This document provides an overview of prenatal care, including when it should begin, what is assessed at prenatal visits, common tests and screenings, risk factors, and how high-risk pregnancies are managed. Prenatal care aims to monitor the health of the mother and fetus, identify potential complications, educate the patient, and promote a healthy pregnancy outcome. Key components of prenatal visits include assessment of gestational age, physical exam, labs, history, abdominal exam checking fundal height and fetal heart tone.

2. Prenatal Care Doris K Ramirez MD Visiting Professor UAG [email_address]

3. Outline Background Assessement of gestational age Physical exam Lab test Educate the patient

4. Prenatal Care Most frequently used health service in USA 80% start in 1 st Trimester Ave 12 visits per patient

5. WHAT DO WE KNOW ABOUT PRENATAL CARE

6. WHEN SHOULD PRENATAL CARE START?

7. WHEN TOM CRUISE RETURNS YOUR CALL? 1 ST DAY AFTER ONE HAVE MISSED THEIR PERIOD? PRECONCEPTIONAL? B/C A/B ALL OF THE ABOVE? NONE OF THE ABOVE?

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). *

9. Prenatal is helpful: Managing the remaining weeks of the pregnancy Planning for possible complications with the birth process Planning for problems that may occur in the newborn infant Determine the outcome of pregnancy Deciding whether to continue the pregnancy Help promote a live and healthy baby

10. How do you detect if your are pregnant? 1) urine or blood test 2) ultrasound

11. bHCG “Beta Human Chorionic Gonadotropin “ Where? This hormone is released by trophoblastic tissue in the placenta It may be produced by a choriocarcinoma or some other germ cell tumors, or even other forms of cancer, e.g. lung cancer.

12. Pregnancy (HCG) Urine pregnancy test-2wks after ovulation Serum pregnancy test-6-8 days after ovulation Qualitative: measures whether bHCG is present (25mlU/ml is +) Quantitative: measures the exact amount of bHCG produced.

13. Levels of bHCG Below bHCG 1200 mlU/ml- doubles Q 48-72hrs 1200-6000mlU/ml- doubles Q72-96hrs >6000mlU/ml- may take more than 4 days to double. Failure to double: miscarriage or ECTOPIC

14. + Pregnancy test: Clinical Visits with no high risk: Q4Wks until 28wks Q2W from 28-36wks Every wk from >36wks

15. Ultrasonography When? As early as 4.5wks What do you see? Transvaginal- bHCG>1500 see gestational sac. Abdominal sono: bHCG>6000 see heart beat

16. 5wks embryo and yolk sac

17. 7wk embryo and yolk sac

18. Accurate Assessment of gestational age May be critical information later. CRL ( crown rump length)- 1-13wks accurate date within +/- 3-5 days of the actual due date. 2 nd tri(14-28wks): biparietal diameter will accurately predict the due date within 7-10 days in most cases . 3 rd tri(>28wks): + or – 2-3wks, femur is most accurate Naegele rules- EDC=LMP+7d-3m Fundal height= gest. Age from 18-30wks

19. First prenatal visit: take a careful detail history ( looking for factors that might increase the risk for the pregnant woman.) Check for BP, urine, weight at every visit. Physical examination Routine laboratory test ( looking for specific issues that could influence pregnancy ) Expectations and preparation for delivery (childbirth classes, preferred pain mgt, plans for feeding )

20. Risk Assessment A. Obtain detailed family history from all patient/PMH 1. Hx. Of MR, ONTD other anomalies 2. if adopted B. Formal questionnaire 1. helps with difficult areas 2. Fill out prior to visit C. Social history 1. smoking 2. Drug and alcohol use 3. other exposures D. Allergies and medications

21. PHYSICAL EXAMINATION Steps you should take to prepare for the examination: *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.

22. Each prenatal visit: Maternal Weight Maternal BP UA History Abdominal Examination: Fundal height Fetal heart Fetal position and shape

23. Maternal Weight The amount of weight you should gain depends on your weight before pregnancy. You should gain: 25-35 pounds: If you were a healthy weight before preg. 28-40 pounds: If you were underweight before pregnancy 15-25 pounds: If you were overweight before pregnancy

24. Healthy Weight Before Pregnancy: 3-5 pounds during the first trimester Approximately 1-2 pounds per week in the second trimester Approximately 1-2 pounds per week in the third trimester Underweight Before Pregnancy: 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 1-2 pounds per week in the second and third trimesters Overweight Before Pregnancy: Approximately 1-2 pounds in the first trimester Approximately 1 pound per week during the last six months

25. Maternal BP Check the Blood pressure every visit and compare to pre-pregnancy BP. <20wks with high BP is considered Chronic Hypertension >20 with high BP no proteinuria= PIH High BP, proteinuria, and edema= preeclampsia. Low BP you want to think about endocrine dis.

26. Evaluating UA PH- Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration. 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. 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. Leukoesterase: UTI vs trich. 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.

27. History Ask for: Bleeding/ spotting: sex, cervicitis, chlamydia, polyp, cancer Leaking: color and quantity- urine or amnio Quickening: 17-19wks wk Nausea and vomiting Nutrition- hydration History of recent illness

28. Abdominal Exam Inspection (Look for scars, linea,striae,symmetry) Palpation: Assess Fundal Height (cm) approximates weeks of gestation, position, presentation and EFW. Auscultation: Detect heart beat (120-160bpm) with doppler– usually heard after 9wks or stethoscope @16wks

29. Fundal Height The height of the fundus in cm. equals the number of weeks gestation +/-2. FUNDAL HEIGHT

30. MacDonald’s Rule: (cm of fundal height=wks of gestation) 12wks- pubis bone 16wks- between the pubis bone & umbilicus 20wks- umbilicus Full term- xyphoid process

31. Leopold’s Maneuver First Maneuver (What is at the fundus) Examiner faces woman's head Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse). Palpate the uterine fundus

32. 2 nd Maneuver Second Maneuver (Assess Spine and small parts) Examiner faces woman's head Palpate with one hand on each side of abdomen Palpate fetus between two hands Assess which side is spine and where extremities are located

33. 3 rd Maneuver Third Maneuver (what is presenting at the pelvis) Examiner faces woman's feet and Palpate just above symphysis pubis Palpate fetal presenting part between two hands The purpose of this maneuver is to determine the pelvic position of the presenting part Assess for Fetal Descent

34. 4 th Maneuver Fourth Maneuver (Where is the Cephalic prominence) Examiner faces woman's head Apply downward pressure on uterine fundus Hold presenting part between index finger and thumb Assess for cephalic versus Breech Presentation

35. Labs:

36. Initial visit Pap smear Urinalysis Urine &cervical CX CBC Blood type &AB screening Rubella, Hep B, HIV, syphilis, Sickle cell, cystic fibrosis.. sono 15-20wks Triple screen/sono 24-28wks GTT, Rhogam, CBC 36wks Cervical cultures

37. Triple Marker testing A . Components 1. AFP 2. Estriol 3. beta HCG B. When Drawn 1. between 14-21wks 2. Send only to certified lab 3. provide key adjustment information a. obese- run low c. Multiple- run high b. diabetes- run low d. dates

38. Risk assessment in pregnancy Triple screen (16-20wks) 1. should be offered to all patients >35y/o 2. consider written form if declining Routine ultrasono Weekly assessment 1. ongoing assessement of fetal well being 2. Further tests as indicted 3. Counseling as needed

39. Triple Marker testing Abnormal results in: Anencephay, Spina bifida, ventral wall de Incidence of Anenceph. 1-2/1000 births Incidence increase to 15X if affected sibling Marker: elevated AFP(>2.5MOM) Morbidity, death, paralysis, MR Further test: level II US, amniocentesis Plans: method of delivery, perinatology, schedule C/S

40. 1. confirm Dates 2. if too early, repeat test 3. approx 70/1000 are abnl low If low AFP, Estriol, and elevated HCG there is a risk in Downs syn If unexplained consider level IIUS or Amnio Low AFP (.8MoM)

41. Third Trimester lab Third trimester 26-28wks: hematocrit (if low, mother will receive iron supplementation) 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. >36wks- vaginal/rectal culture for Group B strep.,Gonn, Chlamydia

42. Prenatal Diagnostics Non-invasive: 1. maternal serum testing- triple screen 2. Diagnostic ultrasound (level 2) 3. Fetal echo Invasive 1 .Amniocentesis –performed 15-20wks 2. Chorionic villus sampling -@ 9.5-12.5wks, (associated with limb defects in the fetus) 3. fetal tissue sampling

43. Educate Educated the patient about pregnancy Educated the patient about danger signs Educated them of things they should avoid during pregnancy. Breast swelling and tenderness Linea nigra from umbilicus to pubis Telangiectasias Palmar erythema Amenorrhea Nausea and vomiting Breast pain Fetal movement 17-19wks Sciatica (Pain caused by compression of the sciatic nerve)

44. AVOID DURING PREGNANCY CIGARETTE SMOKING ALCOHOL AND DRUG USE EXPOSURE TO TERATOGENS. EXCESSIVE PHYSICAL WORK

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 .

46. What constitutes a high risk pregnancy?

47. 2 Factors that influence high risk pregnancy: Maternal risk: Preexisting medical condition Age <20 or >35 Social economic>lower Work environment Recreational habits Multiple fetus Previous pregnancy hx Access to medical care Fetus risk: Genetic defects Structural anomaly Size and number of fetus (twins) Intrauterine death

48. Risk factors associated with MOM Factors primarily physiological in origin Multiple pregnancy Previous hx. Preterm labor Vaginal bleeding in 2 nd trimester undx,. UTI  pyelonephritis Teenage pregnancy Maternal low body wt. Polyhydramnios Incompetent cervix Hx. Of multiple D&C or abortions Previous uterine or cervical sx. DES exposure

49. What are lifestyle risk Factors? Recreational drug use Cigarette smoking during pregnancy Low weight gain in pregnancy Physically demanding work: factory, nursing Stress: physical, emotional, mental Poor diet/dehydration Alcoholism Lack of family or social support

50. How do high risk factors affect pregnancy? Greatest risk is preterm labor Preterm labor resulting in preterm birth accounts for 75% or preventable perinatal mortality Preterm birth increases the risk for neonatal health issues: Cerebral palsy Respiratory difficulties Cardiac aliments Blindness Long term development delays

51. Smoking: Abruptio placenta Placenta previa PROM Prematurity Spontaneous abortion Sudden infant death syndrome Low birth wt. Respiratory illness Reduction in supply of breast milk

52. Drugs: Cocaine: placental abruption Low birth wt Preterm labor Neonatal withdrawal Opiates: neonatal withdrawal, low birth wt, death Alcohol: fetal ETOH syndrome Caffeine: assoc. low birth wt. with excessive caffeine ingestion.

53. Multipara Has increase risk: Placenta previa Postpartum hemorrhage secondary to uterine atony Increased incidence of twins

54. Second trimester elective abortion Risk: Spontaneous abortion Incompetent cervix Preterm delivery Low birthweight

55. MFM Offers assessment and screening of fetus Ultrasound Umbilical sampling

56. Management Increase medical attention in the form of increase office visits to monitoring fetal well-being. ultrasound level one/two-doppler flow, fetal echo Amniocentesis or CVS genetic testing blood testing drug therapy work restriction bed rest and hospitalization. NST and biophysical profiles

57. NST- noninvasive test of fetal activity the correlates with fetal well-being. Two accelerations At least 15 beats Amplitude of 15sec During a 20min Period.

58. BPP The score for a nonstress test with a healthy (reactive) result is 2. During the ultrasound exam four things are checked and given a score of 0 or 2: the amount of amniotic fluid movements of the baby's body the baby's muscle tone breathing movements made by the baby

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

60. BPP-designed to identify a compromised fetus during the antepartum period score of 8 or 10 is considered normal. A score of 6 is borderline. A score of 4 or less suggests there may be problems. Your health care provider may recommend an early delivery of the baby.

61. Thank You