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Problems in Prenatal Care

Problems in Prenatal Care. First things first:. But there are challenges…. Poverty Violence Drugs and alcohol Smoking Environmental toxins Cross cultural care Transition to parenthood Discomforts of pregnancy Challenges in providing interdisciplinary care

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Problems in Prenatal Care

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  1. Problems in Prenatal Care

  2. First things first:

  3. But there are challenges… • Poverty • Violence • Drugs and alcohol • Smoking • Environmental toxins • Cross cultural care • Transition to parenthood • Discomforts of pregnancy • Challenges in providing interdisciplinary care • Medical complications of pregnancy (bleeding, hypertension, diabetes, infections, etc) • IUGR/assessment of fetal wellbeing • Preterm labor • Abnormal lie • Schedule challenges • Fetal death

  4. Objective of this session • Develop an awareness of some of the “problems” in prenatal care • Practice a family-medicine approach to problem-solving • Consider the need for interdisciplinary care of the pregnant woman and her fetus • Recognize the importance of the relationship between the family physician and pregnant patient in the provision of challenging prenatal care

  5. Case 1 • It is Friday afternoon. Your cellphone rings, and the answering service tells you Alice Smith has called and is having some bleeding. She is 35 weeks pregnant. She wants you to call her back…

  6. Case 2 • You are in your office with Sheena Wright, a 17y old G2P0 who is 28 weeks pregnant and whom you have been following for prenatal care. She missed her last appointment, so the last time you saw her was at 20 weeks. Her SFH is currently 24 cm.

  7. Points to consider • Small for gestational age: babies under the 10th percentile by US are SGA • SGA ≠ IUGR: IUGR babies are SGA because of a pathological process which inhibits them from reaching their full growth potential • Accurate dating is essential in order to assess possible IUGR • Uterine artery Dopplers may identify babies at risk of stillbirth and preterm delivery due to IUGR and placental disease • An US examination for EFW and AF volume should be considered after 26 weeks if the SF height deviates by 3cm or more, or if there is a plateau in SFH SOGC Intrauterine Growth Restriction: Screening, Diagnosis, and Management

  8. Case 3 • Meena Richards is a 20 year old woman with significant developmental disability and diagnosed schizophrenia. On a routine appointment for a depo-provera shot (for which she was a week late) she had a positive pregnancy test. She is now 16 weeks pregnant. What are your considerations?

  9. Points to consider • Consider psychotropic medication in pregnancy… • SSRIs are generally considered safe, with the possible exception of Paxil, though this is still debated • Anticonvulsants are considered to increase risk of birth defects • Antipsychotics are generally considered to be safe, though there is some concern around neuro-motor functioning during infancy, and minimal data on long term effects • Then consider the effects of not treating psychiatric conditions during pregnancy 2. Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk

  10. Points to consider (2) • Competency of persons with significant developmental disability • Child and family services involvement • Adult protective worker involvement (eg: Community Living Kingston, Ongwanada) • Public health: one on one prenatal counselling • Better Beginnings for Kingston Children: prenatal classes, parenting support • Frontenac Community Mental Health Services (FCMHS) for mental health support • ODSP: Special Diet Form for pregnant & breastfeeding women

  11. Case 4 • Elisha Makerere comes in for routine prenatal care at 36 weeks. You explain the GBS swab to her, ask how she is doing, and proceed to fetal auscultation. You are unable to find a fetal heart rate.

  12. Points to consider • 80-90% of women will spontaneously go into labor within 2 weeks of an intrauterine fetal death. However most do not want to wait, and induction is recommended. • Risks of waiting include coagulopathy, though this usually occurs after 4 weeks (which may occur in up to 25%) • In the 3rd trimester, induction occurs as it would in a live birth (ie with oxytocin) • In the 2nd trimester, WHO suggests the use of misoprostol intravaginally q6h • VBAC procedures are followed as in the case of a live birth • Psychological impact on the parents can be huge. Remember that this is a dead baby, not a failed or miscarried pregnancy. Up to Date: Diagnosis and management of stillbirth

  13. Case 5 • It is Saturday afternoon and you are lying in the sun. Your cellphone rings and the answering service tells you that Alice, who is now 38 weeks and 5 days, thinks her water is broken and wants you to call her back.

  14. Points to consider • Back to the initial questions: do you send her to the hospital, see her in clinic, or have her call you if it happens again? • Term PROM occurs in 8% of all pregnancies • Patient history has a 90% accuracy in diagnosis of PROM (!!) and should not be ignored • Avoid digital examination • Speculum examination to confirm diagnosis • GBS prophylaxis if indicated • Induction versus expectant management based on patient preference, logistics, and GBS status ALARM – SOGC Obstetrical Content Review Committee 2010

  15. Go to hospital

  16. Meet me at clinic

  17. Call me if it happens again

  18. I don’t know

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