PreConception Care 4 Student Version

8/11/2019 PreConception Care 4 Student Version

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Preconception Care:

Providing Fetal/MaternalHealth Risk AssessmentsLecture 4


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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 beforeconception.

Healthy pregnancy closely related to womans health

before conception.

Improves chances for healthy baby.


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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 supportmaternal/infant pre & post natal care ?

IMPORTANT COMPONENTS OF PRECONCEPTION CARE

See a health care provider. Get physical exam.

Discuss risks. Maintain follow-up care. Update

Immunizations


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Prenatal High-Risk Factors

Social/Personal: Low income level, poor diet,multiparity > 3, weight < 100lb; weight > 200lb; age 35; smoking, addictions

Pre-existing medical hx: Diabetes mellitus,cardiac disease, anemia, hypertension, thyroiddisorder, renal disease.

Obstetric: Previous stillborn, habitual abortion,cesarean delivery, Rh or blood groupsensitization. [ABO or Rh incomp.]


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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 infectionscontracted during pregnancy/delivery.

1sttrimester more severe defects


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Current pregnancy: Check titers: vaccines available butmost not during preg.

Toxoplasmosisrare; toxoplasma gondii [protozoal infec]transmitted to mom thru raw meat or exposure toinfected cats 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.Bvaccine & Immunoglobulin @ delivery; followed by 2

more Hep.B vaccines in 1st yr.Syphilisuntreated can cause fetal death. Tx PCN

Repeat VDRL > tx.


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Rubella(1st trimester) 50% rate of malformation.

(2ndtri) 6% rate of damageIf 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


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Cytomegloviruspart of herpesvirus family.

Defects: Mental retardation, hydrocephaly , microcephaly,blindness; deafness.May be picked up during 1styear or > 1 yr of age.

If 1st trimes.infection, may consider AB.

HSV 2 [genital ].Valtrex -suppress lesions; C/S if lesions @me of del. Blindness, MR, death


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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 3mos.of vaccine. Live virus. SC injection


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HIV: test done in NYS to all newborns - NewbornScreening Test

36% of HIV-infected women using illicit drugs duringpregnancy 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 & ACOGsupport policy of universal HIV testing as routinecomponent of prenatal care. [2001]

Retest for HIV in 3rdtrimester (new practice)


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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 riskof 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. New (2003): 3 drug tx reduces rate to 1-2 %. Start in

2ndtrimester. For viral load > 1,000.

Woman must deal with guilt, depression, stigma.


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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


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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

Interventions: Support bra with wide shoulder straps;jacket/sweater.


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Urinary Frequency & Urgency Causes: pressure of uterus on bladder; lasts 3 mos. &

disappears; reappears in late preg. when head isengaged. + blood/burning on urination - signs of UTI.

Interventions: UA & urine Cx & Tx with AB. Reduce caffeine. Do Kegels. 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 notampons, tight pants or underwear > infection.Pruritis/erythema - poss. fungal infection.


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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.


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Hemorrhoids [varicosities rectal veins]

Causes: Pressure on pelvic veins; in ^ 3rd trimesInterventions: modified Sims position; stool softeners;witch hazel/cold compresses.

ConstipationCauses: oral iron supplements; peristalsis;displacement of bowels by fetus.Interventions: No mineral oil; interferes with vitaminmetabolism. ^ po fluids; ^ roughage; attempt regularBMs.


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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; dont bend.Firm mattress; heat therapy; Tylenol.

Leg Cramps Causes:Pressure from enlarging uterus, poor

circulation; fatigue, Ca & Phosphorus

Interventions: dorsiflex affected foot; elevatelegs. Aluminum hydroxide [Amphogel] binds

phosphorus & reduces it in circulation.


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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 EdemaCauses: fluid retention & poor venous return from

ower extremities; aggravated by prolonged sitting orstanding & warm weather. Occurs near term.Interventions: ^ legs, avoid tight fitting pants


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CONTROLLABLE RISK FACTORS

Nutrition: Know ideal weight for your height. Instructclient to keep food diary. Examine food choices in dailydiet.

If underweight/overweight before conception, counsel aboutproper nutrition.

Calcium/zinc- beneficial for long-term health needs &growth/development of baby.

Folic acid:protects against neural tube defects aka spina bifida.


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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 withbones, soy milk, OJ, legumes.


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US Public Health Service & March of Dimes recommends allwomen 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.


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Nutrition

RDA: add 300 kcal in 2nd& 3rdtrimester. 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 dailyrecommended intake; * teens < 19 need 1300mg./day.


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Vegetarianism

Vegen dietno food from animal sources (eggs,fish, chicken) most challenging for health careproviders.

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. Cannedlight tuna, shrimp, salmon, catfish is ok.

No swordfish, shark, tilefish, king mackerel (highmercury)


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Lactose intolerance or cultural avoidancecan leadto lowered calcium intake; recommend yogurt, cheese,sardines, beans, collard greens, figs, OJ, tofu, Lactaid.(commercial lactose).

* Few demands placed on maternal nutrition in 1sttrimester.

RDA fluids= 6-8 glasses (1500-2000 ml); water, milk,

juices. > 200mg caffeine daily doubles risk for miscarriage

1 cup ~ 100 mg ~ 250ml


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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 6lbs. in 1st trimester, 1.5 pounds per week in 2ndand 3rd trimester, for total of 35 to 45 lbs.


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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, womenfrom 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. Folic Acid for ^ RBC production. 50% more in

pregnancy (800 ug/day); enriched grain products.


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Controllable Risk Factors: Drug, Alcohol,Tobacco Use

Alcohol:. Avoid all alcohol during timeattempting conception/pregnancy.

No known safe level during pregnancy.Associated

with malformation, slow fetal growth, fetal death, lowbirth-weight, CNS abnormalities, neurologicaldefects,spontaneous abortion, abruption.

Tobacco: Associated with spontaneous abortion,ectopic pregnancy; low birth-weight, infant mortality.Can potentially decrease fertility. Vasoconstrictionrestricts blood flow to fetus & reduces % of oxygen& nutrients carried by blood.


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Illicit or Street Drugs: May be associated with

severe medical & developmental problems innewborns.

1. Marijuana, most common - tend to have babiesearlier & may be smaller than term babies.

2. Cocaine: associated with miscarriage, abruption, lowbirth-weight, premature birth, brain damage.

3. Heroin - IV drug users - evaluate for AIDS & HepB. In HIV + women, studies show treatment with

AZT reduces ransmission to baby from ~ 25% to8%.


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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 to102F if women stayed in tubs for up to 15minutes. ^ risk of neural tube defects inoffspring.


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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 hr.with frequent rest periods aday.


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Common STDs & effects to baby if untreated:

Chlamydia: Ear/eye infections, pneumonia. Genital Herpes: Active infection - baby born thru

vaginal opening with open soresleads to severe skininfections, 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, blood vessels

Other Infections that can cause PTL: UTI & BV


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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 home/work. Paint Thinners, Varnish Removers, Cleaning Solvents, Glue

X-rays, Radioactive materials, Cat litter (toxoplasmosis)

Leave job with questionable hazards.

Use protective equipment/safety protocols.


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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 areconsidered. Animal studies have shown adversereaction; no human studies available

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)


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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 planning.


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Age is a Big Factor

Teenagers and Women over 40 years - greatestrisk.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 samechances as younger women for healthy

pregnancy outcome.


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TEENS: more likely [than women in 20s] to have

labor, delivery & low-birth-weight problems.

Almost half of all pregnant teens do not get prenatalare in 1st trimester of pregnancy.

Teens less likely to gain appropriate weight & oftenractice unhealthy eating habits.

PreConception Care 4 Student Version

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