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4.Prenatal Care 2009

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4.Prenatal Care 2009

  1. 1. Antepartum Care: Preconception and Prenatal Care <ul><li>Du Xue , PHD </li></ul><ul><li>Department of Obstetrics </li></ul><ul><li>& Gynecology </li></ul><ul><li>General Hospital of TianJin </li></ul><ul><li>Medical University </li></ul>
  2. 2. The importance and definition of prenatal care <ul><li>Provide </li></ul><ul><li>---health promotion </li></ul><ul><li>---risk reduction </li></ul><ul><li>---diease prevention </li></ul><ul><li>Definition : Prenatal care should be a continuation of preconception counseling, a physician-supervised program, provided for the pregnant women. </li></ul>
  3. 3. The objective of prenatal care <ul><ul><li>to ensure every wanted pregnancy is given the maximal chance of culminate in the delivery of a healthy baby </li></ul></ul><ul><ul><li>without impairing the health of the mother. </li></ul></ul><ul><ul><li>to prevent and manage conditions that cause poor pregnancy outcomes. </li></ul></ul><ul><ul><ul><li>Premature labor and delivery, intrauterine growth retardation, birth defects, perinatal infections, post-term pregnancy </li></ul></ul></ul><ul><ul><ul><li>hypertension, diabetes mellitus, </li></ul></ul></ul>
  4. 4. The three basic Components of pregnant care <ul><li>Early and continuing risk assessment </li></ul><ul><li>---a complete history </li></ul><ul><li>---a physical examination </li></ul><ul><li>---laboratory tests </li></ul><ul><li>---assessment of fetal growth and well-being </li></ul><ul><li>Health promotion </li></ul><ul><li>Medical and psychosocial interventions and follow-up </li></ul><ul><li>---treatment of existing illness </li></ul><ul><li>---provision of resouces </li></ul>
  5. 6. Regular visit schedule <ul><li>The first visit may be in preconception or most commonly present to the clinician after missed menses. </li></ul><ul><li>Additional prenatal visit are routinely scheduled every 4 weeks until 28 week’s gestation,every 2 to 3 weeks until 36 week’s gestation, and then weekly until delivery. </li></ul>
  6. 7. The first prenatal visit <ul><li>Thorough history-> </li></ul><ul><li>A complete physical examination -> </li></ul><ul><li>routine test during pregnancy -> </li></ul><ul><li>Confirming Pregnancy and Determining Viability-> </li></ul><ul><li>Estimating Gestational age and Date of Confinement-> </li></ul><ul><li>Advice (alleviating unpleasant symptoms,nutritional,lifestyle,breast feeding ):-> </li></ul><ul><li>Genetic Evaluation and Teratology ( omit ) </li></ul>
  7. 8. thorough history <ul><ul><li>Medical history : (peripartum cardiomyopathy) </li></ul></ul><ul><ul><li>Reproductive history : </li></ul></ul><ul><ul><li>Previous pregnancy history(preterm birth, low birth weight, pre-eclampsia, stillbirth, DM) </li></ul></ul><ul><ul><li>Prior cesarean delivery circumstances(the cause of cs,time ,fetal weight, et al.The mode of current pregnancy must be discussed). </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Genetic history :congenital anomalies of newborn or mother </li></ul></ul><ul><ul><li>Nutritional history </li></ul></ul><ul><ul><li>Social history/psychosocial history </li></ul></ul>
  8. 9. Complete physical examination <ul><li>Sign of normal pregnancy : </li></ul><ul><li>systolic murmurs, exaggerated splitting S3 during cardiac auscultation, linea nigra(pigmentation on midline of the lower abdomen), striae gravidarum on inspection of the skin </li></ul><ul><li>Breast examination:engorgement </li></ul><ul><li>Pelvic examination : </li></ul><ul><li>uterus is soft and enlarge slightly. Hegar’s sign </li></ul>
  9. 10. Routine tests[1] <ul><li>1. Complete blood count (anemia, leukemia and thrombocytopenia) </li></ul><ul><ul><li>RBC COUNT and Hemoglobin and Hemotocrit </li></ul></ul><ul><ul><li>WBC </li></ul></ul><ul><ul><li>Platelet </li></ul></ul><ul><li>2. Urinalysis and screen for bacteriuria (clean-catch midstream urine specimen) </li></ul><ul><ul><li>protein, glucose, ketone body and et al. </li></ul></ul><ul><ul><li>microscope examination (cast) </li></ul></ul><ul><ul><li>other tests (bacterial culture or other methods) </li></ul></ul><ul><li>3. Blood group, Rh factor, and antibody screen </li></ul>
  10. 11. Routine tests[2] <ul><li>4. TORCH </li></ul><ul><ul><li>rubella antibody titer </li></ul></ul><ul><ul><li>toxoplasma </li></ul></ul><ul><ul><li>cytomegaly virus </li></ul></ul><ul><ul><li>herpes simplex virus </li></ul></ul><ul><ul><li>and others </li></ul></ul><ul><li>5. Serology test for syphilis </li></ul><ul><li>6. hepatitis B surface antigen titer </li></ul><ul><li>7. test for HIV </li></ul><ul><li>8. Cervical cytology </li></ul><ul><ul><li>Threaten abortion </li></ul></ul><ul><ul><li>cervical carcinoma </li></ul></ul>
  11. 12. Commonly performed tests[1] <ul><li>blood glucose screen </li></ul><ul><ul><li>to screening GDM </li></ul></ul><ul><ul><li>24-28 w for the first time </li></ul></ul><ul><ul><li>50g glucose load: 1 hour 7.8mmol/L </li></ul></ul><ul><li>Glucose tolerance test </li></ul><ul><li>> 30y, obesity, family history of DM, previous birth of macrosomic, previous stillbirth infant, previous congenitally deformed infant, previous polyhydramnious, history of recurrent abortions, glycouria, previous gestational diabetes </li></ul>
  12. 13. Commonly performed tests[2] <ul><li>AFP: serum а -fetoprotein (open neural tube defect) </li></ul><ul><li>Ultrasonagraphy </li></ul><ul><ul><li>to confirm the gestational week if last menstrual period is uncertain </li></ul></ul><ul><ul><li>To distinguish congenital anomalies </li></ul></ul><ul><ul><li>18-24 weeks(22w) </li></ul></ul><ul><li>Screeniong for the down”s syndrome and congenital anomalies </li></ul>
  13. 15. Estimating Gestational age and date of confinement <ul><li>Accurate determination of gestational age is very important for the management of obstetric conditions such as preterm labor,IUGR,postdate pregnancy. </li></ul><ul><li>LMP :the first day of the last menstrual period </li></ul><ul><li>EDC :adding 9 months and 7 days to the LMP. </li></ul>
  14. 16. Confirming Pregnancy and Determining viability <ul><li>Pregnancy test </li></ul><ul><li>Transvaginal ultrasonography </li></ul><ul><li>Early pregnancy sign </li></ul><ul><li>Physical examination </li></ul>
  15. 17. Pregnancy test <ul><li>Detects Human chorionic gonadotropin(hCG) in the serum or the urine. </li></ul><ul><li>first detectable 6 to 8 days after ovulation. </li></ul><ul><li>less than 5 IU/L : negtive, </li></ul><ul><li>above 25 IU/L :positive </li></ul><ul><li>6~24 IU/L : equivocal, again in 2 days. </li></ul><ul><li>In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days,but in patients whose pregnancies are destined to abort, the level of hCG rises more slowly,plateaus,or declines. </li></ul><ul><li>It’s important to differentiate a normal pregnancy from a nonviable abort or ectopic gestation. </li></ul>
  16. 18. Transvaginal ultrasonography(1) <ul><li>Relationship between ultrasonography and hCG </li></ul><ul><li>Weeks--- ultrasonography------hCG( IU/L) </li></ul><ul><li>5---------gestational sac------------1500 </li></ul><ul><li>6---------fetal pole ------------------5200 </li></ul><ul><li>7---------fetal cardiac motion-----17,500 </li></ul><ul><li>probable embryonic demise : </li></ul><ul><li>--gestational sac of 8 mm(mean sac diameter) without a demonstrable yolk sac, </li></ul><ul><li>--16mm without a demonstrable embryo, </li></ul><ul><li>--or the absence of fetal cardiac motion in an embryo with a crown-rump length of greater than 5 mm </li></ul>
  17. 23. Advice(1) :Alleviating unpleasant symptoms during pregnancy <ul><li>Nausea and vomiting </li></ul><ul><li>Heartburn </li></ul><ul><li>Constipation </li></ul><ul><li>Hemorrhoids </li></ul><ul><li>Leg cramps </li></ul><ul><li>Backaches </li></ul>
  18. 24. Advice (2):Nutritional counseling <ul><li>BMI(Body mass index) =weight(kg)/height(m) 2 </li></ul><ul><li>BMI(before pregnancy) weight gained(pounds) </li></ul><ul><li><19.8(underweight) 28-40 19.8~26(normalweight) 25-35 > 26 (overweight) 15-25 </li></ul><ul><li>Advice on nutrition </li></ul><ul><li>--balanced for at least 3 months before conception. </li></ul><ul><li>--obese is the great risk for obstetric complications, </li></ul><ul><li>(e.g. GDM,PIH, femal macrosomia) </li></ul><ul><li>Sudden weight gain in the third trimester is a warning sign of impending pre-eclampsia. </li></ul>
  19. 25. <ul><li>Inadequate weight gain or <10pounds at 28 weeks is associated with the risk of premature labor or IUGR </li></ul><ul><li>Vitamin and iron supplementation: </li></ul><ul><li>--folic acid at least 0.4mg daily ( scrinanen 0.4mg,qd) </li></ul><ul><li>--ferrous iron </li></ul><ul><ul><li>non-anemia :30mg/d </li></ul></ul><ul><ul><li>anemia patients:120mg/d for at least 6 weeks </li></ul></ul><ul><li>--copper and zinc (for iron-taking anemic patients) </li></ul><ul><li>--vitamin A (excessive is not benificial ) </li></ul><ul><li>--calcium supplement </li></ul>Advice (2):Nutritional counseling
  20. 26. Advice (3):Lifestyle <ul><li>Exercise :beneficial, same level, avoid Aggressive exercise </li></ul><ul><li>Work : Avoid fatigue,Heavy forms or Stressful work (risk of preterm delivery and poor fetal growth) </li></ul><ul><li>Travel and change in residence: Avoid fatigue and stress </li></ul><ul><li>Sexual intercourse: second trimester pregnancy except in patients at risk for abortion or preterm labor, or in patients with placenta previa. </li></ul><ul><li>Breast stimulation can induce uterine activity. </li></ul><ul><li>Labor may follow coitus near term. </li></ul>
  21. 27. Have A Break
  22. 28. Follow-up visits--Objectives <ul><li>To monitor the pregression of the pregnancy </li></ul><ul><li>To provide education and recommended screening and interventions </li></ul><ul><li>To assess the well-being of the fetus and the mother </li></ul><ul><li>To detect and treat medical and psychsocial complications </li></ul>
  23. 29. Follow-up visits(1) <ul><li>History : </li></ul><ul><li>--abnormal symptoms(preterm labor, pre-eclampsia,labor near term) </li></ul><ul><li>--fetal movements(>20w) </li></ul><ul><li>--confirm gestational week </li></ul><ul><li>PE : </li></ul><ul><li>--Genenal examinations: </li></ul><ul><li>----Weight gain, </li></ul><ul><li>----Bp( systolic and diastolic) </li></ul><ul><li>----HR( arrythmia ,Atrial tachycardiac, Vetricular premature contraction) </li></ul><ul><li>----Edema </li></ul>
  24. 30. Follow-up visits(2) <ul><li>--Abdomen examination(maneuvers of leopold) </li></ul><ul><li>---->28w </li></ul><ul><li>----Lie,positation,presentation </li></ul><ul><li>----uterine size </li></ul><ul><li>Test : </li></ul><ul><li>--blood rutine (Hb) </li></ul><ul><li>--urine rutine(protein,glucose,ket) </li></ul><ul><li>--universal Screening for GDM(24-28w) </li></ul><ul><li>--repeated Test (sexually transmitted infections, eg,syphilis) </li></ul><ul><li>--screening for maternal clonization of Group B streptococcus(35-37 w) </li></ul><ul><li>--B ultrasonography and so on </li></ul>
  25. 31. Fundus height <ul><li>from the symphysis pubis to the top of the fundus </li></ul><ul><li>The discrepancy of greater than 2 to 3cm suggests a size-for-dates problem </li></ul><ul><li>Multiple gestation (size at least 3 cm more than expected for dates) </li></ul><ul><li>Intrauterine growth retardation (size at least 3 cm less than expected for dates) </li></ul>
  26. 33. lie <ul><li>Definition: </li></ul><ul><li>--the relationship of the long axis of the fetus to the long axis of the mother. </li></ul><ul><li>Class: </li></ul><ul><li>--Longitudinal </li></ul><ul><li>--transverse </li></ul><ul><li>--oblique </li></ul>
  27. 34. <ul><li>Lie </li></ul><ul><li>Longitudinal </li></ul>
  28. 35. <ul><li>Lie </li></ul><ul><li>Tansverse </li></ul>
  29. 36. Presentation <ul><li>Definition: </li></ul><ul><li>--the portion of the fetus that descends first through the birth canal </li></ul><ul><li>Class: </li></ul><ul><li>--longitudinal </li></ul><ul><li>----head(cephalic presentation) </li></ul><ul><li>----breech(breech presentation) </li></ul><ul><li>--Transverse </li></ul><ul><li>----shoulder </li></ul>
  30. 37. head breech shoulder Presentation
  31. 38. Position <ul><li>Definination </li></ul><ul><li>--refers to the relationship of some definite part of the fetus (the denominator ) to the maternal pelvis </li></ul><ul><li>Denominator </li></ul><ul><li>----vertex ------------- occiput(O) --mentum(chin) </li></ul><ul><li>----breech------------- sacrum(S) </li></ul><ul><li>----Transverse-------- Scapula(Sc) </li></ul><ul><li>Left or right </li></ul><ul><li>Anterior, posterior, transverse (Occiput) </li></ul><ul><li>Class </li></ul><ul><li>----LOA,LOP,LOT,ROA,ROP,ROT </li></ul><ul><li>----LMA,LMP,LMT,RMA,RMP,RMT </li></ul><ul><li>----LSA,LSP,LST,RSA,RSP,RST </li></ul><ul><li>----LScA,LScP,RScA,RScP </li></ul>
  32. 39. Leopold maneuvers <ul><li>To determine the fetal location within the uterus </li></ul><ul><li>To be carried out at each visit during the third trimester </li></ul><ul><li>To identify an abnormal lie, presentation, or position of the fetus. </li></ul>
  33. 40. <ul><li>To determine which part of the fetus occupies the fundus </li></ul><ul><li>head(round,hard) </li></ul><ul><li>breech(irregular,soft) </li></ul>The procedure of Leopold maneuvers--1
  34. 41. <ul><li>To determine which side the fetal back lies </li></ul><ul><li>back(linear,firm) </li></ul><ul><li>extemities(multiple parts) </li></ul>The procedure of Leopold maneuvers--2
  35. 42. <ul><li>To determine the presenting part(head, breech) </li></ul><ul><li>grasp the part using thumb and the finger, above the symphysis </li></ul><ul><li>) </li></ul>The procedure of Leopold maneuvers--3
  36. 43. <ul><li>To determine the fetal head position (vertex) </li></ul><ul><li>place both hands on the lower abdomen above the inlet </li></ul><ul><li>press in the direction of the inlet </li></ul><ul><li>touch the occiput (extended) or brow(flexed) </li></ul>The procedure of Leopold maneuvers--4
  37. 44. Assessment of fetal well-being <ul><li>Maternal assessment: fetal movement(3/h) </li></ul><ul><li>Nonstress test [learn on job] </li></ul><ul><li>Ultrasonic assessment (real-time) </li></ul><ul><li>Biophysical profile testing </li></ul><ul><li>Contraction stress test [learn on job] </li></ul>
  38. 45. Nonstress test <ul><li>Fetal heart beat response to fetal motion (degree and time) </li></ul><ul><li>--Left lateral supine position </li></ul><ul><li>--20 minutes </li></ul><ul><li>Reactive </li></ul><ul><li>--2 fetal motions </li></ul><ul><li>--fetal heart rate acceleration >15 bpm </li></ul><ul><li>-- acceleration >15 bpm for at least 15 senconds. </li></ul><ul><li>--Basic fetal heart beat:120-160/min </li></ul><ul><li>--Basic Fetal heart beat variation> 15 bpm </li></ul>
  39. 48. Ultrasonic assessment <ul><li>To determine the adequary of the amniotic fluid </li></ul><ul><li>AFI (the amniotic fluid index) </li></ul><ul><li>----represents the total of the linear measurements in centimeter of the largest amniotic fluid pockets noted on the ultrasonic inspection of each of the four quadrants of the gestational sac </li></ul><ul><ul><li>----Oligohydramnios: AFI less than 5 </li></ul></ul><ul><ul><li>----Polyhydramnios: AFI more than 23 </li></ul></ul><ul><li>Fetal breathing (30/10min) </li></ul><ul><li>fetal movements (3/10min) </li></ul><ul><li>Placenta maturation (calcification) </li></ul>
  40. 55. Biophysical profile test <ul><li>NST </li></ul><ul><li>Amniotic fluid </li></ul><ul><li>Muscle movement </li></ul><ul><li>Respiratory movement </li></ul><ul><li>Fetal tone </li></ul>
  41. 57. Contraction stress test <ul><li>To determine the uteroplacental function </li></ul><ul><li>Definition: A diluted oxytocin is given to establish at least 3 uterine contractions in 10 minutes </li></ul><ul><li>Positive: late decelerations with each contraction---delivered </li></ul><ul><li>Suspicious: only one deceleration is observed. </li></ul>
  42. 59. Questions <ul><li>How to culculate EDC recording to LMP </li></ul><ul><li>How to confirm pregnancy by test </li></ul><ul><li>What is the procedure of Leopold maneuvers </li></ul><ul><li>How to assess NST/CST </li></ul><ul><li>Which parameter the biophysical profile test includes </li></ul><ul><li>Definitions: TORCH,Lie,Presentation,position </li></ul>
  43. 60. Thanks

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