Prenatal Care

Maria Stephanie Fay S. Cagayan, MD, PhD, FPOGS, FPSSTD,

FPSECP
Professor 12, UP College of Medicine
Contents of Prenatal Care

▣ Preconceptional care
▣ Prompt diagnosis of pregnancy
▣ Initial prenatal evaluation
▣ Follow-up prenatal visits
Preconceptional Care

▣ Goal: To identify factors that could affect perinatal

outcome – advise patient of her risks
▣ Preventive medicine for obstetrics
▣ Reduction of unplanned pregnancies
▣ Improves pregnancy outcome
□ Chronic medical disorders (diabetes mellitus,
epilepsy)
□ Genetic diseases (birth defects)
Goals of Prenatal Care

4
Preconceptional Counseling

▣ Family history
▣ Medical history
▣ Personal and social history
▣ Lifestyle and work habits
▣ Immunizations
▣ Screening tests – Rubella, Varicella, Hep B
Initial Prenatal Evaluation

Major goals:
□ To define the health status of the mother and
fetus
□ To determine the gestational age of the fetus
□ To initiate a plan for continuing obstetric care

Timing: not later than 2 months

Recommended Components of the Initial
Prenatal Visit

▣ Risk assessment
■ genetic, medical, obstetrical and psychosocial factors
▣ Estimated due date
▣ General physical examination
▣ Laboratory tests
■ CBC, urinalysis, blood typing, rubella status, Hbs Ag, Pap
smear, offer HIV testing
▣ Patient education
■ avoid alcohol and tobacco
▣ Diagnose pregnancy
▣ Past medical history
▣ Present medical history
▣ Physical examination
▣ Internal examination
▣ Advice
Diagnosis of Pregnancy

▣ Signs and symptoms

▣ Beta hCG
▣ Sonography
Signs and Symptoms

Amenorrhea
□ Not a reliable pregnancy indicator until 10 days or
more after expected menses

Low reproductive tract changes

□ Chadwick sign
□ Cervical changes

Uterine changes
□ Hegar sign
□ Uterine souffle vs Funic souffle
Signs and Symptoms

▣ Breast and skin changes

▣ Fetal movement
□ Quickening
■ 16-18 weeks in multigravida
■ 18-20 weeks in primigravida
□ Detected by examiner by 20 weeks
Signs of Pregnancy
Presumptive Probable Positive
• Amenorrhea • Goodell’s • Fetal heart
• Nausea and • Hegar’s sounds
vomiting • Chadwick’s • Outline and
• Urinary sign, move on
frequency ballottement ultrasound
• Quickening • Braxton hicks
• Uterine contractions
enlargement • (+) pregnancy
• Pigmentation test
changes
Human Chorionic Gonadotropin

▣ Heterodimer composed of two dissimilar subunits,

designated α and β, which are noncovalently linked
▣ α-subunit is identical to those of LH, FSH and TSH
▣ B-subunit is structurally distinct
▣ Produced by the syncytiotrophoblasts, prevents
involution of the corpus luteum, which is the principal
site of progesterone formation during the first 6 weeks
of pregnancy
Detection of Serum Beta hCG

▣ Detected in maternal serum or urine by 8 to 9 days

after ovulation
▣ Doubling time of serum hCG concentration is 1.4 to 2.0
days
▣ HCG levels increase from the day of implantation and
reach peak levels at 60 to 70 days. Thereafter, the
concentration declines slowly until a plateau is
reached at approximately 16 weeks
Sonography

▣ Embryo
□ Threshold for embryo detection is when the
embryonic disk measures 1-2 mm in length
(usually 5-6 weeks AOG or when MSD is 5-12
mm)
Sonography

▣ After 6 weeks, an embryo is seen as a linear

structure immediately adjacent to the yolk sac,
and cardiac motion is typically noted at this point
▣ Up to 12 weeks’ gestation, the CRL is predictive of
gestational age within 4 days
19
History

1. Past medical history

□ previous hospitalizations/surgeries; diseases (cardiac,
hypertension, diabetes, asthma, tuberculosis, STD, allergies);
intake of meds

2. Family history
□ cardiovascular disease, cancer, diabetes, congenital
malformations, multifetal gestation

3. Personal/social history
□ marital status, educational attainment, vices, age at first coitus,
no. of sexual partners, use of contraceptives, pre-pregnant
weight or BMI
History

4. Menstrual history
■ Frequency, duration, regularity and amount or flow of menses,
LNMP, PMP
5. Obstetrical history: OB score, AOG, EDC
□ Previous deliveries – prenatal consults, pregnancy
outcome, place and manner of delivery, fetal weight and
sex, maternal/fetal complications
□ Present pregnancy – prenatal consults, pre-pregnancy
weight, history of maternal illness, intake of medications,
exposure to radiation, smoking, alcohol, abnormal
symptoms
Terminologies

Nulligravida A woman who is not now, and never has been pregnant
Gravida A woman who is, or has been pregnant, irrespective of
the pregnancy outcome (primi- vs multigravida)

Nullipara A woman who has never completed a pregnancy beyond

20 weeks gestation
Primipara A woman who has delivered only once of a fetus or fetus
of AOG ≥ 20 weeks
Multipara A woman who has completed two or more pregnancies
to 20 weeks or more
Parturient A woman in labor
Puerpera A woman who has just given birth
Terminologies

LNMP Last normal menstrual period

PMP Previous menstrual period
EDD/EDC Expected date of delivery confinement
Obstetrical G_P_ (_-_-_-_)
Score
1st digit: term infants
2nd digit: preterm infants
3rd digit: abortions
4th digits: children currently alive

*Not universal, may be confusing

Normal Duration of Pregnancy

▣ Mean duration of pregnancy = 280 days or 40 weeks

▣ Pregnancy divided into 3 trimesters:
□ 1st trimester – up to 14 weeks AOG
□ 2nd trimester – 15 to 28 weeks AOG
□ 3rd trimester – 29 to 42 weeks AOG
▣ Age of Gestation (AOG) – weeks of completed gestation
▣ Expected date of delivery/confinement (EDD/EDC)
□ Add 7 days to the date of the 1st day of the LNMP, and
count back 3 months (Naegele rule)
High-Risk Pregnancies

1. Preexisting medical illness

2. Previous poor pregnancy outcome
□ Perinatal mortality
□ Preterm delivery
□ Fetal growth restriction
□ Fetal malformations
□ Placental accidents
□ Maternal hemorrhage
3. Evidence of maternal undernutrition
High-Risk Pregnancies Risk Factors

▣ Asthma ▣ Hemoglobinopathy
▣ Cardiac disease ▣ Hypertension
▣ Diabetes mellitus ▣ Prior pulmonary
▣ Drug and alcohol use embolus or deep vein
thrombosis
▣ Epilepsy
▣ Psychiatric illness
▣ Family history of
genetic problems ▣ Pulmonary disease
(Down syndrome, Tay- ▣ Renal disease
Sachs)
High-Risk Pregnancies
▣ Obstetrical History and Conditions
• Age > 35 years at delivery
• Cesarean delivery, prior
classical or vertical incision
• Incompetent cervix
• Prior fetal structural or
chromosomal abnormality
• Prior neonatal death
• Prior fetal death
• Prior preterm delivery or
preterm ruptured
membranes
• Prior low birthweight
(<2500 g)
• Second-trimester
pregnancy loss
• Uterine leiomyomata or
malformation
• Condylomata (extensive,
covering vulva or vaginal
opening)
Obstetrical Examination

1. Physical Examination
□ Vital signs: BP, RR,
temperature, weight,
height
□ Complete systemic PE
□ Abdominal exam:
fundic height,
estimated fetal weight,
Leopold’s presenting
part, fetal heart tones
Obstetrical Examination

2. Speculum examination
□ Bluish-red hyperemia of the cervix –characteristic of pregnancy
□ Cervical discharge
□ Pap smear

3. Digital pelvic examination

□ Consistency, length and dilatation of the cervix
□ Fetal presenting part
□ Bony pelvis –assess adequacy
□ Vulva, vagina, perineum
□ Digital rectal exam
Fetal Heart Sounds

▣ Doppler: 10 weeks AOG ▣ Stethoscope: 20 weeks

AOG
Fundal Height

▣ The distance (cm) over the abdominal

wall from the top of symphysis pubis
to the top of the uterine fundus
▣ Has good correlation between
gestational age (weeks) &
measured height of fundus (cm)
between 20-34 weeks AOG
▣ Measured on an empty bladder
Gestational Age Assessment

▣ ACCURATE knowledge of gestational age is

IMPORTANT
▣ Last menstrual period (LMP) – usual basis for
AOG
▣ First trimester crown-rump length (CRL) is
the most accurate tool for gestational age
assignment

32
Gestational Age

▣ LNMP
▣ Fundic height
▣ Quickening (16-20 weeks)
▣ Ultrasound (UTZ)
□ Routine UTZ – not currently recommended in
low-risk pregnancies by the American College
of Obstetricians and Gynecologists (2002)
Prenatal Surveillance
Fetal
▣ Heart rate
▣ Size: actual and rate of
change
▣ Amount of amniotic fluid
▣ Presenting part and station
▣ Activity/ movement
Maternal
▣ Blood pressure
▣ Weight
▣ Symptoms
□ Headache, blurring of vision,
abdominal pain, nausea &
vomiting, bleeding, vaginal fluid,
dysuria
▣ Fundic height
▣ Vaginal examination (late in pregnancy)
▣ Confirmation of presenting part
□ Station
□ Clinical assessment of pelvis
□ Cervical consistency, effacement
and dilatation
Laboratory/Ancillary Tests

▣ Hematocrit or hemoglobin determination

▣ Rh and typing
▣ urinalysis/urine culture
▣ GDM screening
□ First visit
□ 24-28 weeks
□ 32 weeks
▣ Ultrasound for fetal aging
Algorithm for Women at Low Risk for DM

36
Algorithm for Women at High Risk for DM

37
Cut off values for the diagnosis of DM

38
▣ Rubella testing
▣ Hep B
▣ Syphilis serology if it is prevalent in the population, should be
repeated at 28 to 32 weeks
▣ Pap smear
▣ Vaginal and rectal group B Streptococcal culture at 35-37
weeks (CDC, ACOG)
▣ For those with high risk of acquisition, repeat HIV testing
during 3rd trimester before 36 weeks AOG
Subsequent Prenatal Visits

▣ Return visits
▣ Recommended components of routine prenatal care after the first visit
Subsequent Prenatal Visits

□ Complicated pregnancies require more

frequent visits ( every 1-2 wks)
□ Immediate consult
■ Follow-up lab results
■ Results of 100 grams OGTT if positive 50
grams GCT
■ With problems
Subsequent Laboratory Tests

□ CBC (hb/hct) at 24-28 weeks

□ Maternal serum alpha-fetoprotein at 15-20
weeks (open neural tube defects and some
chromosomal anomalies)
□ 50 grams Glucose challenge test at 24-28
weeks
Nutrition

▣ Birthweight can be significantly influenced by

starvation during later pregnancy.
□ Perinatal mortality rate, incidence of malformations
and poor mental performance did not increase.

▣ Maternal weight gain during pregnancy influences

birth weight of the infant.
□ Greatest risk for a low birth weight infant (<2500 g)
maternal weight gain of < 16 lbs.
46
Calories

▣ Pregnancy requires an additional 80,000 kcal,

mostly during the last 20 weeks
▣ To meet this demand, a caloric increase of 100 to
300 kcal per day is recommended during
pregnancy (AAP, ACOG 2012)
▣ Adding 0, 340, and 452 kcal/day to the estimated
nonpregnant energy requirements in the first,
second, and third trimesters, respectively (IM 2006)
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

FOLIC ACID
RDA 400 µg /day (or 0.4 mg / day) throughout
periconceptional period and first trimester
4 mg / day if with prior child with neural-tube
defect (69% decrease in NTD)
Inadequate intake Neural tube defects
Notes • Diet alone is insufficient
• Women taking anti-seizure medications and
other drugs that interfere with folic acid
metabolism, carrying multiple gestation, and
obese need higher doses
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

IRON
RDA 27 mg /day
60-100 mg / day if obese, twin gestation, late
iron supplementation, irregular intake of iron,
or with iron deficiency anemia
Inadequate intake Anemia
Notes • Diet alone insufficient
• Iron requirements are slight during first 4
months of pregnancy hence not necessary to
supplement during this time
• Ingestion of iron at bedtime or on an empty
stomach aids absorption
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

CALCIUM
RDA 1000 mg /day
Inadequate intake Demineralization of mother’s bones
Notes • Development of fetal skeleton increases
demand for calcium , maternal intestinal
calcium absorption is doubled dietary
intake of calcium is necessary
• Recommended for pregnant women with
poor dietary calcium intake
• Unclear if supplementation may prevent
preeclampsia
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

PROTEIN
RDA 71 g /day
FuncGon Growth and remodeling of fetus, placenta,
uterus
Notes • Preferably supplied from animal sources
such as meat, milk, eggs, cheese, poultry and
fish
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

VITAMIN B12
RDA 2.6 µg /day
Inadequate intake Increased risk for neural tube defects
Notes • Occurs naturally only in foods of animal
origin
• Strict vegetarians may give birth to infants
deficient in Vitamin B12
• Breastmilk of a vegetarian mother contains
li`le Vit B12
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

VITAMIN D
RDA 15 µg /day (600 IU/day)
Inadequate intake Disordered skeletal homeostasis, congenital
rickets and fractures in the newborn
Notes • Supplementation can be considered in
women with limited sun exposure
NUTRITIONAL COUNSELING
Recommended Daily Dietary Allowances

IODINE
RDA 220 µg /day
Inadequate intake Neonatal cretinism
Notes • Dietary sources may be sufficient (iodized
salt, bread products)
• Consider supplementation in areas where
iodine deficiency is common
Advice on Nutrition

▣ Well- balanced meal

▣ Adequate weight gain (25-35 lbs)
▣ Iron and folate supplements
▣ Recheck Hb or Hct at 28-32 weeks
Vaccines routinely recommended during
every pregnancy

▣ Inactivate Influenza
▣ Tetanus, diphtheria (Td) or tetanus, diphtheria,
acellular pertussis (Tdap)
Vaccines contraindicated during pregnancy: can be
initiated postpartum or when lactating

▣ Herpes zoster vaccine

▣ Live attenuated influenza vaccine
▣ Measles, mumps, rubella (MMR)
▣ Varicella vaccine
▣ Smallpox vaccine
Vaccines that may be given during pregnancy
in certain populations

▣ Hepatitis A: Risk VS benefit

▣ Hepatitis B: recommended in some circumstances
▣ Meningococcal (ACWY)
▣ Meningococcal (B): risk VS benefit
▣ PCV13: no recommendation
▣ PPSV23: inadequate data for specific recommendation
Prenatal Screening

▣ Pregnant women should be evaluated for immunity to

rubella and varicella and be tested for the presence of HBsAg
during every pregnancy
▣ Women susceptible to rubella and varicella should be
vaccinated immediately after delivery
▣ A woman found to be HBsAg positive should be monitored
carefully to ensure that the infant receives HBIG and begins
Hepatits B vaccine series no later than 12 hours after birth and
that the infant completes the recommended hepatits B
vaccine series on schedule
Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Passive Immunization during Pregnancy

▣ No known risk exists for the fetus from passive

immunization of pregnant women with
immune globulin preparations

Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Immunization: Inactivated Influenza
vaccine

▣ Influenza vaccine can be administered

anytime during pregnancy before and during
the influenza season
▣ Women who are or will be pregnant during
the influenza season should receive influenza
vaccine.
▣ Good safety record
Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Influenza
▣ Indications
□ Anyone starting at 6 months
▣ Contraindications
□ Anaphylaxis with a prior dose
□ Moderate to severe illness +/- fever
□ Age < 6 months
□ Active Guillain Barre Syndrome
□ Egg allergy
▣ Dose
□ Single dose once a year (February to June)
▣ Pregnancy
□ Given at any trimester
Immunization: Tetanus, Diphtheria,
acellular Pertussis

▣ Target population: Pregnant women with no previous tetanus

immunization or unknown tetanus immunization history
▣ Administer a dose of Tdap during each pregnancy irrespective of the
patient’s prior history of receiving Tdap
▣ To maximize antibody response and passive antibody transfer to infant,
optimal timing for Tdap administration is between 27 to 36 weeks age of
gestation
▣ Pregnant women whose last Td/Tdap vaccination was more than ten years
ago should receive Td booster in the second or third trimester of
pregnancy.

Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Immunization: Tetanus, Diphtheria,
acellular Pertussis

▣ Dose Regimen: The primary tetanus immunization series consists of 3 Td

injections given intramuscularly
▣ Dose: 0.5ml Td/Tdap dose Schedule

1st Second trimester

2nd 1 month after Td 1

3rd 6-12 months after Td2

Given as Tdap preferably 27 ro 36
weeks age of gestation

Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Immunization: Tetanus, Diphtheria,
acellular Pertussis

▣ Contraindication: Severe allergic reaction after a previous dose or to a

vaccine component
▣ Precaution: History of arthus-type hypersensitivity reactions following
a previous dose of TT containing vaccine - defer vaccination until at
least 10 years have lapsed since the last TT containing vaccine
▣ Adverse events – TDaP
□ Pain
□ Redness or swelling
□ Fever
□ Headache or tiredness
Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Tdap

▣ Contraindications
□ Moderate to severe illness +/- fever
□ Allergy to thimerosal
□ Allergy to a prior dose
□ Bleeding disorders
▣ Dose
□ Primary Td series (3 doses): 0, 1, 6-12 months
□ Tdap recommended as one time substitute dose
▣ Pregnancy
□ 1 dose of Tdap during each pregnancy after 20 weeks AOG, preferably at
27-36 weeks
□ 3 doses of Td one month apart starting at 2nd trimester, 3rd dose between
27-36 weeks as Tdap

67
Immunization: Hepatitis vaccination

▣ Hepatitis A vaccine
□ Should be given during pregnancy or during the postpartum
period, to pregnant women with certain conditions such as
chronic liver disease
▣ Hepatitis B vaccine
□ Should be given to pregnant women who are HBsAg (-) and:
■ Whose husband/partner is HBsAg )(+)
■ Who live in a household with a member who is HBsAg
(+)
■ Current or recent injection drug users
■ Recent sex partner <months duration
■ Diagnosed with an STD
Reference: Vaccinations for Pregnant Women and Breastfeeding women, Task force for
immunization for women
Hepatitis A*
▣ Indications
□ For all living in areas of high prevalence (e.g. Asia)
▣ Contraindications
□ Allergy to a vaccine component, not given to those highly febrile
▣ Dose
□ 2 doses
■ 1st dose at age 1 or older
■ Booster dose after 6-18 months
▣ Pregnancy
□ May be given if at high risk
Hepatitis B*
▣ Indications
□ Universal immunization of all infants, adolescents and adults
▣ Contraindications
□ Allergy to a vaccine component, not given to those highly febrile
▣ Dose
□ 3 doses (0, 1-2, 4-6 months)
▣ Pregnancy
□ May be given if at high risk
□ (if without proof of immunity)
Pneumococcal *
▣ Indications
□ For all susceptible especially > 50 years old
□ High risk adult < 50 years old: immunocompromised or asplenic,
sickle cell, HIV< CRF, leukemia, lymphoma, malignancy, Hodgkin’s
solid organ transplant, multiple myeloma

▣ Contraindications
□ Previous severe allergic reaction to the vaccine, including (for PCV13)
to any diphtheria toxoid containing vaccine or any of its compinent

▣ Dose
□ Single dose
■ Booster dose after 6-18 months

▣ Pregnancy
□ Given if needed
Meningococcal *
▣ Indications
□ Adults at risk for meningococcal disease
▣ Contraindications
□ Severe allergic reaction to a vaccine component or following
a prior dose of vaccine
□ Moderate or severe acute illness
▣ Dose
□ 1 dose
▣ Pregnancy
□ Given if needed
Rabies *
▣ Recommendations
□ Because of the potential consequences of
inadequately managed rabies exposure,
pregnancy is no considered a
contraindication to post-exposure
prophylaxis
Measles, Mumps, Rubella !
▣ Indications
□ 10-65 yrs old without evidence of immunity

▣ Contraindications
□ Allergy to prior dose
□ Allergy to gelatin/neomycin
□ Pregnancy
□ Those on large doses of steroids

▣ Dose
□ 2 doses (0, 1 month)

▣ Pregnancy
□ CONTRAINDICATED
□ May give immediately postpartum to those without evidence of immunity
to Rubella (Rubella IgG negative)
Varicella !
▣ Indications
□ All adults with no evidence of immunity

▣ Contraindications
□ Allergy to a prior dose
□ Malignant conditions of bone marrow/lymphatic system
□ Primary acquired immunodeficiency
□ On high dose immunosuppresants
□ Low dose steroids > 2 weeks

▣ Dose
□ 2 doses (0, 1-2 months)

▣ Pregnancy
□ CONTRAINDICATED
Human Papilloma Virus
▣ Pregnancy
□ If found to be pregnant, give remaining
doses after pregnancy
□ If a vaccine dose has been administered
during pregnancy, no intervention is
needed
Immunization

Reference: William’s Obstetrics 25th edition

Immunization

Reference: William’s Obstetrics 25th edition

Immunization

Reference: William’s Obstetrics 25th edition

Immunization

Reference: William’s Obstetrics 25th edition

Immunization

Reference: William’s Obstetrics 25th edition

Common Concerns during Pregnancy

□ Exercise
□ Women who are used to aerobic exercise
before pregnancy may continue during
pregnancy – shorter active labor, fewer
cesarean deliveries, less meconium-stained
fluids, less fetal distress – reduced birth
weight
□ Restricted activities
■ Hypertensive disorders
■ Multiple gestation
■ Growth restricted fetus
■ Severe heart disease
Common Concerns during Pregnancy

▣ Exercise recommendations
□ Thorough clinical evaluation – contraindications
□ Regular, moderate-intensity physical activity (30
min/day)
□ Avoid activities with high risk for falling or
abdominal trauma

ACOG 2002b
Common Concerns

▣ Employment
□ Physically demanding work: 20-60% increase in
preterm birth, IUGR, or HPN.
□ Working women: 5-fold increased risk of
preeclampsia
□ Occupational fatigue (no. of hrs. standing, intensity of
physical & mental demands, environmental
stressors): increased risk of preterm membrane
rupture.
Common Concerns

▣ Travel
□ No harmful effect on pregnancy
□ Safe to fly up to 36 weeks AOG
□ Greatest risk with travel – absence of facilities
when complications arise

(ACOG 2004)
Common Concerns

▣ Bowel Habits
□ Constipation – common; prolonged transit time and uterine/fetal
compression of the bowels
□ Treatment: fluids, exercise, laxative

Coitus
□ Not harmful in healthy pregnant women
□ Avoided in cases of threatened abortion or preterm labor
▣ Immunization
□ Current information on the safety of vaccines given during
pregnancy is subject to change (CDC)
Common Concerns

▣ Smoking
□ Harmful to pregnancy: low birthweight due
to preterm delivery or fetal growth restriction,
infant and fetal deaths, abruption placenta
□ Pathophysiology: increased fetal
carboxyhemoglobin levels, reduced
uteroplacental blood flow, fetal hypoxia
Common Concerns

▣ Alcohol
□ Fetal alcohol syndrome - prenatal and postnatal
growth deficiency, mental retardation, behavioral
disturbances, atypical facial appearance,
congenital heart defects and brain anomalies
□ Absolutely prohibited during pregnancy
Common Concerns

▣ Caffeine
□ No evidence of increased teratogenic or reproductive
risks
□ May increase the risk of spontaneous abortion
(> 5 cups/day)
□ No association of moderate consumption (<
500mg/day) with low birthweight, IUGR, preterm
delivery
□ American Dietetic Association (2002) recommends:
caffeine intake < 300 mg/day (three 5-oz cups)
Common Concerns

▣ Illicit Drugs
□ Opium derivatives, barbiturates and
amphetamines
□ Fetal growth restriction, fetal distress, severe
perinatal complications

▣ Medications
□ Given to the mother -cross the placenta
Common Concerns

▣ Nausea and Vomiting

□ First trimester
□ Etiology: hCG, estrogen
□ Treatment: small frequent feedings, avoid precipitating
factors
□ Mild symptoms respond to Vitamin B6 with Doxylamine
□ Hyperemesis gravidarum – severe vomiting that results
to dehydration, electrolyte and acid-base abnormalities
Common Concerns

▣ Backache
□ In 70% of pregnant women; increased with
duration of gestation
□ Risk factors: prior back pain, obesity
□ Treatment:
■ squat, not bend over; back support; avoid
high-heeled shoes
Common Concerns

▣ Varicosities
□ Genetic predisposition
□ Increase in femoral venous pressure
□ Exaggerated by prolonged standing, pregnancy, and
advancing age
□ Worsened by advancing pregnancy, increasing weight and
prolonged upright position
□ Treatment:
■ Periodic rest with elevation of the legs
■ Elastic stockings
■ Surgery during pregnancy – not advised
Common Concerns

▣ Hemorrhoids
□ Due to increased pressure in the rectal veins due to obstructed venous return
by the large uterus, & increased constipation during pregnancy
□ Treatment: Topical anesthetics, hot sitz bath, stool softeners
▣ Heartburn
□ One of the most common complaints
□ Reflux of gastric contents into the lower esophagus
□ More common in pregnancy – upward displacement & compression of the
stomach by the uterus, with relaxation of lower esophageal sphincter
□ Treatment: small frequent meals, avoid bending over or lying flat, antacids
Common Concerns

▣ Pica
□ Cravings for strange foods/nonfoods
□ Ice (pagophagia), starch (amylophagia), clay (geophagia)
□ Iron deficiency in some cases

▣ Ptyalism
□ Profuse salivation
□ Stimulated salivary glands by the ingestion of starch
□ Mostly unexplained
Common Concerns

▣ Fatigue
□ Remits by the 4th month of gestation
□ Progesterone effect
▣ Headache
□ Common in early pregnancy
□ Idiopathic
□ Disappears by midpregnancy
▣ Leukorrhea
□ Physiologic vs. Pathologic
□ Increased vaginal discharge due to hyperestrogenemia