Factors of care during pregnancy, Toe UTS Attila Molvarec, MD, PhD 1st Department of Obstetrics and Gynecology Semmelweis University, Budapest, HungaryPrenatal care A comprehensive antepartum care program that involves a coordinated approach to medical care and psychosocial S11) ce08 Optimally begins before conception and extends throughout the antepartum period One of the most frequently used health services in developed countries The average number of prenatal care visits is 12 per pregnancy More than 80 percent of women initiate prenatal care in ip ebemeelidtoePrenatal care (Oye « Preconceptional care ¢ Prompt diagnosis of pregnancy « Initial presentation for pregnancy care ¢ Follow-up prenatal visitsDiagnosis of pregnancy Cessation of menses Positive home urine pregnancy test Detection of hCG in maternal blood or urine: 8-9 days after ovulation Ultrasonic recognition of pregnancy — 0. (zero) screening (transvaginal): gestational sac, yolk sac, embryo with heartbeatCos rae)PME O oe elmer Prenatal care should be initiated as soon as there is a reasonable likelihood of pregnancy The major goals: * To define the health status of the mother and fetus * To determine the gestational age of the fetus * To initiate a plan for continuing obstetrical careRecommended components of the initial prenatal care visit (ACOG) Risk assessment to include genetic, medical, obstetrical and psychosocial factors JK aR IT NKere MOU eMe Ete] General physical examination Laboratory tests: hematocrit (hemoglobin), urinanalysis, urine culture, blood grouping, Rh, antibody screen, rubella status, syphilis screen, Pap smear, HBsAg testing; offer iS UAYAos iit Patient education, e.g. use of seatbelts, avoidance of alcohol and tobaccoAssessment of gestational age The duration of pregnancy from the first day of the last normal menstrual period (LMP) is 280 days or 40 weeks (266 days (38 weeks) from conception) IN ETerere CM AEM COMI EVIE CoM UNTO. quelle Mero MCRL R (EDD): add 7 days to the date of the first day of the LMP and count back 3 months (menstrual history!) LMP: 20 September — EDD: 27 June We divide pregnancy into 3 trimesters of appx. 3 calendar months (1-12, 13-24, 25-40) Clinicians designate gestational age using completed weeks and days: 33+3 means 33 completed weeks and 3 EWANDetermination of fetal age: ultrasonography in the first trimester — crown-rump length (CRL)Taking a maternal history * Almost a fourth of pregnant women have significant, identifiable, treatable complications * Major categories for increased risk: (1) Preexisting medical illness (2) Previous poor pregnancy outcome (perinatal mortality, preterm delivery, IUGR, malformations, placental accidents, maternal hemorrhage) (3) Evidence of maternal undernutrition * Detailed information concerning past obstetrical history is crucial because most prior pregnancy complications tend to recur in subsequent pregnanciesMeN a ar OCC) Cigarette smoking: spontaneous abortion, low birthweight due to either preterm delivery or IUGR, infant and fetal deaths, placental abruption, attention-deficit/hyperactivity Alcohol use: ethanol is a potent teratogen and causes the fetal alcohol syndrome (IUGR, facial abnormalities, CNS dysfunction-mental retardation) Illicit drugs (opium derivatives, barbiturates, amphetamines): fetal distress, low birthweight, drug withdrawal soon after birth Domestic violence: violence against adolescent and adult females within the context of family or intimate relationships Increased risk of antepartum hemorrhage, IUGR, perinatal CeCe)aH RCE LOTT Obstetrical examination * The cervix is visualized using a speculum (bluish-red hyperemia is characteristic of pregnancy), colposcopy Chadwick sign: the vaginal mucosa appears dark bluish or purplish- red and congested + Pap smear, vaginal smear, specimens for identification of Neisseria gonorrhoeae and Chlamydia trachomatis if screening is indicated + Bimanual pelvic examination: cervix, corpus, bony architecture of fate oat Hegar sign: softening at the isthmus; Piskacek sign: soft prominence over the site of implantation + Examination of the breasts A thorough general physical examination with BMI, blood pressure, pulse rate, ECG (family physician), dental examinationHegar and Piskacek sign s virenyés Fellazulisa jllemz ivotosulss| corpus uter! N 6/6. abra 6/18. abraNPN a ACCRA OE Complete blood count (WBC, Hb, Htc, Plt) Fasting glucose Liver and renal function parameters, coagulogram (if indicated) Blood group, Rh, irregular antibody screening Lues serology SIS hyag Urinanalysis: gravity, protein, glucose, pus, ubg, ketonesSubsequent prenatal visits At intervals of 4 weeks until 28 weeks BU a een od cet ee ORL .49 Weekly thereafter Taree u ns a kate lile eee Le COL ed a Tear At each return visit, steps are taken to determine the well- [oti Tee) im oLOLU MUNI U OMT OM Nom CLAM Ge Kot rleT surveillance)Prenatal surveillance — fetal Heart rate(s): fetal stethoscope from 16-19 weeks, Doppler equipment from 10 weeks, transvaginal US from 5-6 Siete ey NSP A emo atone Become TLE Amount of amnionic fluid Presenting part and station (late in pregnancy) Activity (fetal movements from 18-20 weeks) Non-stress test: from 35 weeks weekly, from 38 weeks twice in a week, from 40 weeks daily Amnioscopy: from 40 weeks every second dayLeopold maneuvers — abdominal palpation First maneuver: height of the fundus, which fetal pole (breech or head) occupies the uterine fundus Second maneuver: fetal lie and position Third maneuver: fetal presenting part (head, breech) and its relationship to the pelvic inlet (engagement) Fourth maneuver: presenting part, engagement, descensus of the head into the pelvis Fifth (Zangemeister) maneuver: cephalopelvic disproportion (the head lies at the same level as or even projects above the symphysis)A: Fetal heartbeat; B: Indicator showing movements felt by mother (caused by pressing a button); C: Fetal movement; D: Uterine contractions NST: two or more accelerations of 15 beats/min or more, each lasting at least 15 seconds within 20 minutesPrenatal surveillance — maternal Blood pressure, pulse rate Weight: current and amount of change Complaints: headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, dysuria Height in centimeters of uterine fundus from symphysis (between 18 and 30 weeks in agreement with gestational age in weeks) Vaginal examination late in pregnancy: 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 (CI)20 weeks: 2 finger widths below umbilicus 24 weeks: at umbilicus 28 weeks: 2 finger widths above umbilicus 32 weeks: 4 finger widths above umbilicus 35 weeks: between umbilicus and xyphoid process 36 weeks: 4 finger widths below xyphoid process (xy/4) 37 weeks: xy/3 38 weeks: xy/2 39 weeks: xy/3 LOR ed <8 7c)Subsequent laboratory tests (Ooi cme MeO eMeH (OMe leCCoU Irregular antibody screening: Rh-negative women — each trimester (Anti-D at 28 weeks), Rh-positive women — first and third trimester Serum alpha-fetoprotein (AFP) for open neural tube defects: at 16 weeks (15-20 weeks) - discontinued Gestational diabetes screening (WHO): 75 g oral glucose tolerance test (OGTT) at 24-28 weeks Urine sediment or culture for bacteriuria: each trimester WEEMS elm Comore OSS ARO MmtaT (oe Group B Streptococcus (GBS): vaginal and rectal cultures between 35 and 37 weeks (culture-based approach, ACOG recommendation) Screening for chlamydial and gonococcal infection (ACOG): cervical culture in the first and third trimester in high-risk women (unmarried, recent partner change, multiple partners, <25 years, other STD)Special screening for genetic diseases Screening methods for aneuploidies (optional): ¢ Combined test: pregnancy-associated plasma protein-A (PAPP-A), free 8-human chorionic gonadotropin (free B- hCG) and nuchal translucency (NT) at 11 (10-13) weeks Quadruple test: alpha-fetoprotein (AFP), total hCG, unconjugated oestriol (uE3) and inhibin-A at 15-16 (14- 22) weeks Integrated test: NT and PAPP-A at 11 (10-13) weeks + AFP, total hCG, uE3 and inhibin-A at 15-16 (14-22) a Kero) 63 Cystic fibrosis, Tay-Sachs disease, 3- and a-thalassemia, sickle-cell anemia: screening can be offered based on family history, or the ethnic or racial background of the couple, ideally in the preconceptional period (ACOG)Ultrasound screening (Hungarian protocol) 0. screening: transvaginal diagnostic US in early Fe Kera ITA 1. screening (12-13 weeks): CRL (gestational age), nuchal translucency, nasal bone 2. screening (18-19 weeks): survey of fetal anatomy (,,genetic US”) 3. screening (30-31 weeks): fetal size TUGR) 4. screening (36-37 weeks): information for delivery (fetal lie, presentation, fetal size, location and maturity of placenta, amnionic fluid volume)Nutrition during pregnancy Maternal weight gain during pregnancy influences birthweight of the infant Underweight women deliver smaller infants, whereas the opposite is true for overweight women Excessive weight gain: hypertensive disorders, fetal macrosomia Limited weight gain: preterm birth, IUGR During the severe European winter of 1944-1945 in the Netherlands occupied by the German military (,,Hunger Winter’), starvation was associated with a decrease in median birthweight about 250 g, a decline in the frequency of ,,toxemia”, but the perinatal mortality rate was unchangedRecommended total weight gain for singleton pregnancies based on pre-pregnancy BMI Low (BMI<19.8): 12.5-18 kilograms Normal (19.8-26): 11.5-16 kg High (>26-29): 7-11.5 kg Obese (>29): <7 kg For women with twins: 16-20 kg The rate of weight gain should be about 0.7 pound (320 grams)/week from 8 to 20 weeks, while after 20 weeks about | pound (450 grams)/weekProm eee) Pregnancy requires an additional 80.000 kcal, which are accumulated primarily in the last 20 weeks To meet this demand, a caloric increase of 100-300 kcal/day is recommended during pregnancy There are extra protein demands for growth and repair of the fetus, placenta, uterus, breasts and increased maternal blood volume During the second half of pregnancy, about 1000 g of protein are deposited , amounting to 5-6 g/day Most protein should be supplied from animal sources, such as meat, milk, eggs, cheese, poultry and fish, because they furnish amino acids in optimal combinations Milk and dairy products are ideal sources of nutrients, especially protein and calcium for pregnant or lactating womenPrenatal mineral supplementation 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 zal The iron requirements of normal pregnancy total appx. 1000 mg (300 mg transferred to the fetus and placenta, 200 mg lost through excretion, 500 mg for erythropoiesis), of which nearly all is used after Pan Cehe Keune talon At least 30 mg of ferrous iron supplement should be given cE TOM ULOyeUmMUCR Nero yee MNU TENT COMmUZUN CONNELL NTIS contained in most prenatal vitaminsDRIEIEL MAIER ya neLaCIT BUR e Ket m Ke eco rlor AB COMAaTE TLR ET bar 1es supplied by any general diet that provides adequate calories and protein, except for folic acid Daily intake of 400 j1g of folic acid throughout the joleru (ey Cee oLaCO eV melee Cole COM eC aMert mire MAU elem O(n Cd mg/day for a woman with prior NTD) Routine multivitamin supplementation is not recommended unless the maternal diet is questionable (multiple gestation, substance abuse, complete vegetarians, epileptics)Pragmatic nutritional surveillance In general, advise the pregnant woman to eat what she wants in amounts she desires and salted to taste Make sure that there is ample food to eat, especially in the case of the socio-economically deprived woman Monitor weight gain, with a goal of about 11.5-16 kg in women ATT Keyan ET SD\Y ON Periodically explore food intake by dietary recall to discover the occasional nutritionally absurd diet Give tablets of simple iron salts that provide at least 30 mg of elemental iron daily. Give 400 jg daily of folate supplementation before and in the early weeks of pregnancy Recheck the hematocrit (hemoglobin) at 28-32 weeks to detect any significant decreaseUra CUMOC MI NMOCoe MMO ET Cac) TABLE 5-6 National Research Council Recommended Daily Dietary Allowances for Women Before and During Pregnancy and Li Nutrient Nonpregnant Pregnant Lactating a 00 2601 60 D0 vitamins Folate (j:9) Niacin (mg) Riboflavin (mg) niamine (mg) yridoxine Bg (mg) Sobalamin Biz (ig) Minerals Calcium (mg) hosphorus (mg lodine (jg) tron (mg of fetrous iron) agnesium (mg Zinc (mg)Preconceptional counseling Preventive medicine for obstetrics Factors that could potentially affect perinatal outcome are identified, and the woman is advised of her risks Whenever possible, a strategy is provided to reduce or eliminate the pathological influences revealed by her family, medical or obstetrical history, or by specific irritated Has a measurable positive impact on pregnancy outcome By the time most women realize they are pregnant (1-2 weeks after the first missed period), the fetal spinal cord has already formed and the heart is beatingPreconceptional counseling visit ¢ Medical history: maternal and fetal risks, pre-pregnancy evaluation, change of medication (diabetes, hypertension, epilepsy, heart disease, collagen vascular disorders, etc.) ¢ Genetic diseases: neural tube defects, phenylketonuria, Tay-Sachs disease, thalassemias ¢ Reproductive history: infertility, need for assisted reproductive technologies; outcomes of each prior pregnancy: miscarriage, ectopic pregnancy, recurrent pregnancy loss, preterm delivery; complications: preeclampsia, gestational diabetes, placental abruption, previous cesarean delivery (indication); reproductive history of first-degree relatives (familial translocation)Social history AY Enroute ecto Teenagers are more likely to be anemic and are at increased risk for IUGR, preterm labour, and consequent higher infant mortality; STDs are more common during pregnancy; greater caloric requirements (+400 kcal/day for normal and underweight IETS) ‘Women over 35 are at increased risk for obstetrical complications, perinatal morbidity and mortality if they have a chronic illness or are in poor physical condition. For the normal weight, physically fit woman without medical problems, the risks are not appreciably increased. Fetal aneuploidy and dizygotic twinning increase with PEIKOnI re oma Smoking, alcohol, recreational drugs Domestic abuse: inquire about risk factors (partners abuse alcohol or drugs, unemployed, have a poor education or low income, history of arrest), offer interventionDiet + Many vegetarian diets are protein deficient, but can be corrected by increasing egg and cheese consumption * Obesity: maternal complications (hypertension, preeclampsia, gestational diabetes, labor abnormalities, postterm pregnancy, cesarean delivery, operative complications), adverse fetal outcomes (spina bifida, ventral wall defects, late fetal death, preterm delivery) + Anorexia, bulimia: nutritional deficiencies, electrolyte disturbances, cardiac arrhythmias, gastrointestinal pathology, less weight gain, Sire Comp reve te ey Exercise: can continue (avoid supine position, augment heat dissipation), but orthopedic injury (balance problems, joint relaxation) Environmental exposures: infectious organisms (CMV, RSV: neonatal nurses; parvovirus, rubella: day-care workers), chemicals (heavy metals, organic solvents: industrial workers; pesticides: women living in rural areas; mercury: large fishes)TOI MA NICO a * The health and reproductive status of each ,,blood relative” should be reviewed for medical illnesses, mental retardation, birth defects, genetic disease, infertility and peter een mess * Certain racial or ethnic backgrounds may indicate increased risk for specific recessive disorders Immunizations ¢ Toxoids, killed bacteria and viruses have not been associated with adverse fetal outcomes ¢ Live virus vaccines are not recommended during pregnancy and ideally should be given at least 1 month before attempts to conceivePreconceptional screening tests, examinations Complete blood count (exclude inherited anemias) Rubella, varicella, hepatitis B immune status: vaccination preconceptionally Carrier testing for genetic diseases based on family history, racial or ethnic backgrounds, partners of carriers (Tay-Sachs disease, cystic fibrosis, thalassemias, sickle- cell anemia) Specific tests for chronic medical diseases: chronic renal disease (serum creatinine can predict pregnancy outcome), cyanotic heart disease (hemoglobin, arterial oxygen saturation predict fetal outcome), insulin- dependent diabetes (hemoglobin A, to compute risks for major congenital anomalies) General physical, gynecological, dental examination