Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues

1. Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues Presented by DR/ Heba Nour Lecturer f Family Medicine

2. Objectives of ANC part I • Describe protocol of Ante natal care according to up to date evidence • Describe current evidence regarding the use of ultrasonography in ANC • Describe the role of family physician in the management of perinatal care • How to determine due date accurately • How to assess fetal well-being • Discuss immunization during pregnancy • Discuss and agree upon a birth plan with an expectant mother • Discuss nutritional requirements during pregnancy and lactation • Discuss health education during pregnancy • Drugs in pregnancy

3. Introduction • pregnancy can be enhanced by a coordinated program of prenatal medical care and psychosocial support. • Care ideally begins before conception and includes preventive care, counseling, and screeningfor risks to maternal and fetal health

4. Importance of maternal health program 1-Mothers (pregnant and lactating) and children are vulnerable groups asthey are undergoing physiological changes that make them more liable tohave health problems, if their physiologic needs are not adequately met, 2-Mothers and children are at risk of high morbidity and mortality, but almost of their health problems are preventable, 3-Health problems in the in the fetal and early years of life may have longlasting effects and may result in disabling condition for life, 4-Investment in ANC services is highly cost-effective, 5-Females in the reproductive age form 25% of Egypt population and theunder- five children form 12% of the population. Therefore, ANC &child care servicesare expected to cover a more than one thirdof the population,

5. Providing Prenatal Care • In developed countries typically: regular prenatal visits, 7-11 times /pregnancy. • A recent meta-analysis: reducing the (N) visits (X) adverse outcomes for mother or infant; however, women were less satisfied • Caregiver continuity during ANC has been associated with reduced interventions in labor & improved maternal satisfaction.

6. Minimal required visits: • 1st visit as early as in the 1st trimester • 2nd visit 22-26 weeks • 3rd visit 30-32 • 4th visit 34-36 • 5th visit 38-40

7. Providing Prenatal Care • Care provided by midwives, family physicians, and obstetricianswas found to be equally effective • Although women were slightly more satisfied with care from midwives and family physicians

8. Prenatal Examinations prenatal care plans: • choice of caregiver • Initial visit ----1st trimester • > one visit ---cover all pertinent information • (EDD) calculated by accurate determ.of (LMP). • Accurate dating is important ? -timing screening tests -interventions -optimal management of complications

9. prenatal care plans: • The first 12 ws of pregnancy: time of organogenesis & vulnerability to teratogens; counseling about risk behaviors is appropriate

10. Counseling Issues & Health education

11. Level of evidence according to American Academy of Family physician • A = consistent, good-quality patient-oriented evidence; • B = inconsistent or limited-quality patient-oriented evidence • C = consensus, disease-oriented evidence, usual practice, opinion, or case series. See page 1245 for more information

12. Counseling Issues in Pregnancy

16. Evidence regarding physical examination

17. A history and directed physical examination:to detect conditions with increased maternal & perinatal morbidity & mortality

18. Physical examination Most guidelines recommend routine assessment: • Fundal height • Maternal weight • MaternalBP • FHS • Urine testing for protein & glucose • Questions about fetal movement.

19. Recommendations for Routine Prenatal Care

22. ASSESSMENT OF THE FETAL WELL-BEING MNCN CHAPTER 16

23. PROCEDURES AND DIAGNOSTIC TESTING TO ASSESS FETAL STATUS • Fetal Activity: kick counts • Ultrasound: • Transabdominal • Endovaginal • Three dimensional • Doppler Blood Flow studies • Assess uteroplacental function • Beginning at 16 to 18 weeks gestation

24. NON-STRESS TEST • Assess fetal well being • Procedure: • EFM to abdomen • Fetal heart rate measured: at least 2 accelerations of 15 bpm lasting 15 sec or more within 20 minutes • Fetal movement is documented • Possible clinical findings: • Fetus with adequate oxygenation and an intact central nervous system • Fetus at risk

25. CONTRACTION STRESS TEST • Initiation of contractions by pitocin or nipple rolling • Positive CST results: (bad) with persistent late decelerations is evidence that the fetus will not be able to withstand the hypoxic stress of the uterine contractions • Negative CST results: (good) No persistent decelerations noted with at least 3 ctx.

26. BIOPHYSICAL PROFILE • Assessment of 5 variables: • Fetal breathing movements • Fetal movements of body or limbs • Fetal tone • Amniotic fluid volume • Reactive nonstress test • Identifies compromised fetus • Desired BPP score: 8-10 considered normal

27. PROCEDURES AND DIAGNOSTIC TESTING TO ASSESS FETAL STATUS • Amniocentesis • Evaluation of fetal maturity • Lecithin sphingomyelin ratio • Phosphatidylglycerol test • Chorionic villus sampling • Percutaneous umbilical blood sampling

28. Blood Typing • Rh & ABO blood typing at 1st prenatal visit • RhoD IG (Rhogam) is recommended for all nonsensitized Rh-negative women at 28 weeks' (300 mcg) & within 72 hrs after delivery of an Rh+ve infant (120 to 300 mcg). • Nonsensitized, Rh-ve women also should be offered a dose of RhoD IG after spontaneous or induced abortion, ectopic pregnancy termination, chorionic villus sampling (CVS), amniocentesis, cordocentesis, external cephalic version, abdominal trauma, and second- or third-trimester bleeding

29. Blood Typing • Administration of RhoD IG can be considered before 12 w' gestation in women with a threatened abortion and live embryo • Written informed consent is recommended for use of RhoD immune globulin because it is a blood product.

30. Ultrasonography

31. Ultrasonography • No evidence directly links improved fetal outcomes with routine ultrasound scre • Early U/S is more accurate than LMP at determining GA, with uncertainty about the LMP • Diagnostic ultrasound exposure has not been proven to harm the mother or fetus, but more research on its risks is needed.

32. Ultrasonography • good evidence that U/S • (i.e., before 14 weeks' gestation) accurately determines gestational age, decreases the need for labor induction after 41 weeks' gestation, and detects multiple pregnancies. • Ultrasonography at 10 to 14 weeks' gestation can measure nuchal translucency as a screening test for Down syndrome. • ultrasound scan to search for structural anomalies between 18 and 20 weeks' gestation.

33. Nutrition & Food Safety

34. Nutrition and Food Safety • counseling for eat a well-balanced, varied diet. • Caloric requirements increase by 340 to 450 kcal per day in the second and third trimesters. • Most guidelines recommend that pregnant women with a normal BMI gain 11.5 to 16 kgduring pregnancy.

35. Observational studies antenatal weight gains below recommended range are associated with lbw- preterm birth • weight gains above the recommended range are associated with increased risk of macrosomia, cesarean delivery, and postpartum weight retention. • Experimental studies are needed to prove that weight gain outside the recommended range causes poor perinatal outcomes.

36. Use of Dietary Supplements in Pregnancy

37. Use of Dietary Supplements in Pregnancy

38. Use of Dietary Supplements in Pregnancy

39. Use of Dietary Supplements in Pregnancy

40. Medications during pregnancy

41. Drug exposure in early pregnancy • Family physician is faced with important task of counseling patients during preconception and prenatal periods: • Safety of drugs • Unplanned pregnancy • Birth defects

42. Use of medically indicated medications • Chronic conditions diagnosed before pregnancy: Epilpsy, asthma • Pregnancy indicated conditions: PIH, GD • Acute conditions: Infection, nausea & vomiting

43. Medications with known teratogenic effects

44. FDA Drug classification • Class A • No risk in controlled human studies • Examples • Pyridoxine (Vitamin B6) • Class B • No risk in controlled animal studies • Examples • Amoxicillin

45. Class C • Small risk in controlled animal studies • Examples • Codeine • Dicloxacillin • Class D • Strong evidence of risk to the human fetus • Examples • Valium • Class X (Never to be used in Pregnancy) • Very high risk to the human fetus • Examples • Xanax • Accutane

46. Drug prescription during pregnancy • General Recommendations • Avoid medications if possible in first trimester • Limit use to safe, short-acting, non-combination drugs • Topical medications are preferred over systemic agents • Use the lowest effective dose of a medication

47. Tetanus immunization

48. Tetanus immunization • Tetanus vaccine is a toxoid. • Toxoid vaccines are made by treating the toxins (or poisons) produced by clostridium tetani with heat or chemicals, such as formalin. • While this process destroys the toxin's ability to cause illness, the toxin is still able to stimulate the immune system to produce protective antibodies.

49. Tetanus immunization • For prevention of neonatal tetanus, TT is recommended for immunization of women of childbearing age, and especially pregnant women. • After completing the full basic course of 5 doses, there is no need for additional doses during pregnancy at least for the next 10 years; • thereafter a single booster would be sufficient to extend immunity for another 10 years. • If No previous immunisation, at least 2 doses of TT at 4weeks interval: 2 dose at least 2 weeks before delivery.

50. Tetanus immunization • ADMINISTRATIONThe vaccine should be administered by deep IM. Tetanus toxoid should be injected IM into the deltoid muscle in women and older children. • the preferred site for IM injection in young children is the anterolateral aspect of the upper thigh since it provides the largest muscular area. • The vaccine should be well shaken before use.