Prenatal carePrenatal care

Dr.F Mostajeran Dr.F Mostajeran

Prenatal care PNCPrenatal care PNC

1915 10000 consecutive deliveries 1915 10000 consecutive deliveries

40% of prenatal death prevented by PNC40% of prenatal death prevented by PNC

1945 organized PNC “more to save mother”1945 organized PNC “more to save mother”

In adequate PNCIn adequate PNC

Kessner indexKessner index Measuring adequacy PNCMeasuring adequacy PNC Recorded on birth certificateRecorded on birth certificate Length gestation, time first PNC, number of Length gestation, time first PNC, number of

visitsvisits It does not measure quality not consider It does not measure quality not consider

relative risk of mother 2000 12% American relative risk of mother 2000 12% American women inadequate PNCwomen inadequate PNC

2000 50% delayed or no PNC2000 50% delayed or no PNC

Reason cited (social, ethnic group, age, Reason cited (social, ethnic group, age,

method of pyment)method of pyment)

1.1. Women did not know she was pregnantWomen did not know she was pregnant

2.2. Lack of money or insuranceLack of money or insurance

3.3. Inability to obtain an appointementInability to obtain an appointement

Effectiveness of prenatal care Effectiveness of prenatal care past several decades no benefitpast several decades no benefit

↑ ↑ low birth weightlow birth weight

↑ ↑ preterm labor (2 fold)preterm labor (2 fold)

1992 compared the cost an benifit PNC1992 compared the cost an benifit PNC

12000 patient missouri each$ spent PNC12000 patient missouri each$ spent PNC

Savings %1.49 in newborn and postpartum costsSavings %1.49 in newborn and postpartum costs

PNC+ overall F-death rate 2.7/1000 compared PNC+ overall F-death rate 2.7/1000 compared

with 14.1/1000 without PNC with 14.1/1000 without PNC

relative risk stillbith 3.3 fold relative risk stillbith 3.3 fold

(p.previa – IuGR – post term)(p.previa – IuGR – post term)

Maternal – M 690/100000 Maternal – M 690/100000

1920 50/100000 1955 current maternal 1920 50/100000 1955 current maternal

mortality rate 8/100000mortality rate 8/100000

Organization of prenatal careOrganization of prenatal care

2002 have defined prenatal care as 2002 have defined prenatal care as

1.1. Medical careMedical care

2.2. Psychosocial support before conception Psychosocial support before conception throughout antipartum period throughout antipartum period

3.3. Program includes Program includes 4.4. Preconceptional carePreconceptional care

5.5. Prompt diagnasis of pregPrompt diagnasis of preg

6.6. Initial presentation for p-careInitial presentation for p-care

7.7. Follow up prenatal visitsFollow up prenatal visits

Initial prenatal evaluation Initial prenatal evaluation

major goals aremajor goals are

1.1. To define health status mother-fetusTo define health status mother-fetus

2.2. Gestational age of the fetusGestational age of the fetus

3.3. Initiate a plan for continuing obstetrical careInitiate a plan for continuing obstetrical care

Prenatal recordPrenatal record

HistoryHistory Physical ExPhysical Ex Laboratory testsLaboratory tests Nulligravida: Nulligravida: Not now and never has been pregnantNot now and never has been pregnant

GravidaGravida who is or has been pregnant who is or has been pregnant

primigravida – multiprimigravida – multi NulliparaNullipara who has never completed a prey who has never completed a prey

begound 20 wk P±begound 20 wk P± PrimiparaPrimipara who has been delivered once fetus or who has been delivered once fetus or

fetvses alive or dead begon 20 wk fetvses alive or dead begon 20 wk MultiparaMultipara two or more pregnancy completed after two or more pregnancy completed after

20wk20wk

Normal pregnancy durationNormal pregnancy duration

Lmp 280 days 40 wkLmp 280 days 40 wk Expected date of delivery (Naogele role)Expected date of delivery (Naogele role) First trimester 14 wkFirst trimester 14 wk Second trimester through 28 wkSecond trimester through 28 wk Third trimester 29-42Third trimester 29-42

HistoryHistory

detailed information past obstetrical detailed information past obstetrical history complication tend to recur in history complication tend to recur in subsequent pregsubsequent preg

Menstrual history Menstrual history Regular mens – oligomenorrhea Regular mens – oligomenorrhea OCPOCP

Psychosocial screeningPsychosocial screening

Cigarette smokingCigarette smoking

1.1. Spontaneous abortionSpontaneous abortion

2.2. LBW due to PTL or IUGRLBW due to PTL or IUGR

3.3. Infant and fetal deathInfant and fetal death

4.4. P. abruptionP. abruption

Pathophysiologycal mechanismPathophysiologycal mechanism

Increased fetal carbonxhemoglobin Increased fetal carbonxhemoglobin

↓ ↓ utero placental blood flowutero placental blood flow

Fetal hyponxiaFetal hyponxia

AlcoholAlcohol

Potent teratogen F-alcohol synPotent teratogen F-alcohol syn Growth restrictionGrowth restriction Facial abnormalitiesFacial abnormalities CNS disfunctionCNS disfunction

Chronic VSC or lange quantities illicit Chronic VSC or lange quantities illicit

drugs including opium barbiturates drugs including opium barbiturates

amphetamines amphetamines

F- distress, LBW drug withdrawalF- distress, LBW drug withdrawal

Physical ExaminationPhysical Examination

General physical Exam at initial PNCGeneral physical Exam at initial PNC

Pelvic examPelvic exam

Lubricated speculum warm waterLubricated speculum warm water

Bluish-red passive hyperemiaBluish-red passive hyperemia

Nabathian cystsNabathian cysts

Identify cytological abnor pap smearIdentify cytological abnor pap smear

Specimens Identification neisseria gonorrheaSpecimens Identification neisseria gonorrhea

Chlamydia trachomatisChlamydia trachomatis

Digital P.EXDigital P.EX

Consistency length dilatation cervixConsistency length dilatation cervix

Presentation fetusPresentation fetus

Bony architecture pelvisBony architecture pelvis

Anomaly vagina perineum cystocle rectoceleAnomaly vagina perineum cystocle rectocele

Subsequent prenatal visitsSubsequent prenatal visits

Traditionally timing subsequent PN visitsTraditionally timing subsequent PN visits

Interval 4 wk until 28 wkInterval 4 wk until 28 wk

Then every 2 wk until 36 wk thereafter Then every 2 wk until 36 wk thereafter

weekly weekly

Complicated pregnancy 1 to 2 wk Complicated pregnancy 1 to 2 wk

intervalsintervals

Prenatal surveillancePrenatal surveillance

To determine well-being mother and fetusTo determine well-being mother and fetus

FetalFetal

Heart rateHeart rate

Size current – rate of changeSize current – rate of change

AFAF

PresentationPresentation

Activity Activity

MaternalMaternal

BP changeBP change Weight changeWeight change symptoms headache, altered vision, ab-pain symptoms headache, altered vision, ab-pain

vomiting, bleeding, vaginal fluid leakage vomiting, bleeding, vaginal fluid leakage dysuriadysuria

Height uterine fonduesHeight uterine fondues V.E lat in prey (present, station, dilatation, V.E lat in prey (present, station, dilatation,

effacement p-capacity)effacement p-capacity)

Assessment gestational ageAssessment gestational age

LMP F.height (20-31) 34wkLMP F.height (20-31) 34wk

Fetal Heart sounds 16-19 wk Delee fetal Fetal Heart sounds 16-19 wk Delee fetal

stethoscopestethoscope

ultra soundultra sound

Between 8 and 16 wk slightly more Between 8 and 16 wk slightly more

accurateaccurate

Lab test Lab test

Hct hb blood type AR factor Hct hb blood type AR factor

Antibody screen Antibody screen

u/c u/a FBS u/c u/a FBS

Pap smearPap smear

Subsequent lab testsSubsequent lab tests

Maternal serum 15-20 NTD and Maternal serum 15-20 NTD and

chramosomal anomalieschramosomal anomalies

MSAF free B HCG E2 inhebin AMSAF free B HCG E2 inhebin A

Syphilis serologySyphilis serology

Cystic fibrosisCystic fibrosis

Ancillary prenatal testsAncillary prenatal tests Gestational diabetesGestational diabetes 24-28wk24-28wk Ghlamydial infectionGhlamydial infection

Group BS infectionGroup BS infection Gonococcal infectionGonococcal infection Ac OG 2002 centers for disease contral recommend Ac OG 2002 centers for disease contral recommend

vaginal and rectal GBS cultures in all women 35 to 37 vaginal and rectal GBS cultures in all women 35 to 37 wk if + intrapartum antimicrobial praphylaniswk if + intrapartum antimicrobial praphylanis

GBS bacteriuriaGBS bacteriuria Previous infant with invasive diseasePrevious infant with invasive disease

Recommendation for weight gainRecommendation for weight gain

BMI normal (1908-26) 11.5-16 kgBMI normal (1908-26) 11.5-16 kg

BMI over weigh 26-29 7-11.5 kgBMI over weigh 26-29 7-11.5 kg

BMI > 29 obes 7 kgBMI > 29 obes 7 kg

Weight retention after pregnancWeight retention after pregnanc Weight gain 12.5 kg discharged 4.4 kg Weight gain 12.5 kg discharged 4.4 kg

above her-perpregnant weight above her-perpregnant weight

at delivery waight last 5.5 kg at delivery waight last 5.5 kg

in ensuing 2 wk thereafter after 4 kg in ensuing 2 wk thereafter after 4 kg

2.5 kg was lost between 2 weeks and 6 2.5 kg was lost between 2 weeks and 6

months postportummonths postportum

Retain weight 1.4+_4.8kg her-perpregnantRetain weight 1.4+_4.8kg her-perpregnant

Recammended dietary Recammended dietary AllowancesAllowances

Calories 100-300 kcal per day whenever Calories 100-300 kcal per day whenever

caloric intake inadequate protein caloric intake inadequate protein

metabolized (spared for f-growth and metabolized (spared for f-growth and

development)development)

ProteinProtein

Growth and repairGrowth and repair

Fetus placenta uterus breast blood volumeFetus placenta uterus breast blood volume

Most protein supplied from animal sources Most protein supplied from animal sources

Mineral Mineral

Exception Iron all diets supply sufficient Exception Iron all diets supply sufficient

caloric for appropriate weight gain contain caloric for appropriate weight gain contain

enough mineralsenough minerals

IronIron 300 mg Iron trans ferred tofetus placenta 500mg 300 mg Iron trans ferred tofetus placenta 500mg

expanding M Hb mass nearly all is used after mid expanding M Hb mass nearly all is used after mid

pregnancypregnancy

diet seldom contains enough iron to meet this demand diet seldom contains enough iron to meet this demand

recommended at least 27 mg ferrous iron supplement recommended at least 27 mg ferrous iron supplement

dailydaily

This amount is contained in most prenatal vitaminsThis amount is contained in most prenatal vitamins

If she is large ,twin fetuses, begin late in pregnancy or If she is large ,twin fetuses, begin late in pregnancy or

has depressed Hb level benefit from 60-100mg first for has depressed Hb level benefit from 60-100mg first for

months of pregnancy not necessarymonths of pregnancy not necessary

vitaminsvitamins

Usually supplied by general diet provides Usually supplied by general diet provides

adequate calories protein adequate calories protein

Exception folic and during times of un Exception folic and during times of un

usual requirements vomiting, hemolytic usual requirements vomiting, hemolytic

anemia or multiple fetusesanemia or multiple fetuses

Folic acidFolic acid

4000 pregnancy affected by NTD each year > 4000 pregnancy affected by NTD each year >

50y prevented daily 400 Ng preconception 50y prevented daily 400 Ng preconception

recurrent NTD 3100recurrent NTD 3100

4 mg daily folic acid for the month before and 4 mg daily folic acid for the month before and

3 month after preg.3 month after preg.