PRENATAL CAREJaime Aglugub17 June 2011

PRENATAL CARE

• Pre-conceptional care• Prompt diagnosis of pregnancy• Initial Prenatal Evaluation• Subsequent Visits

DIAGNOSIS of PREGNANCYPresumptive. Probable. Positive Signs.

PRESUMPTIVE SIGNS

• Amenorrhea• Nausea and vomiting– Up to 1st trimester

• Breast changes– Enlargement and tenderness

• Chadwick’s sign• Quickening– 20 weeks AOG

PROBABLE SIGNS

• Positive pregnancy test• Changes in uterine size and shape• Palpation of the fetus• Palpation of fetal movement• Piscacek’s sign• Hegar’s sign• Goodell’s sign

POSITIVE SIGNS

• Detection of fetal heart tones– Ultrasound: 5-6 weeks AOG– Doppler: 10 weeks AOG– Stethoscope: 17-19 weeks AOG

• Imaging of the fetus– Ultrasound– Radiograph

• Birth

INITIAL PRENATAL EVALUATIONMedical History. Physical Examination. Laboratory Tests. Patient Education.

MEDICAL HISTORY

• Past Medical Illness• Diseases in the Family• Psychosocial background– Vices (smoking, alcohol, illicit drug use)– Lifestyle (nutrition, exercise)

• Obstetric and gynecologic history– Menstrual cycle– Gynecologic conditions– Previous pregnancies– Obstetric score GP (F-P-A-L)

• Gravida Para (Full-term, Pre-term, Abortion, Live)

PHYSICAL EXAMINATION

• General physical examination• Obstetric and gynecologic examination

Speculum exam. Digital pelvic exam.

ASSESSMENT of GESTATIONAL AGE

• Using patient’s last menstrual period (LMP)

• Fundal height– 18-30 weeks AOG– Pubis symphisis to

uterine fundus• Ultrasound

Determination of fundal height.

ROUTINE LABORATORY TESTS

• Complete blood count (CBC)– Hematocrit and hemoglobin

• Urinalysis and urine culture– Protein and sugar levels

• Blood typing (ABO and Rh)• Rubella status• Syphilis screen• Pap smear• HbsAg testing• Antibody screen (at 28 weeks AOG)

PATIENT EDUCATION

• Medical/surgical complications

• Cessation of vices– Smoking, drinking, drug use

• Danger signs of pregnancy

Vaginal bleeding Pain/burning sensation on urinationPelvic and/or abdominal pain Sudden onset of blurry visionEdema (hands and face) Severe headachesPersistent nausea and vomiting Regular contractions (<37 weeks AOG)Chills and/or fever Decreased fetal movement

PATIENT EDUCATION

• NutritionNutrient Non-pregnant Pregnant

Kilocalories 2200 2500Protein 55 60Fat soluble vitamins

A (ug RE)D (ug)E (mg TE)K (ug)

800108

55

800101065

Water soluble vitaminsC (mg)Folate (ug)Niacin (mg)

6018015

7040017

PATIENT EDUCATION

• NutritionNutrient Non-pregnant Pregnant

Water soluble vitaminsRiboflavin (mg)Thiamine (mg)Pyridoxine (mg)Cobalamin (ug)

1.31.11.62.0

1.61.52.22.2

MineralsCalcium (mg)Phosporus (mg)Iodine (ug)Iron (ferrous) (mg)Magnesium (mg)Zinc (mg)

1200120015015

28012

1200120017530

32015

PATIENT EDUCATION

• Nutrition

Pre-pregnancy BMI (kg/m2)

Recommended total gainPounds Kilograms

Low (BMI < 19.8) 28-40 12.5-18Normal (BMI 19.8-26) 25-35 11.5-16High (BMI > 26-29) 15-25 7-11.5Obese (BMI > 29) <15 <7

PATIENT EDUCATION

• Other Common Maternal Concerns– Exercise– Employment– Travel– Bowel Habits– Sex– Nausea and Vomiting– Immunization– Varicosities– Heartburn– Medicinal Drug Intake

PATIENT EDUCATION

• Schedule of subsequent visits– Depends on whether pregnancy is low-risk or

high-risk

Factors for High-Risk PregnancyExtremes of reproductive age (<17 y.o. and >35 y.o.)With medical complicationsPoor obstetric and gynecologic historyWith fetal problems (aging, structure, size)Polyhydramnios or oligohydramnios

PATIENT EDUCATION

• Schedule of subsequent visitsNormal Pregnancy High-risk Pregnancy

Until 28 weeks AOG: Every 4 weeks

Until 36 weeks AOG:Every 2 weeks

Until delivery:Weekly

Until 32 weeks AOG:Every 2 weeks

Until delivery:Every week

SUBSEQUENT VISITSMedical History. Physical Examination. Laboratory Tests. Patient Education.

MEDICAL HISTORY

• Danger signs of pregnancy

• Nutritional intake • Vitamin

supplementation

PHYSICAL EXAMINATION

• Maternal Health– Blood pressure– Weight increase– Pelvic examination

PHYSICAL EXAMINATION

• Fetal Health– Leopold’s maneuvers• Presentation• Lie• Engagement

– Fetal heart rate and rhythm

– Estimated fetal size and weight

– Fundic height– Fetal movement

SPECIAL LABORATORY TESTS

• Recommended for repeat (28-32 weeks AOG)– Hematocrit (or hemoglobin) determination– Syphilis serology

• Optional tests that should be offered– Screening tests for genetic diseases– HIV screening

• Required later in pregnancy– Oral glucose tolerance test (OGTT) (24-28 weeks AOG)– Rectovaginal culture of Group B Streptococcus (35-37

weeks AOG)

SPECIAL DIAGNOSTICS

• Electronic fetal surveillance– Non-stress test (NST)– Contraction stress test (CST)

• Ultrasound examination– Fetal biometry

• Crown-rump length, femur length• Biparietal diameter, head circumference

– Congenital anomaly scan– Biophysical profile (BPP)

• 5 variables: fetal tone, movement, breathing, amniotic fluid levels and NST

SUMMARY

• Prenatal care encompasses maternal and fetal health from pre-conception to delivery.

• History, physical examination, diagnostics and patient education form the tetrad of every prenatal care visit.

THANK YOU!Prenatal Care.