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  1. 2. <ul><li>Prenatal Care </li></ul><ul><li>Doris K Ramirez MD </li></ul><ul><li>Visiting Professor UAG </li></ul><ul><li>[email_address] </li></ul>
  2. 3. Outline <ul><li>Background </li></ul><ul><li>Assessement of gestational age </li></ul><ul><li>Physical exam </li></ul><ul><li>Lab test </li></ul><ul><li>Educate the patient </li></ul>
  3. 4. Prenatal Care <ul><li>Most frequently used health service in USA </li></ul><ul><li>80% start in 1 st Trimester </li></ul><ul><li>Ave 12 visits per patient </li></ul>
  6. 7. <ul><li>WHEN TOM CRUISE RETURNS YOUR CALL? </li></ul><ul><li>1 ST DAY AFTER ONE HAVE MISSED THEIR PERIOD? </li></ul><ul><li>PRECONCEPTIONAL? </li></ul><ul><li>B/C </li></ul><ul><li>A/B </li></ul><ul><li>ALL OF THE ABOVE? </li></ul><ul><li>NONE OF THE ABOVE? </li></ul>
  7. 8. Before Pregnancy: IDEALLY , a woman planning to have a child should have a medical evaluation before she becomes pregnant. * Place the patient on PNV-Folic acid (Vit B) 400mcg or .4 mg to prevent neural tube defects ( which are birth defects of the baby's brain (anencephaly) or spine (spina bifida). *
  8. 9. Prenatal is helpful: <ul><li>Managing the remaining weeks of the pregnancy </li></ul><ul><li>Planning for possible complications with the birth process </li></ul><ul><li>Planning for problems that may occur in the newborn infant </li></ul><ul><li>Determine the outcome of pregnancy </li></ul><ul><li>Deciding whether to continue the pregnancy </li></ul><ul><li>Help promote a live and healthy baby </li></ul>
  9. 10. How do you detect if your are pregnant? <ul><li>1) urine or blood test </li></ul><ul><li>2) ultrasound </li></ul>
  10. 11. bHCG “Beta Human Chorionic Gonadotropin “ <ul><li>Where? </li></ul><ul><ul><li>This hormone is released by trophoblastic tissue in the placenta </li></ul></ul><ul><ul><li>It may be produced by a choriocarcinoma or some other germ cell tumors, or even other forms of cancer, e.g. lung cancer. </li></ul></ul>
  11. 12. Pregnancy (HCG) <ul><li>Urine pregnancy test-2wks after ovulation </li></ul><ul><li>Serum pregnancy test-6-8 days after ovulation </li></ul><ul><ul><li>Qualitative: measures whether bHCG is present (25mlU/ml is +) </li></ul></ul><ul><ul><li>Quantitative: measures the exact amount of bHCG produced. </li></ul></ul>
  12. 13. Levels of bHCG <ul><li>Below bHCG 1200 mlU/ml- </li></ul><ul><ul><li>doubles Q 48-72hrs </li></ul></ul><ul><li>1200-6000mlU/ml- </li></ul><ul><li> doubles Q72-96hrs </li></ul><ul><li>>6000mlU/ml- </li></ul><ul><li>may take more than 4 days to double. </li></ul><ul><li>Failure to double: miscarriage or ECTOPIC </li></ul>
  13. 14. + Pregnancy test: <ul><li>Clinical Visits with no high risk: </li></ul><ul><li>Q4Wks until 28wks </li></ul><ul><li>Q2W from 28-36wks </li></ul><ul><li>Every wk from >36wks </li></ul>
  14. 15. Ultrasonography <ul><li>When? </li></ul><ul><ul><li>As early as 4.5wks </li></ul></ul><ul><li>What do you see? </li></ul><ul><ul><li>Transvaginal- </li></ul></ul><ul><ul><li>bHCG>1500 see gestational sac. </li></ul></ul><ul><ul><li>Abdominal sono: </li></ul></ul><ul><ul><li>bHCG>6000 see heart beat </li></ul></ul>
  15. 16. 5wks embryo and yolk sac
  16. 17. 7wk embryo and yolk sac
  17. 18. Accurate Assessment of gestational age <ul><li>May be critical information later. </li></ul><ul><li>CRL ( crown rump length)- 1-13wks accurate date within +/- 3-5 days of the actual due date. </li></ul><ul><li>2 nd tri(14-28wks): biparietal diameter will accurately predict the due date within 7-10 days in most cases . </li></ul><ul><li>3 rd tri(>28wks): + or – 2-3wks, femur is most accurate </li></ul><ul><li>Naegele rules- EDC=LMP+7d-3m </li></ul><ul><li>Fundal height= gest. Age from 18-30wks </li></ul>
  18. 19. First prenatal visit: <ul><li>take a careful detail history ( looking for factors that might increase the risk for the pregnant woman.) </li></ul><ul><li>Check for BP, urine, weight at every visit. </li></ul><ul><li>Physical examination </li></ul><ul><li>Routine laboratory test ( looking for specific issues that could influence pregnancy ) </li></ul><ul><li>Expectations and preparation for delivery (childbirth classes, preferred pain mgt, plans for feeding ) </li></ul>
  19. 20. Risk Assessment <ul><li>A. Obtain detailed family history from all patient/PMH </li></ul><ul><ul><li>1. Hx. Of MR, ONTD other anomalies </li></ul></ul><ul><ul><li>2. if adopted </li></ul></ul><ul><li>B. Formal questionnaire </li></ul><ul><ul><li>1. helps with difficult areas </li></ul></ul><ul><ul><li>2. Fill out prior to visit </li></ul></ul><ul><li>C. Social history </li></ul><ul><ul><li>1. smoking </li></ul></ul><ul><ul><li>2. Drug and alcohol use </li></ul></ul><ul><ul><li>3. other exposures </li></ul></ul><ul><ul><li>D. Allergies and medications </li></ul></ul>
  20. 21. PHYSICAL EXAMINATION <ul><li>Steps you should take to prepare for the examination: </li></ul><ul><li>*Ask woman to empty bladder (collect urine for testing). *Prepare to follow a logical order. *Prepare to chart logically immediately after exam (make notes). *Remember to explain everything you are doing. </li></ul>
  21. 22. Each prenatal visit: <ul><li>Maternal Weight </li></ul><ul><li>Maternal BP </li></ul><ul><li>UA </li></ul><ul><li>History </li></ul><ul><li>Abdominal Examination: </li></ul><ul><ul><li>Fundal height </li></ul></ul><ul><ul><li>Fetal heart </li></ul></ul><ul><ul><li>Fetal position and shape </li></ul></ul>
  22. 23. Maternal Weight <ul><li>The amount of weight you should gain depends on your weight before pregnancy. You should gain: </li></ul><ul><li>25-35 pounds: If you were a healthy weight before preg. </li></ul><ul><li>28-40 pounds: If you were underweight before pregnancy </li></ul><ul><li>15-25 pounds: If you were overweight before pregnancy </li></ul>
  23. 24. <ul><li>Healthy Weight Before Pregnancy: </li></ul><ul><ul><li>3-5 pounds during the first trimester </li></ul></ul><ul><ul><li>Approximately 1-2 pounds per week in the second trimester </li></ul></ul><ul><ul><li>Approximately 1-2 pounds per week in the third trimester </li></ul></ul><ul><li>Underweight Before Pregnancy: </li></ul><ul><ul><li>5-6 pounds or more in your first trimester; this also can depend on how underweight you were before pregnancy & your health care provider's recommendations </li></ul></ul><ul><ul><li>1-2 pounds per week in the second and third trimesters </li></ul></ul><ul><li>Overweight Before Pregnancy: </li></ul><ul><ul><li>Approximately 1-2 pounds in the first trimester </li></ul></ul><ul><ul><li>Approximately 1 pound per week during the last six months </li></ul></ul>
  24. 25. Maternal BP <ul><li>Check the Blood pressure every visit and compare to pre-pregnancy BP. </li></ul><ul><li><20wks with high BP is considered Chronic Hypertension </li></ul><ul><li>>20 with high BP no proteinuria= PIH </li></ul><ul><li>High BP, proteinuria, and edema= preeclampsia. </li></ul><ul><li>Low BP you want to think about endocrine dis. </li></ul>
  25. 26. Evaluating UA <ul><li>PH- Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. </li></ul><ul><li>Glucose: Normal = <+ 1. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high. </li></ul><ul><li>Protein: Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH. </li></ul><ul><li>Leukoesterase: UTI vs trich. </li></ul><ul><li>Ketones: Normal = Negative. Ketones are products of the breakdown of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus. </li></ul>
  26. 27. History <ul><li>Ask for: </li></ul><ul><ul><li>Bleeding/ spotting: sex, cervicitis, chlamydia, polyp, cancer </li></ul></ul><ul><ul><li>Leaking: color and quantity- urine or amnio </li></ul></ul><ul><ul><li>Quickening: 17-19wks wk </li></ul></ul><ul><ul><li>Nausea and vomiting </li></ul></ul><ul><ul><li>Nutrition- hydration </li></ul></ul><ul><ul><li>History of recent illness </li></ul></ul>
  27. 28. Abdominal Exam <ul><li>Inspection (Look for scars, linea,striae,symmetry) </li></ul><ul><li>Palpation: </li></ul><ul><li>Assess Fundal Height (cm) approximates weeks of gestation, position, presentation and EFW. </li></ul><ul><li>Auscultation: </li></ul><ul><li>Detect heart beat (120-160bpm) with doppler– usually heard after 9wks or stethoscope @16wks </li></ul>
  28. 29. Fundal Height <ul><li>The height </li></ul><ul><li>of the fundus </li></ul><ul><li>in cm. equals </li></ul><ul><li>the number </li></ul><ul><li>of weeks </li></ul><ul><li>gestation +/-2. </li></ul><ul><li>FUNDAL HEIGHT </li></ul>
  29. 30. MacDonald’s Rule: (cm of fundal height=wks of gestation) <ul><li>12wks- pubis bone </li></ul><ul><li>16wks- between the pubis bone & umbilicus </li></ul><ul><li>20wks- umbilicus </li></ul><ul><li>Full term- xyphoid process </li></ul>
  30. 31. Leopold’s Maneuver <ul><li>First Maneuver (What is at the fundus) </li></ul><ul><li>Examiner faces woman's head </li></ul><ul><li>Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). </li></ul><ul><li>Palpate the uterine fundus </li></ul>
  31. 32. 2 nd Maneuver <ul><li>Second Maneuver (Assess Spine and small parts) </li></ul><ul><li>Examiner faces woman's head </li></ul><ul><li>Palpate with one hand on each side of abdomen </li></ul><ul><li>Palpate fetus between two hands </li></ul><ul><li>Assess which side is spine and where extremities are located </li></ul>
  32. 33. 3 rd Maneuver <ul><li>Third Maneuver (what is presenting at the pelvis) </li></ul><ul><li>Examiner faces woman's feet and Palpate just above symphysis pubis </li></ul><ul><li>Palpate fetal presenting part between two hands </li></ul><ul><li>The purpose of this maneuver is to determine the pelvic position of the presenting part </li></ul><ul><li>Assess for Fetal Descent </li></ul>
  33. 34. 4 th Maneuver <ul><li>Fourth Maneuver (Where is the Cephalic prominence) </li></ul><ul><li>Examiner faces woman's head </li></ul><ul><li>Apply downward pressure on uterine fundus </li></ul><ul><li>Hold presenting part between index finger and thumb </li></ul><ul><li>Assess for cephalic versus Breech Presentation </li></ul>
  34. 35. <ul><li>Labs: </li></ul>
  35. 36. Initial visit <ul><li>Pap smear </li></ul><ul><li>Urinalysis </li></ul><ul><li>Urine &cervical CX </li></ul><ul><li>CBC </li></ul><ul><li>Blood type &AB screening </li></ul><ul><li>Rubella, Hep B, HIV, syphilis, </li></ul><ul><li>Sickle cell, cystic fibrosis.. </li></ul><ul><li>sono </li></ul>15-20wks Triple screen/sono 24-28wks GTT, Rhogam, CBC 36wks Cervical cultures
  36. 37. Triple Marker testing <ul><li>A . Components </li></ul><ul><li>1. AFP </li></ul><ul><li>2. Estriol </li></ul><ul><li>3. beta HCG </li></ul><ul><li>B. When Drawn </li></ul><ul><li>1. between 14-21wks </li></ul><ul><li>2. Send only to certified lab </li></ul><ul><li>3. provide key adjustment information </li></ul><ul><li>a. obese- run low c. Multiple- run high </li></ul><ul><li>b. diabetes- run low d. dates </li></ul>
  37. 38. Risk assessment in pregnancy <ul><li>Triple screen (16-20wks) </li></ul><ul><ul><li>1. should be offered to all patients >35y/o </li></ul></ul><ul><ul><li>2. consider written form if declining </li></ul></ul><ul><li>Routine ultrasono </li></ul><ul><li>Weekly assessment </li></ul><ul><ul><li>1. ongoing assessement of fetal well being </li></ul></ul><ul><ul><li>2. Further tests as indicted </li></ul></ul><ul><ul><li>3. Counseling as needed </li></ul></ul>
  38. 39. Triple Marker testing <ul><li>Abnormal results in: </li></ul><ul><ul><li>Anencephay, Spina bifida, ventral wall de </li></ul></ul><ul><ul><li>Incidence of Anenceph. 1-2/1000 births </li></ul></ul><ul><ul><li>Incidence increase to 15X if affected sibling </li></ul></ul><ul><ul><li>Marker: elevated AFP(>2.5MOM) </li></ul></ul><ul><ul><li>Morbidity, death, paralysis, MR </li></ul></ul><ul><ul><li>Further test: level II US, amniocentesis </li></ul></ul><ul><ul><li>Plans: method of delivery, perinatology, schedule C/S </li></ul></ul>
  39. 40. <ul><li>1. confirm Dates </li></ul><ul><li>2. if too early, repeat test </li></ul><ul><li>3. approx 70/1000 are abnl low </li></ul><ul><li>If low AFP, Estriol, and elevated HCG there is a risk in Downs syn </li></ul><ul><li>If unexplained consider level IIUS or Amnio </li></ul>Low AFP (.8MoM)
  40. 41. Third Trimester lab <ul><li>Third trimester </li></ul><ul><li>26-28wks: hematocrit (if low, mother will receive iron supplementation) </li></ul><ul><li>26-28wks: glucose loading test (GLT) - screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; if fasting glucose > 105 mg/dL, gestational diabetes is suggestive. </li></ul><ul><li>>36wks- vaginal/rectal culture for Group B strep.,Gonn, Chlamydia </li></ul>
  41. 42. Prenatal Diagnostics <ul><li>Non-invasive: </li></ul><ul><ul><li>1. maternal serum testing- triple screen </li></ul></ul><ul><ul><li>2. Diagnostic ultrasound (level 2) </li></ul></ul><ul><ul><li>3. Fetal echo </li></ul></ul><ul><li>Invasive </li></ul><ul><ul><li>1 .Amniocentesis –performed 15-20wks </li></ul></ul><ul><ul><li>2. Chorionic villus sampling -@ 9.5-12.5wks, (associated with limb defects in the fetus) </li></ul></ul><ul><ul><li>3. fetal tissue sampling </li></ul></ul><ul><li>  </li></ul>
  42. 43. Educate <ul><li>Educated the patient about pregnancy </li></ul><ul><li>Educated the patient about danger signs </li></ul><ul><li>Educated them of things they should avoid during pregnancy. </li></ul><ul><li>Breast swelling and tenderness </li></ul><ul><li>Linea nigra from umbilicus to pubis </li></ul><ul><li>Telangiectasias </li></ul><ul><li>Palmar erythema </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Breast pain </li></ul><ul><li>Fetal movement 17-19wks </li></ul><ul><li>Sciatica (Pain caused by compression of the sciatic nerve) </li></ul>
  43. 44. AVOID DURING PREGNANCY <ul><li>CIGARETTE SMOKING </li></ul><ul><li>ALCOHOL AND DRUG USE </li></ul><ul><li>EXPOSURE TO TERATOGENS. </li></ul><ul><li>EXCESSIVE PHYSICAL WORK </li></ul>
  44. 45. Encourage Good Nutrition Should include: Whole and organic foods; Proteins, fats; micronutrients such as, calcium, iron, magnesium, zinc and vitamins; moderate salt restriction, all in a balanced diet .
  45. 46. What constitutes a high risk pregnancy?
  46. 47. 2 Factors that influence high risk pregnancy: <ul><li>Maternal risk: </li></ul><ul><ul><li>Preexisting medical condition </li></ul></ul><ul><ul><li>Age <20 or >35 </li></ul></ul><ul><ul><li>Social economic>lower </li></ul></ul><ul><ul><li>Work environment </li></ul></ul><ul><ul><li>Recreational habits </li></ul></ul><ul><ul><li>Multiple fetus </li></ul></ul><ul><ul><li>Previous pregnancy hx </li></ul></ul><ul><ul><li>Access to medical care </li></ul></ul><ul><li>Fetus risk: </li></ul><ul><ul><li>Genetic defects </li></ul></ul><ul><ul><li>Structural anomaly </li></ul></ul><ul><ul><li>Size and number of fetus (twins) </li></ul></ul><ul><ul><li>Intrauterine death </li></ul></ul>
  47. 48. Risk factors associated with MOM Factors primarily physiological in origin <ul><li>Multiple pregnancy </li></ul><ul><li>Previous hx. Preterm labor </li></ul><ul><li>Vaginal bleeding in 2 nd trimester </li></ul><ul><li>undx,. UTI  pyelonephritis </li></ul><ul><li>Teenage pregnancy </li></ul><ul><li>Maternal low body wt. </li></ul><ul><li>Polyhydramnios </li></ul><ul><li>Incompetent cervix </li></ul><ul><li>Hx. Of multiple D&C or abortions </li></ul><ul><li>Previous uterine or cervical sx. </li></ul><ul><li>DES exposure </li></ul>
  48. 49. What are lifestyle risk Factors? <ul><li>Recreational drug use </li></ul><ul><li>Cigarette smoking during pregnancy </li></ul><ul><li>Low weight gain in pregnancy </li></ul><ul><li>Physically demanding work: factory, nursing </li></ul><ul><li>Stress: physical, emotional, mental </li></ul><ul><li>Poor diet/dehydration </li></ul><ul><li>Alcoholism </li></ul><ul><li>Lack of family or social support </li></ul>
  49. 50. How do high risk factors affect pregnancy? <ul><li>Greatest risk is preterm labor </li></ul><ul><li>Preterm labor resulting in preterm birth accounts for 75% or preventable perinatal mortality </li></ul><ul><li>Preterm birth increases the risk for neonatal health issues: </li></ul><ul><ul><ul><li>Cerebral palsy </li></ul></ul></ul><ul><ul><ul><li>Respiratory difficulties </li></ul></ul></ul><ul><ul><ul><li>Cardiac aliments </li></ul></ul></ul><ul><ul><ul><li>Blindness </li></ul></ul></ul><ul><ul><ul><li>Long term development delays </li></ul></ul></ul>
  50. 51. Smoking: <ul><ul><ul><li>Abruptio placenta </li></ul></ul></ul><ul><ul><ul><li>Placenta previa </li></ul></ul></ul><ul><ul><ul><li>PROM </li></ul></ul></ul><ul><ul><ul><li>Prematurity </li></ul></ul></ul><ul><ul><ul><li>Spontaneous abortion </li></ul></ul></ul><ul><ul><ul><li>Sudden infant death syndrome </li></ul></ul></ul><ul><ul><ul><li>Low birth wt. </li></ul></ul></ul><ul><ul><ul><li>Respiratory illness </li></ul></ul></ul><ul><ul><ul><li>Reduction in supply of breast milk </li></ul></ul></ul>
  51. 52. Drugs: <ul><li>Cocaine: placental abruption </li></ul><ul><ul><ul><ul><ul><li>Low birth wt </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Preterm labor </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Neonatal withdrawal </li></ul></ul></ul></ul></ul><ul><li>Opiates: neonatal withdrawal, low birth wt, death </li></ul><ul><li>Alcohol: fetal ETOH syndrome </li></ul><ul><li>Caffeine: assoc. low birth wt. with excessive caffeine ingestion. </li></ul>
  52. 53. Multipara <ul><li>Has increase risk: </li></ul><ul><li>Placenta previa </li></ul><ul><li>Postpartum hemorrhage secondary to uterine atony </li></ul><ul><li>Increased incidence of twins </li></ul>
  53. 54. Second trimester elective abortion <ul><li>Risk: </li></ul><ul><ul><ul><li>Spontaneous abortion </li></ul></ul></ul><ul><ul><ul><li>Incompetent cervix </li></ul></ul></ul><ul><ul><ul><li>Preterm delivery </li></ul></ul></ul><ul><ul><ul><li>Low birthweight </li></ul></ul></ul>
  54. 55. MFM <ul><li>Offers assessment and screening of fetus </li></ul><ul><li>Ultrasound </li></ul><ul><li>Umbilical sampling </li></ul>
  55. 56. Management <ul><li>Increase medical attention in the form of increase office visits to monitoring fetal well-being. </li></ul><ul><li>ultrasound level one/two-doppler flow, fetal echo </li></ul><ul><li>Amniocentesis or CVS </li></ul><ul><li>genetic testing </li></ul><ul><li>blood testing </li></ul><ul><li>drug therapy </li></ul><ul><li>work restriction </li></ul><ul><li>bed rest and hospitalization. </li></ul><ul><li>NST and biophysical profiles </li></ul>
  56. 57. NST- noninvasive test of fetal activity the correlates with fetal well-being. <ul><li>Two accelerations </li></ul><ul><li>At least 15 beats </li></ul><ul><li>Amplitude of 15sec </li></ul><ul><li>During a 20min </li></ul><ul><li>Period. </li></ul>
  57. 58. BPP <ul><li>The score for a nonstress test with a healthy (reactive) result is 2. </li></ul><ul><li>During the ultrasound exam four things are checked and given a score of 0 or 2: </li></ul><ul><li>the amount of amniotic fluid </li></ul><ul><li>movements of the baby's body </li></ul><ul><li>the baby's muscle tone </li></ul><ul><li>breathing movements made by the baby </li></ul>
  58. 59. Management based on BPP score Score Interpretation MGT 10 Normal Repeat testing 8 Normal Repeat testing 6 Suspect chronic asphyxia If>36wk, deliver or rpt in 4-6hr 4 Suspect chronic asphyxia If >32wk, deliver Or rpt 4-6 0-2 Strongly suspect chronic asphyxia Extend testing 120min, if score<4 deliver @ any gest. age
  59. 60. BPP-designed to identify a compromised fetus during the antepartum period <ul><li>score of 8 or 10 is considered normal. </li></ul><ul><li>A score of 6 is borderline. </li></ul><ul><li>A score of 4 or less suggests there may be problems. Your health care provider may recommend an early delivery of the baby. </li></ul>
  60. 61. <ul><li>Thank </li></ul><ul><li>You </li></ul>