RESIDENT’S REVIEW: A WEBINAR SERIES

PRENATAL CARE by Dr. Cagayan

Goals of Prenatal Care Signs and Symptoms

Timing: Not later than 2 months Amenorrhea – not a reliable pregnancy indicator until 10
1. Determine maternal health status days or more after expected menses
2. Determine Fetal health status Low reproductive tract changes - Chadwick’s sign, cervical
3. Estimate Gestational age changes
Uterine changes - Hegar sign, uterine soufflé vs funic
4. Initiate Plan for Continuing care
soufflé
Recommended Components of the Initial Prenatal Visit Breast and skin changes
Risk assessment - genetic, medical, obstetrical and Fetal movement – detected by examiner by 20 weeks
o Quickening
psychosocial factors
 16-18 weeks in MULTIGRAVIDA
Estimated due date  18-20 weeks in PRIMIGRAVIDA
General physical examination
Laboratory tests - CBC, urinalysis, blood typing, rubella Signs of Pregnancy
status, Hbs Ag, Papsmear, offer HIV testing PRESUMPTIVE PROBABLE POSITIVE
Patient education - avoid alcohol and tobacco Amenorrhea Goodell’s Fetal heart sounds
Nausea and vomiting Hegar’s Outline and
*Question: Which of the following is a presumptive signs of Urinary frequency Chadwick’s sign movement on
pregnancy? Quickening Ballottement ultrasound
Uterine enlargement Braxton Hicks
A. Amenorrhea Pigmentation changes contractions
B. (+) Pregnancy test (+) Pregnancy Test
C. Chadwick’s sign
D. Quickening Human Chorionic Gonadotropin
Heterodimer composed of two dissimilar subunits designated
Diagnosis of Pregnancy α and β which are noncovalently linked
Signs and symptoms α-subunit is identical to those of LH, FSH and TSH
Beta hCG β-subunit is structurally distinct
Sonography Produced by the synctiotrophoblasts, prevents involution of
the corpus luteum which is the principal site of progesterone
formation during the first 6 weeks of pregnancy
With a sensitive test, the hormone can be detected in
maternal serum or urine by 8 to 9 days after ovulation
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Doubling time of serum hCG concentration - 1.4 to 2.0 days 4. Menstrual history – frequency, duration, regularity and
Reach peak levels at 60 to 70 days amount or flow of menses, LNMP, PMP
5. Obstetrical history: OB Score, AOG, EDC
Sonography a. Previous deliveries – prenatal consults, pregnancy
After 6 weeks, an embryo is seen as a linear structure outcome, place and manner of delivery, fetal weight
immediately adjacent to the yolk sac, and cardiac motion is and sex, maternal/fetal complications
typically noted at this point b. Present pregnancy – prenatal consultrs, pre-
Up to 12 weeks gestation, the CRL is predictive of pregnancy weight, history of maternal illness, intake
gestational age within 4 days of medical , exposure to radiation, smoking, alcohol,
abnormal symptoms

Normal Duration of Pregnancy

Mean duration of pregnancy = 280 days or 40 weeks
Pregnancy divided into 3 trimesters:
o 1st trimester – up to 14 weeks AOG
o 2nd trimester – 15 – 28 weeks AOG
o 3rd trimester – 29 – 42 weeks AOG
Age of gestation (AOG) – weeks of completed gestation
Expected date of delivery/confinement (EDD/EDC)
o Add 7 days to the date of the 1st day of LNMP and
count back 3 months

High-Risk Pregnancies
Pre-exisiting medical illness
Previous poor pregnancy outcome
o Perinatal mortality
o Preterm delivery
History o Fetal growth restriction
1. Past Medical History - Previous hospitalizations/surgeries, o Fetal malformations
diseases (cardiac, hypertension, diabetes, asthma,
o Placental accidents
tuberculosis, STD, allergies); intake of meds
2. Family History – cardiovascular disease, cancer, diabetes, o Maternal hemorrhage
congenital malformations, multifetal gestation Evidence of maternal undernutrition
3. Personal/social history – marital status, educational Obstetrical History and Conditions
attainment, vices, age at first coitus, no. of sexual partners, o Age>35 years at delivery
use of contraceptives, pre-pregnant weight or BMI o Cesarean delivery, prior classical or vertical incision
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o Incompetent cervix o Doppler: 10 weeks AOG

o Prior fetal structural or chromosomal abnormality o Stethoscope: 20 weeks AOG
o Prior neonatal death
o Prior fetal death V. Fundal Height
o Prior preterm delivery or preterm ruptured o The distance (cm) over the abdominal wall from the top
membranes of symphysis pubis to the top of the uterine fundus
o Prior low birthweight (<2500 grams) o Has good correlation between gestational age (weeks)
o Second-trimester pregnancy loss and measured height of fundus (cm) between 20-34
o Uterine leiomyomata or malformation weeks AOG
o Condylomata (extensive, covering vulva or vaginal o Measured on an empty bladder
opening)
*Question: A 27 yo, G2P1 consults you for the first time for irregular
Obstetrical Examination contractions. Her first pregnancy was delivered via CS for CPD. IE
showed closed cervix, beginning effacement. She reports that she has
I. Physical Examination irregular menses since she delivered last February 2019. You
o Vital signs: BP, RR, temperature, weight, height computed an AOG of 35 weeks AOG based on her recalled LMP.
o Complete systemic PE She has an initial ultrasound done last January 22 showing a live IUP
o Abdominal exam: fundic height, estimated fetal weight, of 6-7 weeks AOG. Her Ultrasound done 1 week ago showed a live
baby compatible with 35-36 weeks AOG. What will you advise?
Leopold’s presenting part, fetal heart tones
A. Send home and prescribe amino acids
II. Speculum Examination
B. Admit for tocolysis
o Bluish-red hyperemia of the cervix – characteristic of
C. Admit for observation
pregnancy D. Admit for repeat CS
o Cervical discharge
o Papsmear Gestational Age
Ways to get AOG: 1. LNMP; 2. Fundic height; 3.
III. Digital pelvic examination Quickening (16-20 weeks); 4. Ultrasound (UTZ) – not
o Consistency, length and dilatation of the cervix currently recommended in low risk pregnancies by the
o Fetal presenting part ACOG (2002)
o Bony pelvis – assess adequacy
o Vulva, vagina, perineum PRENATAL SURVEILLANCE
o Digital rectal exam
Fetal
Heart rate
IV. Fetal Heart Sounds Size: actual and rate of change
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Amount of amniotic fluid Rubella testing

Presenting part and station Hepatitis B
Activity/movement Syphilis serology if it is prevalent in the population should
be repeated at 28 to 32 weeks
Maternal Papsmear
Blood Pressure Vaginal and rectal group B Streptococcal culture at 35 – 37
Weight weeks (CDC, ACOG)
Symptoms - headache, blurring of vision, abdominal pain, For those with high risk of acquisition, repeat HIV testing
nausea and vomiting, bleeding, vaginal fluid, dysuria during the 3rd trimested before 36 weeks AOG
Fundic height
Vaginal examination (late in pregnancy) Subsequent Prenatal Visits
Confirmation of presenting part – station, clinical assessment
of pelvis, cervical consistency, effacement and dilatation Return visits
Recommended components of routine prenatal care
Laboratory/Ancillary Tests
Hematocrit or hemoglobin determination Visit Intervals q4 weeks until 28 weeks; then q2
Rh and typing weeks until 36 weeks & weekyly
Urinalysis/urine culture thereafter
GDM Screening – first visit 24-28 weeks32 weeks WHO (low risk): once in the 1st
Ultrasound for fetal aging trimester – 26 weeks – 32 weeks –
38 weeks
Cut –off values for the diagnosis of DM Each visit Maternal: symptoms, BP, weight,
fundic height
OVERT DM GESTATIONAL DM Fetal: Heart rate, movement, size;
FBS ≥ 126 mg/dL ≥ 92 mg/dL but <126 presenting part and station (late)
mg/dL 15-20 weeks Maternal serum alpha-fetoprotein
1st hour OGTT ≥ 180 mg/dL screening
2nd hour OGTT ≥ 200 mg/dL ≥ 153 mg/dL Cystic fibrosis screening
24-28 weeks Screen for gestational diabetes;
Hb/Hct
Test D-negative women for Ab-
Rhogam (anti-D Ig) if needed
> 28 weeks Syphilis, Chlamydia, Gonorrhea
tests
Rectovaginal GBS culture
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Complicated pregnancies require more frequent visits (every

1-2 weeks)
Immediate consult
o Follow-up lab results
o Results of 100 grams OGTT if positive 50 grams
GCT
o With problems

Subsequent Laboratory Tests

CBC (Hb/Hct) at 24-28 weeks
Maternal serum alpha-fetoprotein at 15-20 weeks (open
neural tube defects and some chromosomal anomalies)
50 grams glucose challenge test at 24-28 weeks

Barker Hypothesis
Concept of fetal programming by which adult morbidity and
mortality are related to fetal health

NUTRITION
Calories
Birthweight can be significantly influenced by starvation Pregnancy requires an additional 80,000 kcal, mostly during
during later pregnancy the last 20 weeks
o Perinatal mortality rate, incidence of malformations To meet this demand, a caloric increase of 100 to 300 kcal
and poor mental performance did not increase per day is recommended during pregnancy (AAP, ACOG
Maternal weight gain during pregnancy influences 2012)
birthweight of the infant Adding 0, 340, and 452 kcal/day to the estimated non-
o Greater risk for a low birth weight infant (<2500 g) pregnant energy requirements in the first, second and third
maternal weight gain of <16 lbs trimesters, respectively (IM, 2006)
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*Question: A 32 year old G2P1 (1001) seeks consult at 6 weeks

AOG for initial obstetric visit. Her previous child had a spina bifida.
How much folate be given to prevent NTDs in her current
pregnancy?

A. There is insufficient evidence that folate can prevent NTDs

B. 40 mcg/day
C. 400 mcg/day
D. 4 mg/day

Nutritional Counseling
Recommended Daily Dietary Allowances

FOLIC ACID
RDA: 400 ug/day (0.4 mg/day) throughout periconceptional
period and first trimester; 4 mg/day if with prior child with
neural-tube defect (69% decrease in NTD)
Inadequate intake - Neural Tube defects
Notes – Diet alone is insufficient; Women taking anti-seizure
medications and other drugs that interfere with folic acid
metabolism, carrying multiple gestation and obese need
higher doses

*Question: A 30 year old G3P2 came in for prenatal check up on her

30th week AOG. She complains of mild irregular contractions which
Prenatal Vitamin and Mineral Supplementation resolves with rest. Ultrasound showed twin pregnancy. On routine
Routine multivitamin supplementation is not recommended laboratory exam, her hemoglobin is noted at 10.8 g/dL. How will you
unless maternal diet is questionable or she is at nutritional manage the case?
risk
o Multiple gestation A. Admit and transfuse with 1 unit pRBC
o Substance abuse B. Admit for expectant management
o Vegetarians C. Advice, bed rest and inject with iron sucrose
o Epileptic D. Give 100 mg elemental iron per day and counsel
o Hemoglobinopathies regarding closer surveillance
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Parenteral iron therapy should not be started before 21 weeks

AOG and shouldnot be given simultaneously with oral
therapy
IRON Maximum cumulative doses are 800 mg (200 mg/day for 4
RDA: 27 mg/day; 60 -100 mg/day if obese, twin gestation, days) for postpartum patients and 1600 mg (200 mg twice
late iron supplementation, irregular intake of iron or with per week to a target Hgb of 100 g/L or for a maximum of 4
iron deficiency anemia weeks) in pregnancy, administered over 30 minutes for short
Inadequate intake - Anemia infusions (in-patients) and over 5-10 minutes for bolus
Notes injections (outpatients)
Diet alone is insufficient
Iron requirement are slight during first 4 months of CALCIUM
pregnancy hence not necessary to supplement during this RDA: 1000 mg/day
time Inadequate intake: Demineralization of mother’s bones
Ingestion of iron at bedtime or on an empty stomach aids Notes:
absorption Development of fetal skeleton increases demand for calcium,
Iron supplementation: 100-200 mg daily maternal intestinal calcium absorption is doubled, dietary
Oral forms: ferrous sulfate (200 mg/g), gluconate (120 intake of calcium is necessary
mg/g), fumarate (330 mg/g), carbonate (480 mg/g), carbonyl Recommended for pregnant women with poor dietary
iron (1000 mg/g) calcium intake
Empty stomach and hour before meals and with vitamin C Unclear if supplementation may prevent pre-eclampsia
for better absorpition
IV iron (sucrose, carboxylmaltose) PROTEIN
Target Hgb at 110 and 0.24 RDA: 71 g/day
Serum ferritin Function: Growth and remodeling of fetus, placenta, uterus
CARBONYL IRON advantages: Slower absorption of iron, Notes: preferably supplied from animal sources such as
Greater bioavailability of iron, Least side effects meat, milk, eggs, cheese, poultry and fish
Computing for Iron deficiency
VITAMIN B12
Weight kg x (Target Hgb – actual Hgb) x 0.24 + 500 mg RDA: 2.6 ug/day
Inadequate intake: increased risk for neural tube defects
Determining the amount needed to correct anemia Notes:
Occurs naturally only in foods of animal origin
Target Hgb – Actual Hgb x 2.5 = # ampules (100 mg) Strict vegetarians may give birth to infants deficient in
Vitamin B12
Breastmilk of a vegetarian mother contains a little Vitamin
B12
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1. Tetanus, diphtheria (Td)

VITAMIN D 2. Tetatnus, diphtheria, acellular pertussis (Tdap)
RDA: 15 ug/day (600 IU/day) 3. Inactive influenza
Inadequate intake: disordered skeletal homeostasis, Vaccines contraindicated during pregnancy: (can be initiated
congenital rickets and fractures in the newborn postpartum or when lactating
Notes: Supplementation can be considered in women with 1. Herpes zoster vaccine
limited sun exposure 2. Live attenuated influenza vaccine
3. Measles, mumps, rubella (MMR)
IODINE 4. Varicella vaccine
RDA: 220 ug/day 5. Smallpox vaccine
Inadequate intake: neonatal cretinism
Notes: Vaccines that may be given during pregnancy in certain
Supplementation can be considered in areas where iodine populations
deficiency is common 1. Hepatitis A: Risk vs benefit
Dietary sources may be sufficient (iodized salt, bread 2. Hepatitis B: recommend in some circumstances
products) 3. Meningococcal (ACWY)
4. Meningococcal (B): Risk vs benefit
IMMUNIZATIONS during PREGNANCY 5. PCV13: no recommendation
6. PPSV23: inadequate data for specific recommendation
Passive immunization during Pregnancy
No known risk exists for the fetus from passive Immunization: Inactivated Influenza vaccine
immunization of pregnant women with immune globulin
preparations Influenza vaccine can be administered anytime during
pregnancy before and during the influenza season
Prenatal Screening Women who are or will be pregnant during the influenza
Pregnant women should be evaluated for immunity to vaccine
Rubella and varicella and be tested for the presence of Good safety record
HBsAg during every pregnancy
Women susceptible to rubella and varicella should be *Question: A 31 year old G2P1 (1001) woman is at 30 weeks
vaccinated immediately after delivery gestation and her obstetrician recommends that she receives the Tdap
A woman found to be HBsAg positive should be monitored vaccine. The physician explains that this is to help prevent neonatal
carefully to ensure that the infant receives HbIg and Hepatis pertussis. The patient states that she received the vaccine after
B vaccine series no later than 12 hours after birth and that delivery of her first baby. Which of the following is the best next
the infant completes the recommended Hepatitis B vaccine step?
series on schedule
Vaccines routinely recommended during every pregnancy
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A. If the patient received the Tdap vaccine within the last 5 a. Presence of positive hepatitis E antigen
years, no vaccine is needed b. Presence of positive antihepatitis B surface antibody
B. If the patient received the Tdap vaccine aat any time in her c. Presence of positive antihepatitis B core antibody
adult life, no vaccine is needed d. Presence of elevated liver function tests
C. The vaccine should not be administered until postpartum
D. The vaccine should be given regardless of whether she Immunization: Hepatitis vaccination
has previously been given
Hepatitis A vaccine
Immunization: Tetanus, Diphtheria, acellular Pertussis Should be given during pregnancy or during the postpartum
period, to pregnant women with certain conditions such as
Target population: Pregnant women with no previous tetanus chronic liver disease
immunization or unknown tetanus immunization history
Administer a dose of Tdap during each pregnancy Hepatitis B vaccine
irrespective of the patient’s prior history of receiving Tdap Should be given to pregnant women who are HbsAg (-) and:
To maximize antibody response and passive antibody 1. Whose husband/partner is HbsAg (+)
transfer to infant, optimal timing for Tdap administration is 2. Who live in a household with a member who is HbsAg
between 27-36 weeks age of gestation (+)
Pregnant women whose last Td/Tdap vaccination was more 3. Current or recent injection drug users
than ten years ago should receive Td booster in the second or 4. Recent sex partner < months duration
third trimester of pregnancy 5. Diagnosed with an STD
Dose regimen: the primary tetanus series consists of 3 Td
injections given IM Indications: universal immunization of all infants,
Dose: 0.5 mL adolescents and adults
Contraindications: Allergy to a vaccine component, not
Td/Tdap dose Schedule given to those highly febrile
1st
Second trimester Dose: 3 doses (0, 1-2, 4-6 months)
2nd 1 month after Td1 Pregnancy – may be given if at high risk or of without proof
3rd 6.12 months after Td2, given as of immunity
Tdap preferably 27-28 weeks
AOG Pneuomococcal
Indications: For all susceptible especially > 50 years old;
*Question: A 31 year old G1P0 woman at 15 weeks’ gestation is High risk adult <50 years old: Immunocompromised or
noted to have a positive Hepatitis B surface antigen. Which of the asplenic, sickle cell, HIV<CRF, leukemia, lymphoma,
following would most significantly increase the risk of vertical malignancy, Hodgkin’s lymphoma, solid organ transplant
transmission?
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Contraindications: Previous severe allergic reaction to the o If a vaccine dose has been administered during
vaccine including PCV13 to any diphtheria toxoid pregnancy, no intervention is needed
containing vaccine or any of its component
Dose: Single dose; Booster dose after 6-18 months COMMON CONCERNS DURING PREGNANCY
Pregnancy: given if needed
Exercise
Meningococcal Women who are used to aerobic exercise before pregnancy
Indications: Adults at risk for meningococcal disease may continue during pregnancy - shorter active labor, fewer
Contraindications: Severe allergic reaction to the vaccine cesearean deliveries, less meconium-stained, less fetal
component or following a prior sinlge dose of vaccine distress – reduced birth weight
Moderate or severe acute illness Restricted activities
Dose: 1 dose a. Hypertensive disorders
Pregnancy: given if needed b. Multiple gestation
c. Growth restricted fetus
Rabies d. Severe heart disease
Recommendations: because of the potential consequence of
inadequately managed rabies exposure, pregnancy is no
considered comtraindication to post exposure prophylaxis Employment
Physically demanding work: 20-60% increase in preterm
Measles, Mumps, Rubella birth, IUGR or HPN
Indications: 10-65 years old without evidence of immunity Working women: 5-fold increased risk of pre-eclampsia
Contraindications Occupational fatigue (no. of hrs. standing, intensity of
o Allergy to prior dose physical and mental demands, environmental stressors):
o Allergy to gelatin/neomycin increased risk of preterm membrane rupture
o Pregnancy
o Those on large doses of steroids Travel
Dose: 2 doses (0, 1 month) No harmful effect on pregnancy
Pregnancy: CONTRAINDICATED; May give immediately Safe to fly up to 36 weeks AOG
postpartum to those without evidence of immunity to Greatest risk with travel – absence of facilities when
Rubella (rubella IgG negative) complications arise

Human Papilloma Virus Bowel Habits

Pregnancy Consipation – common; prolonged transit time and
o If found to be pregnant, give remaining doses after uterine/fetal compression of the bowels
pregnancy Treatment: fluids, exercise, laxative
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Coitus atypical facial appearance, congenital heart defects and brain

Not harmful in healthy pregnant women anomalies
Avoided in cases of threatened abortion or preterm labor Absolutely prohibited during pregnancy

Smoking Caffeine
Harmful to pregnancy: low birthweight due to preterm No evidence of increased teratogenic or reproductive risks
delivery or fetal growth restriction, infant and fetal deaths, May increase the risk of spontaneous abortion (>5 cups/day)
abruption placenta No association of moderate consumption (<500 mg/day)
Pathophysiology: increased fetal carboxyhemoglobin levels, with low birthweight, IUGR, preterm delivery
reduced uteroplacental blood flow, fetal hypoxia American Dietetic Association (2002) recommends caffeine
intake <300 mg/day (three 5-oz cups)

Illicit Drugs
Opium derivatives, barbiturates and amphetamines
Fetal growth restriction, fetal distress, severe perinatal
complications

Medications
Given to the mother – cross the placenta

Nausea and Vomiting

First trimester
Etiology: hCG, estrogen
Treatment: small frequent feedings, avoid precipitating
factors
Mild symptoms respond to Vitamin B6 with Doxylamine
Hyperemesis gravidarum – severe vomiting that results to
dehydration, electrolyte and acid-base abnormalities

Back pain
Minor degrees follow excessive strain or significant bending,
lifting, or walking
Increase with progressing gestation and are more prevalent
Alcohol in obese women and those with a history of low back pain
Fetal alcohol syndrome – prenatal and postnatal growth Treatment: analgesics, heat, and rest, acetaminophen,
deficiency, mental retardation, behavioral distrubances, nonsteroidal anti-inflammatory drugs
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Mostly unexplained
Varicosities
Genetic predisposition Fatigue
Increase in femoral venous pressure Remits by the 4th month of gestation, progesterone effect
Exaggerated by prolonged standing, pregnancy, and
advancing age Headache
Worsened by advancing pregnancy, increasing weight and Common in early pregnancy
prolonged upright position Idiopathic
Treatment: Periodic rest with elevation of the legs, elastic Disappears by midpregnancy
stockings, surgery during pregnancy – not advised
Leukorrhea
Hemorrhoids Physiologic vs. Pathologic
Due to increased pressure in the rectal veins due to Increased vaginal discharge due to hyperestrogenemia
obstructed venous return by the large uterus and increased
constipation during pregnancy
Treatment: topical anesthetics, hot sitz bath, stool softeners

Heartburn
One of the most common complaints
Reflux of gastric contents into the lower esophagus
More common in pregnancy – upward displacement and
compression of the stomach by the uterus, with relaxation of
LES
Treatment: small frequent meals, avoid bending over or
lying flat, antacids

Pica
Cravings for strange foods/non foods
Ice (pagophagia), starch (amylophagia), clay (geophagia)
Iron deficiency in some cases

Ptyalism
Profuse salivation
Stimulated salivary glands by the ingestion of starch