Preconception Care: Providing Fetal/Maternal Health Risk Assessments Lecture 4

1. Preconception Care: Providing Fetal/Maternal Health Risk Assessments Lecture 4

2. Preconception Planning Important because: • Offers best protection against low birth-weight & other poor pregnancy outcomes. • 1989 - federal panel advised women planning to conceive to visit health care provider at least once before conception. • Healthy pregnancy closely related to woman’s health before conception. • Improves chances for healthy baby.

3. Preconception counseling: • Assess risks of medical & non-medical factors: GDM, HTN, heart disease, psychiatric disorders, domestic abuse, depression, Genetic disorders. • Discuss nutrition, meds, exercise, tobacco, alcohol, drug use, family support, unemployment, work-related hazards • Most critical time for fetus is day 17 – 56 when organs, limbs, skeletal, CNS forming. • Exposure to environmental risks harmful to embryo when woman may not realize she is pregnant.

4. Pre & Post-Pregnancy Planning Considerations for Potential Parents: Financial Responsibility: Cost of prenatal care, delivery, loss of work (both), child care (home or day care center), childrearing. Leaving workforce - does she plan to return ? Employment benefits -are they adequate to support maternal/infant pre & post natal care ? IMPORTANT COMPONENTS OF PRECONCEPTION CARE • See a health care provider. Get physical exam. • Discuss risks. Maintain follow-up care. Update Immunizations

5. Prenatal High-Risk Factors • Social/Personal: Low income level, poor diet, multiparity > 3, weight < 100lb; weight > 200 lb; age <16; age >35; smoking, addictions • Pre-existing medical hx: Diabetes mellitus, cardiac disease, anemia, hypertension, thyroid disorder, renal disease. • Obstetric: Previous stillborn, habitual abortion, cesarean delivery, Rh or blood group sensitization. [ABO or Rh incomp.]

6. “TORCH” special group of infections” • Toxoplasmosis, Hepatitis B, Syphilis, Varicella, Rubella, Rubeola, Cytomegalovirus, Herpes simplex O = other • TORCH applies to pregnant women, unborn child, newborn, children. Common cause of birth defects. • Can cause stillbirth. • Infection causes few symptoms in pregnant woman. • In infants - serious birth defects result if infections contracted during pregnancy/delivery. • 1st trimester – more severe defects

7. Current pregnancy: Check titers: vaccines available but most not during preg. Toxoplasmosis – rare; toxoplasma gondii [protozoal infec] transmitted to mom thru raw meat or exposure to infected cat’s feces. Severity > in 1st trimes. Varicella - member of herpesvirus; worse in 1st trimes. Infant may have life-threatening disease. Hep.BsAg – + Hepatits B in mom; infant gets Hep.B vaccine & Immunoglobulin @ delivery; followed by 2 more Hep.B vaccines in 1st yr. Syphilis – untreated can cause fetal death. Tx PCN Repeat VDRL > tx.

8. Rubella (1st trimester) 50% rate of malformation. (2nd tri) 6% rate of damage If non- immune, avoid anyone w. active disease. NO vaccine while pregnant but immunize > del. No preg. for 3 mos. Defects: Hearing loss, Deafness, Blindness, Heart & Neuro defects, Mental Retardation

9. Cytomeglovirus – part of herpesvirus family. Defects: Mental retardation, hydrocephaly , microcephaly, blindness; deafness. May be picked up during 1st year or > 1 yr of age. If 1st trimes.infection, may consider AB. HSV 2 [genital ]. Valtrex - suppress lesions; C/S if lesions @ time of del. Blindness, MR, death

10. Vaccines you can get during pregnancy: • Tetanus & influenza vaccine [flu] • Rubella vaccine: only after delivery • If equivocal [aka borderline] pt. gets vaccine. • MD order, consent signed by pt. • Explain risks of birth defects pregnant within 3 mos.of vaccine. Live virus. SC injection

11. HIV: test done in NYS to all newborns - Newborn Screening Test • 36% of HIV-infected women using illicit drugs during pregnancy had no prenatal care. • # of infants with AIDS (d/t perinatal transmission) declined from 122 in 2000 to 47 in 2004. (CDC) • CDC, AWHONN, Institute of Medicine & ACOG support policy of universal HIV testing as routine component of prenatal care. [2001] • Retest for HIV in 3rd trimester (new practice)

12. Do ELISA (screen) then Western Blot (confirm). • Seroconversion: Usually by 12-22 days after infection. All by 6 mos. • Offer HIV test @ initial visit. Mom can refuse. • Discuss risk of not taking test . HIV+ - treat with ZVD (zidovudine) in 2-3rd trimesters. Transmission ~ 25% without Rx; with tx ~ 8.3 %. If Rx begun @ del. or only to newborn, rate = 15%. • Treat in antepartum, intrapartum & infant x 6 weeks. • Monotherapy (ZVD) for viral load < 1,000. • New (2003): 3 drug tx reduces rate to 1-2 %. Start in 2nd trimester. For viral load > 1,000. • Woman must deal with guilt, depression, stigma.

13. Common Discomforts of Pregnancy 1st Trimester Nausea & vomiting • Causes: hormonal, fatigue, changes in carb metabolism • Interventions: sm. freq. meals; eat slow; dry toast ; deep breaths. • Ends by 2nd trim; if severe, hospitalize & hydrate

14. Nasal Stuffiness: Causes: edema of nasal mucosa d/t ^ estrogen levels Interventions: saline drops; humidifier. Pseudafed 2nd/ 3rd trimester. Breast Enlargement & Tenderness [cold weather] Causes: ^ estrogen & progesterone levels Interventions: Support bra with wide shoulder straps; jacket/sweater.

15. Urinary Frequency & Urgency • Causes: pressure of uterus on bladder; lasts 3 mos. & disappears; reappears in late preg. when head is engaged. + blood/burning on urination - signs of UTI. • Interventions: UA & urine Cx & Tx with AB. • Reduce caffeine. Do Kegel’s. Plan frequent BR stops. Increased vaginal discharge: “leukorrhea” • Causes: ^ estrogen & ^ blood supply to vagina; hyperplasia of vag.mucosa. • Interventions: daily bath; sanitary pads OK but no tampons, tight pants or underwear > infection. Pruritis/erythema - poss. fungal infection.

16. Common Discomforts Of 2nd & 3rd Trimesters Heartburn • Causes: Relaxation of cardiac sphinter, ↓ GI mobility; ↑ progesterone & gastric displacement. Food backs up from stomach into esophagus, irritates lining; “burning”. • Interventions: Small, freq. meals; chew slowly; avoid extra weight gain, avoid tight fitting clothes, avoid fried & fatty foods; sleep with HOB ^; Take antacid if all else fails.

17. Hemorrhoids [varicosities rectal veins] Causes: Pressure on pelvic veins; in ^ 3rd trimes Interventions: modified Sim’s position; stool softeners; witch hazel/cold compresses. Constipation Causes: oral iron supplements; ↓ peristalsis; displacement of bowels by fetus. Interventions: No mineral oil; interferes with vitamin metabolism. ^ po fluids; ^ roughage; attempt regular BM’s.

18. Backache: *R/O UTI 1st • Causes: Posture changes during preg.d/t ^ uterine enlargement • Interventions: Low heels; walk with pelvis tilted forward; squat when lifting; don’t bend. Firm mattress; heat therapy; Tylenol. Leg Cramps • Causes:Pressure from enlarging uterus, poor circulation; fatigue, ↓ Ca & ↑ Phosphorus • Interventions: dorsiflex affected foot; elevate legs. • Aluminum hydroxide [Amphogel] binds phosphorus & reduces it in circulation.

19. Shortness of Breath : Dyspnea Causes: pressure of uterus on diaphragm & compression of lungs; more @ night when flat. Interventions: 2-3 pillows @ night; sitting upright. Ankle Edema Causes: fluid retention & poor venous return from lower extremities; aggravated by prolonged sitting or standing & warm weather. Occurs near term. Interventions: ^ legs, avoid tight fitting pants

20. CONTROLLABLE RISK FACTORS Nutrition: Know ideal weight for your height. Instruct client to keep food diary. Examine food choices in daily diet. • If underweight/overweight before conception, counsel about proper nutrition. • Calcium/zinc - beneficial for long-term health needs & growth/development of baby. • Folic acid: protects against neural tube defects aka spina bifida.

21. GOOD SOURCES: Folic acid: broccoli, collard greens, dried peas, beans, citrus fruits and juices. Zinc: whole grains, oats, wheat, barley, peas, beans. Calcium: milk, yogurt, cheese, tofu, sardines with bones, soy milk, OJ, legumes.

22. US Public Health Service & March of Dimes recommends all women of childbearing age - 0.4 mg [400mcg] of folic acid daily - reduce risk of neural tube defects. No more than 1 mg. • Supplement Folic Acid intake if you are: • Of child bearing age • Planning pregnancy • 800-1000 mcg daily duringpregnancy PNV contain all requirements needed for pregnancy including folic acid & iron.

23. Nutrition • RDA: add 300 kcal in 2nd & 3rd trimester. • Total Calories = 2500kcal/day (pregnant); 2200 non-pregnant • Underweight clients >300 kcal. increase. (~ 2800 kcal/day) • RDA for protein/minerals/vitamins: ^ 60 g./day • Daily iron requirement doubles in preg. (15 to 30 mg) • Minerals (Ca, phos, iodine, Fe, Z) from fruits/veg. • Calcium/phosphorous stays same if client follows daily recommended intake; * teens < 19 need 1300mg./day.

24. Vegetarianism • Vegen diet – no food from animal sources (eggs, fish, chicken) most challenging for health care providers. • Adequate “pure” vegan diet: nuts, grains, vegetables, fruits, legumes, rice, soy milk. • May be anemic & not get enough calories. • FISH: up to 12 oz/wk of low mercury fish. Canned light tuna, shrimp, salmon, catfish is ok. • No swordfish, shark, tilefish, king mackerel (high mercury)

25. Lactose intolerance or cultural avoidance can lead to lowered calcium intake; recommend yogurt, cheese, sardines, beans, collard greens, figs, OJ, tofu, Lactaid. (commercial lactose). * Few demands placed on maternal nutrition in 1st trimester. • RDA fluids = 6-8 glasses (1500-2000 ml); water, milk, juices. • > 200mg caffeine daily doubles risk for miscarriage • 1 cup ~ 100 mg ~ 250ml

26. Weight Gain (new slide) • Women of Normal weight: 25 - 35 lbs. (11.5 - 16 kg) • Underweight women: 28 - 40 lbs. (12.6 - 18 kg) • Overweight women: 15 - 25 lbs. (7 - 11.5 kg) • Twins or Multifetus: woman should gain 4 to 6 lbs. in 1st trimester, 1.5 pounds per week in 2nd and 3rd trimester, for total of 35 to 45 lbs.

27. PICA: eating non-food substances (dirt, clay, laundry starch, paint chips) or foods of low nutritional value (ice, cornstarch) • In US, most common in African Americans, women from rural areas, or women with family hx pica. • Interferes with normal consumption of nutrients; causes anemia in mom. Possible lead poisoning. • In depth diet analysis – nutrition counseling • RN discusses cravings. 24 hr. diet re-call. • Follow up done @ prenatal visits. • Folic Acid for ^ RBC production. 50% more in pregnancy (800 ug/day); enriched grain products.

28. Controllable Risk Factors: Drug, Alcohol, Tobacco Use Alcohol:. Avoid all alcohol during time attempting conception/pregnancy. No known safe level during pregnancy. Associated with malformation, slow fetal growth, fetal death, low birth-weight, CNS abnormalities, neurologicaldefects, spontaneous abortion, abruption. Tobacco: Associated with spontaneous abortion, ectopic pregnancy; low birth-weight, infant mortality. Can potentially decrease fertility. Vasoconstriction restricts blood flow to fetus & reduces % of oxygen & nutrients carried by blood.

29. Illicit or Street Drugs:May be associated with severe medical & developmental problems in newborns. 1. Marijuana, most common - tend to have babies earlier & may be smaller than term babies. 2. Cocaine: associated with miscarriage, abruption, low birth-weight, premature birth, brain damage. 3. Heroin - IV drug users - evaluate for AIDS & Hep B. In HIV + women, studies show treatment with AZT reduces ransmission to baby from ~ 25% to 8%.

30. Exercise in Moderation • Boosts self-image, reduces tension, decreases physical discomfort. • Get medical clearance before starting exercise program. • Don’t exercise in hot/humid weather or to point of exhaustion. • Avoid exercise with risk of traumatic injury: downhill skiing, horseback riding, water skiing, tennis, etc. • Recommended: walking, cycling on stationary bike, swimming

31. Avoid High Internal Body Temp During early pregnancy, can interfere with normal embryonic development. Study published August 1992: use of hot tubs & saunas found to raise body temperature to 102ºF if women stayed in tubs for up to 15 minutes. ^ risk of neural tube defects in offspring.

32. Stress Management Techniques • Relaxation & deep breathing. Planning pregnancy can be stressful. • Stress reduction enhances chances of conception. • Excessive stress can lead to premature birth & low birth weight. Sleep 8-10 hr.with frequent rest periods a day.

33. Common STDs & effects to baby if untreated: • Chlamydia: Ear/eye infections, pneumonia. • Genital Herpes: Active infection - baby born thru vaginal opening with open sores – leads to severe skin infections, nervous system damage, blindness, mental retardation, death can occur. • Genital Warts: (If infection is active during delivery): Warts can grow in voice box & block windpipe. • Gonorrhea: Eye Infections, blindness. • Syphilis: Damage to bone, lung, liver, blood vessels • Other Infections that can cause PTL: UTI & BV

34. Exposure to Contraceptives • Controversial adverse effects on fetus. Do not use. Prescription and Over-the-Counter Drugs • Often unsafe during pregnancy: Accutane (acne) birth defects. • Avoid drugs used for headaches/common colds. Environmental Reproductive Hazards Avoid unnecessary environmental risks at home/work. • Paint Thinners, Varnish Removers, Cleaning Solvents, Glue • X-rays, Radioactive materials, Cat litter (toxoplasmosis) • Leave job with questionable hazards. • Use protective equipment/safety protocols.

35. FDA Pregnancy Risk Category for Drugs • Category A: no risk to fetus in any trimester • Category B: no adverse effects in animals; no human studies available • Category C: Only prescribed after risks to fetus are considered. Animal studies have shown adverse reaction; no human studies available • Category D: Definite fetal risks, may be given in spite of risks in life-threatening situations • Category X: Absolute fetal abnormalities. Do not use anytime in pregnancy (Lithium, Accutane)

36. Male Role in Preparing for Pregnancy Male planning to become father should: • Review family medical & genetic hx • Practice STD risk-reduction behaviors. • Avoid tobacco, alcohol, illicit/street drugs, chemical exposure. • Assess financial status. • Be supportive of partner. • Play active role in pre-pregnancy planning.

37. Age is a Big Factor Teenagers and Women over 40 years - greatest risk. Women over 40 years • Have decreased fertility. • Have increased risk for Downs Syndrome & hypertension. • Should talk with health care provider about Prenatal testing. • Healthy pregnant women > 40 yrs who follow recommended practices have about same chances as younger women for healthy pregnancy outcome.

38. TEENS: more likely [than women in 20’s] to have labor, delivery & low-birth-weight problems. Almost half of all pregnant teens do not get prenatal care in 1st trimester of pregnancy. Teens less likely to gain appropriate weight & often practice unhealthy eating habits.