PRENATAL ASSESSMENT: GUIDELINES FOR ASSESSMENT AND CARE OF THE PREGNANT WOMAN

LESSON #14
John Dorsch, MD Director of Rural Health Programs University of Kansas School of Medicine Wichita Family and Community Medicine And Family Practice Preceptor for Via Christi Regional Medical Center Wesley Medical Center These lecture notes are based on the CR-ROM by Dr. Dorsch and selected references from the course textbook (Swartz, Textbook of Physical Diagnosis, chapter 20) A Generally good Web Site for Womens Health Issues: http://www.medscape.com SIGNIFICANCE OF MATERNAL MORTALITY IN THE UNITED STATES (FROM 1990-1995) Embolism Hypertension Ectopic pregnancy Hemorrhage Stroke Anesthesia complications Abortion related Cardiomyopathy Infection 17% 12% 10% 9% 8% 7% 5% 4% 3.5%

GENERAL APPROACHES AND KEY ADJECTIVES FOR APPROACH TO THE PREGNANT PATIENT Use a gentle, steady approach Be thorough Be efficient Be systematic

INITIAL PRENATAL VISIT: Key Points Provide time for a longer office visit, for example, 45 minutes Have patient come in early & complete paper work Help patient feel comfortable Begin interview with patient fully clothed Sit down & make eye contact

First visit is preferred at 6 weeks gestation (6-8 weeks)

THOROUGH MEDICAL HISTORY: Key points Important, as with any initial health care visit Attitudes can indicate future parent-child relationship risk factors: How does the patient feel about the pregnancy? Was the pregnancy planned Underlying medical problems need to be identified, especially: Diabetes Hypertension Renal disease Hemoglobinopathy Isoimmunization STDs Significant other infections All components of PMH are important, especially Age Last pelvic exam and pap smear Menstrual history Previous pregnancies, abortions, miscarriages, deliveries Birth control (methods used) Fertility infertility issues Anesthesia issues or reactions Pelvic injury Medications: prescription, OTC & complimentary therapies Allergies reactions Emphasize need to communicate all medications considered during pregnancy Social & home environment influences Life-style issues: diet, exercise, sleep, drugs, alcohol, smoking ROS: pre-pregnancy weights & baselines

COMMON SYMPTOMS OF PREGNANCY TO CONSIDER: Key points Amennorrhea: Results from high levels of hormones: estrogen, progesterone & hCG (human chorionic gonadotropin) Currently used pregnancy tests are based on amount of hCG in blood or urine, with hCG present as early as 8 days after fertilization Depending on the specific test used, concentrated urine improves pregnancy detection rate of urine to equal that of serum testing Test may be positive as early as 3-4 days after implantation 98% of test results are positive within 7 days after implantation Nausea or morning sickness of pregnancy: Most common between 8-14 weeks gestation Hypersensitivity to odors may develop Severe vomiting may result in dehydration or ketosis

Breast Changes: Increased tenderness Increased vascularity & sense of heaviness Nipples more erectile, with increased pigmentation Raised Montgomerys tubercles on areola Colostrum secreted by 16th week

Heartburn: Relaxation of gastroesophageal sphincter Upward displacement of stomach due to uterine enlargement Digestions delays, due to decreases in gastric mobility & gastric acid Backache: Increased hormone secretions (estrogen & progesterone) Increased pelvic relaxation Loss of abdominal muscle tone Increased uterine weight

Abdominal Enlargement: Uterus rises out of pelvis into abdomen by 12th week of gestation Quickening: Usually felt at 20 weeks in primigravida, but earlier in multipara Skin Changes: Hyperpigmentation Linea alba darkens to linea nigra Chloasma pigmentation of face Stretch Marks or striae gravidarum Nail changes increased grooving, brittleness or softening Increased sweating Hirsutism Urinary Changes: Increased frequency due to uterine pressure in early & late pregnancy Vaginal Discharge: Increased asymptomatic, white, milky cervical mucous & vaginal discharge

Fatigue: Common in early pregnancy Headaches: Common, especially around 16 20 weeks gestation Other symptoms: Varicose veins Leg cramps Edema of legs & hands Constipation Bleeding gums Insomnia Dizziness

THOROUGH PHYSICAL EXAMINATION Objectives: Evaluate health of mother & fetus Determine gestational age of fetus Initial plan of care Measurements & Vital Signs: Height & Weight Baseline vital signs & BP Skin changes: choasma of face

Teeth & Gums: check for hypertrophy of gums (increased vascularity) Thyroid: symmetrical enlargement (R/O goiter) Heart & Lungs: (In later stages of pregnancy): PMI elevated & lateral in 3rd trimester Non-pathological systolic flow murmurs develop Diastolic murmur is always pathological Breasts & Nipples: Note expected changes Everted nipples indicate possible interference with breast feeding Discrete masses are considered pathological Abdomen: Contour Skin changes: linea nigra, striae gravidarum Fetal movement (felt by 24 weeks) Uterine size & fundal height Fetal Heart Rate (FHR): (120-160 per minute) Fetal Heart Tones audible with Doppler, from 11-13 weeks gestation

Genitalia External genitalia & anus: lesions & varicosities Vaginal leukorrhea Adenexal areas: corpus luteum cyst-like enlargment Bimanual & pelvic measurements

COMMON SIGNS OF EARLY PREGNANCY Sign Goodell Hegar McDonald Chadwick Extremities: Varicosities Edema Finding softening of cervix softening of uterine isthmus fundus flexes easily on cervix bluish color or cervix, Vagina & vulva Gestational Age 4-6 weeks 6-8 weeks 7-8 weeks 8-12 weeks

INITIAL DISCUSSIONS WITH PATIENT Expected weight gain Ideal: 25-30 pounds total 2 pounds per month: 1st & 2nd trimester 1 pound per week average: last trimester Exercise and activity levels Varies with physical conditioning of patient Contact sports not recommended Core temperature elevations about 101.5 may be harmful to fetus Diet Prenatal appointment schedule: Monthly: up to 32 weeks gestation Every 2 weeks from 32 to 36 weeks Every week from 36 to 40 weeks Expected changes of pregnancy & selected important things to know

Prenatal Vitamins: Maternal ingestion of 0.4 0.8 mg of Folic Acid per day reduces the occurrence of fetal neuronal tube defect Most prenatal vitamins contain 1 mg of folic acid Prenatal vitamins with folic acid are often recommended for non-pregnant women of child-bearing age who are planning pregnancy

Calculating the Due Date or Expected Date of Confinement (EDC) Last menstrual period (LMP) LMP less 3 months Add 1 year + 7 days = EDC Or Nageles Rule: LMP Add 9 months + 7 days = EDC

A Prenatal Flow Sheet for recording visits is through & efficient

MILESTONE LABORATORY TESTS Routine, mandatory: completed at first visit CBC: UA: ABO & Rh typing Rubella titer Pap smear HBsAg VDRL detects anemia, hemoglobinopathies, infections baseline for protein, glucose: r/o diabetes, renal disease, hypertensive disease of pregnancy checks compatibility of maternal-fetal blood types & need for Rhogam determine presence or absence of maternal Antibodies (Rubella causes blindness, heart & hearing abnormalities in fetus) Screens for cervical intraepithelial dysplasia or neoplasia Hepatitis B surface antigen. Virus infects fetus, may cause fetal anomalies or RPR: screens for syphilis, which infects fetus, causing congenital anomalies

Highly recommended lab screening (not mandatory) at first visit: STD smears/cultures Gonorrhea, Chlamydia, Herpes Generally cause eye infections & blindness,

HIV

repiratory infections & other infections of newborns. Active herpes near due date indicates need for C-section birth requires permission, and signed informed consent by patient

MILESTONE LAB TESTS & PROCEDURES SCHEDULED LATER IN PREGNANCY 16-18 Weeks: Ultrasound: most accurate for dating pregnancy Not mandatory, but most commonly done 17-21 Weeks: (when standardized values for this test are most accurate) Alpha Fetal Protein (AFP) Medical-legal point: Important to offer this test, and document that it was offered It is not mandatory in the sense that the patient can refuse High levels may indicate neuronal tube defects in the fetus Low values (not as predictive) may be indicative of trisomy 21 &other trisomy defects Triple Screen: may be used, and combines the following: AFP SerumEstriol HCG 24-28 Weeks: 50 Gram Glucose Tolerance Test (glucose challenge) H & H: may repeat at 28 weeks (especially with anemia) 28-36 Weeks Beta Hemolytic Streptococcus Screen Collect culture swabs from vaginal introitus (not cervix) If positive, mother must be treated before delivery to prevent fetal sepsis

EVERY OB VISIT Monitor: weight, BP temp, UA for protein & glucose (dip stick UA), Lower renal threshold in pregnancy 2+ or greater UA protein could signal pregnancy induced hypertension (PIH) Serum glucose screen Fundal height: measured from top of pubic bone to top of uterine fundus Measurement is most accurate from 20-36 weeks gestation Each 1 cm increase indicates one additional week of gestation

Edema: dependent edema from pressure on inferior vena cava & iliac veins Nausea & vomiting: most prominent from 8-14 weeks gestation Pain & contractions Fetal movements Discuss this at 16 weeks & ask patient to record when fetal movements are felt (usually between 17-18 weeks) Bleeding or discharge Recent illness & concerns

MEASURING UTERINE SIZE Nulliparous uterus: 8 weeks gestation (or if second baby): 10 weeks: 12 weeks: Palpable just above symphysis pubis 12-14 weeks: 16 weeks: 20 weeks: 28 weeks: 34 weeks: 38-40 weeks golf ball size hand ball size baseball size soft ball size uterus rises up into abdominal cavity fundus palpable halfway between symphysis & umbilicus fundus at umbilicus (lower border) fundus halfway between umbilicus & xiphoid fundus just below xiphoid fundus drops (lightening)

MILESTONES TO MONITOR ON SUBSEQUENT OB VISITS Fetus: FHT with Doppler: 12 weeks Quickening: 16-19 weeks (ask patient to keep track of movements) Primipara (later, about 18-19 weeks) Multipara (sooner, about 16 weeks)

16-18 Weeks: Ultrasound Offer AFP or Triple Screen: 17-21 weeks 24-28 Weeks: 50 Gm Glucose Tolerance Test (glucose challenge) May repeat H&H at 28 weeks (anemia vs hemodilution) Rhogam given if Rh negative 32 Weeks: Encourage to enroll in Lamaze classes 36 Weeks: Talk about when to go to the hospital

What to do if water breaks Mucous plug Analgesia, anesthesia, epidural Conduct of labor Need to IV access Episiotomy Post natal contraception Tour of birth center Practitioner for infant medical care Circumcision Feeding: breast bottle

PELVIMETRY: Key Points Initial considerations Pelvic shape Diagonal conjugate Obstetrical conjugate Angle of subpubic arch Coccyx Pelvic shapes Gynecoid (50% of women): Pelvic outlet is round & pubic arch is wide Ancticipated delivery is vaginal, spontaneous Android (25% of women): Pelvis outlet is heart shaped & pubic arch is narrow Anticipated delivery could be vaginal with forceps or cesarean Anthropoid (24% of women): Pelvic outlet is vertically oval & pubic arch is narrow Anticipated delivery is vaginal, possible forceps Platypelloid (3% of women): Pelvic outlet is transversely oval & pubic arch is wide Anticipated delivery is vaginal, sponanteous

Diagonal conjugate One of the most import measurements of AP diameter of pelvic inlet 12.5 13 cm measurement from the inferior border of the symphysis pubis to sacral promontory

Obstetric conjugate Also measured the AP diameter of the pelvic inlet, more accurately obtained by x-ray Diagonal conjugate minus 1.5 2 cms from the posterior board of The symphysis pubis to the sacral promontory

Angle of pubic arch or subpubic arch

 Coccyx

Estimation of angle of subpubic arch is done by using both thumbs, & examiner externally traces descending rami down to ischia tuberosities A wide pubic arch (105 degrees or more) accommodates spontaneous vaginal delivery A narrow pubic arch (less than 90 degrees) indicates a more difficult Delivery, with use of forceps or suction, or a cesarean section

When palpated during bimanual examination, a prominent inward pointing coccyx could indicate possible problems with vaginal delivery

COMMON CLINICAL URGENT PATHOLOGICAL CONDITIONS First trimester bleeding: consider normal implantation of ovum, cervicitis, vaginal varicosities, threatened abortion (ectopic pregnancy, especially with abdominal pain) abruptio placenta or placenta previa blood loss over 500 ml during first 24 hours after delivery false pregnancy (psychiatric considerations)

Second semester bleeding: Postpartum hemmorage:

Pseudocesis:

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