Second Trimester work up and Algorithms ADBHUT MATRUTVA

1. Second Trimester work up
and
Algorithms Dr. PRATIMA MITTAL
FOGSI VICE PRESIDENT 2018

2. INTRODUCTION
• The goal of prenatal care is to ensure the birth of a
healthy baby with minimal risk for the mother.
• Antenatal care represents a series of assessments and
interventions over time. It is not a single interventio

3. AIM OF ANTENATAL CARE
• To provide advice, reassurance, education and
support for woman and family.
• To treat associated minor symptoms.
• To provide an ongoing screening program to
confirm that pregnancy continues to be low risk.
• To identify high risk pregnancies so that
appropriate, timely management is provided to
prevent or minimize morbidity & mortality

4. TIMING of ANC
IDEALLY
Prenatal care should be initiated in the first
trimester and should provide comprehensive
medical care in second and third trimester.
BUT-Less than 50 percent of women in developing
regions receive early antenatal care
So second trimester care is important, even after
the initial prenatal assessment and patient
counseling

5. ANTENATAL CARE IN SECOND TRIMESTER
Second Trimester is from 14 to <28 weeks of gestation
Antenatal care in second Trimester is directed at
• Early, accurate estimation of gestational age
• Ongoing evaluation of the health status of both mother and fetus
• Anticipation of problems and intervention.

6. FREQUENCY OF VISITS
ACOG
RECOMMENDATIONS
• NULLIPAROUS WOMEN WITH
UNCOMPLICATED PREGNANCIES
(16 VISITS) :-
1. Every 4 weeks tilL 28 weeks
2. Every 2 weeks from 28 -36
weeks
3. Weekly until delivery
• PAROUS WOMEN WITH
UNCOMPLICATED MEDICAL AND
OBSTETRICAL HISTORIES=less
frequently.
• WOMEN WITH PROBLEMS are
seen more frequently, depending
on the nature of the problems.
NICE GUIDELINES
• 10 appointments
for nulliparous
women
• 7 appointments
for parous women
• Each visit should
have a specific
purpose/goal
•Minimum of eight antenatal
visits for all women, regardless
of parity
•One visit in the first trimester
•Two in the second trimester
•Five in the third trimester.
•High risk pregnancies need
additional care
WHO GUIDELINES 2016

7. CARE PROVIDER ?
Standard one-on-one care
by midwives, obstetrician-
gynecologists, family
medicine clinicians, and
maternal-fetal medicine
(MFM) subspecialists.
Group prenatal care
• Participants with the same
month of expected delivery
receive the majority of their
care in a group setting.
• The only private time
between patient and
clinician is during the initial
prenatal assessment, when
health concerns involving
need for privacy arise, and
during cervical assessment
late in pregnancy.
• Majority of the visit, which
may last two hours, involves
facilitated group discussion,
education, and skills building
to address explicit learning
objectives in prenatal care,
childbirth preparation, and
postpartum and parenting
roles.
Subspecialty obstetrical care
Referral to a MFM subspecialist
• chronic health conditions
• pregnancy complications in the past
• develop complications during their
current pregnancy
Multidisciplinary care
Women with medical comorbidities:
collaborative multidisciplinary care by a
team including obstetric provider and
appropriate medical or surgical
subspecialists, specialists in genetics,
anesthesia and pediatrics.

8. INITIAL EVALUATION IF FIRST
VISIT IN SECOND TRIMESTER
• - Medical/Obstetrical history
• - Psychosocial history
• - Correct estimation of period of gestation.
Examination
General Physical Exam : Resp /cardiac system
Obstetric Examination
History

9. INITIAL EVALUATION IF FIRST VISIT IN
SECOND TRIMESTER
Standard panel
• Rhesus type and antibody screen
• Hematocrit or hemoglobin and mean
corpuscular volume
• Rubella immunity and varicella
• Qualitative assessment of Urine
protein
• Urine culture
• Cervical cancer screening acc to
standard guidelines
• Human immunodeficiency virus
• Syphilis
• Hepatitis B virus
Selective screening
 Thyroid function
 Type 2 diabetes
 Infection
• - Gonorrhea
• - Hepatitis C
• - Tuberculosis
• - Toxoplasmosis
• - Bacterial vaginosis
• - Trichomonas vaginalis
- Herpes simplex virus
- Cytomegaloviru
- Zika
- Chagas disease
Laboratory tests

10. Ongoing Assessments
Screening and diagnostic testing if not performed at the first prenatal
visit or later in the first trimester are done now :
●Red cell antibodies (Rh Negative Prge)
●Current or past infection (sexually transmitted diseases, bacteriuria,
rubella immunity)
●Inherited disorders (eg, cystic fibrosis, fragile X, spinal muscular
atrophy, hemoglobinopathy)
●Fetal aneuploidy (eg, trisomy 21) screening
●Thyroid disease

11. INITIAL EVALUATION IF FIRST VISIT IN
SECOND TRIMESTER
Ultrasound examination
Discussion of screening and testing for
genetic abnormalities in offspring
Aneuploidy
Carrier screening= ethnic-specific, panethnic, and
expanded carrier screening acceptable strategies

12. SONOGRAPHY : SECOND TRIMESTER
Fetal number
Fetal presentation
Placental localization
AFI
Fetal biometry and EFW
To r/o CMF
To evaluate maternal pelvic masses

13. 15 to 24 weeks of Gestation:Screening
• Neural tube defects — maternal serum alpha-fetoprotein
and ultrasound are both effective methods.
• Trisomy 21 — Quadruple test= level of alpha-fetoprotein
(AFP), unconjugated estriol (uE3), hCG, and inhibin A in
maternal serum between 15 and 22 weeks of gestation.
• Fetal anomalies — ultrasound screening for fetal structural
anomalies, is optimally performed in the second trimester,
between 18 and 22 weeks of gestation
• Cervical length — Transvaginal ultrasound measurement of
short cervical length between 16 and 28 weeks of gestation
is associated with an increased risk of spontaneous preterm
birth <35 weeks. It can be measured when the patient
undergoes ultrasound examination for fetal anomalies.

15. 24 to 28 weeks of Gestation: Screening
• Gestational diabetes — Universal screening for
gestational diabetes is recommended at First visit, and
repeated at 24 to 28 weeks of gestation.
• RBC antibodies — In Rh(D)-negative women, red cell
(RBC) antibody screening is repeated at 28 weeks of
gestation and anti-D immune globulin is administered.
• Hemoglobin or hematocrit — The hemoglobin or
hematocrit should be rechecked to assess for anemia.

16. SCREENING FOR DEPRESSION
• Pregnant women should be assessed AT
LEAST ONCE during pregnancy or the
postpartum period for depression and
anxiety symptoms using a` validated
screening tool
• The Edinburgh Postnatal Depression Scale is
commonly used
• No consensus for optimal time
• Women who screen positive referred for
further evaluation and counseling

17. FOLLOW-UP VISITS
Ongoing Assessments
• Measurement of blood pressure
• Measurement of weight
• Urine dipstick for protein, although the value of
this test is questionable in women with normal
blood pressure
• Assess fetal growth either through measurement
of fundal height or by ultrasound evaluation for
women with risk factors for intrauterine growth
restriction.
• Assessment of maternal perception of fetal
activity
• Assessment of significant events since prior visit,
such as recent travel, illness, stressors, or
exposure to infection (eg, Zika virus) etc.

18. FOLLOW UP VISITS-Periodic assessments
Prenatal screening should be performed early WITHIN
RECOMMENDED INTERVALS to allow adequate time for:-
• Follow-up of screening tests
• Performance of diagnostic tests
• Counseling about test results
• Discussion of management options, including
termination of pregnancy if the patient chooses this
approach.

19. MANAGEMENT OF PREGNANCY
COMPLICATIONS -Risk approach
• Risk is the possibility of coming to harm
• Vulnerability is the degree to which one would be
adversely impacted by the risk
• Vulnerability is a parameter which we
can influence

21. Management of common discomforts
- Nausea and vomiting
- Gastroesophageal reflux disease
- Constipation
- Hemorrhoids
- Rhinitis and epistaxis
- Gingivitis
- Difficulty sleeping
- Headache
- Back pain and sciatica
- Leg cramps
- Peripheral edema
- Varicose veins
- Diarrhea
- Urinary frequency and nocturia

22. NAUSEA & VOMITING
Nausea is the most common GI symptoms during pregnancy
(80-85%) during 1st trimester
Nausea + vomiting - 52%
Nausea & vomiting of pregnancy manifests before 9 wks of
POG & subsides by 16-20 wks of pregnancy.
Treatment – reassurance
Dietary modifications
Ginger 250 mg thrice/day
Acupressure
Pharmacological t/t

23. BACKACHE
• Low backache – 70% of pregnant ladies
• Causes –
• excessive straining / fatigue
• excessive bending, lifting, walking
• acute strain / fibrositis
• Reduced by preventing bending, sitting with
back support
• Avoid high healed shoes
• severe backache – orthopaedic consultation

24. PAIN ABDOMEN
• Pain abd results from 3
sources
• Physiological effects of
pregnancy
• pathological causes during
pregnancy
• pathological causes unrelated
to pregnancy
• Physiological conditions
causing pain abd
• Round ligament pain
• Braxton hicks contractions
• Misc – heart burn, excessive
vomiting, constipation
•
RL pain BH
contractions
Misc (heart
burn,
contipation)
pain cramping/stabbing
agg by movement
irregular
tightening
mild/varied
prev
anomaly
- - fibroid
urine - - -
trimester late 1st / 2nd late 2nd /3rd 3rd
tenderness over the area of RL irregular
contraction
-
inv normal normal normal
t/t
(exclude
pathologic
al causes)
reassurance
reduce physical
activity
observation
, rule out
true labour

25. VAGINAL DISCHARGE
• Pregnant women usually produce more vaginal
discharge due to increased mucus secretion in response
to hyperestrogenemia.
• Troublesome & copious vaginal discharge may indicate
infection & a per speculum exam should be done.
• Fishy –smelling discharge
• Curdy white discharge
• Foamy greenish discharge

26. HEART BURN
• Reflux of gastric contents in lower oesophagus
• Occurs in late trimester
• Due to upward displacement & compression of
stomach by uterus & relaxation of lower
oesophageal sphincter
• Management :-
• Dietary modification
• Lying propped up
• Antacids
• Sodium Alginate

27. CONSTIPATION
• Common during pregnancy
• Caused by increased bowel transit time & large bowel compression by
enlarged uterus or by presenting head
• May be ass with pain & bleeding during daefecation
• Management :-
• High fiber diet
• Plenty of fluids
• Laxatives
• Stool softener

28. VARICOSITIES
• Pooling of blood in surface veins as a resulting of
inefficient valves
• Congenital predisposition
• Exaggerated by prolonged standing , pregnancy &
advancing age
• Become prominent as pregnancy advances & weight
increases
• Management :-
• Bed rest
• Leg elevation
• External pneumatic intermittent compressio

29. HAEMORHOIDS
• Exacerbated by pregnancy
• Caused by
• Obstruction of venous return by enlarged uterus
• Constipation during pregnancy
• Symptoms :-
• bleeding per rectum
• pain (thrombosis)
• Management :-
• High fiber diet
• Stool softener
• Local anesthetic agents

30. Assessment of Fetal Well Being at ANC
• Progressive Fundal height growth as per expectation
• Adequate maternal perception of fetal movements
• Ultrasonographic fetal assessment esp. for anomalies

31. Counseling
Counseling about Diet, Exercise, Rest, Immunisation,weight gain ,
Alcohol, Smoking, Dress, Personal hygiene and warning symptoms

32. SECOND TRIMESTER WORK UP
(14-28 Weeks)
Ongoing Preg in Second trimesterInitial Booking in first trimester
Recommended
Wt, BP, Hb
Blood group and
Rh (Both
partners
Urine — R/M,
VDRL, HpB, HIV,
TSH; DIPSI
Dating Scan +NT
+ Dual marker +
Cervical length
Preferable
BMI, MAP, CBC,
(Peripheral) smear,
electrophoresisHPLC
MSU + Culture HCV,
Rubella IgG
Recommended
Repeat blood tests
Hemoglobin
TSH
Urine dipstick DPISI
Quadruple/triple
marker Anomaly scan
Cervical length
Preferable
NIPT
Uterine artery
Doppler 2D-4D scan
Fetal
echocardiography
IDENTIFY HIGH RISK CASES
AND
INDIVIDUUALIZE MANAGEMENT
History & Examination
• Medical/obstetrical history
• Psychosocial history
• Estimation of gestational age

33. SECOND TRIMESTER WORK UP
(14-28 Weeks)
Initial Booking in Second trimester
Rcommended
Wt, BP, Hb
Blood group and Rh (Both
partners
Urine — R/M, VDRL, Hepatitis
B, HIV, TSH; DIPSI
Quadruple/triple marker
Anomaly scan
Cervical length
Preferable
BMI, MAP, CBC,
(Peripheral) smear,
electrophoresis HPLC
MSU + Culture HCV,
Rubella IgG
NIPT
Uterine artery Doppler
2D-4D scan
Fetal echocardiography
History & Examination
• Medical/obstetrical history
• Psychosocial history
• Estimation of gestational age
IDENTIFY HIGH RISK CASES
AND
INDIVIDUUALIZE MANAGEMENT

35. P
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A T I E N T E D U C A T I O N

36. ADVISE TO MOTHERS
NUTRITION
Recommended weight gain in
pregnancy=IOM 2009

37. NUTRITION
CALORIE REQUIREMENTS
• Pregnant women of normal weight with a singleton
pregnancy need to increase daily caloric intake by
340 and 450 additional kcal/day in the second and
third trimesters, respectively, for appropriate weight
gain
• Recommended daily allowance (RDA) for an Indian
reference woman ( 20 – 29 yrs, weighing 50 kg)
•
particulars Kcal/da
y
protein (g/d) fat (g/d)
nonpregnant 2200 50 20
pregnant +300 +15 30
lactating +550
+400
+25
+18
45

38. NUTRITION AND
MICRONUTRIENTS
• Balanced Diet (ICMR)
• Carbohydrate – 50-70%
• Protein – 15 – 20%
• Fat – 20 – 30% ( essential fatty acid – 50%)
• Micronutrients
• The Institute of Medicine and the Centers for
Disease Control and Prevention recommend
multiple-micronutrient supplements (commonly
called multivitamin supplements) for pregnant
women who do not consume an adequate diet or
may have malabsorption.
• Well-nourished women may not need multiple-
micronutrient supplements

40. NUTRITION
FOOD HYGIENE
Practice good personal hygiene (frequent hand washing)
●Consume only meats, fish, and poultry (including eggs) that are
fully cooked
●Avoid unpasteurized dairy products and fruit/vegetable juices
●Thoroughly rinse fresh fruits and vegetables under running water
(about 30 seconds) before eating
●Avoid eating raw sprouts (including alfalfa, clover, radish, and
mung bean). Bacteria can get into sprout seeds through cracks in
the shell; these bacteria are nearly impossible to wash out.
●Wash hands, food preparation surfaces, cutting boards, dishes,
and utensils that come in contact with raw meat, poultry, or fish
with hot, soapy water. Countertops can be sanitized by wiping with
a solution of one teaspoon liquid chlorine bleach per quart of
water and leaving to dry over 10 minutes.

41. EXERCISE DURING PREGNANCY
RECOMMENDATIONS
• Physical activity in pregnancy has minimal risks and
benefits most women, but some modification to exercise
routines may be necessary because of normal anatomic
and physiologic changes and fetal requirements.
• Before recommending an exercise program, a thorough
clinical evaluation should be done to ensure that the
patient does not have a medical reason to avoid exercise.
• Women with uncomplicated pregnancies should be
encouraged to engage in aerobic and strength conditioning
exercises before, during, and after pregnancy.
• Bed rest, although frequently prescribed in the past (for
prevention of second-trimester loss, preterm birth, and
other conditions) is rarely indicated and, in most cases,
allowing ambulation such as walking should be considere

42. EXERCISE DURING PREGNANCY
ACOG(2015)
A thorough clinical exams mandatory before recommending
an exercise program.
In the absence of C/I –regular, moderate intensity physical
activity for 30 min/day is recommended for pregnant women
Activities with a high risk of falling, abdominal trauma/ scuba
diving (increase fetal risk of decompression sickness) should be
avoided.

43. TRAVEL
CONSIDER SEVERAL ISSUES:
● Risk of pregnancy complications away from their usual
source of medical care, as well as the availability of medical
resources and their medical insurance coverage at their
destination.
● Increased risk of venous thromboembolism during
pregnancy and with prolonged immobility during the trip.
●Issues related to air travel (eg, access to medical
providers, lower oxygen environment, restricted
movement).
● Potentially increased risk of exposure to infectious
diseases (eg, travelers' diarrhea, malaria, Zika virus), as
well as prophylaxis, prevention and treatment of these
diseases.

44. TRAVEL:AUTOMOBILE-
Use of seat belts and air bags
• Pregnant women should continue wearing three-point seat
belts during pregnancy.
• The lap belt is placed across the hips and below the uterus;
the shoulder belt goes between breasts and lateral to the
uterus.
• ACOG=pregnant occupants of motor vehicles wear lap and
shoulder seatbelts and should not turn off air bags

45. TRAVEL: AUTOMOBILE
Use of seat belts and air bags
 The correct use of seatbelts in pregnancy:
• Above and below the bump, not over it.
• Use three-point seatbelts with the lap strap placed as
low as possible beneath the ‘bump’, lying across the
thighs with the diagonal shoulder strap above the
bump lying between the breasts.
• Adjust the fit to be as snug as comfortably possible

46. TRAVEL:AIR TRAVEL
• Most airlines allow women to fly up to 37 weeks POG.
• Commercial airline travel is generally safe for women with uncomplicated
pregnancies ;Fetal heart rate is not affected during flight if the mother
and fetus are healthy
• Women with complicated pregnancies that may be exacerbated by flight
conditions or require emergency care should avoid air travel.
• All airline travelers should maintain hydration and periodically move their
lower extremities to minimize stasis and reduce the risk of venous
thrombosis; use of compression stockings and avoidance of restrictive
clothing may also be helpful. Seat belts should be worn continuously to
protect against injury from unexpected turbulence.
• Supplemental oxygen should be administered to pregnant women (eg,
women with sickle cell disease, severe anemia [hemoglobin <8 g/dL], or
cyanotic heart disease) who must travel and may not tolerate the
relatively hypoxic environment of high altitude flying, even in pressurized
aircraft.

47. Hair dyes and Cosmetic products
• Exposure to hair dyes or hair grooming/styling products results in
very limited systemic absorption, unless the integrity of scalp skin is
compromised by disease.
• Therefore, these chemicals are unlikely to cause adverse fetal effects
in women with a normal scalp
• Plant-based hair dyes are probably safe and there is no information
on whether non-ammonia versus ammonia-based products are safer.
• Avoid ammonia- and peroxide-based products, given the wide
availability of non-ammonia-based products.
• Use these products in a well-ventilated area since women with
asthma/allergies may be more sensitive to the scents during
pregnancy.
• Avoid new products since skin sensitivity is more common in
pregnancy.
• limited data on the safety of cosmetics. Skin may be more sensitive in
pregnancy. Some nail polishes have toludene, formaldehyde, and
dibutyl phthalate; these toxins may be inhaled when applied or
absorbed from the nail bed, so it is prudent to apply nail polish in a
well ventilated place.

48. Sexual intercourse in pregnancy
PREGNANT WOMAN SHOULD BE INFORMED THAT
SEXUAL INTERCOURSE IN PREGNANCY IS NOT
KNOWN TO BE ASSOCIATED WITH ANY ADVERSE
OUTCOMES.
• In the absence of pregnancy complications (eg,
vaginal bleeding, ruptured membranes), there is
insufficient evidence to recommend against sexual
intercourse during pregnancy.
• Whenever abortion or preterm labour is a threat,
coitus should be avoided. Otherwise it is allowed
with less frequency and violence.
• Abstinence in the last 4 weeks of pregnancy for fear
of ascending infection may be considered

49. IRON SUPPLEMENTATION
WHO
iron 60mg + folic acid 400μg/day
• supplementation starting in second trimester &
continuing for the rest of pregnancy & 3 mths
postpartum
Anaemia Prophylaxis MOHFW INDIA Six months in
pregnancy and six months after delivery
• Nonanaemic preg women – 100mg elemental iron &
500μg of FA daily
• Anaemic pregnant women – 200mg elemental iron &
1 mg FA/day

50. Immunization
cdc 2015 recommendations

51. IMMUNISATION
Tetanus toxoid. 2 doses or one dose of T Dap
Tetanus Toxoid
1st dose: Between 16–20 weeks, 2nd dose: After 4–6 weeks
after the 1st dose.
Tdap
• Can replace TT (wherever available)
• Single dose replaces both doses of TT
• Administered 28–36 weeks, if previously immunized
• If not Immunized then Two doses of TT and 1 dose of T dap
Influenza:
Infuenza vaccine
(during flu season) Intramuscular after first trimester .(FOGSI Recomm
2017)

52. IMMUNISATION
VACCINES CONTRAINDICATED IN PREGNANCY:
Live attenuated viral /bacterial vaccines
 BCG
 HPV
 Measles
 Mumps
 Rubella
 Varicella
 Yellow fever – contraindicated except if exposure is unavoidable

53. IMMUNISATION
Recommended vaccines under “Special Situations”
• Rabies: Where the benefits outweigh the risks involved
• Hepatitis A
• Hepatitis B
• Cholera
• Typhoid

54. Prevention of infection {ACOG}
 Women should be offered routine screening for asymptomatic
bacteriuria by midstream urine culture early {12 and 16 wks} in
pregnancy, Identification and treatment of asymptomatic bacteriuria
reduces the risk of pyelonephritis.
 Routine screening for bacterial vaginosis should not be offered because
evidence suggests that : identification and treatment of asymptomatic
bacterial vaginosis does not lower the risk for preterm birth and other
adverse reproductive outcomes.
 Chlamydia screening should not be offered as part of routine antenatal
care.
 Serological screening for hepatitis B virus has to be done to provide
effective postnatal intervention to decrease the risk of mother-to child
transmission

55.  Screening for syphilis has to be done in all pregnant women at first
prenatal visit. Repeat serologic testing at 28 wks and delivery is
recommended in women at increased risk.
 Rubella susceptibility screening should be done early in antenatal
period to identify women, at risk of contracting rubella infection and
to enable vaccination in the postnatal period for the protection of
future pregnancies.
 Pregnant women may not be offered routine screening for hepatitis
C virus as there is insufficient evidence to support its effectiveness
and cost-effectiveness.
Prevention of infection {ACOG}

56.  Routine antenatal serological screening for toxoplasmosis is not required
as risks of screening may outweigh the potential benefits.
 Pregnant women should be informed of primary prevention measures
to avoid toxoplasmosis infection such as:
• Washing hands before handling food
• Thoroughly washing all fruit and vegetables, including ready-prepared
salads, before eating
• Thoroughly cooking raw meats and ready-prepared chilled meals
• Wearing gloves and thoroughly washing hands after handling soil and
gardening
• Avoiding cat faeces in cat litter or in soil
Prevention of infection {ACOG}

57.  Group B streptococcal {GBS} screening can be offered in all women
by vaginorectal culture at 35 to 37 wks as recommended by ACOG.
 All pregnant women should be asked about h/o chickenpox. Women
with no h/o varicella should have serologic testing for VZV IgG to
determine immunity {80-90 % are found to be immune}.
Prevention of infection {ACOG}

58. Exposure of high dose ionizing radiation in pregnancy is:
• Lethal------------ preimplantation stage
• Teratogenic----- organogenesis
• Growth restriction & CNS effects---- fetal period
No increased risk of malformations, growth restriction
or
abortion from a radiation dose of <5 rad.
RADIATION

59. Employment
• Physically demanding work - increase preterm birth ,IUGR
&PIH (Mozurlumich,2000 - 1,60,000 pregnant
women)
• Occupation “Fatigue index” incorporates 5 sources of
occupation hazard.
• Posture
• Type of work
• Physical exertion
• Mental stress
• Situational factors or environmental hazards (e.g. noise,heat)
• Strong relation b/w adverse pregnancy outcome & fatigue
index
• Recommendation for pregnant women ACOG 2002
• Any occupation causing severe physical strain should be avoided
• No work should be continued to the extent that undue fatigue develops
• Adequate periods of rest in b/w work
• Women with prev preg. complication (IUGR, preterm delivery) should
minimize physical work
• Women with uncomplicated preg. can continue work till onset of labour

60. BATHING
• Early pregnancy exposure to hot tub/Jacuzzi at 1000F
or higher -increases incidence of miscarriage & NTDs.
• Late pregnancy - (heavy uterus can upset the balance
of pregnant woman) - increase likelihood of slipping/
falling in bath tub.

61. CLOTHING
• Preferably comfortable +non-contricting
• Proper breast support (increase mass of breast may make them pendulous &
painful)

62. SHOES
• Wear low-heeled (but not flat) shoes with good arch
support
• High - heeled shoes should be discouraged as they
increase lumbar lordosis, back strain and risk of falling.

63. ALCOHOL INTAKE
●Alcohol consumption =negative effects throughout pregnancy
●No exact dose-response relationship between the amount of
alcohol consumed and the extent of damage caused by alcohol in
the infant.
Abstinence IS RECOMMENDED from alcohol at conception and
during pregnancy (Grade 1C).
●Identification and counseling of women who use alcohol can
decrease intake during pregnancy.
●The T-ACE, TWEAK, or AUDIT-C screening tool can be used to
identify women who may be at risk for prenatal alcohol use.
●For pregnant women who consume alcohol but are not heavy
drinkers, recommend a brief intervention (eg, educational
session(s), motivational counseling) rather than no intervention or
more extensive alcohol cessation programs (Grade 1A).
● Women with heavy drinking patterns who are unlikely to reduce
their consumption should be referred to professional alcohol
treatment.

64. CIGARETTE SMOKING
NOT RECOMMENDED
Women who smoke/exposed to secondhand smoke during
pregnancy are at greater risk for spontaneous pregnancy
losses, preterm delivery, low birth weight (LBW), preterm
premature rupture of membranes (PPROM), placenta previa,
abruptio placentae, and stillbirth. Most of these risks are
reduced by smoking cessation
Quitting at any time during pregnancy can have some
beneficial effects. Women are more likely to be successful if
encouraged to quit, rather than cut down.
The five A's (ask, advise, assess, assist, and arrange) provide a
general approach to helping patients stop smoking
For women who are heavy smokers and are unable to quit on
their own, pharmacotherapy is advised(Grade 2B). Nicotine
replacement therapy and bupropion are reasonable first-line
drug options.

65. SIGNS AND SYMPTOMS THAT SHOULD BE
REPORTED TO THE HEALTH CARE PROVIDER
OBSTETRIC
●Vaginal bleeding
●Leakage of fluid per vagina
●Decreased fetal activity
●Signs of preterm labor (eg, low backache; increased
uterine activity compared to previous patterns;
menstrual-like cramps; diarrhea; increased pelvic
pressure; vaginal leaking of clear fluid, spotting or
bleeding, contractions)
●Signs of preeclampsia (eg, headache not responsive to
acetaminophen, visual changes that do not resolve after a
few minutes, persistent right upper quadrant abdominal
pain)
● Signs or symptoms suggestive of a MEDICAL
OR SURGICAL DISORDER