PRE NATAL CARE WHEN SHOULD PRENATSAL START?
PRECONCEPTION CARE
 Planned program of medical evaluation, management, observation and
education of pregnant women directed toward making pregnancy, labor,
delivery, and the postpartum recovery, a safe and satisfying experience
 Not a one-time-big time thing, it represents a series of interventions
during the course of the pregnancy so that adverse pregnancy outcomes
are prevented
 Begins with preconceptual counseling when a woman is contemplating
pregnancy and continues with a comprehensive medical and
psychosocial evaluation throughout the antepartum period.
 General GOAL: maintain maternal health and deliver a healthy baby
while minimizing poor obstetrical and fetal outcomes.
OBJECTIVES
 Evaluation of the health status of both the mother and the fetus
 Accurate estimation of gestational age - very important because most of
the decisions is based on the AOG
 Initiate a plan for continued obstetrical care to ensure the birth of a
healthy baby with minimal risk to the mother
 Identification of patients at risk for complications
 Anticipation of problems and intervention if necessary
 Patient education and communication to improve health-seeking
behavior of patients
PREGNANCY TESTS
 Measurement of hCG
 Measurement of beta hCG. Via sandwich immunoassay.
 Sensitivity: can detect as low as 1.0 mIU/L.
 Must rule out other causes of positive assay (molar pregnancy,
exogenous hCG injection for weightloss, renal failure with impaired hCG
clearance, physiological pituitary hCG, hCG producing tumors that most
commonly originate from gastrointestinal sites, ovaries, bladder or lung.
 Home Pregnancy tests
 Pregnancy kits
 Sonographic Recognition
 Transvaginal Ultrasound
 early pregnancy imaging
 commonly used to accurately establish gestational age and
pregnancy location
 gestational sac at 5 weeks AOG
 FHS at 6 weeks
 FHR: 110-160 bpm
 Detectable by 10 weeks using instruments incorporating
Doppler ultrasound
 Stethoscope: 20-22 weeks
Ideally, a woman should have checkups even prior to pregnancy to identify
problems or comorbidities which could complicate the pregnancy
A woman planning to have a child should have a medical evaluation before
she becomes pregnant or as soon as she misses her period as prenatal
care should start as soon as patient is confirmed to be pregnant
SIGNS AND SYMPTOMS OF PREGNANCY
Amenorrhea
- Abrupt cessation in previously healthy females who experience cyclical,
predictable menses is highly suggestive of pregnancy. Not reliable until
10 days or more after expected menses.
Lower Reproductive Tract Changes
- Chadwick's sign- vaginal mucosa appears bluish red and congested
- Goodell's sign - softening of the cervix as pregnancy progresses (other
conditions such as estrogen-progestin contraceptives may cause
similar softening)
- Ferning- fern-like pattern of cervical mucus (seen in midcycle) makes
pregnancy UNLIKELY
Uterine changes
● First few weeks- uterus grows principally in the anteroposterior
diameter
○ feels doughy or elastic on bimanual exam
● Hegar's sign
○ 6-8 weeks menstrual age
○ firm cervix, softer fundus, compressible interposed
softened isthmus
● Uterine souffle (SOOFEL)- on auscultation may hear a soft blowing
sound that is synchronous with maternal pulse; produced by the
passage of blood through dilated uterine vessels and is heard most
distrincly near the lower portion of the uterus
● Funic Souffle- sharp, whistling sound synchronous with fetal pulse;
caused by a rush of blood through the umbilical arteries and may not
be heard consistently
● Breast and changes
○ enlargement, heaviness, discomfort, and prickling sensation
○ Montgomery tubercles - are sebaceous (oil) glands that appear
as small bumps around the dark area of the nipple
○ Characteristic during first pregnancy
○ Less obvious in multiparas
● Fetal movement (Quickening)
○ First perceived between 16-18 weeks gestation
○ Primigravid may not be appreciate until 2 weeks later.
Annual gynecological visits should include the evaluation of a womans
interest in starting a family. the following should be considered:
a) Health history of the mother and the father. Medical problems that
could affect the health of the mother or the fetus during pregnancy
should be addressed. Medications should be reviewed and those
contraindicated in pregnancy should be stopped. For those with
significant medical issues, referral to a maternal fetal medicine
specialist for preconceptional counseling should be considered.
b) Weight
- If obese (body mass index [BMI] greater than 30), patient should be
counseled to lose weight prior to conception.
- If underweight (BMI less than 20), patient should be counseled to gain
weight prior to conception.
c) Folic acid (0.4 mg) supplementation is encouraged to reduce the
incidence of neural tube defects.
d) Rubella immune status: immunize if nonimmune and advise
waiting for 1 month before conception.
- congenital rubella syndrome - a condition that occurs in a developing
baby in the womb whose mother is infected with the rubella virus
- infection is most severe when mother is infected in early pregnancy
(esp in the first 12 weeks/ 1st trimester)
- most common birth defect from CRS: deafness, cataracts, heart
defects, intellectual disabilities, liver and spleen damage, LBW, skin
rash at birth
e) Varicella immune status: if patient does not recall having the chicken
pox; immunize if not immune.
- the risks depend on the timing. If chickenpox develops during the first
20 weeks of pregnancy — particularly between weeks eight and 20 —
the baby faces a slight risk of a rare group of serious birth defects
known as congenital varicella syndrome.
- A baby who has congenital varicella syndrome might develop skin
scarring, and eye, brain, limb and gastrointestinal abnormalities. If
chickenpox develops during the few days before delivery to 48 hours
postpartum, the baby might be born with a potentially life-threatening
infection Called neonatal varicella.
f) Tests may be ordered to screen for genetic diseases:
a. Tay-Sachs, Canavan, Niemann-Pick, Fanconi anemia, Bloom
syndrome, Gaucher, and familial dysautonomia: Ashkenazi Jews
b. Sickle hemoglobinopathies: African Americans
c. β-Thalassemias: Mediterranean, Southeast Asians, and African
Americans
d. β -Thalassemias: Southeast Asians, Mediterraneans, and African
Americans
e. Tay-Sachs: Ashkenazi Jews, French Canadians, and Cajuns
f. If family history is significant for other inherited diseases, genetic
counseling for screening for diseases such as fragile X and
Duchenne muscular dystrophy may be offered
 ROUTINE PRENATALCARE VISIT : 1ST PRENATAL VISIT PHYSICAL EXAMINATION COMPLETED HISTORY AND PE
 8-10 weeks of pregnancy ● Vital signs PAST MEDICAL HISTORY
 iniital history and physical examination ● Height, weight, BMI calculation ○ Genetic disorders
 initial laboratory tests ● Fundal Height examination ○ Cardiovascular diseases
 gestational age ● Leopold's Maneuver ○ Gastrointestinal, kidney, and endocrine disorders
 estimated date of delivery ● Fetal heart rate and position ○ Immunization status of the expecting mother
 pregnancy risk assessment ● Pelvic examination FAMILY HISTORY
● Inspection and Palpation of the External Genitalia ○ Diabetes mellitus
During this time, as physicians we should be able to: ● Speculum Examination ○ Twin pregnancies
● Identify high-risk pregnancies (based on history) ● Internal Examination ○ Chronic hypertension
● Ask about previous pregnancy complications, if she had been ● Bimanual Examination ○ Bronchial asthma
pregnant before ● Recto-vaginal Examination (optional) ○ Allergies
● Address patient's concerns regarding fetal abnormalities, ○ Genetic diseases/ physical abnormalities
especially if they are already elderly primigravidas MENSTRUAL/SEXUAL/OBSTETRICAL HISTORY:
● basically achieve the previously mentioned goals ● MIDAS
● Sexual History
ROUTINE PRENATALCARE VISIT : 1ST PRENATAL VISIT INITIAL BLOODWORKS ● Family Planning History
● Regularity of the cycle
 Evaluation of the health status of both the mother and the fetus  Blood type and antibody screen
○ Evidence of infertility
 Accurate estimation of gestational age - very important because most of  complete blood count (CBC)
SUBSTANCE ABUSE
the decisions is based on the AOG  blood typing ● tobacco, alcohol, other drugs
 Initiate a plan for continued obstetrical care to ensure the birth of a  GDM screening (75g, 2 hour OGTT) ● smoking adverse outcomes: greater rates of miscarriage, stillbirth,
healthy baby with minimal risk to the mother  rubella immune status LBW, and preterm delivery
 Identification of patients at risk for complications  syphilis screen, chlamydia, gonorrhea ● alcohol: potent teratogen that causes a fetal syndrome
 Anticipation of problems and intervention if necessary  hepatitis B surface antigen characterized by facial abnormalities and CNS dysfunction
 Patient education and communication to improve health-seeking  TB screening ● illicit drugs sequelae: fetal-growth restriction, LBW, and drug
behavior of patients  HIV status withdrawal soon after birth
 urinalysis and urine culture GENDER-BASED VIOLENCE
 Pap smear and gram stain ● Ask for history of sexual abuse, as some pregnancies may be a
ESTIMATION OF THE DURATION OF PREGNANCY SUBSEQUENT PRENATAL VISIT result of sexual abuse
NAEGELE'S RULE ● Uncomplicated pregnancies: every 4 weeks until 24 to 28 weeks ● Psychological assessment in cases of abuse/violence
● for patient's with a regular, 28-day menstrual cycle with ovulation ● at 24-28 weeks, frequency increases to every 2 to 3 weeks ● intimate-partner violence is associated with an increased risk of
occuring on the 14th day ● After 36 weeks: every week until delivery several adverse perinatal outcomes including preterm delivery,
● estimates the date of delivery ● Complicated pregnancies: require closer surveillance fetal-growth restriction, and perinatal death
EDD = add 7 days, subtract 3 months to the first day of the LMP, then add ● at least 4-5 (minimum requirement) MENSTRUAL/SEXUAL/OBSTETRICAL HISTORY:
● Previous pregnancy
1 year  vital signs
○ Duration of gestation
○ maternal weight, height, BMI
■ Preterm deliveries
BARTHOLOMEW'S RULE OF 4S ● extent of change is noted
• ■ Induced because 42 weeks AOG was reached
12 weeks AOG: above the symphysis pubis ● symptoms: headache, altered vision, abdominal pain, nausea,
• 16 weeks AOG: halfway between the symphysis pubis and the ○ Type of delivery
vomiting, bleeding, vaginal fluid leak, and dysuria are sought
■ Normal and uncomplicated
umbilicus ○ blood pressure
• ■ Outlet forceps
20 weeks AOG: level of the umbilicus ○ urine dip for glucose and protein
• ■ Caesarean section, and for what indication
36 weeks AOG: below the sternum ○ assessment of uterine size
○ Indications for operative procedures
○ fetal heart rate, growth, and activity, and amnionic fluid
■ Pelvic abnormalities
volume
○ Complications
○ in late pregnancy: vaginal examination provides information that includes:
○ Weight and sex of baby
○ confirmation of presenting part and its station; clinical estimation of pelvic
● Post-partum course
capacity and configuration, amnionic fluid volume adequacy, cervical
consistency AND effacement and dilatation
 MILESTONES COMMON CONCERNS LIFESTYLE MODIFICATION
8-10 weeks nausea and vomiting ● Exercise LEVEL of intensity should not be increased during pregnancy.
● Initial History ● common up to 16 weeks Restriction may occur if complications of pregnancy such as preterm
● general exam to confirm pregnancy ● caused by high levels of hCG labor occur.
● complete needs assessment reflux esophagitis or heartburn ● Travel Air: It is permissible to fly up to 36 weeks. Pregnant women on
11-14 Weeks ● due to relaxation of the lower esophageal sphincter due to long flights should be advised to stay hydrated and move around the
● offer ferrous supplement progesterone cabin every 2 hours to reduce the risk of deep vein thrombosis.
● offer screening for aneuploidy varicose veins ● Coitus In uncomplicated pregnancies, sexual intercourse does not pose
● mother should be offered breastfeeding educational material and ● due to increased venous pressure of the gravid uterus harm to the pregnancy. It is contraindicated if the patient is determined to
classes ● exaggerated by prolonged standing have placenta previa.
15-20 Weeks ● rest with elevation of feet, use of elastic support stockings ● Substance use and abuse All pregnant patients should be screened
● offer complete genetic screening and counseling sexual relation for alcohol, nicotine, and other drug
● offer neural tube defect screening ● not prohibited in normal pregnancy - Smoking should be strongly discouraged during pregnancy
24-28 weeks ● not advised after >32 weeks AOG - Alcohol should be avoided during pregnancy as no known safe
● GDM screening dental care threshold is known. Fetal abnormalities include mental
● 3rd trimester CBC ● pregnancy is not a contraindication for dental care retardation and neurodevelopmental deficits
● if patient is RH-, RhoGAM (300ug) administration ● majority of dentists refuse to do tooth extraction during pregnancy - Other drugs. The use of other drugs should be screened for.
● discuss normal fetal movement, prenatal classes, postpartum ● tooth extraction possible as long as there are no swelling or Often women who use cocaine, heroin, and other drugs may not
contraception infection --> antibiotics if necessary present for routine antenatal care.
27-36 weeks NUTRITIONAL DIET  Caffeine has been associated only with spontaneous abortion at
● DTap should be administered during each pregnancy BMI less than 19: 28 to 40 lb very high levels (greater than five cups per daY.
32-34 weeks BMI 19 to 25: 25 to 35 lb  Flu shot- recommends all pregnant women to have flu shot; the injectable
● group B streptococcus swab BMI 25 to 29: 15 to 25 lb inactivated and not the intranasal version.
● repeat Chlamydia screening BMI greater than 30: 11 to 20 lb  Medications- Administered during pregnancy cross the placenta and
● Leopold's maneuvers ○ this is applicable to adolescents, short women, and women of all racial reach the fetus. Exceptions are the large organic ions such as heparin
36 weeks and ehtnic groups and insulin.
● discuss risks and benefits of HSV prophylaxis in women with ○ Calories In general, caloric intake should be 25 to 35 kcal/kg of ideal a) Category A (e.g., levothyroxine, folic acid). Well-controlled studies
history of genital herpes body weight. An increase of 100 to 300 kcal/d is recommended in in pregnant women show no risk to the fetus in any trimester of
● labor induction pregnancy. pregnancy
38 weeks ○ Obesity is associated with significantly greater risk for gestational b) Category B (e.g., ondansetron(used to prevent nausea and
● review labor education and discuss contraception hypertension, preeclampsia, GDM, macosomia, cesarean delivery ET. vomiting that may be caused by surgery or by medicine to treat
>41 weeks cancer), penicillins). Well-controlled studies in pregnant women
● nonstress test 2x/week Dietary composition have shown no increased risk of fetal abnormalities despite
● Protein: requirement is about 1.1 g/kg/d. adverse findings in animals. Drugs are also placed in this
SIGNS TO LOOK OUT FOR: ○ Required for growth and remodelling of the fetus, category if, in the absence of adequate human studies, animal
20 Weeks placenta, uterus, and breasts, and for increased maternal studies show no fetal risk. The chance of fetal harm is remote but
● preterm labor precautions blood volume possible.
28 weeks ● Iron: recommended intake is 30 mg elemental iron per day. c) Category C (e.g., prochlorperazine (antipsychotic), trimethoprim-
● fetal kick counts ○ supplied as ferrous gluconate, sulfate, or fumarate and sulfamethoxazole). Well-controlled human studies are lacking,
● normal: 10 fetal movements in 2 hours taken daily throughout the latter half of pregnancy and animal studies are lacking as well or have shown a risk to the
after 35 weeks ○ iron requirements are greatly increased during pregnacy fetus. There is a chance of fetal harm if the drug is administered
● warning signs of preeclampsia ● iodine is also needed: 220 ug/day in pregnancy. potential benefits may outweigh the potential risk.
● term labor instructions ○ use of iodized salt and bread products is recommended d) Category D (e.g., phenytoin, carbamazepine). demonstrated a
during pregnancy to offset increased fetal requirements risk to the fetus; therefore, the drug should not be administered
and maternal renal losses of iodine during pregnancy. Potential benefits may be acceptable in cases
○ iodine deficiency predisposes to endemic cretinism of a life-threatening situation or serious disease for which a safer
● Calcium: 1,000 mg daily from diet drug cannot be used or has proven ineffective.
● Folic acid: 400 to 1,000 μg/d to prevent neural tube defects. e) Category X (e.g., diethylstilbestrol, thalidomide,
○ For women with history of infant with neural tube defect, accutane/isotretinoin). Studies in animals or human have
recommended intake is 4 mg/d.. demonstrated evidence of fetal abnormalities or risk that clearly
● Avoid excess vitamin A (no more than 4,000 IU/d outweigh any possible benefit to the patient.