OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ

5. Timing from quickening – movement perceived

th th th th
PRENATAL CARE from 16 to 18 week (multipara); 18 – 20 week
A planned program of medical evaluation and management, (primipara)
observation, and education of the pregnant woman directed - this method is more useful as a confirmation of
toward making pregnancy, labor, delivery, and the postpartum other parameters
recovery a safe and satisfying experience 6. Height of the Fundus
- Fundus above pubic symphysis: 12 wks
Terms - Fundus halfway between symphysis and
Nulligravida – woman who is not now and never has been umbilicus: 16 wks
pregnant - Fundus at level of umbilicus: 20 wks
Gravida – woman who is or has been pregnant irrespective of - Fundus just below the ensiform cartilage: 36 wks
the outcome  The fundus will remain here until onset
Primigravida of labor (esp in multipara)
Multigravida  Fundal height drops at time of lightening
Nullipara – woman who has never completed a pregnancy (in primipara)
beyond 20 wks gestation (beyond stage of viability or beyond - Fundic height in cm is equal to gestational age at
abortion) 16 – 32 weeks
Primipara – woman who has been delivered only once of a
fetus/fetuses, born alive or dead, with an estimated length of 7. Ultrasound
20 or more weeks - Useful in detecting common obstetrical problems
Multipara – has completed 2 or more pregnancies to viability that cluster in each trimester
st
Parturient - woman in labor - 1 term: spontaneous abortions
Puerpera – woman who had just given birth - 3rd term: pregnancy-induced hypertension

Gravidity: fetuses delivered + present pregnancy PRE-NATAL CARE

Parity: delivery of a baby of at least 20 weeks and above
OBSTETRICAL SCORE
1st digit – refers to number of pregnancies terminating at term
nd
2 digit – number of preterm pregnancies terminating before
37 wks
3rd digit – number of abortions (<20 wks)
th
4 digit – number of children currently alive
Important things to remember regarding obstetrical score:
Ex. G -6 P – 4 1–4–1–4
This indicates that the woman has been pregnant 6 times
(including current pregnancy) and has delivered a baby beyond
20 weeks 4 times.
a. One pregnancy terminated at term
b. 4 preterm pregnancies (twins are counted as 2
pregnancies)
c. 1 pregnancy ended in abortion
d. 4 children are currently alive
o Twins are always considered as 2 pregnancies except in
scoring parity
o If a pregnancy reached above 20 weeks, is greater than
500g, but died after 2 minutes = PRETERM
o ABORTION: any pregnancy terminating below 20 weeks
AOG
- If fetus is >20 wks but less than 500g = also
considered as abortion
o STILLBIRTH: count as preterm but subtract one from the
living (or the 4th digit)
DETERMINING PREGNANCY DURATION
1. Naegele’s rule – estimate expected date of
confinement by adding 7 days to the date of the 1st
day of the last normal menstrual period and counting
back 3 months, and add one year
2. Clinicians – use gestational age or menstrual age to
identify events in pregnancy
3. Embryologists – use ovulatory age or fertilization
age (2 wks younger than menstrual age)
4. Timing from ovulation – add 267 days to last
ovulation date to determine EDC
Goals:
o To define health status of mother and fetus
o To estimate the gestational age of the fetus
o To initiate a plan for continuing obstetrical care
o To define those at risk for complications to minimize that
risk
Components of Routine Prenatal Care
1. HISTORY
a. Menstrual History – AOG and EDC
AOG: important because sometimes emergency
deliveries are indicated. Knowing the AOG will
indicate whether doing so would be beneficial.
b. Obstetrical History – Gravidity, Parity, and OB
score
c. Medical and Surgical History – DM, Thyroid,
HPN, Asthma, Seizure disorder
If patient is positive for any of the medical and
surgical history, patient is considered as a high-
risk px.
Other pertinent history:
- Includes complete past and family history & a good
obstetric resume
- Obstetric resume should emphasize the ff:
o Menstrual history
o Evidence of infertility
o Careful inquiry into previous pregnancy
o Time in gestation when labor occurred
o Duration, type of delivery and complications
o Weight and sex of baby
o Woman’s reaction to current pregnancy
o Symptoms during pregnancy
o Dietary history – helpful in estimating adequacy of
nutritional intake
o Post-partum course
o Infant’s well-being
OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ
1. Engagement – occurs if both hands converge
PHYSICAL EXAM from each other since presenting part has
entered the pelvis
 If head is not engaged, the cephalic
A. MATERNAL EVALUATION
prominence is palpated
- Do a complete PE from head to foot  Considered negative if fetal head is
- Obtain the ff: engaged
o BP – actual and extent of change
o Maternal weight – actual and extent of 2. Cephalic prominence
change  If on the same side as fetal small parts =
o Fundic height – distance over abdominal wall head is flexed and vertex is the
from the top of the symphysis pubis to the presenting part
 If on same side as fetal back = head is
top of the fundus
extended and presenting part is the face
 At 20-34 wks AOG is equal to the fundic
height in cm)
 Therefore if baby is 28 wks AOG and is B. VAGINAL EXAMINATION
st
only 25cm fundic height, consider SGA - Vaginal exam during 1 visit (subsequent only if
or consider wrong LMP date given indicated)
o Fetal heart tones o However at term: done weekly to determine
 110-160bpm consistency, effacement, and dilatation of
 First heard in most women bet 16- the cervix; presenting part, station of PP;
19 weeks with a standard clinical mensuration of pelvis
nonamplified stethoscope o C/I if with hx of vaginal bleeding
 Doppler ultrasound: 10 weeks - Diagnosis of presentation may be obtained accurately
 Ultrasound: 5 weeks during labor when cervix is dilated
o Leopold’s maneuver - Presentations identified as follows:
o Vertex – sutures and fontanels
Leopold’s Maneuver o Face – portions of fetal face
o Breech – sacrum & ischial tuberosities
- Provides information on
o Shoulder – acromion
o Position
o Presenting part
C. PELVIC EXAMINATION
o Extent to w/c presenting part has descended
- Insert speculum into vagina and is able to visualize
into pelvis
abnormalities in the vagina and the cervix
- Performed during latter months of pregnancy (3rd
- Usually done during initial prenatal care
trimester) and during intervals between uterine
- Do systematically: Inspection -> Palpation
contractions of labor o Inspect vulva for lesions
- First 3 maneuvers are done with the doctor on the right side
of the bed and facing the upper part of the patient
o Observe whether perineum is anatomically
-
th
4 maneuver done facing the lower part of the mother intact or lacerated
o Vaginal discharge/bleeding
1st maneuver: Fundal Grip o Polyps
o Determines what fetal part occupies - Screening for cervico-vaginal infections and
fundus cervical cancer is now considered routine in
o Sensation of large nodular body = buttocks or prenatal care
lower extremities at fundus in cephalic o Obtain cervical scrape
presentation o Inspect cervix for Chadwick’s sign and local
o Hard, freely movable, ballotable part – fetal head lesions (ex. Nabothian cysts – occlusion cyst of
at fundus in breech position endocervical glands bulging beneath exocervical
o Use fingertips of both hands mucosa)

2nd maneuver: Umbilical Grip ROUTINE ANTE-PARTAL TESTS

o Determine location of fetal back - Initial visit should include these (those highlighted
o Palms are placed on each side of mother’s were emphasized as important by Doc)
abdomen and gentle but deep pressure is exerted
o Hard resistant convex structure – fetal back Tests Notes
o Numerous nodulations – fetal small parts
CBC – depends on what To determine hematologic
AOG/trimester status
3rd maneuver: Pawlic/Pawlik’s Grip To r/o anemia
o Determine what is occupying the pelvic 1st trimester: 11g as normal
inlet nd
2 : 10.5g as normal
o Use of thumb and fingers of one hand
o Movable, round and hard body – fetal head not
3rd: 11g
engaged
o Considered negative if lower pole of the fetus is Anything below these values
fixed in the pelvis or engaged = ABNORMAL
Urinalysis, urine culture & To evaluate for UTI and
4th maneuver: Pelvic Grip sensitivity renal function
o Determine whether head is extended or To check for asymptomatic
flexed bacteremia
This will determine 2 things: Blood group, Rh To determine blood type, Rh
status and risk of
OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ
isoimmunization
Serologic test for syphilis To detect previous/ current DANGER SIGNALS – if they experience any of this, they have
(RPR, VDRL) infection to consult IMMEDIATELY, regardless of the time.
If positive, do specific 1. Vaginal bleeding
treponemal tests (FTA-ABS 2. Persistent vomiting
or MHA-TP) 3. Chills and fever
Hep B surface Ag 4. Sudden escape of fluid per vagina (rupture of
rd
Do at 3 trimester for cost- membranes)
effectiveness 5. Swelling of face
If positive: 6. Blurring of vision
- Use double glove 7. Persistent headache
delivery
- Give baby NUTRITION DURING PREGNANCY
immunoglobulin - Normally, px can be expected to lose 2lbs or more, 2-
and Hep B vaccine 3 wks before onset of labor
immediately after o Loss in body water = prelabor diuresis
delivery - Amount of weight a woman needs to gain during
Rubella titer Approx 85% of mothers have pregnancy is based on her pre-pregnancy BMI
evidence of prior infection
If px is seronegative, special Recommended Ranges of Weight Gain
precautions needed
Vaccination is then required
Category BMI Kg Lbs
postpartum
Low <19.8 12.5-18 28-40
Cervical cytology (Pap To screen for cervical
Normal 19.8-26 11.5-16 25-35
Smear) dysplasia/cancer
High 26-29 7-11.5 15-25
Indication: hx of sexual Obese >29 >/=7 >/=15
contact of at least 3 years
(because you want to detect
the pre-cancer stage) Recommended Dietary Allowances (RDA)
- Repeat every year - Level of intakes of energy and essential nutrients
If initial results were normal, most need not be repeated considered adequate to maintain health and provide
- Repeat CBC at 28-32 weeks reasonable levels of reserves in body tissues of
nearly all healthy persons in the population
Subsequent Assessments - Recommendations were given for energy, protein, vit
1. Cervical culture for N gonorrhoeae A and C, thiamine, riboflavin, niacin, Ca, iron
2. Hgb electrophoresis - Recommendations for folate – due to high prevalence
3. HIV titer by ELISA Western blot if HIV + by ELISA of nutritional anemia in pregnant women
4. Glucose screening – for diabetes; all pregnant
women should be tested Calories
a. OGTT (oral glucose tolerance test) – - Add 300kcal/day during 2nd and 3rd trimester
o Needed due to added maternal tissues and growth
performed during 1st trimester if px is at high risk
of fetus and placenta
for diabetes (+ family hx, age >35y/o, previous o If inadequate intake, protein is metabolized for
birth of large baby, (+) sugar in urine) energy rather than spared for its vital role in
b. GCT (glucose challenge test) – performed if px growth and devt
is not a high risk px; done at 24-28 weeks AOG Protein
- Threshold value: 130mg/dl – if glucose is - For tissue synthesis
st nd rd
greater than this, do OGTT - 2.9gm (1 trimester) and 15gm/day (2 & 3
5. MSAFP at 15-18 weeks (usually with hCG, estriol) trimester)
- Average of 9gm/day throughout pregnancy
FREQUENCY OF VISITS - Protein deficiency may cause:
- If patient is normal, prenatal exams scheduled at o hypochromic anemia
intervals of: o water imbalance and nutritional edema
o 4 wks until 28 wks o Impairment in Ca absorption
o Then every 2 wks until 36 wks and - Milk, meats, eggs: best source of CHON
o Weekly thereafter
Carbohydrates
- If px belongs to high risk group, visits are more often - Main source of energy during pregnancy
(1-2 week intervals) -
st
1 trimester: daily intake of 150gm
- Minimum requirement: at least 4 visits - End of pregnancy: 225gm
- Also lessens nausea and vomiting during early pregnancy
FETAL EVALUATION Fats
- Fetal HR - Most concentrated sources of energy
- Size of fetus, actual rate and change (use fundic - Provide 2x more energy than an equivalent weight of CHO
height) or CHON
- Serve as carriers of fat-soluble vitamins and essential fatty
- Amount of amniotic fluid acids
- Presenting part and station (late in pregnancy) - Vital structural components of many body tissues
- Fetal activity - Minimum daily intake: 15-25gms
OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ
o Relieves backache, improves physical and mental
MINERALS well-being
3. Relaxation technique – breathing and concentration
exercises
Calcium
4. Pelvic toning – Kegel exercises
- Main structural element of bones and teeth
o Tone muscles in vaginal and perineal area
- 25-30gm of Ca is deposited in fetus at the rate of 120-
th
150mg/day during 20-30 wk
o
th
260-300mg/d: 38 wk until term **No single exercise can meet the needs of all pregnant
- Obligatory maternal Ca excretion: 100mg/d women
- Required absorption = 350-380mg/day
- Recommended additional Ca intake for pregnant Optimal exercise for pregnant women: brisk walking for 30
women: 400mg/day or total of 900mg minutes to 1 hour

Iron Absolute contraindications for exercise: heart diseases,

- 27mg/day IUGR, severe hypertensive diseases, ruptured membranes,
- If patient is large, has multiple pregnancy, begins uterine bleeding, at risk for premature labor
supplementation late in pregnancy, or anemic = 60-
100mg/day Relative contraindications: essential HPN, anemia, thyroid
- 300mg transferred to fetus, 500mg incorporated into diseases, diabetes, breech presentation in last trimester,
maternal Hgb mass obesity, extreme underweight
- During first 4 months: iron is needed to replace basal
losses only
o Deposition of iron in fetal tissues is minimal BOWEL HABITS
o Not necessary to provide iron - Constipation is a common complaint during
supplements at this time pregnancy
o Avoids risk of aggravating nausea and o Due to steroid induced suppression of bowel
vomiting motility and compression of intestines by enlarging
- Increased need for iron during 2nd and 3rd trimesters uterus
when deposition in fetal and placental tissues occurs - Drink water liberally and have generous amounts of
at a rapid rate fruit and veggies
- Mild laxatives (ex. milk of magnesia) may also be
Iodine used
- 0.15 – 0.30mg/day - Use of enemas or strong cathartics must be avoided
- essential because it is an integral component of the
thyroid hormone COITUS
- maternal iodine deficiency may lead to either neuro - In healthy pregnant women, coitus is not harmful
defects of baby, endemic cretinism - Coitus should be avoided if there is a risk for abortion
or preterm labor
VITAMINS - Orgasm after 32 wks = predispose to premature labor
o Prostaglandins in semen may also induce
Folate preterm labor
- Deficiency leads to megaloblastic anemia - Patients at risk: hx of premature rupture of
- Lowering of folate stores during pregnancy is due to high membranes, preterm labor, those who experience
folate requirements strong uterine contractions after coitus, hypertension
- Minimum of 400 µg/day is recommended for pregnant
women EMPLOYMENT
o Prevent neural tube defects - No need to stop working as long as work is not too
- Found in deep-green colored leafy vegetables, liver strenuous
- Be sure to get adequate rest
Vitamine B1/Thiamine
- Aneuria or antineuritic factor TRAVEL
o Prevents sx involving nerves - Disadvantages associated with travel: changes in
Niacin dietary and sleep pattern, prolonged periods of sitting
- Deficiency leads to pellagra: bilateral dermatitis, glossitis,
(increased venous stasis)
diarrhea, irritability, mental confusion, delirium, psychotic sx
- Ask patient to walk once in a while
BREASTFEEDING
SMOKING
Benefits:
- Low birthweight infants, premature labor, abruptio
o Excellent nutrition for newborn
o Immunologic protection placenta, bleeding, premature rupture of membranes
- Effects of smoking
o Rapid uterine involution
o CO inactivates fetal and maternal Hgb
o Maternal-child bonding
o Natural child spacing o Vasoconstrictor effect of nicotine = induce
placental abrution
o Reduced appetite = reduced caloric intake
EXERCISE
4 types of exercise: o Decreased maternal plasma volume
1. Aerobics – rhythmic, repetitive activities, builds endurance o Unexplained predisposition to ill effects of
o Lessens fatigue and promotes better night sleep nicotine that persists even after quitting
2. Calisthenics – rhythmic, light gymnastic movements that smoking
improve posture
OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ
ALCOHOL - Tx: AlOH, Mg trisilicate, MgOH
- Heavy drinking (5 or 6 drinks of wine, beer or distilled
spirits a day) during pregnancy can cause fetal Pica
alcohol syndrome - Bizarre craving for strange foods and materials that
o Undersized infants are inedible or non-nutritious
o Mentally deficient o Laundry starch, clay, dirt
o Multiple deformities affecting head, face, - Starch ingestion: amylophagia
limbs, heart, CNS - Clay: geophagia
- Even moderate consumption is related to a variety of - Usually practiced more by women in lower
problems socioeconomic group

CAFFEINE
- No harm in humans from moderate use (no more than
300mg of caffeine per day) Ptyalism
- Reasons for quitting caffeinated drinks during pregnancy: - Profuse salivation due to stimulation of salivary
o Diuretic effect may draw fluid and Ca from the glands by ingestion of starch
body Fatigue
o Coffee and tea are filling but not nutritious and can
Headache
spoil appetite
- Frequent complaint in early pregnancy
o Cause mood swings
- Should disappear by mid-pregnancy or else pregnancy
o Interfere w/ adequate rest
complications like pregnancy-induced hypertension must be
o Interfere w/ iron absorption
considered
o Baby may develop diabetes
Round ligament pain
- Sharp groin pain very common
COMMON COMPLAINTS DURING PREGNANCY
Leukorrhea
Nausea and Vomiting
- Excessive vaginal discharge w/c usually has no
- Begin as early as 4th week and continues until 12th
pathologic cause
week
o Due to increased mucus formation by cervical
- Due to increased hCG levels glands in response to hyperestrogenemia
- Deportation theory of Viet: allergic reaction to the possible o If accompanied by pruritus and burning
entrance into maternal circulation of fragments of chorionic sensations, consider infections
villi
- Hyperemesis gravidarum: when nausea and vomiting
become so severe that they interfere with the general well- a. Trichomonas vaginalis
being of the pregnant woman o Foamy yellow vaginal discharge
o Vaginal epithelium and cervix = contains
Back pain small punctuate reddened areas (strawberry
- Often referred to the region of buttocks and down to cervix)
the thighs o Amoeboid
- Muscle spasm pain in lower extremities – responds o Tx: Metronidazole – give orally or
well to analgesics (class B), heat and rest intravaginally after 1st trimester

Varicosities b. Candidiasis or moniliasis

- Increased venous pressure in lower ex may o Cheesy white or curd like discharge w/c
aggravate varicosities of lower ex and vulva adheres to vaginal mucosa
- Tx: rest with elevation of feet, use of elastic support o Accompanied by severe pruritus, burning
stockings, bed rest sensation, redness, excoriation of the skin of
vulva and perineum
Hemorrhoids o Pseudohyphae
- Related to tendency to constipate during pregnancy o Tx: Miconazole, clotrimazole, nystatin –
- Also due to increased pressure in rectal vein caused effective during pregnancy, intravaginally or
by obstruction of venous return by the large uterus topically
- Relieved by topically applied analgesics, warm soaks,
agents that soften the stool c. Gardnerella vaginallis (bacterial vaginosis)
- Surgical removal C/I in pregnancy due to danger of pelvic o Usually attributed to non-specific vaginalis
infection o 3 criteria that must be satisfied before a dx of
- Hemorrhoidectomy is usually postponed until after child GV may be given:
bearing age/period because subsequent pregnancies may 1. Presence of homogenous grayish
produce further hemorrhoids white discharge
2. pH more than 4.5
Heartburn 3. rotten fish odor after addition of 10%
- Burning sensation in the epigastrium accompanied by KOH (positive amine test)
feeling of fullness 4. clue cells in direct microscopic
- Caused by reflux of acid gastric contents into lower preparation
esophagus o Tx: Metronidazole, orally or as suppositories
o Due to upward displacement of stomach by uterus
intravaginally
and progesterone-mediated relaxation of
esophageal sphincter o Alternative: Clindamycin
- Divide eating to 6 small meals to prevent occurrence
OB 1 – PRENATAL CARE, HIGH-RISK PREGNANCY, DRUGS LALALA-LALAϋ
IDENTIFICATION OF HIGH-RISK PREGNANCIES channel blockers)

A. Medical History
Asthma, cardiac disease, DM, drug and alcohol use, D Positive evidence of risk.
epilepsy (on medication), family hx of genetic Potential benefits may
problems (Down Syndrome, PKU), outweigh the potential risk.
hemoglobinopathy, hypertension, prior DVT or
pulmonary embolism, psychiatric illness, COPD, Mothers with seizure
chronic renal disease disorders will need an anti-
seizure drug for
st
B. Obstetrical History maintenance even in 1
Age >35 y/o, caesarean delivery, incompetent cervix, trimester
prior fetal structural/chromosomal abnormality, prior
neonatal death, prior fetal death, prior preterm Ex. Systemic steroids,
delivery or preterm ruptured membranes, prior LBW azathioprine, phenytoin,
(<2500g), uterine leiomyomas or malformation carbamazepine, valproic
acid, lithium, all
C. Initial Lab Tests anticonvulsant drugs
HIV X Contraindicated in
Rh positive pregnancy
Initial examination condylomata
Ex. rubella vaccine

DRUGS, MEDICATIONS, and IMMUNIZATION

IMMUNIZATION safe in pregnancy
Timing of Exposure to Teratogen 1. DPT(tetanus)
1. Preimplantation – all or none 2. Hepatitis B
2. Embryonic period 3. Influenza
o 2-8wks AOG *Rabies may be given if indicated.
o Period of organogenesis
o End result: structural deformities
o Avoid class C, D and X drugs! SOURCES:
3. Fetal period APMC
o 9 wks to term Williams
o Maturation and functional development of
organs
o Still vulnerable to insult
o End result: structurally normal but with
defects in function and minor anomalies

DRUG FDA CATEGORIES

A - controlled studies in
humans show no risk
st
- safe even in 1 trimester
- ex. vitamins,
levothyroxine, potassium
supplementation

B No evidence of risk in
humans

Ex. antibiotics (Amoxicillin,

Cephalosporins, Penicillins),
Macrolides, Paracetamol,
- can be given in 1st
trimester
C Risk cannot be ruled out.
Human studies are lacking,
either positive for fetal risk or
lacking. Potential benefits
may justify the risk.

Ex. Steroids for asthma,

zidovudine and lamivudine
for HIV, anti-hypertensives
(Methyldopa, Hydralazine),
Beta blockers and Ca-