Antenatal Care &

Preconception counselling
Sireen M. AL Attar , MD.
Arab, Jordanian & Palestinian Board
OB/GYN
• « To achieve the Every Woman Every Child vision and the Global
Strategy for Women's, Children's and Adolescents' Health, we need
innovative, evidence-based approaches to antenatal care. »

Ban Ki-moon, United Nations Secretary-General

 Preconceptional care

Postnatal care Antenatal care (prenatal care)

Safe delivery & natal care

• Prenatal care is perhaps the most important factor which determines the
outcome of pregnancy.
• It includes medical, nutritional, and educational interventions to reduce the
risk of adverse pregnancy conditions and outcomes.
• prenatal care is also important for identifying mothers at risk for delivering
a preterm infant.
• Today, prenatal care typically is initiated in the first trimester of pregnancy
and has an increasing schedule of visits as the pregnancy progresses.
Recommendations to Improve Preconception Health and Health Care - United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel
on Preconception Care. Rep. no. 55(RR06). Washington, DC, 2006. Centers for Disease Control and Prevention, 21 Apr. 2006. Web. 4 Mar. 2010.
 Preconception care

• Provides similar aspects but instead targets all women of reproductive age
during
adolescence and before the first pregnancy, as well as between pregnancies.
• The Center for Disease Control has defined preconception care as:
“Interventions that aim to identify and modify biomedical, behavioral and
social risks to a woman’s health or pregnancy outcome through
prevention and management by emphasizing those factors that must be
acted on before conception or early in pregnancy to have maximal impact.”
Recommendations to Improve Preconception Health and Health Care - United States: A Report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on
Preconception Care. Rep. no. 55(RR06). Washington, DC, 2006. Centers for Disease Control and Prevention, 21 Apr. 2006. Web. 4 Mar. 2010.
 Preconception care includes assessing and
identifying
•Nutritional status: fortification or supplementation of the diet with micronutrients such
as iron, iodine, and folic acid
•Preexisting medical conditions: treatment of conditions such as obesity, diabetes,
epilepsy, hypothyroidism, and hypertension
•Infectious diseases: vaccination against rubella, varicella, and hepatitis B; screening
for HIV/AIDS and other sexually transmitted infections
•Family planning for appropriately timed pregnancies
•Genetic disorders: genetic risk assessment and preconception counseling to reduce the
risk of birth defects.
The following goals were established for advancing preconceptional care:
•1. Improve knowledge, attitudes, and behaviors of men and women related to
preconceptional health.
•2. Assure that all women of childbearing age receive preconceptional care services—
including evidence-based risk screening, health promotion, and interventions—that will
enable them to enter pregnancy in optimal health.
•3. Reduce risks indicated by a previous adverse pregnancy outcome through
interconceptional interventions to prevent or minimize recurrent adverse outcomes.
•4. Reduce the disparities in adverse pregnancy outcomes.
 Why ??
• In many other parts of the world, the care of the mother before and during
pregnancy may still be of low standard or may be nonexistent.
• This is evidenced by the fact that every year, approximately 300,000 women die
of pregnancy-related causes, and 99% of these deaths occur in low- and middle-
income countries.
• WHO estimates that only 29-36% of African, 20-61% of Asian and 69-89% of
South American births have maternity care.
 
World Health Organization. Maternal Mortality Fact Sheet. Accessed 10 August 2017. <http://www.who.int/mediacentre/factsheets/fs348/en/>
• The high prevalence of many conditions that may be amenable to intervention during the
preconceptional and interpregnancy periods .
• To be successful, however, preventative strategies that mitigate these potential pregnancy
risks must be provided before conception.
• By the time most women realize they are pregnant—usually 1 to 2 weeks after the first
missed period—the embryo has already begun to form. Thus, many prevention strategies
—for example, folic acid to prevent neural-tube defects—will be ineffective if initiated at
this time.
• Importantly, up to half of all pregnancies are unplanned, and often these are at greatest risk
• Several preconception care models have been
developed. Risk
screening Physical
• The American Academy of Pediatrics and the American assessment
College of Obstetricians and Gynecologists classify the Preconception
care
main components of preconception care into four
categories: physical assessment, risk screening, counseling
vaccinatio
vaccinations, and counseling. n
 COUNSELING SESSION
• Evaluation includes a thorough review of the medical, obstetrical, social, and
family
histories.
• Useful information is more likely to be obtained by asking specific questions
regarding each history and each family member than by asking general, open-
ended questions.
• Some important information can be obtained by questionnaires that address these
topics.
• Answers are reviewed with the couple to ensure appropriate follow-up, including
obtaining relevant medical records.
 Components of Preconception Care

• Reproductive life plan:

Ask your patient if she plans to have children (or additional children if she is
already a mother) and how long she plans to wait until she becomes pregnant;
help her develop a plan, based on her values and resources, to achieve those
goals
• Reproductive history:
Review previous adverse pregnancy outcomes (e.g., infant death, fetal loss, birth
defects, low birth weight, preterm birth) and assess ongoing biobehavioral risks
that could lead to recurrence in a subsequent pregnancy
http://www.cdc.gov/ncbddd/preconception/default.htm,http://www.aafp.org/afp/20020615/2507.html).
• Medical history:
Ask if the patient has a history of conditions that could affect future pregnancies (e.g.,
rheumatic heart disease, thromboembolism, autoimmune diseases); screen for
ongoing chronic conditions such as hypertension and diabetes
• Medication use:
Review the patient's current medication use; avoid FDA pregnancy category X
medications and most category D medications unless potential maternal benefits
outweigh fetal risks; review the use of over-the-counter medications, herbs, and
supplements
• Infections and immunizations:
Screen for periodontal, urogenital, and sexually transmitted infections as indicated;
update immunization with hepatitis B, rubella, varicella, Tdap, human
papillomavirus, and influenza vaccines as needed; counsel the patient about
preventing TORCH infections
• Genetic screening and family history:
Assess the patient's risk of chromosomal or genetic disorders based on family history, ethnic
background, and age; offer cystic fibrosis and other carrier screening as indicated; discuss
management of known genetic disorders (e.g., phenylketonuria, thrombophilia) before and
during pregnancy
• Nutritional assessment:
Assess the ABCDs of nutrition: anthropometric factors (e.g., BMI), biochemical factors (e.g.,
anemia), clinical factors, and dietary risks
• Substance abuse:
Ask the patient about tobacco, alcohol, and drug use; use questionnaires to screen for alcohol
and substance abuse
• Toxins and teratogenic agents:
Counsel the patient about possible toxins and exposure to teratogenic agents at home, in the
neighborhood, and in the workplace (e.g., heavy metals, solvents, pesticides, endocrine
disruptors, allergens)
• Psychosocial concerns:
Screen for depression, anxiety, domestic violence, and major psychosocial
stressors
• Physical examination:
Focus on periodontal, thyroid, heart, breast, and pelvic examinations

Laboratory testing:
Testing should include a complete blood count; urinalysis; blood type and
screen; and, when indicated, screening for rubella, syphilis, hepatitis B, human
immunodeficiency virus, gonorrhea, chlamydia, and diabetes and cervical
cytology; consider measuring thyroid-stimulating hormone levels
Health promotion
• Family planning:
Promote family planning based on the patient's reproductive life plan; for women who are
not planning to become pregnant, promote effective contraceptive use and discuss
emergency contraception
• Healthy weight and nutrition:
Promote a healthy prepregnancy weight (ideal BMI is 19.8 to 26.0 kg per m2) through
exercise and nutrition; discuss macro- and micronutrients, including getting “five-a-day”
(i.e., two servings of fruit and three servings of vegetables) and taking a daily
multivitamin that contains folic acid
• Healthy behaviors:
Promote healthy behaviors such as nutrition, exercise, safe sex, effective contraceptive use,
dental flossing, and use of preventive health services; discourage risky behaviors such as
douching, not wearing a seatbelt, smoking (e.g., use the five A's [Ask, Advise, Assess,
Assist, Arrange] for smoking cessation, and alcohol and substance abuse
• Stress resilience:
Promote nutrition, exercise, sufficient sleep, and relaxation techniques; address
ongoing stressors (e.g., domestic violence); identify resources to help the
patient develop problem-solving and conflict-resolution skills, positive mental
health, and strong relationships
• Healthy environments:
Discuss household, neighborhood, and occupational exposures to heavy metals,
organic solvents, pesticides, endocrine disruptors, and allergens; give practical
tips such as how to avoid exposures
• Interconception care:
Promote breastfeeding, placing infants on their backs to sleep to reduce the risk
of sudden infant death syndrome, positive parenting behaviors, and the
reduction of ongoing biobehavioral risks
Medical and psychosocial interventions for identified risks

Interventions should address identified medical and psychosocial risks;

examples include folic acid supplementation, testing for rubella
seronegativity and vaccination if indicated, tight control of pregestational
diabetes, careful management of hypothyroidism, and avoidance of
teratogenic agents (e.g., isotretinoin [Accutane], warfarin [Coumadin], some
antiseizure medications, alcohol, tobacco)
 Prenatal care
• The essence of prenatal care is described by the American Academy of Pediatrics and
the American College of Obstetricians and Gynecologists (2007) as: “A comprehensive
antepartum care program involves a coordinated approach to medical care and
psychosocial support that optimally begins before conception and extends
throughout the antepartum period.” This comprehensive program includes:
1. Preconceptional care
2. Prompt diagnosis of pregnancy
3. Initial prenatal evaluation
4. Follow-up prenatal visits.
 Diagnosis of pregnancy
• Pregnancy is usually identified when a woman presents with symptoms
and possibly a positive home urine pregnancy test result.
• Typically, such women receive confirmatory testing of urine or blood for
human chorionic gonadotropin (hCG).
• Further, there may be presumptive or diagnostic findings of pregnancy
during examination.
 Signs and Symptoms
• Amenorrhea
• Lower-Reproductive-Tract Changes
• Chadwick sign :During pregnancy, the vaginal mucosa usually appears
dark bluish red and congested
• Changes in cervical mucus
• Uterine Changes
• At 6 to 8 weeks’ menstrual age, the firm cervix contrasts with the now
softer fundus and the compressible interposed softened isthmus—Hegar
sign.
• uterine soufflé
• funic souffle
• Breast and Skin Changes
1. Increased pigmentation …
2. Appearance of abdominal striae.
3. Seen in women taking estrogen-progestin contraceptives
• Fetal Movement
• A primigravida may not appreciate fetal movements until approximately 18 to 20
weeks.
• Multigravida may first perceive fetal movements between 16 and 18 weeks.
 Pregnancy Tests
• Detection of hCG in maternal blood and urine is the basis for endocrine assays
of pregnancy. This hormone is a glycoprotein with high carbohydrate content.
• Syncytiotrophoblast produce hCG in amounts that increase exponentially
during the first trimester following implantation. With a sensitive test, the
hormone can be detected in maternal serum or urine by 8 to 9 days after
ovulation. The doubling time of serum hCG concentration is 1.4 to 2.0 days

• Williams OBSTETRICS, 2 4 ed ,prenatal care

Sonographay
• The use of transvaginal sonography has revolutionized imaging of early
pregnancy and its growth and development.
• A gestational sac may be demonstrated by abdominal sonography after
only 4 to 5 weeks
• By 35 days, a normal sac should be visible in all women, and after 6
weeks, heart motion should be seen.
• Up to 12 weeks, the crown-rump length is predictive of gestational age
within 4 days
FIGURE 9-3 Transvaginal sonogram of a first-
trimester intrauterine
pregnancy. The double decidual sign is noted
surrounding the gestational
sac and is defined by the decidua parietalis (white
asterisk)
and the decidua capsularis (yellow asterisk). The
arrow notes the
yolk sac, and the crown-rump length of the
embryo is marked with
measuring calipers. (Image contributed by Dr.
Elysia Moschos.)
• Presumptive signs of pregnancy
Signs and symptoms suggestive of pregnancy that may also indicate another condition. They occ
ur early and  aremore subjective than other signs. The presumptive signs
 are amenorrhea, nausea and vomiting, frequent urination, and fatigue
• Probable signs of pregnancy
The probable signs are more certain than presumptive signs but are not definitive. They include e
levation of basalbody temperature, breast tenderness and swelling, chloasma, linea nigra, Chad
wick sign, abdominal enlargement,softening of the cervix, ballotability of the uterus, quickeni
ng, and positive pregnancy test results.
• POSITIVE SIGNS OF PREGNANCY
• Positive signs of pregnancy are signs that cannot, under any
circumstances, be mistaken for other conditions, and are evidence that
pregnancy has occurred.
• These signs include fetal heart sounds by a Doppler in the doctor's office,
ultrasound detection of the fetus, or the movement of the fetus felt by a
doctor. These signs cannot be brought on by any other condition. 
 Initial Prenatal Evaluation
• Major goals are to:
1. Define the health status of the mother and fetus.
2. Estimate the gestational age.
3. Initiate a plan for continuing obstetrical care

• The initial plan for subsequent care may range from relatively infrequent routine
visits to prompt hospitalization because of serious maternal or fetal disease.

• Initial prenatal Evaluation includes: Prenatal record, History, Physical

examination, Lab tests and determining high-risk pregnancies
 Definitions
• There are several definitions pertinent to establishment of an accurate prenatal record.
• 1. Nulligravida—a woman who currently is not pregnant nor has ever been pregnant.
• 2. Gravida—a woman who currently is pregnant or has been in the past, irrespective of the pregnancy outcome. With the
establishment of the first pregnancy, she becomes a primigravida, and with successive pregnancies, a multigravida.
• 3. Nullipara—a woman who has never completed a pregnancy beyond 20 weeks’ gestation. She may not have been
pregnant or may have had a spontaneous or elective abortion(s)
• or an ectopic pregnancy.
• 4. Primipara—a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated
length of gestation of 20 or more weeks. In the past, a 500-g birthweight threshold was used to define parity.
• Multipara—a woman who has completed two or more pregnancies to 20 weeks’
gestation or more. Parity is determined by the number of pregnancies reaching 20
weeks.

• Sometimes the obstetrical history is summarized by a series of digits connected

by dashes.
• These refer to the number of term infants, preterm infants, abortuses less than 20
weeks, and children currently alive.
For example: para 2–1–0–3
Normal Pregnancy Duration.

• The mean duration of pregnancy calculated from the first day of the last
normal menstrual period is very close to 280 days or 40 weeks.

• It is customary to estimate the expected date of delivery by adding 7 days

to the date of the first day of the last normal menstrual period and counting
back 3 months—Naegele’s rule
 Trimesters

• Pregnancy is divided into three equal time intervals of approximately 3 calendar months for
each trimester.

• The first trimester extends through completion of 14 weeks, the second through 28 weeks, and
the third includes the 29th through 42nd weeks of pregnancy. Thus, there are three periods of
14 weeks each.

• Certain major obstetrical problems tend to cluster in each of these time periods

• In modern obstetrics, the clinical use of trimesters to describe a specific pregnancy is too
imprecise. Appropriate management for the mother and her fetus will vary remarkably.
 History
• Detailed information concerning past obstetrical history is crucial because many prior
pregnancy complications tend to recur in subsequent pregnancies.

• The menstrual history : Without a history of regular, predictable, cyclic, spontaneous

menses that suggest ovulatory cycles, accurate dating of pregnancy by history and
physical examination is difficult.

• Steroidal Contraceptives: ovulation may not have resumed 2 weeks after the onset of
the last withdrawal bleeding and instead may have occurred at an appreciably later
and highly variable date, using the time of ovulation for predicting the time of
conception in this circumstance may be erroneous…
 Psychosocial Screening:
• The American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists (2012) define psychosocial issues as
nonbiomedical factors that affect mental and physical well-being. Women
should be screened regardless of social status, education level, race, or
ethnicity.
• Cigarette Smoking:
• Cessation of smoking
• Alcohol
• Illicit drug
 Clinical Evaluation
• Pelvic examination is performed as part of the evaluation. The cervix is
visualized employing a speculum lubricated with warm water or water-
based lubricant gel. Bluish-red passive hyperemia of the cervix is
characteristic, but not of itself diagnostic, of pregnancy.
• Dilated, occluded cervical glands bulging beneath the ectocervical mucosa
—nabothian cysts—may be prominent

• Estimation of gestational age

 Laboratory Tests
• Recommended routine tests at the first prenatal encounter are: .
• Initial blood tests include a complete blood count, a determination of blood type with
Rh status, and an antibody screen. The Institute of Medicine recommends universal
human immunodeficiency virus (HIV) testing, with patient notification and right of
refusal, as a routine part of prenatal care. The Centers for Disease Control and
Prevention (2006) as well as the American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2012) continue to support this practice. If a
woman declines testing, this should be recorded in the prenatal record.
• All pregnant women should also be screened for hepatitis B virus,
syphilis, and immunity to rubella at the initial visit. Based on their
prospective investigation of 1000 women, Murray and coworkers (2002)
concluded that in the absence of hypertension, routine urinalysis beyond
the first prenatal visit was not necessary. A urine culture is performed
because treating asymptomatic bacteruria significantly reduces the
likelihood of developing symptomatic urinary tract infections in
pregnancy
Pregnancy Risk
Assessment
 Subsequent Prenatal Visits
• Scheduled at intervals of 4 weeks until 28 weeks, and then every 2 weeks
until 36 weeks, and weekly thereafter.

• Women with complicated pregnancies often require return visits at 1- to 2-

week intervals.

• At each return visit, steps are taken to determine the well-being of mother
and fetus
 Evaluation typically includes:
Fetal
• Heart rate(s)
• Size—current and rate of change
• Amount of amnionic fluid
• Presenting part and station (late in pregnancy)
• Activity

Maternal
• Blood pressure
• Weight—current and amount of change
• Symptoms
• Height in centimeters of uterine fundus from symphysis
• Vaginal examination late in pregnancy
• Assessment of Gestational Age is one of the most important
determinations at prenatal examinations.

1- Through a carefully performed clinical examination, coupled with

knowledge of the time of onset of the last menstrual period.

2- Fundal Height. Between 20 and 34 weeks

* The bladder must be emptied
* Obesity may also distort this relationship.
 Fetal Heart Sounds.
* The fetal heart can first be heard in most women between 16 and 19
weeks when carefully auscultated with a standard nonamplified
stethoscope.
* The fetal heart rate ranges from 110 to 160 bpm and is heard as a double
sound.
* Because the fetus moves freely in amnionic fluid, the site on the maternal
abdomen where fetal heart sounds can be heard best will vary.
* Instruments incorporating Doppler ultrasound instruments are often used
to easily detect fetal heart action, almost always by 10 weeks
*Using sonography with a vaginal transducer, fetal cardiac activity can be
seen as early as 5 menstrual weeks.
 Sonography.

* Many women have an initial sonographic evaluation as part of first-trimester

aneuploidy screening, followed by a standard examination in the second
trimester to evaluate fetal anatomy.

* The American College of Obstetricians and Gynecologists has concluded that a

physician is not obligated to perform sonography without a specific indication in
a low-risk patient, but that if she requests sonography, it is reasonable to honor
her request.
 Subsequent Laboratory Tests
*If initial results were normal, most tests need not be repeated

* Fetal aneuploidy screening may be performed at 11 -14 weeks and/or at 15 -

20 weeks

* Screening for neural-tube defects is offered at 15 to 20 weeks

* Hematocrit or hemoglobin determination, along with syphilis serology if it is

prevalent in the population, should be repeated at 28 -32 weeks
* Women who are D (Rh) negative and are unsensitized should have an
antibody screening test repeated at 28 - 29 weeks, with administration of
anti-D immune globulin if they remain unsensitized.

* Cystic fibrosis carrier screening should be offered to couples with a

family history of cystic fibrosis. Ideally, screening is performed before
conception or during the first or early second trimester.
Group B Streptococcal (GBS) Infection: Vaginal and rectal GBS cultures be
obtained in all women between 35 and 37 weeks.

* Intrapartum antimicrobial prophylaxis is given for those whose cultures are

positive.

* Women with GBS bacteriuria or a previous infant with invasive disease are
given empirical intrapartum prophylaxis.
Gestational Diabetes. All pregnant women should be screened for gestational
diabetes mellitus.
* laboratory testing between 24 and 28 weeks is the most sensitive approach

Gonococcal Infection. Risk factors for gonorrhea are similar for those for
Chlamydia.
* Pregnant women with risk factors or symptoms be tested for N. gonorrhoeae at
an early prenatal visit and again in the third trimester.
* Treatment is given for gonorrhea as well as possible coexisting chlamydial
infection
• Screening for gestational diabetes using risk factors is recommended in a healthy population.
At the booking appointment, the following risk factors for gestational diabetes should be
determined:
• body mass index above 30 kg/m2
• previous macrosomic baby weighing 4.5 kg or above
• previous gestational diabetes
• family history of diabetes (first-degree relative with diabetes)
• family origin with a high prevalence of diabetes: South Asian (specifically women whose
country of family origin is India, Pakistan or Bangladesh) black Caribbean Middle Eastern
(specifically women whose country of family origin is Saudi Arabia, United Arab Emirates,
Iraq, Jordan, Syria, Oman, Qatar, Kuwait, Lebanon or Egypt).
• Women with any one of these risk factors should be offered testing for gestational diabetes.

NICE guidelines,antenatal-care-for-uncomplicated-pregnancies-pdf-975564597445.pd
 NUTRITION
Recommendations for Weight Gain
• In 1990, the Institute of Medicine recommended a weight gain of
25 to 35 lb—11.5 to 16 kg—for women with a normal
prepregnancy body mass index (BMI).
• Weight gains recommended by the Institute of Medicine
according to prepregnant BMI categories
• Currently the focus is on the obesity epidemic.

• This likely explains renewed interest in lower weight gains

during pregnancy.

• Obesity is associated with significantly increased risks for:

*Gestational hypertension *Preeclampsia
*Gestational diabetes *Macrosomia
*Cesarean delivery.
Weight Retention after Pregnancy
• Not all the weight gained during pregnancy is lost during and immediately after
delivery
• Most maternal weight loss is at delivery approximately 12 lb or 5.5 kg—and in the
2 weeks following— approximately 9 lb or 4 kg.
• An additional 5.5 lb or 2.5 kg was lost between 2 weeks and 6 months postpartum.
• Thus, average total weight loss resulted in an average retained pregnancy weight
of 3 lb or 1.4 kg.

• Overall, the more weight gained during pregnancy, the more that was lost
postpartum. Interestingly, there is no relationship between prepregnancy BMI or
prenatal weight gain and weight retention
Recommended Dietary Allowances
• Certain prenatal vitamin–mineral supplements may lead to intakes well in excess of
the recommended allowances. Moreover, the use of excessive supplements, which
often are self-prescribed, has led to concern about nutrient toxicities during
pregnancy
• Those with potentially toxic effects include iron, zinc, and vitamins A, B6, C, and D
• In particular, excessive vitamin A—more than 10,000 IU per day—may be
teratogenic
• Vitamin and mineral intake more than twice the recommended daily dietary
allowance should be avoided
Calories

• Pregnancy requires an additional 80,000 kcal, most are

accumulated in the last 20 weeks.

• To meet this demand, a caloric increase of 100 to 300 kcal per day
is recommended during pregnancy

• whenever caloric intake is inadequate, protein is metabolized rather

than being spared for its vital role in fetal growth and development.
Protein

• To the basic protein needs of the nonpregnant woman are added the
demands for growth and remodeling of the fetus, placenta, uterus, and
breasts, as well as increased maternal blood volume

• During the second half of pregnancy, approximately 1000 g of protein

are deposited, amounting to 5 to 6 g/day

• The concentrations of most amino acids in maternal plasma fall

markedly. Exceptions during pregnancy are glutamic acid and alanine
Minerals

• Iron. Of the approximately 300 mg of iron transferred to the fetus and placenta
and the 500 mg incorporated into the expanding maternal hemoglobin mass,
nearly all is used after midpregnancy.
• Iron requirements imposed by pregnancy and maternal excretion total
approximately 7 mg per day
• At least 27 mg of ferrous iron supplement be given daily to pregnant women.
• The woman who is overtly anemic from iron deficiency responds well to oral
supplementation with iron salts
• Withholding iron supplementation during the first trimester of pregnancy avoids
the risk of aggravating nausea and vomiting
• Calcium: The pregnant woman retains approximately 30 g of calcium, most
of which is deposited in the fetus late in pregnancy
• This amount of calcium represents only approximately 2.5 percent of total
maternal calcium, most of which is in bone, and which can readily be mobilized
for fetal growth
• Zinc: Severe zinc deficiency may lead to poor appetite, suboptimal growth,
and impaired wound healing. Profound zinc deficiency may cause dwarfism and
hypogonadism. It may also lead to a specific skin disorder, acrodermatitis
enteropathica…
• The recommended daily intake during pregnancy is approximately 12 mg.
Vitamins
•Folic Acid: more than half of all neural-tube defects can be prevented
with daily intake of 400 g of folic acid throughout the periconceptional
period
•Because nutritional sources alone are insufficient, however, folic acid
supplementation is still recommended by the American College of
Obstetricians and Gynecologists

•A woman with a prior child with a neural-tube defect can reduce the 2- to
5-percent recurrence risk by more than 70 percent with daily 4-mg folic
acid supplements the month before conception and during the first
trimester
• Vitamin A: Dietary intake of vitamin A in the United States appears to
be adequate, and routine supplementation during pregnancy is not
recommended by the American College of Obstetricians and Gynecologists.
• Conversely, there is an association of birth defects with very high doses
during pregnancy— 10,000 to 50,000 IU daily.

• Vitamin C: The recommended dietary allowance for vitamin C during

pregnancy is 80 to 85 mg/day—about 20 percent more than when
nonpregnant
• Vitamin B-12:Maternal plasma vitamin B12 levels decrease in
normal pregnancy and result mostly from reduced plasma levels of
carrier proteins
• Excessive ingestion of vitamin C also can lead to a functional
deficiency of vitamin B12. Although its role is still controversial,
low levels of vitamin B12 preconceptionally, similar to folate, may
increase the risk of neural-tube defects
1. Advise the pregnant woman to eat what she wants in amounts she desires and
salted to taste.
2. Ensure that there is ample food available in the case of socioeconomically
deprived women.
3. Monitor weight gain, with a goal of approximately 25 to 35 lb in women with a
normal BMI.
4. Periodically explore food intake by dietary recall to discover the occasional
nutritionally absurd diet.
5. Give tablets of simple iron salts that provide at least 27 mg of iron daily. Give
folate supplementation before and in the early weeks of pregnancy.
6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks to detect
any significant decrease.
 Common Concerns
• Employment
• Exercise
• Fish Consumption
• Air travel
• Coitus
• Dental Care
• Nausea and vomitting
• Hemorrhoids
• Heartburn
• Leukorrhea
Thanks