2. Prenatal Care
Doris K Ramirez MD
Visiting Professor UAG
dkramirezmd@yahoo.com

3. Outline
• Background
• Assessement of gestational age
• Physical exam
• Lab test
• Educate the patient

4. Prenatal Care
• Most frequently used health
service in USA
• 80% start in 1st
Trimester
• Ave 12 visits per patient

5. WHAT DO WE KNOW ABOUT
PRENATAL CARE

6. WHEN SHOULD PRENATAL
CARE START?

7. A. WHEN TOM CRUISE RETURNS YOUR
CALL?
B. 1ST
DAY AFTER ONE HAVE MISSED THEIR
PERIOD?
C. PRECONCEPTIONAL?
D. B/C
E. A/B
F. ALL OF THE ABOVE?
G. NONE OF THE ABOVE?

8. 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:

9. 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

10. How do you detect if your are
pregnant?
1) urine or blood test
2) ultrasound

11. 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.

12. 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.

13. 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

14. + Pregnancy test:
Clinical Visits with no high risk:
• Q4Wks until 28wks
• Q2W from 28-36wks
• Every wk from >36wks

15. Ultrasonography
• When?
As early as 4.5wks
• What do you see?
Transvaginal-
bHCG>1500 see gestational sac.
Abdominal sono:
bHCG>6000 see heart beat

16. 5wks embryo and yolk sac

17. 7wk embryo and yolk sac

18. 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

19. 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)

20. 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 exposures
D. Allergies and medications

21. 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.

22. Each prenatal visit:
• Maternal Weight
• Maternal BP
• UA
• History
• Abdominal Examination:
• Fundal height
• Fetal heart
• Fetal position and shape

23. •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

24. • 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

25. 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.

26. 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.

27. 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

28. 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

29. Fundal Height
The height
of the fundus
in cm. equals
the number
of weeks
gestation +/-2.
FUNDAL
HEIGHT

30. 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

31. 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

32. 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

33. 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

34. 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

35. Labs:

36. 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

37. Triple Marker testing
A. Components
1. AFP
2. Estriol
3. beta HCG
B. When Drawn
1. between 14-21wks
2. Send only to certified lab
3. provide key adjustment information
a. obese- run low c. Multiple- run high
b. diabetes- run low d. dates

38. 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

39. 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

40. • 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)

41. 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

42. 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

43. 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)

44. • CIGARETTE SMOKING
•ALCOHOL AND DRUG USE
• EXPOSURE TO TERATOGENS.
•EXCESSIVE PHYSICAL WORK
AVOID DURING PREGNANCY

45. 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.

46. What constitutes a high risk
pregnancy?

47. 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

48. Risk factors associated with MOM
Factors 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

49. 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

50. 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

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

52. Drugs:
• Cocaine: placental abruption
Low birth wt
Preterm labor
Neonatal withdrawal
• Opiates: neonatal withdrawal, low birth wt, death
• Alcohol: fetal ETOH syndrome
• Caffeine: assoc. low birth wt. with excessive
caffeine ingestion.

53. Multipara
Has increase risk:
• Placenta previa
• Postpartum hemorrhage secondary to
uterine atony
• Increased incidence of twins

54. Second trimester elective abortion
• Risk:
• Spontaneous abortion
• Incompetent cervix
• Preterm delivery
• Low birthweight

55. MFM
• Offers assessment and screening of fetus
• Ultrasound
• Umbilical sampling

56. 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

57. 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.

58. 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

59. 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

60. 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.

61. Thank
You