This presentation is created by Tara Tayebi and Vahid Shirzad about antepartum care for obstetrics and gynecology at IAUM Iran. the presentation is based on Danforth.

1. 4THCOFFEE
A n t e p a r t u m
c a r e
Ta ra Tay e b i
Va h i d S h i r z a d

2. 4THCOFFEE
Definition
The time period from the recognition of a pregnancy until
delivery is one of the greatest
physical and psychological transitions that a woman undergoes
in her lifetime. During these
months, the obstetrician, family physician, or midwife serves a
much larger role than just
health care provider. The clinicians' role during this time is not
only to assess the health of
the mother and fetus, prescribe interventions, and try to
influence behaviors but also to
advise and help patients as they undergo this challenging
psychological passage. This presentation
outlines the principles of prenatal care and addresses specific
concerns of a woman's
general health during gestation.

3. 4THCOFFEE
Prenatal care has consisted of adherence to ritual and taboo for
generations. Greek authors suggested that Spartan women exercised in
pregnancy to give birth to better warriors. Roman physicians argued that
strong and violent movements induced rupture of membranes. In the early
twentieth century, hanging clothing to dry on a clothesline was said to
increase the risk of the umbilical cord wrapping around the baby's neck. In
the United States, the first organized prenatal care programs began in
1901 with home nurse visits. The first prenatal clinic was established in
1911. The goal of early prenatal care was to diagnose and treat
preeclampsia in order to decrease maternal mortality. It is not
surprising that this focus on maternal and infant health occurred as a direct
outgrowth of the woman suffrage movement.

4. 4THCOFFEE Over the three trimesters of pregnancy, a woman must
develop new aspects to her identity.
Her self-image develops an additional sense of femininity
beyond what was developed at
puberty, and a maternal self-concept must develop as well.
Reba Rubin, in her works on the maternal experience,
describes a new mother's psychological tasks as the
woman grows into her new role. These tasks include:
1.Accepting a new body image, which is often in conflict
with accepted societal views of attractiveness
2.Accepting the child who is growing inside her
3.Reordering her identity with her mother, her friends, and
4. the father of the pregnancy
Symbolically finding acceptance and safety for her child
(i.e., making a new home).

5. 4THCOFFEE Content of the
preconception visit
The preconception visit is a focused visit for the woman who is planning to
become or is considering becoming pregnant in the near future. The
content of this interval visit includes a complete history; when appropriate,
a complete physical examination;
Risk assessment and intervention; selected laboratory testing based on the
patient's age and the results of the foregoing evaluation; ongoing
management of medical conditions;
and a plan of care. A purposeful discussion of contraception, sexually
transmitted disease prevention, and timing of conception is appropriate.
Timely administration of routine immunizations, educational counseling,
and advice complete the visit.

6. 4THCOFFEE
Risk assessment
A goal specific to the preconception interval visit is
the systematic identification of potential risks to
pregnancy and the implementation of early
intervention as necessary.
These risks fall into several categories, described in
the following sections.
Unalterable Factors
Unalterable factors are preexisting factors that cannot be altered in
any medical way by clinical intervention. These include the patient's
height, age, reproductive history, ethnicity, educational level,
socioeconomic status, genetic composition, and to some
extent her body mass index (BMI). Genetic and family histories,
although unalterable, may lend themselves to screening and
evaluation.
A detailed family history should be obtained, including inquiry of
thromboembolic disease, recurrent miscarriage, neonatal or early
infant death, congenital cardiac disease, mental retardation, or other
major disease affecting health in family members.

7. 4THCOFFEE
Risky
health
habits
The use of illicit drugs or abuse of alcohol represents a significant health hazard to
pregnancy.
Alcohol is a known teratogen.
There is no consensus on the correlation between the quantity of alcohol consumed and the
manifestation of adverse fetal effects.
Therefore, the best advice to women who wish to become pregnant is to stop drinking.
The T-A-C-E screen for alcohol abuse has been well studied. The letters stand for four
questions asked in a nonjudgmental manner:
1. T—“How much do you drink to feel drunk?” (tolerance)
2. A—“Does your drinking annoy anyone?”
3. C—“Has anyone told you to cut down?”
4. E—“Do you drink in the morning to feel better?” (eye-opener).
Smoking cigarettes is associated with adverse pregnancy outcomes, including low birth
weight, premature birth, and perinatal death. Smoking by both the pregnant woman and
members of the household should be avoided during pregnancy and, preferably, not
resumed postpartum. The relative risk of intrauterine growth restriction (IUGR) among
pregnant smokers has been calculated at 2.2 to 4.2. Because of the morbidity associated
with smoking, various methods to assist women to quit smoking should be encouraged prior
to pregnancy.

8. 4THCOFFEE
Initial Prenatal Visit
This visit represents the first detailed assessment of the pregnant
patient. The optimal timing of this visit may vary. For women who
have not undergone the comprehensive preconception visit,
prenatal visits should begin as soon as pregnancy is recognized.
For these women, much of the content of the preconception visit
will need to be addressed at this time—for example, screening for
domestic abuse and alcohol use.
All other women should be seen by about 8 menstrual weeks (6
weeks after conception) gestation.
For all patients, the appropriate content of prenatal care and the
first prenatal visit is contained in the antepartum record published
by the American College of Obstetrics and Gynecology (ACOG).
Identifying data, a menstrual history, and a pregnancy history are
obtained. Past medical, surgical, and social history are recorded,
along with symptoms of pregnancy.
The patient's current medications, including over-the-counter
(OTC) and herbal supplements should be evaluated. A focused
genetic screen, infection history, and risk status evaluation are
performed or reconfirmed.

9. 4THCOFFEE
Gestational Age
The Nägele rule is commonly applied in calculating an estimated date
of confinement (EDC).
The clinician should remember that this is an approximate rule. Using
the date of the patient's last menstrual period minus 3 months plus 1
week and 1 year, the rule is based on the assumptions that a normal
gestation is 280 days and that all patients have 28-day , 280 days is the
currently accepted average gestation. After adjustment for a patient's
actual cycle length, natality statistics indicate that the majority of
pregnancies deliver within 2 weeks before or after this estimated date.
During prenatal care, the week of gestation can be obtained based on
the calculated EDC. When the last menstrual period is unknown or the
cycle is irregular, ultrasound measurements between the 14 and 20
weeks gestation provide an accurate determination of gestational age
(Chapter 9). Care should be taken not to change the EDC unless the
ultrasound differs by 10 or more days from the menstrual dates.
Once dates are appropriately confirmed, continued alterations of EDC
based on fetal size are problematic and ill advised.

10. 4THCOFFEE Physical Examination
A targeted physical examination during the first prenatal visit includes
special attention to the patient's BMI, blood pressure, thyroid, skin, breasts,
and pelvis.
On pelvic examination, the cervix is inspected for anomalies and for the
presence of condylomata, neoplasia, or infection. A Pap smear is
performed, and cultures for gonorrhea and chlamydia are taken, if
indicated.
A small amount of bright red bleeding may occur after these manipulations,
and the patient can be assured that this is normal. On bimanual
examination, the cervix is palpated to assess consistency and length as
well as to detect the presence of cervical motion tenderness. Size, position,
and contour of the uterus are noted.
The adnexa are palpated to assess for masses. The pelvic examination
may include evaluation of the bony pelvis—specifically, the diagonal
conjugate, the ischial spines, the sacral hollow, and the arch of the
symphysis pubis. This evaluation need only be performed once during the
pregnancy.

11. 4THCOFFEE Laboratory Evaluation
Blood Tests
Hematologic testing includes a white blood cell count, hemoglobin,
hematocrit, and platelet count. Full red cell indices are advised for women
of Asian descent to evaluate for thalassemia, a serologic test for syphilis
(RPR, rapid plasma region or VDRL), a rubella titer, a hepatitis B surface
antigen, a blood group (ABO), and Rh type and antibody screen.
HIV testing should be recommended to all pregnant patients and
documented in the chart.
Routine assessment for toxoplasmosis, cytomegalovirus, and varicella
immunity is not necessary but may be obtained if indicated. The National
Institutes of Health and ACOG recommend offering all white women testing
for cystic fibrosis status. Women with histories suggestive of thrombophilia,
or a personal or family history for thromboembolic disease, should be
evaluated at this time. Women with a history suggestive of thyroid
disease should also be evaluated. Although TSH is normally used to
evaluate for thyroid disease, TSH may be affected by other pregnancy
hormones and not accurately affect thyroid status. Thus, a free T4 should
always be obtained when evaluating thyroid disease in pregnancy.
Appropriate screening for genetic carrier status, if not performed at the
preconception visit, includes but is not limited to Tay–Sachs disease,
Canavan disease in women of Jewish ancestry, α- and β-thalassemia in
women of Asian and Mediterranean descent, and sickle cell disease in
women of African descent. Women with a suggestive history of mental
retardation should be screened for fragile X syndrome.
Urine Tests
All women should have a clean-catch urine sent for
culture. Asymptotic bacteriuria occurs in 5% to 8% of
pregnant women. Urinary stasis is present during
pregnancy secondary to physiologic changes in the
urinary system, including decreased ureteral peristalsis
and mechanical uterine compression of the ureter at the
pelvic brim as pregnancy progresses.
Bacteriuria combined with urinary stasis predisposes the
patient to pyelonephritis, the
most common nonobstetric cause for hospitalization
during pregnancy.

12. 4THCOFFEE
Cultures and Infections
The use of routine genital tract cultures in pregnancy is
controversial. While it is clear that chlamydia, gonorrhea, GBS
disease, herpes infection, and potentially bacterial vaginosis
can be detrimental to the ultimate health of the fetus or newborn,
the indications for and timing of cultures for these infections are
debated.
The ACOG recommends assessment for
chlamydiosis and gonorrhea at the first prenatal visit for high-risk
patients. The high-risk patient is defined as less than 25 years of
age with a past history or current evidence of any sexually
transmitted disease, a new sexual partner within the preceding 3
months, or multiple sexual partners. Any abnormal discharge
should be assessed with a wet prep or Gram stain.
Symptomatic patients should be treated. Symptomatic bacterial
vaginosis may be treated in the first trimester.
Tuberculosis skin testing in high-risk populations or in certain
geographic areas should be done if the patient has not been
vaccinated with BCG vaccine.
BCG vaccinations are not given in the United States.

13. 4THCOFFEE
Routine Antepartum Surveillance
It is at this point in the patients' care that individualization should occur. For
women in high-risk categories—such as those with previous preterm birth,
chronic medical diseases, family history of problems, and the like—an
individualized frequency of visits should be established and documented.
For example, a woman with a previous unexplained second trimester
loss that was suspicious but not diagnostic for incompetent cervix might be
observed weekly between 17 and 24 weeks, or a woman with chronic
hypertension might be seen every 2 weeks throughout the first and second
trimesters. In contrast, a woman with previous uncomplicated pregnancies
might be seen every 6 weeks in the first and second trimesters and every
other week in the last 8 weeks. The traditional timing of 14 prenatal
visits was established empirically in the 1930s and has never been
validated. In the mid 1980s and 1990s, several randomized trials
demonstrated that for low-risk women, 6 to 8 total prenatal visits were
equally effective in achieving good pregnancy outcomes.

14. 4THCOFFEE
Physical Examination
The patient's weight is measured, and total weight gain and trends are
evaluated (see Nutrition later in the chapter). The blood pressure is taken
and trends are assessed for possible pregnancy-induced hypertension. As
blood pressure tends to decrease during the second trimester, increases of
30 mm Hg systolic or 15 mm Hg diastolic over first-trimester pressures are
considered abnormal and warrant further evaluation.
The fundal height is measured with a tape from the top of the symphysis
pubis, over the uterine curve, to the top of the fundus (Figs. 1.1, 1.2). This
technique places an emphasis on change in growth patterns rather than
the absolute measurement in centimeters, which can vary between
patients. In women who are obese, periodic ultrasound assessments of
fetal growth may be necessary. Gestational age is approximately equal to
fundal height in centimeters from 16 to 36 weeks gestation. Measurements
that are more than 2 cm smaller than expected for week of gestation are
suspicious for oligohydramnios, IUGR, fetal anomaly, abnormal fetal lie, or
premature fetal descent into the pelvis. Conversely, larger than expected
measurements may indicate multiple gestation, polyhydramnios, fetal
macrosomia, or leiomyomata. These concerns can be resolved with
ultrasound examination. Figure 1.1 The height of the fundus at
comparable gestational dates varies among
patients. Those shown are the most common.
A convenient rule of thumb is that at 20 weeks
gestation, the fundus is at or slightly above the
umbilicus.

15. 4THCOFFEE Leopold maneuver

16. 4THCOFFEE First Trimester Screening Tests
Ultrasound
An ultrasound uses sound waves to create an image of the
baby in the uterus. The test is used to determine the size
and position of your baby, confirm how far along you are in
your pregnancy, and find any potential abnormalities in
the structure of your baby’s growing bones and organs.
A special ultrasound called a nuchal translucency
ultrasound is performed between the 11th and 14th weeks
of pregnancy. This ultrasound checks the accumulation of
fluid at the back of your baby’s neck. When there’s more
fluid than normal, this means there’s a higher risk of Down
syndrome. During the second trimester, a more detailed
ultrasound, which is often called a fetal anatomy survey, is
used to evaluate the baby carefully from head to toe for
any birth defects. However, not all birth defects are visible
by ultrasound.
Early Blood Tests
During the first trimester, two types of blood tests called a sequential integrated
screening test and a serum integrated screening are conducted. They’re used to
measure the levels of certain substances in your blood, namely, pregnancy-
associated plasma protein-A and a hormone called human chorionic
gonadotropin. Abnormal levels of either mean there’s a higher risk of a
chromosome abnormality. At your first prenatal visit, your blood may also be
tested to see if you’re immunized against rubella and to screen for syphilis,
hepatitis B, and HIV.
Chorionic Villus Sampling
Chorionic villus sampling is an invasive screening test that involves taking
a small piece of tissue from the placenta. It’s usually performed between
the 10th and 12th weeks and is used to test for genetic abnormalities, like
Down syndrome, and birth defects. There are two types. One type tests
through the belly, which is called a transabdominal test, and one type tests
through the cervix, which is called a transcervical test.
Testing has some side effects, like cramps or spotting. There’s also a small
risk of miscarriage.

17. 4THCOFFEE
Second Trimester Screening Tests
Blood Tests
A quad marker screening test is a blood test conducted during the second
trimester. It’s done to test your blood for indications of birth defects, such as
Down syndrome. It measures four of the fetal proteins.
A quad marker screening is typically offered if you start prenatal care too late to
receive either the serum integrated screening or the sequential integrated
screening. It has a lower detection rate for Down syndrome and other birth
defects than a sequential integrated screening test or serum integrated screening
test.
Glucose Screening
A glucose screening test checks for gestational diabetes. This is usually a
condition that can develop during pregnancy. It’s usually temporary. Gestational
diabetes can increase your potential need for a caesarean delivery because
babies of mothers with gestational diabetes are usually born larger. Your child
may also have low blood sugar in the days following delivery.
The test is usually performed during the second trimester. It involves drinking a
sugary solution, having your blood drawn, and then checking your blood sugar
levels. If you do test positive for gestational diabetes, you have a higher risk of
developing diabetes within the following 10 years, and you should get the test
again after the pregnancy.
Amniocentesis
During amniocentesis, amniotic fluid is removed from the uterus
for testing. Amniotic fluid surrounds the baby during pregnancy.
It contains fetal cells with the same genetic makeup as the baby,
as well as various chemicals produced by the baby’s body. There
are several types of amniocentesis.
A genetic amniocentesis tests for genetic abnormalities, such as
Down syndrome and spina bifida. A genetic amniocentesis is
usually performed after week 15 of the pregnancy. It may be
considered if:
•a prenatal screening test showed abnormal results
•you had a chromosomal abnormality during a previous
pregnancy
•you’re 35 or older
•you have a family history of a specific genetic disorder
•you or your partner is a known carrier of a genetic disorder
A maturity amniocentesis is performed later, during the third
trimester, to determine whether or not your baby’s lungs are
ready for birth. This diagnostic test is only done if a planned early
delivery through either induction of labor or a cesarean delivery
is being considered for medical reasons. It’s usually done
between weeks 32 and 39.

18. 4THCOFFEE
Third Trimester Screening Tests
Group B Strep Screening
Group B Streptococcus (GBS) is a type of bacteria that can cause serious infections
in pregnant women and newborns. GBS is often found in the following areas in
healthy women:
•the mouth
•the throat
•the lower intestinal tract
•the vagina
GBS in the vagina generally isn’t harmful to a woman regardless of whether she’s
pregnant. However, it can be very harmful to a newborn baby who doesn’t yet
have a robust immune system. GBS can cause serious infections in babies
exposed during birth. You can be screened for GBS with a swab taken from your
vagina and rectum at 35-37 weeks.
If you test positive for GBS, you’ll receive antibiotics while you’re in labor to
reduce your baby’s risk of contracting a GBS infection.
Prenatal Diagnostic Tests
Diagnostic tests are the next step after a screening test that yields a
positive result. They leave virtually no doubt as to the existence or absence
of certain birth defects.
Diagnostic tests are more invasive than screening tests. They’re usually
only done if there’s a specific concern, if a screening test indicates a
problem, or if your age, family history, or medical history suggests that you
may have an increased risk for a problematic pregnancy. Diagnostic tests
can carry a very small risk of miscarriage.

19. 4THCOFFEE Nutrition and Weight Gain
The objectives of nutritional assessment and counseling are to develop, in
concert with th, an analysis of maternal nutritional risk, a goal for total weight
gain, and diet plan that will fit the patient's lifestyle and is ethnically sensitive.
The principle of good nutrition is that there is a positive linear relationship
between maternal weight gain and newborn weight and that prepregnant
maternal BMI can affect fetal weight independently of the amount gained by the
mother during pregnancy. Together, initial weight and weight gain have an impact
on IUGR and low birth weight.
However, for a woman of normal weight and normal nutrition, the relationship
between poor weight gain and fetal growth restriction may be an association, not
a cause and effect. Importantly, excess maternal weight gain is also directly
proportional to adverse perinatal outcome.
The BMI is a calculation that relates the patient's weight to her height, thereby
providing a more accurate indirect estimate of the patient's body fat distribution
than can be obtained by weight alone. The BMI is calculated by dividing weight in
kilograms by height in meters squared. If pounds and inches are used, the
quotient is multiplied by 700.
The BMI of a patient is categorized as underweight, normal weight, overweight,
or obese.

20. 4THCOFFEEMaternal Diet
While weight gain is an important gauge of caloric intake, the quality of the
diet and the frequency of meals may also affect patient and fetal well-
being. A diet should be balanced by containing foods from all of the basic
food groups. Specifics of a diet will vary considerably according to patient
preference, family eating patterns, and cultural and ethnic background.
Women should be instructed not to diet during pregnancy in terms of
decreasing calories, but the issues of dietary requirements should be
addressed.
Vitamin and Mineral Supplementation
Multivitamin supplements are not routinely necessary in a woman eating a
well-balanced diet. However, 800 to 1,000 mg of supplemental folic acid
daily is necessary because the requirement cannot be met with food alone.
Additional folate and sometimes B12 may be necessary for women with a
hemoglobinopathy or MTHFR mutation, for women on antiseizure
medications, or for women with a history of neural tube defects. Vitamin D
supplementation is appropriate. Most women will have low levels of vitamin
D, particularly women in northern latitudes and women in their mid thirties.
Mineral supplementation is also not needed in healthy women. The
exception is iron. The iron requirements of pregnancy total about 1 g. Due
to the monthly menses, most women have less than optimal iron stores
during their reproductive years. Therefore, supplementation with 30 mg of
elemental iron is recommended in the second and third trimesters to
prevent anemia and to meet this requirement. One tablet of iron salts per
day, ingested between meals or at bedtime, is sufficient to meet this
requirement. Women with iron deficiency anemia require 60 to
120 mg of elemental ferrous iron per day. Additional zinc (15 mg)
and copper (2 mg) are then needed, as iron inhibits the
absorption of these ions. Iron is better absorbed in the ferrous
state and with an acid ph. For women
taking H2 blockers and proton pump inhibitors, taking the iron
with orange juice or in a citric acid compound may be helpful.
Pregnancy is a time in which the mother usually experiences
bone loss of calcium. Calcium supplementation is not necessary
in women with a diet that includes adequate dairy foods.
Unfortunately, many women will not meet their dietary needs for
calcium. Absent this, calcium supplementation may be used on
an as-needed basis to meet the recommended
dietary allowance (RDA) of 1,200 to 1,500 mg per day during
pregnancy and 2,000 mg per day with lactation. Women with
twins may be given 2,000 mg daily. Women in their mid thirties
should also receive increased dosing. Calcium is best absorbed
in an acidic pH, similar to iron. To absorb calcium, adequate
vitamin D is needed. Many women have insufficient vitamin D.
Calcium supplements that contain vitamin D are desirable.
Zinc is a trace mineral. A zinc deficiency may be teratogenic in
humans, although this has not yet been conclusively
demonstrated. Zinc levels in amniotic fluid correlate with
antimicrobial activity, suggesting that zinc plays a role in
protecting against intrauterine infection. Low dietary intake of zinc
has been associated with IUGR, although it does not cause
IUGR. The RDA for zinc during pregnancy is increased from 15 to
20 mg per day. Iodine deficiency can be associated in the
mostsevere forms with cretinism—congenital hypothyroid. Most
table salt contains iodine. For
women who do not eat iodized salt, this can become a concern.

21. 4THCOFFEE Food Restriction
Dieting and fasting on a chronic basis in an otherwise healthy woman can
result in suboptimal fetal growth. Eating disorders such as bulimia and
anorexia nervosa reflect extreme forms of food restriction and malnutrition.
Pica
Pica is the compulsive ingestion of nonfood substances with little or no
nutrient value. The practice most commonly involves ice, clay (geophagia),
or starch (amylophagia). Although pica is most commonly recognized
during pregnancy, it is not specific to the gravid state.
Phenylketonuria
Women with phenylketonuria who are not on a phenylalanine-controlled
diet are at increased risk of bearing fetuses with microcephaly, growth
retardation, and mental retardation. The goal of dietary management is to
minimize these adverse fetal outcomes by reducing the maternal serum
phenylalanine levels to <20 mg/dL before and during the pregnancy.
Megadose Vitamins
The misuse of megadose nutrients can be categorized as
a fad type of dietary manipulation. Water-soluble vitamins
such as vitamin C cannot be consumed in harmful
quantities because they are readily excreted in the urine.
However, a problem occurs with fat-soluble vitamin A.
There is an association between high doses of
supplemental vitamin A and birth defects similar to those
seen with isotretinoin. Although the minimum
teratogenic dose in humans has not been identified, it may
be a little as 10,000 IU per day.
Beta-carotene is a provitamin of vitamin A, but it does not
produce similar toxicity. Most
prenatal vitamins contain less than 5,000 IU of vitamin A
and, until further data are available, this should be
considered the maximum safe supplemental dose.

22. 4THCOFFEE Women Who Have Had Bariatric Surgery
Women with gastric bypass and gastric stapling have an increased risk of
nutritional problems. Calcium and iron are best absorbed in an acidic pH,
and thus extra supplementation is recommended for these women in
combination with an acid such as citric acid and vitamin D. Because many
women with bariatric surgeries can eat only small meals, such supplements
need to be spread out, and counseling regarding adequate protein
intake is recommended as well. B12 absorption is promoted by an acidic
environment in the stomach and by the binding of intrinsic factor made in
the stomach. Thus, women with gastric bypass will develop B12 deficiency
if they do not receive either parenteral B12 supplementation or the B12
formulation that is absorbed in the mouth. It is recommend that B12 levels
are checked in women who have had bariatric surgery at the first visit and
providing appropriate supplementation 500 mcg per day
caffeine
Several large human studies have
failed to show that caffeine has deleterious effects on the fetus when
ingested in low amounts. However, it is associated with an increased risk of
miscarriage when taken in greater than the equivalent of three cups of
coffee. Caffeine intake of the equivalent of two to three cups is thus
discouraged. Adverse maternal effects of caffeine include insomnia, acid
indigestion, reflux, and urinary frequency. As these problems are already
exaggerated in pregnancy, moderation in the consumption of caffeine is
advisable.
Seafood
High levels of seafood intake are associated with high
levels of mercury in umbilical cord blood samples as
well as in maternal blood and tissue samples. Mercury
is a teratogen and a neural toxin in the developing
fetus and child.

23. 4THCOFFEE
Nausea and Vomiting
Recurrent nausea and vomiting during the first trimester occurs in over one
half of pregnancies. While the term morning sickness is well known, it is a
misnomer, as these symptoms can occur at any time throughout the day or
night. Symptoms usually begin in weeks 6 to 8, peak during weeks 12 to
14, and are significantly resolved by week 22. The etiology of this problem
is not clear. Hormonal as well as emotional factors have been investigated
without consistent results. Symptoms can be mild or so severe that the
patient becomes dehydrated and risks electrolyte imbalance and caloric
malnutrition. Nonpharmacologic measures often suffice and may
completely relieve the symptoms in some women. These include
avoidance of fatty or spicy foods; eating small, more frequent meals, thus
keeping something in the stomach; and inhaling peppermint oil vapors.
Randomized trials have validated the effectiveness of fresh ginger—which
may be made into a tea, candies, or compounded—in decreasing nausea
and vomiting. Several studies have evaluated vitamin B6, 25 mg two to
three times a day, and found this helpful in eliminating nausea and
vomiting. The use of the Nguyen pressure point on the wrist is also
suggested to be helpful. Motion sickness bands on the wrists employ this
technique. In more severe cases of emesis, various pharmacologic agents
have been used with varying success. These include a variety of
antihistamines, doxylamine, promethazine, metoclopramide,
trimethobenzamide, methylprednisolone, and serotonin 5-Ht3 antagonists
such as ondansetron. Because supplemental vitamin and mineral
preparations may exacerbate symptoms of nausea, they should be stopped
until the symptoms have resolved. Women and their families may be
reassured that minimal weight gain in the first 18 weeks is common.
Hyperthyroid disease will exacerbate nausea and vomiting, and if signs of
thyroid disease are present, free T4 levels should be obtained and
treatment initiated. Some studies have found Helicobacter pylori infection in
women with more severe hyperemesis and resolution or decrease in
symptoms with treatment.

24. 4THCOFFEE Ptyalism
Ptyalism is the increased production of saliva, sometimes induced by the
consumption of starch. There is no cure, although reducing carbohydrate
intake may be helpful. The problem is often self-limiting. It is not
uncommon in pregnancy and is not associated with adverse outcome.
Heartburn
Heartburn is usually caused by reflux esophagitis from both mechanical
factors (the enlarging uterus displacing the stomach above the esophageal
sphincter) and hormonal factors (progesterone causing a relative relaxation
of the esophageal sphincter). Treatment consists of eliminating acidic and
spicy foods, decreasing the amount of food and liquid at
each meal, limiting food and liquid intake before bedtime, sleeping in a
semi-Fowler position or propped up on pillows, and use of antacids. Liquid
forms of antacids and H2- receptor inhibitors provide the most consistent
relief of symptoms. Patients should be cautioned that antacids containing
aluminum may cause constipation, while diarrhea may be associated with
use of those containing magnesium. Proton pump inhibitors are sometimes
necessary in severe cases. In women with chronic antacid use, careful
attention should be given to iron and calcium absorption.
Constipation, Diarrhea and Gas
Progesterone-induced relaxation of the intestinal smooth
muscle slows peristalsis and increases bowel transit time.
Dietary management of this common condition includes
increased fluids and liberal intake of high-fiber foods. Iron
salts may exacerbate the problem. OTC products
containing psyllium draw fluid into the intestine and
promote a more rapid transit time. Enemas and strong
cathartics should be avoided. Many women
develop very different bowel patterns during pregnancy.
Extra gas and loose stools are not uncommon symptoms.
As long as there are no signs of underlying diseases such
as parasites or inflammatory bowel disease, the patient
may be reassured

25. 4THCOFFEE
Exercise
Exercise is a routine part of many women's daily activities. For a
normal pregnancy, a low impact exercise regimen may be
continued throughout pregnancy. Additionally, studies also show
that women may increase their levels of fitness during pregnancy
without problems.
There are no data to indicate that pregnant women must decrease
the intensity of their exercise or lower their target heart rates.
However, physiologic changes of pregnancy may alter the effect of
various exercises on the body or may limit the body's ability to
perform certain types of exercise.

26. 4THCOFFEE
Varicosities and Hemorrhoids
Varicosities most often occur in the lower extremities
and may be seen in the vulva as well. Contributing
factors include genetic predisposition, advanced
maternal age, increased parity, and prolonged standing.
Manifestations can range from mild cosmetic effects to
chronic pain and superficial thrombophlebitis. Treatment
includes avoidance of garments that constrict at the
knee and upper leg, support stockings, and increased
periods of rest with the legs elevated.

27. 4THCOFFEE Fatigue
Pregnant women will usually have an increased sense of fatigue during
pregnancy. This is a normal symptom. A sense of breathlessness is also
normal because of the progesterone stimulation of the respiratory centers.
Syncope
Venous pooling in the lower extremities increases as the pregnancy
progresses. This can lead to dizziness or lightheadedness, especially after
standing upright abruptly or for long periods of time.
Sleep Disturbances, Restless Leg Syndrome,
and Leg Cramps
Most women will develop alterations from their normal sleep patterns
during pregnancy. More frequent urination, more common gastric reflux,
and physical discomfort with the growing pregnancy all contribute to poorer
sleep. Some authors have described more common snoring (up to 30%),
less rapid eye movement (REM) sleep, and much more vivid
dreams. Antihistamines are usually recommended as a first-line sleeping
aid, if necessary. Restless leg syndrome (RLS) is also a common complaint
for pregnant women (approximately 25% of women may develop RLS
during pregnancy).

28. 4THCOFFEE
Backache
Most pregnant women experience lower backaches as pregnancy
progresses. These are usually alleviated by minimizing the amount of time
spent standing, increasing rest, wearing a specially designed support belt
over the lower abdomen, and taking an analgesic such as acetaminophen.
Round Ligament Pain
Round ligament pain most frequently occurs during the second trimester
when women report sharp, bilateral, or unilateral groin pain. It has been
called round ligament pain, although it is not known if round ligament
stretch is the true etiology. The pain may be increased with sudden
movement or change in position.
Headache
Generalized headaches are not uncommon during the first trimester of
pregnancy. Muscle tension headaches may occur intermittently. The
frequency and intensity of migraine headaches may increase or decrease
during pregnancy. Headaches during the second and third trimesters are
not an expected symptom of pregnancy.
Emotional Changes
Pregnancy is a time of significant psychological stress.
Changes in hormonal levels; changes in relationships to
partners, family, and friends; and changes in body
image all lead to increased psychological stress.
Increased levels of placental corticotropin-releasing
hormone toward the end of pregnancy also affect the
maternal hypothalamic–pituitary axis and other brain
loci involved in stress responses.
Sexual Relations
Coital activity during normal pregnancy need not be
restricted. The couple can be counseled regarding
changing positions to achieve better comfort. Deep
penetration may be more uncomfortable as pregnancy
progresses. It is common for women to have changes
in sexual desire over the course of gestation. Many
women achieve orgasm easier during pregnancy;
however, libido often decreases in the first and third
trimesters.

29. 4THCOFFEE
Employment
Most patients are able to continue to work throughout their pregnancy. In
general, work activities that increase the risk of falls or trauma, especially
to the abdomen, should be avoided. Hazardous toxic or chemical
exposures should be identified early and avoided.
Strenuous physical activity, including repetitive lifting and prolonged
standing for more than 5 hours, has been associated with a greater rate of
adverse outcomes, and work routines should be modified accordingly.
Urinary Frequency
Patients often experience urinary frequency during the first 3 months of
pregnancy, as the enlarging uterus compresses the bladder, and again
during the last weeks, as the fetal head descends into the pelvis.
Skin Changes
Hair growth has variable patterns in pregnancy, although many women
experience
increased growth during pregnancy and hair loss postpartum. Skin
commonly darkens over
the face and the median ventral line of the abdomen in many women. Any
nevi that
change color should be excised.
Immunizations
Four immunizations using vaccines containing live viruses
are relatively contraindicated during pregnancy. These are
measles, mumps, rubella, and yellow fever. However, in
certain circumstances, risk/benefit assessment may lead to
receiving the immunizations. The risks for the fetus from
the administration of rabies vaccine are unknown, and each
case must be considered individually since the indications
for prophylaxis are not altered by pregnancy. Tetanus
toxoid, if needed, is acceptable in pregnancy. Flu vaccine is
recommended for pregnant women. Women who are
receiving hepatitis B vaccine may continue receiving it
during pregnancy. Immune globulin for acute exposures to
hepatitis A also is considered safe

30. 4THCOFFEE
Travel
Most issues concerning travel involve the comfort of the mother.
When prolonged sitting is involved, the patient should try to stretch
her legs and walk for 10 minutes every 2 hours to decrease the risk
of thrombosis that can occur secondary to the hypercoagulable
pregnancy state and mechanical compression of venous blood flow
from the extremities. Dependent edema may also be more
pronounced after prolonged sitting. If the patient will
be away from home for a significant period of time, she should take a
copy of her medical record with her. Pregnant women can and
should always wear seat belts when riding in a
car. Travel in a pressurized airplane presents no additional risk to
pregnant women. In traveling abroad, especially to underdeveloped
countries, the usual precautions should be taken regarding ingestion
of unpurified drinking water and uncooked fruits and vegetables

31. 4THCOFFEE
t h a n k s
f o r
y o u r p a t i e n c e