Transcript Chapter 8. Prenatal Care

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
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Exercise
Employment
Travel
Bathing
Clothing
Bowel Habits
Coitus
Dentition
Immunization
Caffeine
Medications
Nausea and vomiting
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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 !