Presumptive Signs of Pregnancy o 16-22 weeks: abdomen

1st trimester o 20 weeks: umbilicus

 6 weeks:  Leopold’s maneuver: 28-30 weeks
o Chadwick’s sign (blue-violet vagina)  Confirming fetal viability and location via UTZ
o Beading of cervical mucus o <12 weeks: transvaginal (CRL)
o Increased temperature o >12 weeks: transabdominal
 Hyperemesis gravidarum: 6-18 weeks  Antepartum surveillance: 24-28 weeks, every 2
o Peak: 9-10 weeks weeks (non-high risk), every week (high risk)
o Plateau: 16 weeks o Fetal biometry (can start at 13 weeks)
 Changes in breast: 6-8 weeks  No growth: IUGR
 Hyperemesis gravidarum: 12-14 weeks  If growing: constitutionally small
 Quickening: 16-20 weeks  No surgery after 1st trimester
o 16-18 weeks: multigravida (baby not formed)
o 18-20 weeks: primigravid o Congenital anomaly scan
nd
2 trimester o Biophysical profile (28 wk: start of FHT
 Disturbance in urination: variability, detect fetal hypoxia-
2nd–3rd month while uterus is still a pelvic organ hypoxemia)
↓ Embryogenesis ↑ Hypoxia (1-3-1-2-1)
Probable Signs of Pregnancy  Tone: ≥1 active extension-flexion
1st trimester  Movement: ≥3 body/limb
 Goodell’s sign (cervix): 4 weeks movements in 30 mins
 Abdominal enlargement: 6 weeks  Breathing: ≥1 breathing of ≥30 s
 Hegar’s sign (uterine isthmus): 6-8 weeks within 30 mins
2nd trimester  NST: FHR ≥2 accelerations of ≥15
 Ballottement of amniotic sac: 21 weeks bpm in >15 sec w/ mvt in 20 mins
 Braxton-Hicks contractions: 28 weeks  AFV: ≥1 pockets of fluid ≥2 cm
 (+) Pregnancy test: 8-9 days post-ovulation o Doppler velocimetry
o Peak: 60-70 days  Uterine artery notching
o Nadir: 14-16 weeks  Normal: <16 weeks
 Vasoconstriction:
Positive Signs of Pregnancy >16 weeks (increased risk
 Fetal Heart Tone for preeclampsia)
o 6-8 weeks: transvaginal ultrasound  Umbilical artery (↓ inc severity)
o 10-12 weeks: doppler ultrasound  Decreased EDV
o 18 weeks: stethoscope  Absent EDV
 Perception of fetal movement: 20 weeks  Reversed EDV
 UTZ recognition of embryo/fetus  Middle cerebral artery
o Gestational sac: 4-5 weeks  Decreased resistance in
o Yolk sac: 5 weeks compensatory states
o Fetal heart beat: 6-8 weeks (brain sparing effect)
o CRL: up to 12 weeks
 Intrapartum fetal monitoring: 26-28 weeks
o Normal trace: every 2 hours
Current Pregnancy
o Abnormal & high risk: continuous
 1st trimester: 14 weeks
o Spontaneous abortions o Normal baseline FHR: 110-160 bpm in 10
 nd
2 trimester: 28 weeks min segment
 3rd trimester: 42 weeks  Tachycardia: >160 bpm
o Hypertensive disorders  Bradycardia: <110 bpm
o Absent variability: straight line
Physical Exam o Minimal variability: </=5 bpm
 Fundic height: 16-32 weeks o Moderate variability: 6-25 bpm
o 12 weeks: symphysis pubis o Marked variability: >25 bpm
  saltatory pattern
o Acceleration
 <32 wks: peak of ≥10 bpm
 (2 boxes)
 in 10 secs to <2 mins
 ≥32 wks: peak of ≥15 bpm
 (3 boxes)
 in 15 secs to <2 mins
 Prolonged:
 ≥15 bpm
 >2 mins but <10 mins
 Baseline changes: >10 mins
o Early deceleration
 Head compression
 Symmetrical, ≥30 secs
o Late deceleration
 Uteroplacental insufficiency
 Delayed mirror image, ≥30 secs
o Variable deceleration
 Cord compression
 Abrupt decrease, ≤30 secs
Antepartum Laboratory Tests
 CBC (Hemoglobin cut-off)
o 1st trimester: 11.5 g/dL
o 2nd trimester: 10.5 g/dL
o 3rd trimester: 11.5 g/dL
 Anemia
o Mild: 9.5-10.5 g/dL
o Moderate: 8-9.4 g/dL
o Severe: 6.9-7.9 g/dL
 HBsAg and syphilis (VDRL/RPR): 3rd trimester
Maternal Nutrition
 Weight gain
o Underweight: 1 lb/wk
o Normal weight: 1lb/wk
o Overweight: 0.6 lb/wk
o Obese: 0.5 lb/wk
 Caloric intake
o 1st trimester: 0 kcal/day
o 2nd trimester: 340 kcal/day
o 3rd trimester: 452 kcal/day
 Vitamins and Minerals
o Iron: 27 mg elemental iron
o Calcium: 1000 mg/day
o Vit D: 200-600 IU
o Zinc: 12 mg/day
o Iodine: 220 mcg/day
o Folic acid
 400 mcg/day
 4 mg/day (hx of NTD)
Follow-up
 <28 weeks: 4 week interval
 28-36 weeks: every 2 weeks
 >36 weeks: weekly
 Air travel: up to 36 weeks
 Caffeine: <300 mg/day (<3 cups)
Pre-term Labor
 Tocolytic – give up to 48 hours (to allow completion of
corticosteroids)
 Nifedipine: 30 mg loading dose, then 10-20 mg
orally q4-6 hours until contraction stops
o Not controlled: add 20 mg (max 120 mg)
o If controlled: maintain 20-40 mg twice
daily
 Micronized progesterone as maintenance: given
until 36 weeks nightly, 200 mg vaginal capsules
 Isoxsuprine: 10 mg oral or 20 mg 4 ampoules in
500 mL of D5W, give in microdrops, 20-25
drops/min
 Corticosteroids – 24-34 weeks for those at risk of
preterm delivery within 7 days
 Betamethasone: 7 mg/mL ampule, 2 doses IM, 24
hours apart
 Dexamethasone: 6 mg, 4 doses IM, every 12 hours
 Rescue dose: 2 weeks after initial dose if still <34
weeks AOG
 MgSO4 – single dose only (not given if >34 weeks)
 Loading dose 4-6 g in 10-20% solution over 30
mins
 Maintenance infusion of 1 g/hr
 (4-1): 4g slow IV push via infusion pump then
1g/hr
Markers of pre-term labor:
 Cervical length: <2.5 cm
 Fetal fibronectin: >50 ng/mL by ELISA
Preeclampsia
 24 hr urine protein: >300 mg
 Protein creatinine ratio: >3.0
 Serum creatinine: >0.9 mg/dL
Diabetes
 FBS at first prenatal visit
o Normal: <92 mg/dL
o GDM: ≥92 but <126 mg/dL
o Overt DM: ≥126 mg/dL
 75-gram OGTT (already w/ FBS)
o Low risk and FBS <92:
 Request OGTT at 24-28 weeks
 If normal: repeat at 32 weeks
o High risk and FBS >92:
 Request OGTT immediately
  If normal: repeat at 24-28 weeks
then at 32 weeks
o Abnormal values (If present  GDM)
 FBS ≥ 92 mg/dL
 1 hr ≥ 180 mg/dL
 2 hr ≥ 153 mg/dL
 Overt Diabetes
o Fasting plasma glucose: 126 mg/dL
o Random plasma glucose: 200 mg/dL
o HbA1c: 6.5%
o 2-hour postprandial glucose: 200 mg/dL
 Preconceptional Care (Optimal levels)
o Folate supplement: 5 mg/day 3 months
preconception and during early pregnancy
o Preprandial glucose: <95 mg/dL
o 1-hour postprandial glucose: <140 mg/dL
o 2-hour postprandial glucose: <120 mg/dL
o Glycosylated hemoglobin (HbA1c): <6.5%
 Antepartum Management
o Daily caloric intake: 30-35 kcal/kg/day
o Caloric composition
 Complex carbohydrates – 40%
 Proteins – 20%
 Fats – 40%
o Given as 3 meals and 3 snacks daily
 To stabilize insulin release
o 30 mins moderate exercise
 Self-Monitoring of Blood Glucose (SMBG)
o GDM on diet: SMBG 4x/day
 FBS 1x/day
 Postprandial 3x/day
o Women on pharmacologic therapy
 SMBG 4-6x/day
 Include preprandial values
o Fasting: <95 mg/dL
o 1-hour postprandial glucose: <140 mg/dL
o 2-hour postprandial glucose: <120 mg/dL
 Insulin dosage
o 1st trimester: 0.7-0.8 U/kg/day
o 2nd trimester: 0.8-1.0 U/kg/day
o 3rd trimester: 0.9-1.2 U/kg/day
o 2/3 of daily dose – before breakfast
o 1/3 of daily dose – before dinner

OB Skills
 Amniotomy done at 4 cm (active phase)
 NSD transfer to OR:
o Primigravid: 8-9 cm
o Multigravid: 5-6 cm
o Episiotomy and episiorrhaphy: done at
station +5: crowning