about prenatal visit and how to manage health during pregnancy.

1. PRENATAL CARE
INTERNSHIP MED STUDENT
MANDAL, AJAY KUMAR

2. Initial Prenatal evaluation
Prenatal care should be initiated as soon as there
is a reasonable likelihood of pregnancy.
Major goals:
1. define the health status of the mother and
fetus
2. estimate the fetal gestational age
3. initiate a plan for continuing obstetrical care.

3. Definition of Terms
1. Nulligravida—a woman who currently is not
pregnant nor has ever been pregnant.
2. Gravida—a woman who currently is pregnant
or has been in the past, irrespective of the
pregnancy outcome.
• Primigravida- woman on her first pregnancy
• Multigravida – woman on her subsequent
pregnancies
3. Nullipara—a woman who has never completed
a pregnancy beyond 20 weeks’ gestation.

4. Definition of Terms
4. 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.
5. Multipara—a woman who has completed two or
more pregnancies to 20 weeks’ gestation or more.
• Parity is determined by the number of
pregnancies reaching 20weeks. It is not

5. Normal Pregnancy Duration
mean duration of pregnancy calculated from the
first day of the last normal menstrual period is
very close to 280 days or 40 weeks.
Naegele rule- estimate the expected delivery
date by adding 7 days to the date of the first day
of the last normal menstrual period and
counting back 3 months
· For example:
· LMP September 10, 2017, EDD is expected date of delivery
will be June 17, 2019

6. Trimesters
It has become customary to divide pregnancy into
three parts of approximately 3 calendar months.
first trimester: 1 to 14 weeks
2nd trimester: 15 to 28 weeks
3rd trimester: 29 to 42 weeks

7. PrenatalVisit
Advise office visit at 8-10 weeks of pregnancy (or earlier if the
patient is at risk for ectopic pregnancy)
Every 4 weeks for first 28 weeks.
Every 2 – 3 weeks until 36 weeks gestation.
Every week after 36 weeks gestation.
Frequency of visits is determined by individual needs and
assessed risk factors.
Goal: Coordination of care for detected medical and psychosocial
risk factors.

8. Routine
Prenatal Care

9. INITIAL PRENATAL VISIT
 Complete history-taking
□ Previous and current health status
□ Obstetric history
□ Menstrual history
□ Psychosocial screening, depression, intimate
partner violence
□ Cigarette, alcohol, illicit drug use

10.  Psychosocial Screening
Previous and Current Health Status
define psychosocial
issues as
nonbiomedical factors
that affect mental and
physical well-being.
Women should be
screened for: barriers
to care, communication
obstacles, nutritional
status, unstable
housing, desire for
pregnancy, safety
concerns that include
intimate partner
violence, depression,
stress, and use of
substances such as
tobacco, alcohol, and
illicit drugs
• This screening should
be performed on a
regular basis, at least
once per trimester,
• to identify important
issues and reduce
adverse pregnancy
outcomes.

11.  Cigarette
Smoking
twofold risk of placenta previa, placental abruption, and premature
membrane rupture
Pathophysiology: fetal hypoxia from increased carboxyhemoglobin, reduced
uteroplacental blood flow, and direct toxic effects of nicotine and other
compounds in smoke.
Previous and Current Health Status

12.  Alcohol
Previous and Current Health Status
Ethyl alcohol or ethanol is
a potent teratogen that
causes a fetal syndrome
characterized by growth
restriction, facial
abnormalities, and central
nervous system
dysfunction
Women who are pregnant
or considering pregnancy
should abstain from using
any alcoholic beverages.
 Illicit drugs Can cause -fetal-growth restriction, low birthweight,
and drug withdrawal soon after birth.

13.  Intimate Partner Violence
Previous and Current Health Status
Screen at the first prenatal visit, then again at least once per trimester, and
again at the postpartum visit.
associated with an increased risk of several adverse perinatal outcomes including
preterm delivery, fetal- growth restriction, and perinatal death.
refers to a pattern of assaultive and coercive behaviors that may include physical
injury, psychological abuse, sexual assault, progressive isolation, stalking,
deprivation, intimidation, and reproductive coercion

14. INITIAL PRENATAL VISIT
Blood pressure
Pelvic / cervical examination
Maternal weight and height / BMI
Fetal heart sounds
Fundal height
Clinical Evaluation-PHYSICAL EXAMINATION

15. Clinical
Evaluation
GestationalAgeAssessment
1. Based on uterine size:

16. Clinical
Evaluation
2. Based on ultrasound
 first-trimester crown-rump
length is the most accurate tool
for gestational age assignment
 Ultrasound done during 2nd and
3rd trimesters can also provide
an estimated gestational age,
but with declining accuracy.
Gestational Age Assessment

17. Clinical Evaluation
Laboratory tests

18. LABORATORY TESTS
To document blood typing should there be a need
for emergency blood transfusion during
pregnancy
To identify the Rh (-) woman who will need anti-
D immunoglobulin at 28 weeks
Blood type,
Rh factor
Recommended at initial visit to evaluate
for iron deficiency and anemias
Repeat at 28-32 weeks
Complete
blood count

19. Screen for asymptomatic bacteriuria If
positive, treat then do test of cure
Urine culture
Screen at initial visit; if high-risk, rescreen
in 3rd trimester
If positive, counsel regarding health risks,
administer Hepatitis B vaccine and
immunoglobulin to baby upon delivery
HBsAg
LABORATORY TESTS

20. If high-risk, rescreen in the third trimester
If reactive, confirm with FTA-ABS / TP-PA
Watch out for congenital syphilis
Recommended in all pregnant women but may be
done on opt-out basis
If high-risk, rescreen in the third trimester
HIV screen
RPR / VDRL
LABORATORY TESTS

21. Recommended for all pregnant women
Repeat in the third trimester if woman is at risk Test include
endocervical or vaginal swab NAAT
Recommended for pregnant women with risk factors Tests
include endocervical swab culture or NAAT
If left untreated, may cause gonococcal infection in
the neonate
Neisseria
gonorrhea
Chlamydia
trachomatis
Rubella IgG Screen all women
Non-immune pregnant women should be counselled to
avoid exposure, and seek immunization postpartum
LABORATORY TESTS

22. Screen for gestational diabetes mellitus and
overt diabetes mellitus
FBS / HBA1c /
RBS / 75g OGTT
OTHER TESTS
Obtained in all women at 35-37 weeks age of
gestation
If positive, intrapartum antibiotic prophylaxis is
given
Group B
Streptococcus
screen

23. POGS CPG ON DIABETES MELLITUS IN PREGNANCY PROTOCOL FOR
THE EVALUATION OF DIABETES IN PREGNANT WOMEN
FIRST PRENATAL VISIT
FBS, HBA1c or RBS
FBS < 92 mg/dl or
RBS <200 mg/dl or
HBA1c < 6.5 %
FBS > 92 g/dl or
but <126 mg/dl
FBS >126 mg/dl or
RBS ≥ 200 mg/dl or
HBA1c ≥ 6.5 %
NORMAL GDM
No further testing
OVERT DM
No further testing

24. POGS CPG ON DIABETES MELLITUS IN PREGNANCY PROTOCOL FOR THE
EVALUATION OF DIABETES IN PREGNANT WOMEN
If initial screening is NORMAL
WITH other risk factors
Proceed immediately to 2-
hour 75g OGTT
NORMAL
NO other risk factors
2-hour 75g OGTT at
24-28 weeks
NORMAL
Repeat 2-hour 75g OGTT at 32 weeks
or anytime with maternal / fetal signs of DM

25. First trimester “dating” ultrasound
• <14 weeks
• Second trimester “anatomy” ultrasound
• 18-24 weeks
• Third trimester “growth” ultrasound
• >28, 32-35 weeks
OTHER TESTS
Ultrasonography
Screen for pre-malignant cervical lesions,
treatable infections
Pap Smear

26. • Subsequent prenatal visits have been traditionally
• scheduled at
• 4-week intervals until 28 weeks,
• then every 2 weeks until 36 weeks,
• and weekly thereafter.
• Women with complicated pregnancies often require
return visits at 1-to 2-week intervals.
SUBSEQUENT PRENATAL VISITS

27. SUBSEQUENT PRENATAL VISITS
 Prenatal Surveillance
□ Maternal weight, blood pressure
□ Fundal height measurement
□ Fetal heart sounds
□ Abdominal examination for fetal presentation
□ Cervical examination at term or as necessary

28. 1. Fundal/fundic Height
• Between 20 and 34 weeks, the height of the uterine
fundus measured in cm correlates closely with
gestational age in weeks
• measurement is used to monitor fetal growth
and amnionic fluid volume.
• It is measured as the distance along the abdominal
wall from the top of the symphysis pubis to the top
of the fundus.
Prenatal Surveillance

29. 2. Fetal Heart Sounds
• detectableby:
• 10weeks AOG using fetaldoppler
• 16weeks AOG by stethoscope
Prenatal Surveillance
3. Sonography
• Sonography provides invaluable information
regarding fetal anatomy, growth and developmental.

30. 1. Group B Strep (GBS) Infection
• Recommend that vaginal and rectal group B
streptococcal (GBS) cultures be obtained in all women
between 35 and 37 weeks’ gestation
• Intrapartum antimicrobial prophylaxis is given for
those whose cultures are positive.
SUBSEQUENT LAB TESTS

31. 2. Gestational Diabetes
• All pregnant women should be screened for gestational
diabetes mellitus, whether by history, clinical factors, or
routine laboratory testing.
• Done between 24 and 28 weeks’ age of gestation
• Can be done during the first trimester check-up for high
risk women.
SUBSEQUENT LAB TESTS

32. • Serum screening for neural-tube defects is offered at 15
to 20 weeks.
• Fetal aneuploidy screening may be performed at 11 to
14 week’s gestation and/or at 15 to 20 weeks
3.Neural-Tube Defect and Genetic Screening
SUBSEQUENT LAB TESTS

33. NUTRITIONAL COUNSELING
 Obesity
□ Diabetes, hypertension, macrosomia, and
cesarean delivery
 Undernutrition
□ Preterm delivery
□ Low birthweight
 Weight Gain Recommendations

34. Recommended Dietary
Allowance
NUTRITIONAL COUNSELING

35. Recommended Dietary Allowance
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
0 kcal / day
340 kcal / day
450 kcal / day
first trimester
2nd trimester
3rd trimester

36. PROTEIN
RDA 5-6 g /day OR 1 g/kg/d
Function Growth and remodeling of fetus, placenta,
uterus
Notes • Preferably supplied from animal sources
such as meat, milk, eggs, cheese, poultry and
fish
Recommended Dietary Allowance

37. 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
Recommended Dietary Allowance

38. FOLIC ACID
RDA 400 g /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
Recommended Dietary Allowance

39. VITAMIN B12
RDA 2.6 g /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 little Vitamin
B12
Recommended Dietary Allowance

40. VITAMIN D
RDA 15  g /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
Recommended Dietary Allowance

41. IODINE
RDA 220  g /day
Inadequate intake Neonatal cretinism
Notes • Dietary sources may be sufficient (iodized salt,
bread products)
• Consider supplementation in areas where
iodine deficiency is common
Recommended Dietary Allowance

42. 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
Recommended Dietary Allowance

43. Vitamin A  Beta-carotene, the precursor of vitamin A found in fruits
and vegetables, has not been shown to produce vitamin A
toxicity.
 Most prenatal vitamins contain vitamin A in doses
considerably below the teratogenic threshold.
 Vitamin A deficiency, whether overt or subclinical, was
associated with an increased risk of maternal anemia and
spontaneous preterm birth.
Recommended Dietary Allowance

44. Vitamin B6 (Pyridoxine)
 For women at high risk for inadequate
nutrition- for substance abusers,
adolescents, and those with multifetal
gestations
 a daily 2-mg supplement is recommended.
Vitamin C
 recommended dietary allowance
for vitamin C duringpregnancy is 80
to 85 mg/day—approximately 20
percent more than when
nonpregnant
Recommended Dietary Allowance

45. Pragmatic Nutritional Surveillance
1. In general, advise the pregnant woman to eat what she wants in amounts she desires
and salted to taste.
2. Ensure that food is amply available for socioeconomically deprived
women.
3. Monitor weight gain, with a goal of approximately 25 to 35 lb in women with a
normal BMI.
4. Explore food intake by dietary recall periodically to discover the occasional
nutritionally errant diet.
5. Give tablets of simple iron salts that provide at least 27 mg of elemental iron daily.
Give folate supplementation before and in the early weeks of pregnancy. Provide
iodine supplementation in areas of known dietary insufficiency.
6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks’ gestation
to detect significant decreases.

46. Reference

47. THANK YOU!!!