comprehensive health supervision of a woman want to be pregnant@ pregnant woman before delivery

Personal historyFamily history Medical and surgical history Menstrual history Obstetrical history History of present pregnancy

FH:familial marriage (increase risk

thallassemia in some families,…=> do Genetic consult if needed )

Obstetrition HX:in recurrent Abortion =>do some tests

pulmonary HTN(50% mortality) IDDM(increased risk of

malformation=>good control of BS before pregnancy &in organogenesis period is very preventive

Rubella:vaccinate ,pregnancy suggested after 3 months

Hepatitis B :In high risk cases :vaccinate in contaminated husband ,hospital personnels if HBSAg is negative

DX HIV ,VDRL positve DH:teratogen(isotertinoin),Warfarrin ,so

me anticonvulsant drugs,ACEI X_ray:better not do esp in 3/1

Folic Acid Supplementation with 0.4 mg of folic acid (4 mg

for secondary prevention:hx NTD ,Anticonvulsant therapy ,thallassemia,…) should begin at least one month before conception◦ prevents neural tube defects

Due to lack of folate in most women esp these days suggest=> more green leaf vegetables :legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread per day◦ Folate deficiency is associated with low birth weight,

congenital cardiac and orofacial cleft anomalies,NTD, abruptio placentae, and spontaneous abortion

Smoking ,alcohol (not have safe borderline)

Remember LMP

Pregnancy is confirmed(U/A GT ,B HCG,…)

The initial visit should occur during the first trimester

EDC should be calculated by accurate determination of the last menstrual period (LMP)=>(plus 7 days ,_3 months)◦ Accurate dating is important for timing screening

tests and interventions, and for optimal management of complications

◦ Some research indicates that early ultrasonography is more accurate than LMP at determining gestational age should be considered if LMP is uncertain

The first visit or initial visit should be made as early is pregnancy as possible.

Lab tests:CBC,BG,Rh,IDC,FBS,BUN/Cr,HBSAg.VDRL,HIV Ab ,Rubela ab (IgG,IgM),U/A,U/C,TSH lately?,PAP SMEAR

Due to the risk of exposure and alloimmunization…

Rhogam should also be offered after◦ spontaneous or induced abortion◦ ectopic pregnancy termination◦ chorionic villus sampling (CVS)◦ amniocentesis◦ cordocentesis ◦ external cephalic version◦ abdominal trauma◦ second- or third-trimester bleeding

Sonography early sono ;best for GA NT,NB,CL:11 TO 14 W(Best:13w) R/O anomaly:18 w to 20 w Fetal growth:32-34w Lab&procedure(Cvs,amniocentesis,cordocentesis) double test (PAPP-A,FREE HCG) Tripple test (UE3,HCG,AFP) Quadripple test (plus inhibin) 26 TO 28 WEEKS=>>CBC,GCT,U/A 28 WEEKS=>>IDC,RHOGAM 32 WEEKS=>>CBC,Sopnography

Genetic Screening◦ Family history of genetic disorders?◦ Previous fetus or child who was affected by a genetic

disorder?◦ History of recurrent miscarriage?

All women should be offered serum marker screening for neural tube defects and trisomies 21 and 18◦ Increased risk? amniocentesis or CVS may be offered

Disease-specific screening should be offered to patients who belong to an ethnic group with an increased incidence of a recessive condition

Return Visits: Once every month till 7th month(28 w) Once every 2 weeks till the 9th month(36 w) Once every week during the 9th month(36

to 40 w)

Assessment

History Examination Investigation

Fundal height Maternal weight Blood pressure measurements Fetal heart auscultation Urine testing for protein and glucose Questions about fetal movement

Evidence supporting these practices is variable…

Height of over 150 cm indication of an average-sized statue =>may be not have good pelvic)

BMI(20-26=>OK)In normal BMI: the approximate weight gain

during pregnancy is 12 kg.; 2kg in the first 16 weeks and 10 kg in the remaining 20 weeks (1.5 kg per week until term).

More BW=>less weight gain7 to 18 Kg can be nl dependent to BMI

Most guidelines recommend that pregnant women with a normal body mass index gain approximately 10- 12 Kg during pregnancy◦ decreased weight gain=>low birth weight and

preterm birth◦ Increased weight gain =>: increased risk of

macrosomia, cesarean delivery, and postpartum weight retention

Determine FH & check with GA(bladder must be empty)

12 W =>SP 20 w=>umblicus 18-32 w =>(cm equal with week)

◦ The uterus may be higher than expected due to large fetus, multiple pregnancy, polyhydrammnios (PHA)or mistaken date of last menstrual period.

◦ The uterus may be lower than expected due to small fetus, intrauterine growth retardation(IUGR), oligohydramnios(OHA) or mistaken date of last menstrual period(LMP).

Blood pressure measurement It is not known how often blood pressure

should be measured, but most guidelines recommend measurement at each antenatal visit

Evaluation for edema Edema occurs in 80 percent of pregnant

women◦ Edema is defined as greater than 1+ pitting

edema after 12 hours of bed rest, or weight gain of 2 kg in one week

◦ Important esp in hand &face It lacks specificity and sensitivity for the

diagnosis of preeclampsia

Fetal heart sound is heard by sonicaid as early as 10thweek of pregnancy.

Fetal heart sound is heard by Pinard' s fetal stethoscope after the 20thweek of pregnancy.

The normal fetal heart rate is 120-160 beats/min

◦In primi =>20 to 22 w as kick at first ◦In MP =>16 W◦Ask in each visit ◦The pregnant woman reports at least 10

movements in 12 hours.◦In decreased FM =>eat sweet food then

left lat position &palp abd &count FM

◦Absence of fetal movements precedes intrauterine fetal death by 48 hours.

Physiological changes during pregnancy

Weight gain Fresh air and sunshine Rest and sleep Diet Daily activities Exercises and

relaxation Hygiene Teeth Bladder and bowel Sexual counseling

Smoking : Medications Infection Irradiation Occupational and

environmental hazards

Travel Follow up Minor discomforts Signs of Potential

Complications

Women should be counseled to eat a well-balanced, varied diet◦ Caloric requirements increase by 400 kcal per day in the

second and third trimesters

Iron Pregnant women should be screened for

anemia (hemoglobin, hematocrit) and treated, if necessary◦ IDA(Iron-deficiency anemia) is associated with

preterm delivery(PTL) and low birth weight(LBW) Pregnant women should supplement with

30 mg of iron per day from 16-20 w to the end of pregnancy.

Vitamin A Pregnant women in industrialized countries

should limit vitamin A intake to less than 5,000 IU per day◦ High dietary intake of vitamin A (i.e., more than

10,000 IU per day) is associated with cranial-neural crest defects

◦ High Liver eating not suggested in pregnancy ◦ Read dose of Vit A on each supplement drug

Calcium RDI is 1,000 mg per day in women tht not take enough from nutrition

Vitamin D Vitamin D supplementation can be considered in

women with limited exposure to sunlight (e.g., northern locations)◦ Evidence on the effects of supplementation is limited

◦ High doses of vitamin D can be toxic◦ Article======more beautiful with ca-bicarbonate

than ca-D

Caffeine-containing drinks Mild to Moderate amounts probably are safe Some guidelines recommend limiting

consumption to 150 to 300 mg per day◦ Association between high caffeine consumption

and spontaneous abortion and low-birth-weight infants

Exercise should be simple, mild exercise avoid lifting heavy weights

A tooth can be extracted during pregnancy, but local analgesia is recommended (if x-ray needed =>use abd shield)

Pregnant woman should avoid contact with infectious diseases especially rubella or (German measles) because it has deleterious effects on the fetus

Influenza vaccine suggestable Pregnant woman should avoid exposure

to x-ray or irradiation because of possible teratogenic effects on the fetus such as birth defects or childhood leukemia

Urinary frequencyRELIEF MEASURES:

Decrease fluid intake at night. Maintain fluid intake during day. Void when feel the urge.

RELIEF MEASURES:

Rest frequency.

Go to bed earlier.

RELIEF MEASURES: Rest frequency Decrease fluid intake at night

RELIEF MEASURES:

Wear a good supporting bra. Assess for other conditions.

ETIOLGY: Elevated estrogen levels◦RELIEF MEASURES : Avoid decongestants. Use humidifiers, and normal saline

drops.

ETIOLGY: UnknownRELIEF MEASURES:

Perform frequent mouth care.Chew gum.Decrease fluid intake at night.Maintain fluid intake during day.

◦RELIEF MEASURES: Avoid food or smells that exacerbate condition. Eat dry crackers or toast before rising in morning. Eat small, frequent meals. Avoid sudden movements. Get out of bed slowly Breath fresh air to help relieve nausea.

◦ RELIEF MEASURES: Use extra pillows at night to keep more upright.

Limit activity during day

RELIEF MEASURES: Eat small, more frequent meals. Use antacids. Avoid overeating and spicy foods.

Avoid standing for long periods. Elevate legs when laying or sitting. Avoid tight stockings.

Elevate legs regularly. Avoid crossing legs. Avoid tight stockings. Avoid long periods of standing

RELIEF MEASURES:

Maintain regular bowel habits.Use prescribed stool softeners.Apply topical or anesthetic ointments to area.

RELIEF MEASURES:

Maintain regular bowel habits. Increase fiber in diet. Increase fluids.Find iron preparation that is least constipating

RELIEF MEASURES:Take a daily bath or shower.Wear cotton underwear.

RELIEF MEASURES:Wear shoes with low heels.Walk with pelvis tilted forward.Use firmer mattress.Perform pelvic rocking or tilting

◦ RELIEF MEASURES: Extend affected leg and dorsiflex the foot. Elevate lower legs frequently. Apply heat to muscles. Evaluate diet.

•Rise slowly from sitting to standing.•Evaluate hemoglobin and hematocrit.•Avoid hot environments

Air travel? Hair dye?

Exercise?

Alcohol?Hot tubs?

Sex?

Smoking?

Air travel Safe for pregnant women until 4 weeks

before the EDC◦ Consider the availability of medical resources at

the destination Lengthy trips are associated with increased

risk of venous thrombosis

Exercise Pregnant women should avoid activities that

put them at risk for falls or abdominal injuries◦ At least 30 minutes of mild to moderate aerobic

exercise on most days of the week is a reasonable activity level for most pregnant women

Hair Treatments Although hair dyes and treatments have not

been associated clearly with fetal malformation, exposure to these treatments should be avoided during early pregnancy

Hot tubs and saunas Hot tubs and saunas probably should be

avoided during the first trimester of pregnancy

Maternal heat exposure during early pregnancy has been associated with neural tube defects and miscarriage

Labor and delivery All pregnant women should be counseled

about what to do when their membranes rupture, what to expect when labor begins, strategies to manage pain, and the value of labor support

Breastfeeding Breastfeeding is the best feeding method for

most infants◦ Contraindications include galactosemia of

neonate, breast cancer,maternal hepatitis C,breast abcess,post partum psychosis, HIV infection, chemical dependency(immune suppressive medication), and use of certain medications

Structured behavior counseling and breastfeeding-education programs may increase breastfeeding success