Download Prenatal care ROBAB DAVAR MD Obstetrician and Gynecologist

Prenatal care
ROBAB DAVAR M.D.
Obstetrician and Gynecologist, Fellowship of
Infertility
Shahid sadoughi university of medical sciences
• In the United States, the first
organized prenatal care programs
began in 1901 with home nurse
visits. The first prenatal clinic was
established in 1911.
Content of the Preconception Visit
• Unalterable Factors
• are preexisting factors that cannot be altered in
any medical way by clinical intervention.
These include the patient's height, age,
reproductive history, ethnicity, educational
level, socioeconomic status, genetic
composition, and to some extent her body
mass index (BMI).
• Factors Benefiting from Early Intervention
poor nutrition; an underweight or obese BMI;
and poorly controlled medical diseases such as
diabetes mellitus, asthma, epilepsy,
phenylketonuria, hypertension, and thyroid
disease.
• Some prescription medications that are known
teratogens should be discontinued . These include
medications such as isotretinoin (Accutane),
warfarin sodium (Coumadin), certain
anticonvulsants, and angiotensin-converting
enzyme inhibitors. However, many medications
are safe, such as medications for asthma and most
antihistamines. Some medications such as
antidepressants need to be evaluated for the
risk:benefit ratio.
• Alcohol is a known teratogen. There is no
correlation between the quantity of alcohol
consumed and the manifestation of adverse
fetal effects. Therefore, the best advice to
women who wish to become pregnant is to
stop drinking.
• Smoking cigarettes is associated with adverse
pregnancy outcomes, including low birth
weight, premature birth, and perinatal death.
• status of a patient's immunity to rubella,
varicella, and hepatitis is appropriate during
the preconception visit. If needed, the
influenza vaccine is safe. In high-risk
populations or endemic geographic areas,
patients should be assessed for active
tuberculosis with skin testing and chest x-ray.
• evaluation of the thyroid and breasts is
important.
• If a Pap smear has not been done within a
year, this test should be repeated at this time.
• assessment of dental hygiene is important.
• Folic acid can reduce the occurrence and
recurrence of neural tube defects and may
reduce the risk of other birth defects as well.
• Women who have had a previous pregnancy
affected by neural tube defects should take 4
mg of folic acid per day, starting 4 weeks prior
to conception through the first trimester.
• For all other women , 1 mg of folic acid
should be prescribed.
Initial Prenatal Visit
• The optimal timing of this visit may vary. For
women who have not undergone the
preconception visit, prenatal visits should
begin as soon as pregnancy is recognized.
• All other women should be seen by about 8
menstrual weeks (6 weeks after conception)
gestation.
• Gestational Age
• The NÃgele rule is commonly applied in calculating an
estimated date of confinement (EDC).
• Using the date of the patient's last menstrual period
minus 3 months plus 1 week and 1 year, for
convention, 280 days is the currently accepted average
gestation.
• The majority of pregnancies deliver within 2 weeks
before or after this estimated date.
• When the last menstrual period is unknown or the
cycle is irregular, ultrasound measurements between the
14 and 20 weeks for determination of gestational age .
Physical Examination
• includes BMI, blood pressure, thyroid, skin, breasts, and pelvis.
• On pelvic examination, the cervix is inspected for anomalies and for
the presence of condylomata, neoplasia, or infection. A Pap smear is
performed, and cultures for gonorrhea and chlamydia are taken, if
indicated. On bimanual examination, the cervix is palpated to assess
consistency and length as well as to detect the presence of cervical
motion tenderness. Size, position, and contour of the uterus are
noted. The adnexa are palpated to assess for masses.
• The pelvic examination may include evaluation of the bony pelvis
specifically, the diagonal conjugate, the ischial spines, the sacral
hollow, and the arch of the symphysis pubis.
Laboratory Evaluation
• Blood Tests
• white blood cell count, hemoglobin, hematocrit,
and platelet count. Full red cell indices are
advised for women of Asian descent to evaluate
for thalassemia, a serologic test for syphilis (RPR,
rapid plasma reagin or VDRL), a rubella titer, a
hepatitis B surface antigen, a blood group (ABO),
and Rh type and antibody screen. HIV testing.
• Urine Tests
• All women should have a clean-catch urine
sent for culture. Asymptotic bacteriuria occurs
in 5% to 8% of pregnant women.
• The use of routine genital tract cultures in
pregnancy is controversial.
• The ACOG recommends assessment for
chlamydiosis and gonorrhea at the first
prenatal visit for high-risk patients.
• Physical Examination
• The patient's weight is measured, and total weight
gain are evaluated .
• The blood pressure is taken and trends are
assessed for possible pregnancy-induced
hypertension. As blood pressure tends to decrease
during the second trimester, increases of 30 mm
Hg systolic or 15 mm Hg diastolic over firsttrimester are considered abnormal .
• The fundal height is measured.
• Gestational age is approximately equal to fundal
height in centimeters from 16 to 36 weeks
gestation.
• Measurements that are more than 2 cm smaller
than expected for week of gestation are suspicious
for oligohydramnios, IUGR, fetal anomaly,
abnormal fetal lie, or premature fetal descent into
the pelvis.
• larger than expected measurements may indicate
multiple gestation, polyhydramnios, fetal
macrosomia, or leiomyomata.
• Screening for Gestational Diabetes
• The 1-hour, 50-g oral glucose screen is used to
detect glucose intolerance in pregnancy.
Following an abnormal screen, a 3-hour
glucose tolerance test, commencing with a
fasting blood sugar, followed by a 100-g
glucola, is currently recommended.
• Two or more abnormal values on this test are
considered diagnostic of GDM.
• All Rh-negative women who are unsensitized
should be retested at approximately 26 to 28
weeks gestation. If the antibody screen remains
negative, the mother should receive Rh0(D)
immune globulin 300 mcg at 28 weeks to prevent
isoimmunization in the third trimester.
• Approximately 1% of Rh-negative women will
become sensitized if not given Rh immune
globulins.
• Routine Ultrasound
• ultrasound should be performed before 20
weeks so that appropriate referrals and
consultation can be obtained if abnormalities
are discovered.
The list of warning signs includes the following:
• Vaginal bleeding
• Leaking of fluid from the vagina
• Rhythmic cramping pains of more than six per hour
• Abdominal pain of a prolonged or increasing nature
• Fever or chills
• Burning with urination
• Prolonged vomiting more than 24 hours
• Severe continuous headache, visual changes, or generalized
edema
• A pronounced decrease in the frequency or intensity of fetal
movements.
Maternal Weight Gain
• Women with a BMI <19.8 should gain between 30 and
40 lb.
• Women with a normal BMI of 19.8 to 26 should gain
between 25 and 35 lb.
• Women with a high BMI, between 26.1 and 29, should
gain 15 to 25 lb.
• Women who are obese should aim for a 15 lb weight
gain .
• The optimal weight gain for women with twins with a
normal BMI is approximately 40 lb or 10 to 15 lb more
than for a singleton.
Maternal Diet
• A diet should be balanced by containing foods
from all of the basic food groups.
Vitamin and Mineral Supplementation
• Multivitamin supplements are not routinely
necessary in a woman eating a well-balanced diet.
However, 800 to 1,000 mg of supplemental folic
acid daily is necessary .
• Mineral supplementation is also not needed in
healthy women. The exception is iron. The iron
requirements of pregnancy total about 1 g.
• supplementation with 30 mg of elemental iron is
recommended in the second and third trimesters.
• Calcium supplementation is not necessary in
women with a diet that includes adequate dairy
foods.
• recommended dietary allowance (RDA) of 1,200
to 1,500 mg per day during pregnancy and 2,000
mg per day with lactation.
• Women with twins may be given 2,000 mg daily.
Women in their mid thirties should also receive
increased dosing. Calcium is best absorbed in an
acidic pH, similar to iron. To absorb calcium,
adequate vitamin D is needed.
Pica
• Pica is the compulsive ingestion of nonfood
substances with little or no nutrient value.
• Megadose Vitamins
• There is an association between high doses of
supplemental vitamin A and birth defects similar
to those seen with isotretinoin.
• minimum teratogenic dose in humans has not
been identified, it may be 10,000 IU per day.
Beta-carotene is a provitamin of vitamin A, but it
does not produce similar toxicity.
• Most prenatal vitamins contain less than 5,000 IU
of vitamin A and, this should be considered the
maximum safe supplemental dose.
Nausea and Vomiting
• Recurrent nausea and vomiting during the first trimester
occurs in over one half of pregnancies.
• Symptoms usually begin in weeks 6 to 8, peak during weeks
12 to 14, and are significantly resolved by week 22.
• Hormonal as well as emotional factors have been
investigated. Symptoms can be mild or so severe that the
patient becomes dehydrated and risks of electrolyte
imbalance and caloric malnutrition.
• Nonpharmacologic measures include avoidance of fatty or
spicy foods; eating small, more frequent meals, and inhaling
peppermint oil vapors.
• vitamin B6, 25 mg two to three times a day.
• antihistamines, doxylamine, promethazine,
metoclopramide, trimethobenzamide,
methylprednisolone, and serotonin 5-Ht3 antagonists
such as ordansetron.
• Because supplemental vitamin and mineral
preparations may exacerbate symptoms of nausea, they
should be stopped until the symptoms have resolved.
• Hyperthyroid disease will exacerbate nausea and
vomiting, and if signs of thyroid disease, free T4 levels
and treatment initiated.
• Some studies have found Helicobacter pylori infection.
• Ptyalism
• Ptyalism is the increased production of saliva
Heartburn
• is usually caused by reflux esophagitis from both
mechanical factors (the enlarging uterus displacing the
stomach above the esophageal sphincter) and hormonal
factors (progesterone causing a relative relaxation of the
esophageal sphincter).
• Treatment consists of eliminating acidic and spicy foods,
decreasing the amount of food and liquid at each meal,
limiting food and liquid intake before bedtime, sleeping in a
semi-Fowler position or propped up on pillows, and use of
antacids. Liquid forms of antacids and H2-receptor
inhibitors.
• Proton pump inhibitors are sometimes necessary in severe
cases.
Constipation
• Progesterone-induced relaxation of the intestinal
smooth muscle slows peristalsis and increases
bowel transit time.
• Dietary management includes increased fluids
and liberal intake of high-fiber foods.
• Iron salts may exacerbate the problem.
• OTC products containing psyllium draw fluid into
the intestine and promote a more rapid transit
time.
• Enemas should be avoided.
Exercise
• For a normal pregnancy, a low-impact exercise regimen
may be continued throughout pregnancy.
• There are no data to indicate that pregnant women must
decrease the intensity of their exercise or lower their
target heart rates.
• motionless standing or the supine position can result in
decreased venous return and cardiac output. This will
result in hypotension or syncope.
• women who exercise regularly have shorter labors.
• women with GDM, regular exercise has been shown
to be helpful for glucose control.
Varicosities and Hemorrhoids
• Varicosities most often occur in the lower extremities
and may be seen in the vulva as well. Treatment
includes avoidance of garments that constrict at the
knee and upper leg, support stockings, and increased
periods of rest with the legs elevated.
• Hemorrhoids, which are varicosities of the rectal veins,
are due to mechanical compression by the enlarging
uterus as well as from constipation and straining at
stool.
• Treatment includes OTC preparations, topical
preparations, cool sitz baths, and stool softeners.
Fatigue
• Pregnant women will usually have an
increased sense of fatigue during pregnancy.
Syncope
• Venous pooling in the lower extremities
increases as the pregnancy progresses. This
can lead to dizziness or lightheadedness,
especially after standing upright abruptly or for
long periods of time.
• Other causes of syncope include dehydration,
hypoglycemia, and the shunting of blood flow
to the stomach after eating a large meal.
Sleep Disturbances, and Leg Cramps
• Most women will develop alterations from their normal sleep
patterns during pregnancy.
• More frequent urination, more common gastric reflux, and physical
discomfort with the growing pregnancy all contribute to poorer
sleep.
• Antihistamines are usually recommended.
• Almost half of all pregnant women suffer from recurrent painful
spasms of the muscles of the lower extremities, especially the
calves.
• Leg cramps are more frequent at night and usually occur during the
third trimester. therapeutic options have been suggested , calcium
lactate and high-potassium foods such as banana, kiwi . Massage,
heat, and stretching the affected muscle(s) relieves the cramps .
Backache
• Most pregnant women experience lower
backaches as pregnancy progresses.
• These are usually alleviated by minimizing
the amount of time spent standing, increasing
rest, wearing a specially designed support belt
over the lower abdomen, and taking an
analgesic such as acetaminophen.
Round Ligament Pain
• most frequently occurs during the second
trimester when women report sharp, bilateral,
or unilateral groin pain. it is not known if
round ligament stretch is the true etiology. The
pain may be increased with sudden movement
or change in position.
Headache
• Generalized headaches are not uncommon
during the first trimester.
• The frequency and intensity of migraine
headaches may increase or decrease during
pregnancy.
• Headaches during the second and third
trimesters are not an expected symptom of
pregnancy.
Emotional Changes
• Pregnancy is a time of significant psychological
stress.
• Changes in hormonal levels; changes in
relationships to partners, family, and friends; and
changes in body image all lead to increased
psychological stress.
• Increased levels of placental corticotropinreleasing hormone also affect the maternal
hypothalamic pituitary axis and other brain loci
involved in stress responses.
Sexual Relations
• Coital activity during normal pregnancy need not be restricted.
• libido often decreases in the first and third trimesters.
• Nipple stimulation, vaginal penetration, and orgasm can cause
uterine contractions secondary to the release of prostaglandins and
oxytocin.
• The question of the effect of coitus in women at risk for preterm
labor or early spontaneous pregnancy loss remains unanswered.
• There are two concrete interdictions to coitus during pregnancy. The
first is that intercourse should not occur after membrane rupture or
in the presence of known placenta previa. The second is that forceful
introduction of air into the vagina should be avoided because of the
risk of fatal air embolism.
Employment
• Strenuous physical activity, including
repetitive lifting and prolonged standing for
more than 5 hours, has been associated with a
greater rate of adverse outcomes.
Urinary Frequency
• Patients often experience urinary frequency
during the first 3 months of pregnancy, as the
enlarging uterus compresses the bladder, and
again during the last weeks, as the fetal head
descends into the pelvis.
Skin Changes
• many women experience increased hair growth
during pregnancy and hair loss postpartum.
Leukorrhea
• An increase in the amount of vaginal discharge
is physiologic during pregnancy.
• Discharge accompanied by itching or burning
or a malodorous discharge should be treated.
• Douching has no place in the treatment or
management of leukorrhea in pregnancy.
X-rays/Ionizing Radiation
• Patients may undergo dental x-rays as needed,
provided that the abdomen is fully covered by
a lead apron. Exposure to video display
terminals is safe in pregnancy.
Travel
• the patient should try to stretch her legs and
walk for 10 minutes every 2 hours.
Immunizations
• Four immunizations using vaccines containing
live viruses are relatively contraindicated during
pregnancy. These are measles, mumps, rubella,
and yellow fever.
• Tetanus toxoid, if needed, is acceptable in
pregnancy.
• Flu vaccine is recommended for pregnant
women.
• Women who are receiving hepatitis B vaccine
may continue receiving it during pregnancy.