Prenatal Care

Doris K Ramirez MDVisiting Professor UAG

dkramirezmd@yahoo.com

Outline• Background

• Assessement of gestational age

• Physical exam

• Lab test

• Educate the patient

Prenatal Care

• Most frequently used health service in USA

• 80% start in 1st Trimester

• Ave 12 visits per patient

WHAT DO WE KNOW ABOUT PRENATAL CARE

WHEN SHOULD PRENATAL CARE START?

A. WHEN TOM CRUISE RETURNS YOUR CALL?

B. 1ST DAY AFTER ONE HAVE MISSED THEIR PERIOD?

C. PRECONCEPTIONAL?D. B/CE. A/BF. ALL OF THE ABOVE?G. NONE OF THE ABOVE?

IDEALLY, a woman planning to have a child should have a medical evaluation before she becomes

pregnant.

*Place the patient on PNV-Folic acid (Vit B) 400mcg or .4 mg to prevent

neural tube defects (which are birth defects of the

baby's brain (anencephaly) or spine (spina bifida). *

Before Pregnancy:

Prenatal is helpful:

• Managing the remaining weeks of the pregnancy • Planning for possible complications with the birth

process • Planning for problems that may occur in the

newborn infant • Determine the outcome of pregnancy• Deciding whether to continue the pregnancy • Help promote a live and healthy baby

How do you detect if your are pregnant?

1) urine or blood test

2) ultrasound

bHCG “Beta Human Chorionic Gonadotropin “

• Where?

• This hormone is released by trophoblastic tissue in the placenta

• It may be produced by a choriocarcinoma or some other germ cell tumors, or even other forms of cancer, e.g. lung cancer.

Pregnancy (HCG)• Urine pregnancy test-2wks after ovulation

• Serum pregnancy test-6-8 days after ovulation

• Qualitative: measures whether bHCG is present (25mlU/ml is +)

• Quantitative: measures the exact amount of bHCG produced.

Levels of bHCG• Below bHCG 1200 mlU/ml-

doubles Q 48-72hrs

• 1200-6000mlU/ml-

doubles Q72-96hrs

• >6000mlU/ml-

may take more than 4 days to double.

• Failure to double: miscarriage or ECTOPIC

+ Pregnancy test:Clinical Visits with no high risk:

• Q4Wks until 28wks

• Q2W from 28-36wks

• Every wk from >36wks

Ultrasonography

• When?

As early as 4.5wks• What do you see?

Transvaginal-

bHCG>1500 see gestational sac.

Abdominal sono:

bHCG>6000 see heart beat

5wks embryo and yolk sac

7wk embryo and yolk sac

Accurate Assessment of gestational age

• May be critical information later.

• CRL (crown rump length)- 1-13wks accurate date within +/- 3-5 days of the actual due date.

• 2nd tri(14-28wks): biparietal diameter will accurately predict the due date within 7-10 days in most cases .

• 3rd tri(>28wks): + or – 2-3wks, femur is most accurate

• Naegele rules- EDC=LMP+7d-3m

• Fundal height= gest. Age from 18-30wks

First prenatal visit:• take a careful detail history (looking for factors

that might increase the risk for the pregnant woman.)

• Check for BP, urine, weight at every visit.• Physical examination• Routine laboratory test (looking for specific issues

that could influence pregnancy) • Expectations and preparation for delivery

(childbirth classes, preferred pain mgt, plans for feeding)

Risk Assessment• A. Obtain detailed family history from all patient/PMH

• 1. Hx. Of MR, ONTD other anomalies• 2. if adopted

• B. Formal questionnaire• 1. helps with difficult areas• 2. Fill out prior to visit

• C. Social history• 1. smoking• 2. Drug and alcohol use• 3. other exposuresD. Allergies and medications

PHYSICAL EXAMINATION

Steps you should take to prepare for the examination:*Ask woman to empty bladder (collect urine for testing).*Prepare to follow a logical order.*Prepare to chart logically immediately after exam (make notes).*Remember to explain everything you are doing.

Each prenatal visit:• Maternal Weight• Maternal BP• UA• History• Abdominal Examination:

• Fundal height• Fetal heart• Fetal position and shape

•The amount of weight you should gain depends on your weight before pregnancy. You should gain:

25-35 pounds: If you were a healthy weight before preg. 28-40 pounds: If you were underweight before pregnancy 15-25 pounds: If you were overweight before pregnancy

Maternal Weight

• Healthy Weight Before Pregnancy: • 3-5 pounds during the first trimester • Approximately 1-2 pounds per week in the second trimester • Approximately 1-2 pounds per week in the third trimester

• Underweight Before Pregnancy: • 5-6 pounds or more in your first trimester; this also can depend

on how underweight you were before pregnancy & your health care provider's recommendations

• 1-2 pounds per week in the second and third trimesters • Overweight Before Pregnancy:

• Approximately 1-2 pounds in the first trimester • Approximately 1 pound per week during the last six months

Maternal BP• Check the Blood pressure every visit and compare

to pre-pregnancy BP. • <20wks with high BP is considered Chronic

Hypertension• >20 with high BP no proteinuria= PIH• High BP, proteinuria, and edema= preeclampsia.• Low BP you want to think about endocrine dis.

Evaluating UA

• PH- Measures acidity/alkalinity of the urine, Levels below normal indicate high fluid intake, levels above the norm indicate inadequate fluids & dehydration.

• Glucose: Normal = <+ 1. High levels of glucose may be one indicator of high blood sugar, gestational diabetes or diabetes mellitus. Always ask what woman has recently eaten if her BS is high.

• Protein: Normal = Negative, Small amounts may be in urine from vaginal secretions & dehydration, Amounts of 2+ to 4+ may indicate be one indicator of possible UTI, Kidney Infection or PIH.

• Leukoesterase: UTI vs trich.• Ketones: Normal = Negative. Ketones are products of the breakdown

of fatty acids caused by fasting. The body breaks down fats because there are not enough carbohydrates and proteins available. Ketones may be deleterious to fetus.

History• Ask for:

• Bleeding/ spotting: sex, cervicitis, chlamydia, polyp, cancer

• Leaking: color and quantity- urine or amnio• Quickening: 17-19wks wk • Nausea and vomiting• Nutrition- hydration • History of recent illness

Abdominal Exam• Inspection (Look for scars, linea,striae,symmetry)• Palpation:

Assess Fundal Height (cm) approximates weeks of gestation, position, presentation and EFW.

• Auscultation:

Detect heart beat (120-160bpm) with doppler– usually heard after 9wks or stethoscope @16wks

Fundal Height

The height

of the fundus

in cm. equals

the number

of weeks

gestation +/-2.

FUNDAL HEIGHT

MacDonald’s Rule:(cm of fundal height=wks of gestation)

• 12wks- pubis bone

• 16wks- between the pubis bone & umbilicus

• 20wks- umbilicus

• Full term- xyphoid process

Leopold’s Maneuver• First Maneuver (What is

at the fundus)

• Examiner faces woman's head

• Using two hands and compressing the maternal abdomen, a sense of fetal direction is obtained (vertical or transverse).

• Palpate the uterine fundus

2nd Maneuver• Second Maneuver (Assess

Spine and small parts)• Examiner faces woman's

head • Palpate with one hand on

each side of abdomen • Palpate fetus between two

hands • Assess which side is spine

and where extremities are located

3rd Maneuver• Third Maneuver (what is

presenting at the pelvis)• Examiner faces woman's

feet and Palpate just above symphysis pubis

• Palpate fetal presenting part between two hands

• The purpose of this maneuver is to determine the pelvic position of the presenting part

• Assess for Fetal Descent

4th Maneuver• Fourth Maneuver (Where

is the Cephalic prominence)

• Examiner faces woman's head

• Apply downward pressure on uterine fundus

• Hold presenting part between index finger and thumb

• Assess for cephalic versus Breech Presentation

Labs:

Initial visit

•Pap smear

•Urinalysis

•Urine &cervical CX

•CBC

•Blood type &AB screening

•Rubella, Hep B, HIV, syphilis,

•Sickle cell, cystic fibrosis..

•sono

15-20wks Triple screen/sono

24-28wks GTT, Rhogam, CBC

36wks Cervical cultures

Triple Marker testingA. Components

1. AFP2. Estriol3. beta HCG

B. When Drawn1. between 14-21wks2. Send only to certified lab3. provide key adjustment information

a. obese- run low c. Multiple- run high b. diabetes- run low d. dates

Risk assessment in pregnancy• Triple screen (16-20wks)

• 1. should be offered to all patients >35y/o• 2. consider written form if declining

• Routine ultrasono• Weekly assessment

• 1. ongoing assessement of fetal well being• 2. Further tests as indicted• 3. Counseling as needed

Triple Marker testing• Abnormal results in:

• Anencephay, Spina bifida, ventral wall de• Incidence of Anenceph. 1-2/1000 births• Incidence increase to 15X if affected sibling• Marker: elevated AFP(>2.5MOM)• Morbidity, death, paralysis, MR• Further test: level II US, amniocentesis• Plans: method of delivery, perinatology,

schedule C/S

• 1. confirm Dates

• 2. if too early, repeat test

• 3. approx 70/1000 are abnl low

• If low AFP, Estriol, and elevated HCG there is a risk in Downs syn

• If unexplained consider level IIUS or Amnio

Low AFP (.8MoM)

Third Trimester lab• Third trimester• 26-28wks: hematocrit (if low, mother will receive

iron supplementation) • 26-28wks: glucose loading test (GLT) - screens

for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; if fasting glucose > 105 mg/dL, gestational diabetes is suggestive.

• >36wks- vaginal/rectal culture for Group B strep.,Gonn, Chlamydia

Prenatal Diagnostics• Non-invasive:

• 1. maternal serum testing- triple screen• 2. Diagnostic ultrasound (level 2)• 3. Fetal echo

• Invasive• 1 .Amniocentesis –performed 15-20wks• 2. Chorionic villus sampling -@ 9.5-12.5wks, (associated with limb

defects in the fetus)

• 3. fetal tissue sampling

 

Educate

• Educated the patient about pregnancy

• Educated the patient about danger signs

• Educated them of things they should avoid during pregnancy.

• Breast swelling and tenderness • Linea nigra from umbilicus to

pubis • Telangiectasias • Palmar erythema • Amenorrhea • Nausea and vomiting • Breast pain • Fetal movement 17-19wks• Sciatica (Pain caused by

compression of the sciatic nerve)

• CIGARETTE SMOKING

•ALCOHOL AND DRUG USE

• EXPOSURE TO TERATOGENS.

•EXCESSIVE PHYSICAL WORK

AVOID DURING PREGNANCY

Encourage Good Nutrition

Should include: Whole and organic foods; Proteins, fats; micronutrients such as, calcium, iron, magnesium,

zinc and vitamins; moderate salt restriction, all in a balanced diet.

What constitutes a high risk pregnancy?

2 Factors that influence high risk pregnancy:

• Maternal risk:• Preexisting medical

condition• Age <20 or >35• Social

economic>lower• Work environment• Recreational habits• Multiple fetus• Previous pregnancy hx• Access to medical care

• Fetus risk:• Genetic defects• Structural anomaly• Size and number of

fetus (twins)• Intrauterine death

Risk factors associated with MOMFactors primarily physiological in

origin• Multiple pregnancy• Previous hx. Preterm

labor• Vaginal bleeding in 2nd

trimester• undx,. UTI

pyelonephritis• Teenage pregnancy• Maternal low body wt.

• Polyhydramnios• Incompetent cervix• Hx. Of multiple D&C

or abortions• Previous uterine or

cervical sx.• DES exposure

What are lifestyle risk Factors?• Recreational drug use• Cigarette smoking

during pregnancy• Low weight gain in

pregnancy• Physically demanding

work: factory, nursing

• Stress: physical, emotional, mental

• Poor diet/dehydration• Alcoholism• Lack of family or

social support

How do high risk factors affect pregnancy?

• Greatest risk is preterm labor• Preterm labor resulting in preterm birth accounts

for 75% or preventable perinatal mortality• Preterm birth increases the risk for neonatal health

issues: • Cerebral palsy• Respiratory difficulties• Cardiac aliments• Blindness• Long term development delays

Smoking:

• Abruptio placenta• Placenta previa• PROM• Prematurity • Spontaneous abortion• Sudden infant death syndrome• Low birth wt.• Respiratory illness• Reduction in supply of breast milk

Drugs:

• Cocaine: placental abruptionLow birth wtPreterm laborNeonatal withdrawal

• Opiates: neonatal withdrawal, low birth wt, death• Alcohol: fetal ETOH syndrome• Caffeine: assoc. low birth wt. with excessive

caffeine ingestion.

MultiparaHas increase risk:

• Placenta previa

• Postpartum hemorrhage secondary to uterine atony

• Increased incidence of twins

Second trimester elective abortion

• Risk:

• Spontaneous abortion

• Incompetent cervix

• Preterm delivery

• Low birthweight

MFM• Offers assessment and screening of fetus

• Ultrasound

• Umbilical sampling

Management• Increase medical attention in the form of increase office

visits to monitoring fetal well-being.• ultrasound level one/two-doppler flow, fetal echo• Amniocentesis or CVS• genetic testing • blood testing• drug therapy• work restriction• bed rest and hospitalization.• NST and biophysical profiles

NST- noninvasive test of fetal activity the correlates with fetal

well-being.

Two accelerations

At least 15 beats

Amplitude of 15sec

During a 20min

Period.

BPP• The score for a nonstress test with a healthy

(reactive) result is 2. During the ultrasound exam four things are

checked and given a score of 0 or 2: • the amount of amniotic fluid • movements of the baby's body • the baby's muscle tone • breathing movements made by the baby

Score Interpretation MGT

10 Normal Repeat testing

8 Normal Repeat testing

6 Suspect chronic asphyxia If>36wk, deliver or rpt in 4-6hr

4 Suspect chronic asphyxia If >32wk, deliver

Or rpt 4-6

0-2 Strongly suspect chronic asphyxia

Extend testing 120min, if score<4 deliver @ any gest. age

Management based on BPP score

BPP-designed to identify a compromised fetus during the

antepartum period

• score of 8 or 10 is considered normal.

• A score of 6 is borderline.

• A score of 4 or less suggests there may be problems. Your health care provider may recommend an early delivery of the baby.

Thank

You