OB GYNE PRENATAL CARE essential ob-gyne

1. BHARAT POKHREL, MD
PRENATAL
CARE

2. Definition of terms
PRIMIPARA
A woman who has delivered only
once of a fetus or fetuses which
reached viability (beyond 20th week
of pregnancy or beyond the stage
of abortion).

3. MULTIPARA
A woman who has completed two or
more pregnancies to viability. It is
the number of pregnancies reaching
viability, and not the number of
fetuses delivered that determines
parity

4. NULLIGRAVIDA: Is a woman who is not
now and never has been pregnant
GRAVIDA: Is a woman who is, or has bee
n pregnant irrespective of the pregna
ncy outcome

5. NULLIPARA
Is a woman who has never co
mpleted a pregnancy beyond the sta
ge of viability or beyond an abortion
.
PARTURIENT
Is a woman in labor
PUERPERA
Is a woman who had just given
birth

6. How do we make the
diagnosis of pregnancy?
Based on:
Presumptive signs and symptoms
Probable signs and symptoms
Positive Evidence

7. PRESUMPTIVE SIGNS
 Amenorrhea
 Thermal signs
 Anatomical breast changes
 Skin pigmentation changes – ch
loasma , linea nigra, striae gravi
darum
 Chadwick’s sign- violaceous dis
coloration of the vaginal mucos
a which is evident at about the
6th wks of gestation

8. Probable evidences
Enlargement of the Abdomen
Changes in the size, shape and consistency of th
e uterus
1.) Hegar’s sign- softening of the uterine isthm
us which is observed on the th-8th wk of pregna
ncy
2.) Goodell’s sign- cyanosis and softening of the
cervix due to increased vascularity of the cervica
l tissue; may occur as early as 4 wks

9. Probable evidences
Anatomical changes in the cervix
Braxton – Hick’s Contraction
Ballottement
Physical Outlining of the fetus
Positive Results of Endocrine Tests- huma
n chorionic gonadotropin(hCG) which is dete
ctable from the maternal serum and urine as
early as 8-9 days after ovulation

10. Positive evidences of
pregnancy
Identification of Fetal Heart Tones (FHT)
– heard by the stethoscope by the 18th wk
on the average; can be detected as early
as 10-12 wks using Doppler
Perception of Fetal Movement by the
Examiner
Recognition of the Embryo or the Fetus
by Ultrasound or Radiologic Methods

11. AFTER THE STRONG
EVIDENCES WHAT'S NEXT?

12. CONFIRMATION OF THE
DIAGNOSIS

13. Ultrasonic Recognition of Pregnancy
Transvaginal sonography: Most
accurate to establish
gestational age and confirm
the location of the pregnancy
Gestational sac : after
4~5weeks gestational age
★ All normal sacs should be
visible by 35 days
FIGURE 8-6 Abdominal sonogram demonstrating a
gestational sac at 4 to 5 weeks’ gestational (menstrual ) age.
(Courtesy of Dr. Diane Twickler.)

14. Differential diagnosis
1. Myoma
2. Hematometra
3. Adhesions or apparent enlargement
attached to it.
4. Ovarian masses
5. PSEUDOCYESIS
-imaginary of spurious pregnancy oc
curing in women nearing menopaus
e, or in those who strongly desire pr
egnancy
-patient may feel signs and sympto
ms of pregnancy without being reall
y pregnant at all

15. 10 danger signs of pregnancy
Signs and symptoms Possible causes
1. Chills and fever
2. Persistent vomiting
3. Dysuria
4. Swelling of face and fingers
5. Severe or persistent
headache
6. Blurring of vision
7. Vaginal bleeding
8. Abdominal pain
9. Fluid leakage from vagina
10.Sudden change in frequency
and intensity of fetal movem
ents
1. Pyelonephritis, chorioamnion
itis
2. Hyperemesis gravidarum
3. Urinary tract infection
4. Severe preeclampsia
5. Severe preeclampsia
6. Severe preeclampsia
7. Placenta previa, placenta abr
uptia, spontaneous abortion
8. Preterm labor, severe preecla
mpsia (epigastric pain)
9. Rupture of fetal membrane
10.Fetal compromise

16. INITIAL PRENATAL VISIT

17. Components of Routine
Prenatal care
1. Prenatal Record
 Normal Pregnancy Duration
 History
2. Psychosocial Screening
 Cigarette smoking
 Alcohol and Illicit Drugs during Pregnancy
 Domestic Violence Screening
3. Physical Examination
 Pelvic Examination
4. Laboratory Tests
5. High-Risk Pregnancies

19. ROUTINE OBSTETRIC TESTS
TEST DISCUSSION
1. Complete blood count (FIRST VISIT) To determine hematologic status;
To rule out anemia
2.2. Urinalysis and urine culture
and sensitivity (FIRST VISIT)
To evaluate for UTI and renal function
3. Blood group, Rh (FIRST VISIT) To determine blood type, Rh status,
and risk of isoimmunization
4. Serologic test for syphilis
(RPR, VDRL) (FIRST VISIT)
To detect previous/current infection;
if positive-- specific treponemal test

20. ROUTINE OBSTETRIC TESTS
TEST DISCUSSION
5.Hepatitis B surface antigen (FIRST
VISIT)
To detect carrier status or active disease;
If positive, further testing indicated
6. Rubella titer Approximately 85% of mothers have evidence
of prior infection; if patient is seronegative,
special precautions are needed to avoid
infection, which can severely affect the fetus;
vaccination is then required postpartum
7. Cervical pathology (FIRST VISIT)
(Pap smear)
To screen for cervical dysplasia.cancer
8.Cervical culture for
Neiserria gonorrhea (FIRST VISIT)
To screen for infection;both cause neonatal and
chlamydia trachomatis conjunctivitis;
association with premature labor and
postpartum endometritis.
9. Glucose screening
(usually 1 – hr Glucose)
(24-28 weeks)
To screen for glucose intolerance in high-risk
patients; usually at 28 weeks in low risk
patients.

21. 75 gm OGTT
 A two-hour 75-gram oral glucose tolerance
test (OGTT) is used to test for diabetes.
 First sample is taken to test fasting glucose
level first
 Then drink 8 ounces of a syrupy glucose s
olution that contains 75 grams of sugar
 Wait for two hours
 Another Blood Sample

22. Values in milligrams/deciliter (mg/dL) to diagnose dia
betes in a 75-gram OGTT:
When blood is
drawn
For prediabetes For diabetes For gestational
diabetes
FASTING 100-125 mg/dL 126 mg/dL or
greater
greater than 92
mg/dL
AFTER 1 HOUR greater than
180 mg/dL
AFTER 2 HOUR 140-199 mg/dL 200 mg/dL or
greater
greater than
153 mg/dL

23. ESTIMATION OF THE DURATION
OF PREGNANCY
Naegele’s Rule
-Average duration of pregnancy calculate
d from the first day of the LMP averages cl
ose to 280 days, 10 lunar months or 40 wks
.
-Convenient method of estimating the d
ate of confinement: to the first day of LMP, a
dd 7 days, subtract three months, add 1 yea
r= EDC

24. ESTIMATION OF THE DURATION OF P
REGNANCY
Timing from Ovulation
Timing from Quickening
- movement is usually perceived b
etween the 16th and 18th wks in a multipara,
and two weeks later in a primigravid

25. ESTIMATION OF THE DURATIO
N OF PREGNANCY
date of sexual contact
ultrasound ageing
– Gestational sac: 4 weeks
– Yolk sac: 6 weeks
– Fetal pole: 6 weeks
– After 7 weeks: crown rump length

26. ESTIMATION OF THE DURATION O
F PREGNANCY
Timing by Trimesters
- most spontaneous abortions occur dur
ing the first trimester
- pregnancy-induced hypertension bec
omes clinically evident during the third trim
ester
fundic height

27. Prenatal Record
History
 Detailed information concerning past obstetrical history is
crucial
 many prior pregnancy complications tend to recur in
subsequent pregnancies
Menstrual history : extremely important
Without a history of regular, predictable, cyclic,
spontaneous menses that suggest ovulatory cycles,
accurate dating of pregnancy by history and physical
examination is difficult.

28. Psychosocial Screening
Cigarette Smoking
Various adverse outcomes
 spontaneous abortion,
 low birthweight due to either preterm delivery or fetal growth
restriction,
 infant and fetal deaths,
 placental abruption
Suggested pathophysiological mechanisms
 increased fetal carboxyhemoglobin,
 reduced uteroplacental blood flow,
 fetal hypoxia

29. Psychosocial Screening
Alcohol and Iilicit drugs during Pregnancy
 Ethanol → potent teratogen
Fetal alcohol syndrome
: characterized by growth restriction, facial
abnormalities, and central nervous system dysfunction

30. Psychosocial Screening
Alcohol and Iilicit drugs during Pregnancy
Chronic use of large quantities of illicit drugs, opium derivatives, barbiturates,
and amphetamines,
» fetal distress,
» low birthweight,
» and drug withdrawal soon after birth are well
documented.
when women who use illicit drugs receive prenatal care, the risks for preterm
birth and low birthweight are reduced.
- El-Mohandes and associates
(2003)

31. Physical Examination
 Palpation
 Consistency, length, and dilatation of the cervix
 Fetal presentation later in pregnancy
 Bony architecture of the pelvis
 Any anomalies of the vagina and perineum, including
cystocele, rectocele, and relaxed or torn perineum.
 The vulva and contiguous structures are carefully inspected.
 All cervical, vaginal, and vulvar lesions are evaluated further by
appropriate use of colposcopy, biopsy, culture, or dark-field
examination.
 digital rectal examination, visualized on the perianal region

32. Fundic Height measurement

33. FUNDIC HEIGHT
Fundus can usually be felt above the
pubic symphysis 12 wks after LMP
-16 wks- Halfway between the
symphysis and the umbilicus
-20wks – At the level of the umbilicus
- 36wks – Right up under the sternum

34. Estimation of the weight of the
fetus
*Johnson’s rule: used to clinically correlate fundic heig
ht with fetal weight by using the following formula by
R.W. Johnson:
estimated fetal weight(gms) = K (x-n)
where: x=fundic height (cms)
n=12 if the station of the fetal head is below the ischi
al spines (engaged)
= 11 if the presenting part is above the ischial spine
s (unengaged)
K= 155 (constant)

35. SUBSEQUENT PRENATAL
VISITS

36. The timing of subsequent prenatal visits
 ~ 28 weeks : intervals of 4 weeks
 28~ 36 weeks : every 2 weeks
 > 36 weeks : weekly
With complicated pregnancies: often require return vis
its at 1- to 2-week intervals.

37. PRENATAL INSTRUCTIONS
1. Inform the patient of any problems an
d discuss the plan of management.
2. Begin the antepartum educational prog
ram by means of personal interviews, r
eading materials and hospital classes.
3. Explain future visits
4. Discuss the economic aspect of pregna
ncy

38. PRENATAL INSTRUCTIONS
5. Give instructions about diet, relaxation and sl
eep, bowel habits, exercise, bathing, taking
recreation, sexual intercourse, smoking, dru
g and alcohol ingestion.
6. Emphasize danger signals which must be rep
orted immediately, day or night. These dan
ger signs are vaginal bleeding, persistent vo
miting, chills
and fever, sudden escape of fluid from vagin
a; abdominal pain, swelling of face, blurring
of vision and continous headache.

39. NUTRITIONAL COUNSELLING

40. RECOMMENDATIONS
FOR WEIGHT GAIN
For the first half of the 20th century
: recommended that weight gain during pregnancy < 20 lb (9.1 kg)
By the 1970s
: encouraged to gain at least 25 lb (11.4 kg)
( to prevent preterm birth and fetal growth restriction, a recommendation
that subsequent research continues to support)
(Ehrenberg and
associates, 2003)
In 1990
: recommended a weight gain of 25 ~ 35 lb (11.5 to 16 kg)
(the Institute of
Medicine)
for women with a normal prepregnancy body mass index (BMI).

41. Weight gain during pregnancy

42. Weight Retention After Pregnancy
average weight gain
: 28.6 ± 10.6 lb (13.0 ± 4.8 kg)
an average retained weight
: 3 ± 10.5 lb (1.4 ± 4.8 kg) d/t pregnancy.
- Schauberger and co-
workers (1992)
Parous women retained more of their pregnancy weight,
→ long-term obesity
The effect of breast feeding on maternal weight loss was negligible.

43. Recommened Dietary Allowances
 Calories
 Protein
 Minerals
 Vitamins
 Toxic effects
 iron, zinc, selenium, and vitamins A, B6, C, and D.
 Vitamin and mineral
 : intake more than twice the recommended daily diet
ary allowance shown in Table 8–7 should be avoided du
ring pregnancy
(American Academy of Pediatrics and the American College
of Obstetricians and Gynecologists, 2002).

44. Table 8–7. Recommended Daily Dietary Allowances for Adolescent and Adult Pregnant and Lactating Women
Pregnant Lactating
14–18 years 19–30 years 31–50 years 14–18 years 19–30 years 31–50 years
Fat-soluble vitamins
Vitamin A 750 μg 770 μg 770 μg 1200 μg 1300 μg 1300 μg
Vitamin Da 5 μg 5 μg 5 μg 5 μg 5 μg 5 μg
Vitamin E 15 mg 15 mg 15 mg 19 mg 19 mg 19 mg
Vitamin Ka 75 μg 90 μg 90 μg 75 μg 90 μg 90 μg
Water-soluble vitamins
Vitamin C 80 mg 85 mg 85 mg 115 mg 120 mg 120 mg
Thiamine 1.4 mg 1.4 mg 1.4 mg 1.4 mg 1.4 mg 1.4 mg
Riboflavin 1.4 mg 1.4 mg 1.4 mg 1.6 mg 1.6 mg 1.6 mg
Niacin 18 mg 18 mg 18 mg 17 mg 17 mg 17 mg
Vitamin B6 1.9 mg 1.9 mg 1.9 mg 2 mg 2 mg 2 mg
Folate 600 μ g 600 μ g 600 μ g 500 μ g 500 μ g 500 μg
Vitamin B12 2.6 μg 2.6 μ g 2.6 μ g 2.8 μ g 2.8 μ g 2.8 μ g
Minerals
Calciuma 1300 mg 1000 mg 1000 mg 1300 mg 1000 mg 1000 mg
Phosphorus 1250 mg 700 mg 700 mg 1250 mg 700 mg 700 mg
Iron 27mg 27mg 27mg 10mg 9mg 9mg
Zinc 13mg 11mg 11mg 14mg 12g 12mg
Iodine 220 μg 220 μg 220 μg 290 μg 290 μg 290 μg
Selenium 60 μg 60 μg 60 μg 70 μg 70μg 70μg
Recommendations measured as Adequate Intake (AI) instead of Recommended Daily Dietary Allowance (RDA). An AI is set instead of an RDA if ins
ufficient evidence is available to determine an RDA. The AI is based on observed or experimentally determined estimates of average nutrient intake
by a group (or groups) of healthy people.
From the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences, 2004.

45. Calories
Pregnancy requires an additional 80,000 kcal, which are acc
umulated primarily in the last 20 weeks.
→ a caloric increase of 100 to 300 kcal per day is recom
mended during pregnancy
(American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2002).

46. Iron
 Iron requirement of normal pregnancy : total approximately 1000mg
 300 mg : transferred to the fetus and placenta
 200 mg : lost through various normal routes of excretion, primarily
the gastrointestinal tract
 500 mg : into the expanding maternal hemoglobin mass,
nearly all is used after midpregnancy.
 the diet seldom contains enough iron to meet this demand.
→ at least 27 mg of ferrous iron supplement be given daily
(The American Academy of Pediatrics and the American College of Obstetricians and
Gynecologists (2002) endorse the recommendation by the National Academy of
Sciences )

47. Iron
 During the first 4 months of pregnancy
not necessary to provide supplemental ir
on the risk of aggravating nausea and
vomiting.
 Ingestion of iron at bedtime or on an e
mpty stomach
(facilitates absorption and appears to mi
nimize the possibility of an adverse ga
strointestinal reaction.)

48. Folic Acid
Deficiency
: neural-tube defects
A woman with a prior pregnancy complicated by a neural-
tube defect
( recurrence risk : ≥ 70%)
Folic acid : 4 mg/day
for the month before conception
for the first trimester of pregnancy

49. Common Concerns

50. COMMON CONCERNS DURING
PREGNANCY
NAUSEA AND VOMITING
 4TH to 12th wk of pregnancy
 ETIOLOGY : Hormonal –hCG levels are high at t
he same time that nausea and vomiting are most com
mon
Deportation theory of Viet
 MANAGEMENT : small frequent feedings
anti nausea medications

51. COMMON CONCERNS DURING
PREGNANCY
BACKPAIN
LOCATION : region of the buttocks
thighs
MANAGEMENT : analgesics
heat
rest

52. COMMON CONCERNS DURING
PREGNANCY
VARICOSITIES
Increased venous pressure in the lower
extremities and the vulva
MANAGEMENT : elevation of the feet
support stockings

53. COMMON CONCERNS DURING
PREGNANCY
HEMORRHOIDS
Increased pressure in the rectal vein cau
sed by obstruction of venous return by t
he large uterus
MANAGEMENT : topical anesthetics
stool softeners
** Hemorrhoidectomy postponed until
after childbearing

54. HEARTBURN
 Burning sensation in the epigastrium accompanied by
feeling of fullness
 Reflux of acid gastric contents into the lower esophag
us
 Upward displacement of the stomach by the uterus an
d progesterone mediated relaxation of esophageal sp
hincter
 MANAGEMENT: antacids
aluminum hydroxide
magnesium trilicate/ hydroxide
avoidance of large meals

55. PTYALISM
Profuse salivation
FATIGUE
 desire for excessive periods of sleep
 usually disappears by the 4th month of
pregnancy
PICA
 bizarre carving for strange foods and m
aterials hardly considered edible

56. HEADACHE
Treatment is symptomatic
LEUKORRHEA
Increased vaginal discharge
Secondary to increased mucus formatio
n by cervical glands in response to hypere
stogenemia

57. • EMPLOYMENT
– In the absence of complications, most wome
n can continue to work until the onset of la
bor
– Any occupation that subjects the pregnant t
o severe physical strain should be avoided
– Adequate periods of rest should be provide
d

58. • EXERCISE
– Pregnant women do not need to limit exe
rcise provided that the do not become ex
cessively fatigued or risk injury
– With complicated pregnancies, it is wise t
o abstain from exercise and even limit ph
ysical activity

59. EXERCISE IN PREGNANCY
ABSOLUTE CONTRAINDICATIONS RELATIVE CONTRAINDICATIONS
•Hemodynamically significant heart
disease
•Restrictive lung disease
•Incompletent cervix/on cerclage
•Multifetal gestation (at risk for
preterm labor)
•Persistent 2nd of 3rd trimester
bleeding
•Placenta previa after 26 weeks
•Preterm labor during current
pregnancy
•Ruptured membranes
•Preeclampsia/pregnancy-induced
hypertension
•Severe anemia
•Unevaluated maternal cardiac
arrythmia
•Chronic bronchitis
•Poorly controlled Type 1 Diabetes
•Extreme morbid obesity
•Extreme underweight (BMI <12)
•History of extremely sedentary
lifestyle
•Fetal growth restriction
•Poorly controlled hypertension
•Orthopedic limitations
•Poorly controlled seizure disorder
•Poorly controlled hyperthyroidism
•Heavy smoker

60. • TRAVEL
– Women should be encouraged to wear pr
operly positioned 3-point restraints
– Lap belt portion should be placed under t
he abdomen across her upper thighs
– Shoulder belt should be snugly positioned
between the breasts

61. • AIR TRAVEL
– Properly pressurized aircraft has no unusu
al risk
– Uncomplicated pregnancies can be allowe
d to travel up to 36 weeks

62. • COITUS
– Whenerver abortion or preterm labor thre
atens, coitus should be avoided

63. Caffeine
No evidence that caffeine caused increased
teratogenic or reproductive risks
(The Fourth International Caffeine Workshop,Dews and colleagues, 1984)

64. Caffeine
Risk of spontaneous abortion related to caffeine consumption
→ controversial
Only extremely high serum paraxanthine concentrations
(high levels : > 5 cups/day)
: associated with abortion.
Klebanoff and co-workers (1999) measured paraxanthine as a biological serum marker of caffeine consumption.
moderate caffeine consumption < 500 mg/day
: no association with
caffeine intake during pregnancy
< 300 mg/day
or about three, 5-oz(140g) cups of percolated coffee.
The American Dietetic
Association (2002)
low birthweight,
fetal growth restriction
preterm delivery