PHYSIOLOGIC OBSTETRICS: PRENATAL CARE 2

Reference: Williams Obstetrics 24th Edi Cunningham et al 2014

Transcriber: docdemetillo@icloud.com
“To toil and not to seek for rest... “

PRENATAL CARE 2
Various Slides

SCHEDULES OF PRENATAL VISITS  Women at increased risk for:

 HIV acquisition during pregnancy, repeat testing is recommended before 36 AOG
I. Schedules of Pre – Natal Visit  Hepatitis B infection should be retested at the time of hospitalization for delivery
Age of Gestation (weeks) Intervals (weeks)
4 – 28 4 o Group B Streptococcal Infection:
29 – 36 2  Vaginal and rectal GBS cultures be obtained in all women between 35 0 37 weeks’
37 – 40 Weekly gestation
>40 weeks Every 3 days  Intrapartum antimicrobial prophylaxis is given to those whose cultures are positive
 Women with GBS bacteruria or a previous infant with invasive disease are given
SUBSEQUENT PRENATAL VISITS empirical Intrapartum prophylaxis

o Gestational diabetes
II. Subsequent Prenatal Visits: Prenatal Surveillance  All pregnant women should be screened for gestational diabetes mellitus
Fetal heart rate  Done between 24 – 28 weeks
Fetal growth  OGTT
Amniotic fluid volume  OGCT
Presenting part and station
Fetal movement/Activity o Fetal Fibronectin
Maternal Blood Pressure  Detection in vaginal fluid  used to forecast preterm delivery
Maternal Weight Gain
o Chlamydial/Gonococcal Infection
Symptoms:  Women at risk should be screened
o Headache/change of vision  Risk factors:
o Abdominal pain  Unmarried status
o Nausea and vomiting  Recent change in in sexual partners or multiple noncurrent partners
o Bleeding  Age under 25
o Vaginal fluid leak  Inner city residence
o Dysuria  History or presence of other STD
 Little or no prenatal check up
Fundic Height (cm) Measurement
o From symphysis pubis to uterine fundus o Genetic Screening
o Assessment of Gestational Age  Selected screening
 20 – 34 weeks  height in centimeters of the uterine fundus correlates closely with  Maternal age
AOG  Family history
 Bladder must be emptied before making the measurement  Ethnic or racial background of the couple
 At 17 – 20 AOG, fundal height was 3cm higher with a full bladder  Examples:
 Used to monitor fetal growth and amniotic fluid volume  Trisomy 21  advance maternal age
o The following limit the fundic height accuracy:  Tay – Sachs Disease  eastern European Jewish or French Canadian ancestry
 Obesity  ß – Thalassemia  Mediterranean, south east Asian, Indian, Pakistani, or African
 Presence of uterine mass (myoma) ancestry
 Fetal – growth restriction  α – thalassemia  SEA or African ancestry
 Sickle Cell Anemia  African, Mediterranean, middle east, Caribbean, Latin
Last Trimester Vaginal Examination provides valuable information: American, or Indian descent
o Confirmation of presenting part
o Station of presenting part NUTRITIONAL COUNSELING RECOMMENDED DIETARY ALLOWANCES
o Clinical estimation of pelvic capacity and its general configuration
o Amniotic fluid volume adequacy III. Nutritional Counseling Recommended Dietary Allowances
o Consistency, effacement, and dilatation of the cervix Pragmatic Nutritional Surveillance
o In general, advise pregnant woman to eat what she wants in amounts she desires and
Fetal Heart Sounds salted to taste
o Doppler utz: 10 weeks AOG o Make sure there is ample food to eat in the case of socioeconomically deprived women
o Standard non – amplified stethoscope: 16 – 20 AOG o Monitor weight gain, with a goal of about 25 – 35 Lbs. or 11 – 12 Kg in women with a normal
o Normal range of FHT: 110 – 160 BPM BMI
o Site on the maternal abdomen where fetal heart sounds can be best heard will differ o Periodically explore food intake by dietary recall to discover occasional nutritionally absurd
o Fetal movement diet
o Give tables of simple iron salts that provide at least 27 mg of iron daily. Give folate
Sonography: supplementation before and in the early weeks of gestation
o Provides information regarding fetal anatomy, growth, and well being o Recheck hct or hmg concentration at 28 – 32 weeks to detect any significant decrease
o Should be performed only when there is a valid medical indication under the lowest possible
utz exposure setting Recommendation based on Pre – Pregnant BMI
o Done at 8 – 16 weeks was slightly more accurate, by approximately 2 days for predicting
the actual date of delivery Category (BMI) Total Wight Gain Range (lb) Weight Gain in 2nd and
3rd Trimesters Mean in
Subsequent Laboratory Test lb/wk (range)
o If the initial results were normal, most tests need not be repeated 28 – 40 1 (1 – 1.3)
o Hemoglobin or hematocrit determination – repeated at about 28 – 32 weeks Normal Weight 25 – 35 1 (0.8 – 1)
o Ancillary test (18.5 – 24.9) 37 – 54
 Fetal aneuploidy (neural – tubal defect) may be performed at 11 – 14 weeks and/or at Overweight 15 – 25 0.6 (0.5 – 0.7)
15 – 20 AOG (25.0 – 29.9) 31 – 50
 Syphilis serology if it is prevalent in the population, should be repeated at 28 – 32 weeks Obese (≥ 30.0) 11 – 20 0.5 (0.4 – 0.6)
AOG 25 - 42

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 PHYSIOLOGIC OBSTETRICS: PRENATAL CARE 2
Reference: Williams Obstetrics 24th Edi Cunningham et al 2014
Transcriber: docdemetillo@icloud.com
“To toil and not to seek for rest... “

Recommendation based on pre – pregnant BMI: Obesity

o Obesity is associated with significantly increased risks for
 Gestational htn, preeclampsia, gestation diabetes, Macrosomia, caesarean delivery,
and other complications
o Those who gained less than 15 lbs. had the lowest rates of
 Preeclampsia, large for gestational age neonates, and caesarean delivery
o Women with normal pre – pregnancy BMI
 Who gained less than 25 lbs. during pregnancy had a lower risk for:
 Preeclampsia, false induction, CPD, and large for gestational age infants
 Increased risk for small for gestational age NB
o Maternal weight gain during pregnancy

Nutrient toxicities during pregnancy

o Iron, zinc, selenium
o Vitamins A, B6, C, and D
o Vitamin and mineral intake more than twice the recommended daily dietary allowance
shown should be reduced
o Excessive vitamin A (>10,000 IU per day)  teratogenic
o Pregnancy requires an additional 80,000 kcal mostly during the last 20 weeks
 Caloric increase of 100 – 300 kcal per day is recommended
 Adding 0, 340, 452 kcal/day to the estimated non – pregnant energy requirements in
the 1st, 2nd, and 3rd trimesters.

o Iodide
 RDA: 220 micrograms
Starvation During Pregnancy  Use of iodized salt and bread products is recommended during pregnancy to offset the
o No detectable effects on subsequent mental performance increased feta requirements and maternal renal losses of iodine
o Birthweight decreases 250 gms  Deficiency:
o Perinatal mortality rate was not altered, nor was the incidence of malformations  Reports linking subclinical maternal hypothyroidism to adverse pregnancy outcomes
o Frequency of pregnancy toxemia declined and possible neurodevelopmental defects in children
 Cretinism, characterized by multiple severe neurological defects
Long – Term Consequence to nutritionally deprived women
o Early pregnancy deprivation was associated with: o Calcium
 Increased obesity in adult women but not men  Preggy retains approx. 30 g of Ca++
 Increased CNS anomalies, schizophrenia, and schizophrenia – spectrum personality  Maternal ca++ in bone are mobilized for fetal growth
disorders  Increased ca++ absorption by the intestine
o Offspring deprived in mid to late pregnancy were:
 Lighter, shorter, and thinner at birth o Zinc
 Higher incidence of subsequent diminished glucose tolerance, htn, reactive airway  RDA: 12mg
disease, dyslipidemia, and coronary artery disease.  Severe deficiency lead to poor appetite, suboptimal growth, an impaired wound healing

Weight Retention After Pregnancy: o Folic Acid

o Not all the weight gained (28.6 lbs. or 4.8 kg) during pregnancy is lost during and  Neural tube defects has decreased mandatory fortification of cereal products with folic
immediately after delivery acid since 1998
o Maternal weight loss  Prevented with daily intake of 400micrograms of folic acid throughout the periconceptal
period
Time Approx. weight loss in lbs or kg  Recommendation: planning or capable pregnancy take a daily supplement containing
At delivery 1.2 or 5.5 0.4 – 0.8 mg of folic acid
In the following two weeks 9 or 5.5
Between 2 weeks and 6 mos postpartum 5.5 or 2.5 o Vitamin A
 Vitamin A (isotretinoin – Accutane) – has been associated with congenital malformations
o Average total weight loss resulted in an average retained pregnancy weight of 3 lb or when taken in higher doses (>10,000 IU per day) during pregnancy
1.4kg  Beta carotene, precursor of vitamin A found in fruits and vegetables, has not been shown
to produce vitamin A toxicity
 If deficient, serum below 20 microgram/dL, whether overt or subclinical, was associated
with an increased risk for night blindness, maternal anemia, and spontaneous preterm
birth

o Vitamin D
 RDA when pregnant and lactating: 15 microgram per day or 600 IU per day.
 Fat soluble
 Increases the efficiency of intestinal calcium absorption and promotes bone
mineralization and growth
 Synthesized endogenously with exposure to sunlight
 Deficiency is common during pregnancy
 High risk groups: limited sun exposure, ethnic minorities (darker skins), vegetarians
 Such maternal deficiency can cause disordered skeletal homeostasis, congenital
rickets, and fractures in the NB

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 PHYSIOLOGIC OBSTETRICS: PRENATAL CARE 2
Reference: Williams Obstetrics 24th Edi Cunningham et al 2014
Transcriber: docdemetillo@icloud.com
“To toil and not to seek for rest... “

COMMON CONCERNS Bathing

IV. Common Concerns
Exercise
o Not necessary for the preggy to limit exercise
 Does not become excessively fatigued or risk injury
o Preggy should be encouraged to engage in regular, moderate-intensity physical activity
30 mins or more a day
o Activities with high risk of falling or abdominal trauma should be avoided.
o No contraindication to bathing during pregnancy and puerperium
o Hot tub or Jacuzzi at 100 degree Fahrenheit or higher  risk of miscarriage, neural tube
defects
o Avoid slipping or falling
Clothing
o Comfortable and nonscontricting
o Before, it used to be about covering up, and now it’s about showing it off. Today’s
maternity chic is body hugging not body hiding.
o The increasing mass of the breast may make them pendulous and painful, and a well –
fitting supporting brassiere may be indicated for comfort
o Constricting leg wear should be avoided

Bowel habits
o Constipation is common  prolonged transit time and compression of the lower bowel
by the ureters or by the presenting part
o Greater frequency of hemorrhoids, much less common prolapse of the recta mucosa
o Ingesting sufficient quantities of fluid along reasonable amount of daily exercise
o Supplemented when necessary  mild laxative like prune juice, milk of magnesia, bulk
– producing substances or stool – softening agents

Coitus
o Healthy pregnant women, sexual intercourse usually is not harmful
o Coitus should be avoided  abortion, placenta previa, preterm labor
o Oral – vaginal intercourse is occasionally hazardous

Dental Care
o Examination of the teeth should be included in the prenatal examination
 Good dental hygiene is encouraged
o Dental caries are not aggravated by pregnancy
o Pregnancy is not contraindicated for
 Dental treatment
 Dental radiographs

Immunization during pregnancy

o Current recommendations for immunization during pregnancy
o Groundless: causal link b/w childhood exposure to the thimerosal preservation in some
vaccines and neuropsychological d/o
o Three agent Tdap vaccine:
 Tetanus toxoid
 Reduced diphtheria toxoid
 Acellular pertussis

Employment
o Women with uncomplicated pregnancies usually can continue to work until the onset of
labor
o Avoid severe physical strain

Travel
o Preggy can travel till 36 AOG
o Pressurized aircraft has no harmful effect on pregnancy
o Precautions  periodic movement of the lower extremities, ambulation at least hourly,
and use of seatbelts while seated

Seafood Consumption
o Fish are an excellent source of protein, are low in saturated fats, and contain omega 3
fatty acids
o Fish and shellfish contain trace amounts of methyl mercury
 Pregnant and lactating women are advised to avoid specific types of fish
o High methyl mercury levels
 Shark, swordfish, king mackerel, and tile fish

Lead Screening
o Maternal lead exposure has been associated with several adverse maternal and fetal
outcomes
 Gestational hypertension
 Spontaneous abortion
 Low birthweight
 Neurodevelopmental impairments
o Blood lead levels ≥45 microgram/dL are consistent with lead poisoning  chelation
therapy
o Risk factor for lead exposure in pregnant and lactating women
 Recent immigration from or residency in areas of high ambient lead contamination
 Living near a point source of lead
 Working with lead or _______ with someone who does
o Using lead – glazed ceramic pottery
o Eating nonfood substance (pica)
o Using alternative complementary medicines, herbs, or therapies

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PHYSIOLOGIC OBSTETRICS: PRENATAL CARE 2
Reference: Williams Obstetrics 24th Edi Cunningham et al 2014
Transcriber: docdemetillo@icloud.com
“To toil and not to seek for rest... “

o women who are susceptible to rubella during pregnancy should receive MMR – measles,
mumps, rubella – vaccination postpartum
o MMR vaccine is not recommended during pregnancy
o There is no contraindication to MMR vaccination while breastfeeding

Caffeine
o Risk for spontaneous abortion related to caffeine consumption (5 cups or 500mg/day) is
controversial
o During pregnancy - <300 mg daily or three, 5 – oz cups of percolated coffee

Medication
o Any drug exerts a systemic effect in mother will cross the placenta to reach the embryo
and fetus

Nausea and vomiting (morning sickness)

o Common complaints during the first half of pregnancy and continue until 14 - 16 AOG
o Can be minimized by:
 Eating small meals at more frequent intervals but stopping short of satiation
 Herbal remedy ginger
 Mild symptoms usually respond to vitamin b6 given along with doxylamine
 Phenothiazine or H1-receptor blocking antiemetics

Backache
o 70% of preggy complain of low back pain
o Minor degrees follow excessive strain or fatigue and excessive bending, lifting and
walking
o Back pain increased with duration of gestation
o Prior history of back pain and obesity were risk factors
o Causes of severe pain:
 Pregnancy associated osteoporosis
 Disc disease; Vertebral osteoarthritis
 Septic arthritis; Septic arthritis
 Muscular spasm and tenderness

Varicosities
o Enlarged vein  result from congenital predisposition and are exaggerated by factors
that cause increased lower extremity venous pressures (prolonged standing, weight
increase, pregnancy and advancing age)
o Femoral venous pressures in the supine pregnant woman increase from 8mmHg early to
24mmHg by term

Hemorrhoids
o Varicosities of the rectal veins  first appear during pregnancy
o Increased pressure in the rectal veins (obstruction of venous return by the large uterus
and constipation during pregnancy
o Pain and swelling relieved by:
 Anesthetics
 Warm soaks
 Stool – softening agents
Pica
o Cravings (pica) or pregnant women for strange foods and at times nonfood like ice
(pagophagia), starch (amylophagia), clay (geophagia).
o The desire is considered by some by severe iron deficiency
Ptyalism
o Profuse salivation
o Stimulation of the salivary glands by the ingestion of starch
o Most cases are unexplained
o
CORD BLOOD BANKING
V. Cord Blood Banking
Umbilical cord blood transplantations have been performed to treat hemopoietic cancers
and various genetic conditions.
Two types:
o Public banks promote allogeneic donation, for use by a related or in related recipient,
similar to blood product donation
o Private Banks were initially developed to store stem cells for future autologous use and
charged fees for initial processing and annual storage.
It is recommended that directed donation be considered when an immediate family
member carries diagnosis of specific condition known to be treatable by hematopoietic
transplantation.

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