Pregnancy

Care
Cua, Go, Divinagracia
 Outline

Preconceptional Care Diagnosis of Pregnancy Prenatal Care

Preconceptional
Care
“Pregnancy may be associated with certain
diseases that existed before the inception of
pregnancy. As a rule, all disease which subject
the organism to a considerable strain are much
more serious when occurring in a pregnant
woman”
- J. Whitride Williams (1903)
 Brief Overview

Counseling Genetic Diseases Parental Age and Social Hx

Medical History Reproductive History Screening Tests

 Counseling Medical History

● Diabetes Mellitus
● Gynecologists, internists, family med ● Epilepsy
specialists and pediatricians have the ○ Teratogenic Medications
best opportunity to provide preventive (Phenytoin, Carbamazepine,
counseling
Valproic acid)
● Counselor should be knowledgeable
regarding relevant medical diseases, ○ Folic acid supplement (4mg)
prior surgeries, reproductive and ● Immunizations
genetic disorders. ○ Toxoid Containing
○ C/I Live attenuated
○ Covid 19
 Genetic Diseases
● Family History
○ Medical illnesses
○ Race and Religious Practices
● Neural Tube Defects
○ Second to cardiac anomalies
○ Folic acid therapy
○ Folic acid dose: 400-800
micrograms
● Phenylketonuria
○ Causes fetal organ (neural and
cardiac) abnormalities
○ MC: Developmental Delay
○ Advise PKU Restricted diet
● Thalassemia
Reproductive History
● Infertility
● OB History
○ Miscarriages
○ Ectopic Pregnancy
○ Recurrent Pregnancy loss
● OB Complications
○ Reasons for prior CS delivery
○ Preeclampsia
○ Placental Abruption
○ Preterm Delivery
 Parental Age and Social Hx Screening Tests

Maternal
● Young pregnant women
● Older pregnant women
● ARTs

Paternal ● Diabetes
● Increased incidence of complex ● Hypertension
neuropsychiatric conditions
● New autosomal dominant mutations
● Thyroid Disease
● Infectious Disease
Social history ● Cancer
1. Drugs and smoking
2. Environmental exposures
3. Diet
4. Exercise
5. Intimate partner violence
Diagnosis of
Pregnancy
 Presumptive Signs and Symptoms

Symptoms Signs
• Nausea and vomiting • Cessation of menstruation
• Disturbances in urination • Anatomical breast changes
• Fatigue • Chadwick’s sign
• Quickening • Thermal signs
• Breast symptoms • Chloasma/Melasma gravidarum
• Striae Gravidarum
 Probable Signs
● Abdominal enlargement
● Hegar’s Sign
● Goodell’s Sign
● Softening of the cervix
● Crystallization of Cervical Mucus
● Braxton-Hicks Contractions
● Ballottement of the Amniotic Sac
● Outlining of the fetus
● Positive Home Pregnancy Test
 Positive Signs

Ultrasound Perception of Fetal

Detection of Fetal
Recognition of movement by
Heart Tone
Embryo/Fetus examiner
 35y/o female
CC: Missed menses
OB Score: G_P_ (T-P-A-L)
LMP: April 5-8. 2021 Diagnosis:
PMP: March 4-7, 2021
Uterine pregnancy confirmed via ultrasound

OB History:
● 2012
○ Complete abortion
○ AOG: 10-12 weeks
● 2015
○ NSD
○ AOG: 40 weeks
○ live baby boy 3. 9 kg
● 2018
○ Primary LTCS for severe preeclampsia
○ AOG: 33-34 weeks,
○ twin boys: one of the twins died at the
10th hour of life
 35y/o female
CC: Missed menses OB Score: G4P2 (1112)

LMP: April 5-8. 2021 Diagnosis:

PMP: March 4-7, 2021
Uterine pregnancy confirmed via ultrasound G4P2 (1112) Pregnancy Uterine 11
weeks 3/7 days AOG by LMP, previous
OB History: low transverse cesarean section
● 2012 secondary to severe preeclampsia
○ Complete abortion
○ AOG: 10-12 weeks
● 2015
○ NSD
○ AOG: 40 weeks
○ live baby boy 3. 9 kg
● 2018
○ Primary LTCS for severe preeclampsia
○ AOG: 33-34 weeks,
○ twin boys: one of the twins died at the
10th hour of life
Prenatal Care
 Definitions

● Gravida- number of pregnancies, regardless of outcome

○ Nulligravida
○ Primigravida
○ Multigravida

● Parity- number of pregnancies reaching 20 weeks

○ Nullipara
○ Primipara
○ Multipara
 Definitions

● Normal pregnancy duration= 280 days (40 weeks)

● Trimesters
○ 1st trimester: 0-14 weeks
○ 2nd trimester: 15-28 weeks
○ 3rd trimester: 29-42 weeks

● Weeks of gestation- more clinically appropriate

○ 1st trimester ultrasound- most accurate
 Initial Prenatal Visit

● Obstetric & Gynecologic History

○ Previous pregnancies
○ Obstetric score: GP(TPAL)
○ Menstrual history (MIDAS)
○ Contraceptive history (CPCPS)
○ Gestational or menstrual age
○ Based on LMP, EUS, EDD, fundal height (McDonald’s Rule)
○ Estimated date of delivery
○ Based on LMP (Naegele’s Rule), EUS, known date of conception
 Determination of AOG

● Based on last menstrual period

○ From day 1 of LMP until reference date

● Based on early ultrasound

○ From date of US until reference date + AOG on date of US

● Based on fundal height (McDonald’s Rule)

○ Between 20-34 weeks, correlate fundal height (cm) with AOG
 Determination of EDD

● Based on last menstrual period (Naegele’s Rule)

○ Determine day 1 of LMP, minus 3 mos, plus 1 yr & 7 days

● Based on early ultrasound (until 13 6/7 weeks)

○ Preferred over LMP-established dates when the discrepancy is >7 days in
the 1st trimester & 10 days in the 2nd trimester

● Based on known date of conception

○ E.g., ART
○ Date of conception + 266 days
 Initial Prenatal Visit

● Psychosocial History
○ Psychosocial screening
○ At least x1 per trimester
○ Cigarette smoking
○ Quit at any stage of pregnancy
○ Close supervision with nicotine replacement
○ Alcohol
○ Illicit drugs
○ Methadone- heroin abusers
○ Intimate partner violence
○ 1st prenatal, at least x1 per trimester, postpartum
 Initial Prenatal Visit
Linea nigra

● Clinical Evaluation
Nabothian
○ General physical examination cyst
○ Pelvic examination
○ Speculum exam + Pap smear + cervical swab
○ Bimanual exam + DRE
○ Gestational age assessment
○ Uterine size
● 6 weeks: small orange
● 8 weeks: large orange
● 12 weeks: grapefruit

Chadwick sign w/
leukorrhea
 Initial Prenatal Visit

● Laboratory Tests
○ Complete blood count
○ Blood typing + antibody screen
○ HIV, HBV, syphilis, rubella screening
○ Urinalysis & culture
○ Cervical infections
○ C. trachomatis (all)
○ N. gonorrhoeae (if with risk factors)
○ Unmarried, recent change/multiple concurrent sex partners, <25 years old,
history of STDs, inadequate prenatal care
 Initial Prenatal Visit

● Pregnancy Risk Assessment

○ Referral to other medical
specialists
 Subsequent Prenatal Visits

● Uncomplicated pregnancies
○ Every 4 weeks until 28 weeks AOG
○ Every 2 weeks until 36 weeks AOG
○ Every week thereafter

● Complicated pregnancies
○ Every 1-2 weeks
 Subsequent Prenatal Visits

● Prenatal surveillance
○ Maternal wellbeing
○ HA, vision changes, abd pain, nausea, vomiting, bleeding, leakage, dysuria
○ Fundal height
○ Between 20-34 weeks, correlate with AOG
○ Fetal heart sounds
○ Doppler US (10 weeks)
● 110-160 bpm as a double sound
● Funic souffle- sharp whistling, with fetal pulse, umbilical arteries
● Uterine souffle- soft blowing, with maternal pulse, uterine vessels
○ Stethoscope (20-22 weeks)
 Subsequent Prenatal Visits

● Prenatal surveillance
○ Ultrasonography- only if indicated
Subsequent Prenatal Visits
 Subsequent Prenatal Visits

● Subsequent Laboratory Tests

○ Repeat testing in increased risk:
○ Antibody screening (28-29 weeks)
○ Hct, hgb, syphilis, chlamydia, gonorrhea (28-32 weeks)
○ HIV (3rd trimester before 36 weeks)
○ HBV (before delivery)
○ GBS culture (35-37 weeks)
○ GDM (24-28 weeks)
○ Neural tube defect & genetic testing
○ Neural tube defect (15-20 weeks)
○ Fetal aneuploidy (11-14 and/or 15-20 weeks)
○ Other abnormalities according to risk factors
 Nutritional Counseling

● Weight gain recommendations

 Nutritional Counseling

● DRI-RDA
○ Calories
○ +80,000 kcal
○ +0, 340, 452 kcal/d in 1st, 2nd & 3rd trimesters
○ Protein
○ 1 g/kg/d in 2nd half then x2 during late gestation
○ AA fall except glutamate & alanine
○ Vitamins & Minerals
○ Folic acid- 400-800 ug/d before & early gestation
○ Iron- 27 mg/d elemental iron starting mid-gestation
○ Iodine- in areas with deficiency
○ Vitamin D- limited sun exposure, vegetarians, ethnic minorities (darker skinned)
 Common Concerns

● Employment- until the onset of labor*

● Exercise- regular, moderate-intensity, 150 mins/wk*
● Caffeine- <300 mg/d (~5 oz. cup x 3)
● Seafood consumption- mercury in shellfish, etc.
● Lead screening- if with risk factors
● Travelling
○ Car- lap belt under the abd & across upper thighs, shoulder belt: between breasts
○ Air- until 36 weeks*
● Coitus- unharmful*
● Dental care- unharmful
 Common Concerns

● Immunization
○ Contraindicated:
○ Measles, mumps, rubella, varicella
○ Recommended:
○ Influenza (during flu season)
○ Tdap (27-36 weeks)
 Common Concerns

● Nausea- 1st half of gestation

○ Morning sickness- vitamin B6 + doxylamine, phenothiazine/H1 receptor blockers
○ Hyperemesis gravidarum
● Heartburn
● Pica & ptyalism
● Headache & back ache
● Varicosities & hemorrhoids
● Sleep & fatigue
● Cord blood banking
Thank you!