what should i know about prenatal care if i
TRANSCRIPT
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2016 FMF
What Should I Know
About Prenatal Care If I
Don’t Deliver Babies?
William Ehman MDVancouver, B.C.
11:15 to 11:45.
Thursday, November 10th, 2016
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Learning Objectives
1. Provide the essential advice for woman
planning pregnancy
2. Identify currently recommended early
pregnancy tests
3. Correctly identify the expected date of delivery
4. Provide up-to-date counselling regarding the
recommended options for genetic screening
5. Discuss Immerging antenatal assessment
options
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Disclosure
None
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I am thinking about
getting pregnant, any
recommendations?
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Newsweek; Sept.1999
Time, Oct. 2010
Why is Prenatal Care Important?
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Developmental Origins of Health & Disease
Adverse
Pre-pregnancy
health
Adverse
Intrauterine
EnvironmentAdult Disease
CHD, Stroke,
Hypertension
Insulin resistance
Dyslipidemia
Anxiety/depression
Adverse
Postnatal
Environment
%
Birthweight
Prevalence of
future diabetes
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• Genome
▫ complete set of DNA
• Epigenome
▫ compounds - modify, or mark the genome
altering activity of genes without changing the
order of DNA sequence
▫ the marks can be passed on from cell to cell &
from one generation to the next
Epigenetics:- “The study of gene
expression causing phenotypic effect”
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PSBC Guideline Maternity Care Pathway 2010
Where Optimal Prenatal care starts:
• Preconception
Why?
• 40% unplanned (50% contraceptive failure)
• Early organogenesis
▫ Placenta at 7days
▫ neural tube closes @ 28days
• Influences future health
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PSBC Guideline Maternity Care Pathway 2010
• The benefits of planned pregnancy
• Folic acid supplementation (0.4-5mg)
• Vitamin supplementation
• Healthy diet
• Food safety: to reduce food acquired infection
• Weight management (ideal BMI 19-27);risk of underweight, overweight,
obesity
• Physical activity
• Contraception choices for timed pregnancy
• Genetic counselling/testing (e.g. Ashkenazi Jewish Panel, Thalassemia,
Sickle Cell anemia
• Use of medications and supplements
• Lifestyle: including smoking cessation, alcohol, substance use
• History of communicable disease: e.g. rubella, varicella, STI, HIV, HSV
• Healthy sexuality
• Assess the Impact and identify additional resources (if needed) for:
• chronic medical/mental health conditions: pre-pregnancy planning
• past gynecologic history (e.g. cone bx, PCOS)
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NTD Prevention
• Failure of neural tube closure in 3rd – 4th wk after
conception (day 26 - day 28)
• Folic acid with multivitamins reduces:
▫ NTDs
▫ heart defects
▫ urinary tract anomalies
▫ oral facial clefts (and palate)
▫ limb reduction defects
• **Advise all fertile women; folic acid in vitamin pillSOGC CPG Pre-conception folic acid May 2015
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Folic Acid: New Recommendations(?folic acid ↑resp. inf. & asthma in children)
Low risk:
Moderate risk:• Medication (epileptic, metformin,
Sulfasalazine, trimethoprim, triamterene,etc.)
• NTD in 1st/2nd degree relative woman/partner
• GI disease (Celiac, IBD), liver, dialysis,
alcohol
• Prior folate sensitive affected infant(cleft,
cardiac, limb)
High risk:• Personal or previous infant
(woman or partner) with NTD
0.4mg/d x 3mon prior
1mg x 3mon
prior →12wks then 0.4/d
4mg x 3mon
prior→ 12wks then 0.4(or5)/d
SOGC CPG May 2015
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• Multivitamin
• may reduce anomalies, SGA & PTB (BMI<25)1
• Vit. A ≤ 5000 IU (avoid >1 MultiV/day)
• Vit. D - 400-2000 IU/d
• Deficiency
▫ Risk factors: melanin, sun exposure, dairy intake
▫ Outcomes: fet.growth, ossification/enamel, cardiomyopathy
• ?400 vs. 4,000 IU in TM 2&3 GDM, preeclampsia and PTB2
• Vit. C – 500 mg/d supplementation in pregnant smokers• improved NB PFT’s & wheezing through 1 yr
• Calcium – 1000 mg/d
Preconception/Prenatal - Supplements
1Catov J, Am J Clin Nutr. Sept. 20112Wagner, Ped Acad Soc, Van. BC, May, 2010
3McEvoy, RTC n=159; JAMA, May 18, 2014
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IRON• pregnancy need is ~ 27 mg/d
• North American diet = 15mg/d
• Most require15 to 20 mg supplement1
1Health Canada, 2010
150
108
65
35
0
20
40
60
80
100
120
140
160
PolysaccharideIron Complex
FerrousFumarate
Ferrous Sulfate FerrousGluconate
Elemental Iron Per Table
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• Wash
▫ fruits & vegetables
• Eat
▫ fully cooked meat & eggs
▫ avoid
pate, dried meats
raw fish, shellfish (oysters & clams)
unpasteurized dairy, raw eggs
• Avoid
▫ Direct contact with soil, animal feces
Food Safety:Listeriosis/Salmonella/Toxoplasmosis:
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• Good: omega-3FAs: fetal brain/eye
• Bad: Mercury
Fish (the good & the bad)
Fish with High Mercury Shark, Swordfish, King Mackerel, or Tilefish
300gm (12oz)
(~2 meals)
of Low-Mercury Fish/week
Cod, salmon, canned light tuna, rainbow
trout, Atlantic mackerel, sole, shrimp, crab,
scallops, pollock, and catfish etc.
Note: Albacore "White" tuna contains more
mercury. Limit 150 gm (6oz) (~1 meal) per wk
Health Canada, FDA, EPA
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“HERBS TO AVOID OR USE WITH
CAUTION DURING PREGNANCY”• Angelica - stimulates suppressed
menstruation• Black Cohosh - uterine stimulant - mostly
used during labor• Blue Cohosh - a stronger uterine stimulant• Borage oil - a uterine stimulant - use only
during the last few days of pregnancy• Comfrey - can cause liver problems in
mother and fetus - use only briefly, externally only, for treating sprains and strains
• Dong Quai - may stimulate bleeding• Elder - do not use during pregnancy or
lactation• Fenugreek - uterine relaxant• Goldenseal - too powerful an antibiotic for
the developing fetus, also should not be used if nursing
• Henbane - highly toxic• Horsetail - too high in silica for the
developing fetus
• Licorice Root - can create water
retention and/or elevated blood pressure
• Motherwort - stimulates suppressed
menstruation
• Mugwort - can be a uterine stimulant
• Nutmeg - can cause miscarriage in large
doses
• Pennyroyal Leaf - stimulates uterine
contractions (NOTE: Pennyroyal
essential oil should not be used by
pregnant women at any time!) - do not
handle if pregnant or nursing
• Rue - strong expellant
• Shepherd's Purse - used only for
hemmorhaging during/after childbirth
• Uva Ursi - removes too much blood
sugar during pregnancy and nursing
• Yarrow - uterine stimulant
Waltz, The Herbal Encyclopedia, http://www.naturalark.com/herbpreg.html
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• maximum daily caffeine intake = 1501-2002-3003 mg
Caffeine
Foods and Beverages Caffeine
(mg)
Coffee (8 oz.)
Brewed, drip
Instant
137
76
Tea (8 oz.)
Brewed
Instant
48
30
Cola & caffeinated drinks (12
oz) 37
Hot cocoa (12 oz) 10
Chocolate Milk (8 oz) 8
1Motherisk2Food Standard Agency, UK3Health Canada, NICE 2008
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Does Pre-pregnancy BMI (kg/m2) Matter?
OW/Obese (BMI>25&30)• Maternal: GDM, GH, TED, dystocia, C/S,
infection1
• Neonate: LGA, asphyxia, PNM,
congenital defects, BS, BR1
• “Even modest” BMI: PN mortality2
1Canadian Maternity Experiences Survey, 2009; 2Aune
et al JAMA 2014
Underweight
(BMI<18.5)• PTB, SGA,
Neonatal M&M,
adult illness1
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• Family history, ethnicity▫ offer carrier screening and/or management
• With 3 pregnancy losses:▫ 3.5% - 5% risk of maternal chromosomal rearrangement
▫ 1% - 2% risk of a paternal rearrangement.
Genetic screening & family history
Phenylketonuria Thrombophilia
Hemophilia A Muscular dystrophies
Cystic fibrosis Mental retardation
Tay-Sachs Hemoglobinopathies
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Substance use:• Screen
• Council, refer
• Harm reduction
Medications:• Prescription
• OTCs▫ E.g. NSAIDs (not ASA) in early pregnancy:
cardiac septal defects1
spont. abortion (OR 2.43, 95% CI. 2.12–2.79).2
1Ofori , Birth Defects Res B Dev Reprod Toxicol 2006;77:268-79.2Nakhai-Pour CMAJ Sept. 2011
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Marijuana
• Fetal levels are 10% maternal
• Can take 30d for complete excretion
• Fetal effect:
▫ disrupt brain development/function
▫ Low scores visual problem solving, coordination
▫ Decreased attention span and school
performance
ACOG Committee opinion July 2015
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Tobacco• Screen all1
Alcohol “insufficient evidence to define
any threshold for low-level
drinking in pregnancy.”2
2SOGC ‘10
1BCPHP Guideline 09
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Toxins/Teratogens• Heavy metals, solvents, pesticides, etc.
Infections• Screen for periodontal, urogenital, STIs
• Counsel re: TORCH
▫ Note: Rubella: adverse effects in 90% infants in 1st 10wks
• Hx of STI, substance use, Soc/Economic
herpes syphilistoxoplasmosis rubella CMV
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Women Who May Need Additional
Care: Previous History• Recurrent miscarriage
• Preterm birth▫ e.g. previous PTB <34wks or Cx ≤ 20mm ≤ 24wk
Rx vag micr progesterone 16-20 wks to 36 wks
• Pre-eclampsia, HELLP syndrome or eclampsia▫ e.g. Rx ASA 81 mg & 1-2 g calcium
• Rhesus isoimmunization or other significant blood
group antibodies
• Gestational diabetes requiring insulin
• Puerperal psychosis
• Grand multiparity (≥5)
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I am 7 weeks
pregnant, what
should I do?
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Two resources
http://www.perinatalservicesbc.ca/health-professionals/professional-resources/health-promo/pregnancy-passport
http://www.perinatalservicesbc.ca/health-professionals/professional-resources/aboriginal-resources/pregnancy-passport
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Essential Early Prenatal Care:
Time Sensitive!!
1.Folic Acid supplementation
2.Estimate due date
3.Screen/counsel
1. Medications, alcohol/tobacco/substance, genetics
4.Screening lab tests
5.Prenatal genetic screening for aneuploidy & US
offered to all
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1. Folic Acid supplementation
• 0.4 – 4 (5) mg depending on risk factors
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• “all women should be offered a fetal ultrasound between 11 and
14 weeks, to confirm viability, gestational age, number of fetuses,
chorionicity in multiples, early anatomic assessment, and NT
measurement (if accredited sonographer is available).”1
• Will reduce “post-date” inductions2
• Use earliest US > 7 wks (CRL=10mm)
2. Estimate due date
1SOGC Committee Opinion, 2016; 2SOGC 2008 3SOGC CPG, No. 303, 2014
• 7-23 wks US alone is more accurate than a
“certain” menstrual date.3
• A suggestion:
• If possible: approx. 9 wks to confirm EDD for
maternal serum screening.
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3. Screen/counsel re:
▫ medications and supplements
▫ Alcohol; assess risk; cessation/reduction, local
supports/resources
▫ Tobacco: referral/nicotine replacement Rx(smoke >10
cig./day or not quit by 12 wks
▫ substance use. Referral/resources
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4. Screen/Diagnostic Tests(0-14wks)
Test LOR
Blood Group, Rh, Antibodies C Hemolytic disease
Hb, MCV B Anemia, hemoglobinopathy
HIV A reduce transmission to NB
Rubella Ab Titre B PP vaccination if not immune
STS A
HBsAg A Guide Mat. & NB care
TSH B Offer all
Chlamydia screen B Offer to all
Gonorrhoea A Offer to all
Midstream urine C/S A
C
Early pregnancy - all
Recurrent UTIs - each TM A Good evidence for
B Fair evidence for
C Conflicting
D Fair evidence against
I Insufficient
PSBC Guideline Maternity
Care Pathway 2010
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4. Screen/Diagnostic Tests(0-14wks)
Test LOR
Blood Group, Rh, Antibodies C Hemolytic disease
Hb, MCV B Anemia, hemoglobinopathy
HIV A reduce transmission to NB
Rubella Ab Titre B PP vaccination if not immune
STS A
HBsAg A Guide Mat. & NB care
TSH B Offer all
Chlamydia screen B Offer to all
Gonorrhoea A Offer to all
Midstream urine C/S A
C
Early pregnancy - all
Recurrent UTIs - each TM A Good evidence for
B Fair evidence for
C Conflicting
D Fair evidence against
I Insufficient
PSBC Guideline Maternity
Care Pathway 2010
0.1 to 2.5 mIU/L 1st TM
0.2 to 3.0 mIU/L 2nd TM
0.3 to 3.0 mIU/L 3rd TMRef. Thyroid disorders during pregnancy.
Yazbeck CF - Med Clin North Am - 01-MAR-
2012; 96(2): 235-56
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Screening/Diagnostic Tests (0-14wks)
Test L.O.R.
Hep C testing A Recommend with risk factors
GTT or FBG A With risk factors (FH, Obese, etc.)
Pap test B If indicated
B19, Mumps,
Toxoplasmosis, CMV, etc
I No routine testing
B If women exposed/symptoms
TWEAK B Screen alcohol use, most sensitive in 1st
15 wks
A Good evidence for
B Fair evidence for
C Conflicting
D Fair evidence against
I Insufficient
PSBC Guideline Maternity
Care Pathway 2010
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5. Prenatal genetic screening for
aneuploidy & US offered to all
“All pregnant women in Canada, regardless of age,
should be offered, through an informed counselling
process, the option of a prenatal screening test for
the most common clinically significant fetal
aneuploidies in addition to as second trimester
ultrasound for dating and assessment of fetal
anatomy, and detection of multiples. (I-A)*
*J Obstet Gynaecol Can 2011;33(7):736-750
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2016
Prenatal
Aneuploidy
Screening
http://www.perinatalservicesb
c.ca/Documents/Guidelines-
Standards/Maternal/Prenatal
ScreeningGuideline.pdf
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SIPS Serum Integrated Prenatal Screen
9-13+6 PAPP-A
15-20+6 AFP, uE3, hCG and inhibin-A
IPS Integrated Prenatal Screen
SIPS + NT: 11-136
QUAD One blood test
15-20+6 AFP, uE3, hCG and inhibin-A
NT Nuchal Translucency
11-13+6
CVS Chorionic villus sampling 10+3 – 12+6 wks
Amniocentesis ≥15 wks
NIPT Non Invasive Prenatal Testing: ≥10 wks
Summary of Prenatal Genetic Screening
All
BC ≥35
≥14 wks
BC ≥35Multiples,
HIV, T21,
T18, IVF-ICSI
BC Prenatal Genetic Screening Program, PSBC January 2014
best 10-116
best 152-16
best 12-133
best 152-16
best 12-133
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Non Invasive Prenatal Testing (NIPT):
cffDNA In Maternal Plasma
• Fragments of extracellular
cffDNA detectable by 4 wks
• cffDNA with gestation
▫ 10% total cfDNA by 7-10wk
▫ up to 50% by term
• Rapid clearance Post Partum (~1-2 h)
Sufficient
• “Real-time snapshot of fetal genetic status”
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Prenatal Screening/Diagnostic
Applications of cffDNA
• Fetal autosomal
aneuploidies
• Fetal sex determination• X-linked disorders, etc.
• Sex-chromosome
aneuploidy
• Rhesus typing
• Single gene disorders• Huntingtons, achondroplasia, MD
• Microdeletion syndromes
• Whole fetal genome
sequencing
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*
*Accurate dating is essential!BC Prenatal Genetic Screening Program, PSBC June 2016
Woman’s
age
Gestational Age at the First Prenatal Visit
≤ 13+6 wks 14 – 20+6 wks
No prior screening
≥ 21 wks
< 35 years • SIPS • (if patient is HIV+ & NT is
available, IPS)
• Quad • Detailed US
35 – 39yrs • IPS; or
• If NT N/A, SIPS
• Quad • Detailed US;
• & Amnio
40+ yrs • IPS; or
• If NT N/A, SIPS;
• Or CVS or Amnio
• Quad; or
• Amnio
• Detailed US
• & Amnio
NIPT: BC
Elligibility
• +ve SIPS, IPS or Quad screen for DS or T18
• Previous pregnancy with T21, T18 or T13
• Risk of T21, T18 or T13 >1/300 (based on screen & Us)
Screening options available through the BC
Prenatal Genetic Screening Program
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*
*Accurate dating is essential!BC Prenatal Genetic Screening Program, PSBC June 2016
Woman
Gestational Age at the First Prenatal Visit
≤ 136 wks 14 – 206 wks ≥ 21 wks
Personal/ FHx risk
DS, T18, T13
• IPS; or
• NIPT; or
• CVS or Amnio
• Quad; or
• NIPT; or
• Amnio
• Detailed US &
• NIPT; or
• Amnio
Personal / FHx risk
chromosomal abn.
other than DS, T18
• CVS or Amnio • Amnio • Detailed US &
• Amnio
Twin gestation • IPS;
• or SIPS if no NT
• or if ≥ 35, Amnio
• Quad;
• Or If ≥ 35,
Amnio
• Detailed US
& if ≥ 35, Amnio
Pregnant following
IVF with
intracytoplasmic
sperm injection
• IPS
• or SIPS if no NT
• Or CVS or Amnio
• Quad; or
• Amnio
• Detailed
ultrasound; &
Amnio
Screening options available through the BC
Prenatal Genetic Screening Program
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Aneuploidy Screening Across Canada
• It varies.
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Alberta
Two options (gest. age
dependent)1. 1st TM screen(11w2-13w6)
a) NT
b) β-HCG & PAAP-A
2. Quad(15w0-20w6)a) αFP, uE3,hCG,DIA
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Aneuploidy screening*• Saskatchewan: 1ST TM (PAPP-A & fßhCG)
▫ If high risk: NT if low risk Quad testing then report
• Manitoba▫ Nt if risk factors then blood test after 15 wks
• Ontario▫ IPS, SIPS, FTS, Quad
• Quebec▫ SIPS
• New Brunswick▫ SIPS, ?other
• Nova Scotia & PEI▫ SIPS and NT if risk factors
• Newfoundland▫ MSS
• Yukon, NWT▫ Uncertain
• Nunavut▫ Quad
▫ *As best as I could find in the internet!
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Hypothyroid and Pregnant
• Women taking thyroid hormone:
▫ Will need due to TBG
▫ “should be advised to increase their thyroid
hormone dose by 2 extra tablets per week
immediately following a positive pregnancy test”
• Ideal TSH level:
▫ < 2.5 mU/L 1st TM, < 3 mU/L 2nd & 3rd TM
• TSH: q 6 wks or 4 wks after dosage change
• Remember:
▫ TSH may be low in 1st TM due to HCG : no
dose is needed if the fT4 & fT3 normalLochnan 2014, McMaster Plus
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(0-14wks)
PSBC Guideline Maternity Care Pathway 2010
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PSBC Guideline Maternity Care Pathway 2010
(0-14wks)
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Pre-pregnancy
BMI category
Meana rate of weight gain in the
2nd and 3rd trimester
Recommendedb range of total
weight gain
kg/week lb/week kg lbs
BMI < 18.5
Underweight0.5 1.0 12.5 - 18 28 - 40
BMI 18.5 - 24.9
Normal weight0.4 1.0 11.5 - 16 25 - 35
BMI 25.0 - 29.9
Overweight0.3 0.6 7 - 11.5 15 - 25
BMI ≥ 30c
Obese0.2 0.5 5 - 9 11 - 20
WEIGHT GAIN (SINGLETON)
a Rounded values.b Calculations assume a total of 0.5 - 2 kg (1.1 - 4.4 lbs) weight gain in the first trimester.c A narrower range of weight gain may be advised for women with a pre-pregnancy BMI of
35 or greater. Individualized advice is recommended for these women.Health Canada Gestational Weight Gain Recommendations
15
12.5
10
7.5
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http://www.healthcanada.gc.ca/f
oodguide
calories:
TM Cal.
2nd 350
3rd 450
Breast
feed
350
- 400
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Hot Tubs/Baths• water temp < 39 ℃ 3
Stretch marks• Prevention: nothing proven
▫ May harm: Retinoids, Salicylic acid,
Soy(chloasma)
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
1Institute for Clinical Systems Improvement, 13th Ed. Aug. 20092 AAP 1997, 3 ACOG
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Work – risk factors1
• 36 hrs/wk or 10 hrs/day
• standing(>3-6h/shift), heavy lifting
• mental stress
• noise: LBW,PTB,hearing loss2
▫ avoid prolonged exposure to low-frequency
sound levels (<250 Hz) above 65 dB during
pregnancy
▫ Not louder than 115 dBA after 20-24 wks
INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT
1Institute for Clinical Systems Improvement, 13th Ed. Aug. 20092 AAP 1997
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Dental and Periodontal Care
• Safe
• Some evidence that
“periodontal treatment
may have an effect on
reducing preterm birth”*
*Antenatal care
Evidence Update May 2013
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Exercise• “All without contraindications encouraged to participate in
aerobic and strength-conditioning exercises” (II-1, 2B)1
• “activities that minimize the risk of loss of balance and
fetal trauma”(III-C)1 eg. extensive jumping, contact sports
• “at least 30 min. most days”2
• Core, talk test, temp. not > 38°
• “reduces risk of cesarean delivery.”3
Absolute Contraindications Relative Contraindications
Ruptured membranes Previous spontaneous abortion
Preterm labour Previous preterm birth
Hypertensive disorders of pregnancy Mild/moderate cardiovascular disorder
Incompetent cervix Mild/moderate respiratory disorder
Growth restricted fetus Anemia (Hb <100 g/L)
High order multiple gestation (≥ triplets) Malnutrition or eating disorder
Placenta previa after 28th week Twin pregnancy after 28th week
Persistent 2nd or 3rd trimester bleeding Other significant medical conditions
Uncontrolled type 1 DM, thyroid, CV, Resp. Disease or systemic disorder
1SOGC CPG No. 129, June 2003
(Canadian Society for Exercise Physiology)2http://www.healthypregnancybc.ca/page194.htm
3Domenjoz, Am J Obstet Gynecol. 2014
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The Model of Care
16w
41w40w39w38w37w
36w34w32w30w
28w24w
Memorandum on Antenatal Clinics UK
Min. of Health, 1929
Traditional
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A New Model of Care?
By 11-13 weeks,
possibly identify:• 90% aneuploides
• Most major structural
abnormalities
• Risk for SB/spont. abortion
• Gestational DM
• Fetus at risk for:
▫ PTB
▫ SGA
▫ macrosomia
11-13 wk: maternal history,
serum tests, US
Specialist care
12-34w
20w
37w
41w
From Nicolaides K, Prenat Diagn 2011
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Today’s Model of Care
As early as
possible
Postpartum
Delivery
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Resources…..
• http://www.perinatalservicesbc.ca/health-professionals/professional-resources/pathways-
toolkits/maternity-care-pathway
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Thank you
William Ehman MD