MATERNAL AND CHILD HEALTH😍

United Nations

• The United Nations framed the Sustainable Development Goals.

• Headquarters is in: New York

Sustainable Development Goals (2015-2030)

• Formulated by United Nations.

• Chart for India → Prepared by NITI Ayog

• Total goals:
• 17 goals + 169 targets
• Goal 3: Health related.

• Targets of goal 3: MNOP
• 3.1:
• M → Reduce MMR <70/ 1 lakh live birth.
• 3.2:
• N → NMR <12/1000 live births (20)
• U5MR <25/1000 live births (32)
• 3.3:
• O → End epidemic of AIDS, TB, malaria & neglected tropical diseases by 2030.
• OATM
• 3.4:
• P → Reduce 1/3rd of premature deaths from NCD by 2030.

• <2500g:
• Low birth weight (LBW)
• M/c cause Prematurity > IUGR
• Average birth weight (India): 2.8-2.9 Kg.

• <1500g:
• Very low birth weight (VLBW)

• <1000g:
• Extremely low birth weight (ELBW)

High-Risk Neonates (AIIMS Protocol)

1. Birth weight < 1.5 kg – Very Low Birth Weight (VLBW)

2. Preterm < 32 weeks

3. Persistent or recurrent hypoglycemia

4. Born to HIV-positive mother

• Overall m/c cause: Atonic uterus

• Direct causes:
• Traumatic delivery.
• Prolonged labour.
• Embolism.

• Indirect causes:
• Anemia (most common).
• Iron deficiency in India: 98%
• Anemia: 50%
• Heart/liver disease.

• m/c cause of primary PPH (Within 24 hours of delivery): 
• Atonic uterus > Trauma
• Also include Succenturiate placenta

• m/c cause of secondary PPH (>24 hours to 3 months after delivery): 
• Retained placental tissue.

• Other causes
• Retained cotyledon
• Endometritis
• Infection of endometrium
• Polymicrobial
• Risk Factors
• Occurs post-LSCS
• LSCS → Most important R/F for Endometritis
• Prolonged rupture of membranes > 18 hrs
• Features
• Fever
• Subinvolution of Uterus
• impaired involution
• Foul smelling lochia
• Tender Uterus
• increased uterine activity → bleeding
• Rx
• Broad spectrum Antibiotics
• Not responding after 48 hrs
• Think Septic Pelvic Thrombophlebitis
• Add LMWH
• Vs Puerperal sepsis
• Fever > 38 degree C (100.4 F) on 2 occasions
• form D2 - D10 postpartum
• Placental polyp
• Retained placental tissue
• Forms polyp on uterine wall
• Leads to persistent bleeding if not removed

NOTE

• Secondary PPH → 24 hrs to 3 months

• Postpartum cardiomyopathy → 1 month before to 5 months after delivery

• Postpartum eclampsia → within 48 hrs after delivery

Visits :

• National health mission, GOI :
• Recommended : 13-14 visits
• Minimum: 4 visits
• Answer if WHO not mentioned

• Antenatal vs Postnatal visits

Visit	Antenatal Period	Postnatal Period
Visit 1	< 12 weeks	1st day of delivery
Visit 2	14–26 weeks	3rd day of delivery
Visit 3	28–32 weeks	7th day of delivery
Visit 4	> 36 weeks till term	6 weeks (42 days) after delivery

• WHO care model : 8 visits

Trimester	Number of Visits
1st Trimester	1 visit
2nd Trimester	2 visits
3rd Trimester	5 visits

RDA Update (2020)

• 1 Kcal = 4.184 KJ

Macronutrients

• Pregnancy : Average +350 Kcal/day

• Trimester Kcal/day

Trimester	Calorie (Kcal/day)	Protein (g/day)
Non-pregnant	• 1660	• 45
ㅤ	Additional	ㅤ
1st Trimester	• 70–80 OR • No additional calorie requirement	• Nil
2nd Trimester	• 280	• + 10g
3rd Trimester	• 450	• +20g

• Lactation:
• 0 to 6 months: + 600 Kcal/day
• 6 to 12 months: + 520 Kcal/day

• Carbs in females:
• Non-pregnant: 130 g/day .
• Pregnant: 175 g/day .
• Lactating: 200 g/day .

• Fat req:
• 28 g/day

Micronutrients

• Sodium: 2000 mg/day (5g of salt)
• Double of calcium

• Potassium: 3500 mg/day.
• Triple of calcium

• Iodine (I2) req. : 250 mcg/day.

• Vitamin A = Calcium

Nutritional Requirement ↑

• During pregnancy:
• Iron, Folic Acid, Protein, Zinc

• During lactation:
• Calcium, Vitamin A, Iodine, Vitamin C, Carbohydrate
• Ac yil irunn choru thinn paalu kudikkanam

• Iodine requirement in pregnancy
• 280 µg/day

• Iodine requirement for children
• 90-120 µg/day

Recommended Weight Gain in Pregnancy

• In normal BMI females: 11-12.5 kg

• In females with low BMI (Thin females): 12.5 - 18 kg

• In females with BMI >30 (Obese): 7 kg (5 - 9 kg)

Td vaccine

• Given to all pregnant females

• 1st dose:
• Schedule :
• 1st antenatal visit OR
• 1st dose at 2nd trimester (Preferred)
• To ensure foetal protection against neonatal tetanus by maternal antibodies

• 2nd dose: 4 weeks after 1st dose

• Previous immunisation - 2 doses within 3 yrs :
• Booster dose: 1 dose only

TdaP vaccine

• Tetanus + Diphtheria + acellular Pertussis

• Protection against pertussis for the baby

• ACOG Recommended single shot TdaP vaccine b/w 27-36 weeks

Swasth Nari Sashakt Parivar Abhiyan

• Theme: Healthy Women, Empowered Families

• By Ministry of Health and Family Welfare

• Linked to 8th Rashtriya Poshan Maah (Nutrition Month)

• Implementation sites
• Ayushman Arogya Mandirs
• Community Health Centres
• District Hospitals
• Other government health facilities

• Objectives
• Improve nutrition
• Increase health awareness
• Enhance overall well-being
• Women
• Children

Mission Shakti

• For women empowerment
• Under Ministry of Women & Child Development.
• Sambal: Safety & security of women.
• Samarthya: women empowerment.
• Includes
• Ujjawala
• Pradhan Mantri Matru Vandana Yojana
• Swadhar Greh & National Creche Scheme.

POSHAN Abhiyaan

• Prime Minister Overarching Scheme for Holistic Nourishment (2018).

• Abhi - overacting

• Under Ministry of Women & Child Development (WCD).

• Integrated with
• National nutrition mission.
• Anemia mukt Bharat.

• Target: SULA
• ↓ Anemia prevalence by 3% per year.
• ↓ Low birth weight by 2% per year.

• Nutritional status improvement
• Children (0-6 years).
• Adolescent, Pregnant & lactating females.

Poshan Shakti Nirman Scheme (2021)

• Mid-day meal scheme under Ministry of Education.

• 1/2 protein and 1/3 calorie requirements

• Beneficiaries: Balvatika (<Class I) + Class I-VIII students.

ㅤ	For primary classes	For upper primary classes
Calorie	450	700
Proteins (g)	12	20

Rashtriya Bal Swasthya Karyakram (RBSK):

• Under National Health Mission (NHM)

• Screening + early intervention for age 0–18 years

• “Bal” : 0-18 yrs children

• Strategy :
• Screening of children for 4D’s in anganwadi & schools
• Developmental delays
• Diseases
• except Congenital glaucoma
• Deficiencies
• except Vit K and C
• Defects
• Newly added :
• Hypothyroidism, sickle cell anemia, β-thalassemia
• Tuberculosis, Leprosy
• Total diseases screened
• 32

• Screened By:

Age Group	Target Group	Screened By
Birth – 6 weeks	Born at public health facilities	Mobile health team
6 weeks – 6 years	Rural areas, urban slum	ANM
6 years – 18 years	School children	Questionnaire by district hospitals

Health Conditions Screened under RBSK

Anemia in Pregnancy

• M/c indirect cause of maternal mortality in India.

• Causes :
• Physiological Anemia
• Hb cut off is raised for defining anemia in pregnancy.
• M/c cause of anemia in pregnancy.
• Normocytic normochromal anemia.
• Hb : Never falls below 11 g/dL.
• Pathological Anemia
• M/c cause : Iron Deficiency Anemia (IDA).
• Microcytic hypochromic anemia.
• Hb : <11 g/dL.

• WHO Classification : 7 - 10 - 11
• Mild : 10-10.9 g/dL.
• Moderate : 7-9.9 g/dL.
• Severe : <7 g/dL.

• Best Screening test for anemia in Pregnancy
• S. ferritin > MCHC

Iron requirements

• Total iron requirement during pregnancy - 1000 mg
• Fetus and placenta -300 mg
• Rest for mother

• Fe - trimester wise
• 1st : 1-2 mg/day
• 2nd: 4-6 mg/day
• 3rd: 6-8 mg/day
• 2nd half of pregnancy : 6-8 mg/day

• Note :
• ICMR Very severe anemia : Hb <4 g/dL.
• Thalassemia : Rx with iron is C/I.
• Nestroft test.
• IDA : Rx with iron supplementation.

ANEMIA MUKT BHARAT PROGRAM

• 6 x 6 x 6 Initiatives

Interventions :

1. IFA pill : Weekly

2. Deworming : Albendazole for hookworm infection
• 200 mg (1/2 tab) for 1-2 yrs
• 400 mg (1 tab) for >2 yrs
• Biannually (Twice a year) :
• (National deworming days)
• 10th February &
• 10th August
• Not against ascariasis

3. Delayed cord clamping : Prevention of neonatal anemia

4. Digital hemoglobinometer.

5. Mandatory iron & folic acid fortified foods

6. Non-nutritional causes of anemia

• Pregnant woman IFA
• From 4th month of pregnancy till 6 months post-delivery

Mnemonic

• Pink → Primary kids (5–9 yrs)

• Blue → Boys & girls (Adolescents)

• Red → Reproductive (Pregnant + Lactating)

Supplementation in Pregnancy

• Deworming: Once in second trimester.

IFA Pill

• Red color pill.

• Fe : 60 mg + Folic acid : 500 mcg (To prevent megaloblastic anemia).

• Dose to
• Prevent anemia : 1 tablet/day 
• Rx anemia : 2 tablets/day.

• Recommended after 12 weeks

• 1 tablet/day for at least 180 days in pregnancy

MANAGEMENT

Parenteral iron :

• C/I : 1st trimester.

• Rate of Hb ↑ :  0.7 g/dL/week after 3rd week.

Dose : Ganzoni formula.

• 2.4 x Pre-pregnancy weight x Hb deficit (target Hb - Patients Hb) + 500 mg

• Mnemonic Iron man te set Gansoni

• Note:
• Target Hb can be 11 or 14
• If target = 11
• Need maintenance till 180 days after delivery
• Oral Iron is given
• If target is 14
• Do not need maintenance

• Minimum time gap b/w oral & parenteral iron : 
• 3 weeks (Oral iron tablets C/I with parenteral therapy).

Oral iron therapy :

• Rate of Hb↑ : Same as parenteral

• For loading as well as maintenance therapy
• If target Hb = 11 g/dL

• Maintenance dose : 
• 1 pill/day continued throughout pregnancy up to 180 days after delivery.

Treatment Algorithm :

Blood transfusion at any GA if

• Hb <5g%

• Signs of heart failure

1st trimester

• No parenteral iron therapy
1. 2 IFA tab per day OR
• 60 mg elemental Fe + 0.5 mg FA
2. Blood transfusion if
1. Unstable vitals.
2. Signs of heart failure
3. Thalassemia.
4. Hb <5 g/dL at any gestational age.

2nd and 3rd trimester

Special Considerations

• Thalassemia & Sickle Cell Disease: 
• Folic acid only

• Calcium Recommendation (Pregnant & Non-Pregnant Females): 
• 1000 mg