Transcript Slide 1
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 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
2000 50% delayed or no PNC Reason cited (social, ethnic group, age, method of pyment) 1.
Women did not know she was pregnant 2.
Lack of money or insurance 3.
Inability to obtain an appointement
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
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
Organization of prenatal care
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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
Initial prenatal evaluation major goals are
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To define health status mother-fetus Gestational age of the fetus Initiate a plan for continuing obstetrical care
Prenatal record
History Physical Ex Laboratory tests Nulligravida: Not now and never has been pregnant
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
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
History
detailed information past obstetrical history complication tend to recur in subsequent preg Menstrual history Regular mens – oligomenorrhea OCP
Psychosocial screening
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Cigarette smoking Spontaneous abortion LBW due to PTL or IUGR Infant and fetal death P. abruption
Pathophysiologycal mechanism
Increased fetal carbonxhemoglobin ↓ utero placental blood flow Fetal hyponxia
Alcohol
Potent teratogen F-alcohol syn Growth restriction Facial abnormalities CNS disfunction
Chronic VSC or lange quantities illicit drugs including opium barbiturates amphetamines F- distress, LBW drug withdrawal
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
Digital P.EX
Consistency length dilatation cervix Presentation fetus Bony architecture pelvis Anomaly vagina perineum cystocle rectocele
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
Prenatal surveillance
To determine well-being mother and fetus Fetal Heart rate Size current – rate of change AF Presentation Activity
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)
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
Lab test Hct hb blood type AR factor Antibody screen u/c u/a FBS Pap smear
Subsequent lab tests
Maternal serum 15-20 NTD and chramosomal anomalies MSAF free B HCG E2 inhebin A Syphilis serology Cystic fibrosis
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
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
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
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
Most protein supplied from animal sources Mineral Exception Iron all diets supply sufficient caloric for appropriate weight gain contain enough minerals
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
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
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.