gynecology and obstetrics
Evaluation of the Obstetric Patient
Treatment
Problems identified during evaluation are managed. Women are counseled about exercise and diet and advised to follow the Institute of Medicine guidelines for weight gain, which are based on prepregnancy body mass index (BMI—see table Guidelines for Weight Gain During Pregnancy* ). Nutritional supplements are prescribed. What to avoid, what to expect, and when to obtain further evaluation are explained. Couples are encouraged to attend childbirth classes. To provide nutrition for the fetus, most women require about 250 kcal extra daily; most calories should come from protein. If maternal weight gain is excessive (>1.4 kg/month during the early months) or inadequate (<0.9 kg/month), diet must be modified further. Weight-loss dieting during pregnancy is not recommended, even for morbidly obese women. Most pregnant women need a daily oral iron supplement of ferrous sulfate 300 mg or ferrous gluconate 450 mg, which may be better tolerated. Woman with anemia should take the supplements twice a day. All women should be given oral prenatal vitamins that contain folate 400 mcg (0.4 mg), taken once a day; folate reduces risk of neural tube defects. For women who have had a fetus or infant with a neural tube defect, the recommended daily dose is 4000 mcg (4 mg). Exercise during pregnancy has minimal risks and has demonstrated benefits for most pregnant women, including maintenance or improvement of physical fitness, control of gestational weight gain, reduction in low back pain, and possibly a reduction in risk of developing gestational diabetes or preeclampsia. Moderate exercise is not a direct cause of any adverse pregnancy outcome; however, pregnant women may be at greater risk of injuries to joints, falling, and abdominal trauma. Abdominal trauma can result in abruptio placentae, which can lead to fetal morbidity or death. Most experts agree that exercise during pregnancy is safe and can improve pregnancy outcomes (eg, reduced excessive gestational weight gain, gestational diabetes [ Treatment reference ]). Sexual intercourse can be continued throughout pregnancy unless vaginal bleeding, pain, leakage of amniotic fluid, or uterine contractions occur. The safest time to travel during pregnancy is between 14 and 28 weeks, but there is no absolute contraindication to travel at any time during pregnancy. Pregnant women should wear seat belts regardless of gestational age and type of vehicle. Travel on airplanes is safe until 36 weeks gestation. The primary reason for this restriction is the risk of labor and delivery in an unfamiliar environment. During any kind of travel, pregnant women should stretch and straighten their legs and ankles periodically to prevent venous stasis and the possibility of thrombosis. For example, on long flights, they should walk or stretch every 2 to 3 hours. In some cases, the clinician may recommend thromboprophylaxis for prolonged travel. Vaccines During Pregnancy for measles, mumps, rubella, and varicella should not be used during pregnancy. Thehepatitis B vaccinecan be safely used if indicated, and the influenza vaccine is strongly recommended for women who are pregnant or postpartum during influenza season. Booster immunization for diphtheria, tetanus, and pertussis (Tdap) between 27 and 36 weeks gestation or postpartum is recommended, even if women have been fully vaccinated. Although the COVID-19 vaccination has not been specifically evaluated in pregnant women, the American College of Obstetricians and Gynecologists (ACOG) recommends that COVID-19 vaccines not be withheld from pregnant women who meet the criteria for vaccination based on the Advisory Committee on Immunization Practices (ACIP) recommended priority groups. Various COVID 19 vaccines have received authorization for emergency use from the Food and Drug Administration (FDA) and the World Health Organization (WHO) as listed on its Emergency Use Listing. (See also the Because pregnant women with Rh-negative blood are at risk of developing Rh(D) antibodies, they are given Rh(D) immune globulin 300 mcg IM in any of the following situations: After any significant vaginal bleeding or other sign of placental hemorrhage or placental abruption After a spontaneous or therapeutic abortion After amniocentesis or chorionic villus sampling Prophylactically at 28 weeks If the neonate has Rh(D)-positive blood, after delivery Pregnant women should not use alcohol and tobacco and should avoid exposure to secondhand smoke. They should also avoid the following: Exposure to chemicals or paint fumes Direct handling of cat litter (due to risk of toxoplasmosis) Prolonged temperature elevation (eg, in a hot tub or sauna) Exposure to people with active viral infections (eg, rubella, parvovirus infection [fifth disease], varicella) Women with substance abuse problems should be monitored by a specialist in Overview of High-Risk Pregnancy . Drugs and vitamins that are not medically indicated should be discouraged (see Drug Safety in Pregnancy ). Women should be advised to seek evaluation for unusual headaches, visual disturbances, pelvic pain or cramping, vaginal bleeding, rupture of membranes, extreme swelling of the hands or face, diminished urine volume, any prolonged illness or infection, or persistent symptoms of labor. Multiparous women with a history of rapid labor should notify the physician at the first symptom of labor. 1.Syed H, Slayman T, Thoma KD: ACOG [American College of Obstetricians and Gynecologists] Committee Opinion No. 804: Physical activity and exercise during pregnancy and the postpartum period. 2020. PMID: 33481513. doi: 10.1097/AOG.0000000000004266 