P R E C O N C E P T I O N A L , P R E N ATA L A N D P O S ...

P R E C O N C E P T I O N A L , P R E N A T A L A N D P O S T N A T A L

C O U N S E L L I N G

D R R E N U A R O R AC O N S U L T A N T

V M M C A N D S A F D A R J U N G H O S P I T A L

IS IT IMPORTANT ?

• Improving mothers pre-conceptional health resulting in

improved reproductive health outcome –

• Reduced maternal morbidity and mortality

• Prevent LBW, STILL BIRTH and PREMATURE BIRTH.

WHEN TO INITIATE PRECONCEPTIONAL COUNSELLING-

• Any visit to doctor in reproductive year.

• Annual health check up

• Postpartum check up

• Premarital counselling

• A visit for infertility treatment

GOAL -• SCREENING FOR HIGH RISK FACTORS BY -

• Medical and surgical history

• Previous obstetrical history

• Personal history

• Family history

• Physical examination

• Laboratory screening

FOLIC ACID RECOMMENDATION PRECONCEPTIONALLY

• All women of child bearing age -

• folic acid 0.4/0.5 mg daily, 1 month before conception to up to 3 month after

conception

• Moderate risk [ family history of NTD in a first or second relative, maternal

diabetes, maternal malabsorption syndrome] – 1mg

• High risk [ history of NTDs in women or their partner, or NTDS in previous

pregnancy , BMI >30 KG/M2 ]- 4MG

Strength of recommendation: A, level of evidence : 1

GENETICS :-Factors requiring genetic counselling :-

1. Consanguinity

2. Suspected hereditary disease in family member.

3. Advanced parental age during a pregnancy which predispose to aneuploides( i.e. downs syndrome )

4. Teratogen exposure or infection during early pregnancy

5. Presence of birth defects, chromosomal abnormality (down’s syndrome ), intellectual disability, developmental delay in a parent , a child, or the child of family member.

6. Recurrent pregnancy loss

7. Family history of early onset cancer

IMMUNIZATIONS• Preconceptional counseling includes assessment of immunity against common pathogens.

• Vaccines that contain toxoids such as tetanus or those containing killed bacteria or

viruses—such as influenza, pneumococcus, hepatitis B, meningococcus, and rabies

vaccines—are not associated with adverse fetal outcomes and are not contraindicated

preconceptionally or during pregnancy.

• Conversely, live-virus vaccines are not recommended during pregnancy. Examples

are vaccines against varicella-zoster, measles, mumps, rubella, polio, chickenpox, and yellow

fever.

• Moreover, 1 month or longer should ideally pass between vaccination and conception

attempts. That said, inadvertent administration of measles, mumps, rubella (MMR) or

varicella vaccines during pregnancy should not generally be considered indications for

pregnancy termination.

• Most reports indicate that the fetal risk is only theoretical.

SAFE IN PREGNANCY CONTRAINDICATED IN

PREGNANCY

Toxoids:Diptheria,Tetanus

BacterialVaccines:Acellular

pertussis

Inactivated viral vaccines:

Inactivated influenza

Inactivated Polio Vaccine (IPV)

Hepatitis A

Rabies

Fractional

Typhoid (parenteral)

Hepatitis B

Pneumococcal

Meningococcal

Yellow Fever ,though live

attentuated ,can be given if

indicated

Live Attenuated Vaccines

Viral Bacterial

Measles BCG

Mumps Oral Typhoid

Rubella Human Papilloma

Virus

Vaccinia

Varicella

Herpes Zoster

Rotavirus

Live attenuted influenza

Oral Polio

PRE NATAL CARE :-• Aim :-

• To screen the high risk cases.

• To prevent or detect or treat any earliest complication.

• To educate the mother about the physiology of pregnancy and labour by

demonstrations

• To discuss with couple about place time and mode of delivery

• To advise mother about breast feeding , postnatal care and immunization.

ANTENATAL VISITS :-• Ideally 13 visits :-

• 7 in first 7 month

• 2 in 8th month

• 4 in 9th month

• WHO ANC MODEL (2016)

• As soon as pregnancy is suspected up to 12 weeks

• 2nd – 20weeks

• 3rd - 26weeks

• 4th – 30 weeks

• 5th- 34 weeks

• 6th- 36 weeks

• 7th-38 weeks

• 8th- 40 weeks

FIRST VISIT

• ANC BEGINS AS SOON AS PREGNANCY IS CONFIRMED-

• CONFIRMATION OF PREGNANCY – UPT

• HISTORY TAKING

• GENERAL AND SYSTEMIC EXAMINATION

• INVESTIGATION

INVESTIGATION• HB

• BLOOD GROUPING AND RH TYPING

• URINE R/M

• HBSAG

• HIV

• VDRL

• OGTT ( 75 grams glucose followed 2 hrs later )

• SERUM TSH (not a part of universal screening)

• HPLC

S.TSH and HPLC depending on facility

FIRST TRIMESTER

• Confirm pregnancy and period of gestation

• Calculate EDD

• USG preferably around 11-13weeks

Confirm date, No of fetus, Chorionicity aneuplody

Dual test (B-HCG and PAPPA)

Predict Risk of--- Preeclampsia, IUGR

INVERTED PYRAMID approach

SCREENING FOR FETAL ANOMALIES-

First trimester screening-

• Biochemical screening –

Dual test : measures serum levels of beta HCG and PAPP-A

• Ultrasound screening –

NT/NB scan between 11-13+6 weeks of gestation

NUCHAL THICKNESS, NT>3 MM is abormal

Absent and hypoplastic NASAL BONE is abnormal

• COMBINED TEST- NT+HCG+PAPP-A

It detect trisomy 21 in 92% of cases

Second trimester screening –

• Biochemical Screening: Quadruple Test

• It includes 4 biochemical analytes-

• MSAFP, UE3, INHIBIN A AND HCG

• Ultrasound screening : TIFFA Scan (Targeted Imaging For Fetal

Anomalies)

• BEST SCREENING PROCEDURE IS COMBINED FIRST

AND SECOND TRIMESTER PROCEDURES (ACOG).

GENERAL PHYSICAL EXAMINATION• General condition

• Build -average/short/tall, height of <142 cm

assosc. with small pelvis

• Nutrition –

average/good/poor/malnourished/obese

• Breast examination

• Weight

Pre-pregnancy weight to be noted to

calculate weight gain during pregnancy

• BMI= weight in kg/height in square metres

• Temperature

• Pulse – rate, rhythm, volume, character,

radiofemoral delay

• Respiratory rate

< 18.5 Underweight

18.5 – 22.9 Normal

23 – 24.9 Overweight

25 – 29.9 Pre-Obese

≥30 Obesity

BLOOD PRESSURE

• measured in sitting/ semi-recumbent position at an angle of about

30 degree, with back supported, with arm supported on table at the

level of heart, legs should not be crossed.

• Position of cuff: wrapped 2-3 cm above the elbow and it should be

applied firmly but not tightly.

• Size of cuff: it should be 1.5 times the mid arm circumference,

rubber bladder inside the cuff should go at least 80% around the

arm. Bladder width should be 40% of the arm circumference.

• In pregnant women korotkoff 5 is taken instead of korotkoff 4 as a

measure of diastolic BP.

• Tongue, teeth, gum – glossitis, stomatitis, caries teeth,

gingivitis

• Pallor – lower palpebral conjunctiva, nail beds, tip of tongue,

soft palate, palms and soles

• Cyanosis – Heart disease, corpulmonale

Peripheral cyanosis – hands, feet, fingers, toes and nail

beds

Central cyanosis – tongue, lips

• Icterus – upper bulbar conjunctiva, undersurface of tongue,

soft palate, sole, palm and skin

• Clubbing – Congenital heart disease/sub-acute bacterial

endocarditis/atrial myxoma/lung disease/

gastrointestinal and hepatobiliary disease

• Edema – bilateral or unilateral, pitting or non- pitting

• Breast examination

• Thyroid examination

SYSTEMIC EXAMINATION :-

Cardiovascular System

Respiratory System

G.I. System

Neurological System

Obstetrics Examination – Prerequisites are:

• Bladder evacuation

• Explain the procedure, informed consent to be taken, wash hands.

• Stand on right side of the patient

• Examine in dorsal position- thighs and knees flexed

• Abdomen exposed fully and other parts covered(xiphisternum to pubic symphysis)

ABDOMINAL EXAMINATION INSPECTION• Abdominal distension

• Pregnancy skin changes- linea nigra, stria gravidarum

• Umbilicus- normal, everted or inverted

• Uterine Ovoid- longitudinal, transverse or oblique

• Dilated veins, hernial sites, any surgical scar mark

• Abdominal wall edema

• Fundus/ suprapubic region- convex or flattening

OBSTETRIC EXAMINATION

FUNDALHEIGHT AT DIFFERENT WEEKS OF PREGNANCY

Should be gentle

Dextrorotation to be corrected

Assessing fundal height – using

the ulnar aspect of hand, moving

downwards from xiphisternum

PALPATION

Symphysio-fundal height – between 20-34 weeks, SFH in cm roughly corresponds

to weeks of gestation

– Distance between the upper border of pubic symphysis and top of fundus

– A difference of ± 2 cm is normal

– Gravidogram is a simple, inexpensive screening method in low-resource

setting, recommended by WHO

Abdominal girth – at the level of umbilicus, taken in inches,

after 30 weeks – correspond to POG in weeks

JOHNSONS FORMULA-

• Fetal weight is estimated

• Fetal weight(grams) =( SFH(cm) – 12 ) × 155(unengaged head)

• Fetal weight(grams) = (SFH(cm) – 11) × 155(engaged head)

LEOPOLD’S MANOEUVRES

• THIRD MANEUVER –

PAWLIK GRIP

• FOURTH MANEUVER –

PELVIC GRIP

Effective fetal weight - Johnson method

Palmar method

Amount of liquor –• Normal liquor – fetal part easily palpable

• Increased liquor – difficulty in palpation

• Decreased liquor – full of fetus

Uterine contractions

AUSCULTATION : FHS with bell or diaphragm of

stethoscope or Pinard’s fetoscope or hand held Doppler

ULTRASOUND • Early pregnancy (10-13 weeks )to

• Determine gestational age

• Detect multiple pregnancies

• At 11-14 weeks

• Offer nuchal translucency screening for downs syndrome

• At 18-20 weeks

for screening congenital anomalies.

At 36 weeks

For fetal maturity , placenta previa

IMMUNIZATION• TETANUS TOXOID – Safe and mandatory

• 1st dose at first visit and second dose 4 weeks later.

• If already taken within 3 years, then booster dose.

• TT has been replaced with tetanus and adult diptheria (Td) vaccine

nowadays.

SAFE ONLY IN EPIDEMICS CONTRAINDICATED

TETANUS TYPHOID RUBELLA, MMR

HEPATITIS CHOLERA BCG, YELLOW FEVER

RABIES VARICELLA

MEDICATIONS

NURTRITION THERAPY-

• The increased calorie requirement is to extent of 300 over non pregnancy state during second half of pregnancy.

• Foods to avoid during pregnancy:

– High mercury fish e.g. shark, tuna (especially albacore tuna)

– Fatty fish has omega 3 fatty acids which are healthy

– Avoid raw fish as infections like listeria can cross placenta lead to premature delivery, miscarriage and still birth

– Raw eggs may be contaminated with salmonella infection

– Caffeine <200 mg per day (2-3 cups of coffee), it crosses placenta and high levels in fetus lead to LBW, FGR

– Raw papaya avoided as it has latex which leads to premature delivery

• SLEEP – the patient should be in bed for 10 hrs (8 hrs at night and 2 hrs at noon) especially in last 6 weeks.

• DENTAL CARE- good hygiene should be maintained. Excessive bacteria form oral infections can enter blood stream and cause premature delivery

SMOKING AND ALCOHOL-

• Smoking causes low birth weight babies and increases

chances of abortion . Similarly , alcohol be avoided to

prevent maldevelopment and growth restriction.

• TRAVEL-

• It should be avoided in first trimester and last 6 weeks. Air

travel is contraindicated in cases with placenta previa , pre-

eclampsia, severe anemia, and sickle cell disease.

• Prolong sitting should be avoided due to risk of venous

stasis and thromboembolism.

DANGER/WARNING SIGNS

• High fever with /without abdominal pain

• Difficulty in breathing

• Decreased or absent fetal movement

• Excessive vomiting

• Any bleeding per vaginum

• Severe headache with blurred vision.

• Convulsion or loss of consciousness.

• Preterm labour

• PROM

• Good antenatal care includes regular screening

• Can detect high risk pregnancy

• Prevent early complications

• Antenatal visit can be individualised for high risk

• Women with complicated pregnancies may require frequent

visits

SUMMARIZE

POSTNATAL CARE :-• Postpartum care encompasses management of mother, newborn and

infant during post-partum period.

• It refers to 6 weeks following childbirth, during which pelvic organs

return to prepregnant state and physiological changes of pregnancy

are reversed.

• Immediate – within 24hrs

• Early- up to 7 days

• Remote – up to 6 weeks

OBJECTIVES OF POSTNATAL CARE -

• To prevent complication of post-partum period.

• To provide care for rapid restoration

• To check adequacy of breast feeding

• To provide contraceptive/ family planning advise

• To provide health education to mother/ family.

POSTPARTUM ASSESSMENT-

VITAL SIGNS – The temperature should not be above 99 f within first 24 hrs

after delivery.

On 3rd day slight rise of temperature due to breast engorgement which should

not be more than 24 hrs.

Genitourinary tract infection should be excluded if there is rise of temperature.

LOOK FOR BP- HYPOTENSION, HYERTENSION OR BRADYCARDIA

PATHO-PHYSIOLOGY OF POSTPARTUM PERIOD

• Involution – rapid reduction in size of uterus to pre

pregnant state within 6 weeks.

• Contraction cause uterine muscles to act like living

ligatures and compress blood vessels. It is caused by

sudden withdrawal of estrogen and progesterone.

• Uterus become a pelvic organ by the end of 2nd week.

• Vagina –it takes 6-10 weeks to involute.

LOCHIA-

• It is vaginal discharge for first fortnight during puerperium.

• Lochia rubra (1-4 days )- it consist of blood, shreds of fetal

membrane and decidua, vernix caseosa .

• Lochia serosa (5-9 days )- it consist of ;less RBC but more

leukocytes , wound exudate, mucous from cervix and micro-

organism. The presence of bacteria is not pathogonomic

unless associated with clinical signs of sepsis.

• Lochia alba (10-15 days )- it consist plenty of decidual cells,

leukocytes, mucus, cholesterin crystals, fatty and granular epithelial

cells and microorganism

POSTNATAL VISIT FOR MOTHER AND NEW BORN -

•First visit (could be a home

visit)

within 1 week, preferably on

day 3

•Second visit 7-14 days after birth

•Third visit 4-6 weeks after birth

SCHEDULE OF POSTNATAL VISITS FOR MOTHER AND NEWBORN

PROBLEMS DURING POSTPARTUM PERIOD

DANGER SIGNS

• Signs and symptoms of PPH: sudden and profuse blood loss or persistent

increased blood loss, faintness, dizziness, palpitations/tachycardia.

• Signs and symptoms of pre-eclampsia/eclampsia: headaches accompanied by one

or more of the symptoms of visual disturbances, nausea, vomiting, epigastric or

hypochondrial pain, feeling faint, convulsions (in the first few days after birth).

• Signs and symptoms of infection: fever, shivering, abdominal pain and/or offensive

vaginal loss.

• Signs and symptoms of thromboembolism: unilateral calf pain, redness or swelling

of calves, shortness of breath or chest pain.

BREAST ASSESSMENT-

• Breast should be soft, non tender , warm upon palpation.

• Secrete colostrum for 1st 2-3 days yellowish fluid enrich in

protein and antibody to provide passive immunity and nutrition.

• Nipple soreness- it is avoided by frequent short feedings rather

than prolonged feeding, keeping nipple clean and dry.

• Nipple confusion – it is a situation where infant accepts artificial

nipple but refuses mothers nipple. It is avoided by making

mothers nipple more protractile

PSYCHIATRIC DISORDERS-

Puerperal blues

• Transient state of mental illness ( 4-5 days- few days)

• Occurs in 50 % of postpartum women.

• Manifestation are- Depression , anxiety, tearfulness, insomnia,

negative feeling towards infant .

• Treatment – reassurance, psychological support

PSYCHIATRIC DISORDER

Postpartum depression

• Occurs in 10-20% of women

• Gradual in onset over first 4-6 month following delivery

• Manifestation – loss of energy and appetite, insomnia, social withdrawal ,

suicidal attempt.

• Risk of recurrence is high

• TREATMENT – Serotonin reuptake inhibitors like fluoxetine or paroxetine is

effective .(good prognosis )

POSTPARTUM PSYCHOSIS

• Occurs in 0.14- 0.26 % of mothers. ( sudden, within 4 days)

• Manifestation – fear, restlessness, confusion followed by

hallucination, delusion, disorientation.

• Risk of recurrence is 20-25 %.

• Treatment – hospitalization is needed. Chlorpromazine 150 mg stat

ECT if it remains unresponsive

• Lithium is indicated in manic depressive psychosis in that case

breast feeding is contraindicated

POSTPARTUM CONTRACEPTION-

• Counsel prior to delivery

• Basket contains

Lactation amenorrhea method

IUCD

Ligation

Progesteron (DMPA)

Condoms

•

THANK YOU