Transcript Antenatal Care - Isfahan University of Medical Sciences

comprehensive health supervision of a woman
want to be pregnant@ pregnant woman
before delivery
 Personal
history
 Family history
 Medical and surgical history
 Menstrual history
 Obstetrical history
 History of present pregnancy
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FH:familial marriage (increase risk
thallassemia in some families,…=> do
Genetic consult if needed )
Obstetrition HX:in recurrent Abortion =>do
some tests
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pulmonary HTN(50% mortality)
IDDM(increased risk of malformation=>good
control of BS before pregnancy &in
organogenesis period is very preventive
Rubella:vaccinate ,pregnancy suggested after
3 months
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Hepatitis B :In high risk cases :vaccinate in
contaminated husband ,hospital personnels if
HBSAg is negative
DX HIV ,VDRL positve
DH:teratogen(isotertinoin),Warfarrin
,some
anticonvulsant drugs,ACEI
X_ray:better not do esp in 3/1
Folic Acid
 Supplementation with 0.4 mg of folic acid (4 mg
for secondary prevention:hx NTD ,Anticonvulsant
therapy ,thallassemia,…) should begin at least one
month before conception
◦ prevents neural tube defects
Due to lack of folate in most women esp these days
suggest=> more green leaf vegetables :legumes,
green leafy vegetables, liver, citrus fruits, whole
wheat bread per day
◦ Folate deficiency is associated with low birth weight,
congenital cardiac and orofacial cleft anomalies,NTD,
abruptio placentae, and spontaneous abortion
Smoking ,alcohol (not have safe borderline)
Remember LMP
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Pregnancy is confirmed(U/A GT ,B HCG,…)
The initial visit should occur during the first
trimester
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EDC should be calculated by accurate
determination of the last menstrual period
(LMP)=>(plus 7 days ,_3 months)
◦ Accurate dating is important for timing screening
tests and interventions, and for optimal
management of complications
◦ Some research indicates that early ultrasonography
is more accurate than LMP at determining
gestational age
 should be considered if LMP is uncertain
The first visit or initial visit should be made as
early is pregnancy as possible.
Lab
tests:CBC,BG,Rh,IDC,FBS,BUN/Cr,HBSAg.VDR
L,HIV Ab ,Rubela ab (IgG,IgM),U/A,U/C,TSH
lately?,PAP SMEAR
Due to the risk of exposure and alloimmunization…
Rhogam should also be offered after
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spontaneous or induced abortion
ectopic pregnancy termination
chorionic villus sampling (CVS)
amniocentesis
cordocentesis
external cephalic version
abdominal trauma
second- or third-trimester bleeding
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Sonography
early sono ;best for GA
NT,NB,CL:11 TO 14 W(Best:13w)
R/O anomaly:18 w to 20 w
Fetal growth:32-34w
Lab&procedure(Cvs,amniocentesis,cordocentesis)
double test (PAPP-A,FREE HCG)
Tripple test (UE3,HCG,AFP)
Quadripple test (plus inhibin)
26 TO 28 WEEKS=>>CBC,GCT,U/A
28 WEEKS=>>IDC,RHOGAM
32 WEEKS=>>CBC,Sopnography
Genetic Screening
◦ Family history of genetic disorders?
◦ Previous fetus or child who was affected by a genetic
disorder?
◦ History of recurrent miscarriage?
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All women should be offered serum marker
screening for neural tube defects and trisomies 21
and 18
◦ Increased risk? amniocentesis or CVS may be offered
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Disease-specific screening should be offered to
patients who belong to an ethnic group with an
increased incidence of a recessive condition
Return Visits:
 Once every month till 7th month(28 w)
 Once every 2 weeks till the 9th month(36 w)
 Once every week during the 9th month(36 to
40 w)
Assessment
History
Examination
Investigation
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Fundal height
Maternal weight
Blood pressure measurements
Fetal heart auscultation
Urine testing for protein and glucose
Questions about fetal movement
Evidence supporting these practices is
variable…
Height of over 150 cm indication of an
average-sized statue =>may be not have
good pelvic)
 BMI(20-26=>OK)
In normal BMI: the approximate weight gain
during pregnancy is 12 kg.; 2kg in the first
16 weeks and 10 kg in the remaining 20
weeks (1.5 kg per week until term).
More BW=>less weight gain
7 to 18 Kg can be nl dependent to BMI
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Most guidelines recommend that pregnant
women with a normal body mass index gain
approximately 10- 12 Kg during pregnancy
◦ decreased weight gain=>low birth weight and preterm
birth
◦ Increased weight gain =>: increased risk of macrosomia,
cesarean delivery, and postpartum weight retention
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Determine FH & check with GA(bladder must
be empty)
12 W =>SP
20 w=>umblicus
18-32 w =>(cm equal with week)
◦ The uterus may be higher than expected due to
large fetus, multiple pregnancy, polyhydrammnios
(PHA)or mistaken date of last menstrual period.
◦ The uterus may be lower than expected due to
small fetus, intrauterine growth retardation(IUGR),
oligohydramnios(OHA) or mistaken date of last
menstrual period(LMP).
Blood pressure measurement
 It is not known how often blood pressure
should be measured, but most guidelines
recommend measurement at each antenatal
visit
Evaluation for edema
 Edema occurs in 80 percent of pregnant
women
◦ Edema is defined as greater than 1+ pitting edema
after 12 hours of bed rest, or weight gain of 2 kg
in one week
◦ Important esp in hand &face
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It lacks specificity and sensitivity for the
diagnosis of preeclampsia
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Fetal heart sound is heard by sonicaid as
early as 10thweek of pregnancy.
Fetal heart sound is heard by Pinard' s fetal
stethoscope after the 20thweek of pregnancy.
The normal fetal heart rate is 120-160
beats/min
◦ In primi =>20 to 22 w as kick at first
◦ In MP =>16 W
◦ Ask in each visit
◦ The pregnant woman reports at least 10
movements in 12 hours.
◦ In decreased FM =>eat sweet food then
left lat position &palp abd &count FM
◦ Absence of fetal movements precedes
intrauterine fetal death by 48 hours.
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Physiological changes
during pregnancy
Weight gain
Fresh air and sunshine
Rest and sleep
Diet
Daily activities
Exercises and relaxation
Hygiene
Teeth
Bladder and bowel
Sexual counseling
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Smoking :
Medications
Infection
Irradiation
Occupational and
environmental hazards
Travel
Follow up
Minor discomforts
Signs of Potential
Complications
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Women should be counseled to eat a wellbalanced, varied diet
◦ Caloric requirements increase by 400 kcal per day in the
second and third trimesters
Iron
 Pregnant women should be screened for
anemia (hemoglobin, hematocrit) and treated,
if necessary
◦ IDA(Iron-deficiency anemia) is associated with
preterm delivery(PTL) and low birth weight(LBW)
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Pregnant women should supplement with 30
mg of iron per day from 16-20 w to the end
of pregnancy.
Vitamin A
 Pregnant women in industrialized countries
should limit vitamin A intake to less than
5,000 IU per day
◦ High dietary intake of vitamin A (i.e., more than
10,000 IU per day) is associated with cranial-neural
crest defects
◦ High Liver eating not suggested in pregnancy
◦ Read dose of Vit A on each supplement drug
Calcium
 RDI is 1,000 mg per day in women tht not take
enough from nutrition
Vitamin D
 Vitamin D supplementation can be considered in
women with limited exposure to sunlight (e.g.,
northern locations)
◦ Evidence on the effects of supplementation is limited
◦ High doses of vitamin D can be toxic
◦ Article======more beautiful with ca-bicarbonate than
ca-D
Caffeine-containing drinks
 Mild to Moderate amounts probably are safe
 Some guidelines recommend limiting
consumption to 150 to 300 mg per day
◦ Association between high caffeine consumption and
spontaneous abortion and low-birth-weight infants
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Exercise should be simple, mild exercise
avoid lifting heavy weights
A tooth can be extracted during pregnancy,
but local analgesia is recommended (if x-ray
needed =>use abd shield)
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Pregnant woman should avoid contact with
infectious diseases especially rubella or
(German measles) because it has
deleterious effects on the fetus
Influenza vaccine suggestable
Pregnant woman should avoid exposure to
x-ray or irradiation because of possible
teratogenic effects on the fetus such as
birth defects or childhood leukemia
Urinary frequency
RELIEF MEASURES:
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Decrease fluid intake at night.
Maintain fluid intake during day.
Void when feel the urge.
RELIEF MEASURES:
 Rest frequency.
 Go to bed earlier.
RELIEF MEASURES:
 Rest frequency
 Decrease fluid intake at night
RELIEF MEASURES:
 Wear a good supporting bra.
 Assess for other conditions.
ETIOLGY: Elevated estrogen levels
◦ RELIEF MEASURES :
 Avoid decongestants.
 Use humidifiers, and normal saline drops.
ETIOLGY: Unknown
RELIEF MEASURES:
 Perform frequent mouth care.
 Chew gum.
 Decrease fluid intake at night.
 Maintain fluid intake during day.
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Avoid food or smells that exacerbate condition.
Eat dry crackers or toast before rising in morning.
Eat small, frequent meals.
Avoid sudden movements. Get out of bed slowly
Breath fresh air to help relieve nausea.
◦ RELIEF MEASURES:
 Use extra pillows at night to keep more upright.
 Limit activity during day
RELIEF MEASURES:
 Eat small, more frequent meals.
 Use antacids.
 Avoid overeating and spicy foods.
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Avoid standing for long periods.
Elevate legs when laying or sitting.
Avoid tight stockings.
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Elevate legs regularly.
Avoid crossing legs.
Avoid tight stockings.
Avoid long periods of standing
RELIEF MEASURES:
 Maintain regular bowel habits.
 Use prescribed stool softeners.
 Apply topical or anesthetic
ointments to area.
RELIEF MEASURES:
 Maintain regular bowel habits.
 Increase fiber in diet.
 Increase fluids.
 Find iron preparation that is
least constipating
RELIEF MEASURES:
 Take a daily bath or shower.
 Wear cotton underwear.
RELIEF MEASURES:
 Wear shoes with low heels.
 Walk with pelvis tilted forward.
 Use firmer mattress.
 Perform pelvic rocking or tilting
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Extend affected leg and dorsiflex the foot.
Elevate lower legs frequently.
Apply heat to muscles.
Evaluate diet.
•Rise slowly from sitting to standing.
•Evaluate hemoglobin and
hematocrit.
•Avoid hot environments
Air travel?
Hair dye?
Exercise?
Alcohol?
Hot tubs?
Sex?
Smoking?
Air travel
 Safe for pregnant women until 4 weeks
before the EDC
◦ Consider the availability of medical resources at the
destination
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Lengthy trips are associated with increased
risk of venous thrombosis
Exercise
 Pregnant women should avoid activities that
put them at risk for falls or abdominal
injuries
◦ At least 30 minutes of mild to moderate aerobic
exercise on most days of the week is a reasonable
activity level for most pregnant women
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
Hot tubs and saunas
 Hot tubs and saunas probably should be
avoided during the first trimester of
pregnancy
 Maternal heat exposure during early
pregnancy has been associated with neural
tube defects and miscarriage
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
Breastfeeding
 Breastfeeding is the best feeding method for
most infants
◦ Contraindications include galactosemia of neonate,
breast cancer,maternal hepatitis C,breast
abcess,post partum psychosis, HIV infection,
chemical dependency(immune suppressive
medication), and use of certain medications
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Structured behavior counseling and
breastfeeding-education programs may
increase breastfeeding success