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Preconception Care:

Providing Fetal/Maternal
Health Risk Assessments
Lecture 4
Preconception Planning
Important because:
Offers best protection against low birth-
weight &
other poor pregnancy outcomes.
1989 - 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.
Preconception counseling:
 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
 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
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 ?
IMPORTANT COMPONENTS OF PRECONCEPTION
CARE
 See a health care provider. Get
Prenatal High-Risk Factors
 Social/Personal: Low income level,
poor diet, multiparity > 3, weight <
100lb; weight > 200 lb; age <16;
age >35; smoking, addictions
 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.
 “TORCH” special group of infections”
 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.
 Can cause stillbirth.

 Infection causes few symptoms in


pregnant woman.
 In infants - serious birth defects result if
infections contracted during
pregnancy/delivery.
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 & Immunoglobulin @
delivery; followed by 2 more Hep.B
vaccines in 1st yr.
Syphilis – untreated can cause fetal death.
Rubella
(1st trimester) 50% rate of
malformation.
(2nd 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
Cytomeglovirus – part of herpesvirus family.
Defects: Mental retardation, hydrocephaly ,
microcephaly,
blindness; deafness.
May be picked up during 1st year or > 1 yr of age.
If 1st trimes.infection, may consider AB.

HSV 2 [genital ]. Valtrex - suppress lesions; C/S


f lesions @ time of del. Blindness, MR, death
Vaccines you can get during
pregnancy:
 Tetanus & influenza vaccine [flu]

 Rubella vaccine: only after delivery

 If equivocal [aka borderline] pt. gets


vaccine.
 MD order, consent signed by pt.

 Explain risks of birth defects


pregnant within 3 mos.of vaccine.
Live virus. SC injection
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.
 # of infants with AIDS (d/t perinatal
transmission) declined from 122 in 2000
to 47 in 2004. (CDC)

 CDC, AWHONN, Institute of Medicine &


ACOG support policy of universal HIV
testing as routine component of prenatal
care. [2001]
 Retest for HIV in 3rd trimester (new
practice)
 Do ELISA (screen) then Western Blot
(confirm).
 Seroconversion: Usually by 12-22 days
after infection. All by 6 mos.
 Offer HIV test @ initial visit. Mom can
refuse.
 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 begun @ del. or only to newborn, rate
= 15%.
 Treat in antepartum, intrapartum & infant
x 6 weeks.
 Monotherapy (ZVD) for viral load < 1,000.
Common Discomforts of
Pregnancy

1st Trimester

Nausea & vomiting


 Causes: hormonal, fatigue, changes
in carb metabolism
 Interventions: sm. freq. meals; eat
slow; dry toast ; deep breaths.
 Ends by 2nd trim; if severe,
hospitalize & hydrate
Nasal Stuffiness:
Causes: edema of nasal mucosa d/t ^
estrogen levels

Interventions: saline drops; humidifier.


Pseudafed 2nd/ 3rd trimester.

Breast Enlargement & Tenderness [cold


weather]
Causes: ^ estrogen & progesterone
levels
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.
 Interventions: UA & urine Cx & Tx with
AB.
 Reduce caffeine. Do Kegel’s. Plan
frequent BR stops.

Increased vaginal discharge: “leukorrhea”


 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.
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.
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; ^
Backache: *R/O UTI 1st
 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.

Leg Cramps
 Causes:Pressure from enlarging
uterus, poor circulation; fatigue, ↓
Ca & ↑ Phosphorus
 Interventions: dorsiflex affected
foot; elevate legs.
 Aluminum hydroxide [Amphogel]
Shortness of Breath : Dyspnea
Causes: pressure of uterus on diaphragm
&
compression of lungs; more @ night when
flat.
Interventions: 2-3 pillows @ night; sitting
upright.

Ankle Edema
Causes: fluid retention & poor venous
return from lower extremities;
aggravated by prolonged sitting or
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.
 Calcium/zinc - beneficial for long-term health
needs & growth/development of baby.
 Folic acid: protects against neural tube defects
aka spina bifida.
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.
 US Public Health Service & March of Dimes
recommends all women of childbearing age -
0.4 mg [400mcg] of folic acid daily - reduce risk
of neural tube defects. No more than 1 mg.
 Supplement Folic Acid intake if you
are:
 Of child bearing age
 Planning pregnancy

 800-1000 mcg daily during pregnancy

PNV contain all requirements needed for


pregnancy
including folic acid & iron.
Nutrition

 RDA: add 300 kcal in 2nd & 3rd trimester.


 Total Calories = 2500kcal/day (pregnant);
2200 non-pregnant
 Underweight clients >300 kcal. increase.
(~ 2800 kcal/day)
 RDA for protein/minerals/vitamins: ^ 60
g./day
 Daily iron requirement doubles in preg.
(15 to 30 mg)
 Minerals (Ca, phos, iodine, Fe, Z) from
fruits/veg.
 Calcium/phosphorous stays same if client
follows daily recommended intake; *
Vegetarianism
 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.
 May be anemic & not get enough
calories.
 FISH: up to 12 oz/wk of low mercury fish.
Canned light tuna, shrimp, salmon,
 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 1st trimester.
 RDA fluids = 6-8 glasses (1500-2000 ml);
water, milk, juices.
 > 200mg caffeine daily doubles risk for
miscarriage
 1 cup ~ 100 mg ~ 250ml
Weight Gain (new slide)

 Women of Normal weight: 25 - 35 lbs.


(11.5 - 16 kg)

 Underweight women: 28 - 40 lbs.


(12.6 - 18 kg)

 Overweight women: 15 - 25 lbs. (7 -


11.5 kg)

 Twins or Multifetus: woman should


gain 4 to 6 lbs. in 1st trimester, 1.5
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 done @ prenatal visits.
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.

Tobacco: Associated with


spontaneous abortion, ectopic
pregnancy; low birth-weight, infant
mortality. Can potentially decrease
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%.
Exercise in Moderation
 Boosts self-image, reduces tension,
decreases physical discomfort.
 Get medical clearance before starting
exercise program.
 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.
 Recommended: walking, cycling on
stationary bike, swimming
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
Stress Management
Techniques
 Relaxation & deep breathing.
Planning pregnancy can be
stressful.
 Stress reduction enhances
chances of conception.
 Excessive stress can lead to premature
birth & low birth weight. Sleep 8-10
Common STDs & effects to baby if
untreated:

 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 Warts: (If infection is active
during delivery): Warts can grow in voice
box & block windpipe.
 Gonorrhea: Eye Infections, blindness.
 Syphilis: Damage to bone, lung, liver,
Exposure to Contraceptives
 Controversial adverse effects on fetus. Do not
use.

Prescription and Over-the-Counter


Drugs
 Often unsafe during pregnancy: Accutane (acne)
birth defects.
 Avoid drugs used for headaches/common colds.

Environmental Reproductive
Hazards
Avoid unnecessary environmental risks at
FDA Pregnancy Risk
Category for Drugs
 Category A: no risk to fetus in any
trimester
 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 D: Definite fetal risks, may
be given in spite of risks in life-
threatening situations
Male Role in Preparing for Pregnancy
Male planning to become father
should:
 Review family medical & genetic hx

 Practice STD risk-reduction


behaviors.
 Avoid tobacco, alcohol, illicit/street
drugs, chemical exposure.
 Assess financial status.

 Be supportive of partner.

 Play active role in pre-pregnancy


Age is a Big Factor

Teenagers and Women over 40


years - greatest risk.
Women over 40 years
 Have decreased fertility.
 Have increased risk for Downs
Syndrome
& hypertension.
 Should talk with health care
provider about Prenatal testing.
 Healthy pregnant women > 40 yrs
who follow recommended practices
have about same chances as younger
TEENS: more likely [than women in 20’s]
to have
labor, delivery & low-birth-weight
problems.

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