Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues

Presented by DR/ Heba NourLecturer f Family Medicine

Objectives of ANC part I 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 pregnancy can be enhanced by a

coordinated program of prenatal medical care and psychosocial support.

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 In developed countries typically: regular

prenatal visits, 7-11 times /pregnancy.

A recent meta-analysis: reducing the (N) visits (X) adverse outcomes for mother or infant; however, women were less satisfied

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

Providing Prenatal Care Care provided by midwives, family

physicians, and obstetricians was found to be equally effective

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

prenatal care plans:

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 patient-

oriented evidence; B = inconsistent or limited-quality patient-

oriented evidence C = consensus, disease-oriented evidence,

usual practice, opinion, or case series. See page 1245 for more information

Counseling Issues in Pregnancy

Issue Guideline Label Comments

Air travel safe for pregnant 4 weeks before EDD

C Consider the availability of medical resources at the destination.

Lengthy trips are + with increased risk of venous thrombosis.

C

Breastfeeding

best feeding method for most infants. contraindications include maternal HIV infection, chemical dependency,- use of certain drugs

B It is not known how advice from caregivers to new or expectant mothers affects breastfeeding success.

Structured behavior counseling and BF-education programs may breastfeeding success.

Exercise avoid risk for falls or abdominal injuries.

C At least 30 minutes of moderate exercise on most days of the week is a reasonable activity level for most pregnant women.20

Scuba diving during pregnancy is not recommended.

C

Hair treatments

Although hair dyes and ttt not associated clearly with fetal malformationthese ttt should be avoided early

C --

Hot tubs and saunas

avoid during the first trimester of pregnancy

B --

Early NTD& miscarriage B

Medications: prescription, over-the-counter, 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.

SexSI during is not associated with adverse outcomes.

B --

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 during pregnancy. Abstinence is recommended

B

Substance use: illicit drugs

should be informed of potential adverse effects of drug use on fetus.

C Women who use illicit drugs require specialized interventions.

Admission to a detoxification unit may be indicated. Methadone in opiate-addiction may be life-saving.

C

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.

A history and directed physical examination:to detect conditions with increased maternal & perinatal morbidity & mortality

Physical examinationMost 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 one week.

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 height measurement

should be measured at each antenatal visit Plotting measurement on a graph is suggested for monitoring purposes.

B subject to interobserver and intraobserver errorsimple, 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:

Transabdominal Endovaginal Three dimensional

Doppler Blood Flow studies Assess uteroplacental function Beginning at 16 to 18 weeks gestation

NON-STRESS TEST Assess fetal well being Procedure:

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:

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.

BIOPHYSICAL PROFILE Assessment of 5 variables:1. Fetal breathing movements2. Fetal movements of body or limbs3. Fetal tone4. Amniotic fluid volume5. Reactive nonstress test Identifies compromised fetus Desired BPP score: 8-10 considered normal

PROCEDURES AND DIAGNOSTIC TESTING TO ASSESS FETAL STATUS

Amniocentesis Evaluation of fetal maturity Lecithin sphingomyelin ratio Phosphatidylglycerol test

Chorionic villus sampling Percutaneous umbilical blood sampling

Blood Typing 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.

Ultrasonography No evidence directly links improved fetal

outcomes with routine ultrasound scre

Early U/S is more accurate than LMP at determining GA, with uncertainty about the LMP

Diagnostic ultrasound exposure has not been proven to harm the mother or fetus, but more research on its risks is needed.

Ultrasonography good evidence that U/S

(i.e., before 14 weeks' gestation) accurately determines gestational age, decreases the need for labor induction after 41 weeks' gestation, and detects multiple pregnancies.

Ultrasonography at 10 to 14 weeks' gestation can measure nuchal translucency as a screening test for Down syndrome.

ultrasound scan to search for structural anomalies between 18 and 20 weeks' gestation.

Nutrition and Food Safety counseling for eat a well-balanced, varied

diet.

Caloric requirements increase by 340 to 450 kcal per day in the second and third trimesters.

Most guidelines recommend that pregnant women with a normal BMI gain 11.5 to 16 kgduring pregnancy.

Observational studies antenatal weight gains below recommended range are associated with lbw- preterm birth

weight gains above the recommended range are associated with increased risk of macrosomia, cesarean delivery, and postpartum weight retention.

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 1,000 to 1,300 mg per day9Routine supplementation with calcium to prevent pre-eclampsia 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

A Calcium supplementation has been shown to decrease blood pressure and pre-eclampsia, but not perinatal mortality.

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 Supplementation prevents neural tube defects.

RDA (in addition to supplements) is 600 mcg of dietary folate equivalents (e.g., legumes, green leafy vegetables, liver, citrus fruits, whole wheat bread) per day.

B 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

Use of Dietary Supplements in Pregnancy

Iron Pregnant women should be screened for anemia (hemoglobin, hematocrit) and treated, if necessary.

B Iron-deficiency anemia is associated with preterm delivery and low birth weight.

Pregnant women should supplement with 30 mg of iron /day

C

Vit A Pregnant women in industrialized countries should limit vitamin A intake to less than 5,000 IU per day.

B High dietary intake of vitamin A (i.e., more than 10,000 IU per day) is associated with cranial-neural crest defects.85,86

Vit D Vitamin D supplementation can be considered in women with limited exposure to sunlight However, evidence on the effects of supplementation is limited.

RDA is 5 mcg per day (200 IU per day).

C Vitamin D deficiency is rare but has been linked to neonatal hypocalcemia and maternal osteomalacia.88,89High doses of vitamin D can be toxic.

Use of Dietary Supplements in Pregnancy

Drug exposure in early pregnancy Family physician is faced with important

task of counseling patients during preconception and prenatal periods:

Safety of drugs

Unplanned pregnancy

Birth defects

Use of medically indicated medications Chronic conditions diagnosed before

pregnancy:Epilpsy, asthma

Pregnancy indicated conditions:PIH, GD

Acute conditions:Infection, nausea & vomiting

Medications with known teratogenic effects

AlcoholAndrogensACEIARBAnticonvulsants:Valporic acidPhenytoin carbamazepinewarfarin

Chemotherapeutic agents:Antimetabolites,Alkylating agentsIodidesIsotretinoinLithiumTetracyclinesThalidomideDiethylstibesterol

FDA Drug classification Class A No risk in controlled human studies Examples

Pyridoxine (Vitamin B6) Class B No risk in controlled animal studies Examples

Amoxicillin

Class C Small risk in controlled animal studies Examples

Codeine Dicloxacillin

Class D Strong evidence of risk to the human fetus Examples

Valium Class X (Never to be used in Pregnancy) Very high risk to the human fetus Examples

Xanax Accutane

Drug prescription during pregnancy General Recommendations Avoid medications if possible in first trimester

Limit use to safe, short-acting, non-combination drugs

Topical medications are preferred over systemic agents

Use the lowest effective dose of a medication

Tetanus immunization Tetanus vaccine is a toxoid.

Toxoid vaccines are made by treating the toxins (or poisons) produced by clostridium tetani with heat or chemicals, such as formalin.

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 For prevention of neonatal tetanus, TT is

recommended for immunization of women of childbearing age, and especially pregnant women.

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;

thereafter a single booster would be sufficient to extend immunity for another 10 years.

If No previous immunisation, at least 2 doses of TT at 4weeks interval: 2 dose at least 2 weeks before delivery.

Tetanus immunization ADMINISTRATION

The vaccine should be administered by deep IM. Tetanus toxoid should be injected IM into the deltoid muscle in women and older children.

the preferred site for IM injection in young children is the anterolateral aspect of the upper thigh since it provides the largest muscular area.

The vaccine should be well shaken before use.

Tetanus immunization ScheduleTT1 After the 1st trimester

TT2 At least 4 weeks after TT1 or during subsequent pregnancy

TT3 At least 6 months after TT2or during subsequent pregnancy

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 laborPreparation 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)

Referral In current pregnancy: Antepartum hemorrhage PMROM HTN Fundal level> amenorrhea ( macrosomia,

polyhydramnios multiple pregnancy) Fundal level < amenorrhea (IUFGR-

oligohydramnios) 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