antinatal care lecture note for student pdf

lecture note

1. Antenatal surveillance
Objective
At the end of this lesson students able to
Define fetal surveillance
Describe rationale
Indication for fetal surveillance
Describe basic method of fetal surveillance

2/16/2024 gdgd2015 1

2. Antenatal surveillance
Antenatal surveillance is method of assessment
and monitoring the fetal behaviors and wellbeing
during pregnancy after the fetus reach viability.
Techniques employed to forecast fetal well-being.
It is offered to detect early sign of utero placental
insufficiency and fetal hypoxia as early as
possible, so that proper interventions are
considered.
2/16/2024 gdgd2015 2

3. Antenatal surveillance
Rationale:
1.Two thirds of fetal deaths occur before the onset
of labor.
2.Many antepartum deaths occur in women at risk
for utero-placental insufficiency.
Ideal test: Allows intervention before fetal death or
damage from asphyxia.
Not done where there are fetal abnormalities that
are incompatible with life detected.


2/16/2024 gdgd2015 3

4. Antenatal surveillance
Patient selection
Patients selection depend on the following
Individualized client condition.
Based on the facilities available.
Fetal viable.
Patients at risk for perinatal morbidity and/or
mortality
2/16/2024 gdgd2015 4

5. Antenatal surveillance
Indication
All pregnancies require fetal well-being assessment.
The intensity focuses on complication and high risk.
categories:-
I.Uteroplacental insufficiency
Inadequate delivery of nutritive or respiratory
substances to appropriate fetal tissues.
Inadequate exchange within the placenta due to
decreased blood flow, decreased surface area or
increased membrane thickness.
Inadequate maternal delivery of nutrients or oxygen to
the placenta or to problems of inadequate fetal uptake.

2/16/2024 gdgd2015 5

6. Antenatal surveillance
They includes
- Post term - Suspected IUGR
- DM - Increased age
-Multiple P. -PIH
- Previous still birth -PROM
-Maternal medical disorder

2/16/2024 gdgd2015 6

7. Antenatal surveillance
II. Fetal compromise detected or suspected.
- Suspected IUGR -Rh sensitized women
- Decrease fetal movement
- Oligohydraminose
III. Routine surveillance

2/16/2024 gdgd2015 7

8. Antenatal surveillance
Time of initiating
Actually it depends on the patient conditions:-
Insulin requiring GD/DM  32- 36 wks.
Post dated pregnancy  41-42wks.
 fetal movement  instantly.
Other conditions  variable according to severity & GA
2/16/2024 gdgd2015 8

9. Antenatal surveillance
Frequency of testing:
It should be individualized to reflect the risk
factors associated with the pregnancy and should
correspond to perceived risk of fetal asphyxia.
Usual testing is once to twice weekly
Daily – aid in the timing of delivery to maximize
gestational age while avoiding significant
intrauterine morbidity in preterm fetuses

2/16/2024 gdgd2015 9

10. Antenatal surveillance
Techniques of antenatal surveillance
1.symphysis fundal height measurement
2.Daily fetal movement count.
3.Non-stress test.
4.amniocentesis and cordocentesis.
5.early ultrasound examination.
6.Contraction stress test.
7.Standard biophysical profile.
8.Modified BPP
9.Umbilical artery doppler velocimetry

2/16/2024 gdgd2015 10

11. Antenatal surveillance
1.Symphysis fundal height measurement
Mother supine, leg straight, bladder empty.
Uterine fundus identified and marked.
Keep the tape smoothly in contact with natural curve of
abdomen along linea nigra.
Gestational age best corresponds with SFH in cm at 18-
30 weeks.
Discrepancy of >2 cm consider abnormal.

2/16/2024 gdgd2015 11

12. Antenatal surveillance
2.Fetal movement count.
The first fetal movement perceived by the mother is
called quickening.
It varies from women to women (16-18 in multi and 18-
20 in prim).
Period of active movement lasts for 40min.
Longest period without movement75-80min.
Mother is given paper and pen then record fetal
movement on kick chart.
Pearson and weaver formula. <10 movement per 12 hrs(
e.g. 9Am-9 Pm)


2/16/2024 gdgd2015 12

13. 2/16/2024 gdgd2015 13

14. Fetal movement
Types of movement
1.Startles:-
are quick generalized movements that always begin in
the limbs and often spread to the trunk and neck.
2.General body movements
are slower movements that involve the whole body.
3.Clonic movements are repetitive tremulous
Movements of one or more limbs at a rate of
approximately three per second.
2/16/2024 gdgd2015 14

15. Antenatal surveillance
If decrease in fetal movement is observed, the
mother is asked to
Eat or drink
Change her position
Go to quite room
Additional 2 count is ordered

2/16/2024 gdgd2015 15

16. 2/16/2024 gdgd2015 16

17. Antenatal surveillance
Non-stress test (NST)
A NST measures the fetal heart rate in response to
the fetal movements.
Generally, the heart rate of a healthy fetus increases
when the fetus moves.
The NST is usually performed in the last trimester of
pregnancy.
Can be done at out patient department.
Mother can sit or tilt to the left.
Fetal heart beat monitored using Doppler ultrasound

2/16/2024 gdgd2015 17

18. 2/16/2024 gdgd2015 18
Interpretation
1.Reactive: presence of two or more fetal heart
rate accelerations within a 20-minute period.

19. 2/16/2024 gdgd2015 19
1.Non–reactive : criteria for reactivity are not
met, extend test time for 40 minutes.
if still not reactive do biophysical profile.

20. Biophysical profile
Between 24 and 28 weeks' gestation,
approximately 50 percent of NSTs are nonreactive.
In contrast sonographically evaluated variables are
valid early in gestation and account for three of the
five components of the biophysical profile.
The biophysical profile may be used to verify fetal
well being when the nonstress test is not reactive
2/16/2024 gdgd2015 20

21. Biophysical profile
Comprehensive assessment of five parameter
1.Fetal breathing movement
2.Fetal movements of body or limbs
3.Fetal tone (extension and flexion of extremities)
4.Amniotic fluid volume visualized as pockets
around the fetus
5.Reactive FHR with activity (reactive NST)

2/16/2024 gdgd2015 21

22. Biophysical profile
•

2/16/2024 gdgd2015 22

23. 2/16/2024 gdgd2015 23

24. Biophysical profile
Result interpretation
Each component of BPP is worth 2 points;
The following value hold the following
interpretation
1.8 -10 is normal,
2.5- 6 is equivocal, and
3.0-4 or less is abnormal.
2/16/2024 gdgd2015 24

25. Modified Biophysical Profile
Combines NST, with amniotic fluid index (AFI)
AFI is measured by dividing the uterus into 4 equal
quadrants and measuring the largest vertical pocket in
each quadrant; the results are then summed and expressed
in millimeters.
The modified Biophysical Profile become a primary
mode of antepartum fetal surveillance;
A nonreactive NST or
An AFI less than 50 mm (oligohydramnios)
requires further intervention

2/16/2024 gdgd2015 25

26. Modified Biophysical Profile
The linea nigra is used to divide the
uterus into right and left halves.
The umbilicus serves as the
dividing point for the upper and
lower halves.
The transducer is kept parallel to
patient’s longitudinal axis and
perpendicular to the floor.
Add these numbers together and the
sum represents the Amniotic fluid
Index (AFI).



2/16/2024 gdgd2015 26

27. Modified Biophysical Profile
2/16/2024 gdgd2015 27

28. Contraction stress test
Checks to see if your unborn baby (fetus) will
stay healthy during the reduced oxygen levels
that normally occur during contractions.
The test is performed by placing transducers
(ultrasound and toco), on patient's abdomen as
with the non stress test.

2/16/2024 gdgd2015 28

29. 2/16/2024 gdgd2015 29

30. 2/16/2024 gdgd2015 30

31. Amniocentesis
Collection of Amniotic Fluid
for Testing
An invasive procedure
Requires a consent form to be
signed
Performed about 14 - 16
weeks gestation

2/16/2024 gdgd2015 31

32. Cordocentesis.
Small amount of blood
obtained from umbilical
cord and tested

2/16/2024 gdgd2015 32

33. Introduction to drugs in
pregnancy

34. At The end of this session students should be able to
know:
1.Factors affecting drug placental transfer
2.Harmful effects of drugs during different stages of
development
3.FDA classifications of drugs.
4.Teratogenic drugs
5.Adverse effects of drugs
6.Drugs of abuse

35. •Majority of pregnant women are exposed to
medications during pregnancy.
•Unless absolutely necessary, drugs should not be
used during pregnancy because many can harm
fetus.
•About 2 to 3 % of all birth defects result from
the use of drugs.
Medications in pregnancy

36. •Most drugs can cross placenta by passive
diffusion.
•Placental membrane is semi-permeable.
•The movement of drugs across the placenta is
limited by a single layer of cells called
trophoblasts.
Medications in pregnancy

37. Factors controlling placental drug transfer
I.Physiochemical properties of the drug
–Lipid solubility or diffusion.
–Molecular size.
–Protein binding.
II.The stage of placental and fetal development
at the time of exposure to the drug.
III.Duration of exposure to the drug.

38. I. Physiochemical properties of the drug
Lipid solubility of the drug:
Lipophilic drugs
diffuse readily across the placenta and enter
fetal circulation. e.g. Thiopental crosses
placenta & causes sedation, apnea in newborn
infants.
Ionized drugs
cross the placenta very slowly  very low conc.
in the fetus e.g. Succinylcholine & pancuronium

39. Molecular size of the drug
MW affects the rate of transfer:

•250 - 500 cross placenta easily.
•500 - 1000 cross placenta with more difficulty.
• 1000 can not cross placenta e.g. Heparin

40. Protein binding
•Protein binding in maternal circulation
hinders passage of drugs
•e.g propythiouracil and chloramphenicol

41. II.The stage of mammalian fetal development
Harmful action of drugs depend upon stage of
fetal development at time of drug exposure.
Mammalian fetal development passes through
three phases:
Blastocyste formation (up to 16 days).
Organogenesis (17-60 days).
Histogenesis & maturation of function.

42. Blastocyst formation (First 2 weeks)
•Occurs from (1-16 days) in the first trimester.
•Period of dividing zygote and implantation
•Pre-differentiated period (conceptus).
•Drugs have an all-or-nothing effect.
•Exposure to harmful drugs during this
period Prenatal death & abortion.

43. Organogenesis: (2-8
weeks)
•is the process by which cells specialize and
organize to form the tissues and organs of an
organism.
•Occurs in (17- 60 days) in the first trimester.
•The most sensitive period of pregnancy.
•Exposure to harmful drugs  major birth
defect in body parts or major congenital
malformation.

44. Histogenesis and functional
maturation (8 weeks onwards)
• Growth and fetal development occur during
this stage.
•Fetus depends upon nutrients & hormonal
supply.
•Exposure to drugs can cause “Function
problems” rather than “gross malformation”

45. Histogenesis and functional
maturation
• Exposure to drugs during 2
nd
and 3
rd
will not
induce major malformation but drugs can
produce minor morphologic abnormalities,
growth retardation and functional defects.

46. II. The stages of mammalian fetal development
First trimester: week 1- week 12
Organogenesis week 2- week 8
major congenital malformations (teratogenesis).

Second & Third trimesters: (week 13-week 28)
affect growth & fetal development
Near Term: (week 29-week 40)
adverse effects on labor or neonates after
delivery.

47. Critical Periods of Human
Development

48. Teratogenesis
Occurrence of congenital defects of the fetus.
What is a teratogen?
is any agent that is able to interferes with fetal
development and leads to permanent birth defects.
This could be severe during critical periods of
development e.g. (organogenesis).
Agent may be: medication, street drug, chemicals,
disease, environmental agents.

49. FDA Classification System
Category A
•Adequate and well-controlled human studies
have failed to demonstrate a risk to fetus
•Drugs can be used

Category B
•No risk in animal studies
•No adequate and well-controlled human studies
•Drugs can be used in pregnancy

50. FDA Classification System
Category C
•Adverse effects on the fetus in animals only
•No adequate and well-controlled studies in
humans.
•Drug may be used in serious situation despite
its potential risk.

51. FDA Classification System
Category D
•Positive evidence of human fetal risk based on
adverse reaction data from studies in humans,
investigational or marketing experience.

•May be used in serious diseases or life
threatening situations

52. FDA Classification System
Category X
•Proven fetal abnormalities in animal and
human studies
•the risks involved in the use of the drug in
pregnant women clearly outweigh potential
benefits.
•Drugs are teratogens and contraindicated in
pregnant women or planning to conceive.

53. Category Characteristics Examples
A Controlled human studies
show no risk
Folic acid
Thyroxine
B Animal studies ok
No human data
Paracetamol
Erythromycin
C Animal studies are not ok
No human data
Risk can not be ruled out
morphine
D Positive evidence of risk
Benefits outweigh risks
Antiepileptics
X Contraindicated in pregnancy Thalidomide
FDA Classification System

54. Proven teratogens
The following drugs are contraindicated
during pregnancy (category X):
Retinoids
Thalidomide (sedative/ hypnotics ).
Lithium
Alcohols
Cytotoxic drugs
Folate antagonists (methotrexate).
Alkylating agents (cyclophosphamide).
Anticonvulsant drugs (valproic acid,
phenytoin, carbamazepines).

55. Anticoagulants (warfarin).
Antibiotics (tetracyclines, quinolones)
ACEIs(for treatment of systolic heart disease)
Ionizing radiation (diagnostic X-ray or
radiation therapy).
Radioactive iodine (I
131
).
Corticosteroids.
Hormones
Proven teratogens

56. •Retinoids e.g.
–vitamin A ( should be limited to 700 μg/day)
–isotretinoin (used in treatment of acne)
Proven teratogens

57. Teratogenesis of drugs
Thalidomide Phocomelia
shortened or absent long bones of the limbs

Alcohol Fetal Alcohol Syndrome (FAS)
Microcephaly
Craniofacial abnormalities
Intrauterine growth retardation
CVS abnormalities
CNS abnormalities (attention deficits,
intellectual disability, mental retardation)

58. Teratogenesis of drugs
Phenytoin Fetal Hydantoin Syndrome:-Nail
& Digital hypoplasia(underdevelopment
of an organ or tissue)
Oral Clefts (cleft lip and palate)
Cardiac Anomalies

Valproic acid
Neural tube defect (spina bifida)
Antiepileptic drug
Impairs folate absorption
Tetracyclines Altered growth of teeth and bones
Permanent teeth staining
Enamel hypoplasia
Warfarin Hypoplasia of nasal bridge
CNS malformation

59. Corticosteroids

Cleft lip and Palate
Hormones Serious genital malformation
Estrogens Testicular atrophy in male fetus
Androgens
Fetal masculinization in female fetus
Diethylstilbestrol
Vaginal carcinoma of female offspring
Teratogenesis of drugs

60. Lithium
Ebstein's anomaly
Cardiovascular anomalies mainly
valvular heart defect involving tricuspid
valve
ACE inhibitors
Captopril
Renal damage
Fetal & neonatal anurnia
Fetal hypotension
Enalapril
Hypo- perfusion
Growth retardation
ACE inhibitors disrupt the fetal renin-
angiotensin system, which is essential for
normal renal development
Teratogenesis of drugs

61. Valproic acid
Spina bifida Phocomelia
Thalidomide

62. Fetal hydantoin
syndrome
Cleft lip and
palate

63. Cleft lip Teeth staining
Corticosteroids and
phenytoin
Tetracycline

64. During second and third trimesters
•Some drugs can produce adverse effects on the
fetus more likely than major malformations
due to their pharmacological actions.
•Affect growth & fetal development or toxic
effects on fetaltissues
Adverse effects of drugs

65. Adverse effects of drugs
Tetracyclines Impaired teeth & bone development,
yellow-brown discoloration of teeth
Aminoglycosides Streptomycin, kanamycin
Ototoxicity = 8th Cranial nerve damage
Cloramphenicol Gray baby syndrome
Corticosteroids Adrenal atrophy – growth retardation
Propranolol Bradycardia, neonatal hypoglycemia,
placental insufficiency, reduced uterine
blood flow, fetal distress
Antithyroid drugs Iodide, methimazole, carbimazole,
propylthiouracil, risk of neonatal
hypothyroidism and goiter

66. NSAIDs e.g. Aspirin-indomethacin
Prostaglandin synthesis inhibitors
Constriction of ductus arteriosus (close
prematurely), pulmonary hypertension
in newborns
Increase in gestation time
prolong labor, neonatal
bleeding Risk of postpartum
hemorrhage
Benzodiazepines
as Diazepam
Chronic use → neonatal dependence
and withdrawal symptoms
ACEIs Renal damage
warfarin Risk of bleeding
Adverse effects of drugs

67. CNS depressants e.g. diazepam,
morphine Interference
with suckling Respiratory
depression
Reduced blood flow, fetal distress
Sulfonamides can displace bilirubin from
albumin (neonatal
hyperbilirubinemia,
Jaundice)
Adverse effects of drugs prior to labor or
near term

68. Hypertension in pregnancy

Probably safe
α- methyl dopa
Labetalol
Contraindicated
- • ACE inhibitors
Angiotensin II receptor blockers
Thiazide diuretics
Propranolol
Calcium channel blockers in mild hypertension

Emergency
Hydralazine
Labetalol

69. Contraindicated
warfarin is contraindicated in all trimesters Cross
placenta
1
st
trimester : teratogenicity (Chondroplasia) 2
nd
,
3
rd
: risk of bleeding
Probably safe
Heparin
Polar, does not cross placenta
The antidote, protamine sulphate is available
Coagulation disorders in pregnancy

70. Are used in thyrotoxicosis or Grave’s disease
–Propylthiouracil
–Methylthiouracil (Methimazole)
–Carbimazol
–Radioactive Iodine All can cross placenta
All have risk of congenital goiter and hypothyroidism
The lowest dose of antithyroid drugs should be used.
Propylthiouracil is preferable over others.
Antithyroid drugs in pregnancy

71. Contraindicated :
•Tetracyclines: Teeth and bones deformity
•Quinolones as ciprofloxacin: arthropathy (bone and
cartilage damage)
•Aminoglycosides: ototoxicity
•Sulfonamides: neonatal jaundice-kernicterus
•Chloramphenicol: Gray baby syndrome
Probably safe
•Penicillins: (ampicillin, amoxicillin)
•Cephalosporins
•Macrolides (erythromycin and azithromycin) as
alternative in penicillin-sensitive individuals BUT
erythromycin estolate should be avoided (risk of hepatic
injury to mother).
Antibiotics in pregnancy

72. Antihypertensive
α-methyl dopa
Labetalol ( -  Blocker)
Hydralazine (emergency only)
Antibiotics penicillin, cephalosporins, erythromycin
Antidiabetics Insulin, avoids oral antidiabetics
Anticoagulants Heparin
Analgesics Acetaminophen
Antithyroid drugs Propylthiouracil (protein-bound)
Anticonvulsants All antiepileptics have potential to cause
malformations
avoid valproic acid (highly teratogenic)
Folic acid supplementation prevents neural
tube defects in women receiving AEDs
Drugs of choice in pregnancy

73. Drugs of Abuse in Pregnancy

74. Drug abuse
Drug abuse:
Habitual use of drugs not for therapeutic
purposes but for alteration of one's mood or
state of consciousness.

75. Drug abuse
•The most commonly abused drugs are alcohol;
barbiturates; benzodiazepines, opium alkaloids
amphetamines; cocaine; nicotine; marijuana.

•Drug abuse may lead to organ damage,
dependence, addiction, and disturbance of
behavior.

76. Alcohols
The use of alcohol is contraindicated
during all trimesters of pregnancy

77. Fetal Alcohol Syndrome (FAS)
•Caused by chronic maternal alcohol
abuse during early weeks of first trimester of
pregnancy.
Characters
–Microcephaly
–Low weight birth
–Craniofacial abnormalities
–CVS abnormalities
–CNS abnormalities (attention deficits,
intellectual disability, mental retardation)

78. Fetal Alcohol Syndrome ( FAS )

79. Cocaine
•Cocaine has low molecular weight, easily passes
into fetus through placenta.
•Inhibits re-uptake of sympathomimetics
(epinephrine, NE, dopamine), causing
vasoconstriction, rapid heart rate, hypertension
(Vascular disruption).
•It decreases blood flow to uterus and fetal
oxygenation (Hypoxia).
•It increases uterine contractility

80. Cocaine
•Microcephaly
•Prematurity
•Intrauterine growth retardation.
•Placental abruption (separation of placenta
from uterus wall before delivery)
•Growth retardation
•Mental retardation

82. Tobacco
•Tobacco contains nicotine and carbon monoxide
that may harm fetus. No evidence it causes birth
defects but Tobacco can increase risk of:
•Reduced blood flow to placenta
•Fetal hypoxia
•Retarded fetal growth
•Low birth weight
•Spontaneous abortion
•Prematurity (Preterm labor)
•Perinatal mortality

83. Conclusions
•The use of drugs during pregnancy should be
avoided unless absolutely necessary.
•Most drugs cross the placenta to some extent.
•Birth defects are of great concern.
•Drugs can harm the embryo or foetus depending
upon the stage of foetal development.
•The most critical period of pregnancy is
organogenesis (2– 8 weeks).
•Alcohol, nicotine and other addicting drugs
should be avoided.

84. M IN O R D ISO RD ER D U RIN G
PREGNANCY

85. •Many women experience some minor disorders
during pregnancy .These disorders should be treated
adequately as they may escalated and become life
threatening .
•Minor disorder may occur due to hormonal changes
,accommodation changes ,metabolic changes and
postural changes.
INTRODUCTION

86. Nausea and vomiting :-
•It is a common disorder affect 50% of women
between 4
th and 14
th week of gestation.
•Nausea and vomiting especially in the morning,
soon after getting out of bed, are usually common
in primigravidae.
•The exact cause is not known but it is thought to
be a combination of hormonal changes,
psychological adjustment and neurological factors
.
DIGESTIVE SYSTEM

87. Hormonal influences are thought to be most likely
cause .
Human chorionic gonadotrophin, that is present in
the large amount in the first trimester, estrogen,
and progesterone are all contribute to this .
The smell of food, cooking will often cause the
mother to this.

88. Three main measures can reduce the problem
To take the dry toast biscuit or cracker with the
drink before rising in the morning, avoidance of
spicy and pungent orders and eating little and often.
Eating small frequent meal will help to maintain the
body’s blood sugar level and having small amount
of fluids between meals will help to maintain
dehydration.
herbal remedy like ginger was likely effective
MANAGEMENT

89. •Avoid deep fried or greasy foods, garlic and other
spices and also avoid drinking coffee.

•Avoid brushing your teeth and tongue immediately
after eating.

•If vomiting become severe the mother may lose
weight and become dehydrated . This condition is
called hyperemesis gravidarum and wants
specialized care appropriate refferal

90. •This is a burning pain in the mediastinal region of
the chest caused by reflux of stomach content in the
esophagus .
•It occurs because the cardiac sphincter relaxes
during pregnancy due to the effect of progester
•The condition tends to worsen at 30-40 weeks
gestation because the stomach is displaced upward
by the enlarging uterus .
GASTRIC REFLUX (HEARTBURN)

91. If the heart burn is occasional the reflux can be
prevented by avoiding bending and kneeling.
sleeping with more pillows than usual.
maintaining upright positions (especially after
meals),
Wear loose-fitting clothing.
dietary modifications:- Fried and fatty food should
be avoided .
For persistent heart burn may be prescribe antacids
MANAGEMENT

92. This occur from eighth week of gestation
Women during pregnancy are occasionally
distressed by profuse salivation—ptyalism.
Although usually unexplained, ptyalism sometimes
appears to follow salivary gland stimulation by the
ingestion of starch.
It commonly occurs with hyperemesis gravidarum
(Bronshtein, 2018).
EXCESSIVE SALIVATION (Ptyalism)

93. Management
Brush your teeth, and use mouthwash several
times a day.
Eat small meals and don't eat a lot of starchy
food.
Drink plenty of water helps you stay hydrated.
Swallow any excess saliva if you can.
Also, try sucking on hard candy or chewing
sugarless gum.
If swallowing your saliva makes you feel
nauseated, spit out the excess

94. •This is the term used when mother craves certain
foods on unnatural substance such as coal.
•The cause is unknown but hormones and changes in
the metabolism are thought to contribute to this
Management:
•If the substances craved are harmful to the unborn
baby, the mother must be helped to seek medical
advice.
PICA

95. Constipation during Pregnancy is due to :
1.Reduced motility of large intestine (progesterone effect).
2.Increased water reabsorption from large intestine
(aldosterone effect).
3.Pressure on the pelvic colon by the pregnant uterus.
4.Sedentary(inactivity) life during pregnancy .
Management:
•Advice includes drinking plenty of fluids, high fiber foods and
get exercise.
•When fiber supplementation is not effective, stimulant
laxatives have been shown to be more effective but cause
abdominal pain.
CONSTIPATION

96. MUSCULOSKELETAL SYSTEM
•Pelvic pain:
–As the uterus grows, pulling and stretching of pelvic
structures causes ligament pain.
•Backache:
Causes:
1.Lumbar lordosis.
2.Relaxation of ligaments and intervertebral joints by
progesterone effect.
Management
Adequate rest and support the back when sitting in a
chair by a pillow.
Avoid wearing high heeled shoes
Avoid heavy lifting
Massaging the back muscle .

97. CRAMPS
Leg Cramps : Sudden gripping contraction of
calf muscles frequently occur during third
trimester . It is due to deficiency of diffusible
serum calcium or elevation of serum
phosphorous.
•Management:
 Make gentle leg movement,
massaging the legs, the application of
local heat.
Advice mother to reduce intake of soft
drink and processed food.
Supplementary calcium therapy.
Sleep with the foot end of the bed elevate

98. Frequency of micturition:
This occur in first trimester when there is presence of gravid
uterus on the urinary bladder.
It also occur in late pregnancy when the foetal head descent
into the pelvis .
Beside the urinary tract of the pregnant woman is more
susceptible to infection may lead to nephritis and preterm
delivery if not treated.
GENITOURINARY SYSTEM

99. Never restrict fluid intake .
In case of urine infection take a course of
antibiotics for urinary tract infection
MANAGEMENT

100. Leukorrhea : The term used for increase
white non-irritant vaginal discharge.
MANAGEMENT
Frequent washing of vulva with plain water.
Advice mother to wear cotton underwear and
avoid tight.
Presence of infection should be treated with
vaginal application of metronidazole and
meconazole.

LEUKORRHEA

101. 1. Fainting : In early pregnancy fainting may
occur due to vasodilation under influence of
progesterone and compensatory increase in
blood volume.
o In late pregnancy fainting may be due to
weight of uterine content presses on inferior
vena cava and slows the return of blood to
heart.
CIRCULATORY SYSTEM

102. Avoid long period of standing as well as sitting
or lying down.
Turning the mother quickly on to her side and
advice not to lie on her back except during
abdominal examination.
MANAGEMENT

103. 2. Varicose Vein :
Varicose vein in the legs and vulva and rectum my
appear for the first time or aggravate during
pregnancy usually in later months.
It is due to obstruction in the venous return by the
pregnant uterus.

104. Exercise calf muscle.
Resting with legs vertical against the wall for
short time.
Avoidance of constipation by including fiber in the
diet and adequate fluids.
Seeking medical advice for topical application like
hydrocortisone.
MANAGEMENT

105. 3. Edema: It is result of venous and lymphatic stasis
and changes in oncotic pressure of blood and altered
capillary permeability.
MANAGEMENT
Check the blood pressure if the mother has PIH
(Pregnancy induced hypertension).
Elevation of leg ,sleeping in left lateral position and
avoid sitting with feet hanging down.

106. Skin:
Mother complains of generalized itching
which start over the abdomen.
This is thought to have some connection with
the liver response to the hormone in
pregnancy and with raised bilirubin level.
INTEGUMENTARY SYSTEM

107. Antihistamines is often prescribed .
In case of vulvul irritation, infection such as
thrush washing with mild soap and cotton under
wear might help to ease the irritation .
MANAGEMENT

108. complaints of numbness and pins
PARAESTHESIA (Carpal tunnel syndrome :
mother




needles in their fingers and hands due to fluid
retention leads to compression of peripheral
nerves.
.
NERVOUS SYSTEM

109. •Wearing a splint at night
•Restriction of salt intake and flexing of finger
•Sitting in a straight back chair using a cushion
for lumbar support .
MANAGEMENT

110. •Insomnia:- It is caused by foetal movements
and frequency of micturition and difficulty in
finding comfortable position .

111. •Take rest in afternoon
•Drink glass of warm milk at bed time .
•Tuck a pillow under the abdomen when lying
in a lateral position.
MANAGEMENT

112. HAEMORRHOIDS
•They occur due to:
1.Mechanical pressure on the pelvic veins.
2.Laxity of the walls of the veins by progesterone.
3.Constipation.
•Management
•Treatment for haemorrhoids includes:
1.diet modification,
2.topical preparations and surgery.
–However, surgery is rarely considered since
haemorrhoids may resolve after delivery.