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Prenatal Care

Prenatal Care. Kommerien Daling. History Goals Statistics Effects Current recommendations & evidence.

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Prenatal Care

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  1. Prenatal Care KommerienDaling

  2. History • Goals • Statistics • Effects • Current recommendations & • evidence

  3. After Dr. Delee's slander campaign against the midwives and his successful campaign to scare our grandmothers to the hospital so that resident physicians might learn and have women to experiment upon during birth, Mary Breckenridge became the first American nurse midwife Convinced that prolonged pounding of the fetal head against a rigid perineum caused brain injury, DeLee proposed his "prophylactic forceps" operation in 1922

  4. History of PNC & its goals • 1901: Prevention of fetal abnormalities • Reduction fetal/maternal/neonatal † • Physicians vs midwives • Concerns about eclampsia • Reduce low BW, PTL, infant † • 1985: Expanded Medicaid. Improve populations birth weight distribution. • Counseling, education

  5. Statistics • 4.3 million American babies/2006 • 440.000 to teenage mothers • 75% receive adequate PNC • 7-11 visits/ pregnancy

  6. Studies until mid 70s – no clear criteria • for adequate care • Most early studies uncorrected for confounding • factors • Kessner index of adequate PNC • - EGA month of first visit • - total # of visits adjusted for EGA at delivery • - site of prenatal care: private vs public • Shifting Demographics

  7. Tuesdays: 13,000, Sundays: 7,000 • Increasing induction rates • CS 2006: 31% • breech > 40yo: 65/1000 • < 20yo: 30/1000

  8. Medical risk factors for maternal & infant • morbidity/mortality: HTN, DM • gestational DM 1990 21/1000 births • 2004 36/1000 • chronic DM > 40 81/1000 • < 20 11/1000 • gestational HTN 2004 38/1000steady  1990-2000 • chronic HTN 1990 6.5/1000 • 2004 9.6/1000 • > 40 27 /1000 • < 20 3.5/1000

  9. Effects • Decreased infant mortality rates attributed to BW specific mortality • No improved weight distribution • Succes of high tech advances vs prevention • Decreased maternal mortality • Meta-analysis: reducing to 4-5 visits: equal outcome, less satisfaction • PN Caregiver contituity ->  labor intervention,  satisfaction • Care by FP -> cesarean section rate

  10. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, or case series

  11. table 1 Counseling Issues in Pregnancy Air travel Air travel generally is safe for pregnant women until four weeks before the expected date of delivery.17 C Lengthy trips are associated with increased risk of venous thrombosis.2 C Breastfeeding Breastfeeding is the best feeding method for most infants. Breastfeeding contraindications include maternal HIV infection, chemical dependency, and use of certain medications.18 B Structured behavior counseling and breastfeeding-education programs may increase breastfeeding success.18,19 B Exercise Pregnant women should avoid activities that put them at risk for falls or abdominal injuries.20 C Scuba diving during pregnancy is not recommended.20 C 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.21 C Hot tubs and saunas Hot tubs and saunas probably should be avoided during the first trimester of pregnancy.22,23 B Maternal heat exposure during early pregnancy has been associated with neural tube defects and miscarriage.22,23 B 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.1 C Medications: prescription, over-the-counter, and herbal remedies Few medications have been proven safe for use in pregnant women, particularly during the first trimester of pregnancy.2 C Sex Sexual intercourse during pregnancy is not associated with adverse outcomes.2 B Substance use: alcohol All pregnant women should be screened for alcohol misuse.25 B There is no known safe amount of alcohol consumption during pregnancy. Abstinence is recommended.2,25 B Substance use: illicit drugs All pregnant women should be informed of the potential adverse effects of drug use on the fetus.27 C Admission to a detoxification unit may be indicated. Methadone therapy in opiate-addicted women maybe life-saving.3 C Substance use: smoking All pregnant women should be screened for tobacco use, and pregnancy-tailored counseling should be provided to smokers.2,28 A Workplace Some working conditions, such as prolonged standing and exposure to certain chemicals, are associated with pregnancy complications.10 B HIV = human immunodeficiency virus. 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. Information from references 1 through 3, 10, and 17 through 28.

  12. Seafood Caffeine- containing drinks Supplement Pregnant women should avoid shark, swordfish, king mackerel, tilefish, and tuna steaks.109,110 Pregnant women should limit intake of other fish (including canned tuna) to 12 oz (2 to 3 meals) per week.109 Guidelines Moderate amounts probably are safe. Some guidelines83,92,93 recommend limiting consumption to 150 to 300 mg per day.* B B l Calcium Recommended daily intake is 1,000 to 1,300 mg per day1,79 Routine supplementation with calcium to prevent pre-eclampsia is not recommended.1 However, calcium supplementation may be beneficial for women at high risk for gestational hypertension or in communities with low dietary calcium intake.10,80 A Folic acid Supplementation with 0.4 to 0.8 mg of folic acid (4 mg for secondary prevention) should begin at least one month before conception. A RDA (in addition to supplements) is 600 mcg of dietary folate equivalents (e.g., legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread) per day.82,83 B Iron Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary.78 B Pregnant women should supplement with 30 mg of ironper day.1,77 C Vitamin A Pregnant women in industrialized countries should limit vitamin A intake to less than 5,000 IU per day.*1 B Vitamin D Vitamin D supplementation can be considered in women with limited exposure to sunlight (e.g., northern locations, women in purdah).10,83 However, evidence on the effects of supplementation is limited.87 RDA is 5 mcg per day (200 IU per day).79 C Food & supplements

  13. Abdominal palpation Abdominal palpation should be used to assess fetal presentation beginning at 36 weeks' gestation.34,35 B Blood pressure measurement It is not known how often blood pressure should be measured, but most guidelines recommend measurement at each antenatal visit.27 C Evaluation for edema Edema occurs in 80 percent of pregnant women. It lacks specificity and sensitivity for the diagnosis of preeclampsia.36 C Fetal heart tones Auscultation for fetal heart tones is recommended at each antenatal visit. Heart tones confirm a viable fetus, but there is no evidence of other clinical or predictive value.10,33 C Fetal movement counts Routine fetal movement counting should not be performed.37,38 A Symphysis fundus height measurement Symphysis fundus height should be measured at each antenatal visit. Plotting the measurement on a graph is suggested for monitoring purposes.39-42 B Urinalysis Dipstick urinalysis does not detect proteinuria reliably in patients with early preeclampsia; measurement of 24-hour urinary protein excretion is the gold standard but is not always practical. Trace glycosuria also is unreliable, although higher concentrations may be useful.43-45 C Weight measurement Maternal height and weight measurements should be made at the first antenatal visit to determine body mass index, which is the basis for recommended weight gain in pregnancy.46-49 B Maternal weight should be measured at each antenatal visit.46-49 C Recommended examinations

  14. SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical recommendation Comments Azithromycin (Zithromax) is an effective treatment for chlamydia during pregnancy. B No long-term safety studies have been performed. Intramuscular ceftriaxone (Rocephin) and oral cefixime (Suprax) are similar in effectiveness for gonorrhea during pregnancy. B Spectinomycin (Trobicin; not available in the United States) is also effective but is painful to use. Initiation of acyclovir (Zovirax) or valacyclovir (Valtrex) treatment at 36 weeks' gestation reduces the recurrence of genital herpes lesions and the number of cesarian deliveries performed because of genital herpes. A In patients with known herpes. Serologic screening is not advocated. Penicillin is effective in the prevention of congenital syphilis. A Needs to be found and treated early. Screening should be carried out at the first visit. Treatment of trichomoniasis does not reduce the incidence of preterm birth. A Screening in asymptomatic women is not recommended. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 176 or http://www.aafp.org/afpsort.xml.

  15. Labor induction should be offered after 41 weeks' gestation. A All pregnant women should be screened for active hepatitis B infection by surface antigen. A All pregnant women should be screened for asymptomatic bacteriuria by urine culture at 12 to 16 weeks' gestation. A Sweeping of the membranes should be offered at term to reduce the need for labor induction. A All pregnant women should be screened for syphilis during their first prenatal visit. A Routine screening for bacterial vaginosis is not recommended. A All pregnant women should be tested for human immunodeficiency virus infection. B Third trimester care

  16. table 3 Disease-Specific Genetic Screening Disease Risk groups Carrier frequency Test Cystic fibrosis Ashkenazi Jews Caucasians 1 in 25 to 30 Molecular diagnostic testing*: standardized screening panelof 25 common mutations of the CFTR gene Tay-Sachs disease† Ashkenazi Jews Cajuns French Canadiansin Eastern Quebec 1 in 20 to 30 Serum hexosaminidase-A levels in men and nonpregnant women WBC hexosaminidase-A levels in pregnant women Molecular diagnostic testing is available in some centers. Canavan's disease† Ashkenazi Jews 1 in 40 Molecular diagnostic testing (not available in all centers) a- and b-thalassemia Africans East Indians Hispanics Mediterraneans Middle Easterners Southeast Asians 1 in 10 to 75 If MCV is less than 80 fL, hemoglobin electrophoresis, ferritin levels, and RBC morphology. DNA analysis may be required to detect a-thalassemia carriers. Sickle cell anemia Africans 1 in 11 Hemoglobin electrophoresis to detect hemoglobin S

  17. FGR / IUGR • condition in which a fetus is unable to achieve its genetically determined potential size • SGA: growth at the 10th or less percentile 40% at risk of perinatal death 40% are constitutionally small 20% 2-ndary (eg. Trisomy 18, CMV, FAS) • Screening: fundal Ht @ 20wks. if <> 3cm -> US • Diagnosis: US • Further eval: MFM

  18. IUGR. Maternal causes • Chronic hypertension • Pregnancy-associated hypertension • Cyanotic heart disease • Class F or higher diabetes • Hemoglobinopathies • Autoimmune disease • Protein-calorie malnutrition • Smoking • Substance abuse • Uterine malformations • Thrombophilias • Prolonged high-altitude exposure

  19. Pregnancy causes • Twin-to-twin transfusion syndrome • Placental abnormalities • Chronic abruption • Placenta previa • Abnormal cord insertion • Cord anomalies • Multiple gestations

  20. IUGR. Interventions • Quit Smoking • Thrombophilia: anticoagulation next pregnancy • Select the right time for delivery if at all possible >32wk • No evidence for benefit: – nutritional suppl – maternal O2 – ASA – ß mimetic – heparin – CCB – bedrest – anti-HTN treatment – corticosteroids

  21. Early US Might decrease need for labor induction PAP Might be less reliable in pregnancy Domestic violence Screening improves identification, No evidence for improved outcome Genetic screening Counsel about ltd sens/spec of tests What to do with POS Risks of amniocentesis/CVS

  22. GBS screening/tx Goal: reduce EONS, chorioamnionitis CDC guidelines: screen everyone, treat all positives. Penicillin. Canadian gdl: screen everyone, treat only high risk 2001: 2/1000 EONS cases 2004: 0.34/1000 Fatality 4-23% (8-46/10.000) Saved: 0.5-3/10.000 births

  23. RF EONS: PROM >18h chorioamnionitis sustained fetal tachycardia temp in labor > 38 prior GBS • Concerns: increase of ampi R non GBS • ampi R GBS • R to 6 of 12 alternative Abx • (cetriaxone, clinda, Azithr) • Racial disparity: 70% increase of EONS in AA infants • Vaccins on the way

  24. GBS bacteriuria • What is the definition of bacteriuria • Risk pyelonephritis chorioamnionitis OR 7.2 First line of tx: nitrofurantoin

  25. BV screening Amsel criteria

  26. NVP / hyperemesis • Weight loss > 5%, ketonuria • factors: psychological? Hormonal? • HCG related? • Abn gastric motility? • RF: migraine, motion sickness, • N/V after estrogen/taste • Anosmia -> low risk • Labs: Ht , K , met. alk, LE , • amylase/lipase x5, TSH , • fT4 .

  27. treatment • Avoid triggers • Dietary change – low fat, high carb • Meds: pyridoxine, phenergan, • reglan, meclizine, (zofran) • IVF, gut rest • corticosteroids ?

  28. Gestational DM • Incidence 2-5% • Screen all, except low risk (<25yo) • 2-step test: 1h 50gm glucola • 3h 100g GTT • Has not shown to predict • adverse perinatal outcomes • RTC on the way.

  29. Post-term • Stillbirth 1/3000 @ 37 • 3/3000 @ 42 • 6/3000 @ 43 • 1 meta-analysis: routine induction at 41 • weeks reduces perinatal death, no  CS • EGA >42 : NST, US, AFI • Sweeping of membranes: NNT 8 to prevent • 1 labor induction

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