PRENATAL CARE

Department of Obstetrics and Gynecology

FEU-NRMF Institute of Medicine
DIAGNOSIS OF PREGNANCY

SIGNS & SYMPTOMS OF PREGNANCY

AMENORRHEA Not a reliable indication of pregnancy until 10 days or
more after the time of expected onset of menstrual
period
CHANGES IN FERN 7th to 18th day of menstrual cycle
CERVICAL PATTERN
Dependent on increased concentration of
MUCUS sodium chloride
Presence of estrogen
BEADED After 21st day
PATTERN
Usually encountered during pregnancy

Presence of progesterone
DISCOLORATION CHADWICK SIGN
OF VAGINAL • vaginal mucosa appears dark blue and congested
MUCOSA

CHANGES IN THE Increased softening as pregnancy advances

CERVIX
Photomicrograph of cervical mucus obtained on day 11 of
the menstrual cycle
Photomicrograph of dried cervical mucus obtained from the
cervical canal of a woman pregnant at 32 to 33 weeks
 SIGNS AND SYMPTOMS
SKIN CHANGES Increased Pigmentation
Abdominal striae
CHANGES IN THE 1st few weeks Increased uterine size limited to AP
UTERUS diameter
6 – 8 weeks Hegar sign – softening of isthmus
12 weeks Uterus almost globular
Uterine Souffle Soft blowing sound synchronous with the maternal pulse

Funic souffle Whistling sound synchronous with the fetal pulse

CHANGES IN THE Characteristic during first pregnancy

BREASTS
PERCEPTION OF Primigravid: 18 – 20 weeks
FETAL MOVEMENT Multigravid: 16 – 18 weeks
FETAL HEART 17 – 19 weeks Standard non-amplified stethoscope
ACTION Using doppler equipment
10 weeks
(110-160 bpm)
5 weeks Transvaginal
 SOUNDS PERCEIVED BY THE
EXAMINER OTHER THAN THE FHT
Funic (umbilical cord) souffle
• Rush of blood through the umbilical arteries
• Sharp, whistling sound synchronous with fetal pulse

Uterine souffle
• Produced by passage of blood through dilated uterine vessels
• Soft blowing sound that is synchronous with maternal pulse

Sounds resulting from fetal movement

Maternal pulse

Sounds from maternal intestinal peristalsis

PREGNANCY TESTS
 HCG
α-subunit is LH
similar to FSH
TSH
Prevents involution of the corpus luteum (principal site
of progesterone formation during the first 6 weeks)
Detectable in maternal plasma or urine by 8 – 9 days
after ovulation
Doubling 1.4 – 2 days
time:
Peak Levels: 60 - 70 days

Nadir: 16 weeks
False In women with circulating factors in their
Positive serum that may interact with the hCG
 POSITIVE Pregnancy Test
W/O PREGNANCY
 Exogenous hCG injection for weight
loss
 Renal failure with impaired hCG
clearance
 Physiological pituitary hCG
 hCG producing tumors
 ULTRASONIC RECOGNITION
OF PREGNANCY
4-5 weeks Gestational sac by
transabdominal UTZ
5-6 weeks Yolk sac
6 weeks Embryo with cardiac
activity
12 weeks CRL is predictive of
gestational age within 4
days
INITIAL PRENATAL
EVALUATION
PRENATAL CARE SHOULD
BE INITIATED AS SOON AS
THERE IS REASONABLE
LIKELIHOOD OF
PREGNANCY
 GOALS OF PRENATAL
CARE
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
 Typical Components of Routine Prenatal
Care
Weeks
First Visit 15–20 24–28 29–41
History
Complete *
Updated * * *
Physical examination
Complete *
Blood * * * *
Maternal weight * * * *
Pelvic / Cervical exam *

Fundic height * * * *
Fetal Heart rate & position * * * *
 Typical Components of Routine
Prenatal Care
Weeks
First Visit 15–20 24–28 29–41
Laboratory tests
Hematocrit or Hemoglobin * *
Blood type & Rh factor *
Antibody screen * A
Pap smear screenig *
Glucose Tolerance test *
Fetal Aneuploidy Ba and/or B
screenning
Neural- tube defect * B
screening
Cystic fibrosis B or B
screening
 Typical Components of Routine
Prenatal Care
Weeks
First Visit 15–20 24–28 29–41
Laboratory tests
Urine protein *
assessment
Urine culture *
Rubella serology *

Syphilis serology * C

Gonococcal D D
culture
Chlamydial * C
culture
Hepatitis B *
serology
HIV serology B
Group B E
streptococcus
culture
A Performed at 28 weeks, if indicated.
B Test should be offered.
C High-risk women should be retested at
the beginning of the third trimester.
D High-risk women should be screened at
the first prenatal visit and again in the
third trimester.
E Rectovaginal culture should be
obtained between 35 and 37 weeks.
 DEFINITIONS
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
NULLIPARA A woman who has never completed a pregnancy
beyond 20 weeks’ age of gestation
PRIMIPARA A woman who has been delivered only once of a fetus
or fetuses born alive or dead with an estimated length of
gestation of 20 or more weeks
MULTIPARA Completed 2 or more pregnancies to 20 weeks or more
PARITY Number of pregnancies reaching 20 weeks and not by
the number of fetuses delivered
*same for singleton or multifetal delivery or delivery of a
live or stillborn infant
 NORMAL PREGNANCY DURATION
MEAN DURATION FROM 280 days or 40 weeks
LAST NORMAL MENSTRUAL
PERIOD
(GESTATIONAL AGE OR
MENSTRUAL AGE)
EXPECTED DATE OF LMP + 7 days then count
DELIVERY back 3 months
(NAEGELE’s RULE)
OVULATORY AGE OR 2 weeks short of the
FERTILIZATION AGE menstrual age
3 TRIMESTERS
1st TRIMESTER Extended through completion of 14 weeks
2nd TRIMESTER Through 28 weeks
3rd TRIMESTER 29th through 42nd weeks
 HISTORY
OBSTETRICAL HISTORY
Prior pregnancy complications
HISTORY tend to recur in subsequent
pregnancies

MENSTRUAL Ovulatory cycles important for

HISTORY 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
CIGARETTE SMOKING
ADVERSE OUTCOMES Teratogenic effects
Spontaneous abortion
Low BW due to preterm delivery or fetal
growth restriction
fetal death, SIDS
Placental abruptio, placenta previa
PROM
PATHOPHYSIOLOGY for Fetal hypoxia
adverse pregnancy
effects Reduced uteroplacental blood flow
Direct toxic effects of nicotine and other
compounds in smoke
ALCOHOL AND ILLICIT DRUGS DURING
PREGNANCY
ETHANOL Potent teratogen and causes
FETAL ALCOHOL
SYNDROME
FETAL Growth restriction
ALCOHOL Facial abnormalities
SYNDROME
CNS dysfunction
ILLICIT DRUGS Fetal growth restriction
Low birthweight
Drug withdrawal soon after
birth
INTIMATE PARTNER VIOLENCE SCREENING
Pattern of assualtive and coercive behaviour
Includes : physical injury, psychological abuse
sexual assualt progressive isolation
stalking, deprivation
intimidation, reproductive coercion

Preterm delivery
Fetal growth restriction
ADVERSE Perinatal death
OUTCOMES
First prenatal visit
FREQUENCY At least once per trimester
OF SCREENING postpartum
 PHYSICAL EXAMINATION
PELVIC EXAMINATION
SPECULUM CERVIX: Hyperemic, bluish-red
EXAM
Nabothian cysts
Not normally dilated above the internal os
Pap smear is obtained
Specimen for N. gonorrhea and Chlamydia when
indicated
BIMANUAL Consistency, length, and dilatation of the cervix
EXAMINATION
Uterine and adnexal size
Bony architecture of the pelvis
Fetal presentation later in pregnancy
Anomalies of the vagina and perineum
Vulvar inspection
 Typical Components of Routine
Prenatal Care- Laboratory Tests
Weeks
First Visit 15–20 24–28 29–41
Laboratory tests
Hematocrit or Hemoglobin * *
Blood type & Rh factor *
Antibody screen * A
Pap smear screenig *
Glucose Tolerance test *
Fetal Aneuploidy Ba and/or B
screenning
Neural- tube defect * B
screening
Cystic fibrosis B or B
screening
 Typical Components of Routine
Prenatal Care
Weeks
First Visit 15–20 24–28 29–41
Laboratory tests
Urine protein *
assessment
Urine culture *
Rubella serology *

Syphilis serology * C

Gonococcal D D
culture
Chlamydial * C
culture
Hepatitis B *
serology
HIV serology B
Group B E
streptococcus
culture
A Performed at 28 weeks, if indicated.
B Test should be offered.
C High-risk women should be retested at
the beginning of the third trimester.
D High-risk women should be screened at
the first prenatal visit and again in the
third trimester.
E Rectovaginal culture should be
obtained between 35 and 37 weeks.
PREGNANCY RISK ASSESSMENT
PREGNANCY RISK ASSESSMENT
PREGNANCY RISK ASSESSMENT
SUBSEQUENT PRENATAL VISITS

Every 4 weeks until 28 weeks

Every 2 weeks until 36 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 ( 10 Danger Signals)
 Fundic height
 Vaginal examination
 Presenting part
 Station
 Pelvimetry
 Consistency, effacement and
dilatation of the cervix
 ASSESSMENT OF GESTATIONAL AGE
FUNDAL HEIGHT 20 – 34 weeks
Height of the fundus (cm) correlates with
AOG in weeks
Distance over the abdominal wall from the
top of the symphysis pubis to the top of the
fundus
Bladder must be emptied before making
measurement
FETAL HEART as early as 16 weeks
SOUNDS Audible in all by 22 weeks
10 weeks – doppler; 5 weeks - TVS
ULTRASOUND If performed between 8 – 16 weeks was
accurate by 2 days for predicting the actual
date at delivery
 SUBSEQUENT LABORATORY
TESTS
 Fetal aneuploidy at 11-14 weeks or 15-20 weeks
 NTD screening at 15-20 weeks
 Hemoglobin, hematocrit repeated at 28-32 weeks
 As well as Syphilis if prevalent
 HIV repeated before 36 weeks for high risk
 Hepatitis B retested at time of delivery if high risk
 Unsensitized Rh negative with antibody screen retesting at
28-29 weeks
 Group B streptococcal Infection
 Gestational Diabetes
 Selected Genetic Screening
NUTRITION
WEIGHT GAIN
NUTRIENTS THAT CAN POTENTIALLY
EXERT TOXIC EFFECTS

Iron

Zinc

Selenium

Vitamin A, B6, C and D

 RDA
CALORIES Requires 80,000 Kcal
Increase intake of 100 –
300kcal/day
Protein is metabolized whenever
caloric intake is inadequate

PROTEIN 1000g deposited latter half

of pregnancy= 5-6 g/day
Most amino acids fall in
maternal plasma
Preferably supplied from animals
 MINERALS
IRON 300 mg transferred to the fetus
500 mg incorporated into maternal hemoglobin mass

Iron requirement by midpregnancy = 7 mg/day

Recommended daily ferrous iron supplement = 27
mg
Increase to 60 – 100 mg/day if
• large woman
• twin fetuses
• late iron supplementation
• irregular intake
• depressed hemoglobin levels
Ingest at bedtime or on empty stomach facilitates
absorption and minimize adverse GI reaction
MINERALS continued

CALCIUM 30 g is retained, most of which is deposited in

the fetus late in pregnancy
There is increased absorption by the intestine
and progressive retention throughout pregnancy
PHOSPHORUS Plasma levels do not differ from prepregnancy
levels
ZINC Recommended daily intake = 12 mg
ZINC Poor appetite
DEFICIENCY
Suboptimal growth
Impaired wound healing
Dwarfism and hypogonadism
Acrodermatitis enteropathica
MINERALS
IODINE RDA 220 micrograms; use of Iodized salt, bread
Severe deficiency predispose endemic Cretinism
MAGNESIUM Deficiency during pregnancy has not been
recognized
POTASSIUM Decreases by 0.5 mEq/L by midpregnancy
Predisposed by prolonged nausea and vomiting
SODIUM Increased total sodium accumulation
Serum concentration is decreased due to expanded
plasma volume

Excretion unchanged
FLUORIDE Metabolism unchanged
Supplementation not required
MINERALS
CHROMIUM Co-factor for insulin by facilitating attachment to peripheral
receptors
No data suggesting supplementation is advisable for
pregnancy
MANGANES Co-factor for enzymes glycosyltransferase which are
E necessary for synthesis of polysaccharides and glycoproteins

COPPER Marked increase in serum ceruloplasmin and plasma coper

during pregnancy
Deficiency not documented in humans during pregnancy
SELENIUM Essential component of glutathione peroxidase which
catalyzes hydrogen peroxide to water
Important defensive component against free radical damage

Severe Deficiency manifested by fatal cardiomyopathy in

children and women of childbearing age
 VITAMINS
FOLIC Supplementation prevents NTD
ACID Daily intake of 400mcg throughout periconceptional 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
B-carotene has not been shown to produce vitamin A
toxicity
Deficiency associated with increased risk of maternal
anemia and preterm birth, severe with night blindness
VITAMIN Daily supplement of2mg recommended for women at high
B6 risk for inadequate nutrition; for nausea & vomiting
VITAMIN C RDA = 80 – 85 mg/day
Maternal plasma level decline during pregnancy but cord
level is higher
 VITAMINS
Vitamin Decrease in normal pregnancy
B12 Occurs naturally in foods of animal origin
Deficiency: vegetarians, excessive vitamin C
ingestion
Vitamin Increases intestinal Ca absorption
D Promotes bone mineralization & growth
DEFICIENCY in women w/limited sun exposure
- disordered skeletal homeostasis
- congenital rickets
- fractures in the newborn
COMMON CONCERNS
 EMPLOYMENT
Greater risk for preterm delivery with jobs that
require prolonged standing

Occupational fatigue was associated 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
 Absolute Contraindications to
Aerobic Exercise during Pregnancy
 Hemodynamically significant heart disease
 Restrictive lung disease
 Incompetent cervix/cerclage
 Multifetal gestation at risk for preterm labor
 Persistent second- or third-trimester bleeding
 Placenta previa after 26 weeks
 Preterm labor during the current pregnancy
 Ruptured membranes
 Preeclampsia/pregnancy-induced hypertension
 Relative Contraindications to
Aerobic Exercise during Pregnancy
 Severe anemia
 Unevaluated maternal cardiac arrhythmia
 Chronic bronchitis
 Poorly controlled type 1 diabetes
 Extreme morbid obesity
 Extreme underweight (BMI <12)
 History of extremely sedentary lifestyle
 Fetal-growth restriction in current pregnancy
 Poorly controlled hypertension
 Orthopedic limitations
 Poorly controlled seizure disorder
 Poorly controlled hyperthyroidism - heavy smoker
 COMMON CONCERNS

FISH Avoid shark, swordfish, king mackerel, tile fish

CONSUMPTION Ingest no more than 12 oz or 2 servings of
canned tuna /week; no more than 6 oz of
albacore tuna
* If mercury content of local fish unknown,
consumption should be limited to 6 oz/week
LEAD screening Exposure effects: gestational HPN
- spontaneous abortion
- low birthweight
- neurodevelopmental impairments in NB
Done if with identified risk factors
 COMMON CONCERNS
BATHING No contraindications
CLOTHING Comfortable and nonconstricting
Well-fitting supporting brassiere
Avoid constricting leg wear
BOWEL Constipation is common
HABITS
Prolonged transit time and compression of the
lower bowel by the uterus or presenting part
Greater frequency of hemorrhoids
Bleeding and painful fissures of the rectal
mucosa may develop
Prevent constipation by sufficient amount of
fluids and daily exercise
COITUS Not harmful in healthy pregnant women
 COMMON CONCERNS
DENTITION Dental carries are not aggravated by
pregnancy
Pregnancy is not a contraindication for
dental treatment
CAFFEINE No evidence 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
IMMUNIZATION
VACCINES MMR
CONTRAINDICATED
DURING Yellow fever
PREGNANCY Varicella , smallpx
Recommendations for Immunization during Pregnancy
Immunobiological Agent Indications for Immunization Dose Schedule Comments
During Pregnancy
Live Attenuated Virus Vaccines
Measles Contraindicated—see Single dose SC, preferably Vaccinate susceptible
immune globulins as MMRa women postpartum. Breast
feeding is not a
contraindication
Mumps Contraindicated Single dose SC, preferably Vaccinate susceptible
as MMR women postpartum
Rubella Contraindicated, but Single dose SC, preferably Teratogenicity of vaccine is
congenital rubella syndrome as MMR theoretical and not
has never been described confirmed to date; vaccinate
after vaccine susceptible women
postpartum
Poliomyelitis Oral = live Not routinely recommended Primary: Two doses of Vaccine indicated for
attenuated; injection = for women in the United enhanced-potency susceptible women traveling
enhanced-potency States, except women at inactivated virus SC at 4–8 in endemic areas or in other
inactivated virus increased risk of exposureb week intervals and a 3rd high-risk situations
dose 6–12 months after 2nd
dose
Immediate protection: One
dose oral polio vaccine (in
outbreak setting)
Yellow fever Travel to high-risk areas Single dose SC Limited theoretical risk
outweighed by risk of yellow
fever
Varicella Contraindicated, but no Two doses needed: 2nd Teratogenicity of vaccine is
adverse outcomes reported dose given 4–8 weeks after theoretical. Vaccination of
in pregnancy 1st dose susceptible women should
Recommendations for Immunization during Pregnancy
Immunobiological Indications for Dose Schedule Comments
Agent Immunization During
Pregnancy
Influenza All pregnant women, One dose IM every Inactivated virus
regardless of year vaccine
trimester during flu
season (Nov.-Mar.)
Rabies Indications for Public health Killed-virus vaccine
prophylaxis not authorities to be
altered by pregnancy; consulted for
each case considered indications, dosage,
individually and route of
administration
Hepatitis B Pre-exposure and Three-dose series IM Used with hepatitis B
postexposure for at 0, 1, and 6 months immune globulin for
women at risk of some exposures.
infection Exposed newborn
needs birth-dose
vaccination and
immune globulin as
soon as possible. All
infants should receive
birth dose of vaccine
Recommendations for Immunization during Pregnancy
Immunobiological Agent for
Indications Dose Schedule Comments
Immunization During
Pregnancy
Inactivated Bacterial Vaccines
Pneumococcus Indications not altered In adults, one dose only; Polyvalent
by pregnancy. consider repeat dose in polysaccharide vaccine
Recommended for 6 years for high-risk
women with asplenia; women
metabolic, renal,
cardiac, or pulmonary
diseases;
immunosuppression; or
smokers
Meningococcus Indications not altered One dose; tetravalent Antimicrobial
by pregnancy; vaccine prophylaxis if significant
vaccination exposure
recommended in
unusual outbreaks
Typhoid Not recommended Killed Killed, injectable vaccine
routinely except for Primary: 2 injections IM or live attenuated oral
close, continued 4 weeks apart vaccine. Oral vaccine
exposure or travel to Booster: One dose; preferred
endemic areas schedule not yet
determined
Anthrax See text Six-dose primary Preparation from cell-
Recommendations for Immunization during Pregnancy
Immunobiological Agent Indications for Immunization Dose Schedule Comments
During Pregnancy
Toxoids
Tetanus-diphtheria Lack of primary series, or Primary: Two doses IM at Combined tetanus-
no booster within past 10 1–2 month interval with 3rd diphtheria toxoids preferred:
years dose 6–12 months after the adult tetanus-diphtheria
2nd formulation. Updating
Booster: Single dose IM immune status should be
every 10 years after part of antepartum care
completion of primary series
Specific Immune Globulins
Hepatitis B Postexposure prophylaxis Depends on exposure [see Usually given with hepatitis
Chap. 50, Hepatitis B B virus vaccine; exposed
(HBV)] newborn needs immediate
prophylaxis
Rabies Postexposure prophylaxis Half dose at injury site, half Used in conjunction with
dose in deltoid rabies killed-virus vaccine
Tetanus Postexposure prophylaxis One dose IM Used in conjunction with
tetanus toxoid
Varicella Should be considered for One dose IM within 96 Indicated also for newborns
exposed pregnant women hours of exposure or women who developed
to protect against maternal, varicella within 4 days
not congenital, infection before delivery or 2 days
following delivery
Standard Immune Globulins
Hepatitis A Hepatitis A virus Postexposure prophylaxis 0.02 mL/kg IM in one dose Immune globulin should be given as
soon as possible and within 2
vaccine should be used with and high risk weeks of exposure; infants born to
hepatitis A immune globulin women who are incubating the virus
 COMMON CONCERNS
NAUSEA Commence between 1st and 2nd missed
AND menses and continue until 14 – 16 weeks
VOMITING Caused by high levels of serum B-hCG
which is a surrogate for increasing estrogen
levels
Advise small frequent feedings
BACKACHE Increased with duration of gestation
Prior low back pain and obesity are risk
factors
Squat rather than bend
Provide back support avoid high heeled
shoes
VARICOSITIES Result from congenital predisposition exaggerated by
COMMON CONCERNS
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 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
FATIGUE Remits spontaneously by 4th month of pregnancy
May be due to soporific effect of progesterone
HEADACHE Treatment is symptomatic but should be investigated
especially in late pregnancy
LEUKORRHEA Increased mucus secretion by cervical glands in
response to hyperestrogenemia
BACTERIAL Maldistribution of normal vaginal flora
VAGINOSIS Lactobacilli are decreased and overrepresented
species tend to be anaerobic bacteria
Associated with preterm birth
Metronidazole 500 mg BID x 7 days
TRICHOMONIAS Foamy leukorrhea with pruritus
IS and irritation
Treat with Metronidazole
CANDIDIASIS Asymptomatic colonization
requires no treatment
Extremely profuse, irritating
vaginal discharge associated
with pruritic, tender, and
edematous vulva
Treat with miconazole,
clotrimazole, and nystatin