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Instruct patient in symptoms and signs of preterm labor and rupture of membranes Consider cervical length measurement by ultrasound after 18 weeks with history of prior preterm delivery (> 25 cm is normal)
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Obtain adequate rest each day Abstain from strenuous physical work or activities, particularly when heavy lifting or weight bearing is required Exercise regularly at a mild to moderate level Avoid exhausting or hazardous exercises or new athletic training programs during pregnancy Heart rate should be kept below 140 beats/min during exercise
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G 24 Weeks to Delivery
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Ultrasound examination is performed as indicated Typically, fetal size and growth are evaluated when fundal height is 3 cm less than or more than expected for gestational age In multiple pregnancies, ultrasound should be performed every 4 weeks to evaluate for discordant growth
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Enroll with your partner in a childbirth preparation class well before your due date
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H 26 28 Weeks
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A Each Visit
Weight, blood pressure, fundal height, fetal heart rate are measured, and a urine specimen is obtained and tested for protein and glucose Review any concerns the patient may have about pregnancy, health, and nutrition
Screening for gestational diabetes by a 50-g glucose load (Glucola) and a 1-hour post-Glucola blood glucose determination Abnormal values should be followed up with a 3-hour glucose tolerance test (see Table 18 3)
I 28 Weeks
If initial antibody screen is negative, repeat antibody testing for Rh-negative patients, but result is not required before Rho(D) immune globulin is administered
B 6 12 Weeks
Confirm uterine size and growth by pelvic examination Document fetal heart tones (audible at 10 12 weeks of gestation by Doppler) Perform transvaginal chorionic villus sampling between 10 and 12 weeks when indicated or screening for trisomy 18, 21, and cardiac defects using
J 28 32 Weeks
Repeat the complete blood count to evaluate for anemia of pregnancy
CMDT 2008
K 28 Weeks to Delivery
Determine fetal position and presentation Question the patient at each visit for symptoms or signs of preterm labor or rupture of membranes Assess maternal perception of fetal movement at each visit Antepartum fetal testing is performed as medically indicated
NUTRITION IN PREGNANCY
Nutrition in pregnancy can affect maternal health and infant size and well-being Pregnant women should have nutrition counseling early in prenatal care and access to supplementary food programs if necessary Counseling should stress abstention from alcohol, smoking, and recreational drugs Caffeine and artificial sweeteners should be used only in small amounts Empty calories should be avoided, and the diet should contain the following foods: protein foods of animal and vegetable origin, milk and milk products, whole-grain cereals and breads, and fruits and vegetables especially green leafy vegetables Weight gain in pregnancy should be 20 40 lb, which includes the added weight of the fetus, placenta, and amniotic fluid and of maternal reproductive tissues, fluid, blood, increased fat stores, and increased lean body mass Maternal fat stores are a caloric reserve for pregnancy and lactation; weight restriction in pregnancy to avoid developing such fat stores may affect the development of other fetal and maternal tissues and is not advisable Obese women can have normal infants with less weight gain (15 20 lb) but should be encouraged to eat high-quality foods Normally, a pregnant woman gains 2 5 lb in the first trimester and slightly less than 1 lb/wk thereafter She needs approximately an extra 200 300 kcal/d (depending on energy output) and 30 g/d of additional protein for a total protein intake of about 75 g/d Appropriate caloric intake in pregnancy helps prevent the problems associated with low birth weight Rigid salt restriction is not necessary While consumption of highly salted snack foods and prepared foods is not desirable, 2 3 g/d of sodium is permissible The increased calcium needs of pregnancy (1200 mg/d) can be met with milk, milk products, green vegetables, soybean products, corn tortillas, and calcium carbonate supplements The increased need for iron and folic acid should be met from foods as well as vitamin and mineral supplements (See section on anemia in pregnancy) Megavitamins should not be taken in pregnancy, as they may result in fetal malformation or disturbed metabolism However, a balanced prenatal supplement containing 30 60 mg of elemental iron, 05 08 mg of folate, and the recommended daily allowances of various vitamins and minerals is widely used in the United States and is probably beneficial to many women with marginal diets There is evidence that periconceptional folic acid supplements can decrease the risk of neural tube defects in the fetus For this reason, the United States Public Health Service recommends the consumption of 04 mg of folic acid per day for all pregnant and reproductive age women Women with a prior pregnancy complicated by neural tube defect may require higher supplemental doses as determined by their providers Lactovegetarians and ovolactovegetarians do well in pregnancy; vegetarian women who eat neither eggs nor milk products should have their diets assessed for adequate calories and protein and should take oral vitamin B12 supplements during pregnancy and lactation
Rosello-Soberon ME et al Twin pregnancies: eating for three Maternal nutrition update Nutr Rev 2005 Sep;63(9):295 302 [PMID: 16220640]
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