Preconceptional and Prenatal Care

PRECONCEPTIONAL AND PRENATAL CARE
GULLAS COLLEGE OF MEDICINE

MANDAL, AJAY KUMAR
Preconceptional CARE
DISCUSSION OUTLINE
• COUNSELING SESSION
• MEDICAL HISTORY
• GENETIC DISEASES
• REPRODUCTIVE HISTORY
• PARENTAL AGE
• SOCIAL HISTORY
• SCREENING TESTS
Preconceptional Care
Defined as a set of interventions that aim to identify and

modify biomedical, behavioral and social risks to a woman’s
health or pregnancy outcome through prevention and
management.
Preconceptional Care Goals
1. Improve knowledge, attitudes, and behaviors of men and women related to

preconceptional health
2. Assure that all childbearing-aged women receive preconceptional care
services- including evidence-based risk screening, health promotion and
interventions
3. Reduce risks indicated by a previous adverse pregnancy outcome through
interconceptional interventions.
4. Reduce the disparities in adverse pregnancy outcomes.
Preconceptional Care
• To be successful, strategies that ease potential pregnancy risks must be
provided before conception.
COUNSELING SESSION
1. Gynecologists, internists, and pediatricians have the

best opportunity to provide preventive counseling
during periodic health examinations.
2. The occasion of a negative pregnancy test is also an

excellent time for education.
3. Counselors should be knowledgeable regarding
relevant medical diseases and must be able to
interpret data.
COUNSELING SESSION
Factors that can affect future pregnancy are:
• medical or reproductive problems-52%
• family history of genetic disease-50%
• increased risk of HIV infection-30%
• Increased risk of hepatitis B and illegal substance abuse-25%
• alcohol use-17%
• nutritional risks-54%
COUNSELING SESSION
 May be time consuming, depending on the number and

complexity of factors that require assessment.
 The intake evaluation includes a thorough review of the medical,
obstetrical, social, and family histories.
 Useful information can obtained by asking specific questions

regarding each of medical histories by asking general or open-
ended questions.
 Answers are reviewed with the couple to ensure appropriate
follow-up.
MEDICAL HISTORY
 These are some specific high risk medical conditions:

A. Diabetes Mellitus
B. Epilepsy
C. GENETIC DISEASES
 By knowing general points about these high risk specific medical

conditions, which might affect the fetus and maternal health. Can be
treated and improve outcome by providing advices.
MEDICAL HISTORY
Diabetes Mellitus
 Because maternal and fetal pathology associated with hyperglycemia is well
known,
 Diabetes is the prototype of a condition for which Preconceptional counseling
is beneficial.
 Many of these complications can be avoided if glucose control is optimized
before conception.
 Thus, Preconceptional counseling for women with pregestational diabetes is
both beneficial and cost-effective and should be encouraged.
 In addition to assessing diabetic control during the preceding 6 weeks,

hemoglobin A1c measurement can also be used to estimate risks for major
anomalies
MEDICAL HISTORY
Epilepsy
 Compared with unaffected women, those with a seizure disorder carry an certain
risk of having neonates with structural anomalies.
 And Untreated women had anomaly rates that were similar to those of nonepileptic
controls.
 Ideally, seizure control is optimized preconceptionally. Treatment goals attempt to
achieve seizure control with monotherapy and with medications considered less
teratogenic.
 Epileptic women should be advised to daily take a 4-mg folic acid supplement,
which may reduce congenital abnormality risk.
MEDICAL HISTORY
Immunizations
 Preconceptional counseling includes assessment of immunity against common
pathogens depending on health status, travel plans and other immunizations
may be indicated.
 Vaccines that contain toxoids such as tetanus are suitable before or during
gestation.
 Also, killed bacteria or viruses containing vaccines such as influenza,
pneumococcus, hepatitis B are not contraindicated preconceptionally or during
pregnancy.
 live-virus vaccines are not recommended during pregnancy. I.e. varicella-zoster,
measles, mumps, rubella, polio, chickenpox and yellow fever.
GENETIC DISEASES
 The CDC (2016) estimates that 3 percent of neonates born each year in the USA will
have at least one birth defect.
 Such defects are the leading cause of infant mortality and account for 20 percent
of deaths.
 So, The benefits of preconceptional counseling usually are measured by
comparing the incidence of new cases before and after initiation of a counseling
program.
 Congenital conditions that clearly benefit from patient education include neural-
tube defects, phenylketonuria, thalassemias.
GENETIC DISEASES
Family History
 Pedigree construction is the most thorough method for obtaining a family
history as a part of genetic screening.
 The health and reproductive status of each “blood relative” should be

individually reviewed for medical illnesses, mental retardation, birth
defects, infertility, and pregnancy loss.
 Certain racial, ethnic or religious backgrounds may indicate elevated risk for
specific recessive disorders.
GENETIC DISEASES
Neural-Tube Defects
 The incidence of NTDs is 0.9 per 1000 live births and second only to cardiac
anomalies as the most frequent structural fetal malformation.
 Preconceptional folic acid therapy significantly reduced the risk for a

recurrent NTD by 72 percent and reduced priori risk of a first NTD
occurrence.
GENETIC DISEASES
Neural-Tube Defects
 So, currently recommended, that all women who may become pregnant take daily
400 to 800 μg of folic acid orally before conception and through the first
trimester.
 Despite the demonstrated benefits of folate supplementation, only half of women

have taken folic acid supplementation periconceptionally. So, health care provider
encourage mother to take folic acid.
GENETIC DISEASES
Phenylketonuria
• Mothers with PKU who eat an unrestricted diet have abnormally high blood
phenylalanine levels.
• This amino acid readily crosses the placenta and can damage developing fetal organs.
• With appropriate preconceptional counseling and phenylalanine-restricted diet

before pregnancy, the incidence of fetal malformations is dramatically reduced.
• Therefore,Ideally normalized 3 months before conception and maintained

throughout pregnancy
• The target phenylalanine blood concentration is 120 to 360 μmol/L.
GENETIC DISEASES
Thalassemias
 These disorders of globin-chain synthesis are the most
common single- gene disorders worldwide.
 In endemic areas such as Mediterranean and Southeast

Asian countries, counseling and other prevention
strategies have reduced the incidence of new cases by up to
80 percent.
REPRODUCTIVE HISTORY
 During preconceptional screening, information is sought regarding:
 Infertility
 abnormal pregnancy outcomes(miscarriage, ectopic pregnancy and recurrent
pregnancy loss)
 obstetrical complications( cesarean delivery, preeclampsia, placental abruption,
and preterm delivery).
 Identification of these abnormality can help determine the recurrence risk and
aid in the preconceptional or prenatal management in subsequent pregnancies.
PARENTAL AGE
Maternal Age
 Women at both ends of the reproductive-age spectrum have unique outcomes to
be considered.
 First, according to the CDC, 3.4 percent of births in the United States were in
women between the ages of 15 and 19 years.
 Adolescents are at increased risk for anemia, preterm delivery and preeclampsia
and incidence of sexually transmitted diseases higher during pregnancy
compared with women aged 20 to 35 years.
 Because most of their pregnancies are unplanned, adolescents
rarely seek preconceptional counseling.
PARENTAL AGE
Maternal Age
 Older women(Age after 35 years) are more likely to request preconception
counseling, because of postponed pregnancy with a desire to optimize outcomes or
because of plans to undergo infertility treatment.
 The older woman who has a chronic illness or who is in poor physical condition
usually has readily apparent risks.
 Overall, the maternal mortality rate is higher in women aged 35 and older;
Compared with women in their 20s.
PARENTAL AGE
Maternal Age
For the fetus, maternal age-related risks primarily stem from:
1. Indicated preterm delivery fo maternal complications such as
hypertension and diabetes.
2. spontaneous preterm birth.
3. fetal growth disorders related to chronic maternal disease or
multifetal gestation
4. fetal aneuploidy and
5. pregnancies resulting from assisted reproductive technology
SOCIAL HISTORY
Recreational Drugs and Smoking

• The first step in preventing drug-related fetal risk is an honest
assessment of use by the patient.
• Preconceptional counseling about fetal risks associated with

alcohol, marijuana, cocaine, amphetamines and heroin should be
encourage to prevent numerous adverse perinatal outcomes.
SOCIAL HISTORY
Recreational Drugs and Smoking

• Toward this end, questioning should be nonjudgmental and Screening for at-risk
drinking can be accomplished using several validated tools(i.e. TACE questions).
• Smoking in pregnancy has been consistently associated with numerous adverse

perinatal outcomes.
• These risks are largely diminished by cessation before pregnancy, highlighting

the importance of screening for tobacco use in the preconceptional period and
during prenatal care.
SOCIAL HISTORY
Environmental Exposures
 Exposures to infectious diseases have myriad deleterious effects.
 Likewise, contact with some chemicals may impart significant
maternal and fetal risks.
 Excess exposure to methyl mercury or lead is associated with
neurodevelopmental disorders.
SOCIAL HISTORY
Diet
• Pica is the craving for and consuming of ice, laundry starch, clay,
dirt, or other nonfood items. Which may represent an unusual
physiological response to iron deficiency.
• It should be discouraged due to its inherent replacement of

healthful food with nutritionally empty products.
• Many vegetarian diets are protein deficient but can be corrected by

increasing egg and cheese consumption.
SOCIAL HISTORY
Diet
 Anorexia and bulimia increase maternal risks of nutritional
deficiencies, electrolyte disturbances, cardiac arrhythmias, and
gastrointestinal pathology.
 Which may lead to greater risks of low birthweight, smaller head
circumference, microcephaly, and small-for-gestational-age
newborns.
 Obesity also appears to be associated with a range of structural fetal
anomalies
 So, during Preconceptional counseling, advice to eat regular healthy
diet.
SOCIAL HISTORY
Exercise
• Trained pregnant women usually can continue to exercise
throughout gestation.
• One caution is that as pregnancy progresses, balance problems
and joint relaxation may predispose to orthopedic injury.
• Advised not to exercise to exhaustion
• Further avoidances include
 prolonged supine position
 activities requiring good balance
 extreme weather conditions.
SCREENING TESTS
 Certain laboratory tests may help assess the risk for and
prevent some pregnancy complications.
 These include basic tests that are usually performed during

prenatal care .
 More specific tests may assist evaluation of women with
certain chronic medical diseases.
 With proper screening tests, optimizing maternal condition

before conception will improve pregnancy outcomes.
PRENATAL CARE
DISCUSSION OUTLINE: -
A. Initial prenatal evaluation
B. Subsequent prenatal visits
C. Nutritional counseling
Initial Prenatal evaluation
 Prenatal care should be initiated as soon as there
is a reasonable likelihood of pregnancy.
 Major goals:
1. define the health status of the mother and
fetus
2. estimate the fetal gestational age
3. initiate a plan for continuing obstetrical care.
Definitio 1. Nulligravida—a woman who currently
n of is not pregnant nor has ever been
Terms pregnant.
2. Gravida—a woman who currently is
pregnant or has been in the past,
irrespective of the pregnancy outcome.
• Primigravida- woman on her first
pregnancy
• Multigravida – woman on her
subsequent pregnancies
3. Nullipara—a woman who has never
completed a pregnancy beyond 20
weeks’ gestation.
• She may may have had a spontaneous or
elective abortion(s) or an ectopic
pregnancy.
Definitio
n of
Terms 4. Primipara—a woman who has been delivered only once of a
fetus or fetuses born alive or dead with an estimated length of
gestation of 20 or more weeks.
5. Multipara—a woman who has completed two or more

pregnancies to 20 weeks’ gestation or more.
• Parity is determined by the number of pregnancies

reaching 20weeks. It is not
Routine Prenatal
Care
th
mean duration of pregnancy calculated from
Normal the first day of the last normal menstrual period
Pregnancy is very close to 280 days or 40 weeks.
Duration Naegele rule- estimate the expected delivery
date by adding 7 days to the date of the first day
of the last normal menstrual period and
counting back 3 months
· For example:
· LMP September 10, 2017  EDD is expected date of
delivery is June 17, 2019
It has become customary to divide
pregnancy into three parts of
approximately 3 calendar months.
Trimesters first trimester: 1 to 14 weeks
2nd trimester: 15 to 28 weeks
3rd trimester: 29 to 42 weeks
Previous and Current Health Status
 The American Academy of Pediatrics and the American
College of Obstetricians and Gynecologists (2012) define
psychosocial issues as nonbiomedical factors that affect
mental and physical well-being.
 Women should be screened for: barriers to care,
Psychosocia communication obstacles, nutritional status, unstable
l Screening housing, desire for pregnancy, safety concerns that
include intimate partner violence, depression, stress,
and use of substances such as tobacco, alcohol, and
illicit drugs.
 This screening should be performed on a regular
basis, at least once per trimester, to identify important
issues and reduce adverse pregnancy outcomes.
 Numerous adverse outcomes have been linked to
smoking during pregnancy.
 Potential teratogenic effects
 twofold risk of placenta previa, placental abruption, and
premature membrane rupture
Cigarett  neonates born to women who smoke are more likely to be
e preterm, have lower birth- weights, and are more likely to
die of sudden infant death syndrome (SIDS) than infants
Smoking born to nonsmokers
 Pathophysiology: fetal hypoxia from increased
carboxyhemoglobin, reduced uteroplacental blood flow,
and direct toxic effects of nicotine and other compounds
in smoke
 Ethyl alcohol or ethanol is a potent teratogen that
causes a fetal syndrome characterized by growth
restriction, facial abnormalities, and central
Alcohol nervous system dysfunction
 Women who are pregnant or considering
pregnancy should abstain from using any alcoholic
beverages.
 Chronic use of large quantities is harmful
to the fetus
Illicit drugs
 Sequelae include fetal-growth
restriction, low birthweight, and drug
withdrawal soon after birth.
 refers to a pattern of assaultive and coercive
Intimate behaviors that may include physical injury,
Partner psychological abuse, sexual assault,
progressive isolation, stalking, deprivation,
Violence intimidation, and reproductive coercion
 associated with an increased risk of several
adverse perinatal outcomes including preterm
delivery, fetal- growth restriction, and perinatal
death.
 Screen at the first prenatal visit, then again at least
once per trimester, and again at the postpartum
visit.
Frequency:
 Advise office visit at 8-10 weeks of
pregnancy (or earlier if the patient is at risk for
Prenatal ectopic pregnancy)
 Every 4 weeks for first 28 weeks.
Visit  Every 2 – 3 weeks until 36 weeks gestation.
 Every week after 36 weeks gestation.
Frequency of visits is determined by
individual needs and assessed risk factors.
Goal: Coordination of care for detected
medical and psychosocial risk factors.
Gestational Age Assessment
1. Based on uterine size:
Clinical
Evaluation
Gestational Age Assessment
2. Based on ultrasound
 first-trimester crown-rump
length is the most accurate tool
Clinical for gestational age assignment
Evaluation
 Ultrasound done during 2nd and
3rd trimesters can also provide
an estimated gestational age,
but with declining accuracy.
Laboratory tests
Clinical
Evaluation
Cervical Infections
 American Academy of Pediatrics and the American College of

Obstetricians and Gynecologists (2012) recommend that all
women be screened for chlamydia during the first prenatal visit,
with additional third-trimester testing for those at increased
Clinical risk.
Evaluation Following treatment, a second test—a so-called test of cure—is
recommended in pregnancy 3 to 4 weeks after treatment
completion
 American Academy of Pediatrics and the American College of
Obstetricians and Gynecologists (2012) recommend that
pregnant women with risk factors for Neisseria gonorrhea infection
or those living in an area of high N gonorrhoeae prevalence be
screened at the initial prenatal visit and again in the third
trimester.
Identification of
High Risk Pregnancy
Clinical
Evaluation
.
Subsequent Prenatal Visits
• Subsequent prenatal visits have been
traditionally
• scheduled at 4 week intervals until 28
weeks, then every 2 weeks until 36 weeks,
and weekly thereafter.
• Women with complicated pregnancies often
require return visits at 1-to 2-week intervals.
1. Fundal /fundic Height
• Between 20 and 34 weeks, the height of the uterine
Prenatal fundus measured in centimeters correlates closely
with gestational age in weeks
Surveillan • measurement is used to monitor fetal growth
ce and amnionic fluid volume.
• It is measured as the distance along the abdominal
wall from the top of the symphysis pubis to the top
of the fundus.
• Obesity or the presence of uterine masses such as
leiomyomata may limit fundal height accuracy. In
such cases, sonography may be necessary for
assessment.
Prenatal
Surveillan
ce
2. Fetal Heart Sounds
• detectable by:
• 10 weeks AOG using fetal doppler
• 16 weeks AOG by stethoscope
• fetal heart rate ranges from 110 to 160
beats per minute and is typically heard as
a double sound.
• Best heard along the fetal back
3. Sonography
• sonography provides invaluable information
Prenatal
regarding fetal anatomy, growth
Surveillan
• American College of Obstetricians and
ce Gynecologists (2011b) recommends that
repeated sonography should be performed only
when there is a valid medical indication under
the lowest possible ultrasound exposure
setting.
1. Group B Strep (GBS) Infection

Subsequent Lab Tests
• Centers for Disease Control and Prevention (2010b)
recommend that vaginal and rectal group B
streptococcal (GBS) cultures be obtained in all women
between 35 and 37 weeks’ gestation
• Intrapartum antimicrobial prophylaxis is given for
those whose cultures are positive.
• Women with GBS bacteriuria or a previous infant
with invasive disease are given empirical
intrapartum prophylaxis.
2. Gestational Diabetes
Subseque • All pregnant women should be screened for
nt Lab gestational diabetes mellitus, whether by
Tests history, clinical factors, or routine laboratory
testing.
• Done between 24 and 28 weeks’ age of
gestation
• Can be done during the first trimester check-up
for high risk women.
3.Neural-Tube Defect and Genetic Screening
• Serum screening for neural-tube defects is offered
Subsequent at 15 to 20 weeks.
Lab Tests • Fetal aneuploidy screening may be performed at
11 to 14 weeks’ gestation and/or at 15 to 20
weeks
• Additionally, screening for certain genetic
abnormalities is offered to women at increased
risk based on family history, ethnic or racial
background or age.
Weight Gain Recommendations
TABLE 9-5. Recommendations for Total and
Rate of Weight Gain During
Pregnancy, by Prepregnancy BMI
Total Weight Gain in 2nd
Nutritional Category Weight Gain and 3rd Trimesters
Counseling (BMI)
Underweight
Range (lb)
28–40
Mean in lb/wk (range)
1 (1–1.3)
( 18.5)
Normal weight 25–35 1 (0.8–1)
(18.5–24.9)
Overweight 15–25 0.6 (0.5–0.7)
(25.0–29.9)
Obese ( 30.0) 11–20 0.5 (0.4–0.6)
Recommended
Dietary Allowance
1. Calories
Recommended  Pregnancy requires an additional 80,000 kcal, mostly
during the last 20 weeks.
Dietary  To meet this demand, a caloric increase of 100 to 300 kcal
Allowance per day is recommended during pregnancy
 Institute of Medicine (2006) recommends adding 0, 340,
and 452 kcal/day to the estimated nonpregnant energy
requirements in the first, second, and third trimesters,
respectively.
2. Protein
 Needed for the demands for growth and remodeling of the
Recommended fetus, placenta, uterus, and breasts, as well as increased
Dietary maternal blood volume
Allowance  During the second half of pregnancy, approximately 1000
g of protein are deposited, amounting to 5 to 6 g/day
 Preferably, most protein should be supplied from
animal sources, such as meat, milk, eggs, cheese,
poultry, and fish.
3. Iron
Recommended  at least 27 mg of elemental iron supplement be given daily
to pregnant women. This amount is contained in most prenatal
Dietary vitamins.
Allowance  As little as 30 mg of elemental iron, supplied as ferrous gluconate,
sulfate, or fumarate and taken daily throughout the latter half of
pregnancy, provides sufficient iron to meet
pregnancy requirements and to protect preexisting iron stores
 the pregnant woman may benefit from 60 to 100 mg of elemental
iron per day if she is large, has twin fetuses, begins
supplementation late in pregnancy, takes iron
irregularly, or has a somewhat depressed hemoglobin level.
4. Iodine
Recommended  recommended daily iodine allowance is 220 μg
Dietary  use of iodized salt and bread products is recommended
Allowance during pregnancy to offset the increased fetal
requirements and maternal renal losses of iodine.
 Severe maternal iodine deficiency predisposes offspring to
endemic cretinism, characterized by multiple severe
neurological defects.
Recommended 5. Calcium
Dietary  the pregnant woman retains approximately 30 g of
Allowance calcium. Most of this is deposited in the fetus
late in pregnancy
1. Folic Acid
 Neural-tube defects can be prevented with daily intake of

400 μg of folic acid throughout the periconceptional period.
Vitamin  Because nutritional sources alone are insufficient, folic

acid supplementation is recommended
s  All women planning or capable of pregnancy take a daily
supplement containing 0.4 to 0.8 mg of folic acid.
 A woman with a prior child with a neural-tube defect can
reduce the recurrence risk with daily 4-mg folic acid
supplements the month before conception and during the
first trimester.
2. Vitamin A
 this vitamin has been associated with congenital

malformations when taken in higher doses (> 10,000 IU per
day) during pregnancy.
Vitamins  Beta-carotene, the precursor of vitamin A found in fruits
and vegetables, has not been shown to produce vitamin A
toxicity.
 Most prenatal vitamins contain vitamin A in doses
considerably below the teratogenic threshold.
 Vitamin A deficiency, whether overt or subclinical, was
associated with an increased risk of maternal anemia and
spontaneous preterm birth.
3. Vitamin B12
 Vitamin B12 occurs naturally only in foods of animal
origin, and strict vegetarians may give birth to infants
Vitamins whose B12 stores are low.
 Excessive ingestion of vitamin C also can lead to a
functional deficiency of vitamin B12.
 Although its role is still controversial, low levels of
vitamin B12 preconceptionally, similar to folate, may
increase the risk of neural-tube defects
4. Vitamin B6 (Pyridoxine)
 For women at high risk for inadequate nutrition—for

Vitamins example, substance abusers, adolescents, and those
with multifetal gestations—a daily 2-mg supplement
is recommended.
 when combined with the antihistamine doxylamine, is
helpful in many cases of nausea and vomiting of
pregnancy
5. Vitamin C
Vitamins  recommended dietary allowance for vitamin C
during pregnancy is 80 to 85 mg/day—
approximately 20 percent more than when
nonpregnant
1. In general, advise the pregnant woman to eat
what she wants in amounts she desires and
salted to taste.
2. Ensure that food is amply available
for socioeconomically deprived
women.
Pragmatic 3. Monitor weight gain, with a goal of approximately
Nutritional 25 to 35 lb in women with a normal BMI.
Surveillanc 4. Explore food intake by dietary recall
periodically to discover the occasional
e nutritionally errant diet.
5. Give tablets of simple iron salts that provide at
least 27 mg of elemental iron daily. Give folate
supplementation before and in the early weeks
of pregnancy. Provide iodine supplementation
in areas of known dietary insufficiency.
6. Recheck the hematocrit or hemoglobin
concentration at 28 to 32 weeks’ gestation to
detect significant decreases.
DIAGNOSIS OF PREGNANCY
3 Categories of Manifestations of Pregnancy:
1. Presumptive evidence: based on signs and symptoms that may

resemble pregnancy; very non-specific
2. Probable evidence: signs that indicate pregnancy the majority of the

time. However, there is still the chance they can be false or caused
by something other than pregnancy.
3. Positive signs: guarantees the presence of pregnancy; signs that

cannot, under any circumstances, be mistaken for other conditions.
1. Presumptive evidence of pregnancy 2. Probable evidence of
Presumptive symptoms pregnancy
a) Nausea with or without vomiting  Enlargement of the abdomen
b) Disturbance in urination  Changes in the size, shape and
c) Fatigue
consistency of the uterus
d) Maternal perception of fetal movement
 Anatomical changes in cervix
e) Breast symptoms
 Braxton-Hick’s contractions
Presumptive signs
 Ballottement
a) Amenorrhea
 Physical outlining of the fetus
b) Thermal signs
 Positive results of endocrine tests
c) Anatomic breast changes
d) Skin pigmentation changes
e) Changes in vaginal mucosa
3. Positive evidence of pregnancy
Identification of fetal heart tones
Perception of fetal movement by the examiner
Recognition of embryo or fetus by ultrasound imaging
4. Differential diagnosis of pregnancy
Presumptive Evidences of Pregnancy:
A. Presumptive Symptoms:
• 1) Nausea with or without Vomiting
• approximately 50% of pregnant women
• experience peculiar distaste for food, food idiosyncracies, or certain
“cravings” even for non-edible material (Pica), & other gastrointestinal
disturbances
• first 2 to 3 months of pregnancy
• often occurs in the morning (“morning sickness”); may occur in other times
of the day
• Stress & emotional tension play an important role in the severity
• extreme nausea & vomiting is associated with “hyperplacentosis”
(multiple pregnancies & molar pregnancies)
• a condition of heightened trophoblastic activity  increased
placental weight & circulating hCG levels higher than those in normal
pregnancy
• Persistent vomiting aggravated by inability to take in food  severe
dehydration & ketonuria (Hyperemesis gravidarum)  necessitates
Hospitalization
• correlates with amount of circulating serum hCG levels, appearing at 6
weeks  reaching a peak at 60 to 70 days  disappear soon thereafter
Management: small frequent feedings, avoidance of fatty food;
• a light dry, low fat diet is recommended (crackers)
• Ice chips
• Emotional support from family, especially the husband, & reassurance
from the obstetrician
Management:
• occasionally, a need for prescription of anti-emetics may arise
• Hospitalization for uncontrolled vomiting, especially for those unable
to take in food & oral anti-emetics
• Hydration and correction of fluid & electrolyte imbalance should be
done intravenously
• 2) Disturbances in urination
• enlarging uterus causes direct pressure on the urinary bladder
• frequent urination, bladder irritability, dribbling, nocturia, & susceptibility
to Urinary tract infection
• most marked during the 2nd & 3rd months when the uterus is still a pelvic
organ and is quite adjacent to the bladder
• gradually disappear as the uterus rises from the pelvis to become an
abdominal organ
• Reappear at or near term when the presenting part engages
• 3) Fatigue
• many pregnant women experience lassitude
& easy fatigability in the first few weeks of
pregnancy
• attributed to the increased metabolism
during pregnancy
• 4) Perception of fetal movement
• pregnant woman may experience a slight flutter or brisk movements within
her abdomen
• “Quickening”  awareness of the first movement
• Primigravidas: 18 to 20th week of pregnancy
• Multigravidas: 14th to 16th week of gestation
• increase in intensity & frequency as pregnancy progresses
• may be mistaken by primigravids for peristalsis or spasm of Gastrointestinal
system
• 5) Breast symptoms
• breast tenderness / “Mastodynia”
• range from tingling sensation to frank pain during first few
weeks of pregnancy
• described as tightness or heaviness of the breasts resulting from
breast engorgement
• effects of estrogens which stimulate the mammary duct system
& by progesterones which stimulate the alveolar component
• 5) Breast symptoms
• more pronounced in primigravidas
• less obvious in multiparas (whose breasts may still contain minimal
amounts of milky material or colostrum for months or even years after
their last childbirth especially if breastfeeding was done)
B. Presumptive Signs:
• 1) Cessation of Menstruation
• one of the earlist signs of pregnancy in an otherwise healthy woman
during reproductive years who has regular menstrual cycles
• a delay of 10 or more days  strongly suspect pregnancy
• a 2nd missed period  makes the suspicion stronger
• Amenorrhea is not always a reliable indicator
• 1) Cessation of Menstruation
• Other factors that cause delays: irregular menstrual cycles, emotional
stress, chronic disease, drugs, endocrine disorders, lactation, & other
genitourinary tumors
• Occasionally, uterine bleeding may occur even after conception in 25% of

cases  lesser in amount and paler in color  “implantation bleeding” as
the blastocyst implants in the uterus  will resolve by itself spontaneously
• 2) Anatomical breast changes
• Hormonal stimulation that accompanies pregnancy causes breast
enlargement & vascular engorgement  delicate veins appear visible
just beneath the skin
• Evident at 6 to 8 weeks after conception
• The circumlacteal sebaceous glands of the areola (Montgomery’s
tubercles) become hypertrophied & very prominent
• Areola becomes broader, darker & more prominent
• 2) Anatomical breast changes
• Nipples become considerably larger, more deeply pigmented & with
increased erectility
• By the 16th week, a thick, yellowish fluid (“colostrum”) may be expressed
from the breasts by gentle massage
• If breast enlargement is extensive, striae similar to those in the abdomen
may appear
• Breast size before pregnancy does not necessarily correlate with the
volume of milk production during lactation.
• 3) Changes in the vaginal mucosa
• At 6th week of pregnancy, vaginal mucosa becomes congested &
violaceous, bluish to purplish in color.
• described by James Read Chadwick in 1886
• Chadwick’s sign
• 4) Skin pigmentation changes
• Increased pigmentation of the skin occurs during pregnancy, though not
necessarily specific
• 4.1> Chloasma / “mask of pregnancy” / Melasma gravidarum
• Darkening of the skin over the forehead, bridge of the nose, cheekbones &
neck area
• More prominent in those with darker complexion
• More intensified with exposure to sunlight
• May disappear or at least regress significantly after delivery
• 4.2> Linea nigra
• Darkening of the linea alba (midline of the abdominal skin from
the xiphoid to the symphysis pubis)
• Basis: stimulation of the melanophores by the increase in
melanocyte stimulating hormone
• Other areas may likewise darken (areola, nipples, lower midline of
the abdomen, axilla, neck & groins)
• 4.3> Striae gravidarum / “stretch marks”
• caused by the separation of underlying collagen tissues &
appear as irregular scars
• may appear later in pregnancy when the skin is under
great tension
• the irregular breaks in the abdominal skin may be reddish
or purplish (recent rupture) but may turn silvery white
after delivery
• 4.4> Spider telangiectasias
• Vascular stellate marks which result from high levels of
circulating estrogen
• Blanch when pressure is applied on them
• “Palmar erythema” is an associated sign
• 5) Thermal signs
• a perceptible elevation of body temperature for more
than 3 weeks
• Attributed to the thermogenic effect of progesterone
• During the luteal phase of the menstrual cycle, basal
body temperature rises approximately
0.3 to 0.5ºC over the basal body temperature of
the follicular phase
Probable Evidences of Pregnancy:
• 1) Abdominal enlargement
• progressive increase from 6 weeks onward to near term
• By the end of 12th week of gestation, uterine fundus
may be palpated on the level of the symphysis pubis
• At 16 to 22 weeks, growth appears to be more rapid as
the uterus rises out of the pelvis and into the abdomen
• Linear measurement from symphysis pubis to the
uterine fundus on an empty bladder correlates with the
age of gestation from 16 to 32 weeks (Fundal/fundic
height)
• 1) Abdominal enlargement
• Fundic height measurement is one of the useful tools
in estimating the AOG when the woman cannot recall
her last menstrual history, or not menstruating
regularly, especially when ultrasound is not readily
available
• more pronounced in a multigravida  abdominal wall
has been previously distended by a previous pregnancy
or pregnancies  more lax, flaccid, & pendulous
•  more so if with history of multifetal pregnancies,
polyhydramnios, or fetal macrosomia
• 2) Changes in Uterine Size, Shape & Consistency

• Uterus increases in size to accommodate the
growing products of conception
• Inititally, growth is within the anteroposterior
diameter  urinary frequency & bladder
irritability
• By the 12th week, uterus becomes globular 
average diameter above 8cm all around
• Bimanual examination reveals a softening of the
corpus as compared to the firm to doughy
consistency of the non-pregnant uterus
• 2) Changes in Uterine Size, Shape &

Consistency
• Recognized signs:
• a) “Hegar’s sign”
- softening of the uterine isthmus
resulting in compressibility on bimanual
examination
• b) “Goodell’s sign”
- softening and cyanosis of the cervix
due to increased vascularity of the cervical
tissue; may occur as early as 4 weeks
• 3) Changes in the cervix

• softening of the cervix occurs at about 6 to 8
weeks
• during pregnancy, the cervix is likened to the
consistency of the lips or the nasal cartilage
• Cervical mucus during pregnancy has a
characteristic “beaded” cellular pattern
under the microscope  characterizes the
progestational effect on normal cervical
mucus  replaces the “ferning” pattern
characteristic of estrogen predominance in
the first half of the cycle
• 4) “Braxton – Hicks Contractions”

• Painless irregular contractions which may be both
palpable & visible as the pregnancy progresses
• begin early in pregnancy but become more
perceivable towards the 28th week
• increase in number when the abdomen is
massaged or stimulated
• may be documented during a 2nd trimester
ultrasonography
• 5) Ballottement
• by the 20th week, volume of the fetus is small compared to the
amniotic fluid
• When the examiner moves the uterus from side to side with both
palms on each side of the uterus, one appreciates that something
hard is bouncing inside against the palm’s of one’s hand
• In an internal exam, the examiner may feel the “bounce back” of
the presenting part on the examining finger  “internal
ballottement”
• 6) Physical outlining of the fetus

• With the fetus now becoming bigger, it is possible to feel parts,
especially if mother is not obese & is cooperative
• Huge masses such as myomas or ovarian new growths may be
mistaken for the fetal head
• 7) Endocrine Tests
• Development of various very sensitive & very specific
hormones, particularly, human chorionic gonadotropin (hCG)
• These assays have revolutionized the management of abnormal
pregnancies specifically ectopic pregnancies & gestational
trophoblastic disease resulting in lower maternal rates due to
these diseases
• “hCG”
• Glycoprotein produced by fetal trophoblasts
• basis of most commonly used tests all over the world
• high carbohydrate content (30%)
• molecule has 2 dissimilar subunits: alpha (92 a.a.) and beta (145
a.a.)
• Alpha subunit is similar to those of the luteinizing hormone (LH),
follicle stimulating hormone (FSH), & thyroid stimulating
hormone (TSH)
• “hCG”
• supports early pregnancy by preventing involution of the corpus
luteum (principal site of progesterone formation before the
placenta takes over)
• knowing that LH and hCG both contain the alpha & beta subunits
and these subunits are structurally different with different amino
chains, antibodies very specific for the Beta subunit were
developed  basis for detection of hCG in maternal urine &/or
blood
• “hCG”
• Numerous commercially available OTC tests use various
combinations of different hormones  different sensitivities of
tests
• Although these tests may demonstrate different mixtures of
hormones, all these immunoassays are appropriate for testing
normal pregnancy
• “hCG”
• can be detected from maternal biological fluids (serum & urine)
as early as 8 to 9 days after ovulation (depending of the
sensitivity of the test used)
• Levels increase from day of implantation with peak levels at
about 60 to 90 days with serum levels of approximately 50,000
mIU and decline slowly thereafter until a nadir is reached at
about 14 to 16 weeks of pregnancy
• “hCG”
• False positive results, though rare, can occur
• Women have circulating factors (e.g. heterophilic antibodies in
animal handlers & animal lab technicians) in their serum that
interact with hCG antibodies
• Caution should be exercised whenever clinical & laboratory
results are discordant
• Repeat assay reruns or utilizing other tests may help
• “hCG”
• False positive results
• If unrecognized, this may lead to unwarranted clinical interventions
for conditions such as persistent trophoblastic disease
• One should judge the risks of waiting for confirmation of the results
& the risk of failing to take immediate action
• Several commercially available tests involve the principle of
agglutination-inhibition, radioimmunoassay, enzyme-linked
immunosorbent assay (ELISA), & immunochromatography
Positive Evidences of Pregnancy:
• Presence of any 1 of the following positive signs guarantees the

presence of pregnancy:
• 1) Identification of fetal heart action separately from the that of
the mother
• 2) Perception of active fetal movement by the Examiner
• 3) Recognition of the embryo or fetus by Ultrasound
• 1) Fetal heart action

• Auscultation of distinct FHT separate from the
mother’s own pulse is an assurance of a live
pregnancy
• FHT is faster than that of the mother, 110 to 160
bpm, as compared to 60 to 80 bpm of the mother
• Special precaution must be observed that FHT and
not the maternal pulse is heard  in certain
maternal conditions, the pulse rate can be
increased [e.g. maternal fever, drugs (tocolytics), &
thyrotoxicosis]

• FHT is heard with the ordinary stethoscope by the
18th week
• with a more sensistive instrument using Doppler
principle, FHT can be detected as early as 10 to 12
weeks AOG
• Fetal Echocardiography can demonstrate as early as
48 days from the last normal menstruation  6 to 8
weeks gestational age
• Realtime sonography can demonstrate fetal heart
action & movement by the 2nd month of pregnancy

• Other sounds that may be audible through the abdominal wall other
than that of the FHT are:
• a) Funic souffle or umbilical cord souffle
• b) Uterine souffle
• c) sounds from the movement of the fetus
• d) maternal pulse
• e) gurgling gas in the mother’s GIT

• Other sounds that may be audible through the
abdominal wall other than that of the FHT are:
a) Funic souffle or umbilical cord souffle
- produced by the sound of blood rushing through
the umbilical arteries
- a sharp whistling sound synchronous with the
FHB

• Other sounds that may be audible through the abdominal wall
other than that of the FHT are:
b) Uterine souffle
- a soft blowing sound synchronous with
maternal pulse
- appreciable near both sides of hypogastric
areas of the abdomen
- due to maternal blood rushing through the
dilated uterine vessels
- sometimes can be heard with conditions
resulting from increased flow through the
uterine vessels;
- also, some women have unusually loud aortas
• 2) Perception of Fetal movement

by the Examiner
• After the 20th week, active fetal
movement may be seen & actually
felt by the examiner
• On realtime sonography, actual fetal

movements can be observed much
earlier.
• 3) Recognition of Embryo or Fetus by

Ultrasound Techniques
• the advent of transvaginal sonography (TVS)
has revolutionized the recognition &
management of early pregnancy as well as its
growth & development
• the use of the vaginal probe gives the
opportunity to assess early pregnancies better
with more accuracy
• 3) Recognition of Embryo or Fetus by Ultrasound

Techniques
• A gestational sac may be demonstrated by Abdominal
ultrasonography after only 4 to 5 weeks menstrual age
• Gestational sac as small as 2mm corresponds to about 16
days from ovulation or 10 days from implantation
• By the 5th week, all sacs should be visible
• By the 6th week, FHB must be detected
• Up to 12 weeks, the CRL (crown-rump length) should be
predictive of gestational age
• 3) Recognition of Embryo or Fetus by Ultrasound Techniques

• Other information about the pregnancy that could be verified with
ultrasound & become helpful in subsequent management:
- blighted ovum, number of fetuses, ectopic gestation,
presenting part, fetal anomalies, hydramnios, and IUGR
Differential Diagnosis:
• Pregnancy may be mistaken for other conditions that result in

enlargement of the abdomen
• e.g. myomas (esp. fundal solitary subserous variety), adenomyosis, solid
ovarian masses, hematometra, etc.
• Sensitive hCG tests & ultrasound should settle the problem easily
• “Pseudocyesis”
• aka “Imaginary pregnancy” or “Spurious pregnancy”
• may occur in women nearing menopause or in those who are strongly desirous of pregnancy
• Patient may actually feel or have some or majority of the signs & symptoms pregnancy
without really being pregnant at all
• A careful assessment including a bimanual pelvic exam (BPE) will lead to a correct diagnosis
 uterus evaluated as small & none of the positive signs will be present
• “Pseudocyesis”
• Ultrasound will negate the presence of pregnancy & will convince the
patient that she is not pregnant
• help from a Psychiatrist may be needed to help the patient accept the
situation
Identification of Fetal Life or Death:
• Diagnosis of fetal demise is oftentimes a difficult situation especially in

patients who are very conscientious in coming for regular prenatal check-
ups.
• In 50% of cases, cause of fetal death is unexplainable  important that
every effort must be exhausted to establish the cause of demise
• most will resort to sonography to establish that the fetus is non-viable
• In areas where ultrasound is not available, accessible or affordable, the

clinician must rely on serial BPE & a thorough search for the FHT.
• In cases of fetal demise, uterus may cease to grow or even become
smaller  due to shrinkage or collapse of fetal skeleton and skull with
liquefaction of the fetal brain
• Pregnancy test may not be helpful  trophoblasts of the placenta
continue to produce hCG for several days or weeks after fetal demise
• In the latter half of pregnancy, when the patient has already experienced
quickening, typical story is cessation of fetal movements
• However, some mothers may interpret positional changes for
fetal movements as the fetus floats in the amniotic fluid
• Certain clues may be obtained from physical exam (if the fetal demise had
occurred for sometime already):
• Patients with hyperemesis may not vomit anymore
• Patients with hypertension may have improved BP
• Breasts may lose their turgor & engorgement
• Patient’s weight may start to decrease
• Decrease in fundic height may be appreciated
• On IE, a soft, collapsible fetal skull may be felt through a soft cervix that
may already have started to dilate
• Efforts to hear the FHT with the stethoscope or Doppler are unsuccessful
• Ultrasound should settle the issue of life or death with demonstration of
fetal heart activity
• Tobacco-stained amniotic fluid obtained by amniocentesis or amniotomy
strongly suggests fetal demise
• Ultrasound can also document oligohydramnios / anhydramnios as well as
particulate matters floating in the scanty amniotic fluid
• Radiographic evidences of Fetal Demise: (rarely used)

• 1) Overlapping of the fetal skull (“Spalding’s sign”)
- due to the liquefaction of the brain
• 2) Exaggeration of the fetal spine curvature
• 3) demonstration of gas bubbles in the fetus (“Robert’s sign”)
In Summary
• Availability of commercially over-the-counter ‘do-it-yourself’ pregnancy

test kits that are sensitive enough to diagnose most pregnancies, and the
advent of Ultrasound have made diagnosis of pregnancy a relatively easy
task for the clinician
• However, on occasions where availability, accessibility or affordability of
these tests become a concern, a good history taking & physical
examination including a well-perfomed pelvic examination are important
‘tools’ on hand  where the presumptive, probable and positive signs &
symptoms of pregnancy will be most useful
In Summary
• Once pregnancy is established as viable with proper age assigned, proper

management & monitoring can be started (prenatal care)  to assure a
good healthy fetus to be born at the most appropriate time.
In Summary
Presumptive Symptoms: Presumptive Signs:

1. Nausea with or without Vomiting 1. Amenorrhea
2. Disturbances in Urination 2. Anatomic breast changes
3. Fatigue 3. Changes in the vaginal mucosa
4. Maternal perception of fetal 4. Skin pigmentation changes
movement
5. Thermal signs
5. Breast symptoms
In Summary
Probable evidences: Positive Evidences:

1. Enlargement of the Abdomen 1. Identification of Fetal Heart Tones
2. Changes in the size, shape & consistency 2. Perception of fetal movements by the
of the Uterus Examiner
3. Anatomic changes of the Cervix 3. Recognition of the Embryo or the Fetus
4. Braxton Hicks Contractions by Ultrasound or radiologic methods
5. Ballottement
6. Physical Outlining of the Fetus
7. Positive results of Endocrine Tests
Reference
William’s Obstetrics 25th edition; 2018 chapter 9 Prenatal

Care
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PRECONCEPTIONAL AND PRENATAL CARE

GULLAS COLLEGE OF MEDICINE

Defined as a set of interventions that aim to identify and

1. Improve knowledge, attitudes, and behaviors of men and women related to

1. Gynecologists, internists, and pediatricians have the

2. The occasion of a negative pregnancy test is also an

 May be time consuming, depending on the number and

 Useful information can obtained by asking specific questions

 These are some specific high risk medical conditions:

 By knowing general points about these high risk specific medical

 In addition to assessing diabetic control during the preceding 6 weeks,

 The health and reproductive status of each “blood relative” should be

 Preconceptional folic acid therapy significantly reduced the risk for a

 Despite the demonstrated benefits of folate supplementation, only half of women

• With appropriate preconceptional counseling and phenylalanine-restricted diet

• Therefore,Ideally normalized 3 months before conception and maintained

 In endemic areas such as Mediterranean and Southeast

Recreational Drugs and Smoking

• Preconceptional counseling about fetal risks associated with

Recreational Drugs and Smoking

• Smoking in pregnancy has been consistently associated with numerous adverse

• These risks are largely diminished by cessation before pregnancy, highlighting

• It should be discouraged due to its inherent replacement of

• Many vegetarian diets are protein deficient but can be corrected by

 These include basic tests that are usually performed during

 With proper screening tests, optimizing maternal condition

5. Multipara—a woman who has completed two or more

• Parity is determined by the number of pregnancies

 American Academy of Pediatrics and the American College of

1. Group B Strep (GBS) Infection

 Neural-tube defects can be prevented with daily intake of

Vitamin  Because nutritional sources alone are insufficient, folic

 this vitamin has been associated with congenital

 For women at high risk for inadequate nutrition—for

1. Presumptive evidence: based on signs and symptoms that may

2. Probable evidence: signs that indicate pregnancy the majority of the

3. Positive signs: guarantees the presence of pregnancy; signs that

• Occasionally, uterine bleeding may occur even after conception in 25% of

• 2) Changes in Uterine Size, Shape & Consistency

• 2) Changes in Uterine Size, Shape &

• 3) Changes in the cervix

• 4) “Braxton – Hicks Contractions”

• 6) Physical outlining of the fetus

• Presence of any 1 of the following positive signs guarantees the

• 1) Fetal heart action

• 1) Fetal heart action

• 1) Fetal heart action

• 1) Fetal heart action

• 1) Fetal heart action

• 2) Perception of Fetal movement

• On realtime sonography, actual fetal

• 3) Recognition of Embryo or Fetus by

• 3) Recognition of Embryo or Fetus by Ultrasound

• 3) Recognition of Embryo or Fetus by Ultrasound Techniques

• Pregnancy may be mistaken for other conditions that result in

• Diagnosis of fetal demise is oftentimes a difficult situation especially in

• In areas where ultrasound is not available, accessible or affordable, the