GUIDE to Pregnancy by Edwin Climaco

8/19/2019 GUIDE to Pregnancy by Edwin Climaco

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GUIDE to Pregnancy by Edwin Climaco.

[NAEGELE’s RULE

!irst o"# $now yo%r L&P 't(e day yo%r last )eriod began*+ ,(at wast(e day yo% -rst started bleeding d%ring yo%r last )eriod //////////////// 0 L&P

1(ere is a t(ing called 2Naegele’s R%le.3 It is %sed to calc%late t(e D%eDate 4 or 5 6 wee$s 'a))ro7imation*.

8o% ta$e t(e !irst day o9 yo%r last menstr%al )eriod# min%s : mont(s#)l%s ; days# )l%s < year.

E7am)le= L&P 0 No>ember 6?# 6@<?# t(en t(e D%e date is 0 A%g%st:<# 6@<.

[BIGNB B8&P1&B

<. No more )eriods+ Pregnancy is (ig(ly li$ely i9 <@ or more days(a>e )assed 9rom t(e time o9 e7)ected )eriod in a woman w(o’s)re>io%sly (ad reg%lar cycles.

6. reast c(anges= Increased breast tenderness# increased breastsiFe# ni))les become larger# dar$er# and more erectile. Aerolaebecome broader and more )igmented. A9ter a 9ew mont(s o9)regnancy# t(e breast may e7)ress Col%str%m coming o%t o9ni))les 'lea$ing t(ic$ yellow %id*. 1(ere can be striations in t(es$in.

:. B$in c(anges= Btretc( mar$s or linea nigra 'midline o9 stomac(wall becomes dar$*. 1(ere co%ld be irreg%lar brown )atc(es o9>arying siFe on t(e 9ace and nec$. 1(ere co%ld be angiomas 'redele>ation at a central )oint wit( branc(ing on t(e 9ace# nec$#

c(est# and arms d%e to estrogens. Hasc%lar s)iders. 1(e )almscan start loo$ing more red t(an %s%al.

?. Uter%s c(anges and increases in siFe. y wee$ <6# it is abo%t t(esiFe o9 gra)e9r%it and t(e 9%nd%s o9 t(e %ter%s becomes barely)al)able abo>e t(e )%bic bone.



. Haginal m%cosa discoloration= ,it( )regnancy and increasedblood ow# t(e >agina a))ears dar$ bl%is( or )%r)lis( red.Haginal secretions become t(ic$er wit( a w(ite color d%e toin%ence o9 )rogesterone.

. Perce)tion o9 aby mo>ing= A woman (a>ing (er -rst c(ild mayre)ort 9eeling t(e baby mo>e at 6@ wee$s. A woman w(o’s (ad ababy be9ore# may 9eel t(e baby mo>e at <J wee$s.

;. Na%sea andKor >omiting 'morning sic$ness*= Na%sea and or>omiting are more notable at 6<6 wee$s. It (a))ens mored%ring t(e morning# b%t can occ%r t(ro%g(o%t t(e day. Persistent>omiting can occ%r d%ring early )regnancy.

J. Mair growt( c(anges= 1a$es longer 9or (air to grow.

. Pee= Increased )ress%re 9rom t(e growing %ter%s res%lts inincreased %rinary 9reO%ency# )eeing at nig(t# and bladderirritability.

[I&PR1AN1 MR&NEB 1 N,

(CG 0 MR&NE ! PREGNANC8

It is )rod%ced by 1RPMLAB1B ')eri)(eral cells o9 t(e baby*

(CG can be detected in t(e maternal blood or %rine.

(CG (el)s s%stain t(e cor)%s l%te%m 'a str%ct%re in t(e o>ary t(at*d%ring t(e !IRB1 ; wee$s. 1(e Cor)%s l%te%m ma$es PRGEB1ERNE'(ormone t(at maintains t(e )regnancy*.

In ot(er words# baby ma$es (CG# w(ic( s%stains t(e Cor)%s l%te%m o9t(e mom# w(ic( t(en ma$es )rogesterone to maintain t(e )regnancy.

(CG 9rom baby s%))orts cor)%s l%te%m in mom w(ic( )rod%ces

)rogesterone s%))orts early )regnancy

A9ter ; wee$s# t(e )lacenta ta$es o>er and maintains t(e )regnancy.

(CG can be detected in t(e maternal blood or %rine <6 days a9ter9ertiliFation '::. wee$s a9ter t(e L&P*



(CG increases e>ery ?J (o%rs )rior to <@ wee$s. In general# (CGs(o%ld do%ble e>ery two days. It )ea$s at <@ wee$s. It (its its lowest)oint at <?< wee$s.

Pregnancy tests detect (CG )rod%ced by t(e baby# b%t it can also

detects (CG )rod%ced by ot(er t(ings s%c( as= (ydatidi9orm mole#c(oriocarcinoma# germ cell t%mors# breast cancers# and large cellcarcinoma o9 t(e l%ng.

A gestational sac can be seen in trans>aginal %ltraso%nd w(en (CGle>els are Q<@@.I9 (CG le>els are Q<@@ and yo% don’t see a sac in t(e %ter%s# t(is isan ecto)ic )regnancy.

[PREGNANC8 1EB1B

!irst morning s)ecimens are more acc%rate. (CG concentrationis (ig(er in t(e morning.

1(e tests detect 6 mUKmL o9 (CG and diagnose wit( sensiti>ity by < wee$ a9ter t(e -rst missed menstr%al )eriod.

!ALBE NEGA1IHEB may occ%r i9=

t(e test is )er9ormed too early 'be9ore t(e -rst missed )eriod* t(e %rine is >ery dil%te 'too m%c( water# not concentrated*

!ALBE PBI1IHEB may occ%r wit(=Protein%ria '$idney )roblem* 'con-rm wit( blood (CG*Urinary tract in9ection

1IP= I9 aby’s (eart is not (eard by <@ wee$s# an UB '%ltraso%nd*e>al%ation s(o%ld be )er9ormed to see i9 t(ere is a >iable 'li>ing*

intra%terine )regnancy.

1IP= CRL 0 CrownR%m)lengt( 'lengt( 9rom (ead to b%tt*# is)redicti>e o9 age wit(in ? days.



Pregnancy is di>ided into : 1RI&EB1ERB.

!IRB1 1RI&EB1ER '1<* 0 <<: wee$s.

BECND 1RI&EB1ER '16* 0 <?6; wee$s.

1MIRD 1RI&EB1ER '1:* 0 6J wee$ 5 term.

1erm '29%lly grown3* 0 :;?6 wee$s

,(en yo% do %ltraso%nds in t(e !irst 1rimester# t(e d%e datescalc%lated are more acc%rate and >ary as little as 4K ? days.Ultraso%nds in t(e 6nd and :rd trimester and less acc%rate.

[UL1RABUNDB

Con-rms intra%terine )regnancy 'it r%les o%t an ecto)ic)regnancy# a )regnancy t(at grows o%tside o9 t(e %ter%s*. 1(e%ltraso%nds ma$es s%re t(at t(e baby is growing in t(e %ter%s#w(ere its s%))osed to be.It can be %sed to estimate gestational ageIt can screen 9or str%ct%ral abnormalities

Limitations= Less acc%rate a9ter 6@ wee$s.

[CNCEP1IN= Mow did it (a))en

!ertiliFation is w(en a s)erm -nds t(e egg# and 9ertiliFes it toma$e a Fygote 'baby*. It occ%rs wit(in 6? (o%rs a9ter o>%lation.B)erm can li>e in t(e >agina 9or : days.

1(e Fygote di>ides and 9orms a blastocyst t(at 9reely oats downinto t(e %ter%s.

n day a9ter o>%lation# t(e blastocyst 'baby* im)lants into

t(e endometri%m o9 t(e %ter%s 't(e 2car)et3 o9 t(e %ter%s*.(CG is detected in maternal blood a9ter im)lantation (as ta$en)lace# a))ro7imately J<< days a9ter conce)tion.



[E&R8LG8

,ee$ <= !ertiliFation and start o9 im)lantation

,ee$ 6= !ormation o9 yol$ sac and embryonic dis$

,ee$ := !irst missed menstr%al )eriodS 9ormation o9 )rimiti>estrea$ and ne%ral groo>e.

E&R8NIC PERID

,ee$ ?= Primiti>e (eartbeat# Crownr%m) lengt( 'CRL*a))ro7imately ?.@mm.

,ee$ = Mand and 9oot )lates de>elo).,ee$ = Mand )lates de>elo) digital raysS %))er li)# nose# and

e7ternal ear 9ormed.

,ee$ ;= Umbilical (erniation 'intestines begin growt( o%tsideabdominal ca>ity*

,ee$ J= M%man a))earance# tail (as disa))eared# CRLa))ro7imately :@ mm.

PREHIALE !E1AL PERID

,ee$ = Eyes closing or closed

,ee$ <@= Intestines in abdomenS t(yroid# )ancreas# andgallbladder de>elo)ment.

,ee$ <<= !etal $idneys begin e7creting %rine into amniotic %idS9etal li>er begins to 9%nctionS baby teet( 9ormed in soc$ets.

,ee$ <6= Be7 disting%is(able e7ternallyS 9etal breat(ingmo>ements beginS colonic rotationS 9et%s acti>eS -rst trimesterends.

,ee$ <?= Mead and nec$ ta$e an erect# straig(tline alignment.

,ee$ <= Increased !etal acti>ityS %ltraso%nd can determine se7Smyelination o9 ner>es and ossi-cation o9 bones begin.

,ee$ <J= Egg cells# o>aries# and %ter%s de>elo) in 9emales.



,ee$ 6@= Mead and body 'lan%go* >isibleS testes begin descent inmales.

,ee$ 66= !et%s can (ear# will ree7i>ely mo>e in res)onse tolo%d noise.

HIALE !E1AL PERID

,ee$ 6?= !etal l%ngs de>elo) al>eoli and secrete s%r9actant#9et%s generally ca)able o9 breat(ing air by wee$ 6;.

,ee$ 6J= 1(ird trimester beginsS eyelids %n9%seS m%scle toneincreases.

,ee$ :@= Cerebral gyri and s%lci# w(ic( began to 9orm in wee$6# are now )rominent and begin accelerated 9ormation.

,ee$ :6= !etal imm%ne system 9%nctioning and ca)able o9res)onding to mild in9ections.

,ee$ :?= Herni7 t(ic$ens 'wa7y c(eese li$e s%bstance on baby’ss$in*

,ee$ := !et%s ca)able o9 s%c$ingS meconi%m )resent in 9etalintestines.

,ee$ ?@= D%e Date

[U1ERUB

1(ro%g(o%t t(e )regnancy# m%scle cells o9 t(e %ter%s wills)ontaneo%sly contract. 1(ese contractions# also $nown as ra7ton Mic$ contractions ares)ontaneo%s and irreg%lar. 1(ey may increase in 9reO%encyd%ring t(e last mont( o9 )regnancy.

[,EIGM1 GAIN

I9 normal )re)regnancy weig(t# yo% s(o%ld gain 6: lb d%ring)regnancy. 1(ere s(o%ld be little weig(t gain in 1< wit( most o9t(e weig(t gain in 16 and 1:.



In )re)regnancy &I is T<# weig(t gain s(o%ld be 6J?@lbw(ile w(ose wit( a &IQ6 s(o%lld gain no more t(an 6@lbd%ring )regnancy.

Use an online c(art to -nd o%t yo%r &I.

IDEAL ,EIGM1 GAIN= 1<= <.: lb gained 16 and 1:= .JlbKw$

[DIBEABEB

1(ere are two conditions to watc( o%t 9or d%ring )regnancy.

<. Pr%ritic %rticarial )a)%les and )laO%es o9 )regnancy 'PUPPP*')olymor)(ic er%)tion o9 )regnancy*.nset= 161: # t(e itc(ing is se>ere# red )atc(es andele>ations# distrib%ted in abdomen# t(ig(s# b%ttoc$s#occasionally arms and legs. It’s common.aby= It doesn’t a"ect t(e baby. 1reatment= 1o)ical steroids# antiitc(ing dr%gs '(ydro7yFine#di)(en(ydramineKbenadryl# calamine lotion

6. Intra(e)atic c(olestasis o9 )regnancy 'bile not )ro)erlye7creted 9rom li>er*.nset= 1:# se>ere itc(ing# e7coriations common 'brea$s in t(es$in*# distrib%tion is generaliFed# )alms# and soles. It’scommon '<6*.aby= Btillbirt( 'baby dies in %ter%s* 1reatment= C(ec$ ser%m bile acids# li>er 9%nction tests#antiitc(ing med# %rodeo7yc(oic acid# 9etal testing.

[DIAE1EB+

1(e )lacental (ormone (%man )lacental lactogen is t(o%g(tto ca%se gestational diabetes beca%se it ca%ses ins%linresistance as it increases in )regnancy.



1(e o)timal time to screen 9or gl%cose intolerance is at 66Jwee$s gestation.

!irst 6@ wee$s= Ins%lin sensiti>ity increases in -rst (al9 o9

)regnancy# lower 9asting gl%cose le>els allow 9or glycogensynt(esis and 9at de)osition.

A9ter 6@ wee$s= Ins%lin resistance de>elo)s and )lasma'blood* ins%lin le>els rise. Mig(er le>els o9 bot( ins%lin andgl%cose stim%late %tiliFation o9 gl%cose and li)ids 9or energy.As a res%lt# )regnant women will (a>e mild 9asting(y)oglycemia# )ost)randial (y)erglycemia# and(y)erins%linemia.

[lood Hol%me,ill increase 'es)ecially )lasma*. &ore red blood cells will bemade 'increased retic%locyte co%n*. ot( Memoglobin 'Mb*and t(e (ematocrit will decrease slig(tly.Memoglobin a>erages <6. gKdLLe>els below <<.@ gKdL# es)ecially late in )regnancy s(o%ldbe considered abnormal.

[IRN

ReO%irements 9or iron increase in )regnancy to abo%t <@@@mgKday.Reg%lar diet is not eno%g(# )atients need to ta$e s%))lemental iron.

Normal Anemia o9 )regnancy de>elo)s in 16 d%e to a greatere7)ansion o9 intra>asc%lar >ol%me 'more %id in blood*

[CH systemlood )ress%re decreases in mid )regnancy and rises d%ring t(e lasttrimester. Diastolic )ress%re decreases more t(an systolic.Cardiac 9%nction c(anges begin in t(e -rst J wee$s o9 )regnancy.Cardiac o%t)%t is increased as early as t( wee$ o9 )regnancy d%e to

Decreased systemic >asc%lar resistance and increased (eart rate.

[idneys!ilter 9aster 'increased G!R# Cr clearance# RP,# decreased ser%m Cr#UN*. Bince t(ey -lter 9aster# t(ere is red%ced e"ecti>e dose o9antibiotics and ot(er medications.



Renal t%b%les lose some o9 t(eir resor)ti>e ca)acity= Amino acids# %ricacid# and gl%cose com)letely absorbed. Bodi%m is retained in (ig(erle>els in t(e )regnant 9emale.

[Ureters t%bes t(at carry )ee

Dilate d%e to com)ression 9rom %ter%s at t(e )el>ic brim and t(ee"ect o9 )rogesterone. Dilation in t(e Rig(t side Q Le9t side.Dilated %reters ca%se increased glomer%lar siFe and increased %idow enlarged $idneys. 'rig(t (ydrone)(rosis is a normal -nding in)regnancy*.I9 t(ere is decreased %reteral )eristalsis 'ow*# and increased %reteralcom)ression it can ca%se %rinary stasis '%rine not mo>ing t(ro%g(*w(ic( can lead to asym)tomatic bacter%ria and )yelone)(ritis'in9ection*

[ladderDecreased tone# increased ca)acity )rogressi>ely d%ring )regnancy.Increased %rinary 9reO%ency is d%e to com)ression 9rom %ter%s.Btress incontinence de>elo)s as a res%lt o9 rela7ation o9 bladders%))orts.

[GI tract

E"ects o9 )rogesterone=Decreased lower eso)(ageal s)(incter tone (eartb%rnDecreased bowel )eristalsis consti)ation

Memorr(oids# common in )regnancy# are ca%sed by consti)ation andele>ated )ress%re in >eins below t(e le>el o9 t(e %ter%s.

[Gallbladder

Progesterone im)airs gallbladder contraction by in(ibiting CC smoot(mediated smoot( m%scle stim%lation.Estrogen in(ibits intrad%ctal trans)ort o9 bile acids# also contrib%ting toc(olestasis 'w(ic( can lead to itc(ing*.

C(olestasis wit( increased li)ids and c(olesterol leads to (ig(erincidence o9 gallstones# c(olecystitis# and biliary obstr%ction.

[MR&NEB

Prolactin 5 main 9%nction is to ens%re mil$ )rod%ction. Le>els increaset(ro%g(o%t )regnancy d%e to estradiol.



7ytocin 5 res)onsible 9or lactation# es)ecially mil$ letdown. Increasest(ro%g(o%t t(e )regnancy. Released by ni))le stim%lation and in9antcrying. Ca%ses %terine contractions.

[PRENA1AL CARE

Bome De-nitions.

Gestational age= 1(e time o9 )regnancy co%ting 9rom t(e -rst day o9t(e last menstr%al )eriod 'L&P*.

De>elo)mental age= 1(e time o9 )regnancy co%nting 9rom 9ertiliFation.

!irst 1rimester= @<: wee$s.Becond 1rimester= <?6; wee$s. 1(ird 1rimester= 6J wee$birt(Embryo= !ertiliFation 5 J wee$s!et%s= wee$sbirt(Pre>iable= T6? wee$sPreterm= 6@: wee$s 1erm= :;?6 wee$s

Gra>idity= 1(e n%mber o9 times a woman (as been )regnant. 8o% areGra>ida <.

Parity= 1(e n%mber o9 times a woman (as (ad a )regnancy t(at led toa birt( a9ter 6@ wee$s gestation or an in9ant Q @@g. 8o% are Para @.

[!reO%ency o9 bstetric >isits

T6J wee$s= E>ery mont(6J: wee$s= E>ery 6: wee$s:?< wee$s= nce )er wee$

?<?6 wee$s= E>ery 6: days 9or 9etal testing.?6 wee$s or more= Plan 9or deli>ery

[Prenatal >isits

!IRB1 HIBI1<. Mistory and P(ysical e7am



6. Labs= MctKMgb# R( !actor# lood ty)e# Ab screen# Pa) smear#Gonorr(ea and C(lamydia c%lt%res# %rine analysis ')rotein#gl%cose# $etones*# Urine c%lt%re# In9ection screen 'R%bella#By)(ilis# Me) # MIH# 1*# Cystic -brosis screen# %rine dr%gscreen# (emoglobin electro)(oresis.

[<< <: wee$s

<. MP6. !etal e7am= !etal (eart tones:. Urine di)= Protein# gl%cose# le%$ocytes?. !irsttrimester screen

[<6@ wee$s

<. MP6. !etal e7am= !etal (eart !%ndal (eig(t:. Urine Di)= Protein# gl%cose# and le%$ocytes?. !etal Ultraso%nd= Anatomy# dating. V%ad screen. Genetic amniocentesis 'i9 indicated*

[66J wee$s

<. MP6. !etal e7am= !etal (eart !%ndal (eig(t:. Labs=

Com)lete blood co%nt# Ab screen# Gonorr(ea and C(lamydiac%lt%res 'o)tional*# Diabetes screen# Urine Di)= Protein# gl%cose#le%$ocytes# By)(ilis screen 'o)tional*.

?. Gi>e anti D imm%noglob%lin i9 indicated '6J wee$s*

[,ee$ :6

<. MP6. !etal e7am= !etal (eart 9%ndal (eig(t:. Urine di)= Protein# gl%cose# le%$ocytes

[,ee$ :



<. MP6. !etal e7am= !etal (eart# 9%ndal (eig(t# 9etal )resentation:. Urine Di)= Protein# gl%cose# le%$ocytes?. Gro%) stre) c%lt%re

. MIH 5 reO%ired in some states

[,ee$ :J

<. MP6. !etal e7am= !etal (eart# 9%ndal (eig(t# 9etal )resentation:. Urine di)= Protein# gl%cose# le%$ocytes?. Cer>ical e7am '9reO%ency is contro>ersial*

[,ee$ :

<. MP6. !etal e7am= !etal (eart# 9%ndal (eig(t# 9etal )resentation:. Urine di)= Protein# gl%cose# le%$ocytes

[,ee$ ?@

<. MP6. !etal e7am= !etal (eart# 9%ndal (eig(t# 9etal )resentation.:. Urine di)= )rotein# gl%cose# le%$ocytes

1MINGB 1 L U1 !R ..

<. Presence o9 aby mo>ement 'no mo>ements are bad*6. Haginal bleeding:. Lea$age o9 %id?. ContractionsKabdominal )ain. Preeclam)sia sym)toms= Meadac(e# >is%al dist%rbances# rig(t

%))er O%adrant )ain.

RU1INE 1I&EB I&P1AN1 1EB1B

<<<: wee$s= !irst trimester screenS only 9or Down syndromeN%c(al transl%cency meas%red by %ltraso%nd&aternal ser%m )regnancy associated )lasma )rotein A 'PAPPA* and9ree beta(%man c(orionic gonadotro)in 'b(CG*.



In Down syndrome# t(e N1 is increased# beta(CG is increased# PAPPAis decreased.

<<J wee$s= V%ad screen 'range <6< wee$s*.UnconW%gated estriol

A!Pbeta(CGIn(ibin A

<J6@ wee$s= Ultraso%nd 9or anatomyKdating

66J wee$s= ne (o%r @g gl%cose tolerance test 'G11* to screen 9orgestational diabetes

6J wee$s= Rec(ec$ antibody screen# administer R(ogam i9 indicated.

::; wee$s=Gro%) stre) c%lt%re1(ird trimester MIH testing is mandated by law in some states

[!UNDAL MEIGM1

Uter%s 0 m%scle t(at (o%ses t(e baby.

As t(e baby grows# t(e leading edge o9 t(e %ter%s 'to)*# or t(e 9%nd%sgrows s%)eriorly in t(e abdomen# toward t(e maternal (ead 'in ot(er

words it grows %)wards*. !%ndal (eig(t 'in cm* ro%g(ly corres)onds togestational age 'in wee$s*.

Uter%s at le>el o9 )%bic sym)(ysis= <6 wee$sUter%s between )%bic sym)(ysis and %mbilic%s= < wee$sUter%s at t(e le>el o9 t(e %mbilic%s= 6@ wee$sUterine (eig(t correlates to wee$s gestation= 6@ 5 : wee$s

!%ndal (eig(t s(o%ld correlate to gestational age 'wee$s* 4K :. I9 notsconsider inacc%rate dating 'most common*# m%lti)le gestations# ormolar )regnancy.

Past a))ro7imately : wee$s gestation# t(e 9%ndal (eig(t may notcorres)ond to t(e gestational age d%e to t(e 9etal descent into t(e)el>is.

[!E1AL BURHEILLANCE



Be>eral tests can be %sed to monitor t(e (ealt( o9 t(e 9et%s. 1(eyincl%de 9etal mo>ement co%nts# nonstress test 'NB1*# contractionstress test 'CB1*# bio)(ysical )ro-le 'PP*# t(e modi-ed PP 'mPP*#and Do))ler %ltrasonogra)(y. In general t(ey are )er9ormed in 1:# b%tmay be done earlier. 1(ese tests assess 9or c(ornic %tero)lacental

ins%Xciency.

!E1AL &H&EN1 CUN1B

!etal mo>ment co%nts# or $ic$ co%nts# may be )er9ormed at (ome byt(e )atient in order to monitor t(e baby’s (ealt(. 1(e )atient s(o%ldselect a time at w(ic( t(e 9et%s %s%ally is acti>e# %s%ally a9ter a meal. 1(e le>el o9 acti>ity di"ers 9or eac( baby# and most (a>e slee) cycleso9 6@?@ min.

1(ere are se>eral ways to assess 9etal mo>emnts=

As$ t(e )atient to record daily (ow long it ta$es t(e 9et%s to ma$e <@mo>ements. !or most# t(is is %s%ally ac(ie>ed in abo%t 6 (r# (owe>ert(is is >ariable.Alternati>ely# as$ t(e )atient to record t(e n%mber o9 9etal mo>emntsin < (r t(ree times )er wee$. A baseline is establis(ed in t(is way.!or bot( o9 t(ese strategies# contact a doctor i9 t(ere is a c(ange 9romt(e normal )attern or n%mber o9 mo>ements recorded.

NNB1REBB 1EB1 'NB1*

NB1 e>al%ates 9o%r com)onents o9 t(e 9etal (eart rate tracing.

aseline= Normally <<@<@ beatsKmin.Hariability= eattobeat irreg%larity and wa>iness o9 t(e !MR '9etal(eart rate*. Presence o9 >ariability reects an intact and mat%re brainstem and (eart.

Period c(anges= transient accelerations or decelerations=YEarly deceleration= Hagally mediated# ca%sed by (ead com)ression%s%ally at cer>ical dilation o9 ?;cm.YHariable deceleration= Ca%sed by cord com)ressionYLate deceleration= Reects (y)o7emiaYAcceleration= At least two accelerations o9 at least < beatsKmin abo>e

baseline 9or < sec in a 6@ min )eriod. Presence o9 accelerations 09etal well being. Reacti>e NB1 0 6 or more accelerations o>er 6@min%tes.

Uterine contractions are also recorded to (el) inter)ret t(e NB1.

Preterm 9et%ses are 9reO%ently nonreacti>e=



Y6?6J wee$s= U) to @ nonreacti>eY6J:6 wee$s= < nonreacti>e

An NB1 %s%ally ta$es 6@?@ min%tes to com)lete. I9 t(e NB1 isnonreacti>e# t(e baby may be aslee). I9 t(is is s%s)ected# as$ t(e

)atient to eat or drin$ to ma$e t(e baby acti>e i9 not acti>e wit(in <6(o%rs# t(en additional testing may need to be )er9ormed.

CN1RAC1IN B1REBB 1EB1 'CB1*

1(e contraction stress test meas%res (ow t(e !MR reacts to %terinecontractions. 1(e CB1 can be )er9ormed i9 t(e NB1 is nonreacti>e. 1(e!MR and t(e contractions are recorded sim%ltaneo%sly. D%ring acontraction# t(e blood ow to t(e )lacenta briey decreases. A wello7ygenated 9et%s can com)ensate# and t(ere are no decels in t(e !MR.I9 t(e 9et%s is already com)romised wit( low le>els o9 o7ygen# t(e

contraction may ca%se a late deceleration in !MR# w(ic( reects(y)o7emia in t(e 9et%s.

Patient is )laced in lateral rec%mbent )osition and contractions arestim%lated.Administration o9 o7ytocin 'Pitocin*Ni))le stim%lation '6 min sel9 stim%lation t(ro%g(o%t clot(es e>ery min*

AdeO%ate contractionscc%r t(ree times in <@ min%tes

Lasting at least ?@ sec&oderate to )al)ation

Inter)reted as t(e )resence or absence o9 late decelerationsNegati>e= No late or signi-cant >ariable decelerations.Positi>e= Late decelerations 9ollowing @ or more o9 contractionsEO%i>ocal= Intermittent late decels or signi-cant >ariable decelerationsUnsatis9actory= !ewer t(an t(ree contractions in <@ min%tes

Contraindications=Preterm labor )atients at (ig( ris$ o9 deli>ery

Premat%re r%)t%re o9 membranes 'PR&*Mistory o9 e7tensi>e %terine s%rgery or )re>io%s csectionnown )lacenta )re>ia

[UL1RABUNDB



<. Btandard UB )er9ormed 9or= 9etal n%mber# )resentation# 9etal>iability# gestational age assessment# amniotic %id >ol%me# 9etalbiometry# 9etal anatomic s%r>ey# )lacental location.

6. Limited 5 goal directed UB= )resentation# )lacental locationintra)art%m# adW%ct to in>asi>e )roced%res

:. B)ecialiFed 'le>el 6* 5 )er9ormed w(en (ig( s%s)icion o9 anomaly

DPPLER 5 A baby’s (eartbeat can be detected wit( Do))ler at J<6wee$s o9 gestation. !etal (eart starts beating at 666? days.

io)(ysical Pro-le 'PP*

A PP is t(e combo o9 t(e nonstress test and an %ltraso%nd e7am# 9ora total o9 ->e com)onents=

<. NB1= A))ro)riate >ariation o9 9etal (eart rate.

6. reat(ing= Q or 0 < e)isode o9 r(yt(mic breat(ing mo>ements o9 :@ sec or more wit(in :@ min%tes.

:. &o>ement= Q or 0 : discrete body or limb mo>ements wit(in :@min%tes

?. &%scle tone= Q or 0 < e)isode o9 e7tension wit( ret%rn to e7ionor o)eningKclosing o9 a (and

. Determination o9 amniotic %id >ol%me= Bingle >ertical )oc$et o9amniotic %id meas%ring Q or 0 6cm is considered adeO%ate 'oran A!I Qcm*.

Eac( o9 t(e category is gi>e a score o9 @ or 6@= Abnormal# absent# or ins%Xcient

6= Normal and )resent as )re>io%sly de-ned 1otal )ossible score is <@ )ointsNormal score= J<@EO%i>ocal= Abnormal= T or 0 ?

&odi-ed io)(ysical Pro-le 'mPP* 0 NB1 4 A!IA modi-ed bio)(ysical )ro-le 'mPP* incl%des two com)onents. AnNB1 and an amniotic %id inde7 'A!I*Normal amniotic %id >ol%me >aries and increases wit( gestationalage. 1(e )ea$ >ol%me is J@@<@@@mL at ::; wee$s gestation. In t(e

late 1: or 1:# amniotic %id >ol%me re)resents 9etal %rine o%t)%t. I9t(ere is %tero)lacental dys9%nction and decrease o7ygentaiton to t(e9et%s# t(e 9et%s )re9erentially s(%nts blood to brain and (eart# lea>ingt(e 9etal $idneys %nder)er9%sed. 1(is res%lts in decreased 9etal %rineo%)%t and as a res%lt decreased amniotic %id. 1(ere9ore# t(e A!I is%sed as a meas%re o9 c(ronic %tero)lacental 9%nction. 1(e A!I is t(e s%m o9 amniotic %id meas%red in ? O%adarants o9 t(e%ter%s >ia t(e UB.



A!I Q cm= AdeO%ateA!I T or 0 cm= Abnormal 'oligo(ydramnios*A!I Q or 0 6 cm= Abnormal ')oly(ydramnios*

LIGM8DRA&NIB=&ost common ca%se= R%)t%red membranesAssociated wit( Intra%terine growt( restriction @ o9 timeE>al%ate 9or GU mal9ormations

PL8M8DRA&NIB&any ca%ses# incl%ding!etal mal9ormation 'anence)(aly# eso)(ageal atresia*Genetic disorders&aternal diabetes

&%lti)le gestation!etal anemiaHir%ses

Associated wit( %terine o>erdistention# res%lting inPreterm laborPR& ')remat%re r%)t%re o9 membranes*!etal mal)osition

DPPLER HELCI&E1R8

Do))ler sonogra)(y is a nonin>asi>e tec(niO%e %sed to assess 9etal(emodynamic >asc%lar resistance by imaging s)eci-c 9etal >esselsUmbilical Artery and %mbilical >einAortaMeart&CA

Commony meas%red ow indices arePea$ systolic 9reO s(i9t 'B*Pea$ diastolic 9reO s(i9t 'D*

&ean )ea$ 9reO s(i9t o>er t(e cardiac cycle 'A*Bystolic to diastolic ratio 'BKD*Resistance inde7 'BDKA*

!low >elocity wa>e9orms di"er in normal siFed 9et%ses as com)ared tot(ose s%"ering 9rom growt( restriction!et%ses wit( normal growt(= Mig(>elocity diastolic ow



!et%ses wit( restricted growt(= Decreased >elocity diastolic ow#increased ow resistance 'increased BKD* in %mbilical artery anddecreased resistance 'decreased BKD* in &CAHery se>ere intra%terine growt( restriction= !low may be absent ore>en re>ersed.

Abnormalow is %s%ally t(e res%lt o9 )lacental ins%Xciency anddys9%nction# res%lting in 9etal (y)o7ia and acidosis. 1(is may ind%cet(e )(enomenom o9 brain s)aring=

<. Increased BKD in %mbilical artery 'increased resistance*6. Decreased BKD in &CA 'decreased resistance*:. Ada)ti>e res)onse to 9etal (y)o7ia

!IRB1 1RI&EB1ER BCREEN

)tional nonin>asi>e e>al%ation )er9ormed between << and <:. It is ascreening test and may reO%ire 9%rt(er diagnostic tests i9 t(e res%ltsare abnormal.

1(e !1B combines a maternal blood screening test wit( a 9etal UBe>al%ation to identi9y ris$ 9or Down Byndrome 'trisomy 6<*. It can alsodetect trisomy <: 'Pata%*# 1%rner syndrome# Edwards syndrome'trisomy <J*# b%t N1 ne%ral t%be de9ects. 'DEP1*

1(e res%lts o9 maternal (ormone le>els and 9etal UB# along wit( t(e

mot(er’s age# are combined to determine ris$ 9actors. 1(e 9ollowing isassessed in !1B=

P N1++

&aternal ser%m= !ree or total beta(CG# PAPPAUB at <<<: wee$s gestation= N1 meas%rement o9 %id %nder t(ebaby’s s$in at t(e le>el o9 t(e nec$. 'increased in down’s*In t(e case o9 Down syndrome# beta(CG will be increased and PAPPAwill be decreased.

1(e !1B is considered t(e most acc%rate nonin>asi>e screeningmet(od a>aialbe wit( sensiti>ity o9 J 9or Down syndrome.

VUAD BCREEN



Bcreening test o9 maternal ser%m t(at e>al%ated t(e ris$ a )atient (as9or deli>ering a baby wit( Down syndrome# Edwards syndrome# orN1Ds 'DEN*. nly indicates t(e ris$. !%t(er diagnostics tests may be)er9ormed to con-rm -ndings.Ideally )er9ormed at <<J wee$s gestation 'range is <6< wee$s*.

Bensiti>ity= J<E>al%ates 9o%r maternal ser%m analytes= MIAEZ(CGZIn(ibin AZ&aternal Ber%m A!PZUnconW%gated estriol

Abnormal O%ad screen con-rm dates 'UB* genetic co%nseling 4targeted UB diagnostic )roced%re 'amniocentesis to obtain 9etalcells* $aryoty)e analysis

&ost common ca%se o9 abnormal O%ad screen= Incorrect dates

&A1ERNAL BERU& A!P

&BAPP -rst )rod%ced in t(e yol$ sac and t(en by t(e 9etal GI tract andli>er.Normall# it )asses by di"%sion t(ro%g(t t(e c(orion and amnion.

Y It begins to rise at <: wee$s and )ea$s at :6 wee$s.

In general &BA!P le>els Q 66. m%lti)les o9 t(e mean '&&* warrant

9%rt(er in>estrigation# as t(ey are s%s)icio%s o9 N1Ds

&BA!P screening more acc%rate btwn < and <J wee$s.

Mig( le>els are associated wKUnderestimation o9 gestational ageN1DsAbdominal wall de9ects 'gastroc(isis and om)(alocele*.9etal deat()lacental abnormalities 'abr%)tion*m%lti)le gestations

ot(ers= low maternal weig(t# 9etal s$in de9ects# cystic (ygroma#sacrococcygeal teratoma# oligo(ydrmamnios

Low le>els are associated wit(=>erestimation o9 gestational age



C(romosomal trisomies= Down syndrome 'trisomy 6<*# Edwardssyndrome 'trisomy <J*# 9etal deat(# molar )regnancy# (ig( maternalweig(t.

VUAD BCREEN BU&&AR8

Down '1risomy 6<*= In(ibin A beta (CG 0 increased# Estriol A!P 0decreased

Edwards '1risomy <J*= A!P# beta (CG# Estriol 0 decreased# decreasedin(ibin.

N1D= increased A!P# ot(er t(ree are normal.

[EB1RIL

Low le>els associated wit(=1risomy 6< 'Down*1risomy <J 'Edwards*Possibly low in 1risomy <: 'Pata%*

[(CGMig( le>els associated wit( 1risomy 6<Low le>els are associated wit(= 1risomy <J# anence)(aly.

[In(ibin A

1(is (ormone secreted t(e )lacenta and gran%losa celsl in t(e 9emaleMig( le>els associated wit( 1risomy 6<Low le>els associated wit( 1risomy <J

[B)ecialiFed Le>el 6 Utraso%ndPer9ormed by maternal 9etal s)ecialistsE>al%ates t(e 9etal anomaly 9or mar$ers

A&NICEN1EBIB&ost 9reO em)loyed tec(niO%e %sed to obtain 9etal cells. Needle )laced

t(ro%g( maternal ab wall and %ter%s wit( UB g%idance. Amniotic %idis obtained 9or >ario%s )%r)oses. Us%ally done at <6@ wee$s.

Yaryoty)e= !etal cells obtained >ia amniocentesis are c%lt%red and ane>al%ation o9 t(e c(romosomes is )er9ormed in t(e 9ollowingcirc%mstances.9etal anomaly s%s)ected on UBabnormal ser%m O%ad



!amily (Ko o9 congenital abnormalitiesindicateed 9or )ts Q or 0 : years o9 age beca%se t(ey (a>e a (ig(erris$ o9 ane%)loidy

!etal l%ng mat%rity= Us%ally done near term in order to deli>er t(e baby

t(ers= rKo in9ection# c(ec$ bilir%bin

Ris$s=PainKcram)ingHaginal s)otting 'resol>es s)ontaneo%sly*Amniotic 9%id lea$age in <6 o9 casesBym)tomatic amnionitis in T< in <@@@ )tsRate o9 !E1AL LBB is T or 0 . '< in 6@@* and is less in e7)erienced(ands.

CMRINIC HILLUB BA&PLING 'CHB*CHB is a tec( in w(ic( as small sam)le o9 c(orionic >illi is ta$entranscer>ically or transabdominally and analyFed. 1y)ically done E1,EEN <6 ,EEB GEB1A1IN YYYYYY

In9o on 9etal $aryoty)eioc(emical assays or DNA tests can be done earlier t(anamniocentesis.Com)lications .<)reterm deli>eryPR&

9etal inW%ry# es)ecially limb abnormalities i9 )er9ormed be9ore wee$sgestation

Di"erences btwn CHB and Amniocentesis

YCHB1rans>aginal or transabdominal as)iration o9 )rec%rsor cells in t(eintra%terine ca>itye>al%ates c(romosomal abnormalities b%t does N1 e>al%ate N1DsDone at <6 wee$s

(ig(er ris$s '9etal loss (as < ris$# limb de9ects i9 done T w$s*#diagnosis acc%racy com)arable to amniocentesis.

YAmniocentesis1ransabdominal as)iration o9 amniotic %id %sing UB g%ided needleE>al%ates c(romosomal abnormalitiesdone at <6@ wee$sindicated i9 Q: yo mot(er at time o9 deli>ery



ris$ o9 9etal loss '.*

CRDCEN1EBIBa$a )erc%nteano%s %mblilical blood sam)ling 'PUB*# 9etal bloodsam)ling# and %mbilical >ein sam)ling. Needle ad>anced

transabdominally %nder UB g%idance into a cord >essel to sam)le 9etalbood. 1y)ically )er9ormed a9ter <; wee$s.Allows 9or ra)id diag beca%se o9 t(e (ig( n%mber o9 n%cleated cells',Cs* w(ic( reO%ire no c%lt%ring.

Indications9etal $aryoty)ing beca%se o9 9etal anomaliesto determine t(e 9etal (ematocrit in isomm%niFation or se>ere 9etalanemia.to assay 9etal )latelet co%nts# acid base stat%s# antibody le>els# bloodc(emistries.

GENE1IC testingIndicationsAd>anced maternal age is t(e most common indication 9or )renataltesting.)re>io%s c(ild wK abnormal $aryoty)e$nown )arental c(romosomal abnormality 'balanced translocation or)oint m%tation*9etal str%ct%ral abnormality on sonogram%ne7)lained IUGR 'intra%terine growt( retardation*

abnormal O%ad screen

tec(niO%es=<. !IBM= a s)eci-c DNA )robe wK a %orescent label t(at binds

(omologo%s DNAS allows ID o9 s)eci-c sites along a c(romosome.Loo$s 9or s)eci-c abnormalities# >ery sensiti>e.

6. aryoty)ing= allows >is%aliFation o9 c(romosome siFe# banding)atterns# and centromere )osition. Loo$s 9or ALL c(romosomalabnormalities b%t not as sensiti>e.

[!D+ N%tritional needs o9 )regnant woman

,eig(t gain in )regnancy i9 yo%r &I is normal '<J.6?.*= 6: lbs

,eig(t gain 9or normal &I= 6: lbs YYYY,eig(t gain o9 T<lb '%nless obese* can ca%se 9etal IUGR,eig(t gain o9 Q?@lb increased morbidity.



1arget weig(t gain o9 < lb in 1<S :?lb Kmont( in remaining)regnancy.

Ris$ 9actors 9or IUGR)oor n%trition

tobacco smo$ingdr%g addictionalco(olismse>ere anemiat(rombo)(ilia '(y)ercoag%lability*)rolonged )regnancy)reeclam)siac(romosomal abnormalities)lacental in9arctionK(ematomain9ectionsm%lti)le gestations

DIE1t(e a>g woman m%st cons%me an additional :@@$calKday beyondbaseline needs and an additional @@$calKday w(en breast9eeding(ig( )rotein ';@;gKday*# low sim)le carbs and 9ats# (ig( -ber.

1o )re>ent N1Ds 'ne%ral t%be de9ects* !olic acid ?@@microgramKday # or .?mgKday.increased dietary 9olate is reO%ired to )re>ent N1Ds?@@ microgramsKday is reO%ired. Ideal i9 started : mont(s be9ore

)regnancyi9 )re>io%s c(ild wit( N1D# need 9olic acid ?mgKday starting ? wee$s)rior to conce)tion and t(ro%g( 1<.

:@mg o9 elemental iron is recommended in 16 and 1:. 1otal o9 <gneeded 9or )regnancy. '@@mg 9or increased RC mass# :@@ mg 9or9et%s# 6@@ mg 9or GI losses*

1(e recommended dietary allowance 9or calci%m is increased in)regnancy to <6@@mgKday and may be met adeO%ately wit( diet alone

1(e RDA 9or Finc is increased 9rom < to 6@ mgKday.

Hegetarians=YLactoo>o>egetarians in general (a>e no n%tritional de-ciencies#e7ce)t )ossibly iron and Finc.YHegans 5 m%st cons%me s%Xcicient >egetable )roteins to )ro>ide allessential amino acids normally 9o%nd in animal )rotein.B%))lementation o9 Finc# <6# and iron is necessary.



Pica 5 ocassionally seen# com)%lsi>e ingestion o9 non9ood s%bstancess%c( as ice# clay or starc( 'amylo)(agia*.

Ca"eine 5 contained in co"ee# tea# c(ocolate# cola be>erages.

Ingestion o9 ca"eine 'Q:@@ mgKd* may increase ris$ o9 earlys)ontateno%s abortion among nonsmo$ing women.Ad>erse maternal e"ects incl%de=insomniaacid indigestionre%7%rinary 9reO

E7erciselow ris$# abdominal e7ercises# water e7ercises ideala>oid e7ercise t(at reO%ires )rolonged time in t(e s%)ine )osition

s(o%ld be a>oided in 16 and 1:.e7ercise s(o%ld be sto))ed I9 )t e7)ericnes o7ygen de)ri>ation'9atig%e# diFFiness# or s(ortness o9 breat(*Contraindications to e7ercise=E>idence o9 IUGRPersistent >aginal bleedingIncom)etent cer>icRis$ 9actors 9or )reterm laborR%)t%re o9 membranesPregnancy ind%ced (y)ertensionK)reeclam)siaKeclam)sia

NAUBEA H&I1ING

Rec%rrent NH in 1< occ%rs in @ o9 )regnanciesi9 se>ere# can res%lt in de(ydration# electrolyte imbalance# andmaln%trition.&anagement o9 mild cases incl%des=a>oid 9atty or s)icy 9oods# eat small 9reO%ent meals# in(aling)e))ermint oil >a)ors# drin$ing ginger teas.

My)eremesis gra>idar%m= e7cessi>e >omiting d%ring )regnancy#de(ydration# electrolyte imbalances. A (y)oc(loremic al$alosis may

occ%r. R7 wit( IH! de7trose# antiemetics.

De7trose incl%ded beca%se it (el)s to decrease t(e $etosis# w(ic( canca%se a >icio%s cycle o9 na%sea. Dectrose can (el) brea$ t(e cycle.

&anagement o9 se>ere cases incl%des=IH %ids '%s%ally wK de7trosecontaining %id*



discontin%ation o9 >itaminKmineral s%))lements %ntil sym)tomss%bsideanti(istmanines)romet(aFine 'R7 nK>*metoclo)ramide 'R7 nK>*

i> dro)eridol 'R7 nK>*

MEAR1URN:@ o9 )regnanciesEtiology=normal rela7ation o9 LEBmec(anical 9orces 1reatmentelimination o9 s)icyKacidic 9oodssmall 9reO%ent mealsdecreasing amo%nt o9 liO%id cons%med wit( eac( meal

limiting 9ood and liO%id cons%med wit( eac( meallimiting 9ood and liO%id inta$e a 9ew (o%rs )rior to bedtimeslee)ing wit( (ead ele>ated on )illows%tiliFing liO%id 9orms o9 antacids and M6 rece)tors in(ibitors.

CNB1IPA1INcommong+&anagement=increasing inta$e o9 (ig( -ber 9oods#increasing liO%ids%se )sylli%m containing )rod%cts '&etam%cil*

a>oid enemas# strong cat(artics 'accelerates de9ecation*# andla7ati>es.

HARCBI1IEBcommon in )reg# )artic%larly in lower e7tremities and >%l>a.can ca%se c(ronic )ain and s%)er-cial t(rombo)(lebitis&anagemnt=A>oidance o9 garments t(at constrict at t(e $nee and %))er legUse o9 s%))ort stoc$ingsincreased )eriods o9 rest wit( ele>ation o9 t(e lower e7tremities.

ME&RRMIDB 'im)ro>ae a9ter deli>ery*

Haricosities o9 t(e recta l >eins are common in )regnancy.&anagement=Cool sitF bat(sstool so9tenersincreased %id and -ber inta$e to )re>ent constit)ation(emorr(oidal ointment to decrease swelling# itc(ing and discom9ot



to)ical anest(etic s)ray or steroid cream 9or t(e se>ere )ain o9t(rombosed (emorr(oids. '(emmor(oidectomy can be )er9ormedsa9ely d%ring )regnancy i9 necessary*.

LEG CRA&PB

ccc%r in @ o9 )regnant# ty)ically at nig(t and in 1:most commonly occ%r in t(e cal>esrecommendation is to massage and stretc( a"ected m%scle gro%)s

ACACME 1y)ically )rogressi>e in )regnancy ':@@*&anagement=minimiFing time standingwearing a s%))ort belt o>er t(e lower abdomenacetamino)(en 9or )ain as needed

e7ercise to increase bac$ strengt(s%))orti>e s(oes and a>oidance o9 (ig( (ellsgentle bac$ massage

RUND LIGA&EN1 PAINs(ar)# bilateral or %nilateral groin )ain.9reO%ently occ%rs in 16&ay increase wit( s%dden mo>ementKc(ange in )ositionmay be alle>iated by )atient getting on (ands and $nees wit( (ead onoor and b%ttoc$s in air.

Be7%al interco%rseno restrictions d%ring normal )regnancyni))le stim%lation# >aginal )enetration and orgasm may ca%se releaseo9 o7ytocin and )rostaglandins.# res%lting in %terine contractions.CI= r%)t%red membranes# )lacentia )re>ia# )reterm labor

Em)loymenta>oid wor$ aciti>ities t(at increase ris$ o9 9allsKtra%ma# a>oid to7ins#c(emicals

1ra>el

est time to tra>el is in 16. Past )ossible com)lications o9 miscarriagein 1< and not yet enco%ntered ris$ o9 )reterm labor o9 1:I9 sitting 9or long time# )atient s(o%ld attem)t to stretc( lowere7tremities and wal$ 9or <@ min%tes e>ery 6 (o%rs. 1(is is to a>oidDH1sAir tra>el not recommended a9ter : wee$s



,(en tra>eling abroad# t(e %s%al )reca%tions regarding ingestion o9%n)%ri-ed water and raw 9oods s(o%ld be ta$en. A))ro)riate >acciness(o%ld be gi>en.

[I&&UNI\A1INB

Delaye>accines %ntil a9ter t(e <st

trimester to a>oid tertatogenicity.Li>e >accines are not gi>en in )regnancyImm%ne glob%lins are sa9e in )regnancy and are recommended 9orwomen e7)osed to measles# (e) A # tetan%s # >aricella'c(ic$en)o7*# and rabies.A>oid getting )regnant ? wee$s a9ter recei>ing li>e >accines# s%c( asmeasles# m%m)s# r%bella '&&R* or >aricella.

CN1AC1 DC1R I&&EDIA1EL8 IN 1MEBE BI1UA1INB=Haginal bleeding

Lea$age o9 %id 9rom t(e >aginaR(yt(mic abdominal cram)ing or bac$ )ain# QK(r t(at does notim)ro>e wit( (ydration and lying s%)ine.Progressi>e and )rolonged abdominal )ain!e>er and c(illsDys%ria or abnomrlaly clo%dy %rine 'indicati>e o9 U1I*Prolonged >omiting wit( inability to (old down liO%ids or solids 9or Q6?(rProgressi>e# se>ere (eadac(esS >is%al c(angesS or generaliFed edema')reeclam)tic symotoms*BeiF%res 'eclam)sia*

Prolonged decrease in 9reO%ency o9 9etal mo>ements.

[Haccines t(at are Ba9e in )regnancyInacti>ated )olioInacti>ated ty)(oidInacti>ated in%enFaDi)(t(reia1etan%sRabies&eningococc%s '&PBH?*

Me)

Not well st%died in )regnant woman# b%t de9er %ntil 9%rt(er recs iss%ed=MPH&eningococc%s '&PH?*Pne%mococco%s 'PPH*Me) A



Administer only i9 ris$ o%tweig(ts bene-t8ellow 9e>erAnt(ra7Pert%ssis

UNBA!E 'LIHE*oral )oliooral t(y)(oidintranasal in%enFa&&RHaricellaCGs(ingles

GUIDE to Pregnancy by Edwin Climaco

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Transcript of GUIDE to Pregnancy by Edwin Climaco