ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM.pptx
Prenatal Care In Obstetrics and Gynecology
1. PRENATAL CARE
PGI CECILIO GABRIEL F. MAGSINO
Manila Doctors Hospital
Department of Obstetrics and Gynecology
2. PRENATAL CARE
American College of Obstetricians and Gynecologists (2017)
“A coordinated approach to medical care, continuous risk assessment, and
psychological support that optimally begins before conception and extends
throughout the postpartum period and interconceptional period.”
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
5. DIAGNOSIS OF PREGNANCY
Signs and
Symptoms
Laboratory
Studies
Ultrasonography
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
6. Presumptive Symptoms:
A. Nausea and vomiting
B. Urinary changes
C. Fatigue
D. Quickening
E. Breast symptoms
Presumptive Signs:
A. Amenorrhea
B. Anatomical breast changes
C. Chadwick’s sign
D. Thermal signs
E. Chloasma/melasma gravidarum
F. Striae gravidarum
PRESUMPTIVE SIGNS AND SYMPTOMS
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
7. Noted by the examiner:
A. Abdominal enlargement
B. Hegar’s Sign
C. Goodell’s Sign
D. Cervical softening
E. Cervical mucus crystallization
F. Braxton-Hicks Contractions
G. Ballottement of amniotic sac
H. Outlining of the fetus
I. Positive pregnancy test
PROBABLE SIGNS
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
8. Objective and specific evidence:
A. Detection of fetal heart tones
➢ Transvaginal Sonography: 6-8 weeks, most accurate
➢ Doppler: 10-12 weeks
➢ Stethoscope: 18 weeks
B. Perception of fetal movement by the examiner: 20 weeks
C. Ultrasound recognition of the embryo/fetus
➢ Gestational sac: 4-5 weeks
➢ Fetal heartbeat: 6-8 weeks
➢ Crown-rump length (CRL): up to 13 weeks
POSITIVE SIGNS
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
9. 10 Danger Signs:
1) Persistent headache
2) Blurring of vision
3) Persistent nausea and vomiting
4) Edema of hands and feet
5) Fevers and chills
6) Dysuria
7) Hypogastric pain
8) Bloody vaginal discharge
9) Watery vaginal discharge
10) Decreased fetal movements
10 DANGER SIGNS OF PREGNANCY
Severe
Preeclampsia
Infection/UTI
Preterm
labor/Fetal
compromise
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
11. HISTORY
A. Chief complaint
B. History of present illness
C. Past medical history
D. Family history
E. Personal and social
history
F. Menstrual history
G. Obstetrical history
H. Current pregnancy
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
12. ESTIMATION OF THE AOG
A. 1st trimester ultrasound:
➢ Most accurate
➢ Date the UTZ was done, and AOG: e.g. May 13, 2021; AOG by
UTZ of 7 weeks, 2 days
➢ Convert weeks AOG to days: 7 weeks x 7 days/week + 2 days =
51 days
➢ Date today: September 6, 2022
➢ Days since the UTZ was taken until the day today = May: 14 +
June: 30 + July: 31 + August: 31 + September: 6 = 112 days
➢ 51 days (age indicated in the last UTZ) + 112 days (number of
days that passed since the last UTZ)
➢ 51 + 112 = 163 days x 1 week/7 days = 23 2/7 weeks AOG as
of today
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
13. ESTIMATION OF THE AOG
B. Last menstrual period method
➢ LMP: e.g. January 13-17, 2022
➢ Date today: September 6, 2022
➢ Jan: (31 – 13 = 18) + Feb: 28 + Mar: 31 + Apr: 30 + May:
31 + June: 30 + July: 31 + August: 31 + September: 6 =
236 days
➢ Divide by 7 days to convert to weeks = 33 5/7 weeks
AOG by LMP
➢ Use if UTZ not available and the menstrual cycle is
regular (cannot be used if with irregular menses)
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
14. ESTIMATION OF THE AOG
C. Estimated date of delivery: Naegele Rule
➢ Add 7 days to the first day of the last period and
subtract 3 months, then add 7 days.
➢ Ex. LMP: January 13-17
➢ January, 13 - 3 months, + 7 days = October 20, 2022
➢ We can expect delivery to be ± 2 weeks from this date
(American College of Obstetricians and Gynecologists, 2017e)
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
15. PHYSICAL EXAM
A. General survey
B. Abdominal examination
C. Fundic height - 20 and 34 weeks
AOG, correlates closely with
gestational age.
D. Leopold’s maneuvers
➢ LM 1: Fundic Grip – Fetal lie and
presentation
➢ LM 2: Umbilical Grip – Orientation
of fetal back
➢ LM 3: Pawlic Grip – Engagement
➢ LM 4: Pelvic Grip – Head is flexed
or extended
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
16. PHYSICAL EXAM
E. Fetal heart tone
F. Breast examination
➢ Symmetry, skin coloration, dimpling,
nipple inversion, nipple retractions,
palpable masses, nipple discharge
G. Pelvic examination
➢ External genitalia
➢ Speculum examination - cervix is
smooth, violaceous with minimal
whitish mucoid non-foul discharge
➢ Internal examination - Cervix soft, long,
closed; uterus enlarged to N months’
size, no adnexal masses nor tenderness
➢ Adnexa cannot be evaluated if uterus is
enlarged to 3 months’ size
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
17. LABORATORIES AND ANCILLARIES
A. Ultrasonography:
➢ Determine fetal viability and confirm location, if intrauterine.
➢ 1st trimester ultrasound: most accurate
➢ Types: Transvaginal – if <12 weeks AOG; Transabdominal – if >12 weeks
AOG
B. Fetal biometry:
➢ For fetal aging and viability
➢ Starting at 13 weeks AOG
➢ Crown-rump length – corresponds with fetal age up to 13 weeks AOG
C. Biophysical profile:
➢ Assess fetal well-being
➢ Starting at 28 weeks
➢ Includes: Fetal Tone, Movement, Breathing, NST, and Amniotic Fluid
Index
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
18. ANTEPARTUM LABORATORY TESTS
A. Complete blood count - Determine hematologic status, assess the
physiologic anemia of pregnancy, check for leukocytosis
B. ABO and Rh blood typing – In case transfusion is warranted during
delivery, and to determine risk of isoimmunization
C. Urinalysis and culture - Evaluate for UTI & renal function. Culture can be
used to check for asymptomatic bacteriuria
Trimester Normal Hgb Anemia Hgb
1st 11.5 g/dL Mild 9.5 – 10.5 g/dL
2nd 10.5 g/dL Moderate 8.0 – 9.4 g/dL
3rd 11.5 g/dL Severe 6.9 – 7.9 g/dL
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
19. ANTEPARTUM LABORATORY TESTS
D. Diabetes screening – Done in all pregnant patients
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
20. ANTEPARTUM LABORATORY TESTS
E. Pap smear – Establish a baseline and primarily detects premalignant
lesions as a screening tool for cervical CA
F. Serology:
➢ HBsAg – Ideally done in the 1st trimester and repeated on the 3rd, to
determine Hep B status and possible intervention
➢ VDRL/RPR – Done near term 3rd trimester to detect previous or current
infection of Syphilis; non-specific screening tests
➢ Rubella Antigen - To document rubella immunity or prior infection
➢ HIV - Recommended but not yet required in PH
G. COVID 19 RT PCR – Determine if with current COVID infection
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
22. SUBSEQUENT PRENATAL VISITS
Prenatal Surveillance:
A. Fundal height - used to monitor fetal
growth and amnionic fluid volume.
B. Fetal heart sounds
C. Sonography
Subsequent Laboratory Tests: If initial
results are normal, most tests need not be
repeated.
A. Gestational diabetes – OGTT repeated
at 24 to 28 weeks for initially normal
patients. Then again at 32 weeks.
B. Neural tube defects and genetic
screening - Serum screening for neural-
tube defects start at 15 to 20 weeks.
Fetal aneuploidy screening may be
performed at 11 to 14 weeks and/or at
15 to 20 weeks.
Age of Gestation Subsequent Visits
1st PNCU until 28 weeks Every 4 weeks
28 to 36 weeks Every 2 weeks
37 weeks onwards Weekly
Complicated Pregnancy (e.g.
DM, Twins)
Weekly or every 2 weeks
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
24. NUTRITIONAL COUNSELING
Weight gain recommendations - Stratified based on pre-
pregnancy BMI. Obesity is associated with significantly
increased risk for gestational hypertension,
preeclampsia, GDM, macrosomia, cesarean delivery
Dietary recommendations:
➢ Calories – an increase of 100 to 300kcal/day is
recommended during pregnancy, adding 0, 340, and
452 kcal/day to the estimated nonpregnant energy
requirements in the 1st, 2nd, and 3rd trimesters,
respectively.
➢ Protein - intake that approximates 1 g/kg/day is
recommended
Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
25. NUTRITIONAL COUNSELING
Vitamins and minerals
1. Iron – RDI: 27 mg elemental Iron
➢ Not given at 14 to 16 weeks
➢ 1 hour before or 2 hours after meals
2. Calcium - RDA: 1000 mg elemental Calcium
3. Vitamin D - 200 to 600 IU
4. Zinc - RDI: 12mg/day
5. Iodine - RDI: 220 μg/day
6. Folic acid - Daily intake of 400 μg throughout the periconceptional period
(4 mg/day if with history of neural tube defects)
➢ Supplement containing 0.4 to 0.8 mg of folic acid one month before and
for the first two to three months after conception
Immunizations
1. Tetanus toxoid – given if no/unknown history: 3 doses starting at the 2nd
trimester, 1 month apart, the 3rd dose may be given post-partum
2. Influenza vaccine
*Live vaccines are contraindicated in pregnancy Cunningham, F. G. (2022). William's obstetrics. McGraw Hill.
26. CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, infographics
and images by Freepik
THANK YOU!
References:
William’s 25th edition
Philippine Board of Obstetrics and Gynecology
American College of Obstetricians and Gynecologists
(ACOG)
