PRENATAL CARE

DR. RUBY E ROBISO, FPOGS

DAVAO MEDICAL SCHOOL FOUNDATION, INC
 ASSESSING ADEQUACY OF PRENATAL
CARE
KESSNER INDEX
- A commonly employed system for measuring
prenatal care adequacy
- Incorporates three items from the birth
certificate:
-length of gestation
-timing of first prenatal visit
-number of visits
- Does not measure quality of care nor consider
the relative risks of complications for the mother
 REASONS FOR INADEQUATE
PRENATAL CARE
- Late identification of pregnancy by the patient
- Lack of money or insurance
- Inability to obtain an appointment
 PRENATAL CARE EFFECTIVENESS
- Focused on lowering the extremely high maternal
mortality rates
- The risk of pregnancy-related maternal death was
decreased fivefold among recipients of prenatal
care
- Those with no prenatal care was associated with
more than a twofold increased risk of preterm
birth
- Women with prenatal care had an over all
stillbirth rate of 2.7 per 1000 vs with 14.1 per
1000 for women with no prenatal care
 DIAGNOSIS OF PREGNANCY
SIGNS AND SYMPTOMS
AMENORRHEA
• The abrupt cessation of menstruation in a healthy
reproductive-aged woman who previously has
experienced spontaneous, cyclical, predictable
menses is highly suggestive of pregnancy
• Not a reliable indication of pregnancy until 10
days or more after expected menses
• Uterine bleeding occurs after conception and can
be suggestive of menstruation- likely the
consequence of blastocyst implantation
 LOWER REPRODUCTIVE TRACT
CHANGES
During pregnancy, the vaginal mucosa usually
appears dark-bluish red and congested-
Chadwick sign
Increased cervical softening as pregnancy
advances
UTERINE CHANGES
First few weeks- uterine grows in AP diameter,
feels doughy and elastic
At 6-8 weeks- softer fundus and compressible
interposed softened isthmus-Hegar sign
 BREAST AND SKIN CHANGES
• Anatomical changes that accompany
pregnancy are characteristic during a first
pregnancy and less obvious in multiparas

• increased pigmentation and visual changes in

abdominal striae, may be absent during
pregnancy and may also be seen in women
taking estrogen-containing contraceptives
 FETAL MOVEMENT
• Perception of fetal movement depends on
parity and habitus

• Primigravid- 18 to 20 weeks

• Multigravid- 16 to 18 weeks

• Examiner- 20 weeks
 PREGNANCY TESTS
Human Chorionic Gonadotropin
- Detection in maternal blood and urine is the basis
for endocrine assays of pregnancy
- can be detected in maternal serum or urine 9
days after ovulation
- doubling time of serum concentration- 1.4 to 2.0
days
- reach peak levels at 60 to 70 days, thereafter
declines slowly until a nadir is reached at about
16 weeks
 SONOGRAPHIC RECOGNITION
OF PREGNANCY
After 4 to 5 weeks’ menstrual age
- a gestational sac may be demonstrated by
abdominal sonography
By 35 days
- a normal sac should be visible in all women
After 6 weeks
- heart motion
Up to 12 weeks
- the crown-rump length is predictive of
gestational age within 4 days
 INITIAL PRENATAL EVALUATION
Major goals:
1. Define the health status of the mother and fetus
2. Estimate the gestational age
3. Initiate a plan for continuing obstetrical care
 DEFINITIONS

NULLIGRAVIDA
GRAVIDA
PRIMIGRAVIDA
MULTIGRAVIDA
NULLIPARA
PRIMIPARA
MULTIPARA
 NORMAL PREGNANCY DURATION
• 280 days or 40 weeks
• NAEGELE’s RULE- for expected date of delivery
• Gestational Age or Menstrual Age
• assumes pregnancy have begun 2 weeks
before ovulation
• Ovulatory age or Fertilization Age
• by embryologists and reproductive specialists,
2 weeks shorter
 TRIMESTERS

Pregnancy
- Divided into 3 trimesters
- First Trimester 1- 14 weeks
- Second Trimester 15- 28 weeks
- Third Trimester 29- 42 weeks
 PREVIOUS AND CURRENT HEALTH
STATUS
Menstrual History
- Very important
- If spontaneously menstruates regularly every
28 days is most likely to ovulate at midcycle
- If longer than 28 to 30 days, ovulation
occured more likely beyond 14 days
 PSYCHOSOCIAL SCREENING
Psychosocial Risk Factors
• AAP and ACOG: Psychosocial issues : non
biomedical factors that affect mental and
physical well being
• Women should be screened at least once each
trimester to increase the likelihood of
identifying important issues and reducing
adverse pregnancy outcomes
• performed regardless of social status, education
level, race or ethnicity
 CIGARETTE SMOKING
• 2000 to 2010: 12-13% prevalence rate
• most likely to smoke- younger, less education
Numerous adverse outcomes:
• Two fold risk of placenta previa
• placental abruption
• PROM
Infants of mothers who smoke:
• preterm
• low birth weights
• more like to die of SIDS
 CIGARRETTE SMOKING
• Increased risk of spontaneous abortion
• fetal death
• fetal digital anomalies
• asthma, infantile colic, childhood obesity
Pathological Mechanisms to explain adverse
outcomes:
• fetal hypoxia from increased carboxyhemoglobin
• reduced uteroplacental blood flow
• direct toxic effects of nicotine and other
compounds in smoke
 ALCOHOL
ETHANOL
- potential teratogen causing fetal alcohol
syndrome:
- growth restriction
- facial abnormalities
- central nervous system dysfunction
-women who are pregnant or considering
pregnancy should abstain from using alcoholic
beverages
 ILLICIT DRUGS
• U.S.: 10% OF fetuses are exposed to one or more
• illicit drugs – cocaine, amphetamines,
barbiturates, marijuana
Chronic use of large quantities have the ff sequelae:
• fetal growth restriction
• low birthweight
• drug withdrawal soon after birth
• those who receive prenatal care- decreased risk
for preterm birth and low birth weight
 INTIMATE PARTNER VIOLENCE
• refers to a pattern of assaultive and coercive
behaviors that may include physical injury,
psychological abuse, sexual assault, progressive
isolation, stalking, deprivation, intimidation and
reproductive coercion
• ACOG: prevalence during pregnancy: 4-8%
• Intimate partner violence is associated with
increased risk of adverse perinatal outcomes:
- preterm delivery
- fetal growth restriction
- perinatal death
 CLINICAL EVALUATION
- A thorough, general physical examination at the
initial visit
PELVIC EXAM
• Cervix is visualized, pap smear to identify
cytological abnormalities, specimens obtained for
C. trachomatis and N. gonnorhea
• Bimanual examination- cervix, uterine size, any
adnexal masses, fetal presentation, bony pelvis,
any anomalies in the vagina and vulva
• Perianal region visualized and digital examination
performed for complaints of rectal pain, bleeding,
or mass
 LABORATORY TESTS
Recommended routine tests at the first prenatal
visit
CERVICAL INFECTIONS
- C. trachomatis is isolated from the cervix in 2-13%
of pregnant women with additional 3rd-trimester
testing for those at increased risk
- AAP and ACOG recommend screening for all
during the first prenatal visit
- Neisseria gonorrhoeae- risk factors similar for
those for chlamydial infection
 SUBSEQUENT PRENATAL VISITS
- Intervals of 4 weeks until 28 weeks, every 2 weeks
until 36 weeks, and weekly thereafter
- With complicated pregnancies return visits
required at 1-2 week intervals
WHO conducted multicenter randomized trial with
an experimental model designed to minimize visits:
• seen once in the first trimester and screened for
certain risks
• those without anticipated complications (80%)-
seen again at 26, 32 and 38 weeks
• no disadvantages were found with WHO limited
visits
 PRENATAL SURVEILANCE
MATERNAL: FETAL
- Weight - Heart rate (s)
- Blood pressure - Size- current and
change
- Symptoms - Amount of
amniotic fluid
- Fundic Height - Activity
- Vaginal Exam - Presenting part
and station
- presenting part and station
- clinical pelvimetry
- bishops score
 ASSESSMENT OF GESTATIONAL AGE
FUNDAL HEIGHT (FH)
• The distance over the abdominal wall from the
top of the symphysis pubis to the top of the
fundus
• Between 20 and 34 weeks, the FH in cm closely
correlates with gestational age in weeks
• To monitor fetal growth and amniotic fluid
volume
• Obesity or presence of uterine masses may limit
fundal height accuracy
FETAL HEART SOUNDS
• Ranges from 110 to 160 beats per minute
• Doppler ultrasound instruments- detects FHT
by 10 weeks
• Standard nonamplified stethoscope- detects
FHT at 16weeks earliest, 80% at 19 weeks and
100% at 22 weeks
SONOGRAPHY
-Should be performed only when there is a valid
medical indication under the lowest possible
ultrasound exposure setting
 SUBSEQUENT LABORATORY TESTS
• Fetal Aneuploidy screening-11 to 14 and/or
15 to 20 weeks
• NTD screening- 15 to 20 weeks
• Hct or hgb (plus syphilis)- repeated at 28 to
32 weeks
• D ( Rh) negative, unsensitized- antibody
screening test repeated at 28 to 29 weeks
 SUBSEQUENT LABORATORY TESTS
GROUP B STREPTOCOCCAL (GBS) INFECTION
• ACOG and CDC:
• vaginal and rectal GBS cultures at 35 and 37 weeks
• Intrapartum antimicrobial prophylaxis is given for
those with positive cultures
GESTATIONAL DIABETES
• All pregnant women should be screened ( history,
clinical factors or laboratory testing)
• Laboratory Testing between 24 and 28 weeks-
most sensitive
GONOCOCCAL INFECTION
AAP AND ACOG:
-pregnant women with risk factors be tested at
an early prenatal period and again in the third
trimester
-treatment is given as well as for co-existing
chlamydial infection
SELECTED GENETIC SCREENING
-should be offered to those at increased risk
based on family history, ethnic or racial
background, or age
 NUTRITIONAL COUNSELING
Recommendations for Total and Rate of Weight Gain during
Pregnancy, by Prepregnancy BMI
Category (BMI) Total Wt gain Weight gain in 2nd
& 3rd
range (lb) trimesters Mean in
lb/wk
Underweight (<18.5) 28–40 1 (1- 1.3)
Normal Weight (18.5-24.9) 25-35 1 (0.8-1)
Overweight ( 25.0-29.9) 15-25 0.6 ( 0.5-0.7)
Obese ( >/= 30.0) 11-20 0.5 ( 0.4-0.6)
 OVERNUTRITION

Maternal weight gain

• has a positive correlation with birthweight
• Women with the greatest risk (14%) for
delivering an infant less than 2500 g with
those weight gain less than 16 lb.
• nearly 19% of births to women with such low
weight gains were preterm
 WEIGHT RETENTION AFTER
PREGNANCY
• Average total weight loss resulted in an
average retained pregnancy weight of 3 lb or
1.4 kg

• There is no relationship between pre

pregnancy BMI or prenatal weight gain and
weight retention