PRENATAL CARE

Williams Obstetrics
Diagnosis of pregnancy
Signs and symptoms
 Amenorrhea
 Not a reliable indication of pregnancy until 10 days or more after the
time of expected onset of menstrual period

 Uterine bleeding
 Mimics menstration after conception
 Consequence of blastocyst implantation
 fetal movements
 16-18wks in multigravida
 18-20wks in primigravid
 20wks, examiner can detect
 Changes in cervical mucus
 Fern pattern- 7 to 18th day of menstrual cycle,
 Presence of estrogen
 Beaded pattern- after 21st day, usually encountered during pregnancy
 Presence of progesterone
 Chadwicks sign
 Bluish discoloration of vaginal mucosa
 Changes in the cervix
 Increase softening as pregnancy advances
 Changes in the uterus
 Hegar sign- softening of isthmus
 Changes in the breast
 Fetal heart tone (110-160)
 5wks transvaginal ultrasound
 10wks doppler
 20wks- stethoscope
 Pregnancy test
 HCG
 Alpha subunit is similar to: LH,
FSH, TSH
 Prevents involution of the
corpus luteum
 Detactable in maternal plasma
or urine by 8-9days after
ovulation
 Doubling time: 1.4-2days
 Peak levels: 60-70days
Other causes of positive HCG

 Exogenous HCG
 Renal failure
 Impaired HCG clearance
 Physiologic
 Pituitary HCG
 HCG producing tumor
 GI sites, ovary,
 Sonographic recognition of pregnancy
 4-5weeks
 Gestational sac
 5-6weeks
 Yolk sac
 6 weeks
 Embryo with cardiac activity
 12 weeks
 CRL is predictive of gestational age within 4days
Initial Prenatal Evaluation

To define the health status of the

mother and fetus

To estimate the gestational age of

the fetus

To initiate a plan for continuing

obstetrical care
Normal pregnancy duration

 Mean duration from last normal menstrual period (Gestational Age or

Menstrual Age): 280 days or 40 weeks +/-13days

 Expected date of delivery (Naegele’s Rule): LMP + 7 days then count

back 3 months

 Ovulatory Age or Fertilization Age  2 weeks short of the menstrual

age
 3 TRIMESTERS:
 1st Trimester: 1-14 weeks
 2nd Trimester: 15-28 weeks
 3rd Trimester: 29th through 42nd weeks
History

 OBSTETRICAL HISTORY  Prior pregnancy complications

tend to recur in subsequent pregnancies
 MENSTRUAL HISTORY  Ovulatory cycles important for
accurate dating of pregnancy by history and PE
 OCP USE  Ovulation may not have resumed 2 weeks after
onset of the last withdrawal bleeding
 PSYCHOSOCIAL SCREENING

A.Cigarette Smoking
Pathophysiology for Adverse Pregnancy
Adverse Outcomes Effects
 Teratogenic effects • Fetal hypoxia
 Spontaneous abortion • Reduced uteroplacental blood
 Low BW due to preterm delivery or fetal flow
growth restriction • Direct toxic effects of nicotine
 Fetal death, SIDS and other compounds in
 Placental abruptio, Placenta previa smoke
 PROM
B. Alcohol and Illicit Drugs During Pregnancy
Ethanol  Potent teratogen and causes FETAL ALCOHOL SYNDROME
 Fetal Alcohol Syndrome
 Growth restriction
 Facial abnormalities
 CNS dysfunction
Illicit Drugs
 Fetal growth restriction
 Low birth weight
 Drug withdrawal soon after birth
C. Intimate Partner Violence Screening
 Pattern of assaultive and coercive behavior
 Includes: Physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation,
intimidation, reproductive coercion
Adverse Outcomes
 Preterm delivery
 Fetal growth restriction
 Perinatal death
 Physical examination
PELVIC EXAMINATION

Speculum Exam
Cervix
 Hyperemic, bluish-red
 Nabothian cysts
 Not normally dilated above the internal os
 Pap smear is obtained
 Specimen for N. gonorrhea and Chlamydia when
indicated
Bimanual Examination
 Consistency, length, and dilatation of the cervix
 Uterine and adnexal size
 Bony architecture of the pelvis
 Fetal presentation later in pregnancy
 Anomalies of the vagina and perineum
 Vulvar inspection
Pregnancy Risk Assesment
Subsequent prenatal visits

 Every 4 weeks until 28 weeks

 Every 2 weeks 29 to36 weeks
 Weekly thereafter
 Every 1-2 weeks interval for complicated pregnancies
PRENATAL SURVEILLANCE
 Fetal
 Heart rate
 Size-current and rate of change
 Amount of amniotic fluid
 Presenting part and station
 activity
 Maternal
 Blood pressure
 Weight
 Symptoms (10danger signs)
 Fundic height
 Vaginal exam
Assesment of gestational age
 Fundal height
 20-34wks aog
 Height of the fundus (cm) correlates with AOG in weeks
 Empty the bladder
 Fetal heart sounds
 10wks- doppler
 5wks- TVS
 Funic souffle
 Uterine souffle
 Ultrasound
Subsequent laboratories


Fetal enuploidy – 11-14wks or 15-20wks
NTD screening at 15-20wks
Hgb, hematocrit repeated at 28-32wks and syphilis
if prevalent
Grp B streptococcal infection 35-37wk
Gestational diabetes- OGTT on the 24-28wk
Selected genetic screening
NUTRITION
Weight retention after pregnancy

Ave wt gain-12.9kg
Maternal wt loss after delivery- 5.4kg
2wks postpartum - 4kg wt loss
2wks to 6months- another 2kg wt loss
Recommended daily Allowance
 Calories
 Requires 80,000 kcal
 Increase intake of 100-300kcal/day
1st tri- 0kcal
2nd tri 340kcal/day
3rd 452 kcal/day
 Protein
 1000g deposited latter half of pregnancy =5-6g/day
 Recommended 1g/kg/day
 Mostamino acids fall in maternal plasma except glutamic
acid and alanine
 Minerals
Iron
 300mg transferred to the fetus
 500mg incorporated into maternal hemoglobin mass
 Recommended daily ferrous iron supplement = 27mg
 Increase to 60-100mg/day if
 Large woman
 Twin fetus
 Late iron supplementation
 Irregular intake
 Depressed hemoglobin levels
 Ingest at bedtime or an empty stomach facilities absorption and minimize adverse GI
reaction
Calcium
 30g is retained, most of which is deposited in the fetus late in pregnancy
 Increase absorption by the intestine and progressive retention throughout pregnancy
Phosphorus
 Plasma levels do not differ from prepregnancy levels

Zinc
 RDA 12mg
 Zinc deficiency
 Poor appetite
 Suboptimal growth
 Impaired wound healing
 dwarfism
 Iodine
 220microgram/day
 Iodized salt and bread products is recommended
 Potassium
 Decreases by 0.5 mEq/L by mid-pregnancy

 Predisposed by prolonged nausea and vomiting

 Sodium
 Increased total sodium accumulation

 Serum concentration is decreased due to expanded plasma

volume
 Excretion unchanged
VITAMINS
 Folic acid
 Supplementation prevents NTD
 Daily intake of 400mcg throughout peri-conceptional period
 Daily supplementation with 4mg folic acid decrease recurrence rate of NTD by 70%
if with prior child with NTD
 Vitamin A
 Associated w/ birth defects at doses >10000IU/ day
 Isotretinoin is potent teratogen in humans
 Deficiency associated with increased risk of maternal anemia and preterm birth,
severe with night blindness

 Vitamin B6
 Daily supplement of 2mg recommended for women at high risk for inadequate
nutrition
 For nausea & vomiting
 Vitamin B12
 Decrease in normal pregnancy
 Occurs naturally in foods of animal origin
 Deficiency: Vegetarians, excessive vitamin C ingestion

 Vitamin C
 RDA = 80 – 85 mg/day
 Maternal plasma level decline during pregnancy but cord level is higher

 Vitamin D
 Increases intestinal Calcium absorption
 Promotes bone mineralization & growth
 DEFICIENCY in women with limited sun exposure is ordered skeletal homeostasis
 Congenital rickets
 Fractures in the newborn
Recommended Daily Dietary Allowances for
Pregnant and lactating women
Common concerns
Employment
 Greater risk for preterm delivery with jobs that require prolonged standing
 Occupational fatigue was assos with increased risk of PPROM
 Adequate periods of rest should be provided during work period
 Women with uncomplicated pregnancies can continue to work until onset of labor

Exercise
 Oxygen consumption, heart rate, stroke volume, and cardiac output all increase
 Pregnant women who exercised regularly had significantly larger blood volumes
 In the absence of contraindications, encourage regular, moderate-intensity physical activity
30 min or more/day
 Avoid scuba diving because fetus is at increased risk of decompression sickness
Fish consumption
Avoid shark, swordfish, king mackerel, tile fish
Ingest no more than 12 oz or 2 servings of canned tuna/week; No more than 6
oz of albacore or white tuna

Lead screening
>45µg/dl- candidates for chelation therapy
 Exposure effects:
 Gestational HPN
 Spontaneous abortion
 Low birth weight
 Neurodevelopmental impairments in the newborn
Coitus
 Usually not harmful in healthy pregnant
 Avoided in: placenta previa, threatened preterm labor
Dentition

 Dental carries are not aggravated by pregnancy

Caffeine
 unclear that caffeine caused increased teratogenic or reproductive risk
 Only extremely high serum paraxanthine concentration were associated with abortion
(equivalent to >5 cups/day)
 Limit intake to 300 mg daily or three 5 oz cups coffee/day
Immunizations

Vaccines Contraindicated During Pregnancy

MMR
Yellow fever
Varicella
Small pox
NAUSEA AND VOMITING
 Commence between 1st and 2nd missed menses and continue until 14 – 16 weeks
 Caused by high levels of serum B-hCG which is a surrogate for increasing estrogen levels
 Advise small frequent feedings, ginger vit B6 with doxylamine

BACKACHE
 Increased with duration of gestation
 Prior low back pain and obesity are risk factors
 Squat rather than bend
 Provide back support when sitting
 avoid high heeled shoes
VARICOSITIES
 Result from congenital predisposition exaggerated by long standing, pregnancy, and
advancing age
 Femoral venous pressure increases as pregnancy advances
 Advise periodic rest with elevation of the legs, elastic stockings
 Surgical correction during pregnancy not advised

HEMORRHOIDS
 Related to increased venous pressure in the rectal veins
 Caused by obstruction of venous return by the large uterus and by constipation
 Advise topical anesthetics, warm soaks, and stool-softening agents
Heartburn
 Caused by reflux of gastric contents into the lower esophagus
 From upward displacement and compression of the stomach by the uterus,
combined with relaxation of lower esophageal sphincter
 Give antacids, small frequent meals, avoid bending over or lying flat

PICA
 Has been considered to be triggered by severe iron deficiency
 Rate of spontaneous preterm birth at less than 35 weeks was twice as high
Sleeping
 Sleep efficiency progressively diminish as pregnancy advances
 Daytime naps and mild sedatives at bedtime can be helpful

HEADACHE
 Treatment is symptomatic but should be investigated especially
in late pregnancy
Thank you!