Preconception and Antepartum Care 2025 - PDF

1 Preconception and Antepartum Care WOMEN’S HEALTH - OBSTETRICS SPRING 2025 DR S RYAN  2 NCCPA Blueprint – The Reproductive System: OB u Pregnancy u Gestational diabetes u Uncomplicated Pregnancy u Gestation...

1 Preconception and Antepartum Care WOMEN’S HEALTH - OBSTETRICS SPRING 2025 DR S RYAN  2 NCCPA Blueprint – The Reproductive System: OB u Pregnancy u Gestational diabetes u Uncomplicated Pregnancy u Gestational trophoblastic u Normal labor/delivery disease u Prenatal diagnosis/care u Hypertension disorders in u Complicated Pregnancy pregnancy u Abortion u Multiple gestation u Abruptio placentae u Placenta previa u Cesarean section u Postpartum hemorrhage u Dystocia u Premature rupture of u Ectopic pregnancy membranes u Fetal Distress u Rh incompatibility  3 Topics u Preconception u Prenatal Labs u Diagnosis of Pregnancy u Screening Tests u Maternal Fetal u Diagnostic Procedures Physiology u Assessment of Fetal Well- u Antepartum Care Being u EDD u Patient Education u Common Pregnancy Complaints  4 Objectives u Determine a general approach to the obstetric patient with findings based on history, physical examination, laboratory, or radiologic results. u Discuss the issues commonly seen in pregnant women with emphasis on clinical presentations, diagnosis, and treatment. u Discuss the physiologic changes that occur during pregnancy and understand the implications to the mother. u Describe maternal and fetal physiology during pregnancy. 5  6 To optimize a ♀ health for pregnancy ↓ adverse effects for mother & baby Goals of Discuss folic acid supplementation to prevent Neural tube defects (NTD) Preconception Management While attempting to get pregnant & during first trimester Discuss strict metabolic control for those with Diabetes or phenylketonuria (PKU) Maintain good control of HTN, asthma, thyroid disorders, IBD, seizures and SLE  7 Preconception – Pt Education u Maintain a healthy wt u Lose (or gain) wt if needed u Exercise u Prevent HIV infection u Abstain from tobacco, alcohol, & illicit drug use before & during pregnancy u Avoid pregnancy within 1 month after receiving a live attenuated vaccine (rubella)  8 Pregnancy: Dx PREGNANCY TESTS ΒHCG  9 Pregnancy - Dx u Urine pregnancy test u Qualitative u Positive 4 wks post LMP u Serum pregnancy test u Measures ß-hCG u Qualitative (yes or no) or quantitative (provides a #) u This# helps determine gestational age  10 Pregnancy - Dx u Quantitative βhCG Levels  11 Pregnancy - Dx u Abd US u Gestational sac visualized at 5 - 6 wks u TVUS: u Gestational sac noted at 4.5 – 5 wks gestation u Cardiac activity noted at 5.5 – 6 wks ‪www.cmaj.ca‪www.cmaj.ca  12 Pregnancy - Dx u “Quickening”: pt’s initial perception of fetal movements u Felt at 16-20 wks u Feels like “flutters” u Fetal heart tones with external doppler U/S u Heard at 10-12 wks ‪www.medicalexpo.com  13 Pregnancy - PE u Chadwick’s sign: bluish discoloration of cervix, vagina & labia u At 8-12 wks u Hegar’s sign: softening of cervix at 6 wks  14 Maternal Fetal Physiology * at umbilicus &20whs  15 Earliest & most dramatic changes occur in the CV system (hyperdynamic) Blood volume ↑ at 6-8 wks Peaks at 45% at 32 wks Maternal gestation Physiology CO ↑ by 30-50% CO may ↓ late in pregnancy due to pressure from the gravid uterus Venous return from the IVC can be impeded Esp in the supine position  16 At term, > 1/5 of CO goes thru the uterus ↑↑ risk of postpartum hemorrhage Maternal During uterine contractions of Physiology labor, CO ↑ approx 40% > than in late pregnancy CO ↑ significantly immediately after delivery Venous return to the heart is no longer impeded by the gravid uterus Extracellular fluid is quickly mobilized  17 Normal (hyperdynamic) findings on PE: Maternal ↑ 2nd heart sound split with inspiration Physiology Distended neck veins Low grade systolic ejection murmurs HR ↑ 10-15 BPM above normal Diastolic murmurs should always be further evaluated if found during pregnancy  18 Maternal Physiology u Pregnant women > 20 wks gestation should be managed in a left lateral position (15–30°) to reduce aortocaval compression by the gravid uterus u OR, the uterus may be manually displaced  19 Lungs: 15% ↑ in O2 demand 25% ↓ in functional residual Maternal capacity Physiology Hematology: Hypercoguable State ↑ in plasma volume, red cell volume & coag factors (factors VII, VIII, IX, XII)* 1000 mg of additional iron is needed  20 *Pregnancy is considered a hypercoagulable state Cancer Another is...  21 Renal system: Enlarges due to increased renal blood flow Maternal GI system: Physiology Stomach & intestines are displaced as uterus enlarges Progesterone lowers esophageal sphincter tone→ reflux Morning sickness (at 4-8 wks of gestation) Related to ↑ levels of hormones Hemorrhoids can develop  22 Maternal Physiology  23 Maternal Physiology u Pregnancy is considered a hypercoagulable state u ↑ to 5.5x the normal risk u Likely an adaptive mechanism to reduce risk of hemorrhage during & after delivery DIC  24 Fetal Physiology Placenta – O2 & CO2 exchanged here crucial connection btwn Glucose from mother is mother & fetus used for metabolism Fetal blood is oxygenated in Fetal lungs are bypassed the placenta, not until birth the lungs 25  26 Fetal Physiology – Patent Ductus Arteriosus (PDA) u Connects main pulmonary artery to left branch of proximal descending aorta u Allows most of the blood from RV to bypass the fetus's fluid-filled, non- functioning lungs u Abnormal if it remains after the neonatal period  27 Fetal Physiology – Foramen Ovale u Allows blood to enter the LA from RA u 1 of 2 fetal cardiac shunts, the other being the ductus arteriosus (allows blood that escapes to RV to bypass pulmonary circulation) u Normally closes as BP rises in the left side of the heart after birth  28 Fetal Physiology – Ductus Venosus u Shunts a portion of left umbilical vein blood flow directly to IVC u Allows oxygenated blood from placenta to bypass the liver u Closes approx 1 week after full term birth  29 2 umbilical arteries ↓ umbilical vein  30 1) 1-13 2) 14-27 3) 28 - 40 Trimesters  31 Antepartum Care  32 Antepartum Care – First Visit u History u Ob & GYN Hx u PMH u Diet; meds; tobacco/ EtOH/ illicit drug use; activity level u Risk assessment u Physical exam u Pelvic exam  33 Antepartum Care – First Visit u Routine labs: u STIs u Blood type (ABO) & Rh factor u HIV testing (unless u CBC refused) u Cervical cytology (Pap) u Hepatitis B (surface in women > age 21 antigen) and Hep C u U/A, urine culture u TB u Rubella titer  34 Routine US u Info provided: u Fetal # u Fetal lie u Biometry – measures fetal dimensions to estimate fetal age & weight u Documents fetal cardiac activity u Placenta appearance & location u Surveys fetal anatomy u Assesses amniotic fluid volume  35 Fetal Lie u Refers to position of the fetus in the womb in relation to the mother & uterus u A vertical orientation (baby's spine is parallel to the mother's spine (longitudinal lie) ↳ most commo u MC position u The position may be horizontal (transverse) u Or at an incline (oblique)  36 Determining Gestational Age (EDD) u EDD – Estimated Date of Delivery u Gestational age - # of wks from 1st day of LMP to current date  37 Determining EDD u Typical pregnancy: 40 wks +/- 2wks uNagel’s Rule: LMP* + 1 yr, – 3 mos, + 7 days ‪www.datascales.com.au 38  39 Determining Gestational Age u U/S - most accurate u +/- 1 – 2 wks u US is repeated after approx 36 wks gestation as EDD gets closer ‪www.medison.ru  40 Office Visits occur: Every 4 wks until 28 wks Every 2 wks from 30-36 wks Weekly after 36 wks Antenatal Evaluation History at each visit: Vaginal bleeding or discharge? Nausea/vomiting? Dysuria? Decreased fetal movements?  41 U/A for glucose, protein & ketones at every visit Antenatal Evaluation PE at every pre-natal visit: Maternal BP, weight Assess for edema* Esp facial edema (more worrisome) FH tones  42 Fetal Heart Tones u Good indicator of fetal well being u Audible at: u Approx wk 10 gestation by US u At 8 - 14 wks gestation via fetal doppler Won't ask timeline  43 PE Findings u From 18-20 wks, assess uterine size via bimanual exam u State as # wks size (e.g. 12 weeks) u After 20 wks, measure fundal height using tape measure  44 Fundal Height ‪www.ttuhsc.edu 45  46 PE Findings u Measure FH tones via external doppler u Normal: 120-160 BPM u After 34 wks, palpate for fetal presentation u Cephalic (head down) – head is hard u Breech (bottom down) – bottom is soft ⑨ facetoward mom's back  47 Refers to the part of the fetus’s body that leads the way out thru the birth canal (called the presenting part) Fetal Head first is MC ~ MostCommon Presentation Buttocks (breech presentation), shoulder, or face can present first  98 (not -Em good, 180 (not good) 48  49 AKA: perinatology MFM – A branch of medicine that focuses Maternal on managing health concerns of the mother and fetus prior to, Fetal during, and shortly after pregnancy. Medicine Maternal–fetal medicine specialists are physicians who subspecialize within the field of obstetrics.  u Coordinate care for pregnant women with: u Heart disease u HTN u Preeclampsia u Diabetes & other endocrine MFM disorders u Kidney or GI disease u Infectious diseases (flu, strep throat, stomach virus, etc) u High risk pregnancies u Medical, surgical, obstetrical, fetal, or genetic issues 50  u Pts to be referred: u Those with a pre-existing medical condition u Those who develop a medical condition during pregnancy u Those who develop problems MFM during delivery u A fetus with an anomaly u Work up can include: X u Fetal MRI u Ultrasound u Fetal EKG u Genetic tests 51  52 Prenatal Labs LAB TESTS DIAGNOSTIC PROCEDURES  53 Initial Assessment u By end of 1st trimester*: Optional u Fetal nuchal translucency plus PAPP-A (pregnancy associated plasma protein A) OR free or total β-hCG u Screens for Trisomy 21, 18 & 13 (recommended but optional) u 15-18 wks: u Maternal serum (MS) AFP u Screens for open neural defects u 15-20 wks: u Quad screen (serum β-hCG, unconjugated estriol, AFP, inhibin) u Only done if first trimester screening is missed  54 Nuchal Translucency Enlargement of the hypoechoic space in the posterior fetal neck is associated with increased risk of Down syndrome & other fetal abnormalities  55 hCG µE3 AFP Inhibin A (estriol) Quad Open spina Normal Normal High N/A Screen bifida Anencephaly Low Low High N/A Down High Low Low High syndrome (Trisomy 21) Edwards Low Low Low N/A syndrome (Trisomy 18)  56 Screening tests assess the risk of having common birth defect(s) Cannot tell whether the fetus actually has a birth defect There is No risk to the fetus Dx tests can detect many, but ACOG not all, birth defects. 2020 May be done instead of screening if a couple: Has a +FH of a birth defect Belongs to a certain ethnic group, or Already has a child with a birth defect. Available for all pregnant women, regardless of risk factors. Can involve a small risk of pregnancy loss (CVS, amniocentesis)  u Screening & testing for birth defects are a personal choice*. u Some do not want to know if they are at risk of having a child with a birth defect or whether their child will have a birth defect. ACOG 2020 u Others want to know. u Allowsfor the option of deciding not to continue the pregnancy. u Ifpregnancy is desired, allows for time to prepare for a child with a disorder. 57  58 For prenatal Dx of genetic disorders e.g. Down’s Syndrome Chorionic Samples of the placenta are obtained for Villus chromosome or DNA analysis Sampling Same info as amniocentesis but faster (CVS) 1.3% risk for fetal loss within 30 days Safer than early amniocentesis 2 methods: Transcervical; Transabdominal  59 Transcervical CVS  60 Transabdominal CVS  61 Possible after 11 wks gestation Procedures performed before15 wks are associated with higher fetal loss Amniocentesis Common indications: Prenatal genetic Assessment of studies fetal lung maturity Reported rates of fetal loss range from 1/100 - 1/1000  62 Amniocentesis u Withdraws amniotic fluid from uterine cavity by needle via a transabd approach  63 ACOG explains: Prenatal Genetic Testing u https://www.youtube.com/w atch?v=MhWpmZIsZxw  64 Assessment of Fetal Well-Being KICK COUNTS NON-STRESS TEST CONTRACTION STRESS TEST BIOPHYSICAL PROFILE (BPP)  65 Subjective – fetal movements are assessed by the mother Kick counts Assessing Fetal Well- Objective - if problems are suspected, or with multiple risk Being factors, Fetal monitoring tests can include: Non-stress test (NST) Contraction stress test (CST) 4 Oxytocin challenge test (OCT) Biophysical profile (BPP)  66 Kick Counts* u 10 fetal movements during 12 hrs of normal maternal activity u 4 - 5 fetal movements in 1 hr when the mother is at rest and focused on counting  u Uterine contractions are always present during pregnancy u Vary in amplitude, frequency, & duration u Continuous fetal Fetal monitoring tracks the FHR with the Monitoring occurrence of uterine contractions u The relationship btwn these 2 correlates with the oxygenation status of the fetus 67  68 A reassuring fetal monitor pattern should show variability (5 – 25 bpm) from baseline with concurrent contractions Aim - to see some movement Fetal in the fetal HR w/o MAJOR Monitoring upswings, or downswings, from baseline Variability is good – the fetus is not in distress.  u NST - noninvasive method to assess fetal health u Records baby's movement & heartbeat, in Non-Stress response to Test (NST) contractions* by use of an external monitor u Performed after 26-28 wks or prn 69  70 Non-Stress Test (NST) u External transducer monitors FHR in response to fetal activity u Lasts approx 20 – 30 min u Reassuring: ≥ 2 HR accelerations (15 BPM above baseline, lasting 15 sec) in 20 min 71  72 Contraction Stress Test (CST) - done after an abnorm NST (after 34 wks gestation or prn) Abnormal Can be done more than once Oxytocin may be used (Oxytocin NST Challenge Test) Results Measures FHR in response to uterine contractions BPP - uses US during a NST to evaluate a fetus Used more often than CST 73  74 Fetal Monitor Patterns Explanation u Top left: appropriate variability in accelerations. A u Bottom left: great variability in FHR from baseline, and it recurs. Likely indicates cord compression as the uterus contracts & then returns to baseline with decompression on the cord. V u Tracings on right: show late decels. Both strips are worrisome. The fetus is likely in distress. u Little variability noted with contractions on the top tracing. u Bottom tracing shows a marked drop in FHR AFTER contractions and a lot of variability. This requires further investigation ASAP as baby’s O2 supply is likely impaired. L u Not shown: early decompressions which occur as the head becomes compressed as it starts to engage. E 75  76 Recommended for women at risk of pregnancy loss BPP Goal - to prevent pregnancy loss & detect fetal hypoxia Biophysical Profile Performed after wk 32 Measures: fetal breathing; movement; tone; & amniotic fluid volume  77 Patient Education  78 Antepartum Pt Education u Employment u No strenuous lifting, prolonged standing u Allow for rest periods u Exercise u 30 min/day; moderate exercise u Avoid supine exercises after first trimester 79  u Nutrition u Recommended wt gain: 25 - 35 lbs u Required: Supplemental iron intake Antepartum u Pica – urge to ingest Pt Ed non-nutritional substances u Ice, food starch, clay, dirt u Oftenassociated with anemia 80  81 Air travel ok up to 36 wks Avoid long periods of inactivity Antepartum Meds – follow OB’s advice Pt Ed Avoid all alcohol, tobacco, or substance abuse No restriction in sexual activity in a normal pregnancy  82 Common Pregnancy Complaints  83 Common Sxs During Pregnancy u H/A u Constipation u Edema (feet, ankles)* u Fatigue u Nausea, vomiting u Leg cramps u Hyperemesis u Back pain gravidarum u Varicose Veins u Ondansetron (Zofran) u Doxylamine succinate u Hemorrhoids & pyridoxine HCl (Diclegis) u Vaginal discharge u Heartburn  84 Questions?