PRENA

TAL
CARE
Princess Palabrica
USTH OB-GYN
 Table of Contents

01 02 03
Diagnosis of Initial Subsequent
Pregnancy Prenatal Prenatal Visits
Evaluation

04 05
Nutritional Common
Counseling Concerns
01.
Diagnosis of
Pregnancy ?
 Diagnosis of Pregnancy

Neptune Saturn Mercury

Saturn is the ringed one. It’s a gas
Neptune is the fourth-largest planet
giant, composed mostly of
by diameter in our Solar System
hydrogen and helium
Mercury is the closest planet to the
Sun and the smallest one in our
Solar System
 Initial
02. Prenatal
Evaluation
Initial Prenatal Evaluation
Major goals

01 Define the health status of the

mother and fetus

02 Estimate the gestational age

03 Initiate a plan for continued

obstetrical care
Initial Prenatal Evaluation
● Prenatal record
● Clinical evaluation
● Laboratory tests
● Pregnancy risk assessment
 Typical Components of Routine Prenatal Care
      Weeks
  First Visit 15–20 24–28 29–41
HISTORY
  Complete *      
  Updated     * * *
PHYSICAL EXAMINATION
  Complete *      
  Blood pressure * * * *
Maternal weight * * * *
Pelvic / Cervical exam *      
  Fundic height * * * *
  Fetal Heart rate / fetal position * * * *
 Typical Components of Routine Prenatal Care
      Weeks
  First Visit 15–20 24–28 29–41
LABORATORY TESTS
Hematocrit or Hemoglobin *   *
Blood type & Rh factor *    
  Antibody screen *   A
  Pap smear screening *    
Glucose tolerance test     *
  Fetal aneuploidy screening Ba and/or B  
  Neural-tube defect screening   B  
Cystic fibrosis screening B or B  

A – Perform at 28 wks, if indicated

B – Test should be offered
 Typical Components of Routine Prenatal Care
      Weeks
  First Visit 15–20 24–28 29–41
LABORATORY TESTS
  Urine protein assessment *      
  Urine culture *      
  Rubella serology *      
  Syphilis serology *     C
  Gonococcal culture D     D
  Chlamydial screening *     C
  Hepatitis B serology *      
  HIV serology B      D
  Group B streptococcus culture       E

B – Test should be offered D - High-risk women should be screened at the first prenatal visit and again in
C – High-risk women should be retested at the the third trimester.
beginning of the third trimester. E - Rectovaginal culture should be obtained between 35 and 37 weeks.
 Prenatal Record: Definitions
A woman who is currently not pregnant nor has ever been
NULLIGRAVIDA
pregnant
A woman who currently is pregnant or has been in the past,
irrespective of the pregnancy outcome
GRAVIDA
Establishment of first pregnancy: primigravida
Successive pregnancies: multigravida
A woman who has never completed a pregnancy beyond 20
NULLIPARA
weeks’ age of gestation
A woman who has been delivered only once of a fetus or fetuses
PRIMIPARA born alive or dead with an estimated length of gestation of 20
or more weeks
Completed 2 or more pregnancies to 20 weeks gestation or
MULTIPARA more. Parity is determined by the number of pregnancies reaching
20 weeks and not by the number of fetuses delivered
 (3003)
B.
G4P2(2022)
C. G1P1
(2002)
D. G1P0
(0010)
E. G2P1
(1011)
Prenatal Record: Normal Pregnancy
Duration
MEAN DURATION FROM LAST
NORMAL MENSTRUAL PERIOD 280 days
(GESTATIONAL AGE OR 40 weeks
MENSTRUAL AGE)
EXPECTED DATE OF DELIVERY LMP + 7 days then
(NAEGELE’s RULE) count back 3 months
Prenatal Record: Trimesters
3 TRIMESTERS
1st Until completion of 14
weeks
2nd Until completion of 28
weeks
3rd 29th through 42nd weeks of
pregnancy
Prenatal Record: Previous and Current
Health Status
PAST MEDICAL Any medical or surgical disorders
HISTORY
OBSTETRICAL Many obstetrical complications tend to recur in
HISTORY subsequent pregnancies
MENSTRUAL HISTORY Ovulatory cycles important for accurate dating of
pregnancy by history and PE
CONTRACEPTIVE Ovulation may not have resumed 2 weeks after onset
HISTORY of the last withdrawal bleeding
Some methods of contraception favor ectopic
implantation following method failure
Prenatal Record: Previous and Current
Health Status
PYSCHOSOCIAL Any barriers to care, communication obstacles,
SCREENING nutritional status, unstable housing, desire for
pregnancy, safety concerns, depression, stress, use
of substances
At least once per trimester
CIGARETTE SMOKING Greater rates of miscarriage, stillbirth, low birth
weight, preterm delivery
Twofold risk of placenta previa, placental abruption,
and premature membrane rupture
5 A’s of smoking cessation: ASK, ADVICE, ASSESS,
ASSIST, ARRANGE
Prenatal Record: Previous and Current
Health Status
ETHANOL Potent teratogen and causes FETAL
ALCOHOL SYNDROME
• Growth restriction
• Facial abnormalities
• CNS dysfunction

ILLICIT DRUG Fetal growth restriction

USE Low birthweight
(opiates, cocaine, Drug withdrawal soon after birth
amphetamines, Low health-seeking behavior of women
barbiturates and who use such drugs associated with
marijuana)
preterm and LBW newborns
Prenatal Record: Previous and Current
Health Status
INTIMATE PARTNER Pattern of assaultive and coercive behavior
VIOLENCE Includes : physical injury, psychological abuse
SCREENING sexual assault, progressive isolation
stalking, deprivation,
intimidation, reproductive coercion

Preterm delivery
Fetal growth restriction
Perinatal death

Frequency of screening:
First prenatal visit
At least once per trimester
Postpartum visit
renatal Record: Clinical Evaluation
PELVIC EXAMINATION
SPECULUM EXAM CERVIX: bluish-red passive hyperemia
Nabothian cysts
Not normally dilated except at the external os
Pap smear is obtained
Specimen for N. gonorrhea and Chlamydia trachomatis are
obtained when indicated
BIMANUAL Consistency, length, and dilatation of the cervix
EXAMINATION Uterine and adnexal size
Bony architecture of the pelvis
Fetal presentation later in pregnancy
Anomalies/lesions of the vagina and perineum
Vulvar inspection
DIGITAL RECTAL Performed as reuired for rectal pain, bleeding or mass
EXAMINATION
renatal Record: Clinical Evaluation
Gestational Age
Assessment
 Precise knowledge of
gestational age is one of
the most important
aspects of prenatal care
 First trimester ultrasound
is best correlated with
menstrual history
 Can also be estimated by
Prenatal Record: Laboratory Tests
      Weeks
  First Visit 15–20 24–28 29–41
LABORATORY TESTS
Hematocrit or Hemoglobin *   *
Blood type & Rh factor *    
  Antibody screen *   A
  Pap smear screening *    
Glucose tolerance test     *
  Fetal aneuploidy screening Ba and/or B  
  Neural-tube defect screening   B  
Cystic fibrosis screening B or B  

A – Perform at 28 wks, if indicated

B – Test should be offered
 Diabetes in Pregnancy:
Risk Factors
1 > 25 yo
2 < 25 and obese (BMI > 27 kg/m2)
3 Pre pregnant weight (BMI > 30 kg/m2)
4 Family history of DM in the first degree relative
5 Previous delivery of a baby > 9 lbs (4.1 kg)
6 Personal history of abnormal glucose intolerance
7 Previous unexplained perinatal loss or birth of a malformed child
8 Glycosuria at first prenatal care
9 PCOS
10 Current use of steriods
11 Essential hypertension or PIH
DIABETES MELLITUS IN PREGNANCY, POGS CPG, 2011
Prenatal Record: Laboratory Tests
      Weeks
  First Visit 15–20 24–28 29–41
LABORATORY TESTS
Hematocrit or Hemoglobin *   *
Blood type & Rh factor *    
  Antibody screen *   A
  Pap smear screening *    
Glucose tolerance test     *
  Fetal aneuploidy screening Ba and/or B  
  Neural-tube defect screening   B  
Cystic fibrosis screening B or B  

A – Perform at 28 wks, if indicated

B – Test should be offered
Prenatal Record: Laboratory Tests
      Weeks
  First Visit 15–20 24–28 29–41
LABORATORY TESTS
  Urine protein assessment *      
  Urine culture *      
  Rubella serology *      
  Syphilis serology *     C
  Gonococcal culture D     D
  Chlamydial screening *     C
  Hepatitis B serology *      
  HIV serology B      D
  Group B streptococcus culture       E

B – Test should be offered D - High-risk women should be screened at the first prenatal visit and again in
C – High-risk women should be retested at the the third trimester.
beginning of the third trimester. E - Rectovaginal culture should be obtained between 35 and 37 weeks.
 Prenatal Record: Pregnancy Risk
Assessment
Conditions for Which Maternal-Fetal Medicine Consultation May Be Beneficial
Medical History and Conditions
Cardiac disease-moderate to severe disorders
Diabetes mellitus with evidence of end-organ damage or uncontrolled hyperglycemia
Family or personal history of genetic abnormalities
Hemoglobinopathy
Chronic hypertension if uncontrolled or associated with renal r cardiac disease
Renal insuficiency if associated with significant proteinuria (>/=500 mg/24 hour), serum
creatinine >/=1.5 mg/dL, or hypertension
Pulmonary disease if severe restrictive or obstructive, including severe asthma
Human immunodeficiency virus infection
Prior pulmonary embolus or deep-vein thrombosis
Severe systemic disease, including autoimmune conditions
Bariatric surgery
Epilepsy if poorly controlled or requires more than one anticonvulsant
Cancer, especially iftreatment is indicated in pregnancy
 Prenatal Record: Pregnancy Risk
Assessment
Conditions for Which Maternal-Fetal Medicine Consultation
May Be Beneficial
Obstetrical History and Conditions
CDE (Rh) or other blood group alloimmunization (excluding ABO, Lewis)
Prior or current fetal structural or chromosomal abnormality
Desire or need for prenatal diagnosis or fetal therapy
Periconceptional exposure to known teratogens
Infection with or exposure to organisms that cause congenital infection
Higher-order multifetal gestation
Severe disorders of amnionic fluid volume
03.Subsequent
Prenatal
Visits
 Subsequent Prenatal Visits

Every 4 weeks until 28 weeks

Every 2 weeks until 36 weeks

Weekly thereafter

Every 1-2 weeks interval for complicated pregnancies

Subsequent Prenatal Visits: Prenatal
Surveillance
Fetal Maternal
Heart rate Blood pressure
Growth – current and rate of Weight
change Symptoms ( 10 Danger
Amount of amniotic fluid Signals)
Presenting part and station Fundic height
Vaginal examination
• Presenting part
• Station
• Pelvimetry
• Consistency, effacement
and dilatation of the cervix
Subsequent Prenatal Visits: Prenatal
Surveillance
FUNDAL HEIGHT Between 20-34 weeks
Height of the fundus (cm) correlates with AOG in
weeks
Measured along the abdominal wall from the top of
the symphysis pubis to the top of the fundus
Bladder must be emptied before making
measurement
FETAL HEART as early as 16 weeks (standard non amplified
SOUNDS stethoscope)
Audible in all by 22 weeks
10 weeks – doppler; 5 weeks - TVS
ULTRASOUND If performed between 8 – 16 weeks was accurate by
2 days for predicting the actual date at delivery
FUNDIC HEIGHT FETAL POSITION
MEASUREMENT
04.
Nutritional
Counseling
Weight Gain Recommendations
Dietary Reference Intakes
Dietary Reference Intakes
 Calories

80,000 kcal
100-300 kcal/day
AAP and ACOG, 2017

0, 340, 452 kcal/day

Institute of Medicine, 2006
 Protein

1 g/kg/day
doubled in late gestation
Minerals
 Minerals
IRON Iron requirement by mid-pregnancy due to expanding plasma
volume = 7 mg/day
300 mg transferred to the fetus
500 mg incorporated into the expanding maternal Hb mass
Recommended daily ferrous iron supplement = 27 mg of
elemental iron
Increase to 60 – 100 mg/day if
• large woman
• twin fetuses
• late iron supplementation
• irregular intake Minerals
• depressed hemoglobin levels
Ingest at bedtime or on empty stomach to facilitate absorption
and minimize adverse GI reaction
 Minerals
IODINE Recommended: 220 Lg/day
Use of iodized salt and bread products
Offset increased fetal requirements and maternal renal losses
Deficiency leads to endemic __________  multiple severe
neurological defects
CALCIUM 30 g is retained, most of which is deposited in the fetus late in
pregnancy
Most of total maternal calcium is deposited in the bone and can
be readily mobilized for fetal growth
ZINC Recommended daily intake = 12 mg
Deficiency leads to poor appetite, subopti­mal growth, impaired
wound healing, dwarfism and hypogonadism
 Minerals
MAGNESIUM Deficiency as a consequence of pregnancy has not been
recognized
TRACE All with important roles in certain enzyme functions
METALS Most are provided by an average diet
Minerals
(copper,
selenium, Selenium deficiency: fatal cardio myopathy in young children
and reproductive-aged women
chromium,
manganese) Selenium toxicity from over supplementation also observed
POTASSIUM Levels decline by approximately 0.5 mEq/L by mid-pregnancy
Develops in the same circumstances as in nonpregnant
individuals i.e. hyperemesis gravidarium
FLUORIDE Metabolism unchanged
Supplementation not required
Vitamins
 Vitamins
FOLIC ACID Supplementation lowers neural tube defect risks
Daily intake of 400 mcg or 0.4 to 0.8 mg daily throughout
periconceptional period
If with prior child with NTD: 4mg folic acid before conception and

Minerals
during the first trimester decreases recurrence rate of NTD by
more than 70%
Should be consumed as a separate supplement to avoid excessive
intake of fat-soluble vitamins
VITAMIN A Associated with congenital malformations at doses >10,000 IU/day
Isotretinoin is a potent teratogen in humans
B-carotene has not been shown to produce vitamin A toxicity
Deficiency associated with increased risk of maternal anemia and
preterm birth, severe with night blindness
 Vitamins
VITAMIN B12 Decrease in normal pregnancy due to decrease transcobalamins
(cobalamin) Occurs naturally in foods of animal origin
Deficient in vegetarians and excessive vitamin C ingestion

Minerals Deficiency elevates risk for NTD

VITAMIN B6 Does not require supplementation in most gravidas

(pydridoxine) Daily supplement of 2 mg recommended for women at high risk
for inadequate nutrition
Combine with anti-histamine oxylamine for N/V
VITAMIN C RDA of 80 – 85 mg/day (20% more than nonpregnant)
Maternal plasma level decline during pregnancy but cord level is
higher
 Vitamins
Vitamin D 1.5 ug/day or 600 IU daily
Increases intestinal Ca absorption
Promotes bone mineralization & growth
DEFICIENCY in women w/ limited sun exposure
Minerals - disordered skeletal homeostasis
- congenital rickets
- fractures in the newborn
Occurs naturally in foods of animal origin
 VITAMINS
VITAMIN RDA = 80 – 85 mg/day
C Maternal plasma level decline during pregnancy but
cord level is higher
Vitamin Decrease in normal pregnancy due to decrease
B12 transcobalamins
Occurs naturally in foods of animal origin
Deficiency: vegetarians, excessive vitamin C
ingestion
Vitamin D 1.5 ug/day or 600 IU daily
Increases intestinal Ca absorption
Promotes bone mineralization & growth
DEFICIENCY in women w/ limited sun exposure
- disordered skeletal homeostasis
- congenital rickets
- fractures in the newborn
Introduction
Mercury is the closest planet to the Sun and the
smallest one in the Solar System—it’s only a bit
larger than our Moon. The planet’s name has
nothing to do with the liquid metal, since it was
named after the Roman messenger god,
Mercury
05. Common
Concerns
 Identifying Information

Neptune Saturn Mercury

Saturn is the ringed one. It’s a gas
Neptune is the fourth-largest planet
giant, composed mostly of
by diameter in our Solar System
hydrogen and helium
Mercury is the closest planet to the
Sun and the smallest one in our
Solar System
 Identifying Information

Venus
Venus has a beautiful name and is the
second planet from the Sun. It’s terribly
hot—even hotter than Mercury—and its
atmosphere is extremely poisonous. It’s
the second-brightest natural object in the
night sky after the Moon
Mercury
Mercury is the closest planet to the Sun
and the smallest one in the Solar System
—it’s only a bit larger than our Moon.
The planet’s name has nothing to do with
the liquid metal, since it was named after
the Roman messenger god
Patient Medical History
❏Age: 25-35 2008
❏Gender: female Neptune is the fourth-largest
planet by diameter in our Solar
❏Allergies: none System

❏Location: Madrid,
Spain 2013
Saturn is the ringed one. It’s a
❏Habits: unhealthy gas giant, composed mostly of
hydrogen and helium
eating, sedentary
lifestyle 2019
Venus has a beautiful name and
is the second planet from the
Sun. It’s terribly hot
 Review of Systems

Neptune Saturn
Neptune is the Saturn is composed

01 farthest planet from

the Sun 02 mostly of hydrogen
and helium

Mercury Jupiter Mars

Mercury is the This gas giant is the Despite being red,

03 smallest planet in
our Solar System 04 biggest planet in our
Solar System 05 Mars is actually a
cold place
 Physical Examination

Neptune Saturn Mars Venus Mercury

45% 12% 78% 36% 62%

To change the size of Yes, Saturn is the Mars is a cold place Venus has a beautiful Mercury is the closest
the graph, click the ringed one. It’s a gas full of iron oxide dust, name and is the planet to the Sun and
arc of the circle and giant, composed which gives the planet second planet from the smallest one our
drag one of the orange mostly of hydrogen its reddish cast the Sun. It’s terribly the Solar System
handles and helium hot
Results
Mercury is the closest planet to the Sun and
the smallest one in the Solar System—it’s
only a bit larger than our Moon. The planet’s
name has nothing to do with the liquid metal,
since it was named after the Roman
messenger god
 4,497,374
Big numbers catch your audience’s attention
 Findings
Evolution Prevalence

32%
Pluto
24%
Venus

12%
Saturn
32%
Mars

If you want to modify this graph, click on it,

follow the link, change the data and replace it 200,000,000
Big number
 02
Discussion
You could enter a subtitle here if you need it
Discussions

“Neptune is the farthest planet from the Sun

and the fourth-largest in our Solar System’’ Dr. John Doe

“Venus has a beautiful name and is the second

planet from the Sun. It’s terribly hot’’ Dr. Jenna James

“Mercury is the closest planet to the Sun and Dr. Daniel

the smallest one in our Solar System’’
Patterson
Discussions Summary

01
Venus has a beautiful name and is the second
planet from the Sun. It’s terribly hot and its
atmosphere is extremely poisonous

02
Jupiter is a gas giant and the biggest planet in our
Solar System. It’s also the fourth-brightest object
in the sky

03
Mercury is the closest planet to the Sun and also
the smallest one in our Solar System. It’s only a
bit larger than our Moon
 03
Diagnosis
You could enter a subtitle here if you need it
 Diagnosis
Neptune Mercury
Neptune is the fourth-largest Mercury is the closest planet to
planet by diameter in our Solar the Sun and the smallest one in
System our Solar System

Saturn Mars
Saturn is the ringed one. It’s a Despite being red, Mars is
gas giant, composed mostly of actually a cold place. It’s full of
hydrogen and helium iron oxide dust

Venus Jupiter
Venus has a beautiful name and It’s the fourth-brightest object in
is the second planet from the the sky and the biggest planet in
Sun. It’s terribly hot our Solar System
 Comparison

01 02 03 04
Saturn

Venus

Jupiter

Pluto
 04
Treatment
You could enter a subtitle here if you need it
 Treatment
Mars is full of iron oxide
Week 1 dust, which gives the planet
its reddish cast

Saturn is the ringed one. It’s

a gas giant, composed of
hydrogen and helium
Week 2

Venus has a beautiful name

Week 3 and is the second planet
from the Sun

Jupiter is a gas giant and the

biggest planet in our Solar
System
Week 4
A Picture
Always
Reinforces the
Concept
A Picture Is
Worth a
Thousand
Words
05
Patient Monitoring
You could enter a subtitle here if you need it
 Patient Monitoring
Week 1 Week 2
To change the size of the graph, click the circle and drag the colored handle
Venus has a beautiful name and is the
second planet from the Sun
Venu Satur
Mars Pluto
Venus s n

Mars

Saturn Week 3
Mercury is the
Venu Satu
Marss rn
closest planet to the
Pluto Sun Plut
o
 Contraindications - Indications
Saturn is the ringed one. It’s a Despite being red, Mars is
gas giant, composed of actually a cold place. It’s full
hydrogen and helium of iron oxide dust

Jupiter is a gas giant and the

Neptune is the fourth-largest
fourth-brightest object in the
planet in our Solar System
sky

Venus has a beautiful name Pluto is in the Kuiper belt and

and is the second planet from is considered a dwarf planet
the Sun since 2006

Mercury is the closest planet Ceres is a dwarf planet and

to the Sun and the smallest in the biggest object in the
our Solar System asteroid belt
 Post-prevention

Jupiter is a gas giant and

the biggest planet in our
Jupiter Mercury Mercury is the smallest
planet in our Solar
Solar System System

Venus is terribly hot and

its atmosphere is
Venus Mars Despite being red, Mars
is actually a cold place
extremely poisonous

Neptune is the fourth-

largest planet in our
Neptune Saturn It’s a gas giant,
composed mostly of
Solar System hydrogen and helium
 Case Timeline

Phase 1 Phase 2 Phase 3 Phase 4

Neptune is the fourth- Saturn is the ringed one. Venus has a beautiful name Mars is full of iron oxide
largest planet in our Solar It’s a gas giant, composed and is the second planet dust, which gives the planet
System of hydrogen and helium from the Sun its reddish cast
 Conclusions
Mercury is the closest planet to the Sun
and the smallest one in the Solar
System—it’s only a bit larger than our
Moon. The planet’s name has nothing to
do with the liquid metal, since it was
named after the Roman messenger god,
Mercury
 References

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

 Our Team

Helena James John Doe Jenna

Here you can talk a bit Here you can talk a bit Patterson
Here you can talk a bit
about this person about this person about this person
Thank
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+91 620 421 838

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