OBSTETRICS LECTURE: 1.05 Preconception and Prenatal Care LECTURER: Dr. Jay Arnold Famador DATE: TRANSCRIBER: Group Number 23 (Santos), Sallao, Saluta, Sanarez, Sanchez EDITOR: Franco Sison IV (09175908828)
OUTLINE I. Preconcepti onal Care II. Diagnosis of Pregnanc y III. Initial Prenatal Care IV. Nutrition V. Common Concerns VI. Vaccination Vaccination No objectives were given. References (APA Bibliography format): format) : Lecturer’s powerpoint Williams Obstetrics 24 th ed. Legend: Italicized – Italicized – quoted quoted from the lecturer; bold – bold – emphasis, emphasis, or from references
A.
Medical History
Genetic Diseases
Reproductive Reproductive History
Parental Age Social History
I. PRECONCEPTIONAL PRECONCEPTIONAL CARE Prec on cepti cep tion on al Car e
B.
Table 1. Information collected during counseling sessions that can affect a future pregnancy. Adapted pregnancy. Adapted from lecturer’s lecturer’s powerpoint.
“Set of interventions that aim to identify and modify biochemical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management”
Goals
Improve knowledge, attitudes and behaviors of men and women related to preconceptional health Assure that all women of childbearing age receive preconceptional care services – – including evidencebased risk screening, health promotion, and interventions that will enable them to enter pregnancy in optimal health Reduces risks indicated by a previous adverse pregnancy outcome through interconceptional interventions to prevent or minimize recurrent adverse outcomes Reduce the disparities in adverse pregnancy outcomes
C. Counselli ng Sessio Sessio n
Gynecologists, internists, family practitioners, and pediatricians have the best opportunity to provide preventive counseling during periodic health maintenance examinations Improve knowledge Includes information collection, which may be time consuming depending on the number and complexity of factors that require assessment (Williams 24th ed) Intake evaluation includes a thorough review of the medical, obstetrical, social, and family histories These answers are reviewed with the couple to ensure appropriate follow-up, including obtaining relevant medical records
Screening Tests
A.
Diabetes Mellitus Seizure Disorder Immunizations Neural Tube Defects Phenylketonuria Thalassemia Infertility Abnormal pregnancy outcomes Obstetrical complications Maternal Paternal Drugs and smoking Environmental exposure Diet Exercise Hematological test Diabetes, thyroid, cardiac, neurological
II. DIAGNOSIS OF PREGNANCY Sig ns and Symp to ms
Cessation of menses Abrupt cessation of menses in a woman with with a o spontaneous, predictable cycle Not a reliable indication of pregnancy until 10 days o or more after more after the time of expected onset of menses Occasionally, uterine bleeding suggestive of o menses may occur after conception during the first half of pregnancy as a consequence of blastocyst implantation Changes Changes in cervical mucus Beaded or cellular appearance appearance of cervical mucus o when spread on a glass slide Progesterone lowers Progesterone lowers sodium chloride concentration o = no crystallization = no fernlike pattern of mucus Changes in the breasts Increase in size of breasts and nipples o Nipples deeply pigmented, more erectile o May also be seen in women women taking estrogeno containing contraceptives Discoloration of the vaginal mucosa Vaginal mucosa purplish, engorged (Chadwick o sign) sign ) Presumptive sign, not conclusive o Skin changes Increased pigmentation o Abdominal striae o Changes Changes in the uterus First weeks of pr egnancy egnancy = = Grows principally in o the anteroposterior diameter, feels doughy or elastic 6-8 weeks weeks = firm cervix, soft body, softened o isthmus (Hegar’s sign) 12 weeks = weeks = globular, 8 cm diameter o
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B)
Changes in the cervix Increased softening as pregnancy advances o Soft as lips of the mouth (in primigravidas) o External cervical cervical os and cervical canal may o become sufficiently patulous to admit a fingertip, but the internal os should remain remain closed FHT Ultrasonography by 5 weeks o Doppler by 10 weeks o Stethoscope by 17 weeks o Other Other soun ds Fundic soufflé – soufflé – sharp, whistling sound caused o by the rush of blood through umbilical arteries, synchronous with fetal pulse Uterine Uterine souf flé – flé – soft, blowing sound blowing sound usually at o the lower portion of the uterus caused by passage of blood through dilated uterine vessels, synchronous with maternal pulse Fetal movements o Intestinal peristalsis o Fetal movement perception by 20 weeks o 16-18 weeks – weeks – primigravids primigravids 18-20 weeks - multigravids
Figure 1. Serum hCG levels increase from the day of implantation and reach peak levels at 60 to 70 days. Thereafter, days. Thereafter, the concentration declines slowly until a plateau is reached at approximately 16 weeks. Adapted from Williams Williams Obstetrics 24 th Edition.
C.
Ultrasoni c Recognitio n
B.
Pregnancy Tests (Williams, 24 th ed.) Detection of hCG in maternal maternal blood and urine urine is the basis for endocrine assays of pregnancy hCG hCG - glycoprotein with high carbohydrate content Subtle hCG variants differ by their carbohydrate moieties hCG is a heterodimer composed of two dissimilar subunits, designated and which are non-covalently linked The -subunit is identical to those of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroidstimulating hormone (TSH) The -subunit is structurally distinct from LH, FSH, and TSH With this recognition, antibodies were developed o with high specificity for the hCG -subunit This specificity allows its detection, and numerous o commercial immunoassays are available for measuring serum and urine hCG levels Measurement Measurement of -hCG Prevents involution of corpus luteum o Produced by trophoblast cells o Syncytiotrophoblast produce hCG in amounts o that increase exponentially during the first trimester following implantation (Williams) Detected in maternal plasma or urine 8 – 9 – 9 days after ovulation Doubling time = 1.4 – 1.4 – 2 2 days Reach peak levels at 60 – 60 – 70 70 days Nadir at 4 – 16 – 16 weeks
Transvaginal sonography has revolutionized early pregnancy imaging and is commonly used to accurately establish gestational age and confirm pregnancy location (Williams 24th ed.) Gestational sac as early as 4-5 weeks menstrual age The gestational sac is a small anechoic fluid o collection with the endometrial cavity (Williams 24th ed.) Heart sound detectable by 6 weeks After 6 weeks, weeks, an embryo is seen as a linear o structure immediately adjacent to the yolk sac (Williams 24th ed.) Crown-rump length is predicative of gestational age within 4 days up to 12 weeks
III. INITIAL PRENATAL CARE A. Major Majo r Goals Go als of Pren atal Care
To define the health status of the mother and the fetus To estimate the gestational age of the fetus To initiate a plan for continuing obstetrical care Prenatal care should be initiated as soon as there is a reasonable likelihood of pregnancy (Williams 24 th ed.) Typical components of the initial visit are summarized in the Table 1 in the appendix
B. Prenatal Record (Williams 24th ed.)
C.
Use of a standardized record within a perinatal healthcare systems greatly aids antepartum and intrapartum management Standardizing documentation may allow communication and care continuity between providers and enable objective measures of care quality to be evaluated over time and across different clinical settings
Definitio n of Terms Nulligravida Woman who is not now and has never been o pregnant Gravida Woman who is or has been pregnant, o irrespective of the pregnancy outcome With the establishment of the first pregnancy, o she becomes primigravida (Williams)
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B) With successive pregnancies, a multigravida (Williams) Nullipara Woman who has never completed completed a o pregnancy beyond 20 weeks gestation She may not have been pregnant or may have o had a spontaneous or elective abortion(s) or an ectopic pregnancy (Williams) Primipara Woman who has been delivered only once of a o fetus or fetuses born dead or alive with an estimated length of gestation of 20 or more weeks Multipara Woman who has completed two pregnancies o to 20 or more weeks. It is determined by the number of pregnancies reaching 20 weeks, not by the number of fetuses delivered o
Discharges, dysuria, pruritus Sexual history Coitarche, number of partners(and his/her o previous partner), Post-coital bleed, dyspareunia o Contraceptive history Use of steroidal contraceptives o Past Medical History Social history cigarette smoking, alcohol and illicit drug use o Cigarette smoking – – spontaneous abortion, LBW, preterm delivery, abruptio placenta Fetal alcohol syndrome Domestic violence screening o o
(The following sub-bullets are taken from Williams 24 th Ed)
D. Normal Pregnancy Duration Table 2. 2. Duration of a normal pregnancy. Adapted from lecturer’s powerpoint.
Normal duration of pregnancy Naegele Rule
280 days or 40 weeks
Plus 7 days, minus 3 months from the LMP Gestational Age From the first day of the last menstrual period Ovulatory 2 weeks shorter than the AOG Example of Naegele rule: If the last menstrual period began September 10, the expected date of delivery is June 17 (Williams) Gestational age assumes pregnancy to have begun approximately 2 weeks before ovulation, which is not always the case (Williams)
Table 3. Division of a pregnancy into trimesters. Adapted from lecturer’s powerpoint.
Trimesters 1st trimester Up to 14 weeks 2nd trimester 14 to 28 weeks 3rd trimester 28 to 42 weeks 3 periods of 14 weeks each Clinical use of trimesters trimesters to to describe a specific specific pregnancy is imprecise in modern obstetrics (Williams 24th ed.) Weeks of gestation completed is the clinically appropriate unit, as precise knowledge of fetal age is imperative for ideal obstetrical management E.
History “The same essentials go into appropriate history taking from the pregnant woman as elsewhere in medicine.” (Cunningham, 2014) Queries regarding medical and surgical disorders, detailed information regarding previous pregnancies (Cunningham, 2014) Menstrual history regularity of menses o Obstetric history previous complications during pregnancy o Gynecologic history
F.
Pattern of assaultive and coercive behaviour that may include: Physical injury Psychological abuse Sexual assault Progressive isolation Stalking Deprivation Intimidation Reproductive coercion Recognized as a major public health problem With the possible exception of preeclampsia, domestic violence is more prevalent than any major medical condition detectable through routine prenatal screening Intimate partner violence is associated with an increased risk of severe adverse perinatal outcomes including Preterm delivery Fetal-growth restriction Perinatal dreath
Physical Exam Complete PE Fundic height Distance over the abdominal wall from the top of o the symphysis pubis to the top of the fundus Bladder must be emptied before making making the the o measurement Between 20-31 weeks, weeks , height of uterine fundus in o cm correlates closely with gestational age in weeks “used to monitor fetal growth and amniotic fluid volume” (Cunningham, 2014)
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B)
Fetal Heart Heart Sound s 16-19 weeks o
Table 2. Maternal conditions and related procedures. Adapted from lecturer’s powerpoint.
(The following sub-bullets are taken from W illiams 24th Ed)
Normal FHR: 110-160 bpm Can be heard as early as: 6-7 weeks via real-time sonography 10 weeks via Doppler ultrasound 16 weeks via standard nonamplified stethoscope
Pelvic Exam Speculum Exam o Speculum lubricated with warm water Nabothian cysts may be noted Pap smear Cultures for Neisseria and Chlamydia if warranted Internal Exam o Consistency, length and dilatation of the cervix Fetal presentation Bony architecture of the pelvis Anomalies of the vagina and perineum Examination of vulva and perianal region o Cervical, vaginal and vulvar lesions further evaluated by colposcopy, biopsy, culture or dark-field examination DRE o
GDM
Between 24-28 weeks; Earlier for those with high risk
Chlamydial Infection
Screened during first prenatal visit for those with high risk
Gonococcal Infection
Women with risk factors or symptoms cultured at an early prenatal visit and again in the 3 rd trimester
Fetal Fibronectin
Detection in vaginal fluid used to forecast preterm delivery in women with contractions
GBS Infection
Vaginal and rectal GBS cultures obtained between 35 and 37 weeks
G. Subsequent visits
Traditional Schedule of Visits Monthly until 28 weeks o Every 2 weeks until 36 weeks o Weekly >36 weeks o
H. Prenatal Surveillance
Fetal o
o o o
Maternal o
o
o
Heart rate Size – Size – current current and rate of change Amount of amniotic fluid Presenting part and station (late in pregnancy) Activity
o o
IV. NUTRITION Recommended total weight gain: Women carrying twins o 35-45 lbs. (16-20 kg) Young adolescents (< 2 years after menarche) o Gains at the upper end of the range Short women (< 62 in. or < 157 cm) o Gains at the lower end of the range
Table 3. BMI Classification and Recommended Recommended Total Weight Gain over the Pregnancy. Adapted Pregnancy. Adapted from from the lecturer’s powerpoint.
Weight-for-heigh t Categor Categor y Category LOW NORMAL HIGH OBESE
Blood Pressure Weight Current and amount of change Symptoms Fundic height Vaginal exam late in pregnancy to confirm presenting part and determine station, estimation of pelvic capacity, and consistency, effacement and dilatation of the cervix
CALORIES PROTEIN IRON
ZINC IODINE FOLIC ACID
I.
Ancil lary Procedures
BMI <19.8 19.8-26 26-29 >29
Recommended Total Weight Gain kg lb 12.5-18 28.40 11.5-16 25-35 7-11.5 15-25 7 15
Table 4. Recommended Recommended dietary allowance dur ing a pr egnancy. Adapted from lecturer’s lecturer’s powerpoint. powerpoint.
CALCIUM
o
VITAMIN A
100-300 kcal increases/day Increased protein demands (5-6g/day) 7mg/day used during pregnancy 27mg.day recommended supplement after the first 4 months Increased calcium retention and intestinal absorption during pregnancy 12mg/day Increased birth weight and head circumference 220 ug Deficiency leads to cretinism in the infants 4mg/day supplementation recommended during periconceptional period (before conception to the first 3 months Associated with neural tube tube defects Supplementation not recommended 10,000-50,000 IU daily may cause birth defects (as in Isotretinoin) Vit. A deficiency cause maternal anemia and preterm birth
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B) VITAMIN B12 VITAMIN B6
VITAMIN C VITAMIN 12
Decreased stores in pregnancy Strict vegetarians have very low levels 2mg/day recommended for those at risk for inadequate nutrition (substance abuse, adolescence, multifetal gestations) 80-85mg/day, usually provided by regular diet Decreased stores in pregnancy Strict vegetarians have very low levels V.
EMPLOYMENT
TRAVEL BATHING CLOTHING BOWEL HABITS
COITUS DENTITION CAFFEINE MEDICATIONS
NAUSEA AND VOMITING
BACKACHE
VARICOSITIES
HEMORRHOIDS
HEARTBURN
PICA PTYALISM FATIGUE
LEUKORRHEA
BACTERIAL VAGINOSIS
COMMON CONCERNS
Table 5. 5. Common concerns d uring p regnancy. Adapted regnancy. Adapted from the lecturer’s powerpoint.
EXERCISE
HEADACHE
should be encouraged to engage in regular, moderate-intensity physical activity 30 min or more each day women who work at jobs requiring prolonged standing are at greater risk for preterm delivery uncomplicated pregnancies can continue to work until onset of labor 4-6 weeks generally required before return of physiological condition to normal can safely fly up to 36 weeks No contraindications Avoid tight fitting fitting clothes Constipation is common due to prolonged transit time and compression of the bowel by the uterus Hemorrhoids and prolapsed of the rectal mucosa may occur should be avoided not a contraindication to dental treatment > 5 cups of coffee per day may increase risk for abortion drug that exerts a systemic effect in the mother will cross the placenta to reach the embryo and the fetus between the first and second missed menstrual period and may continue up to 14-16 weeks High levels of serum hCG Small, frequent feedings Increases as gestational age increases Reduced by squatting rather than bending over when reaching down, proving back support with a pillow when sitting down more prominent as pregnancy advances, as weight increases, and as the length of time spent upright is prolonged increased pressure in the rectal veins due to obstruction of venous return by the enlarging uterus upward displacement and compression of the stomach by the uterus, combined with relaxation of the lower esophageal sphincter considered to be triggered by severe iron deficiency stimulation of salivary glands by ingestion of starch Remits spontaneously by the fourth month of pregnancy
TRICHOMONIASIS
CANDIDIASIS
no cause, and treatment is symptomatic May also be due to hypertensive disorders Increased mucus secretion by cervical glands in response to hyperestrogenemia May be due to trichomonal or yeast Maldistribution of normal vaginal flora Gardnerella vaginalis, Mobiluncus, Bacteroides species Bacteroides species Treatment reserved for those with fishysmelling discharge with Metronidazole 500 mg BID x 7 days Foamy leucorrhea with pruritus and irritation Metronidazole 500 mg BID x 7 days Asymptomatic infection requires treatment Miconazole, clotrimazole, nystatin VI.
no
VACCINATION
Table 6. Recommended Recommended vaccinations during pregnancy. Adapted pregnancy. Adapted from from the lecturer’s powerpoint.
IMMUNOBIOLOGICAL AGENT
MMR
Polio (liv e attenuated)
Varicella
Influenza
INDICATIONS FOR IMMUNIZATION DURING PREGNANCY Live vaccine contraindicated; Vaccinate susceptible women postpartum Post exposure prophylaxis for measles given within 6 days of exposure Indicated for susceptible women
Contraindicated, but no adverse outcomes reported during pregnancy; vaccinate postpartum Immune globulin should be considered for exposed pregnant women to protect against maternal infection; for women who will be pregnant during the influenza season
DOSE SCHEDULE
Single dose SC
Primary: Two Primary: Two doses of enhancedpotency inactivated virus SC at 4-8 week intervals and 3 rd dose 6-12 months after 2 nd dose
Two doses needed: 2nd dose 4-8 weeks after first dose
One dose IM every year
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B) Hepatitis B
for those at risk for infection; Exposed newborn needs birth dose vaccination and immune globulin ASAP
Three-dose series IM at 0, 1, and 6 months
IV. KEY MESSAGE A woman planning to have a child should have a medical evaluation before she becomes pregnant. A thorough medical history and physical examination should be done in order to identify high-risk patients and danger signals of pregnancy. Laboratory work-ups must be done to all pregnant patients and abnormal results should be referred for management.
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IV. REVIEW QUESTIONS Set of interventions that aim to identify and modify biochemical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management A. Pren atal Care B. Pregnancy Test C. Preconcepti Preconcepti onal Care T/F: The fundic soufflé is a soft, blowing sound usually heard at the lower portion of the uterus caused by passage of blood through dilated uterine vessels, synchronous with maternal pulse. What term best describes a woman who has never completed a pregnancy beyond 20 weeks gestation? A. Nullipara B. Primipara C. Multipara 32-week G1P0 pregnant woman came to you for her pre-natal checkup. Upon examination, you found out that the fetus was well with good FHR and no signs of distress while the mother exhibited no danger signs. When shall you advise her for her next routine pre-natal visit? A. After two weeks B. After a month C. After a week D. During her 37th week of pregnancy
END OF TRANS
An swer s:
CFAA
OBSTETRICS: PRECONCEPTION PRECONCEPTION AND PRENATAL CARE (2018B) APPENDIX Table 1. Typical 1. Typical components of routine prenatal care. Adapted from Lecturers’ Lecturers’ Powerpoint
