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PRENATAL CARE

By: Clent Banaay Alma Aguda Jude Panuda Maylilene Fuentes Najrah Acraman Ida 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 Naegeles 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 HEIGHT

Between 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:
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

to confirm and support LNMP data and when LNMP

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 Abdominal pain Fluid from vagina - Altered vision - Nausea and vomiting - Dysuria

Fundic height Abdominal examination with Leopolds 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 -Thalassemia Mediterranean, Southeast Asian, Indian, Pakistani, African Sickle cell anemia - African

NUTRITION
Recommendations for weight gain The womans 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 gain Pre pregnancy BMI Pounds Kilograms Low (BMI <19.8) 28-40 12.5-18 Normal (BMI 19.8-26) 25-35 11.5-16 High (BMI 26-29) 15-25 7-11.5 Obese (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 PROTEIN
Daily caloric increase of 100 to 300 kcal throughout pregnancy 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

15-25 g of appropriate fat Adds palatability and satiety value to diet DIETARY FIBER

FATS

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 g for a reference woman (49 kg), additional 25 g/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 g 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 VACCINES Measles: contraindicated Mumps: contraindicated Varicella-zoster: contraindicated LIVE BACTERIAL VACCINE Typhoid (Ty21a) risks vs. benefits Poliomyelitis no longer recommended Yellow fever high risk areas only INACTIVATED VIRUS VACCINES Influenza after first trimester Rabies same as non-pregnant Hepatitis A and B same as non-pregnant Japanese encephalitis weigh risks vs benefits

COMMON CONCERNS
INACTIVATED BACTERIAL VACCINES Pneumococcal - same as non-pregnant Meningococcal same as non-pregnant Hemophilus same as non-pregnant Cholera risks vs benefits TOXOIDS Tetanus-diptheria same as non-pregnant HYPERIMMUNE GLOBULINS Hepatitis B post-exposure prophylaxis, give along with Hepatitis vaccine, then vaccine alone at 1 and months Rabies post-exposure prophylaxis Tetanus post-exposure prophylaxis Varicella consider for post-exposure prophylaxis within 96 h POOLED IMMUNE SERUM GLOBULINS Hepatitis A post-exposure prophylaxis Measles 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!