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Antenatal care presents preventive medicine opportunities par excellence and is the ideal time to develop an optimal therapeutic relationship with the expectant mother.
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General nutritional or lifestyle advice
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Discourage smoking, alcohol, drugs (note: fetal alcohol syndrome is a leading cause of mental retardation)
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Check rubella immune status
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Consider genetic issues—family and personal issues
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Folic acid—about 3 mths prior to conception 0.5 mg (o)/d, those at risk of neural tube defect 5 mg (o)/d; continue in first 3 mths of pregnancy
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Careful history, physical examination
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Establish date of confinement
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Investigations (Table O2)
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Visits during pregnancy
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Average is 12 but some recommend as few as 6 or 8.
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Initial in first trimester: 8–10 wks
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Up to 28 wks: every 4–6 wks
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Up to 36 wks: every 2 wks
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36 wks–delivery: wkly
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weight gain
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blood pressure
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urinalysis (protein and sugar)
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uterine size/fundal height
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fetal heart (usually audible with stethoscope at 25 wks and definitely by 28 wks)
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fetal movements (if present) patients to record date of first
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presentation and position of fetus (third trimester)
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presence of any oedema
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The first trimester maternal serum screening test (MSST)
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(to identify risk for Down syndrome and other fetal abnormalities)
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A new test, the free fetal DNA test (for chromosomal and genetic abnormalities), done on a maternal blood sample at about 10–12 wks, is now available but expensive.
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The second trimester MSST
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This is a blood test done at 15–16 wks: it is a triple or quadruple test. It is less useful for chromosomal abnormalities but the 2 fetoprotein assessment defines the risk of a neural tube defect.
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Management of specific issues
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Medication (for severe cases): pyridoxine 25–50 mg bd or tds
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If still ineffective add: metoclopramide 10 mg tds
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Wear supportive pantyhose (not elastic bandages). Keep to ideal weight.
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Mineral supplements in pregnancy
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Iron is not routinely recommended for pregnant women who are healthy, following an optimal diet and have a normal blood test. Those at risk (e.g. with poor nutrition) will require supplementation—at least 150 mcg. Aim to keep vitamin D levels >70 nmol/L. Increase iodine intake, e.g. iodised salt.
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Pregnancy–induced hypotension
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Due to increased peripheral circulation and venous pooling. Advise avoiding standing suddenly and hot baths. This may cause syncope. Fainting may occur with lying on back in latter half of pregnancy (supine hypotension), so encourage to lie on left side.
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Pregnancy–induced hypertension
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Commonly used medications:
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Beta–blockers, e.g. labetalol, oxprenolol and atenolol (used under close supervision and after 20 wks gestation)
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Methyldopa: good for sustained BP control
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Diuretics and ACE inhibitors contraindicated.
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Physiological breathlessness of pregnancy
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Consider with unexplained dyspnoea which is constant and aggravated by exercise, in 2nd trimester. No special treatment is needed or helpful.
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Transmissible infections in pregnancy
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In utero infection causes fetal clinical disorders up to 19 wks. Screening for rubella IgG positivity. If –ve, at risk.
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Diagnosis: 4-fold rise in IgG or +ve IgM (recent infection)
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Vaccination: routine vaccination → 95% protection. Do not vaccinate during pregnancy. If inadvertent vacc'n in early pregnancy—negligible risk to fetus. Offer vacc'n to IgG –ve women in puerperium.
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Varicella (chickenpox)
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Greatest risk to fetus is <20 wks gestation and very late pregnancy.
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Diagnosis: +ve IgG antibody test
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Contacts: if –ve IgG give varicella zoster immunoglobulin (VZ-Ig) within 3–4 d.
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Maternal infection (early pregnancy): give course of antiviral, (e.g. valaci-clovir) esp. <20 wks.
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Maternal infection (late pregnancy): greatest risk is 5 days before and up to 4 wks after delivery—30% fetal mortality if infected.
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Consider VZ-Ig for baby if <7d before and up to 4 wks after delivery.
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Isolate mother from baby until not contagious.
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Non-immune are at risk. Miscarriage rate is 4% <20 wks.
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Fetal parvovirus syndrome is anaemia—hydrops fetalis and possible death.
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If infection during pregnancy (IgM +ve) refer for fetal monitoring by US.
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If hydrops consider early blood transfusion.
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CMV is the most common viral cause of birth defects. 1% infection usu. asymptomatic. The fetal effects are variable—mild to severe (up to 30% have mental retardation). There is no therapy or preventive strategy. Consider referral and amniocentesis if fetal infection likely or suspected.
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For infected mother vertical transmission during labour is the concern, esp. if HBeAg +ve. Infected infants have a 90% risk of becoming carriers with liver disease.
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At delivery or ASAP give newborn babies of carrier mothers both Hepatitis B vaccine and immunoglobulin (HBV Ig). This gives ∼90–95% efficacy.
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Screen those at risk at first antenatal visit. If +ve transmission rate to fetus is 5% and much higher if maternal infection during pregnancy. Breastfeeding transmission is unclear. Screen infants at risk at 12 mths and treat +ve cases under specialist care.
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The infection rate from an HIV mother is ∼15–25%. If screening detects HIV and both mother and newborn infant require antiretroviral therapy, refer early. Risk of transmission is reduced by treatment for mother antenatally and during labour and to the neonate for first 6 mths, by elective CS and avoiding breastfeeding.
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Both 1° genital herpes (in particular) and recurrent herpes pose a major risk to the neonate. The risk from 1° infection is greatest >28 wks. Main problem is vertical transmission during labour.
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Perform cervical swabs for HSV infection in patients with previous infection and those with apparent infection in pregnancy.
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Consider prophylactice antiviral, e.g. aciclovir, for mother from 38 wks until delivery—to try to prevent recurrent herpes in late pregnancy.
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Arrange caesarean section if:
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If vaginal delivery, give aciclovir to the neonate (check with neonatal paediatrician).
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Although high community carriage rate of HPV, risk of transmission to fetus is very low and no intervention required.
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If infected, usu. transmitted in 2nd trimester—may cause fetal death or congenital infection with mental handicap. Treat mother with IM benzathine penicillin.
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The concern is neonatal conjunctivitis and chlamydia neonatal pneumonia (usu. 2–3 mths). PCR testing of maternal urine as appropriate and eye swabs from the neonate are advisable with appropriate treatment as necessary.
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These are lower abdominal cramps in 1st 2 wks esp. with breastfeeding. Suspect endometritis if offensive lochia, fever and poor involution of uterus. If not, give paracetamol 1 g 4 hrly prn.
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(IUCD: if used, fit ≥6 wks)
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Lactation amenorrhoea method (LAM)
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LAM is an effective contraception method in the first 6 mths but only in the presence of amenorrhoea. If concerned about pregnancy use an additional method (e.g. condoms).
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Insufficient milk supply
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Due mainly to lactation mismanagement such as poorly timed feeds, infrequent feeds and poor attachment. The milk ejection reflex is essential to establish supply—affected by pain, stress, shyness, lack of confidence.
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Important factors are positioning and attachment to breast and getting the baby to feed often (according to supply and demand).
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Regular feeding and demand feeding is the best treatment.
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Feed your baby on demand from day 1 until baby has had enough.
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Finish the first breast completely; maybe use one side per feed rather than some from each breast. Offer the second breast if the baby appears hungry.
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Soften the breasts before feeds or express with a warm washer or shower, which will help to get the milk flowing.
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Avoid giving the baby other fluids.
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Express a little milk before putting the baby to your breast (a must if the baby has trouble latching on) and express a little after feeding from the other side if it is too uncomfortable.
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Massage any breast lumps gently towards the nipple while feeding.
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Apply cold packs after feeding or cool washed cabbage leaves (left in the refrigerator/between feeds).
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Use a good, comfortable brassiere. Remove your bra completely before feeding.
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Take paracetamol or ibuprofen regularly for severe discomfort.
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Lactation suppression
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Avoid nipple stimulation.
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Refrain from expressing milk.
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Use well-fitting brassiere.
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Use cold packs and analgesics.
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Engorgement settles over 2–3 wks.
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Hormonal suppression (for severe engorgement)
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Get baby to latch onto breast fully and properly.
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Do not feed from the affected breast—rest the nipple for 1–2 feeds.
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Express the milk from that breast by hand.
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Start feeding gradually with short feeds.
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Take paracetamol 1 g just before feeding to relieve the pain.
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Avoid drying agents such as spirits, creams and ointments.
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Use a relaxed feeding technique.
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Try to use the ‘chest to chest, chin on breast’ feeding position.
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Start feeding from the less painful side first if one nipple is very sore.
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Express some milk first to soften and ‘lubricate’ the nipple.
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Never pull the baby off the nipple: gently break the suction with your finger.
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Apply covered ice to the nipple to relieve pain.
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Keep the nipples dry (exposure to air or to hair dryer).
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Do not wear a bra at night.
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If wearing a bra by day, try Cannon breast shields.
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Postnatal depressive disorders
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2. Postnatal adjustment disorder
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Support and reassurance
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Cognitive therapy
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Parentcraft support
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Settles with time
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3. Postnatal depression
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Use the Edinburgh Postnatal Depression Scale. A score of ≥12 is significant.
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Occurs in 10–30% of women
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In first 6–12 mths (usually first 6)
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Anxiety and agitation common
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Marked mood swings
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Poor memory and concentration
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Typical depressive features
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Support, reassurance, counselling
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Group psychotherapy
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Couple therapy
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Postnatal depression support group
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Hospitalisation may be nec.
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Medication (e.g. SSRIs (sertraline, paroxetine are agents of choice), amitriptyline, dothiepin)
Note: Beware of puerperal psychosis with onset usually within first 4 wks. Symptoms include irrational behaviour, agitation, delusions, hallucinations, mania and suicidal ideations. Requires urgent inpatient psychiatric care. Check thyroid function.
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Postpartum thyroid dysfunction
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Postpartum thyroiditis may be misdiagnosed as postpartum depression and should always be considered in the tired apparently depressed woman in the first 6 mths after delivery. It must be differentiated from new onset or relapsing Graves disease indicated by antibody studies.
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Hair shedding (telogen effluvium) is common 4–6 mths post delivery. Large clumps of hair with white bulbs come out easily with combing and shampooing. Reassure that it reverts to normal in 3–6 mths. See also
Telogen effluvium.