count FM • Absence of fetal movements precedes intrauterine fetal death by 48 hours.

26. Health Teaching during the First Trimester • Smoking : • Medications • Infection • Irradiation • Occupational and environmental hazards • Travel • Follow up • Minor discomforts • Signs of Potential Complications • 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

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 16-20 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. 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 RELIEF MEASURES: • Rest frequency • 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.