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Preconception Care: Providing Fetal/Maternal Health Risk Assessments Lecture 4.

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Presentation on theme: "Preconception Care: Providing Fetal/Maternal Health Risk Assessments Lecture 4."— Presentation transcript:

1 Preconception Care: Providing Fetal/Maternal Health Risk Assessments Lecture 4

2 Preconception Planning Important because:  Offers best protection against low birth-weight & other poor pregnancy outcomes.  federal panel advised women planning to conceive to visit health care provider at least once before conception.  Healthy pregnancy closely related to woman’s health before conception.  Improves chances for healthy baby.

3 Preconception counseling: Assess risks of medical & non-medical factors: GDM, HTN, heart disease, psychiatric disorders, domestic abuse, depression, Genetic disorders. Assess risks of medical & non-medical factors: GDM, HTN, heart disease, psychiatric disorders, domestic abuse, depression, Genetic disorders. Discuss nutrition, meds, exercise, tobacco, alcohol, drug use, family support, unemployment, work-related hazards Discuss nutrition, meds, exercise, tobacco, alcohol, drug use, family support, unemployment, work-related hazards Most critical time for fetus is day 17 – 56 when organs, limbs, skeletal, CNS forming. Most critical time for fetus is day 17 – 56 when organs, limbs, skeletal, CNS forming. Exposure to environmental risks harmful to embryo when woman may not realize she is pregnant. Exposure to environmental risks harmful to embryo when woman may not realize she is pregnant.

4 Pre & Post-Pregnancy Planning Pre & Post-Pregnancy Planning Considerations for Potential Parents: Financial Responsibility:  Cost of prenatal care, delivery, loss of work (both), child care (home or day care center), childrearing.  Leaving workforce - does she plan to return ? Employment benefits -are they adequate to support maternal/infant pre & post natal care ? Employment benefits -are they adequate to support maternal/infant pre & post natal care ? IMPORTANT COMPONENTS OF PRECONCEPTION CARE See a health care provider. Get physical exam. See a health care provider. Get physical exam. Discuss risks. Maintain follow-up care. Update Discuss risks. Maintain follow-up care. Update Immunizations Immunizations

5 Prenatal High-Risk Factors Social/Personal: Low income level, poor diet, multiparity > 3, weight 200 lb; age 35; smoking, addictions Social/Personal: Low income level, poor diet, multiparity > 3, weight 200 lb; age 35; smoking, addictions Pre-existing medical hx: Diabetes mellitus, cardiac disease, anemia, hypertension, thyroid disorder, renal disease. Pre-existing medical hx: Diabetes mellitus, cardiac disease, anemia, hypertension, thyroid disorder, renal disease. Obstetric: Previous stillborn, habitual abortion, cesarean delivery, Rh or blood group sensitization. [ABO or Rh incomp.] Obstetric: Previous stillborn, habitual abortion, cesarean delivery, Rh or blood group sensitization. [ABO or Rh incomp.]

6 “TORCH” special group of infections” “TORCH” special group of infections” Toxoplasmosis, Hepatitis B, Syphilis, Varicella, Rubella, Rubeola, Cytomegalovirus, Herpes simplex O = other Toxoplasmosis, Hepatitis B, Syphilis, Varicella, Rubella, Rubeola, Cytomegalovirus, Herpes simplex O = other TORCH applies to pregnant women, unborn child, newborn, children. Common cause of birth defects. TORCH applies to pregnant women, unborn child, newborn, children. Common cause of birth defects. Can cause stillbirth. Can cause stillbirth. Infection causes few symptoms in pregnant woman. Infection causes few symptoms in pregnant woman. In infants - serious birth defects result if infections contracted during pregnancy/delivery. In infants - serious birth defects result if infections contracted during pregnancy/delivery. 1 st trimester – more severe defects 1 st trimester – more severe defects

7 Current pregnancy: Check titers: vaccines available but most not during preg. Toxoplasmosis – rare; toxoplasma gondii [protozoal infec] transmitted to mom thru raw meat or exposure to infected cat’s feces. Severity > in 1st trimes. Varicella - member of herpesvirus; worse in 1st trimes. Infant may have life-threatening disease. Hep.BsAg – + Hepatits B in mom; infant gets Hep.B vaccine & delivery; followed by 2 more Hep.B vaccines in 1st yr. Syphilis – untreated can cause fetal death. Tx PCN Repeat VDRL > tx.

8 Rubella (1st trimester) 50% rate of malformation. (2 nd tri) 6% rate of damage If non- immune, avoid anyone w. active disease. NO vaccine while pregnant but immunize > del. No preg. for 3 mos. Defects: Hearing loss, Deafness, Blindness, Heart & Neuro defects, Mental Retardation

9 Cytomeglovirus – part of herpesvirus family. Cytomeglovirus – part of herpesvirus family. Defects: Mental retardation, hydrocephaly, microcephaly, Defects: Mental retardation, hydrocephaly, microcephaly, blindness; deafness. blindness; deafness. May be picked up during 1 st year or > 1 yr of age. May be picked up during 1 st year or > 1 yr of age. If 1st trimes.infection, may consider AB. If 1st trimes.infection, may consider AB. HSV 2 [genital ]. Valtrex - suppress lesions; C/S if time of del. Blindness, MR, death HSV 2 [genital ]. Valtrex - suppress lesions; C/S if time of del. Blindness, MR, death

10 Vaccines you can get during pregnancy: Tetanus & influenza vaccine [flu] Tetanus & influenza vaccine [flu] Rubella vaccine: only after delivery Rubella vaccine: only after delivery If equivocal [aka borderline] pt. gets vaccine. If equivocal [aka borderline] pt. gets vaccine. MD order, consent signed by pt. MD order, consent signed by pt. Explain risks of birth defects pregnant within 3 mos.of vaccine. Live virus. SC injection Explain risks of birth defects pregnant within 3 mos.of vaccine. Live virus. SC injection

11 HIV: test done in NYS to all newborns - Newborn Screening Test 36% of HIV-infected women using illicit drugs during pregnancy had no prenatal care. 36% of HIV-infected women using illicit drugs during pregnancy had no prenatal care. # of infants with AIDS (d/t perinatal transmission) declined from 122 in 2000 to 47 in (CDC) # of infants with AIDS (d/t perinatal transmission) declined from 122 in 2000 to 47 in (CDC) CDC, AWHONN, Institute of Medicine & ACOG support policy of universal HIV testing as routine component of prenatal care. [2001] CDC, AWHONN, Institute of Medicine & ACOG support policy of universal HIV testing as routine component of prenatal care. [2001] Retest for HIV in 3 rd trimester (new practice) Retest for HIV in 3 rd trimester (new practice)

12 Do ELISA (screen) then Western Blot (confirm). Do ELISA (screen) then Western Blot (confirm). Seroconversion: Usually by days after infection. All by 6 mos. Seroconversion: Usually by days after infection. All by 6 mos. Offer HIV initial visit. Mom can refuse. Offer HIV initial visit. Mom can refuse. Discuss risk of not taking test. Discuss risk of not taking test. HIV+ - treat with ZVD (zidovudine) in 2-3rd trimesters. Transmission ~ 25% without Rx; with tx ~ 8.3 %. If Rx del. or only to newborn, rate = 15%. Treat in antepartum, intrapartum & infant x 6 weeks. Treat in antepartum, intrapartum & infant x 6 weeks. Monotherapy (ZVD) for viral load < 1,000. Monotherapy (ZVD) for viral load < 1,000. New (2003): 3 drug tx reduces rate to 1-2 %. Start in 2 nd trimester. For viral load > 1,000. New (2003): 3 drug tx reduces rate to 1-2 %. Start in 2 nd trimester. For viral load > 1,000. Woman must deal with guilt, depression, stigma. Woman must deal with guilt, depression, stigma.

13 Common Discomforts of Pregnancy 1 st Trimester Nausea & vomiting Causes: hormonal, fatigue, changes in carb metabolism Causes: hormonal, fatigue, changes in carb metabolism Interventions: sm. freq. meals; eat slow; dry toast ; deep breaths. Interventions: sm. freq. meals; eat slow; dry toast ; deep breaths. Ends by 2 nd trim; if severe, hospitalize & hydrate Ends by 2 nd trim; if severe, hospitalize & hydrate

14 Nasal Stuffiness: Nasal Stuffiness: Causes: edema of nasal mucosa d/t ^ estrogen levels Causes: edema of nasal mucosa d/t ^ estrogen levels Interventions: saline drops; humidifier. Interventions: saline drops; humidifier. Pseudafed 2 nd / 3rd trimester. Pseudafed 2 nd / 3rd trimester. Breast Enlargement & Tenderness [cold weather] Breast Enlargement & Tenderness [cold weather] Causes: ^ estrogen & progesterone levels Causes: ^ estrogen & progesterone levels Interventions: Support bra with wide shoulder straps; jacket/sweater. Interventions: Support bra with wide shoulder straps; jacket/sweater.

15 Urinary Frequency & Urgency Urinary Frequency & Urgency Causes: pressure of uterus on bladder; lasts 3 mos. & disappears; reappears in late preg. when head is engaged. + blood/burning on urination - signs of UTI. Causes: pressure of uterus on bladder; lasts 3 mos. & disappears; reappears in late preg. when head is engaged. + blood/burning on urination - signs of UTI. Interventions: UA & urine Cx & Tx with AB. Interventions: UA & urine Cx & Tx with AB. Reduce caffeine. Do Kegel’s. Plan frequent BR stops. Reduce caffeine. Do Kegel’s. Plan frequent BR stops. Increased vaginal discharge: “leukorrhea” Causes: ^ estrogen & ^ blood supply to vagina; hyperplasia of vag.mucosa. Causes: ^ estrogen & ^ blood supply to vagina; hyperplasia of vag.mucosa. Interventions: daily bath; sanitary pads OK but no tampons, tight pants or underwear > infection. Pruritis/erythema - poss. fungal infection. Interventions: daily bath; sanitary pads OK but no tampons, tight pants or underwear > infection. Pruritis/erythema - poss. fungal infection.

16 Common Discomforts Of 2nd & 3rd Trimesters Heartburn  Causes: Relaxation of cardiac sphinter, ↓ GI mobility; ↑ progesterone & gastric displacement. Food backs up from stomach into esophagus, irritates lining; “burning”.  Interventions: Small, freq. meals; chew slowly; avoid extra weight gain, avoid tight fitting clothes, avoid fried & fatty foods; sleep with HOB ^; Take antacid if all else fails.

17 Hemorrhoids [varicosities rectal veins] Causes: Pressure on pelvic veins; in ^ 3rd trimes Interventions: modified Sim’s position; stool softeners; witch hazel/cold compresses. Constipation Causes: oral iron supplements; ↓ peristalsis; displacement of bowels by fetus. Interventions: No mineral oil; interferes with vitamin metabolism. ^ po fluids; ^ roughage; attempt regular BM’s.

18 Backache: *R/O UTI 1st Causes: Posture changes during preg.d/t ^ uterine enlargement Causes: Posture changes during preg.d/t ^ uterine enlargement Interventions: Low heels; walk with pelvis tilted forward; squat when lifting; don’t bend. Firm mattress; heat therapy; Tylenol. Interventions: Low heels; walk with pelvis tilted forward; squat when lifting; don’t bend. Firm mattress; heat therapy; Tylenol. Leg Cramps Causes:Pressure from enlarging uterus, poor circulation; fatigue, ↓ Ca & ↑ Phosphorus Causes:Pressure from enlarging uterus, poor circulation; fatigue, ↓ Ca & ↑ Phosphorus Interventions: dorsiflex affected foot; elevate legs. Interventions: dorsiflex affected foot; elevate legs. Aluminum hydroxide [Amphogel] binds phosphorus & reduces it in circulation. Aluminum hydroxide [Amphogel] binds phosphorus & reduces it in circulation.

19 Shortness of Breath : Dyspnea Shortness of Breath : Dyspnea Causes: pressure of uterus on diaphragm & Causes: pressure of uterus on diaphragm & compression of lungs; night when flat. compression of lungs; night when flat. Interventions: 2-3 night; sitting upright. Interventions: 2-3 night; sitting upright. Ankle Edema Ankle Edema Causes: fluid retention & poor venous return from lower extremities; aggravated by prolonged sitting or Causes: fluid retention & poor venous return from lower extremities; aggravated by prolonged sitting or standing & warm weather. Occurs near term. standing & warm weather. Occurs near term. Interventions: ^ legs, avoid tight fitting pants Interventions: ^ legs, avoid tight fitting pants

20 CONTROLLABLE RISK FACTORS Nutrition: Know ideal weight for your height. Instruct client to keep food diary. Examine food choices in daily diet. If underweight/overweight before conception, counsel about proper nutrition. If underweight/overweight before conception, counsel about proper nutrition. Calcium/zinc - beneficial for long-term health needs & growth/development of baby. Calcium/zinc - beneficial for long-term health needs & growth/development of baby. Folic acid: protects against neural tube defects aka spina bifida. Folic acid: protects against neural tube defects aka spina bifida.

21 GOOD SOURCES: Folic acid: broccoli, collard greens, dried peas, beans, citrus fruits and juices. Zinc: whole grains, oats, wheat, barley, peas, beans. Calcium: milk, yogurt, cheese, tofu, sardines with bones, soy milk, OJ, legumes.

22 US Public Health Service & March of Dimes recommends all women of childbearing age mg [400mcg] of folic acid daily - reduce risk of neural tube defects. No more than 1 mg. US Public Health Service & March of Dimes recommends all women of childbearing age mg [400mcg] of folic acid daily - reduce risk of neural tube defects. No more than 1 mg. Supplement Folic Acid intake if you are: Supplement Folic Acid intake if you are: Of child bearing age Of child bearing age Planning pregnancy Planning pregnancy mcg daily during pregnancy mcg daily during pregnancy PNV contain all requirements needed for pregnancy including folic acid & iron.

23 Nutrition RDA: add 300 kcal in 2 nd & 3 rd trimester. RDA: add 300 kcal in 2 nd & 3 rd trimester. Total Calories = 2500kcal/day (pregnant); 2200 non- pregnant Total Calories = 2500kcal/day (pregnant); 2200 non- pregnant Underweight clients >300 kcal. increase. (~ 2800 kcal/day) Underweight clients >300 kcal. increase. (~ 2800 kcal/day) RDA for protein/minerals/vitamins: ^ 60 g./day RDA for protein/minerals/vitamins: ^ 60 g./day Daily iron requirement doubles in preg. (15 to 30 mg) Daily iron requirement doubles in preg. (15 to 30 mg) Minerals (Ca, phos, iodine, Fe, Z) from fruits/veg. Minerals (Ca, phos, iodine, Fe, Z) from fruits/veg. Calcium/phosphorous stays same if client follows daily recommended intake; * teens < 19 need 1300mg./day. Calcium/phosphorous stays same if client follows daily recommended intake; * teens < 19 need 1300mg./day.

24 Vegetarianism Vegen diet – no food from animal sources (eggs, fish, chicken) most challenging for health care providers. Vegen diet – no food from animal sources (eggs, fish, chicken) most challenging for health care providers. Adequate “pure” vegan diet: nuts, grains, vegetables, fruits, legumes, rice, soy milk. Adequate “pure” vegan diet: nuts, grains, vegetables, fruits, legumes, rice, soy milk. May be anemic & not get enough calories. May be anemic & not get enough calories. F ISH: up to 12 oz/wk of low mercury fish. Canned light tuna, shrimp, salmon, catfish is ok. F ISH: up to 12 oz/wk of low mercury fish. Canned light tuna, shrimp, salmon, catfish is ok. No swordfish, shark, tilefish, king mackerel (high mercury) No swordfish, shark, tilefish, king mackerel (high mercury)

25 Lactose intolerance or cultural avoidance can lead to lowered calcium intake; recommend yogurt, cheese, sardines, beans, collard greens, figs, OJ, tofu, Lactaid. (commercial lactose). Lactose intolerance or cultural avoidance can lead to lowered calcium intake; recommend yogurt, cheese, sardines, beans, collard greens, figs, OJ, tofu, Lactaid. (commercial lactose). * Few demands placed on maternal nutrition in 1 st trimester. RDA fluids = 6-8 glasses ( ml); water, milk, juices. RDA fluids = 6-8 glasses ( ml); water, milk, juices. > 200mg caffeine daily doubles risk for miscarriage > 200mg caffeine daily doubles risk for miscarriage 1 cup ~ 100 mg ~ 250ml 1 cup ~ 100 mg ~ 250ml

26 Weight Gain (new slide) Women of Normal weight: lbs. ( kg) Women of Normal weight: lbs. ( kg) Underweight women: lbs. ( kg) Underweight women: lbs. ( kg) Overweight women: lbs. ( kg) Overweight women: lbs. ( kg) Twins or Multifetus: woman should gain 4 to 6 lbs. in 1st trimester, 1.5 pounds per week in 2nd and 3rd trimester, for total of 35 to 45 lbs. Twins or Multifetus: woman should gain 4 to 6 lbs. in 1st trimester, 1.5 pounds per week in 2nd and 3rd trimester, for total of 35 to 45 lbs.

27 PICA: eating non-food substances (dirt, clay, laundry starch, paint chips) or foods of low nutritional value (ice, cornstarch)  In US, most common in African Americans, women from rural areas, or women with family hx pica.  Interferes with normal consumption of nutrients; causes anemia in mom. Possible lead poisoning.  In depth diet analysis – nutrition counseling  RN discusses cravings. 24 hr. diet re-call.  Follow up prenatal visits.  Folic Acid for ^ RBC production. 50% more in pregnancy (800 ug/day); enriched grain products.

28 Controllable Risk Factors: Drug, Alcohol, Tobacco Use Alcohol:. Avoid all alcohol during time attempting conception/pregnancy. No known safe level during pregnancy. Associated with malformation, slow fetal growth, fetal death, low birth-weight, CNS abnormalities, neurologicaldefects, spontaneous abortion, abruption. No known safe level during pregnancy. Associated with malformation, slow fetal growth, fetal death, low birth-weight, CNS abnormalities, neurologicaldefects, spontaneous abortion, abruption. Tobacco: Associated with spontaneous abortion, ectopic pregnancy; low birth-weight, infant mortality. Can potentially decrease fertility. Vasoconstriction restricts blood flow to fetus & reduces % of oxygen & nutrients carried by blood.

29 Illicit or Street Drugs: May be associated with severe medical & developmental problems in newborns. 1. Marijuana, most common - tend to have babies earlier & may be smaller than term babies. 2. Cocaine: associated with miscarriage, abruption, low birth-weight, premature birth, brain damage. 3. Heroin - IV drug users - evaluate for AIDS & Hep B. In HIV + women, studies show treatment with AZT reduces ransmission to baby from ~ 25% to 8%.

30 Exercise in Moderation Boosts self-image, reduces tension, decreases physical discomfort. Boosts self-image, reduces tension, decreases physical discomfort. Get medical clearance before starting exercise program. Get medical clearance before starting exercise program. Don’t exercise in hot/humid weather or to point of exhaustion. Don’t exercise in hot/humid weather or to point of exhaustion. Avoid exercise with risk of traumatic injury: downhill skiing, horseback riding, water skiing, tennis, etc. Avoid exercise with risk of traumatic injury: downhill skiing, horseback riding, water skiing, tennis, etc. Recommended: walking, cycling on stationary bike, swimming Recommended: walking, cycling on stationary bike, swimming

31 Avoid High Internal Body Temp During early pregnancy, can interfere with normal embryonic development. Study published August 1992: use of hot tubs & saunas found to raise body temperature to 102ºF if women stayed in tubs for up to 15 minutes. ^ risk of neural tube defects in offspring.

32 Stress Management Techniques Relaxation & deep breathing. Planning pregnancy can be stressful. Relaxation & deep breathing. Planning pregnancy can be stressful. Stress reduction enhances chances of conception. Stress reduction enhances chances of conception. Excessive stress can lead to premature birth & low birth weight. Sleep 8-10 hr.with frequent rest periods a day. Excessive stress can lead to premature birth & low birth weight. Sleep 8-10 hr.with frequent rest periods a day.

33 Common STDs & effects to baby if untreated: Chlamydia: Ear/eye infections, pneumonia. Chlamydia: Ear/eye infections, pneumonia. Genital Herpes: Active infection - baby born thru vaginal opening with open sores – leads to severe skin infections, nervous system damage, blindness, mental retardation, death can occur. Genital Herpes: Active infection - baby born thru vaginal opening with open sores – leads to severe skin infections, nervous system damage, blindness, mental retardation, death can occur. Genital Warts: (If infection is active during delivery): Warts can grow in voice box & block windpipe. Genital Warts: (If infection is active during delivery): Warts can grow in voice box & block windpipe. Gonorrhea: Eye Infections, blindness. Gonorrhea: Eye Infections, blindness. Syphilis: Damage to bone, lung, liver, blood vessels Syphilis: Damage to bone, lung, liver, blood vessels Other Infections that can cause PTL: UTI & BV Other Infections that can cause PTL: UTI & BV

34 Exposure to Contraceptives Controversial adverse effects on fetus. Do not use. Controversial adverse effects on fetus. Do not use. Prescription and Over-the-Counter Drugs Often unsafe during pregnancy: Accutane (acne) birth defects. Often unsafe during pregnancy: Accutane (acne) birth defects. Avoid drugs used for headaches/common colds. Avoid drugs used for headaches/common colds. Environmental Reproductive Hazards Avoid unnecessary environmental risks at home/work. Paint Thinners, Varnish Removers, Cleaning Solvents, Glue Paint Thinners, Varnish Removers, Cleaning Solvents, Glue X-rays, Radioactive materials, Cat litter (toxoplasmosis) X-rays, Radioactive materials, Cat litter (toxoplasmosis) Leave job with questionable hazards. Leave job with questionable hazards. Use protective equipment/safety protocols. Use protective equipment/safety protocols.

35 FDA Pregnancy Risk Category for Drugs Category A: no risk to fetus in any trimester Category A: no risk to fetus in any trimester Category B: no adverse effects in animals; no human studies available Category B: no adverse effects in animals; no human studies available Category C: Only prescribed after risks to fetus are considered. Animal studies have shown adverse reaction; no human studies available Category C: Only prescribed after risks to fetus are considered. Animal studies have shown adverse reaction; no human studies available Category D: Definite fetal risks, may be given in spite of risks in life-threatening situations Category D: Definite fetal risks, may be given in spite of risks in life-threatening situations Category X: Absolute fetal abnormalities. Do not use anytime in pregnancy (Lithium, Accutane) Category X: Absolute fetal abnormalities. Do not use anytime in pregnancy (Lithium, Accutane)

36 Male Role in Preparing for Pregnancy Male planning to become father should: Review family medical & genetic hx Review family medical & genetic hx Practice STD risk-reduction behaviors. Practice STD risk-reduction behaviors. Avoid tobacco, alcohol, illicit/street drugs, chemical exposure. Avoid tobacco, alcohol, illicit/street drugs, chemical exposure. Assess financial status. Assess financial status. Be supportive of partner. Be supportive of partner. Play active role in pre-pregnancy planning. Play active role in pre-pregnancy planning.

37 Age is a Big Factor Age is a Big Factor Teenagers and Women over 40 years - greatest risk. Teenagers and Women over 40 years - greatest risk. Women over 40 years Have decreased fertility. Have decreased fertility. Have increased risk for Downs Syndrome Have increased risk for Downs Syndrome & hypertension. & hypertension. Should talk with health care provider about Prenatal testing. Should talk with health care provider about Prenatal testing. Healthy pregnant women > 40 yrs who follow recommended practices have about same chances as younger women for healthy pregnancy outcome. Healthy pregnant women > 40 yrs who follow recommended practices have about same chances as younger women for healthy pregnancy outcome.

38 TEENS: more likely [than women in 20’s] to have TEENS: more likely [than women in 20’s] to have labor, delivery & low-birth-weight problems. labor, delivery & low-birth-weight problems. Almost half of all pregnant teens do not get prenatal care in 1st trimester of pregnancy. Almost half of all pregnant teens do not get prenatal care in 1st trimester of pregnancy. Teens less likely to gain appropriate weight & often practice unhealthy eating habits. Teens less likely to gain appropriate weight & often practice unhealthy eating habits.


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