PRENATAL CAREBy:

Clent Banaay Alma Aguda

Jude Panuda Maylilene Fuentes

Najrah AcramanIda Abajon

John Patacsil Liney Santos

“THE POWER OF 8”8 THAT!

PRENATAL CARE

1. PRECONCEPTION CARE

2. PROMPT DIAGNOSIS OF PREGNANCY

3. INITIAL PRESENTATION FOR PREGNANCY CARE

4. FOLLOW-UP PRENATAL VISITS

PRENATAL CARE

• PROMPT DIAGNOSIS OF PREGNANCY-Documentation of Pregnancy

Recommended Components of the Initial Prenatal Care Visit

• Risk Assessment– Include genetic, medical, obstetrical and psychosocial factors

• Estimated Due Date• HPI• Past medical History

– Medical illnesses– Surgical history

• OB history• Menstrual History• Personal and Social, Sexual History• Contraceptive History• General Physical Examination• Laboratory Tests• Patient Education

• OBSTETRICAL HISTORY– Crucial since many prior pregnancy complications tend to

recur in subsequent pregnancies

ASSESSMENT OF AOG• Normal duration of pregnancy

– 280 days, 40 weeks

• Calculated from the first day of the last normal menstrual period (LNMP)

• PRECISE knowledge of the age of the fetus is imperative for ideal obstetrical management

• CLINICAL DATING– Most reliable clinical estimator of gestational age is an accurate LNMP– Naegele’s Rule

ASSESSMENT OF GESTATIONAL AGE

• CLINICAL DATING– Historically, pregnancy divided into trimesters• First trimester: 14 completed weeks• Second trimester: 28 completed weeks• Third trimester: 29 – 42 weeks

– Clinically appropriate measure is weeks of gestation completed• 33 3/7 weeks = 33 completed weeks and 3 days

ASSESSMENT OF GESTATIONAL AGE

HEIGHT OF THE FUNDUS• 12 weeks: uterus felt above the

symphysis pubis

• 16 weeks: approximately halfway between symphysis and umbilicus

• 20 weeks: level of the umbilicus

FUNDIC HEIGHTBetween 20-31 weeks, there is good correlation between the gestational age of the fetus in weeks and the height of the

fundus in centimeters

ASSESSMENT OF GESTATIONAL AGE

• OTHER CLINICAL TOOLS: to confirm and support LNMP data and when LNMP is inaccurate or unknown

– AUDIBLE FETAL HEART TONES• Electronic Doppler devices permits detection by 11-12 weeks• FHT first auscultated using a stethoscope between 16-19 weeks

– QUICKENING• First perception of fetal movements by the mother occurs at predictable times in

gestation• 16 – 20 weeks

• ULTRASOUND– Plays a major role in assessment of size and duration of

pregnancy– Routine ultrasound is currently not recommended in low-risk

pregnancies (ACOG, 1997b)

PELVIC EXAMINATION• Vaginal examination

– Visualization of the cervix and vagina• Bluish hyperemia of the cervix• Pap smear obtained• Specimens collected for identification of N. gonorrhea, Chlamydia

– Digital pelvic examination• Cervix: consistency, length, dilatation• Fetal presenting part• Bony architecture of the pelvis• Anomalies of the vagina and perineum

• Rectal / Rectovaginal examination– Competence of the rectal sphincter– Presence of a pathologic condition of the rectum

ROUTINE LABORATORY TESTS

• Complete blood count• Urinalysis and urine culture and sensitivity• Blood grouping, Rh determination• Serologic test for Syphilis (RPR, VDRL)• Hepatitis B surface antigen• Pap Smear• HIV testing offered

RETURN VISITS

• Every 4 weeks until 28 weeks Every 2 weeks until 36 weeks Weekly thereafter, until delivery

• More frequent if the patient is high risk

SUBSEQUENT PRENATAL VISITS

• Maternal Evaluation– Blood pressure– Weight, Height– Symptoms:• Headache - Altered vision• Abdominal pain - Nausea and vomiting• Fluid from vagina - Dysuria

– Fundic height– Abdominal examination with Leopold’s

maneuvers

SUBSEQUENT PRENATAL VISITS

• Maternal Evaluation– Vaginal examination (if late in pregnancy)• Confirmation of the presenting part• Station of the presenting part• Clinical estimation of the pelvic capacity• Consistency, effacement and dilatation of the cervix

SUBSEQUENT PRENATAL VISITS

• Fetal Evaluation– Heart rate– Size– Amount of amniotic fluid– Presenting part and station– Activity

SUBSEQUENT LABORATORY TESTS

• Repeat hemoglobin (or hematocrit) determination at 28 to 32 weeks

• Repeat Syphilis serology, if in a prevalent population, at 28-32 weeks

• Determination of maternal serum alpha-fetoprotein (MSAFP) at 16-18 weeks to screen for open neural tube defects and some chromosomal anomalies

• Screening for cystic fibrosis

SUBSEQUENT LABORATORY TESTS

• ANCILLARY TESTS– Gestational Diabetes• Universal versus Selective ?• Risk factors for DM

– >25 years of age– <25 years of age and obese– Family history of DM in 1st degree relative– Member of ethnic/racial group with high prevalence of

DM

SUBSEQUENT LABORATORY TESTS• ANCILLARY TESTS

– Gestational Diabetes• ASEAN Study group on DM in Pregnancy

– Historical risk factors» Past pregnancies with abnormal glucose tolerance» Macrosomia» Recurrent abortions, unexplained IUFD

– Obstetric risk factors» Polyhydramnios» Macrosomic fetus» Fetal abnormality» Recurrent genital infections

• Screening recommended at 24-28 weeks for women without risk factors

• With risk factor, screening recommended– First prenatal visit– If negative repeat at 24-28 weeks and 32-34 weeks AOG

SUBSEQUENT LABORATORY TESTS

• ANCILLARY TESTS– Chlamydia Trachomatis

• For women with risk factors• Universal screening not recommended

– Bacterial Vaginosis• Universal screening not recommended• May be considered for women at risk for preterm labor

– Group B Streptococcus• No clear consensus regarding screening cultures

SUBSEQUENT LABORATORY TESTS

• ANCILLARY TESTS– Fetal Fibronectin• Forecast preterm delivery• Routine screening not recommended

– Screening for Genetic Diseases• Offered based on family history or the ethnic or racial

background– Tay-Sachs – Eastern European, French Canadian– Β-Thalassemia – Mediterranean, Southeast Asian, Indian,

Pakistani, African– Sickle cell anemia - African

NUTRITION• Recommendations for weight gain• The woman’s nutritional status before, during, and after pregnancy

contributes to a significant degree to the well-being of both herself and her infant

• Recommended total weight gain ranges for pregnant women with singleton pregnancies

Recommended total weight gainPre pregnancy BMI Pounds KilogramsLow (BMI <19.8) 28-40 12.5-18Normal (BMI 19.8-26) 25-35 11.5-16High (BMI 26-29) 15-25 7-11.5Obese (BMI >29) <15 <7

Twin gestation 35-45 15.9-20.4

• Weight gain from 8-20 wks: 0.7 lb/week• Weight gain from 20 wks to delivery:1 lb/wk

Recommended Dietary Allowances• CALORIES

– Daily caloric increase of 100 to 300 kcal throughout pregnancy

• PROTEIN– Needed for growth and repair of the fetus, placenta, uterus and

increased maternal blood volume– 2.9 and 15 gm/day during the 1st 2nd and 3rd trimesters– Average of 9 gm/day throughout pregnancy

• CARBOHYDRATES– 50-100 gm available carbohydrates per day is sufficient to prevent

ketosis and other symptoms of dietary carbohydrate lack

• FATS– 15-25 g of appropriate fat– Adds palatability and satiety value to diet

• DIETARY FIBER

Recommended Dietary Allowances• Minerals– ZINC: 12 mg/d is recommended• profound deficiency may cause dwarfism and

hypogonadism• acrodermatitis enteropathica: rare skin disorder

– IRON• 30 mg of elemental iron in the form of simple iron salts such as

ferrous sulfate, gluconate, fumarate• 60-100 mg if she is large, has twin fetuses, takes iron irregularly

or has a depressed Hgb level

Recommended Dietary Allowances– IODINE• 100 µg for a reference woman (49 kg), additional 25

µg/d for the pregnant woman• severe maternal iodine deficiency leads to endemic

cretinism in offspring

– CALCIUM• Additional allowance of 400 mg or total of 900 mg/day

– PHOSPHORUS

Recommended Dietary Allowances

• VITAMINS – increased requirements for vitamins during pregnancy

with the exception of folate can be supplied by any general diet

– FOLATE• 400 µg during the periconceptional period• In a woman with a prior pregnancy complicated by

NTDs should supplement her diet with 4 mg of folic acid taken as a separate supplement• deficiency leads to megaloblastic anemia

Recommended Dietary Allowances• VITAMIN A

– 475 RE (retinol equivalent)/d– Required for vision cellular differentiation and proliferation, growth, reproduction and

integrity of the immune system– Excessive intake appears to be teratogenic

• VITAMIN B1, THIAMINE– 1.3 mg/d– aneuria and the antineuritic factor – has a role in preventing symptoms involving nerves

• VITAMIN B2, RIBOFLAVIN– 1.0 mg/d for non-pregnant woman, additional 0.6 mg/d for pregnancy– angular stomatitis, cheilosis, glossitis and seborrheic dermatitis

• VITAMIN B6, PYRIDOXINE– 1.0 mg– symptoms of deficiency: insomnia, confusion, nervousness, depression, irritability, skin

lesions such as seborrhea, glossitis, stomatitis

Recommended Dietary Allowances

• NIACIN– 18 NE/d with 1900 kcal energy, additional 3 and 5 NE for pregnant

and lactating– Pellagra: bilateral dermatitis, glossitis, diarrhea, irritability, mental

confusion, delirium and psychotic symptoms• VITAMIN C, ASCORBIC ACID

– 10 mg/d increment for pregnant women– Scurvy: deficiency in Vit C

• VITAMIN D AND VITAMIN E– Vitamin D: main source is the effect of ultraviolet light on the skin– Vitamin E: sources are vegetable oil, margarine and shortening

COMMON CONCERNS

• Exercise– Women who are accustomed to aerobic

exercise before pregnancy may continue to do so

– Caution against starting new aerobic exercise programs or intensifying training efforts

– With pregnancy complications, mother and fetus may benefit from being sedentary

COMMON CONCERNS– Aerobics: rhythmic repetitive activities strenuous enough to demand

increased oxygen to the muscles but not so strenuous that the demands exceeds supply

– Calisthenics: rhythmic, light gymnastic movements that tone and develop muscles and improve posture

– Relaxation Techniques: breathing and concentration exercises relax the mind and body, help conserve energy, assist the mind to focus on a task and increase body awareness

– Pelvic Toning: Kegel exercises for toning the muscles in the vaginal and perineal area, strengthening them in preparation for delivery and aiding in recovery postpartum

COMMON CONCERNS• Employment

– Equality of opportunity in the workplace– Teitelman and co-workers (1990): evaluated maternal work activity

and pregnancy outcome• Standing: cashiers, bank tellers or dentists; required standing in the same

position for >3 hours/ day• Active jobs: physicians, waitresses and real estate brokers: involved

continuous or intermittent walking• Sedentary jobs: librarian, bookkeeper or bus driver; required less than an

hour of standing/day– Women who work at jobs that required prolonged standing/ day are

at greater risk for preterm delivery but no effect on fetal growth

COMMON CONCERNS• Any occupation that subjects the pregnant women to severe physical

strain should be avoided

• Adequate periods of rest should be provided during the work day

• Women with previous pregnancy complications should minimize physical work

• ACOG: women with uncomplicated pregnancies can continue to work until the onset of labor with a 4-6 week period recommended before return to work after delivery

COMMON CONCERNS• Travel

– No harmful effects on pregnancy– Travel in properly pressurized aircraft infers no unusual risk– Development of complications remote from facilities adequate to

manage the complication– ACOG (1998c): 3 point automobile restraints

• Lap belt portion should be placed under the abdomen and across the upper thighs

• Shoulder belt snugly applied between her breasts

• Bathing• Clothing

– Comfortable and non-restricting– Well-fitting supporting brassieres, maternity girdle

COMMON CONCERNS

• Bowel habits– Constipation is common because of the

prolonged transit time and compression of the lower bowels by the uterus and presenting part

– Hemorrhoids– Sufficient quantities of fluid and reasonable

amounts of daily exercise– Mild laxatives: prune juice, milk of magnesia,

bulk-producing substances

COMMON CONCERNS

• Coitus– Sexual intercourse is not harmful before the

last 4 weeks or so of pregnancy– Whenever abortion or preterm labor threatens,

coitus should be avoided

• Care of the teeth– There is rarely a contraindication to needed

dental treatment

COMMON CONCERNS• Immunizations

– Recommendations for Immunization during Pregnancy

• LIVE VIRUS VACCINESMeasles: contraindicatedMumps: contraindicatedVaricella-zoster: contraindicated

• LIVE BACTERIAL VACCINETyphoid (Ty21a) – risks vs. benefitsPoliomyelitis – no longer recommendedYellow fever – high risk areas only

• INACTIVATED VIRUS VACCINESInfluenza – after first trimesterRabies – same as non-pregnantHepatitis A and B – same as non-pregnantJapanese encephalitis – weigh risks vs benefits

COMMON CONCERNS– INACTIVATED BACTERIAL VACCINES

Pneumococcal - same as non-pregnantMeningococcal – same as non-pregnantHemophilus – same as non-pregnantCholera – risks vs benefits

– TOXOIDSTetanus-diptheria – same as non-pregnant

– HYPERIMMUNE GLOBULINSHepatitis B – post-exposure prophylaxis, give

along with Hepatitis vaccine, then vaccine alone at 1 and 6 months

Rabies – post-exposure prophylaxisTetanus – post-exposure prophylaxisVaricella – consider for post-exposure

prophylaxis within 96 h– POOLED IMMUNE SERUM GLOBULINS

Hepatitis A – post-exposure prophylaxisMeasles – post-exposure prophylaxis

COMMON CONCERNS

• Smoking– Adverse outcomes linked to smoking: • Low birth weight due to either preterm delivery or

fetal growth restriction• Infant and fetal deaths• Placental abruption• Mechanisms:

– Increased fetal carboxyhemoglobin levels– Reduced uteroplacental blood flow– Fetal hypoxia

COMMON CONCERNS

• Alcohol• Ethanol is a potent teratogen• Abstinence from using any alcohol beverages• Fetal Alcohol Syndrome:

– growth restriction– facial abnormalities– CNS dysfunction

• Caffeine• Limit caffeine intake• No evidence that caffeine increases teratogenic or reproductive risk• Limited to <300 mg/day, or 3, 5-oz cups

• Illicit Drugs• Chronic use during pregnancy of opium derivatives, barbiturates,

amphetamines is harmful to the fetus

COMMON CONCERNS

• Nausea and Vomiting– Starts between the first and second missed menses until 14

weeks– Eating small feedings at more frequent intervals but

stopping short of satiation– Avoid foods that precipitate or aggravate symptoms– Hyperemesis gravidarum: severe vomiting that dehydration,

electrolyte and acid-base disturbances, starvation become serious problems

COMMON CONCERNS• Backache

– Advise to squat rather than bend over when reaching down– Provide back support with a pillow when sitting down and avoiding

high-heeled shoes– If severe, thorough orthopedic examination

• Varicosities– Congenital predisposition exaggerated by prolonged pregnancy

and advancing age– Treatment: periodic rest with elevation of the legs, elastic

stockings or both– Surgical correction during pregnancy is generally not advised

COMMON CONCERNS

• Hemorrhoids– Pregnancy causes exacerbation or recurrence

due to increased pressure in the rectal veins caused by obstruction of venous return by the large uterus

– Pain and swelling relieved by topically applied anesthetics, warm soaks, and agents that soften the stool

COMMON CONCERNS• Heartburn

– One of the most common complaints– Caused by reflux of gastric contents in to the lower

esophagus– increased frequency of regurgitation results from upward

displacement and compression of the stomach by the uterus and relaxation of the lower esophageal sphincter

– Frequent but smaller meals, avoidance of bending over or lying flat

– Antacids: aluminum hydroxide, Magnesium trisilicate, Magnesium hydroxide alone or in combination preferred over sodium bicarbonate

COMMON CONCERNS• Pica

– cravings of pregnant for strange foods and at times nonfoods– ice: pagophagia– starch: amylophagia– clay: geophagia– considered to be triggered by severe iron deficiency

• Ptyalism

– May be caused by stimulation of the salivary glands by ingestion of starch

– Most cases are unexplained

COMMON CONCERNS

• Fatigue– Remits spontaneously by the 4th month

• Headache– May be caused by sinusitis, ocular strain caused by refractive

errors– No cause identified in majority of cases– Treatment: symptomatic– May decrease in severity or disappear by midpregnancy

COMMON CONCERNS• Leucorrhea

– Increased mucus formation by cervical glands in response to hyperestrogenemia

– If secretions become troublesome and accompanied by pruritus and burning sensation may be caused by:

• Candidiasis or Moniliasis– cheesy white discharge with severe pruritus, burning sensation,

redness and excoriation of the skin of the vulva and perineum– fresh hanging drop with KOH will demonstrate oval budding cells

or pseudohyphae– Miconazole, clotrimazole, nystatin

COMMON CONCERNS

• Bacterial vaginosis– Maldistribution of bacterial populations that comprise normal

vaginal flora– Lactobacilli are decreased, overrepresented species tends to be

anaerobic Gardnerella vaginalis, Mobiluncus, Bacteroides species– Metronidazole 500 mg BID x 7 days

• Trichomonas vaginalis– Foamy leucorrhea, vaginal and cervical epithelium contains small

punctuate reddened areas– Ameboid organism identified by a fresh hanging drop smear– Metronidazole (Class B) orally or vaginally;

Thank you!