Preconception Care and Treatment Issues in Pregnancy Flashcards
preconception health
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Preconception Care
Obviously diet, looking at their diet, maintaining a well balanced diet, exercising, ceasing smoking. These are all lifestyle things. Avoiding alcohol intake completely. Seeing if there are certain drugs that illicit drugs or whatever ceasing that obviously reducing environmental toxin exposures. If there’s exposure to that, reducing stress and managing stress, managing chronic medical conditions such as the hypertension, identifying those women that may be at risk for morning sickness and controlling it before maintaining a healthy weight.
folic acid
vaccinated
Preconception Care other nutritional recommendations
Folic Acid:
§ Start 2 – 3 months before pregnancy
§ Duration: continue during pregnancy up
to 4 – 6 weeks after pregnancy or as long
as breast feeding continues
Calcium - 1000 mg elemental calcium (preferably diet, add supplements if
inadequate in diet)
Folic Acid dose recommended:
§ Low risk – 0.4 mg 0.4 is fine for most ppl
§ Moderate risk (family history of neural tube
defects, medications increasing neural tube
defects etc) – 1 mg
§ High risk (previous neural tube pregnancy,
either partner has neural tube defect) – 4 mg
immunizations prior to pregnancy
Which immunizations are important to consider?
avoid , live attenuated vaccine would be what they would need to avoid
Normal weight gain in pregnancy
§ ~5 lb in the first 20 weeks gestation
§ ~1 lb per week after 20 weeks
* Perhaps less if BMI>28
* Perhaps more if BMI<20|
If they have a lot of nausea and vomiting, they may not even gave that much, or they may start getting really hungry with things and then they gave more, but on average is about five pounds. What happens is after that 20 weeks is that when you start seeing that really increase, about a pound per week is normal. One to two pounds per week. And that’s just from fluid and the placenta and the baby growth
less weight gain is recommended if they are overweight or especially if they’re obese the BMIs over 28 on here. And then if they’re low, really low, less than 20, then maybe trying to get more weight gain during that time.
On average, what you’re going to see is about 25 to 35 pounds of weight gain during the whole pregnancy is normal.
Common Complications in Pregnancy
§ Hypertension
§ Thromboembolism in women at risk
§ Gestational Diabetes (see endocrine)
§ Infections
§ Nausea and Vomiting (see GI block)
§ GERD
Hypertension in Pregnancy
§ Pre-existing chronic hypertension
§ Gestational hypertension
§ Pre-eclampsia
§ HEELP syndrome
§ Complicates the pregnancy
§ Interferes with maternal health and fetal development (fetal
growth retardation)
§ Hypertension in pregnancy diagnosis:
* Definition:
* BP>140/90
* Non-severe: BP 140/90 and less than 160/110
* Severe: BP > 160/110
§ BP may go down in first trimester:
One thing to keep in mind is that the first trimester, the blood pressure may actually slightly go down 1st trimester because decrease in peripheral vascular resistance during that first trimester and then it then it gets better after that.
Hypertension Canada Guidelines for the
Management of Hypertension in Pregnancy
Target blood pressure in
pregnancy: <85 mmHg
Antihypertensive Medications in Pregnancy
Note:
Need to assess
risks to benefits
first line: labetalol, methyldopa, long acting oral nifedipine, other BB
second line: clonidine, hydralazine, tzd diuretic
meds to avoid: ACEi, ARBs
we’re going to be avoiding any ACE inhibitors or ARBs with that because you can see the effects on the angiotensin system. There could be greater risk of miscarriage in the first trimester. There could be effects and second and third trimester, especially on renal toxicity in the growing fetus.
Pre-eclampsia
Pregnancy specific onset in hypertension that involves
new onset proteinuria
§ Involves multisystem, occurs 20 weeks of gestation and resolves
following delivery.
§ Hypertension: Mild: BP>140/90, Severe: BP>160/110
* and protein in urine
§ Eclampsia means that a seizure has occurred
HELLP Syndrome
Severe form of pre-eclampsia
Hemolysis, Elevated Liver enzymes, Low Platelets
Treatment of Pre-eclampsia
mild and severe
Mild
§ Conservative, symptomatic treatment
Severe
§ Goal – safely reduce BP to level that maintains fetal perfusion and maternal
cardiac output
§ Intravenous antihypertensive therapy
* Hydralazine or labetalol IV (oral immediate release nifedipine also a
consideration)
§ Seizure prophylaxis – magnesium sulphate
* 4 gm IV (over 15 – 20 min) followed by infusion 1 gm/hr for 24hr
* Monitor neurotoxicity closely
Rarely, if potential negative outcomes for mother pregnancy may need to be terminated.
And you will see magnesium e.g. being given a pretty high doses. This is the loading dose and I’m not expecting you to know the doses for anything but it’s just be familiar. They often give a loading dose. It’s pretty high for grams IV and then an infusion over 24 h. And then we’re just going to be monitoring to make sure that they’re not seeing any kind of neurotoxic events from the magnesium.
Hematologic Changes
§ Consider thromboprophylaxis in women at high risk:
ØPrior VTE,
ØInherited thrombophilia (30 – 50% of cases)
§ Low molecular weight heparin is the drug of choice.
§ Warfarin is contraindicated.
Øteratogenic
Induction of Labour
Ripen the cervix:
§ Prostaglandin E2 (dinoprostone) (ProstinⓇ E2 gel, suppository,
vaginal insert (CervidilⓇ)
§ Misoprostil (synthetic PGE1 analogue, various routes – oral,
vaginal)
Stimulate uterine contractions:
§ Oxytocin
* IV pump infusion
Preterm Labour
between week 22, week 30 of just 37 of gestational age is considered preterm labor.
§ Major problem in obstetrics
* ~9% births in Alberta<37 weeks, 1% <30 weeks
* >75% of neonatal deaths or disability
§ Poor understanding of etiology or pathophysiology.
§ Treatment to prevent preterm labour
* Progesterone – vaginal tablet or gel, also oral
what we do to prevent preterm labor is give progesterone. And the progesterone is the course we’ve talked lots about progesterone and maintaining that uterine lining. It’s so important in maintaining pregnancy
- 17-hydroxyprogesterone caproate – weekly IM injections
Unsure of effectiveness. If short cervix = vaginal progesterone. If previous
history = IM or vaginal
if they have a short cervix, then they’ll, they’ll do more like the vaginal progesterone. If somebody has had a history. Of a preterm labor in a previous delivery, then they’ll gonna be a little more aggressive. And that might be when they give more of an IM progesterone at the time.
