Towards Rational Ante Natal Care
Item
- Title
- Towards Rational Ante Natal Care
- Creator
- Anant Phadke
- Date
- 1989
- extracted text
-
TOWARDS RATIONAL ANTE NATAL CARE
'ANC' is one of the routine aspects of medical care. Yet
certain irrationalities are seen in practice in 'ANC-' The following
paragraphs, in a question-answer form, are an attempt to specify
scientific answers to common problems related to ANC. These answers
constitute the consensus that emerged in the series of discussions
at collective and individual level in the Health Committee of the
Lok Vidnyan Sanghatana.
QUESTION: In which cases of suspected pregnancy is the
pregnancy-test ( urinary HCG ) essential and why ?
ANSWER:
(a)
repeated abortions due to corpus luteal
deficiency, so that progesterone replacement therapy can be started
at the earliest.
(b) Cases of infertility with irregular periods;
especially those who are on ovulation induction with clomiphene.
This is because if on clomiphene, and period is delayed and pregnancy
test is negative, we can have withdrawal of clomiphene; again to
start clomiphene in next cycle, And if pregnancy test is +ve then
clomiphene need to be stopped.
(c) Pregnancy test is an important adjunct for
diagnosis of ectopic pregnancy, to detect it well before it ruptures
In all other cases of suspected pregnancy, we can wait for
two weeks more and diagnose pregnancy clinically, Thus there is no
need to do pregnancy-test on each case of suspected pregnancy.
QUESTION; Is it essential for every pregnant woman to
undergo sonography ? Does it help to manage the case
in a better way ?
ANSWER: Obstetric Sonography is essential when the following
clinical findings are present :
i) Pregnancy at any gestational age with
uterine bleeding;
ii) For suspected ectopic pregnancy;
iii) Any 1 large for date' uterus;
iv) Any 'small for date' uterus;
v) For ruling out molar pregnancy;
Vi) Any history of the patient (like
consanguinity, HIO drugs, infections,
radiation in the period of organogenesis)
which might increase the incidence of
congenital anomalies.
Though above are the clinical guidelines for ordering sono
graphy, it may be performed routinely in affording patients; as the
procedure is a sharper means to detect the surprise abnormalities of
pregnancy
___ . Surprise abnormalities do occur, though rarely.
rarely, They
cannot be detected early and with certainty by clinical methods.
For example.. ”
Neural’ Tubal Defect,
P "
'
~
Anencephaly
cannot be detected
clinically early, whereas I.U.G.R. may not be diagnosed with
certainty clinically.
QUESTION; Which is the best time tc do U.S.G. ?
ANSWER:
The most appropriate time to do sonography in
pregnancy is from 16-18 weeks, Before 16 weeks the sonographic
picture may not be certain, For examples Neural tubal defect can't
be detected with certainty before- this.
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Besides detecting any surprise abnormal’—■> es, a routine
can act as a baseline reading in case f Intra Uterine"
Growth Retardation isj suspected later.
70- clinical markers listed above,' sonography can, ci
of course,
be done earlier. than 16 weeks,
r ' if.no
‘
---- • But
such warning signals
are present and if the number of sonographies is tcTbe j.kkeptC to
the minimum, a reading at 16-18 weeks should be suf-F-i
ri nnf.
sufficient.
n
QUESTION ; What specific deleterious effects radiation
has on pregnancy ? Can routine radiological investigations be
safely done ?
ANSWER;
_____
Effects of radiation in pregnancy are foetal
death, abortions, congenital malformations and increased incid
ence of childhood neoplasia i.e. carcinomas and leukemias.
These effects are dose-dependent or nondose-dependent
and they may or may not have a threshold and hence there is
nothing like safe routine radiography in pregnancy.
It should be done only in indicated cases, indispensible
for diagnosis and management of the patient.
i) X Ray chest should be done with shielding of
abdomen. As * odeIka chest' has high exposure*
'full XRC1 is better;
ii) X rays of parts distal to abdomen like XR-limbs/
skull etc. can safely be done with shielding of
abdomen;
iii) Pelvimetry;With the present concept of 'trial of
labour1 , generally radiological pelvimetry is not
needed. But when needed in dielema, single
lateral film of pelvis will yield maximum,
information;
iv) X ray Abdomen for foetal maturity ; now-a-days
totally replaced by sonography;
v ) X Ray Abdomen for 'Acute Abdomen': has to be
done as condition may be life threatening to
the mother. If done- in the period of organo
genesis 'MTP' should be performed;
vi) Renal radiographs s USG is safe and hence should
replace renal radiography in pregnancy;
vii) Cold procedures like barium/IVP etc. can bo
postponed till. 2-3 months post-partum.
QUESTION; Does iron in any other form, other than
oral Ferrous sulfate has any advantage ?
ANSWER;
No '. Contrary to the impression created by
the drug industry, ferrous sulfate remains the preparation of
choice. According to Goodman Gillman, " Contrary to many adver
tisements, gastro-intestinal tolerance of all iron preparations
is primarily a function of the total amount of soluble elemental
iron per dose and of psychological factors and is not normally a
function of the form in which iron is administered."
.....
L
3
" Gastro intestinal absorption of iron is adequate and essentially
equal from the following six ferrous salts : sulphate, fumarate,
gluconate, succinate, glutamate and lactate. Absorption of iron
is lower from ferrous citrate, tartarate, pyrophosphate, cholinisc-citrate and carbonate."
Sustained release, delayed release, enteric coated
preparations tend to transport iron past the duodenum and proximal
jejunum and thus reduce absorption of iron. Hence Martindale's
Extrapharmacopiea remarks " sustained release or enteric coated
products are claimed to produce fewer side effects; but this may
only reflect the lower availability from these preparations. ”
QUESTION: What is the role of addition of vitamins
and minerals to iron ?
ANSWER:
______
acid
deficiency is quite common
Since
folic
in India and since addition of folic acid has shown to give
better results, addition of folic acid is scientifically justified.
But none of the other additions has any positive role. For examples
addition of minerals like copper and menganese is a worthless
gimmick. According to Martindale : " The addition of copper and
manganese to iron compounds does not appear to aid the formation
of Haemoglobin." ” When present in an amount of 200 mg or more,
Ascorbic acid increases the absorption of medicinal iron by 30%.
However, the increase in uptake is associated with significant
increase in side effects; and hence addition of ascorbic acid
seems to have little advantage over increasing the amount of
iron administered.”
Addition of none of the other vitamins, minerals to
iron has any role.
Haemoglobin containing preparations give only .75 to 5 mg
of elemental iron per 15 ml; out of this 30$ may be absorbed.
Hence to get 12 mg of absorbed elemental iron ( equivalent to
2 tablets of ferrous sulfate ) about 120 ml of this tonic needs
to be taken daily *. This turns cut to be 50 times more costly.
Besides, since these haemoglobin tonics are prepared from blood
collected from slaughter houses, they may be infected also.
They are not available in the developed countries.
Considering above facts, oral FeSO
QUESTION:
4
remains the best.
When is injectable iron indicated ?
ANSWER:
Injectable iron is indicated in the
following situaticns-
i) Extremely ncnccmplicent patients not taking
oral iron;
ii) When oral iron is not well tolerated;
iii) Malabsorption of iron.
Ho wav er, there is no statistically significant advantage in
rapidity of Hb regeneration as compared to oral iron and is
associated with many disadvantages.
(Refs Postgraduate Obgy,
Dr. Devi, Dr. Menon, Dr. Rao Textbook.) The practice of giving
injectable iron when Kb--level is low (below 8 gms %) has no
scientific foundation.
k
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QUESTION; How much calcium should be given in a normal
healthy primipara ?
ANSWER; Daily requirement of calcium in nonpregnant
state is SOO mg~and pregnancy allowance is about 400 mg per day.
Use of injectable calcium, is quite irrational. Oral calcium is very
well tolerated and the amount present in injectable preparations is
too low.
One litre milk provides 1 gm of calcium
ents can take 400 c.c. of milk every day.
Affording pati-
QUESTION; What is the role of multivitamins in Pregnancy
in different socio-economic groups ?
ANSWER; Recommended requirements of vitamins in pregnancy
(55 V^/5‘4" woman) are as follows
Vitamin-A
800 + 200 IU.
Ref; William's
"
D
300 + 200 IU.
Obstetrics,
"
C
60 + 20 mg.
16th edition.
F.A.
0.4 + 0.4 mg.
Niacin
2 mg.
14 +
Ribloflarin
1.3 + 0.3 mg.
Thiamine
1.1 +0.4 mg.
2 + 0.6 mg.
B6
mg.
3 + 1
B12
Iodine
Magnesium
Zinc
150 + 25 ug.
300 + 150 mg.
15 +■ 15 mg.
Multivitamin preparations are needed in poor socio
economic groups whose above requirements are not met with nutrition.
QUESTION; How important is to give advice about.care of
nipples, exercises and relaxation techniques to be employed during
labour ? What advice is to be given ? Which specific postnatal
exercises are useful and why ?
ANSWER; Such antenatal advice is of immense importance
as a prophylaxis to avoid morbidity in the times to come e.g. :-
Nipples
If retracted, there is poor sucking 'and
in lactational period can cause fissures, injuries^galactocoeles
and breast obscesses.
Simple advice, when detected in antenatal examination
is to pull the nipples out about 5 min. every a day, so that
desired effect can be obtained until lactation.
- Cleanliness of breasts and nipples;
- Removal of breast secretions and massaging of breast
is also advised.
Breathing exercises :- It is important to teach breathing
exercises so as to avoid fatigue and maternal distress during
labour.
- Breathing exercises improve the compliance and pulm.
functions of the patient?
- It is extremely important to teach as to how to
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perform Valsalva manouvre and how to relax in between
contractions to decrease maternal -and fcetes distress
in second stage of labour.
Postnatal advice for exercises :-
- Important to improve the tone of abdominal and peri
neal muscles to avoid divarication of recti and
uterine prolapses;
- Abdominal tone can be effectively improved by SLR,
neck raising etc. on lying flat on hard bed.
- Walking is best exercise, especially fast walking.
- Perineal exercises, incluio putting perineal muscles
in action of contraction intermitantly;
- Pressing a pilow between thighs.
- Active efforts like in situations to stop the
or defoecation abruptly.
QUESTION; How common is the consumption of alcohol
and tobacco in woman ? What should be the advice ?
Would even little 'Missri' be harmful ?
ANSWER; Alcohol & tobacco consumption is common in
tribals and adivasis. Advice is to stop it completely.
Alcohol causes 'foetal alcohol syndrom© & tobacco in any form
is foetotoxic. decreases placental flow and causes IUGR
Missri :- is quite common is low socioeconomic group
of patients and it may not be 'little-missri1 but they consume
it in gms. and kilograms per month. Hazards are : like tobacco
in any form + poor oral hygiene causing gingivitis in already
hypertrophied groups of pregnant women.
Betal nuts :- Specific alkaloid is present in nuts and
has effect on uterine blood flow.
QUESTION; What is the precise and rational role of use
of progesterone in threatened abortion ?
ANSWER; Progesterone is definately useful in repeated
abortions if progesterone deficiency is found, on serum estimation.
In such cases ideal is the use of natural progesterones.
If the threatened abortion is unlikely to be due to
progesterone deficiency, use of progesterones is irrational,
useless and harmful as well. This is becausei)
ii)
' iii)
iv)
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use in therapeutic dosages is just a drop in ocean
of progesterone secreted by placenta?
Can retain -a dead foetus to convert a threatened
abortion into missed abortion;
some synthetic progestagen's arc sometimes leutiolytic
than leutiotrophic?
vertebral, anal, trocheeoesophageal, renal and limb
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anomalies may occur;
Can cause masculinisation of female foetuses.
v)
QUESTION; What are the problems in O.C. pills in
postnatal period ? What is the selection ?
ANSWER; Breast feeding and amenorohoea is not a fool
proof guarantee against conception and hence some contraception
is a must, However, OC pills cause decrease in milk output
upto 40% ! ( Ref : Dr. Devi, Menon, Rao's Post-graduate Ob-Gy
Textbook ) and hence are not adviseable for our poor patients,
where majority of nourishment of infant comes from breast milk.
The " Progesterone-only " pill ( "mini-pill"-Micronor, cveret )
does not affect milk out-put. Though it is less effective as
compared with the combined pill, the failure rate would be low
since breast-feeding itself offers some protection.
It’D like 1 CuTi though has gone into disrepute due to
various reasons, can be taken as near ideal contraception.
It is inserted 6 weeks after delivery and even after one
caesarian section.
o©o
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Anant Pbadke, Lok Vidnyan Sanghatana
Peoples Science Movement,
Maharastra.
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