prenatal care new

8/8/2019 Prenatal Care New

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Almost a century after itsintroduction, prenatal care has become one

of the most frequently used health services inthe United States A planned program of medical evaluation and

management, observation, and education of

the pregnant woman directed toward makingpregnancy, labor, delivery and thepostpartum recovery a safe and satisfyingexperience.



Well-designed prenatal program should providethe oppurtunities:

For the physician and the patient to become betteracquainted

For the physician to learn something about thepatients emotional attitude toward pregnancy andlabor

For instruction of the patient and her husband inoptimal care for herself and the coming baby

Optimal instruction of the patient and herhusband in a prepared childbirth program



24%

20%

16%

9%

8%

5%

5%

5%3%

2% 2% 1% Gestational Hypertension

Diabetes

Anemia

Hydramnios/oligohydramnios

Lung Disease

Genital Herpes

Chronic Hypertension

D(Rh) Sensitization

Cardiac disease

Renal Disease

Incompetent cervix

Hemoglobinopathy

Data from Martin and Assocaiates (2002b)

Data from Martin and Associates (2002b)



Varied by social and ethnicgroup, age and method of payment

Late identification of pregnancy by the

patient most common

Lack of money or insurance for suchcare

Inability to obtain an appointment



The current low maternal mortality rate of

approximately 8 per 100,000 is likely

associated with the high utilization of prenatal care

Prenatal care was associated withsignificantly lower rates of preterm births as

well as neonatal death associated withseveral high-risk conditions that included

placenta previa, fetal-growth restriction, and

postterm pregnancy



A comprehensive antepartum care program

involves a coordinated approach to medical

care and psychosocial support that optimallybegins before conception and extends

throughout the antepartum period

This comprehensive program includes:

(1) preconceptional care

(2) prompt diagnosis of pregnancy

(3) initial prenatal evaluation

(4) follow-up prenatal visits



The diagnosis of pregnancy usually begins

when a woman presents with symptoms, and

possibly a positive home urine pregnancy testresult

Sonography is often used, particularly inthose cases in which there is question about

pregnancy viability or location



Cessation of menses

The abrupt cessation of menstruation in a healthy

reproductive-aged woman who previously hasexperienced spontaneous, cyclical, predictablemenses is highly suggestive of pregnancy

Amenorrhea is not a reliable indication of

pregnancy until 10 days or more after expectedmenses onset. When a second menstrual period ismissed, the probability of pregnancy is muchgreater



Changes in Cervical Mucus

Mucus crystallization necessary for the production of the

fern pattern is dependent on an increased sodium chlorideconcentration.

Cervical mucus is relatively rich in sodium chloride whenestrogen, but not progesterone, is being produced.

From about the 7th to the 18th day of the menstrual

cycle, a fernlike pattern of dried cervical mucus is seen

After approximately the 21st day, a different patternforms that gives a beaded or cellular appearance



Breast Changes

Anatomical changes in the breasts thataccompany pregnancy are

characteristic during a first pregnancy



Vaginal Mucosa

During pregnancy, the vaginal mucosausually appears dark bluish or purplish-

red and congested - the so-called

Chadwick sign



Skin changes

Increased pigmentation and changesin appearance of abdominal striae are

common to, but not diagnostic

of, pregnancy.

They may be absent during

pregnancy, and they may be seen in

women taking estrogen-progestin



Uterine changes

During the first few weeks of pregnancy, theincrease in uterine size is limited principally to theanteroposterior diameter

By 12 weeks, the body of the uterus is almostglobular, and an average uterine diameter of 8 cm

is attained. At about 6 to 8 weeks' menstrual age, on

bimanual examination a firm cervix is felt whichcontrasts the now softer fundus and compressible

interposed softened isthmus - theHegar sign



Uterine changes

Uterine souffle may be heard in the later months

of pregnancy, a soft blowing sounf that issynchronous with the maternal pulse, producedby passage of blood through the dilated uterinevessels

Funic souffle sharp, whistling sound that issynchronous eith the fetal pulse, caused by therush of blood through the umbilical arteries



Cervical Changes

Increased cervical softening as pregnancy

advances

External cervical os and cervical canal may

become sufficienlty patulous to admit the

fingertip, however, the internal os shouldremain close



Perception of Fetal Movements

May first perceive fetal movements

between 16 and 18 weeks

A primigravida may not appreciate fetal

movements until approximately 2 weeks

later (18-20 weeks) At approximately 20 weeks, depending on

maternal habitus, an examiner may begin

to detect fetal movements



PregnacyTest Detection of hCG in maternal blood and urine

provides the basis for endocrine tests of pregnancy

HCG is a glycoprotein woth a high carbohydrate content

Composed of and subunits

-subunit is identical to those in LH, FSH andTSH

HCG prevents the involution of the corpus luteum (principal siteof progesterone production for the first 6-weeks



PregnacyTest With sensitive test the

hormone can be detectedin maternal palsma orurine by 8-9 days after

ovulation

Doubling time = 1.4 2

days

False positive hCG testresults are rare e.g.heterophilic antibodies

Serum hCG l evel s increase from t heday of impl antation and reach peak l evel s at 60-70days. T hereafter, t heconcentration decl ines sl ow l y unti l

a nadir at about 16 weeks.



A gestational sac may be demonstrated by

abdominal sonography after only 4 to 5

weeks menstrual age. By 35 days, a normal sac should be visible in

all women

After 6 weeks, heart motion should be seen

Up to 12 weeks, the crown-rump length ispredictive of gestational age within 4 days



Prenatal care should be initiated as soon

as there is a reasonable likelihood of

pregnancy.The major goals are to: Define the health status of the mother and

fetus

Estimate the gestational age

Initiate a plan for continuing obstetricalcare.



WEEKS

FirstVisit 15-20 24-28 29-41

History

y Complete *

y Updated * * *

Physical

Examination

y Complete *

y BP * * * *

y Maternal

Weight

* * * *

y Pelvic/Cervical

Exam

*

y Fundal Height * * * *

y Fetal HeartRate/Position

* * * *



WEEKS

FirstVisit 15-20 24-28 29-41

Laboratory Test

y Hct or Hgb y * y *

y Blood type & Rh

factor

y *

y Antibody screen y * A

y Pap smear

screen

y *

y Glucose

tolerance test

y *

y Fetal Aneuploidy

ScreeningBa and/or B

y NeuralTube

defect screeningB

y Cystic Fibrosis

screeing

B or B

y Urine proteinassessment

*



WEEKS

FirstVisit 15-20 24-28 29-41

Laboratory Test

y Urine Culture *

y Rubella

serology

*

y Syphilis

serology

* C

y Gonococcal

culture

D D

y Chlamydial

culture

y * C

y Hepatitis B

serology

y *

y HIV serology B

y Group

B

strepculture E



a First-trimester aneuploidy screening may beoffered between 11 and 14 weeks

A Performed at 28 weeks, if indicated B Test should be offered C High risk women should be retested at the

beginning of the third trimester D High risk women should be screened at the first

prenatal visit and again in the third trimester E Rectovaginal culture should be obtained

between 35 and 37 weeks



Use of a standardized recod with a perinatal

healthcare system greatly aids antepartum

and intrapartum management. Standardizing documentation may allow

communication and continuity of carebetween providers and enable objective

measures of care quality to be evaluated overtime and across different clinical setting.



There are several definitions pertinent to establishment of an accurate prenatal record:

Null igravida: a woman who currently is not pregnant, nor

has she ever been pregnant Gravida: a woman who currently is pregnant or she has

been in the past, irrespective of the pregnancy outcome.With the establishment of the first pregnancy, shebecomes a primigravida, and with successive pregnancies,a mul tigravida

Null ipara: a woman who has never completed a pregnancybeyond 20 weeks' gestation. She may or may not havebeen pregnant or may have had a spontaneous or elective

abortion(s) or an ectopic pregancy



There are several definitions pertinent to establishment of an accurate prenatal record:

Primipara: a woman who has been delivered only once of a fetus

or fetuses born alive or dead with an estimated length of gestation of 20 or more weeks. In the past, a 500-g birthweight

threshold was used to define parity.This threshold is no longeras pertinent because of the survival of infants with birthweights

less than 500 g.

Mul tipara: a woman who has completed two or morepregnancies to 20 weeks or more. Parity is determined by thenumber of pregnancies reaching 20 weeks and not by the

number of fetuses delivered. Parity is the same (para 1) for a

singleton or multifetal delivery or delivery of a live or still born

infant



In some locales, the obstetrical history issummarized by a series of digits connected

by dashes.T

hese usually refer to the number of term infants, preterm infants,

abortus less than 20 weeks, and children

currently alive. (F-P-A-L)



The mean duration of pregnancy calculated from the firstday of the last normal menstrual period is very close to 280 days, or 40 weeks

It is customary to estimate t

he expected date of de

l ivery by adding 7 days to t he date of t he first day of t he l ast normal

menstrual period and counting back 3 mont hs (Naegeles rule).

A gestational age or menstrual age calculated in this way

erroneously assumes pregnancy to have begun approx. 2

weeks before ovulation. Use to mark temporal events inpregnancy

Ov ulatory age or fertilization age employed byembryologist and other reproductive biologist, which are

typically 2 weeks shorter.



It has become customary to divide pregnancyinto three equal epochs of approx. 3 calendar

months. Historically, the first trimesterextends through completion of 14 weeks,

sthe second through 28 weeks, and the third

includes the 29th through 42nd weeks of

pregnancy. Thus, there are three periods of 14 weeks

each



Certain major obstetrical problems tend to cluster ineach of these time periods.

Most spontaneous abortions take place during the first

trimester

Most women with hypertensive disorders due topregnancy are diagnosed during the third trimester

Because precise knowledge of fetal age is

imperative for ideal obstetrical management, theclinically appropriate unit is weeks of gestationcompleted, and more recently, clinicians designategestational age using completed weeks and days.



Detailed information concerning past obstetrical history iscrucial because many prior pregnancy complications tend torecur in subsequent pregnancies

The menstrua

l h

istory is extremely important.T

he womanwho spontaneously menstruates regularly every 28 days orso is most likely to ovulate at midcycle.Thus, the gestationalage (menstrual age) becomes simply the number of weekssince the onset of the last menstrual period.

Without a history of regular, predictable, cyclic, spontaneousmenses that suggest ovulatory cycles, accurate dating of pregnancy by history and physical examination is difficult.



The American College of Obstetricians andGynecologists advocate psychosocial screening atleast once each trimester to increase the likelihood

of identifying issues and reducing adversepregnancy outcomes.

Screening ofr barriers to care includes lacktransportation,child care or family support; unstable

housing, unintended pregnancy, communicationbarriers, nutritional problems, cigarette smoking,subtance abuse, depression and safety concernsthat include domestic violence.



Smoking results in unequivocal adversesequelae for pregnant women and their

fetuses. Numerous adverse outcomes have been

linked to smoking during pregnancy

There is a twofold risk of placenta previa,

placental abruption and prematuremembrane rupture compared with non-smokers.



Babies born to women who smoke areapprox. 30% more likely to be born preterm,

weigh on average a half pound less, and areup to three times more likely to die of SIDS.

Pathophysiological cause:

Fetal hypoxia (increase carboxyhemoglobin)

Reduced uteroplacental blood flow

Direct toxic effects of nicotine and other compounds



The most successful efforts for smoking cessationduring pregnancy involve interventions thatemphasize how to stop.

One example is a 5-step session lasting 15 minutesor less in which the provider:

(1) Asks about smoking status;

(2) Advises those who smoke to stop;

(3) Assesses the willingness to quit within the next 30 days;

(4) Assists interested patients by providing pregnancy-specific self-help materials; and

(5) Arranges follow-up visits to track progress



The American College of Obstetricians and

Gynecologists (2005b) has concluded that it is

reasonable to use nicotine medicationsduring pregnancy if prior nonpharmacological

attempts have failed



Ethanol is a potent teratogen and causes thefetal alcohol syndrome, which is

characterized by growth restriction, facialabnormalities, and central nervous system

dysfunction

Women who are pregnant or considering

pregnancy should abstain from using anyalcoholic beverages



It is estimated taht 10 percent of fetuses areexposed to one or more illicit drug

Agents may include heroin and other opiates,cocaine, amphetamines, barbiturates and

marijuana

Well documented sequelae inlcude fetal

distress, low birthweight, and drugwithdrawal soon afetr birth



Unfortunately, most abused women contibueto be victimized during pregnancy

Domestic violence is more prevalent than anymajor medical condition detectable through

routine prenatal screeining

Intimate partner violence is associated with

an increase risk of a number of adverseperinatal outcomes including pretermdelivery, fetal-growth restriction, and

perinatal death



A thorough, general physical examination should be

completed at the initial prenatal encounter

The cervix is visualized employing a speculum lubricated

with warm water or water-based lubricant gel Bluish-red passive hyperemia of the cervix is characteristic,

but not of itself diagnostic, of pregnancy

Dilated, occluded cervical glands bulging beneath the

exocervical mucosa, so-called nabot hian cysts, may be

prominent.

The cervix is not normally dilated above the level of the

internal os.



Leopolds Maneuver LM 1 (Fundal Grip)

What fetal pole or part occupies the fundus? Breech irregular, nodular

Cephalic round

LM2 ( Umbilical Grip)

Which side is the fetal back?

Back linear, convex, bony ridge

Small parts numerous nodulation



Leopolds Maneuver

LM3 (Pawliks Grip)

What fetal part lies abovbe the pelvic inlet? Head not engaged round, ballotable, easily displaces

Head engaged felt as relatively fixed, knoblike part

LM4 (Pelvic Grip)

Which side the cephalic prominence? Examiner faces the patients feet and places one hand each on either side

of the lower pole of the uterus

Cephalic prominence

x Part of the fetus that prevents the deep descent with one hand

Flexion cephalic prominence same side as fetal parts

Extension same side as the fetal back



There are many risk factors that can be

identified and given appropriate considerationin pregnancy management

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



Asthma

y Symptomatic on medication OBG

y Severe MFM

Cardiac Disease MFM

DM OBG or MFM

Epilepsy (on medication) OBG

Hypertension

y Chronic, with renal and heart disease MFM

y Chronic, without renal and heart disease OBG

Prior fetal death OBG

HIV/AIDS MFM

Multifetal gestation OBG

Preterm Labor,Threatened OBG



Traditionally, the timing of subsequent

prenatal visits has been scheduled at intervalsof 4 weeks until 28 weeks, and then every 2

weeks until 36 weeks, and weekly thereafter.

Women with complicated pregnancies oftenrequire return visits at 1- to 2-week intervals.

Routine prenatal care, required a median of 8 visits



At each return visit, steps are taken to

determine the well-being of mother and fetus

Evaluation typically includes:

Fetal

Heart rate(s)

Size - current and rate of change

Amount of amnionic fluid Presenting part and station (late in pregnancy)

Activity



Evaluation typically includes:

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.



One of the most important determinations at

prenatal examinations is assessment of fetalage.

Precise knowledge of gestational age is

important because a number of pregnancycomplications may develop for which optimal

treatment will depend on fetal age



Between 20 and 34 weeks, the height of the uterine fundus,

measured in centimeters, correlates closely with gestationalage in weeks

The fundal height should be measured as the distance overthe abdominal wall from the top of the symphysis pubis to thetop of the fundus.

12th week above the symphisys pubis

16th week halfway between the symphysis pubis and the umbilicus

20th week level of umbilicus 28th week 6 cm above the umbilicus

36th week 2 cm below the xiphoid

40th week 4 cm below the xiphoid

T he bl adder must be emptied before making t he measurement.



The fetal heart can first be heard in most women between 16

and 19 weeks when carefully auscultated with a non-amplifiedstethoscope

The fetal heart rate now ranges from 110 to 160 bpm and isheard as a double sound resembling the tick of a watch undera pillow.

Instruments incorporating Doppler UTZ instruments are oftenused to easily detect fetal heart action, almost always by 10

weeks. Using real-time sonography with a vaginal transducer, fetal

cardiac activity can be seen as eraly as 5 menstrual weeks.



All pregnant women should be screened for

gestational diabetes mellitus, whether byhistory, clinical risk factors, or routine

laboratory testing.

Although laboratory testing between 24 and28 weeks is the most sensitive approach, there

may be pregnant women at low risk who areless likely to benefit from testing



The American Academy of Pediatrics and the

American College of Obstetricians and

Gynecologists (2002) recommend that

pregnant women with risk factors or

symptoms be cultured for N gonorr hoeae at anearly prenatal visit and again in the third

trimester. Risk factors for gonorrhea are similar for those

for chlamydia.



Selected screening can be offered based on maternal age,

family history, or the ethnic or racial background of the couple

Examples include testing for :

Tay-Sachs disease for people of Eastern European Jewish orFrench Canadian ancestry;

-thalassemia for those of Mediterranean, Southeast Asian,Indian, Pakistani, or African ancestry;

-thalassemia for people of Southeast Asian or Africanancestry; and

Sickle- cell anemia for people of African, Mediterranean,

Middle Eastern, Caribbean, Latin American, or Indiandescent



Recommended Ranges of Weight Gain during SingletonGestations Stratified by Prepregnancy Body Mass Index

Weight-for-Height Category Recommended Total Weight Gain

Category BMI Kg Lb

Low <19.8 12.5-18 28-40

Normal 19.8-26 11.5-16 25-35

High 26-29 7-11.5 15-25

Obese >29 7 15

The range for twin pregnancy is 35-45 lb (16-20 kg). Young adolescents (<2 yearsafter menarc he) and African-American women should stri v e for ganins at t he upper

end of t he range. Shorter women (<62 in. or <157cm) should stri v e for gains at t helower end of t he range.



Disadvantages of excessive maternal weight

gain and fetal macrosomia must be

considered Excessive weight gain - defined as more than

40 lb - correlated closely with fetalmacrosomia



Cohort studies of children born to

nutritionally deprived women have been

performed and were recently reviewed byKyle and Pichard.

Progeny exposed in mid to late pregnancywere lighter, shorter, and thinner at birth and

they had a higher incidence of subsequentdiminished glucose tolerance, hyeprtension,

reactive airway disease, dyslipidemia, and

coronary artery disease.



Average total weight loss resulted in an averageretained pregnancy weight of 3 lb or 1.4 kg.

Overall, the more weight gained during pregnancy,the more that was lost postpartum

Interestingly, there is no relationship betweenprepregnancy BMI or prenatal weight gain andweight retention.

Accruing weight with age rather than parity isconsidered the main factor affecting weight gainover time



Periodically, the Food and Nutrition

Board of the Institute of Medicine (2008)

publishes recommended dietaryallowances, including those for pregnant

or lactating women



AGE(YEARS) 14-18 19-50

FAT-SOLUBLE VITAMINS

VITAMINA 750 g 770 g

VITAMINDa 5 g 5 g

VITAMINE 15 mg 15 mg

VITAMINK 75 g 90 g

WATER SOLUBLE

VITAMINC 80 mg 85 mg

THIAMIN 1.4mg 1.4 mg

ROBOFLAVIN 1.4mg 1.4mgNIACIN 18 mg 18 mg

VITAMIN B6 1.9 mg 1.9 mg

FOLATE 600 g 600 g

VITAMIN b12 2.6 g 2.6 g

F r the Food d N triti on Boar d o f the I nstit te o f Med ici ne ( 8)



AGE(YEARS) 14-18 19-50

MINERALS

CALCIUMS 1300 mg 1000 mg

SODIUM 1.5 g 1.5 g

POTASSIUMS 4.7 g 4.7 g

IRON 27 mg 27 mg

ZINC 12 mg 11 mg

IODINE 220 g 220 g

SELENIUM 60 g 60 g

OTHERPROTEIN 71 g 71 g

CARBOHYDRATE 175 g 175 g

FIBERS 28 g 28 g

F r om the Food and N triti on Boar d o f the I nstit te o f Med ici ne ( 8)



Pregnancy requires an additional 80,000

kcal most are accumulated in the last 20

weeks. To meet this demand a caloric increase

of 100 to 300 kcal per day is

recommended



Added for the demands for growth and

remodeling of the fetus, placenta,

uterus and breast, as well as increasematernal blood volume

Most hould be supplied from animal

sources such as meat, milk, eggs,cheese, poultry and fish, because they

furnish amino acids in optimal

combinations



As little as 30 mg of elemental iron, supplied asferrous gluconate, sulfate or fumarate and taken dailythroughout the latter half of pregnancy, provides

sufficient iron to meet the requirments of pregnancyand to protect preexisting iron stores.

The pregnant woman may benefit from 60 to 100 mgof iron per day if she is large, has twin fetuses, beginssupplementation late in pregnancy, takes ironirregularly, or has a somewhat depressed hemoglobinlevel



The pregnant woman retains about 30 g

of calcium, most of which is deposited in

the fetus late in pregnancy This amount of calcium represents only

about 2.5 percent of total maternal

calcium, most of which is in bone, andwhich can readily be mobilized for fetal

growth



Severe zinc deficiency may lead to poor

appetite, suboptimal growth, and impaired

wound healing. Profound zinc deficiency may cause dwarfism

and hypogonadism

May also lead to a specific skin disorder,

acrodermatitis enteropat hica, as the result of arare, severe congenital zinc deficiency

Recommended daily intake during pregnancy

is about 12 mg



The use of iodized salt and bread products is

recommended during pregnancy to offset the

increased fetal requirements and maternalrenal losses

Severe maternal iodine deficiencypredisposes offspring to endemic cretinism,

characterized by multiple severe neurologicaldefects



More than half of neural tube defects can beprevented with daily intake of 400 g of folic acidthroughout the periconceptional period

Because nutritional sources alone are insufficient,however, folic acid supplementation is stillrecommended

A woman with a prior child with a neural-tibe defectcan reduce the 2-5 percent recurrence risk by morethan 70% with daily 4-mg folic acid supplementrsthe month before conception and during the firsttrimester.



Dietary intake of vitamin A in the United

States appears to be adequate, and routine

supplementation during pregnancy is notrecommended

A small number of case reports suggest anassociation of birth defects with very high

doses during pregnancy, 10,000 to 50,000 IUdaily.



These malformations are similar to those

produced by the vitamin A derivative

isotretinoin (Accutane), which is a potentteratogen in humans

Beta-carotene, the precursor of vitamin Afound in fruits and vegetables, has not been

shown to produce vitamin A toxicity.



The level of vitamin B12 in maternal plasma

decreases variably in otherwise normal

pregnancies This decrease is mostly from a reduction in

plasma transcobalamins and is thusprevented only in part by supplementation.



For women at high risk for inadequate

nutrition (e.g., substance abuse, adolescents,

and those with multifetal gestations), a dailysupplement containing 2 mg is

recommended.



The recommended dietary allowance for

vitamin C during pregnancy is 80 to 85

mg/day, or about 20 percent more than whennonpregnant

A reasonable diet should readily provide thisamount.



More than half of the children in the US are

born to working mothers

Federal law prohibits from excluding womenfrom job categories on the basis that they are

or might become pregnant

In the absence of complications, most

women can continue to work until the onsetof labor



Occupational fatigue, estimated by the number of hours standing, intensity of physical and mentaldemands, and environmental stressors, was

associated with an increased risk of pretermmembrane rupture

Thus, any occupation that subjects the pregnanctwoman to sever physicl strain should be avoided

Adequate period of rest should be provided



The American College of Obstetricians and

Gynecologists advises a thorough clinical

evaluation be conducted beforerecommending an exercise program.

In the absence of contraindications, pregnantwomen should be encouraged to engage in

regular, moderate-intensity physical activity30 minutes or more a day



ABSOLUTE AND REALATIVE CONTRAINDICATIONS TOAEROBIC EXERCISE DURING PREGNANCY

ABSOLUTE CONTRAINDICATIONS

Hemodynamically significant heartdisease

Restrictive lung disease

Incompetent cervix/ cerclage

Multifetal gestation at risk for pretermlabor

Persistent second-or third- trimesterbleeding

Placenta previa afet 26 weeks

Preterm labor during the currentpregnancy

Ruptured membranes

Preeclampsia/ pregnancy- inducedhypertension

RELATIVE CONTRAINDICATIONS

Severe anemiaUnevaluated maternal cardiac arrythmia

Chronic bronchitis

Poorly controlled type 1 diabetes

Extreme morbid obesity

Extreme underweight (BMI <12)

History of extremely sedentary lifestyle

Fetal- growth restriction in currentpregnancy

Poorly controlled hypertension

Orthopedic limitations

Poorly controlled seizure disorder

Poorly controlled hyperthyroidism

Heavy smoker



Automobile Travel

Pregnant women should be encouraged to wear

properly positioned three-point restraints throughout

pregnancy while riding in automobiles. The lap belt portion of the restraining belt should be

placed under the woman's abdomen and across her

upper thighs.

The belt should be as snug as comfortably possible. The shoulder belt also should be snugly applied and

positioned between the breasts



It is generally accepted that in healthy

pregnant woman, sexual intercourse ussually

is not harmful. Whenever abortion or preterm labor

threatens, however, coitus should be avoided

Intercourse late in pregnacy specifically has

not been found to be harmful



LIVE ATTENUATED Indications Dose Schedule Comments

MEASLES Contraindicated Single dose SC, preferably as

MMRa

Vaccinate susceptible women

postpartum.Breast feeding is

not a contraindication

M

M ¡ S Contraindicated Single dose SC, preferably asMMR

Vaccinate susceptible womenpostpartum

R

BELLA Contraindicated, but congenital

rubella syndrome has never

been described after vaccine

Single dose SC, preferably as

MMR

Teratogenicity of vaccine is

theoretical and not confirmed

to date; vaccinate susceptible

women postpartum

¡ OLIOMYELITISORAL= LIVE

ATTENTUATED; INJECTION=ENHANCED-

¡ OTENCY

INACTIVATEDVIRUS

Not routinely recommended

for women in theUnited States,except women at increased risk

for exposure

¡ rimary:Two doses of

enhanced-potency inactivatedvirus SC at 4-8 week intervals

and 3rd dose 6-12 months after

2nd doses

Vaccine indicated for

susceptible women traveling

VARICELLA Contraindicated, but not

adverse outcomes repoted in

pregnancy

Two doses needed: 2nd dose

given 4-8 weeks after 1st dose

Teratogenicity of vaccine is

theoretical.Vaccination of

susceptible women should be

considered postpartum.



INACTIVATED BACTERIAL VACCINES

Indications Dose Schedule Comments

PNEUMOCCOCUS Indications not altered by

pregnancy. Recommended

for women with asplenia;metabolic, renal, cardiac, or

pulmonary diseases;

immunosuppression; or

smokers

In adults, one dose only;

consider repeat dose in 6

years for high-rik women

Polyvalent polysaccharide

vaccine

MENINGOCOCCUS Indications not altered by

pregnancy; vaccination

recommended in unusual

outbreaks

One dose, tetravalent

vaccine

Antimicrobial prophylaxis if

significant exposure

THPHOID Not recommended Killed Primary: 2 injections

IM 4 weeks apart

Booster: One dose:

scheduled

Killed, injectable vaccine or

live attentuated oral vaccine.

Oral vaccine preferred.



TOXOID Indications Dose Schedule Comments

TATANUS-DIPTHERIA Lack of primary series,

or no booster within

pat 10 years

Primary:Two doses IM

at 1-2 month interval

with 3rd dose 6-12 months after the 2nd

Booster: Single dose IM

every 10 years after

completion of primary

series

Combined tetanus-

diptheria toxoids

preferred: adultstetanus-diptheria

formulation. Updating

immune status should

be part of antepartum

care.



SPECIFIC IMMUNE

GLOBULINS

Indications Dose Schedule Comments

HEPA B Postexposure prophylaxis Depends on exposure Usually given with Hepa B

virus vaccine; exposednewborn needs immediate

prophylaxis

RABIES Postexposure prophylaxis Half dose at injury site, half

dose in deltoid

Used in conjugation with

rabies killed- virus vaccine

TETANUS Postexposure prophylaxis One dose IM Used in conjugation with

tetanus toxoid

VARICELLA Should be considered for

exposed pregnant women

to protect against

maternal, not congenital,

infection

One dose IM within 96

hours of exposure

Indicated also for

newborns or women who

developed varicella within

4 days before delivery or 2

days following delivery



In 1980, the FDA advised pregnant women to limit caffeine

intake. The Fourth International Caffeine Workshop concluded

shortly thereafter that there was no evidence that caffeinecaused increased teratogenic or reproductiverisks

In small laboratory animals, caffeine is not a teratogen, but if

given in massive doses it potentiates mutagenic effects of radiation and some chemicals.

The American Dietetic Association (2002) recommends thatcaffeine intake during pregnancy be limited to less than 300 mg daily, or about three, 5-oz cups of percolated coffee.



These are common complaints during the

first half of pregnancy.

Although they tend to be worse in themorning, thus, erroneously called morning

sickness, symptoms usually commencebetween the first and second missed

menstrual period and continue until about 14 to 16 weeks.



Although nausea and vomiting tend to be

worse in the morning, they may continue

throughout the day. Fortunately, the unpleasantness and

discomfort usually can be minimized. Eatingsmall feedings at more frequent intervals but

stopping short of satiation is of value.Thesmell of certain foods often precipitates or

aggravates the symptoms and should be

avoided.



Low back pain to some extent is reported in nearly70 percent of pregnant women

Minor degrees follow excessive strain or fatigue and

excessive bending, lifting, or walking. Back pain can be reduced by having women squat

rather than bend over when reaching down,providing back support with a pillow when sitting

down, and avoiding high-heeled shoes.



These enlarged veins generally result fromcongenital predisposition and are exaggerated byprolonged standing, pregnancy, and advancing age

Become more prominent as pregnancy advances, asweight increases, and as the length of time spentupright is prolonged.

The treatment of varicosities of the lower

extremities is generally limited to periodic rest withelevation of the legs, elastic stockings, or both.

Surgical correction is not advised



Their development or aggravation during pregnancyundoubtedly is related to increased pressure in therectal veins.

This is caused by obstruction of venous return bythe large uterus as well as by constipation duringpregnancy.

Pain and swelling usually are relieved by topically

applied anesthetics, warm soaks, and stool-softening agents.



One of the most common complaints of pregnant women

and is caused by reflux of gastric contents into the loweresophagus

Most likely results from the upward displacement andcompression of the stomach by the uterus, combined withrelaxation of the lower esophageal sphincter

Are relieved by a regimen of more frequent but smallermeals and avoidance of bending over or lying flat.

Antacid preparations may provide considerable relief. Aluminum hydroxide, magnesium trisilicate, or magnesium

hydroxide alone or in combination are given.



The cravings of pregnant women for strange foodsare termed pica

There has been considerable historical interest in

the cravings (pica) of pregnant women for strangefoods and, at times, nonfoods such as ice(pagophagia), starch (amylophagia), or clay(geophagia).

This desire has been considered by some to betriggered by severe iron deficiency.



Women during pregnancy are

occasionally distressed by profuse

salivation. The cause of this ptyalism sometimes

appears to be stimulation of the salivary

glands by the ingestion of starch.



Beginning early in pregnancy, many women experiencefatigue and need increased amounts of sleep

Likely due to soporific effect of progesterone

Fatigue and nonrestful sleep may be exacerbated bymornig sickness

By the late 2nd trimester, total nocturnal sleep isdecerased, and women usuually begin to complain of

sleep distrubances By the third trimester, nearly all women have altered

sleep Daytime naps and mild sedatives at bedtime such as

diphenhydramine are usually helpful



Pregnant women commonly develop increasedvaginal discharge, which in many instances is notpathological.

Increased mucus secretion by cervical glands inresponse to hyperestrogenemia is undoubtedly acontributing factor.

Occasionally, troublesome leukorrhea is the result

of an infection caused by trichomonal or yeastvulvovaginal infections.



CordLife collects, processes and stores your baby's cord

blood stem cells which may later become potential sourcematerial for lifesaving treatment.

T

here is only one chance to collect, which is at birth of yourbaby.

Cord blood has become a major source of stem cells for

transplantation worldwide and is used to treat over 80 diseases, including certain cancers and bone marrow failure

syndromes, inborn errors of metabolism, blood disordersand immunodeficiencies.

Stem cells are also showing great promise in the treatment

of neural injury, diabetes, heart conditions.

prenatal care new

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