Antenatal care

1
Antenatal care

• Piyawadee Wuttikonsammakit,M.D.

2
Scope

• ???????????????????????????
• Risk detection hypertension in pregnancy,
  gestational DM, elderly gravida, thalassemia,
  size ? date

3
Diagnosis of pregnancy

• Signs symptoms cessation of menstruation,
  hyperemesis, breast changes, uterus and cervical
  changes, perception of fetal movements
• Pregnancy test UPT, ßhCG
• Ultrasonographic findings

4
Major goals of prenatal evaluation

• Define the health status of the mother and fetus
• Estimate the gestational age
• Initiate a plan for continuing obstetrical care

5
History

• Menstrual history interval, duration, LMPPMP,
  contraception
• Past obstetrical history
• Past history underlying disease, surgery
• Family history
• Personal history alcohol, cigarette
• Psychosocial screening transportation, child
  care, family support, unintended pregnancy,
  nutrition, depression
• Updated history taking every visit (symptoms)

6
EDC (EXPECTED DATE OF CONFINEMENT)

• LMP 7 ??? 3 ?????
• ?????????? ????????????????? interval, duration,
  amount (pad/day), PMP
• Contraception
• Quickening

7
Past obstetric history

• ???? ????????? ?????????????????? route of
  delivery ??????????? ??????????????????????
  ??????? ????????????????????????
• ???????????????????????????????? ???? ???????
  ???????????? ????????????? ???????????????????????
  
• ???? ?????? ??????????? ?????????
  ??????????????? ??? termination of pregnancy
  ?????????

8
Past history

• ??????????? ???????? ??????????????? ???????
  ??????? ???????? ??????????????? status,
  ????????????????
• ????????????? ??????????????????? ????????
  ????????? ?????????????????
• ??????????????? ??????? ???????????????
  ???????????????

9
????????????????????

• ???????????????
• ??????????
• ???????????????????
• ???????????
• ???????????
• ????????? ??????????????
• ??????????????????????????????
• ????????????????????????
• ???????
• ?????????????

10
Physical examination

• General physical examination especially first
  visit
• Pelvic examination (consider)
• Every visit
• BP
• Body weight
• Fundal height
• Leopolds maneuver fetal position
• FHR

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Hypertension in pregnancy

• Gestational hypertension
• Mild preeclampsia
• Severe preeclampsia
• Chronic hypertension
• Chronic hypertension with superimposed
  preeclampsia

13
Gestational hypertension

• BP gt 140/90
• No proteinuria
• BP returns to normal before 12 weeks postpartum
• Final diagnosis made only postpartum
• May have SS of preeclampsia epigastric
  discomfort or thrombocytopenia

14
Preeclampsia

• Mild preeclampsia BP gt 140/90 after 20 weeks,
  proteinuria gt 300 mg/24hours or gt 1 dipstick
• Severe preeclampsia BP gt 160/110, proteinuria
  2.0 g/24 hours or gt 2 dipstick, Cr gt 1.2,
  platelets lt 100,000, MAHA, elevated ALT or AST,
  presistent headache or visual disturbance,
  epigastric pain
• Eclampsia seizures

15
Chronic hypertension

• Chronic hypertension
• BP gt 140/90 before pregnancy or Dx before 20
  weeks
• or Dx after 20 weeks and persistent after 12
  weeks postpartum
• Superimposed preeclampsia
• New onset proteinuria, but no proteinuria before
  20 weeks
• A sudden increase in proteinuria or BP or
  platelet lt 100,000

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Recommendations for weight gain
Category BMI (kg/m2) Recommended TWG (kg)
Low lt19.8 12.5-18
Normal 19.8-26 11.5-16
High 26-29 7-11.5
Obese gt29 gt7
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Fundal height
20
Size ? date

• Size ? date
• Wrong date
• Full bladder
• Molar pregnancy
• Multifetal pregnancy
• Polyhydramnios
• Macrosomia
• Myoma
• Ovarian tumor

• Size ? date
• IUGR
• Fetal death
• Wrong date

21
Size ? date

• Ultrasound

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Leopolds maneuver
24
Leopolds maneuver
25
Leopolds maneuver
26
Leopolds maneuver
27
Breech or transverse

• Ultrasound confirm
• Refer for delivery

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Assessment of GA

• The most important
• Fundal height Jeminez 20-34 wk
• Fetal heart sound stethoscope 16-19wk, heard in
  all by 22 wk, Doptone 10 wk, TVS 5-6wk
• Sonography first trimester screening for
  aneuploidy followed by a standard scan in second
  trimester

32
GA estimation in late trimester

• Late pregnancy US measurements should never be
  used to change an EDC established by an
  examination performed earlier in pregnancy.
• A single late examination cannot reliably
  distinguish between a pregnancy that is misdated
  and younger than expected, and a pregnancy that
  is complicated by fetal growth restriction.

33
Which biometric parameters?

• BPD ? 3-4 weeks in mid to late third trimester
• FL ? 2.1 - 3.5 weeks in third trimester
• Multiple biometric parameters ? the best test
  performance with the least variability
• Additional measurement transverse cerebellar
  diameter, cardiac area/circumference
• When menstrual dates are discordant with the GA
  suggested by a late pregnancy US? serial
  measurements

34
Additional parameters
Transverse cerebellar diameter (TCD)
Cardiac area/circumference (CA/CC)
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Lab ANC
Lab First visit 15-20 wk 24-28 wk 29-41 wk
Hct or Hb (28-32wk)
Blood type Rh
AntiHIV (high risk)
VDRL (high risk)
HBsAg
Antibody screen (28 wk Rhogram if unsensitized)
GCT
PAP smear
Fetal aneuploidy screening (offered)
Rubella Ab
UA, U/C
GBS culture (35-37wk)
37
Immunization
Vaccine Type Indications during pregnancy
Measles, Mumps, Rubella, Varicella, Smallpox Live attenuated Contraindicated
Poliomyelitis, yellow fever Live attenuated Travel to high-risk areas
Influenza Inactivated virus vaccine All women, regardless of trimester
Rabies Killed virus Postexposure prophylaxis
Hepatitis B Live attenuated Prepostexposure for high-risk women
Typhoid Killed or live attenuate oral Travel to high-risk areas
38
Immunoglobulins Toxoid
Vaccine Indication
Hepatits B Ig (HBIG) Postexposure prophylaxis
Rabies Ig (ERIC, HRIG) Postexposure prophylaxis
Tetanus antitoxin (TAT) Postexposure prophylaxis
Varicella Ig (VZIG) Within 96 hr of exposure Also indicated for NB of women who developed varicella within 4 days before or 2 days following delivery

• Tetanus toxoid combined tetanus-diphtheria
  toxoids preferred
• Primary 1,2,6-12 mo
• Booster single dose every 10 years after
  completion

39
???????????????? Lab

• VDRL reactive
• HBsAg-positive
• AntiHIV positive
• Rh-negative

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Syphilis

• Primary syphilis ulcer, chancre
• Secondary syphillis skin rash, mucocutaneous
  lesion, lymphadenopathy
• Neurologic syphilis cranial nerve dysfunction,
  meningitis, stroke, altered mental status, loss
  vibration sense, auditory or ophthalmic
  abnormalities
• Tertiary syphilis cardiac or gummatous lesions

41
VDRL - reactive

• Latent syphilis serologic positive, lacking
  clinical manifestation
• Early latent syphilis acquired within the
  preceding year
• All other cases of latent syphilis are either
  late latent syphilis or latent syphilis of
  unknown duration.
• Diagnosis FTA-ABS
• VDRL decline after treatment

42
Treatment latent syphilis in pregnancy

• Benzathine Penicillin G 2.4 million unit IM 3
  doses at 1 week interval
• Pregnant patients who are allergic to penicillin
  should be desensitized and treated with
  penicillin
• Alternative for late latent or unknown
• Doxycycline (100 mg orally twice daily) or
  tetracycline (500 mg orally four times daily),
  both for 28 days (not used in pregnancy)
• Ceftriaxone 2 gm IM 10-14 days (insufficient
  data)
• Erythromycin and azithromycin should not be used,
  because neither reliably cures maternal infection
  or treats an infected fetus

43
Treatment latent syphilis in pregnancy

• Sonographic signs of fetal and placental syphilis
  (i.e. hepatomegaly, ascites, hydrops, fetal
  anemia, or a thickened placenta) indicate a
  greater risk for fetal treatment failure
• Women treated for syphilis during the second half
  of pregnancy are at risk for premature labor,
  fever and/or fetal distress if the treatment
  precipitates the Jarisch-Herxheimer reaction

44
Rh -negative

• D-negative nonsensitized mother
• AntiD immunoglobulin 300 ug IM at 28 weeks and
  after delivery
• Sensitized mother (AntiD titer 116)
• Follow up MCA PSV gt 1.5 MoM
• Intrauterine transfusion

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Cause of fetomaternal hemorrhage

• Early pregnancy loss
• Miscarriage
• Missed abortion
• Elective abortion
• Ectopic pregnancy
• Procedures
• Chorionic villus sampling
• Amniocentesis
• Fetal blood sampling
• Other
• Idiopathic
• Maternal trauma
• Manual placental removal
• External version

46
Asymptomatic bacteriuria (ASB)

• Persistent, actively multiplying bacteria within
  the urinary tract in asymptomatic women
• Prevalence 5-6
• A clean-voided urine culture containing more than
  100,000 organisms per milliliter is diagnostic
• If not treat, 25 will develop symptomatic
  infection during pregnancy
• If prevalence is low, the screening leukocyte
  esterase-nitrite dipstick may be used

47
ASB treatment

• Single dose treatment
• Amoxicillin 3 gm
• Ampicillin 2 gm
• Cephalosporin 2 gm
• Nitrofurantoin 200 mg
• TMP/SMZ 320/1600 mg

• 3 day course
• Amoxicillin 500 mg 1x3
• Ampicillin 250 mg 1x4
• Cephalosporin 250 1x4
• Ciprofloxacin 250 1x2
• Levofloxacin 250 1x1
• Nitrofurantoin 100 mg 1x2
• TMP/SMZ 180/800 1x2

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Complication in first trimester

• Abortion
• Blighted ovum (anembryonic pregnancy)
• Embryonic death
• Ectopic pregnancy
• Molar pregnancy

49
Blighted ovum threshold criteria

• Anembryonic pregnancy
• TAS
• MSD 20 mm. without yolk sac
• MSD 25 mm. without embryo
• TVS
• MSD 8 mm. without yolk sac
• MSD 16 mm. without embryonic pole

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Blighted ovum

• 22 (135 pt) without yolk sac seen at 8 mm. MSD
  go on pregnancy
• 8 (59 pt) with MSD gt16 mm. but no embryonic pole
  later develop live embryo

Rowling SE, Coleman BG, Langer JE, et al.
First-trimester US parameters of failed
pregnancy. Radiology. 1997 203211217.
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Common high risk pregnancy

• Elderly gravida
• Couple at risk thalassemia
• GDM
• Obstetric complication preterm, PROM, twin,
  placenta previa, previous C/S, postterm
• Fetal complication IUGR, fetal anomalies
• Medical disease Heart disease, renal disease,
  SLE, anemia, thyroid disease

53
Elderly gravida

• Risk Down syndrome
• Screening DM

54
???????????????????????(??????????)???????????????
?????????????????????
????
55
Advanced maternal age
56
???????????? ??????? ?????? ???????
???????? ????????? ????????????????????
?????,????????????, ???????????????????
57
????????? Down syndrome

• Trisomy 21 (nondisjunction during meiosis) 95
• Translocation
• Mosaicism

Recurrence risk 1 for any trisomy until it is
exceeded by her age-related risk
58
Prenatal diagnosis

• Chorionic villi sampling
• Perform at 10-13 wk
• Transcervical or transabdominal
• Complication
• Fetal loss rate 3.5
• AF leakage infection lt 0.5
• Limitation
• Contamination
• Uninformative result inadequate tissue,
  confined placental mosaicism

59
Prenatal diagnosis

• Amniocentesis
• Perform at 16-20 wk
• Complications
• Fetal loss rate 0.5
• AF leakage 1
• Chorioamnionitis lt0.1
• Needle injury to fetus very rare

60
Prenatal diagnosis

• Fetal blood sampling
• Cordocentesis Ultrasond-guided umbilical cord
  needling
• Perform at 18 wk up
• Complication
• Fetal loss rate 1.4
• Cord hematoma 17
• Bradycardia 3-12
• Fetomaternal hemorrhage 40
• Infection lt1

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???????????????????????????????

• CBC with platelet
• (PT, PTT ?????????????????????????????????????????
  ?????????)
• Rh blood group
• AntiHIV
• Thalassemia screening Hb typing

62
???????? ??????????? ?????????????????

• ??????????? ??????????????????????????????
• ?????????????????????? ???????????????????????????
  ?????? ????????????????????????????????
• ?????????????????????????????????????
• ???????????????????????? 4 ???????

63
Women with increased risk of fetal aneuploidy

• Singleton pregnancy and maternal age older than
  35 at delivery
• Dizygotic twin and maternal age older than 31 at
  delivery
• Previous autosomal trisomy birth
• Previous 47,XXX or 47,XXY birth
• Patient or partner is carrier of chromosome
  translocation or inversion
• History of triploidy
• Some cases of repetitive early pregnancy losses
• Patient or partner has aneuploidy
• Major fetal structural defect by sonography

64
Down syndrome screening test

• First trimester screening
• Ultrasound Nuchal translucency
• Biochemical freeBhCG, PAPP-A
• Additional ultrasound markers nasal bone,
  frontomaxillary facial angle, ductus venosus
  flow, tricuspid regurgitation

• Second trimester screening
• Ultrasound major defects, soft markers
• Biochemical AFP, BhCG, uE3, inhibin A

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Ultrasound screening for Down syndrome in second
trimester

• Soft markers
• Nuchal fold thickness
• Pyelectasis
• Hyperechogenic bowel
• Intracardiac echogenic foci
• Short humerus
• Short femur

• Major defects
• Cardiac defect (AVSD, VSD)
• Duodenal atresia-esophageal atresia
• Exomphalos
• Ventriculomegaly
• Cystic hygroma
• Hydrops

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Thalassemia screening
70
Severe thalassemia in Thailand
Homo ? -Thal ?-Thal/Hb E Hb Barts

71
Detect high risk couples

• Hb Barts hydrops fetalis
• a -thal1 trait
• Hb H disease
• Severe b-thalassemia syndromes
• (Homozygous b-thal disease and b-thal/HbE
  disease)
• b -thalassemia trait
• Hb E trait

72
Carrier Screening Methods

• Identify hypochromic microcytic rbc
• Single tube osmotic fragility test 0.36 NSS
• Red cell indices MCV, MCH
• Identify Hb E genes
• DCIP
• Hemoglobin electrophoresis

73
Single tube Osmotic fragility test (OF)

• 0.36 Saline Solution
• - Normal - ??????
• - Thalassemia trait /
• Homozygous Hb E - ?????????
• Sensitivity Beta - thal 90, Alpha-
  thal 1 93
• False positive - Normal 5
• - Iron deficiency

74
Red cell indices

• MCVlt80 fl (normal range)
• MCH lt 27 pg (normal range 26-30)
• RDW (increase in Fe-def, HbH, ab-thal minor)
• RBC count (decrease in Fe-def)
• Carriers of HbE, HbC, sickel cell trait, usually
  have normal CBC results

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DCIP- Dichorophenolindophenol dye

• Abnormal Hb - HbE
• Sensitivity 95

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?????? 1
Hct MCV/OF DCIP Hb typing ?????
33.3 70.4 negative A2A A2/E2.3, A 61.3
41.8 70.3 negative A2A A2/E2.9, A 60.2
R/O couple at risk alpha thal PCR alpha thal
DNA Prenatal diagnosis if risk Barts hydrops
78
?????? 2
Hct MCV/OF DCIP Hb typing ?????
33.3 78 positive EA E27, A 61.3
41.8 70.3 negative A2A A2/E6.9, A 60.2
couple at risk ß thal/HbE PCR ß thal DNA
?????????????? Prenatal diagnosis
79
?????? 3
Hct MCV/OF DCIP Hb typing ?????
33.3 70.4 positive EA E23, A 61.3
41.8 70.3 negative A2A A2/E6.9, A 60.2
Couple at risk ß thal/HbE 25 R/O couple at risk
alpha thal PCR a and ß thal DNA Prenatal
diagnosis
80
?????? 4
Hct MCV/OF DCIP Hb typing ?????
33.3 70.4 positive EA E23, A 61.3
41.8 70.3 negative A2A A2/E2.9, A 60.2
R/O couple at risk alpha thal PCR alpha thal
DNA Prenatal diagnosis if risk Barts hydrops
81
?????? 5
Hct MCV/OF DCIP Hb typing ?????
33.3 57.4 positive EF E87.4, F 3.9
41.8 70.3 negative A2A A2/E6.9, A 60.2
Couple at risk ß thal/HbE 50 R/O couple at risk
alpha thal PCR a and ß thal DNA Prenatal diagnosis
82
?????? 6
Hct MCV/OF DCIP Hb typing ?????
33.3 70.4 positive EA E27, A 61.3
41.8 70.3 negative EA E26.9, A 60.2
R/O couple at risk alpha thal F/U Ultrasound
until 28 wk
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Genetic Counseling

• 1. Risk assessment
• 2. Disease, its burden, and treatment
• 3. Option for prenatal diagnosis (including
  methods, information, fetal loss rate,
  reliability, rapid)
• 4. Option for termination of pregnancy,
  recurrence risk, PGD

85
Prenatal diagnosis

• Chorionic villi sampling for PCR DNA
• Amniocentesis for PCR DNA
• Fetal blood sampling for Hb typing

86
Ultrasound cordocentesis (Hb Barts)

• Prehydropic signs
• Cardiomegaly
• MCA PSV gt 1.5 MoM for GA

87
Hydropic signs

• Pericardial effusion
• Ascites
• Pleural effusion
• Skin edema
• Oligohydramnios
• Placentomegaly

88
Prenatal Diagnosis of Hb Barts hydrops fetalis
10 - 14 wk. G.A.
18 - 22 wk. G.A.
Cordocentesis(U/S guide)
Amniocentesis
CVS(Chorionic villi sampling)
Hb electrophoresis
DNA analysis
Hb Barts gt80
PCR detection (SEA deletion)
89
Couple at risk of Homozygous Alpha -thalassemia 1
Serial USG at 12 - 14 weeks 18 -
20 weeks 28 - 32 weeks
Sign of fetal anemia (Cardiomegaly, placental
thickness)
Cordocentesis
Hb Electrophoresis
(MCV lt 80fl, MCH lt 25 pg and normal Hb typing)
90
Prenatal Diagnosis of Homo b-thal / b -thal/Hb E
DNA study
Common mutation detected
Yes
No
10 - 14 wk. G.A.
16-22 wk. G.A.
CVS(Chorionic villi sampling)
Amniocentesis
Cordocentesis(U/S guide)
DNA analysis
HPLC, DNA sequencing
gene amplification, reverse dot blot
hybridization
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Weatherall 2001
92
DM screening

• Low risk
• Average risk
• High risk

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DM screening

• Low risk test not routinely required
• Member of an ethnic group with low prevalence of
  GDM
• No known diabetes in first-degree relatives
• Age lt25 years
• Weight normal before pregnancy
• Weight normal at birth
• No history of abnormal glucose metabolism
• No history of poor obestetrical outcome

94
DM screening

• Average risk perform test at 24-28 weeks
• Two step procedure 50 gm GCT, followed by 100
  gm OGTT
• One-step procedure 100 gm OGTT all subjects
• High risk perform test as soon as feasible, if
  GDM is not diagnosed, repeat at 24-28 weeks or at
  any time there are symptoms or signs of
  hyperglycemia
• Severe obesity
• Strong family history of type 2 diabetes
• Previous history of GDM, impaired GT, or
  glucosuria

95
GDM diagnosis
Time NDDG Carpenter-Coustan
Fasting 105 95
1hr 190 180
2hr 165 155
3hr 145 140
GDM A1 (diet) A 2 (insulin)
Fasting lt105 and gt105 or
2hr postprandial gt120 gt120
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Maternal and fetal effects

• Fetal anomalies are not increased
• Fetal death/ unexplained stillbirth
• Increased frequency of hypertension
• Cesarean delivery
• Macrosomia

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Treatment

• Diabetic diet 30 kcal/kg/d (prepregnancy nonobese
  women) CPF 552025 divided into three meals
  and three snacks
• Glucose monitoring
• Fasting lt 95 mg/dl, 1hr postprandial lt 140 mg/dl,
  2 hr postprandial lt 120 mg/dl
• Insulin therapy
• Antepartum fetal testing

98
Postpartum follow up

• 75 gm OGTT at 6-12 weeks
• 50 likelihood of women with GDM developing overt
  diabetes within 20 years
• Increase risk dyslipidemia, hypertension,
  abdominal obesity (metabolic syndrome)
• Recurrence of GDM 40
• Contraception low dose pills ? safe

99
75 gm OGTT
normal Impaired GT DM
Fasting lt110 mg/dl 110-125 mg/dl gt 126 mg/dl
2hr lt 140 mg/dl 2hr gt 140 199 mg/dl 2hr gt 200 mg/dl
100
Multifetal gestation
101
Diagnosis of twin pregnancy
102
Zygosity Chorionicity
103
Amnionicity determination

• Based on visualization of intertwin membrane
• Monoamnionicity increases risk of TTTS, cord
  entanglement, shared organs, and fetal death
• Evaluation becomes increasingly difficult as the
  pregnancy progresses and also limited by
  oligohydramnios in one or more of the fetal
  compartments

104
chorionicity determination
Dichorionic
Monochorionic
105
chorionicity determination
Lambda sign
106
chorionicity determination
T-sign
107
Chorionicity determination

• External genitalia
• The numbers of placental masses
• Qualitative analysis of intertwin membrane,
  particularly the base

• Same sex twins with a single placental mass and
  thin septum are likely to be monochorionic.
  (Accuracy 80-90)

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Chorionicity relevance

• Risk of perinatal morbidity mortality
• Risk of genetic structural abnormality
• Invasive testing management of discordant
  abnormality
• Feasibility of multiple pregnancy reduction
• Risk of sequelae in the presence of fetal
  compromise
• Early detection management of TTTS

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Weight discordance
110
IUGR

• 25 of twins being small for gestational age
• Two thirds of cases are discordant
• Predictors for bad outcome
• MC Weight discordancy in TTTS
• DC Small for gestational age
• Management needs modification, especially in DC
  twins

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Amniotic fluid estimation
112
Amniotic fluid volume

• Oligohydramnios
• Overall AFI lt 5 cm
• DVP in either sac lt 2 cm
• Polyhydramnios
• Overall AFI gt 25 cm
• DVP in either sac gt 8 cm

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TTTS
114
Twin-Twin Transfusion Syndrome
Diagnosis

• Monochorionicity
• Marked discordance in amniotic fluid volume
  between the twins
• Discordance in size with the larger twin in the
  polyhydramniotic sac
• Fetal anomalies are excluded

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Antepartum fetal surveillance

• Doppler velocimetry
• Abnormal UA Doppler Growth
  restriction
• AEDF in UA of donor
• AEDF in DV of recipient
• Biophysical profile
• 80 sensitivity for adverse perinatal outcome
• Lodeiro et al, 1986.

Poor outcome in TTTS
116
?????????????????????????????????

• ??????????????????????????????????????????????????
  ????? (low risk pregnancy) ????????

117
Classifying form

• ???????????
• ??????????????????? ???????????????????? (1
  ????????)
• ?????????? 3 ???????????????? ?????????
• ?????????????????????????? 2500 ????
• ????????????????????????? 4000 ????
• ??????????????????????????????????????????????????
  ??????????????????????????
• ?????????????????????????????? ???? ??????????
  ??????????????????? ?????????????? ???????????

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Classifying form (cont.)

• ????????????????????
• ????????
• ???? lt 17 ?? (?????? EDC)
• ???? gt 35 ?? (?????? EDC)
• Rh negative
• ???????????????????
• ????????????????????
• ???????????? diastolic gt 90 mmHg

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Classifying form (cont.)

• ???????????????????
• ???????
• ?????
• ????????
• ???????????, ???????
• ????????????????? ???? ???????? ??????? SLE ???
• ??????????????????????????????????????????????????
  ?????? ??????????????????????????????????????????
  ??

120
????????????????????????

• 1. ??????????????????
• 2. ??????????????
• 3. ????????????????????????
• 4. ????????????????????????
• 5. ???????????????????????
• 6. ????????????? ??????????????
  ???????????????????????
• 7. ????????????????????????????????????

121
???????????????????????????? (????????????? 12
???????)

• ???????????? ?????????????? ??????????????????
  ??????????????????
• ?????????????? ??????????? ?????????????????????
  ????????????? ??????????????? ?????????????????
  ????????????????? ????????? ????????????????
  ????????????????????????????????
  ????????????????????????????????????????????
  ????????????????????????????????
• ???????????????????????? ???????????????????????
  ???????? ???? VDRL,antiHIV, ABO, Rh blood group,
  Hct/Hb, ?????????????????? OF ???? MCV ??? DCIP

122
???????????????????????????? (????????????? 12
???????)

• ??????????????????????????? ??????????????????????
  ???
• ???????????????????????? ????????
• ??????????????????????????
• ?????????????????????????????????????????? ????
  ??????????????? ???????????????????
  ????????????????? quickening
• ?????? ???????????
• ??????????????????????????????? 20 ???????
• ??????????????????????????????????

123
???????????????????????????? 2 (18-22 ???????)

• ?????? ?????????????? ??????????????????
  ??????????????????
• ?????????????? ??????????? ???????????????
  ????????? ?????????????????????????????
  ????????????????? ?????? ????????????????
• ???????????????????????? ??????????
  proteinuria, glucosuria, ????? ASB
  ???????????????????????? urine dipstick ???

124
???????????????????????????? 2 (18-22 ???????)

• ?????????????????????????????
• ???????????????? 500-1000 mg/d
• ????????????????????????????????????
• ???????????????????????? ??????? 2
  ??????????????????????? ??????????
• ???????????????????????????????????????????????
  ?????????????? ?????????????
• ?????????????????????????????????????? ???
  ???????? ????????? ??????????????????
• ?????????????????????????? 26 ???????

125
???????????????????????????? 3 (24-28 ???????)

• ?????? ?????????????? ??????????????????
  ??????????????????
• ?????????????? ??????????? ???????????????
  ????????? ?????????????????????????????
  ????????????????? ?????? ????????????????
• ???????????????????????? ??????????
  proteinuria, glucosuria, ?????????????????????????
  ?????????????????????????????????????????

126
???????????????????????????? 3 (24-28 ???????)

• ????????????????????????????????????????
• ???????????????????????? 500-1000 mg
• ???????????????????????? (???????????????)
• ???????????????????????????????
• ??????????????????????????????????????????
  ????????????????????????
• ????????????????????? ???? ???????????????????
  ??? ???????? ????????? ?????????????????
  ??????????????????????
• ??????????????????????????????? 32 ???????

127
???????????????????????????? 4 (32 ???????)

• ????????????????????
• ?????????????? ??????????? ???????????????
  ????????? ?????????????????????????????
  ????????????????? ?????? ????????????????
• ????????????????????????????????
  ???????????????????????????????????????????????
• ????????????????????? ???????? proteinuria,
  glucosuria, ??????????????????? ??????? ???
  AntiHIV
• ??????????????????? ??????? ????????????????
• ????????????????????????????????????
  ????????????????????? ??????????
• ?????????????????????????????? ????
  ??????????????????? ??????????? ??????
  ??????????????????????????? ??????????????????????
  ???
• ??????????????????????????????? 38 ???????

128
???????????????????????????? 4 (38 ???????)

• ???????????????????????????????????
  ???????????????? ECV ??????????????
  ????????????????????????????
• ????????????? ????????????????????????????????????
  40 ???????????? 6-7 ??? ?????????????????????????
  ??????????????????????????????????????????????????
  ?????????????????????

129
???????????????????????????? 4 (38 ???????)

• ??????????????????????????????????????????????
• ?????????????? ??????????? ???????????????
  ????????? ?????????????????????????????
  ????????????????? ?????? ????????????????
• ????????????????????? ???????? proteinuria,
  glucosuria
• ????????????????? ???? ???????????????????
  ???????????? ?????????????????? ??????????????
  ????????????? ????????????????? ?????????
• ??????????????????? ??????? ????????????????
• ??????????????????????????????????????????????????
  ? ???? ??????????????????? ???????? ?????????
  ????? ???????????????????????????
• ??????????????????????????????????????????????????
  ?????????????????????????????

130
Thank you