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Transcript
Chapter 8. Prenatal Care R3. Jeong Mi Byun Overview of Prenatal Care Frequency distribution of the number of prenatal visits for the United States in 2001. 50million prenatal visits.- the median was 12.3 visits / pregnancy Overview of Prenatal Care Risk Factor Births Percent 4,025,933 100 Hypertension due to pregnancy 150,329 3.7 Diabetes 124,242 3.1 Anemia 99,558 2.5 Hydramnios / oligohydramnios 54,694 1.4 Acute or chronic lung disease 48,246 1.2 Genital herpes 33,560 0.8 Chronic hypertension 32,232 0.8 D(Rh) sensitization 26,933 0.7 Cardiac disease 20,698 0.5 Renal disease 12,045 0.3 Incompetent cervix 11,251 0.3 Hemoglobinopathy 3,141 0.1 616,929 15.3 Total live births Total Adapted from Martin an associates, 2002b table 8-1 Obstetrical and Medical Risk Factors Detected During Prenatal Care in the United States in 2001 Overview of Prenatal Care Inadequate Prenatal Care Reasons : varied by social and ethnic group, age, and method of payment Not know pregnancy (m/c) Lack of money or insurance Inability to obtain an appointment Kessner Index : for measuring the adequacy of prenatal care Overview of Prenatal Care TABLE 8-2 Kessner Index Criteria Adequate Prenatal Care Kessner Index Initial visit in 1st trimester and: Weeks at Delivery No. of Prenatal Visits 17 and 2 or more 18–21 and 3 or more 22–25 and 4 or more 26–29 and 5 or more 30–31 and 6 or more 32–33 and 7 or more 34–35 and 8 or more 36–47 and 9 or more Inadequate Prenatal Care Initial visit in 3rd trimester or: Weeks at Delivery No. of Prenatal Visits 17–21 and None 22–29 and 1 or fewer 30–31 and 2 or fewer 32–33 and 3 or fewer 34–47 and 4 or fewer Intermediate Care All other combinations Adaptd from Kessner and colleagues, 1973, with permission incorporates information from three items recorded on the birth certificate length of gestation timing of the first prenatal care visit number of visits Limitation measure the quantity of care but not the quality of care not consider the relative risk of the mother Useful measure of prenatal care adequacy Overview of Prenatal Care Effectiveness of Prenatal Care No conclusive evidence that prenatal care improved birth outcome - Fiscella (1995) Risk of preterm birth ≥ (X 2) ↑↑: Prenatal care (-) - Herbst and associates (2003) Cost effect : 1$ for prenatal care/ $1.49 in newborn and postpartum - Schramm(1992) Rate of fetal death ↓ - Vintzileos and colleagues(2002b) Rate of neonatal death associated with several high-risk conditions (placenta previa, fetal growth restriction , and postterm pregnancy.) Fewer preterm birth – Vintzileous and colleagues (2003) Risk of pregnancy-related maternal death (X5)↓ -Harper and co-workers (2003 ) Organization of Prenatal Care Definition “ a comprehensive antepartum care program that involves a coordinated approach to medical care and psychosocial support that optimally begins before conception and extends throughout the antepartum period” - the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002) Comprehensive program I. Preconceptional care II. Prompt diagnosis of pregnancy III. Initial presentation for pregnancy care IV. Follow-up prenatal visits Ι. Preconceptional care A comprehensive preconceptional care program has the potential to assist women by reducing risks, promoting healthy lifestyles, and improving readiness for pregnancy. ΙΙ. Diagnosis of pregnancy 1. Signs and Symptoms 2. hCG home urine pregnanacy test → confirmatory testing for hCG in urine or blood 3. Ultrasound ΙΙ-1. Signs and Symptoms Cessation of menses Changes in cervical mucus Change in the breast Discoloration of the vaginal mucosa Skin changes Changes in the uterus Changes in the cervix Fetal heart action Perception of fetal movements ΙΙ-1. Signs and Symptoms Changes in cervical mucus Determined by cervical glandular response to hormonal action Fernlike pattern : MCD 7th~18th day Estrogen ( ↑↑↑ ) → cervical mucus is relatively rich in sodium chloride → crystallization of the mucus is dependent on an increased concentration of sodium chloride. Beaded pattern : after MCD 21st day, during pregnancy Progesterone ( ↑↑↑ ) → lower sodium chloride concentration ΙΙ-1. Signs and Symptoms FIGURE 8-3 Scanning electron microscopy of cervical mucus obtained on day 11 of the menstrual cycle. fernlike pattern (From Zaneveld and associates, 1975, with permission ) FIGURE 8-4 Photomicrograph of dried cervical mucus obtained from the cervical canal of a woman pregnant at 32 to 33 weeks. The beaded pattern is characteristic of progesterone action of the endocervical gland mucus composition (Courtesy of Dr. J. C. Ullery) ΙΙ-1. Signs and Symptoms Changes in the Breasts Anatomical changes in the breast, during the 1st pregnancy Discoloration of the Vaginal mucosa Chadwick sign : dark bluish or purplish-red and congestion Skin Changes Increased pigmentation, abdominal striae Not just pregnancy – women taking estrogen-progestin contraception ΙΙ-1. Signs and Symptoms Changes in the uterus 12wks body of the uterus – globular, average uterine diameter : 8cm Hegar sign at about 6~8 weeks’ menstrual age, on bimanual examination a firm cervix is felt which contrasts the now softer body of the uterus and compressible interposed softened isthmus. The softening at the isthmus may be so marked that the cervix and the body of the uterus seem to be separate organs ΙΙ-1. Signs and Symptoms Changes in the cervix softening Fetal heart action 5weeks : real-time sonography vaginal probe 10weeks : Doppler ultrasound Mean of 17weeks ~19wks : auscultation Perception of fetal movement at or about 20weeks ΙΙ-1. Signs and Symptoms Other sounds The funic (umbilical cord) “souffle” caused by the rush of blood through the umbilical arteries sharp, whistling sound that is synchronous with the fetal pulse The uterine “souffle” soft, blowing sound shynchronous with the maternal pulse Produced by the passage of blood through the dilated uterine vessels heard with any condition in which uterine blood flow is greatly increased, eg.) large uterine myomas, or ovarian tumors Sounds resulting from fetal movement Maternal pulse Sounds from maternal intestinal peristalsis ΙΙ-2. Chorionic Gonadotropin glycoprotein with a high carbohydrate content Heterodimer composed of two dissimilar subunits, designated α and β α- subunit : similar to those of lutinizing hormone (LH), folliclestimulating horrmoen (FSH), and thyroid-stimulalting hormone (TSH) Prevents involution of the corpus luteum Produced by trophoblast cells Maternal plasma or urine by 8 ~9 days after ovulation Doubling time of plasma hCG concentration : 1.4~2.0 days Peak levels : at about 60~70 days Declines slowly until a nadir is reached at about 14~16 weeks (fig 8-5) ΙΙ-2. Chorionic Gonadotropin FIGURE 8-5 Mean concentration of chorionic gonadotropin(hCG) in serum of women throughout normal pregnancy. The free β-subunit of hCG is in low concentration throughout pregnancy. (Data fromAshitaka and colleagues, 1980;Selenkow and co-workers, 1971.) ΙΙ-3. Ultrasonic Recognition of Pregnancy Transvaginal sonography Transabdominal sonography Gestational sac : after 4~5weeks’ menstrual age ★all normal sacs should be visible : by 35 days Heartbeat : after 6weeks ~12weeks : the CRL is predictive of gestational age within 4days FIGURE 8-6 Abdominal sonogram demonstrating a gestational sac at 4 to 5 weeks’ gestational (menstrual ) age. (Courtesy of Dr. Diane Twickler.) ΙΙΙ. Initial Prenatal Evaluation Major goals 1. To define the health status of the mother and fetus 2. To estimate the gestational age of the fetus 3. To initiate a plan for continuing obstetrical care ΙΙΙ. Initial Prenatal Evaluation Tab 8-3 Typical Compnents of Routine Prenatal Care ΙΙΙ. Initial Prenatal Evaluation 1. Prenatal Record Normal Pregnancy Duration History 2. Psychosocial Screening Cigarette smoking Alcohol and Illicit Drugs during Pregnancy Domestic Violence Screening 3. Physical Examination Pelvic Examination 4. Laboratory Tests 5. High-Risk Pregnancies ΙΙΙ-1. Prenatal Record Use of a standardized record within a perinatal health care system greatly facilitates antepartum and intrapartum management. Definition Nulligravida Not now and never has been pregnant Gravida ♣ Parity Is or has been pregnant, irrespective of the pregnancy outcome Primigravida : with the establishment of the first pregnancy Multigravida : successive pregnancies determined by the number of pregnancies reaching 20weeks not by the number of fetus delivered Nullipara Never competed a pregnancy > 20weeks’ gestation May or may not have been pregnant or May have had a spontaneous or elective abortion(s) Primipara Has been delivered only once of fetus or Fetuses born alive or dead with an estimated length of gestation of≥20weeks Multipara Has completed ≥2 pregnancies to ≥ 20weeks ΙΙΙ-1. Prenatal Record Number of term infant-preterm infants-abortions-children currently alive eg) 6-1-2-6 Normal pregnancy Duration Mean duration of pregnancy from the first day of the last normal menstrual period : 280 days or 40weeks Expected date of delivery : LMP month - 3month / day + 7days (Naegele rule) eg) LMP : 9 / 10 → EDC : 6 / 17 Gestational age or menstrual age from the first day of LMP : erroneously considered to have begun about 2 weeks before ovulation Ovulatory age or fertilization age : typically 2weeks shorter ΙΙΙ-1. Prenatal Record Trimester : divide pregnancy into three equal trimester of approximately 3 calendar months 14 weeks 1st trimester 28 weeks 2nd trimester 42 weeks 3rd trimester Precise knowledge of the age of the fetus is imperative for ideal obstetrical management Gestational age using completed weeks and days eg) 33 3/7 weeks -> 33 completed weeks and 3days ΙΙΙ-1. Prenatal Record History Detailed information concerning past obstetrical history is crucial : many prior pregnancy complications tend to recur in subsequent pregnancies Menstrual history : extremely important : Without a history of regular, predictable, cyclic, spontaneous menses that suggest ovulatory cycles, accurate dating of pregnancy by history and physical examination is difficult. ΙΙΙ-2. Psychosocial Screening ΙΙΙ-2. Psychosocial Screening Cigarette Smoking Various adverse outcomes spontaneous abortion, low birthweight due to either preterm delivery or fetal growth restriction, infant and fetal deaths, placental abruption Suggested pathophysiological mechanisms increased fetal carboxyhemoglobin, reduced uteroplacental blood flow, fetal hypoxia ΙΙΙ-2. Psychosocial Screening Cigarette Smoking Optimally, smokers should be treated before conception. - Wisborg and co-workers (2000) ΙΙΙ-2. Psychosocial Screening Alcohol and Iilicit drugs during Pregnancy Ethanol potent teratogen fetal alcohol syndrome : characterized by growth restriction, facial abnormalities, and central nervous system dysfunction The Surgeon General recommends that women who are pregnant or considering pregnancy abstain from using any alcoholic beverages. ΙΙΙ-2. Psychosocial Screening Alcohol and Iilicit drugs during Pregnancy Chronic use of large quantities of illicit drugs, - opium derivatives, barbiturates, and amphetamines,… fetal distress, low birthweight, and drug withdrawal soon after birth are well documented. when women who use illicit drugs receive prenatal care, the risks for preterm birth and low birthweight are reduced. - El-Mohandes and associates (2003) ΙΙΙ-2. Psychosocial Screening Domestic Violence Screening refers to violence against adolescent and adult females within the context of family or intimate relationships. Janssen and colleagues (2003) Survey (survey of 4750 women ) : found that 1.2 percent were exposed to physical violence by an intimate partner during pregnancy. risk of antepartum hemorrhage and fetal growth restriction (X3) risk of perinatal death. (X8) ΙΙΙ-3. Physical Examination Pelvic Examination Cervix : visualized employing a speculum lubricated with warm water. Bluish-red passive hyperemia of the cervix Nabothian cysts ☞ To identify cytological abnormalities Pap smear Specimens for identification of Neisseria gonorrhoeae and Chlamydia trachomatis are obtained if screening is indicated. ΙΙΙ-3. Physical Examination Palpation consistency, length, and dilatation of the cervix fetal presentation later in pregnancy bony architecture of the pelvis any anomalies of the vagina and perineum, including cystocele, rectocele, and relaxed or torn perineum. The vulva and contiguous structures are carefully inspected. All cervical, vaginal, and vulvar lesions are evaluated further by appropriate use of colposcopy, biopsy, culture, or dark-field examination. digital rectal examination, visualized on the perianal region ΙΙΙ-4. Laboratory Tests human immunodeficiency virus (HIV) testing, with patient notification, as a routine part of prenatal testing. ΙΙΙ-5. High-Risk Pregnancies Some conditions may require the involvement of a maternal–fetal medicine subspecialist, geneticist, pediatrician, anesthesiologist, or other medical specialist in the evaluation, counseling, and care of the patient Recommended Consultation for Risk Factors Identified in Early Pregnancy (table 8-5) IV. Subsequent Prenatal Visits The timing of subsequent prenatal visits ~ 28 weeks : intervals of 4 weeks 28~ 36 weeks : every 2 weeks > 36 weeks : weekly with complicated pregnancies : often require return visits at 1- to 2-week intervals. IV -1. Prenatal surveillance At each return visit, steps are taken to determine the well-being of mother and fetus Certain information is especially important. Ex) assessment of gestational age accurate measurement of blood pressure IV -1. Prenatal surveillance Fetal Heart rate(s) Size—current and rate of change Amount of amnionic fluid Presenting part and station (late in pregnancy) Activity IV -1. Prenatal surveillance Maternal Blood pressure : current and extent of change Weight : current and amount of change Symptoms : including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, and dysuria Height in centimeters of uterine fundus from symphysis Vaginal examination late in pregnancy often provides valuable information: Confirmation of the presenting part Station of the presenting part Clinical estimation of pelvic capacity and its general configuration Consistency, effacement, and dilatation of the cervix IV -2. Assessment of Gestational Age Precise knowledge of gestational age is important (because a number of pregnancy complications may develop for which optimal treatment will depend on fetal age. ) performed clinical examination, coupled with knowledge of the time of onset of the last menstrual period. Fundal Height Fetal Heart sound Ultrasound IV -2. Assessment of Gestational Age Fundal Height measured as the distance over the abdominal wall from the top of the symphysis pubis to the top of the fundus. 20 ~ 31 weeks : the height of the uterine fundus, measured in centimeters, correlates closely with gestational age in weeks -Jimenez and co-workers, 1983 essentially identical observations up to 34 weeks - Quaranta and associates (1981) and Calvert and colleagues (1982). cf) Obesity The bladder must be emptied before making the measurement. IV -2. Assessment of Gestational Age Fetal Heart Sounds 16 ~ 19 weeks : auscultated with a DeLee fetal stethoscope. IV -2. Assessment of Gestational Age Ultrasound between 8 and 16 weeks slightly more accurate than LMP, for predicting the actual date of delivery - Taipale and Hiilesmaa (2001) Routine ultrasound : not currently recommended in low-risk pregnancies - by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002).- IV -3. Subsequent Laboratory Tests initial results : normal → most tests need not be repeated (see Table 8–3). 16 to 18 weeks : Maternal serum screening is recommended for detecting open neuraltube defects and some chromosomal anomalies Hematocrit (or hemoglobin) 28 to 32 weeks : syphilis serology if it is prevalent in the population, should be repeated (Hollier and co-workers; Kiss and colleagues, 2004). Cystic fibrosis carrier screening before conception or during the first or early second trimester. Information about cystic fibrosis screening also should be provided to patients in other racial and ethnic groups who are at lower risk Ancillary Prenatal Tests Gestational Diabetes Chlamydial Infection Gonococcal Infection Fetal Fibronectin Group B Streptococcal (GBS) infection Special Screening for Genetic Diseases 1. Gestational Diabetes Screened by history, clinical risk factors, or routine laboratory testing GA 24 ~28 weeks 2. Chlamydial Infection women at high risk for C trachomatis infection : should be screened during the 1st prenatal visit Risk factors unmarried status recent change in sexual partner or multiple concurrent partners age under 25 years inner-city residence history or presence of other sexually transmitted diseases little or no prenatal care negative prenatal chlamydia or gonorrhea test : should not preclude postpartum screening 3. Gonococcal Infection Risk factors : similar for those for chlamydia. recommend that pregnant women with risk factors or symptoms be cultured for N gonorrhoeae at an early prenatal visit and again in the third trimester. - American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002) Treatment given for gonorrhea as well as possible coexisting chlamydial infection 4. Fetal Fibronectin forecast preterm delivery in women with contractions not recommend routine screening - American College of Obstetricians and Gynecologists (2001b) 5. Group B Streptococcal (GBS) Infection Universal prenatal screening for GBS carriage has been controversial. now recommend that vaginal and rectal GBS cultures be obtained in all women between 35 and 37 weeks. - Based largely on a retrospective study comparing risk-based and culture-based approaches (Schrag and co-workers, 2002), the American College of Obstetricians and Gynecologists (2002c) and the Centers for Disease Control and Prevention (2002c) – Intrapartum antimicrobial prophylaxis cultures (+) Women with GBS bacteriuria or a previous infant with invasive disease are given empirical intrapartum prophylaxis. 5. Group B Streptococcal (GBS) Infection S agalactiae : adverse pregnancy outcomes, preterm labor, prematurely ruptured membranes, clinical and subclinical chorioamnionitis, and fetal and neonatal infections. cause bacteriuria, pyelonephritis, and postpartum metritis. Postpartum maternal osteomyelitis and mastitis (Barbosa-Cesnik and associates, 2003; Berkowitz and McCaffrey, 1990). 5. Group B Streptococcal (GBS) Infection Indications for intrapartum prophylaxis to prevent perinatal group B streptococcal (GBS) disease under a universal prenatal screening strategy based on combined vaginal and rectal cultures taken at 35 to 37 weeks' gestation. (From Centers for Disease Control and Prevention, 2002d.) 5. Group B Streptococcal (GBS) Infection Sample algorithm for prophylaxis for women with group B streptococcal (GBS) disease and threatened preterm delivery. This algorithm is not an exclusive course of management and variations that incorporate individual circumstances or institutional preferences may be appropriate. (Adapted from Centers for Disease Control and Prevention, 2002d.) 5. Group B Streptococcal (GBS) Infection Regimens for Intrapartum Antimicrobial Prophylaxis for Perinatal Prevention of Group B Streptococcal Disease Recommended Penicillin G, 5 million units IV initial dose, then 2.5 million units IV every 4 hours until delivery Alternative Ampicillin, 2 g IV initial dose, then 1 g IV every 4 hours or 2 g every 6 hours until delivery If penicillin allergic a Patients not at high risk for anaphylaxis Cefazolin, 2 g IV initial dose, then 1 g IV every 8 hours until delivery Patients at high risk for anaphylaxis and with GBS susceptible to clindamycin and erythromycin Clindamycin, 900 mg IV every 8 hours until delivery GBS resistant to clindamycin or erythromycin or susceptibility unknown Vancomycin, 1 g IV every 12 hours until delivery GBS = group B streptococcus. OR Erythromycin, 500 mg IV every 6 hours until delivery 6. Special Screening for Genetic Diseases Selected screening can be offered based on maternal age, family history, or the ethnic or racial background of the couple (American College of Obstetricians and Gynecologists, 1995). Nutrition Nutrition birthweight : influenced significantly by starvation during later pregnancy. the perinatal mortality rate : not altered incidence of malformations : not significantly increased. - during the severe European winter of 1944~1945, nutritional deprivation, (Stein and associates, 1972). - Nutrition Maternal weight gain in the United States reported on the birth certificate in 2001. (From Martin and colleagues, 2002b.) maternal weight gain during pregnancy influences birthweight nearly two thirds of pregnant women gained ≥ 26 lb (11.8kg) median weight gain :30.5 lb (13.5kg) Nutrition Maternal weight gain positive correlation with birthweight I. RECOMMENDATIONS FOR WEIGHT GAIN For the first half of the 20th century : recommended that weight gain during pregnancy < 20 lb (9.1 kg) By the 1970s : encouraged to gain at least 25 lb (11.4 kg) ( to prevent preterm birth and fetal growth restriction, a recommendation that subsequent research continues to support) (Ehrenberg and associates, 2003) In 1990 : recommended a weight gain of 25 ~ 35 lb (11.5 to 16 kg) (the Institute of Medicine) for women with a normal prepregnancy body mass index (BMI). I. RECOMMENDATIONS FOR WEIGHT GAIN I. RECOMMENDATIONS FOR WEIGHT GAIN a pregnant woman with a normal BMI : weight gain 15 to 25 lb during pregnancy (Feig and Naylor (1998)) Consideration - Disadvantages of excessive maternal weight gain - frequency of antepartum and intrapartum complications ( including fetal macrosomia ) : highest among women who gained more than 44 lb (20 kg) during pregnancy. - Thorsdottir and associates(2002) I-1.Weight Retention After Pregnancy average weight gain : 28.6 ± 10.6 lb (13.0 ± 4.8 kg) an average retained weight : 3 ± 10.5 lb (1.4 ± 4.8 kg) d/t pregnancy. - Schauberger and co-workers (1992) Parous women retained more of their pregnancy weight, → long-term obesity The effect of breast feeding on maternal weight loss was negligible. I-1.Weight Retention After Pregnancy Cumulative weight loss from last antepartum visit to 6 months postpartum. *Statistically different from 2-week weight loss, **Statistically different from 6-week weight loss. (From Schauberger and co-workers, 1992, with permission.) • As shown in Figure 8–8, the majority of maternal weight loss was at delivery— about 12 lb (5.5 kg)—and in the ensuing 2 weeks thereafter—about 9 lb (4 kg). • An additional 5.5 lb (2.5 kg) was lost between 2 weeks and 6 months postpartum. II. Recommened Dietary Allowances Calories Protein Minerals Vitamins Toxic effects : iron, zinc, selenium, and vitamins A, B6, C, and D. Vitamin and mineral : intake more than twice the recommended daily dietary allowance shown in Table 8–7 should be avoided during pregnancy (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2002). Table 8–7. Recommended Daily Dietary Allowances for Adolescent and Adult Pregnant and Lactating Women Pregnant 14–18 years 19–30 years Lactating 31–50 years 14–18 years 19–30 years 31–50 years Fat-soluble vitamins Vitamin A 750 μg 770 μg 770 μg 1200 μg 1300 μg 1300 μg 5 μg 5 μg 5 μg 5 μg 5 μg 5 μg 15 mg 15 mg 15 mg 19 mg 19 mg 19 mg 75 μg 90 μg 90 μg 75 μg 90 μg 90 μg Vitamin C 80 mg 85 mg 85 mg 115 mg 120 mg 120 mg Thiamine 1.4 mg 1.4 mg 1.4 mg 1.4 mg 1.4 mg 1.4 mg Riboflavin 1.4 mg 1.4 mg 1.4 mg 1.6 mg 1.6 mg 1.6 mg 18 mg 18 mg 18 mg 17 mg 17 mg 17 mg Vitamin B6 1.9 mg 1.9 mg 1.9 mg 2 mg 2 mg 2 mg Folate 600 μ g 600 μ g 600 μ g 500 μ g 500 μ g 500 μg 2.6 μg 2.6 μ g 2.6 μ g 2.8 μ g 2.8 μ g 2.8 μ g Calcium 1300 mg 1000 mg 1000 mg 1300 mg 1000 mg 1000 mg Phosphorus 1250 mg 700 mg 700 mg 1250 mg 700 mg 700 mg Iron 27mg 27mg 27mg 10mg 9mg 9mg Zinc 13mg 11mg 11mg 14mg 12g 12mg 220 μg 220 μg 220 μg 290 μg 290 μg 290 μg 60 μg 60 μg 60 μg 70 μg 70μg 70μg Vitamin D a Vitamin E Vitamin K a Water-soluble vitamins Niacin Vitamin B12 Minerals a Iodine Selenium Recommendations measured as Adequate Intake (AI) instead of Recommended Daily Dietary Allowance (RDA). An AI is set instead of an RDA if insufficient evidence is available to determine an RDA. The AI is based on observed or experimentally determined estimates of average nutrient intake by a group (or groups) of healthy people. From the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, 2004. II-1. Calories pregnancy requires an additional 80,000 kcal, which are accumulated primarily in the last 20 weeks. → a caloric increase of 100 to 300 kcal per day is recommended during pregnancy (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2002). II-1. Calories Cumulative kilocalories of energy required for pregnancy. (From Hytten and Chamberlain, 1991, with permission.) pregnancy requires an additional 80,000 kcal, which are accumulated primarily in the last 20 weeks. II-2. Protein demands for - growth and repair of the fetus, placenta uterus breasts - increased maternal blood volume During the second half of pregnancy, : about 1000 g of protein are deposited, amounting to 5 to 6 g/day concentrations of maternal plasma amino acids ↓↓ ornithine, glycine, taurine, proline ↑↑ glutamic acid, alanine most protein should be supplied from animal sources, such as meat, milk, eggs, cheese, poultry, and fish, II-3. Minerals With the exception of iron, practically all diets that supply sufficient calories for appropriate weight gain will contain enough minerals to prevent deficiency if iodized food is used. Iron Calcium Phosphate Zinc Iodine Magnesium Copper Selenium Chromium Manganese Potassium Sodium Fluoride II-3-1. Iron Iron requirement of normal pregnancy : total approximately 1000mg 300 mg : transferred to the fetus and placenta 200 mg : lost through various normal routes of excretion, primarily the gastrointestinal tract 500 mg : into the expanding maternal hemoglobin mass, nearly all is used after midpregnancy. the diet seldom contains enough iron to meet this demand. → at least 27 mg of ferrous iron supplement be given daily - the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002) endorse the recommendation by the National Academy of Sciences – II-3-1. Iron 30 mg of elemental iron supplied as ferrous gluconate, sulfate, or fumarate taken daily throughout the latter half of pregnancy, - Scott and co-workers (1970) for iron requirements for lactation benefit from 60 to 100 mg of iron per day She is large twin fetuses begins supplementation late in pregnancy takes iron irregularly has a somewhat depressed hemoglobin level. II-3-1. Iron during the first 4 months of pregnancy not necessary to provide supplemental iron the risk of aggravating nausea and vomiting. Ingestion of iron at bedtime or on an empty stomach (facilitates absorption and appears to minimize the possibility of an adverse gastrointestinal reaction.) II-3-2. Calcium the pregnant woman retains about 30 g of calcium only about 2.5 % of total maternal calcium, most of which is deposited in the fetus late in pregnancy (Pitkin, 1985). most of which is in bone, and which can readily be mobilized for fetal growth. calcium absorption↑↑ : by the intestine and progressive retention throughout pregnancy. - Heaney and Skillman (1971) II-3-3. Phosphoros Plasma levels of inorganic phosphorus do not differ appreciably from nonpregnant levels. II-3-4. Zinc Result of severe zinc deficiency poor appetite, suboptimal growth, impaired wound healing. dwarfism and hypogonadism. specific skin disorder, acrodermatitis enteropathica, as the result of a rare, severe congenital zinc deficiency. recommended daily intake during pregnancy : 12 mg level of zinc supplementation for pregnant women (safety) : not been clearly established II-3-5. Iodine Severe maternal iodine deficiency : endemic cretinism, characterized by multiple severe neurological defects Iodide supplementation very early in pregnancy prevents cretinism (Cao and colleagues, 1994) II-3-6. Magnesium Deficiency of magnesium as the consequence of pregnancy has not been recognized. II-3-7. Copper Copper deficiency : not been documented in humans during pregnancy. 2 mg of copper per tablet. ( although several prenatal supplements currently marketed provide) No studies of copper supplementation of pregnant women have been reported II-3-8. Selenium an essential component of the enzyme glutathione peroxidase, ( catalyzes the conversion of hydrogen peroxide to water) important defensive component against free radical damage Deficiency : fatal cardiomyopathy in young children and women of childbearing age. Toxicity (+) II-3-8. Chromium co-factor for insulin by facilitating attachment to peripheral receptors. no data suggesting that supplementation is advisable during pregnancy. II-3-8. Manganese a co-factor for enzymes such as the glycosyltransferases, which are necessary for the synthesis of polysaccharides and glycoproteins. deficiency : has not been observed in human adults supplements are not indicated during pregnancy. II-3-8. Potassium The concentration of potassium in maternal plasma decreases by about 0.5 mEq/L by midpregnancy (Brown and colleagues, 1986). prolonged nausea and vomiting → hypokalemia and metabolic alkalosis. II-3-8. Sodium Deficiency during pregnancy is unusual normal diet → provides an abundance of sodium increased total accumulation of sodium, → the serum concentration decreases slightly d/t the expanded plasma volume. Sodium excretion : unchanged, averages 100 to 110 mEq/day (Brown and colleagues, 1986). II-3-9. Fluoride The value of supplemental fluoride during pregnancy : questioned. II-4. Vitamins The increased requirements for vitamins during pregnancy usually are supplied by any general diet Folic acid Vitamin A Vitamin B12 Vitamin B6 Vitamin C II-4-1. Folic Acid Deficiency : neural-tube defects A woman with a prior pregnancy complicated by a neural-tube defect ( recurrence risk : ≥ 70%→ 3%) folic acid : 4 mg/day for the month before conception for the first trimester of pregnancy II-4-2. Vitamin A very high doses during pregnancy — 10,000 to 50,000 IU daily. an association of birth defects deficiency : maternal anemia spontaneous preterm birth. II-4-2. Vitmin B12 Vitamin B12 (cobalamine ) : naturally only in foods of animal origin. vegetarian mother excessive ingestion of vitamin C → Deficiency of Vitamin B12 II-4-3. Vitamin B6 (pyridoxine ) High risk for inadequate nutrition (e.g., substance abuse, adolescents, and those with multifetal gestations) : a daily supplement containing 2 mg is recommended. II-4-3. Vitmin C the recommended dietary allowance for vitamin C during pregnancy 80 to 85 mg/day or about 20 percent more than when nonpregnant III. Pragmatic Nutritional Surveillance 1. In general, advise the pregnant woman to eat what she wants in amounts she desires and salted to taste. 2. Make sure that there is ample food to eat in the case of socioeconomically deprived women. 3. Monitor weight gain, with a goal of about 25 to 35 pounds in women with a normal BMI. 4. Periodically explore food intake by dietary recall to discover the occasional nutritionally absurd diet. 5. Give tablets of simple iron salts that provide at least 27 mg of iron daily. Give folate supplementation before and in the early weeks of pregnancy. 6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks to detect any significant decrease Common Concerns Common Concerns Exercise Employment Travel Bathing Clothing Bowel Habits Coitus Dentition Immunization Caffeine Medications Nausea and vomiting Backache Varicosities Hemorrhoids Heartburn Pica Ptyalism Fatigue Headache Leucorrhea Bacterial vaginosis Trichomoniasis Candidiasis Exercise Exercise consisted of treadmill running, step aerobics, or stair stepper use for 20 minutes three to five times each week. They did this throughout pregnancy at an intensity between 55 and 60 percent of the preconceptional maximum aerobic capacity. Both placental size and birthweight were significantly greater in the exercise group. - Clapp and associates (2000) Among working women, exercise was associated with smaller infants, more dysfunctional labors, and more frequent upper respiratory infections. - Magann and colleagues (2002) I. Exercise not necessary to limit exercise, a thorough clinical evaluation be conducted before recommending an exercise program. - American College of Obstetricians and Gynecologists(2002b) In the absence of contraindications, pregnant women should be encouraged to engage in regular, moderate-intensity physical activity 30 minutes or more a day. Avoid … Activities with a high risk of falling or abdominal trauma scuba diving ( because the fetus is at an increased risk for decompression sickness.) I. Exercise Table 8–8. Absolute and Relative Contraindications to Aerobic Exercise During Pregnancy Absolute Contraindications Relative Contraindications Hemodynamically significant heart disease Severe anemia Restrictive lung disease Unevaluated maternal cardiac arrhythmia Incompetent cervix or cerclage Chronic bronchitis Multifetal gestation at risk for preterm labor Poorly controlled type 1 diabetes mellitus Persistent second- or third-trimester bleeding Extreme morbid obesity Placenta previa after 26 weeks of gestation Extreme underweight (BMI < 12) Preterm labor during the current pregnancy History of extremely sedentary lifestyle Ruptured membranes Fetal growth restriction in current pregnancy Preeclampsia or gestational hypertension Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker BMI = body mass index. Reproduced from the American College of Obstetricians and Gynecologists, 2002b, with permission. I. Exercise With some pregnancy complications, the mother and her fetus may benefit from a sedentary existence. PIH Multiple pregnanacy a growth-restricted fetus those with severe heart disease II. Employment maternal work activity and pregnancy outcome in 4186 women delivered at Yale–New Haven Hospital. -Teitelman and co-workers (1990) classified according to the type of jobs they held. Standing jobs : a cashier, bank teller, or dentist, required standing in the same position for more than 3hours per day Active jobs : physicians, waitresses, and real estate agents, involved continuous or intermittent walking Sedentary jobs : librarians, bookkeepers, or bus drivers, required less than 1 hour of standing per day. → work at jobs that require prolonged standing are at greater risk for preterm delivery, but it did not have any effect on fetal growth. II. Employment preterm birth fetal growth restriction associated with physically demanding work hypertension 20% ~ 60% ↑ - Mozurkewich and colleagues (2000) develop preeclampsia : fivefold - Higgins and associates (2002) occupational fatigue — estimated by the number of hours standing, intensity of physical and mental demands, and environmental stressors — was associated with an increased risk of preterm membrane rupture. - Newman and colleagues (2001) (reporting the highest degrees of fatigue, the risk :7.4 percent) II. Employment Adequate periods of rest (during work) Women with previous pregnancy complications that are likely to be repetitive, such as low-birthweight infants, → minimize physical work. uncomplicated pregnancies : continue to work until the onset of labor. although a period of 4 to 6 weeks generally is required for return of the physiological condition to normal, → individual circumstances should be considered when recommending resumption of full activity ( American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002)) III. Travel no harmful effect on pregnancy (Aerospace Medical Association, 2003). Travel in properly pressurized aircraft offers no unusual risk safely fly up to 36 weeks. (in the absence of obstetrical or medical complications) - the American College of Obstetricians and Gynecologists (2001a, 2004) It is recommended that pregnant women observe the same precautions for air travel as the general population → including periodic movement of the lower extremities, ambulation at least hourly, and use of seatbelts while seated. IV. Bathing no contraindications to bathing during pregnancy or the puerperium early pregnancy exposure to a hot tub or Jacuzzi ≥ 100°F(37.7°C) increased risk of miscarriage (Li and co-workers, 2003). linked to neural-tube defects During late pregnancy, the heavy uterus usually upsets the balance of the pregnant woman and increases the likelihood of her slipping and falling in the bathtub. → showers at the end of pregnancy may be preferable. V. Clothing comfortable and nonconstricting. Bowel Habits Constipation : common Hemorrhoids Prolapse of the rectal mucosa ( much less commonly ) prevent constipation during pregnancy sufficient quantities of fluid reasonable amounts of daily exercise. mild laxative ( prune juice, milk of magnesia, bulk-producing substances, stoolsoftening agents) Coitus Contraindication : abortion or preterm labor threatens Generally, not harmful (in healthy pregnant women) Dentition Dental caries are not aggravated by pregnancy. Likewise, pregnancy is not a contraindication to dental treatment. Immunization Table 8–9. Recommendations for Immunization During Pregnancy Women who are susceptible to rubella during pregnancy should receive MMR (measles-mumps-rubella) vaccination postpartum. no contraindication to this vaccination while breast feeding (American College of Obstetricians and Gynecologists, 2002d) Immunization Biological Warfare and Vaccines Smallpox vaccine live attenuated vaccinia virus both to smallpox and to cowpox viruses. Complication : vaccinia (fetal infection from this vaccine), rare abortion, stillbirth, or neonatal death Contraindication during pregnancy in women who desire to become pregnant within 28 days of vaccination (Centers for Disease Control and Prevention, 2003b). inadvertently performed in early pregnancy→ not grounds for termination (Suarez and Hankins, 2002) Immunization Anthrax vaccination : limited principally to individuals who are occupationally exposed, such as special veterinarians, laboratory workers, and members of the armed forces. no live virus not be expected to pose significant risk to the fetus. Wiesen and Littell (2002) study : the reproductive outcomes of 385 women in the United States Army who became pregnant after receiving the anthrax vaccine. →no adverse effects on fertility or pregnancy outcome. Caffeine No evidence that caffeine caused increased teratogenic or reproductive risks (The Fourth International Caffeine Workshop,Dews and colleagues, 1984) Caffeine Risk of spontaneous abortion related to caffeine consumption → controversial Only extremely high serum paraxanthine concentrations (high levels : > 5 cups/day) : associated with abortion. Klebanoff and co-workers (1999) measured paraxanthine as a biological serum marker of caffeine consumption. moderate caffeine consumption < 500 mg/day : no association with low birthweight, fetal growth restriction preterm delivery Clausson and associates (2002) caffeine intake during pregnancy < 300 mg/day or about three, 5-oz(140g) cups of percolated coffee. The American Dietetic Association (2002) Medication during pregnancy > 95 % : took prescription medications 92 % : self-medicated with over-the-counter preparations Based on interviews with 578 women, Glover and co-workers (2003) With rare exceptions, any drug that exerts a systemic effect in the mother will cross the placenta to reach the embryo and fetus Nausea and Vomiting common complaints during the first half of pregnancy Erroneously called morning sickness commence between the first and second missed menstrual period continue until about 14 to 16 weeks tend to be worse in the morning, continue throughout the day. <Lacroix and co-workers (2000) > Nausea and vomiting : three fourths of pregnant women lasted an average of 35 days 50% : relief by 14 weeks, 90 % : by 22 weeks. 80 % : nausea lasted all day character and intensity similar to that experienced by patients undergoing cancer chemotherapy. Nausea and Vomiting Genesis : not clear high levels of serum hCG increasing estrogen levels nausea and emesis in early gestation have a functional role in promoting and maintaining early placental growth Huxley (2000) reduced caloric intake lowers maternal insulin and insulin growth factor-1 levels suppresses maternal anabolic synthesis, ensuring that nutrient partitioning favors placental growth. Nausea and Vomiting Treatment Not so successful the unpleasantness and discomfort usually can be minimized eating small feedings at more frequent intervals stopping short of satiation smell of certain foods often precipitates or aggravates the symptoms → avoid vomiting may be so severe that dehydration, electrolyte and acid– base disturbances, and starvation ketosis become serious problems. → hyperemesis gravidarum Backache Low back pain : nearly 70% of pregnant women (Wang and colleagues, 2004) Minor degrees follow excessive strain or fatigue excessive bending, lifting, or walking. Risk factors : prior low back pain and obesity (Orvieto and associates (1994) ) Relief by squat rather than bend over when reaching down, providing back support with a pillow when sitting down, avoiding high-heeled shoes. Muscular spasm and tenderness (classified clinically as acute strain or fibrositis) : respond well to analgesics, heat, and rest. Severe pain : uncommon causes (disc disease, vertebral osteoarthritis, or septic arthritis) Varicosities enlarged veins congenital predisposition exaggerated by prolonged standing, pregnancy, and advancing age Symptoms ( vary ) cosmetic blemishes on the lower extremities mild discomfort → to severe discomfort (at the end of day) : requires prolonged rest with the feet elevated Varicosities Treatment Lower extremities - generally limited to periodic rest with elevation of the legs - elastic stockings, - surgical correction (during pregnancy) : not advised although occasionally the symptoms may be so severe that injection, ligation, or even stripping of the veins is necessary. Vulvar varicosities : application of a foam rubber pad suspended across the vulva large varicosities may rupture, resulting in profuse hemorrhage (rare) Hemorrhoid Varicosities of the rectal veins : first appear during pregnancy. pregnancy → exacerbation or recurrence of previous hemorrhoids Cause : obstruction of venous return by the large uterus as well as by constipation during pregnancy Treatment Pain and swelling :relieved by topically applied anesthetics, warm soaks, and stoolsoftening agents thrombosis of a rectal vein : cause considerable pain clot : evacuated by incising the vein wall under topical anesthesia Heartburn most common complaints of pregnant women caused by reflux of gastric contents into the lower esophagus ☜ results from the upward displacement and compression of the stomach by the uterus, combined with relaxation of the lower esophageal sphincter symptoms mild relieved by a regimen of more frequent but smaller meals and avoidance of bending over or lying flat Antacid preparations Aluminum hydroxide, magnesium trisilicate, or magnesium hydroxide alone or in combination are given. Pica ice (pagophagia), starch (amylophagia), or clay (geophagia) triggered by severe iron deficiency not all pregnant women with pica are necessarily iron deficient prevalence of anemia : 15 % in women with pica anemia : 6 % in women without pica the rate of spontaneous preterm birth (< 35 weeks) : twice as high in women with pica. Ptyalism cause : sometimes, stimulation of the salivary glands by the ingestion of starch. Most cases are unexplained Fatigue remits spontaneously by the fourth month of pregnancy no special significance It may be due to the soporific effect of progesterone(s). leukorrhea Increased vaginal discharge ( many instances is not pathological) → cervical glands in response to hyperestrogenemia leukorrhea is the result of an infection cause : trichomonal or yeast vulvovaginal infections Bacterial Vaginosis not an infection in the ordinary sense a maldistribution of normal vaginal flora Numbers of lactobacilli ↓↓ overrepresented species tend to be anaerobic bacteria ( Gardnerella vaginalis, Mobiluncus, and some Bacteroides species.) prevalence : 10 ~ 30 % associated with preterm birth Bacterial Vaginosis Treatment reserved for symptomatic women who usually complain of a fishy-smelling discharge Metronidazole, 500 mg twice daily orally for 7 days Curable rate : about 90 % treatment does not reduce preterm birth routine screening is not recommended (American College of Obstetricians and Gynecologists, 2001b). Trichomoniasis Incidence 20 % of women Symptomatic infection : much less prevalent Symptom foamy leukorrhea with pruritus and irritation Treatment Metronidazole, orally or vaginally, - crosses the placenta and enters the fetal circulation. - possibility of teratogenicity from first-trimester exposure was raised previously → no increased frequency of birth defects in over 1000 women given metronidazole during early pregnancy - Rosa and colleagues (1987), Trichomoniasis linked trichomonal infection with preterm birth, treatment has not proven to decrease the risk Some studies screening and treatment of asymptomatic women is not recommended during pregnancy Trichomoniasis Trichomonads are demonstrated readily in fresh vaginal secretions as flagellated, pear-shaped, motile organisms that are somewhat larger than leukocytes. Candidiasis Candidia albicans : cultured from the vagina in about 25 % of women approaching term. Asymptomatic colonization requires no treatment Symptom extremely profuse, irritating discharge associated with a pruritic, painfully tender, and edematous vulva. Treatment Miconazole, clotrimazole, and nystatin are effective for the treatment of candidiasis during pregnancy Recurrence (+) → requiring repeated treatment during pregnancy. → symptomatic infection usually subsides after pregnancy. Thank you for your attention !