Transcript Evidence-Based Prenatal Care: Part I. General Prenatal Care and

Evidence-Based Prenatal
Care: Part I. General Prenatal
Care and Counseling Issues
Presented by DR/ Heba Nour
Lecturer f Family Medicine
Objectives of ANC part I
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Describe protocol of Ante natal care according to up to date
evidence
Describe current evidence regarding the use of
ultrasonography in ANC
Describe the role of family physician in the management of
perinatal care
How to determine due date accurately
How to assess fetal well-being
Discuss immunization during pregnancy
Discuss and agree upon a birth plan with an expectant
mother
Discuss nutritional requirements during pregnancy and
lactation
Discuss health education during pregnancy
Drugs in pregnancy
Introduction
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pregnancy can be enhanced by a
coordinated program of prenatal medical
care and psychosocial support.
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Care ideally begins before conception and
includes preventive care, counseling, and
screening for risks to maternal and fetal
health
Importance of maternal health
program
1-Mothers (pregnant and lactating) and children are vulnerable groups
as they are undergoing physiological changes that make them more
liable to have health problems, if their physiologic needs are not
adequately met,
2-Mothers and children are at risk of high morbidity and mortality, but
almost of their health problems are preventable,
3-Health problems in the in the fetal and early years of life may have
long lasting effects and may result in disabling condition for life,
4-Investment in ANC services is highly cost-effective,
5- Females in the reproductive age form 25% of Egypt population and
the under- five children form 12% of the population.
Therefore, ANC &child care services are expected to cover a more than
one third of the population,
Providing Prenatal Care
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In developed countries typically: regular
prenatal visits, 7-11 times /pregnancy.
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A recent meta-analysis: reducing the (N)
visits (X) adverse outcomes for mother or
infant; however, women were less
satisfied
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Caregiver continuity during ANC has been
associated with reduced interventions in
labor & improved maternal satisfaction.
Minimal required visits:
 1st visit as early as in the 1st trimester
 2nd visit 22-26 weeks
 3rd visit 30-32
 4th visit 34-36
 5th visit 38-40
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Providing Prenatal Care
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Care provided by midwives, family
physicians, and obstetricians was found to
be equally effective
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Although women were slightly more
satisfied with care from midwives and
family physicians
Prenatal Examinations
prenatal care plans:
choice of caregiver
 Initial visit ----1st trimester
 > one visit ---cover all pertinent information
 (EDD) calculated by accurate determ.of
(LMP).
 Accurate dating is important ?
-timing screening tests
-interventions
-optimal management of complications
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prenatal care plans:
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The first 12 ws of pregnancy: time of
organogenesis
&
vulnerability
to
teratogens;
counseling
about
risk
behaviors is appropriate
Level of evidence according to American
Academy of Family physician
A = consistent, good-quality patientoriented evidence;
 B = inconsistent or limited-quality patientoriented evidence
 C = consensus, disease-oriented evidence,
usual practice, opinion, or case series. See
page 1245 for more information
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Counseling Issues in Pregnancy
Issue
Guideline
Label
Comments
Air travel
safe for pregnant 4 weeks before
EDD
C
Lengthy trips are + with increased
risk of venous thrombosis.
C
Consider the
availability of
medical
resources at the
destination.
best feeding method for most
infants. contraindications include
maternal HIV infection, chemical
dependency,- use of certain drugs
B
Breast
feeding
Structured behavior counseling
and BF-education programs may
breastfeeding success.
It is not known
how advice from
caregivers to new
or expectant
mothers affects
breastfeeding
success.
Exercise
avoid risk for falls or abdominal
injuries.
C
Scuba diving during pregnancy
is not recommended.
C
At least 30 minutes of
moderate exercise on
most days of the week
is a reasonable activity
level for most pregnant
women.20
Hair
Although hair dyes and ttt not
treatments associated clearly with fetal
malformation
these ttt should be avoided early
C
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Hot tubs
and
saunas
avoid during the first trimester of
pregnancy
B
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Early NTD& miscarriage
B
Medications:
prescription,
over-thecounter, and
herbal
remedies
Few medications proven safe
during 1st trimester of
pregnancy.
C
Risks with individual
medications should be
reviewed based on
patient's needs.
B
--
Sex
SI during is not associated with
adverse outcomes.
Substance
use: alcohol
Screening for all: alcohol
misuse.
B
Counseling is an effec.
intervention in alcohol
consumption and
morbidity in infants
Unknown safe amount of alcohol B
during pregnancy. Abstinence is
recommended
Substance
use: illicit
drugs
should be informed of potential
adverse effects of drug use on
fetus.
C
Admission to a detoxification
unit may be indicated.
Methadone in opiate-addiction
may be life-saving.
C
Women who use illicit
drugs require
specialized
interventions.
Substance
use:
smoking
Screening for all for
tobacco use, and
pregnancy-tailored
counseling should be
provided to smokers
A
Smoking-cessation counseling and
multicomponent strategies are
effective in decreasing the incidence
of low-birth-weight infants.
Workplace
Some working
conditions, such as
prolonged standing
and exposure to
certain chemicals, are
associated with
pregnancy
complications.
B
Employment is associated with
favorable demographic and
behavioral characteristics, and
generally is not associated with
adverse pregnancy outcomes.
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A
history
and
directed
physical
examination:to detect conditions with
increased maternal & perinatal morbidity
& mortality
Physical examination
Most guidelines recommend routine assessment:
 Fundal height
 Maternal weight
 MaternalBP
 FHS
 Urine testing for protein & glucose
 Questions about fetal movement.
Recommendations for Routine Prenatal Care
Ex
component
Recommendation
Label
Comments
Abd
palpation
to assess fetal presentation
beginning at 36 weeks'
gestation.
B
should not be before
36 ws' G because of
potential inaccuracies
-discomfort to patient.
BP meas.
not known how often
measured, but most
guidelines recommend at
each AN visit.
C
Further research is
required to determine
how often blood
pressure should be
measured.
Edema
occurs in 80% . It lacks
specificity and sensitivity for
the diagnosis of
preeclampsia.
C
Edema is defined as
greater than 1+ pitting
edema after 12 hours
of bed rest, or weight
gain of 2.3 kg (5 lb) in
Fetal heart tones
Auscultation
recommended at each
antenatal visit.
confirm a viable fetus
C
It is thought that
FHS aus. provides
psychologic
reassurance to
mother, this has
not been studied.
Fetal movement
counts
Routine fetal
movement counting
should not be
performed.
A
--
Symphysis fundus
should be measured at B
height measurement each antenatal visit
Plotting measurement
on a graph is
suggested for
monitoring purposes.
subject to
interobserver and
intraobserver error
simple,
inexpensive test.
Urinalysis
-Dipstick urinalysis X
proteinuria reliably in
patients with early
preeclampsia;
-24-hour urinary protein
excretion is the gold
standard but is not always
practical.
C
Some guidelines have
encouraged
discontinuation of
dipstick urinalysis;
others retain this test
as part of the routine
antenatal visit.
Weight meas
determine BMI which is the
basis for recommended
weight gain in pregnancy.
B
Patients who are
underweight or
overweight have
known risks.
Weight gain is not
associated with
pregnancy-induced
hypertension.
Maternal weight should be
measured at each antenatal
visit.
C
ASSESSMENT OF THE
FETAL WELL-BEING
MNCN CHAPTER 16
PROCEDURES AND DIAGNOSTIC
TESTING TO ASSESS FETAL STATUS
Fetal Activity: kick counts
 Ultrasound:
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Transabdominal
Endovaginal
Three dimensional
Doppler Blood Flow studies
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Assess uteroplacental function
Beginning at 16 to 18 weeks gestation
NON-STRESS TEST
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Assess fetal well being
Procedure:
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EFM to abdomen
Fetal heart rate measured: at least 2 accelerations of 15
bpm lasting 15 sec or more within 20 minutes
Fetal movement is documented
Possible clinical findings:
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Fetus with adequate oxygenation and an intact central
nervous system
Fetus at risk
CONTRACTION STRESS TEST
Initiation of contractions by pitocin or
nipple rolling
 Positive CST results: (bad) with persistent
late decelerations is evidence that the
fetus will not be able to withstand the
hypoxic stress of the uterine contractions
 Negative CST results: (good) No
persistent decelerations noted with at
least 3 ctx.
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BIOPHYSICAL PROFILE
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1.
2.
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4.
5.
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Assessment of 5 variables:
Fetal breathing movements
Fetal movements of body or limbs
Fetal tone
Amniotic fluid volume
Reactive nonstress test
Identifies compromised fetus
Desired BPP score: 8-10 considered normal
PROCEDURES AND DIAGNOSTIC
TESTING TO ASSESS FETAL STATUS
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Amniocentesis
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Evaluation of fetal maturity
Lecithin sphingomyelin ratio
Phosphatidylglycerol test
Chorionic villus sampling
 Percutaneous umbilical blood sampling
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Blood Typing
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Rh & ABO blood typing at 1st prenatal visit
RhoD IG (Rhogam) is recommended for all
nonsensitized Rh-negative women at 28 weeks'
(300 mcg) & within 72 hrs after delivery of an
Rh+ve infant (120 to 300 mcg).
Nonsensitized, Rh-ve women also should be
offered a dose of RhoD IG after spontaneous or
induced abortion, ectopic pregnancy termination,
chorionic villus sampling (CVS), amniocentesis,
cordocentesis, external cephalic version,
abdominal trauma, and second- or third-trimester
bleeding
Blood Typing
Administration of RhoD IG can be
considered before 12 w' gestation in
women with a threatened abortion and
live embryo
 Written informed consent is recommended
for use of RhoD immune globulin because
it is a blood product.
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Ultrasonography
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No evidence directly links improved fetal
outcomes with routine ultrasound scre
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Early U/S is more accurate than LMP at
determining GA, with uncertainty about the
LMP
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Diagnostic ultrasound exposure has not
been proven to harm the mother or fetus,
but more research on its risks is needed.
Ultrasonography
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good evidence that U/S
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(i.e., before 14 weeks' gestation) accurately
determines gestational age, decreases the need for
labor induction after 41 weeks' gestation, and
detects multiple pregnancies.
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Ultrasonography at 10 to 14 weeks' gestation can
measure nuchal translucency as a screening test for
Down syndrome.
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ultrasound scan to search for structural anomalies
between 18 and 20 weeks' gestation.
Nutrition and Food Safety
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counseling for eat a well-balanced, varied
diet.
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Caloric requirements increase by 340 to 450
kcal per day in the second and third
trimesters.
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Most guidelines recommend that pregnant
women with a normal BMI gain 11.5 to 16
kgduring pregnancy.
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Observational studies antenatal weight
gains below
recommended range are
associated with lbw- preterm birth
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weight gains above the recommended range
are associated with increased risk of
macrosomia,
cesarean
delivery,
and
postpartum weight retention.
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Experimental studies are needed to prove
that weight gain outside the recommended
range causes poor perinatal outcomes.
Use of Dietary Supplements in
Pregnancy
Calcium
Recommended daily intake is
A
1,000 to 1,300 mg per day9
Routine supplementation with
calcium to prevent preeclampsia is not
recommended.1 However,
calcium supplementation may
be beneficial for women at high
risk for gestational
hypertension or in communities
with low dietary calcium
intake.10,80
Calcium
supplementation has
been shown to
decrease blood
pressure and preeclampsia, but not
perinatal mortality.
Use of Dietary Supplements in
Pregnancy
Folic
acid
Supplementation with 0.4 to
0.8 mg of folic acid (4 mg for
secondary prevention) should
begin at least one month
before conception.
A
RDA (in addition to
B
supplements) is 600 mcg of
dietary folate equivalents (e.g.,
legumes, green leafy
vegetables, liver, citrus fruits,
whole wheat bread) per day.
Supplementation prevents
neural tube defects.
Folate deficiency is
associated with low birth
weight, congenital cardiac
and orofacial cleft
anomalies, abruptio
placentae, and spontaneous
abortion
Use of Dietary Supplements in
Pregnancy
Iron
Pregnant women should be
screened for anemia
(hemoglobin, hematocrit)
and treated, if necessary.
B
Pregnant women should
supplement with 30 mg of
iron /day
C
Iron-deficiency anemia is
associated with preterm
delivery and low birth
weight.
Use of Dietary Supplements in
Pregnancy
Vit A
Pregnant women in
B
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 cranialneural crest defects.85,86
Vit D
Vitamin D supplementation can C
be considered in women with
limited exposure to sunlight
However, evidence on the
effects of supplementation is
limited.
Vitamin D deficiency is rare
but has been linked to
neonatal hypocalcemia and
maternal
osteomalacia.88,89
High doses of vitamin D
can be toxic.
RDA is 5 mcg per day (200 IU
per day).
Drug exposure in early
pregnancy
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Family physician is faced with important
task of counseling patients during
preconception and prenatal periods:
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Safety of drugs
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Unplanned pregnancy
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Birth defects
Use of medically indicated
medications
Chronic conditions diagnosed before
pregnancy:
Epilpsy, asthma
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Pregnancy indicated conditions:
PIH, GD
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Acute conditions:
Infection, nausea & vomiting
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Medications with known teratogenic effects
Alcohol
Androgens
ACEI
ARB
Anticonvulsants:
Valporic acid
Phenytoin
carbamazepine
warfarin
Chemotherapeutic
agents:
Antimetabolites,
Alkylating agents
Iodides
Isotretinoin
Lithium
Tetracyclines
Thalidomide
Diethylstibesterol
FDA Drug classification
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Class A
No risk in controlled human studies
Examples
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Pyridoxine (Vitamin B6)
Class B
No risk in controlled animal studies
Examples
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Amoxicillin
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Class C
Small risk in controlled animal studies
Examples
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Class D
Strong evidence of risk to the human fetus
Examples
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Codeine
Dicloxacillin
Valium
Class X (Never to be used in Pregnancy)
Very high risk to the human fetus
Examples
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Xanax
Accutane
Drug prescription during pregnancy
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General Recommendations
Avoid medications if possible in first
trimester
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Limit use to safe, short-acting, noncombination drugs
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Topical medications are preferred over
systemic agents
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Use the lowest effective dose of a
medication
Tetanus immunization
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Tetanus vaccine is a toxoid.
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Toxoid vaccines are made by treating the
toxins (or poisons) produced by clostridium
tetani with heat or chemicals, such as
formalin.
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While this process destroys the toxin's
ability to cause illness, the toxin is still able
to stimulate the immune system to produce
protective antibodies.
Tetanus immunization
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For
prevention
of
neonatal
tetanus,
TT
is
recommended for immunization of women of
childbearing age, and especially pregnant women.
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After completing the full basic course of 5 doses,
there is no need for additional doses during
pregnancy at least for the next 10 years;
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thereafter a single booster would be sufficient to
extend immunity for another 10 years.
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If No previous immunisation, at least 2 doses of TT at
4weeks interval: 2 dose at least 2 weeks before
delivery.
Tetanus immunization
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ADMINISTRATION
The vaccine should be administered by deep
IM. Tetanus toxoid should be injected IM
into the deltoid muscle in women and older
children.
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the preferred site for IM injection in young
children is the anterolateral aspect of the
upper thigh since it provides the largest
muscular area.
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The vaccine should be well shaken before
use.
Tetanus immunization Schedule
TT1
After the 1st trimester
TT2
At least 4 weeks after TT1 or during
subsequent pregnancy
At least 6 months after TT2or during
subsequent pregnancy
TT3
TT4
At least one year after TT3 or during
subsequent pregnancy
TT5
At least one year after TT4 or during
subsequent pregnancy
Preparation to safe labor
Preparation to safe labor depends on:
 Prepared health facility
 patient
 number and outcome of of previous
deliveries. If a woman delivered by CS
refer to higher level facilitycare
 LMP EDD
 Warning symptoms
 Past medical and surgical history
Referral
Grand multipara (parity = >35)
 Previous uterine incision (CS, hysterctomy
or myomectomy)
 Previous intrapartum death or neonatal
death
 Previous postpartum hemorrhage or
retained placenta
 Past medical history (PIH-DM)
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Referral
In current pregnancy:
 Antepartum hemorrhage
 PMROM
 HTN
 Fundal level> amenorrhea ( macrosomia,
polyhydramnios multiple pregnancy)
 Fundal level < amenorrhea (IUFGRoligohydramnios)
 Malpresentation
 Inadequate pelvic capacity
Referral in 1st stage labor
Referral should be in an equipped
ambulance provided with a delivery bkit
 A physician or well trained delivery room
nurse should accompany the patient
 Adminster prophylactic antibiotic before or
during labor
 If referral is due to fetal disteress, position
the woman in left lateral position and
provide 100 % oxygen
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