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Prenatal care

Prenatal care. Dr.F Mostajeran. Prenatal care PNC. 1915 10000 consecutive deliveries 40% of prenatal death prevented by PNC 1945 organized PNC “more to save mother”. In adequate PNC. Kessner index Measuring adequacy PNC Recorded on birth certificate

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Prenatal care

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  1. Prenatal care Dr.FMostajeran

  2. Prenatal care PNC • 1915 10000 consecutive deliveries • 40% of prenatal death prevented by PNC • 1945 organized PNC “more to save mother”

  3. In adequate PNC • Kessner index • Measuring adequacy PNC • Recorded on birth certificate • Length gestation, time first PNC, number of visits • It does not measure quality not consider relative risk of mother 2000 12% American women inadequate PNC

  4. 2000 50% delayed or no PNC • Reason cited (social, ethnic group, age, method of pyment) • Women did not know she was pregnant • Lack of money or insurance • Inability to obtain an appointement

  5. Effectiveness of prenatal care past several decades no benefit • ↑ low birth weight • ↑ preterm labor (2 fold) • 1992 compared the cost an benifit PNC • 12000 patient missouri each$ spent PNC • Savings %1.49 in newborn and postpartum costs

  6. PNC+ overall F-death rate 2.7/1000 compared with 14.1/1000 without PNC • relative risk stillbith 3.3 fold • (p.previa – IuGR – post term) • Maternal – M 690/100000 • 1920 50/100000 1955 current maternal mortality rate 8/100000

  7. Organization of prenatal care • 2002 have defined prenatal care as • Medical care • Psychosocial support before conception throughout antipartum period • Program includes • Preconceptional care • Prompt diagnasis of preg • Initial presentation for p-care • Follow up prenatal visits

  8. Initial prenatal evaluation major goals are • To define health status mother-fetus • Gestational age of the fetus • Initiate a plan for continuing obstetrical care

  9. Prenatal record • History • Physical Ex • Laboratory tests • Nulligravida: • Not now and never has been pregnant

  10. Gravida • who is or has been pregnant primigravida – multi • Nullipara • who has never completed a prey begound 20 wk P± • Primipara • who has been delivered once fetus or fetvses alive or dead begon 20 wk • Multipara • two or more pregnancy completed after 20wk

  11. Normal pregnancy duration • Lmp 280 days 40 wk • Expected date of delivery (Naogele role) • First trimester 14 wk • Second trimester through 28 wk • Third trimester 29-42

  12. History • detailed information past obstetrical history complication tend to recur in subsequent preg • Menstrual history • Regular mens – oligomenorrhea • OCP

  13. Psychosocial screening • Cigarette smoking • Spontaneous abortion • LBW due to PTL or IUGR • Infant and fetal death • P. abruption

  14. Pathophysiologycal mechanism • Increased fetal carbonxhemoglobin • ↓ utero placental blood flow • Fetal hyponxia

  15. Alcohol • Potent teratogen F-alcohol syn • Growth restriction • Facial abnormalities • CNS disfunction

  16. Chronic VSC or lange quantities illicit drugs including opium barbiturates amphetamines • F- distress, LBW drug withdrawal

  17. Physical Examination • General physical Exam at initial PNC • Pelvic exam • Lubricated speculum warm water • Bluish-red passive hyperemia • Nabathian cysts • Identify cytological abnor pap smear • Specimens Identification neisseria gonorrhea • Chlamydia trachomatis

  18. Digital P.EX • Consistency length dilatation cervix • Presentation fetus • Bony architecture pelvis • Anomaly vagina perineum cystocle rectocele

  19. Subsequent prenatal visits • Traditionally timing subsequent PN visits • Interval 4 wk until 28 wk • Then every 2 wk until 36 wk thereafter weekly • Complicated pregnancy 1 to 2 wk intervals

  20. Prenatal surveillance • To determine well-being mother and fetus • Fetal • Heart rate • Size current – rate of change • AF • Presentation • Activity

  21. Maternal • BP change • Weight change • symptoms headache, altered vision, ab-pain vomiting, bleeding, vaginal fluid leakage dysuria • Height uterine fondues • V.E lat in prey (present, station, dilatation, effacement p-capacity)

  22. Assessment gestational age • LMP F.height (20-31) 34wk • Fetal Heart sounds 16-19 wk Delee fetal stethoscope • ultra sound • Between 8 and 16 wk slightly more accurate

  23. Lab test • Hct hb blood type AR factor • Antibody screen • u/c u/a FBS • Pap smear

  24. Subsequent lab tests • Maternal serum 15-20 NTD and chramosomal anomalies • MSAF free B HCG E2 inhebin A • Syphilis serology • Cystic fibrosis

  25. Ancillary prenatal tests • Gestational diabetes • 24-28wk • Ghlamydial infection • Group BS infection • Gonococcal infection • Ac OG 2002 centers for disease contral recommend vaginal and rectal GBS cultures in all women 35 to 37 wk if + intrapartum antimicrobial praphylanis • GBS bacteriuria • Previous infant with invasive disease

  26. Recommendation for weight gain • BMI normal (1908-26) 11.5-16 kg • BMI over weigh 26-29 7-11.5 kg • BMI > 29 obes 7 kg

  27. Weight retention after pregnanc • Weight gain 12.5 kg discharged 4.4 kg above her-perpregnant weight • at delivery waight last 5.5 kg • in ensuing 2 wk thereafter after 4 kg • 2.5 kg was lost between 2 weeks and 6 months postportum • Retain weight 1.4+_4.8kg her-perpregnant

  28. Recammended dietary Allowances • Calories 100-300 kcal per day whenever caloric intake inadequate protein metabolized (spared for f-growth and development) • Protein • Growth and repair • Fetus placenta uterus breast blood volume

  29. Most protein supplied from animal sources • Mineral • Exception Iron all diets supply sufficient caloric for appropriate weight gain contain enough minerals

  30. Iron • 300 mg Iron trans ferred tofetus placenta 500mg expanding M Hb mass nearly all is used after mid pregnancy • diet seldom contains enough iron to meet this demand recommended at least 27 mg ferrous iron supplement daily • This amount is contained in most prenatal vitamins • If she is large ,twin fetuses, begin late in pregnancy or has depressed Hb level benefit from 60-100mg first for months of pregnancy not necessary

  31. vitamins • Usually supplied by general diet provides adequate calories protein • Exception folic and during times of un usual requirements vomiting, hemolytic anemia or multiple fetuses

  32. Folic acid • 4000 pregnancy affected by NTD each year > 50y prevented daily 400 Ng preconception recurrent NTD 3100 • 4 mg daily folic acid for the month before and 3 month after preg.

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