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PRENATAL CAREJaime Aglugub17 June 2011
PRENATAL CARE
• Pre-conceptional care• Prompt diagnosis of pregnancy• Initial Prenatal Evaluation• Subsequent Visits
DIAGNOSIS of PREGNANCYPresumptive. Probable. Positive Signs.
PRESUMPTIVE SIGNS
• Amenorrhea• Nausea and vomiting– Up to 1st trimester
• Breast changes– Enlargement and tenderness
• Chadwick’s sign• Quickening– 20 weeks AOG
PROBABLE SIGNS
• Positive pregnancy test• Changes in uterine size and shape• Palpation of the fetus• Palpation of fetal movement• Piscacek’s sign• Hegar’s sign• Goodell’s sign
POSITIVE SIGNS
• Detection of fetal heart tones– Ultrasound: 5-6 weeks AOG– Doppler: 10 weeks AOG– Stethoscope: 17-19 weeks AOG
• Imaging of the fetus– Ultrasound– Radiograph
• Birth
INITIAL PRENATAL EVALUATIONMedical History. Physical Examination. Laboratory Tests. Patient Education.
MEDICAL HISTORY
• Past Medical Illness• Diseases in the Family• Psychosocial background– Vices (smoking, alcohol, illicit drug use)– Lifestyle (nutrition, exercise)
• Obstetric and gynecologic history– Menstrual cycle– Gynecologic conditions– Previous pregnancies– Obstetric score GP (F-P-A-L)
• Gravida Para (Full-term, Pre-term, Abortion, Live)
PHYSICAL EXAMINATION
• General physical examination• Obstetric and gynecologic examination
Speculum exam. Digital pelvic exam.
ASSESSMENT of GESTATIONAL AGE
• Using patient’s last menstrual period (LMP)
• Fundal height– 18-30 weeks AOG– Pubis symphisis to
uterine fundus• Ultrasound
Determination of fundal height.
ROUTINE LABORATORY TESTS
• Complete blood count (CBC)– Hematocrit and hemoglobin
• Urinalysis and urine culture– Protein and sugar levels
• Blood typing (ABO and Rh)• Rubella status• Syphilis screen• Pap smear• HbsAg testing• Antibody screen (at 28 weeks AOG)
PATIENT EDUCATION
• Medical/surgical complications
• Cessation of vices– Smoking, drinking, drug use
• Danger signs of pregnancy
Vaginal bleeding Pain/burning sensation on urinationPelvic and/or abdominal pain Sudden onset of blurry visionEdema (hands and face) Severe headachesPersistent nausea and vomiting Regular contractions (<37 weeks AOG)Chills and/or fever Decreased fetal movement
PATIENT EDUCATION
• NutritionNutrient Non-pregnant Pregnant
Kilocalories 2200 2500Protein 55 60Fat soluble vitamins
A (ug RE)D (ug)E (mg TE)K (ug)
800108
55
800101065
Water soluble vitaminsC (mg)Folate (ug)Niacin (mg)
6018015
7040017
PATIENT EDUCATION
• NutritionNutrient Non-pregnant Pregnant
Water soluble vitaminsRiboflavin (mg)Thiamine (mg)Pyridoxine (mg)Cobalamin (ug)
1.31.11.62.0
1.61.52.22.2
MineralsCalcium (mg)Phosporus (mg)Iodine (ug)Iron (ferrous) (mg)Magnesium (mg)Zinc (mg)
1200120015015
28012
1200120017530
32015
PATIENT EDUCATION
• Nutrition
Pre-pregnancy BMI (kg/m2)
Recommended total gainPounds Kilograms
Low (BMI < 19.8) 28-40 12.5-18Normal (BMI 19.8-26) 25-35 11.5-16High (BMI > 26-29) 15-25 7-11.5Obese (BMI > 29) <15 <7
PATIENT EDUCATION
• Other Common Maternal Concerns– Exercise– Employment– Travel– Bowel Habits– Sex– Nausea and Vomiting– Immunization– Varicosities– Heartburn– Medicinal Drug Intake
PATIENT EDUCATION
• Schedule of subsequent visits– Depends on whether pregnancy is low-risk or
high-risk
Factors for High-Risk PregnancyExtremes of reproductive age (<17 y.o. and >35 y.o.)With medical complicationsPoor obstetric and gynecologic historyWith fetal problems (aging, structure, size)Polyhydramnios or oligohydramnios
PATIENT EDUCATION
• Schedule of subsequent visitsNormal Pregnancy High-risk Pregnancy
Until 28 weeks AOG: Every 4 weeks
Until 36 weeks AOG:Every 2 weeks
Until delivery:Weekly
Until 32 weeks AOG:Every 2 weeks
Until delivery:Every week
SUBSEQUENT VISITSMedical History. Physical Examination. Laboratory Tests. Patient Education.
MEDICAL HISTORY
• Danger signs of pregnancy
• Nutritional intake • Vitamin
supplementation
PHYSICAL EXAMINATION
• Maternal Health– Blood pressure– Weight increase– Pelvic examination
PHYSICAL EXAMINATION
• Fetal Health– Leopold’s maneuvers• Presentation• Lie• Engagement
– Fetal heart rate and rhythm
– Estimated fetal size and weight
– Fundic height– Fetal movement
SPECIAL LABORATORY TESTS
• Recommended for repeat (28-32 weeks AOG)– Hematocrit (or hemoglobin) determination– Syphilis serology
• Optional tests that should be offered– Screening tests for genetic diseases– HIV screening
• Required later in pregnancy– Oral glucose tolerance test (OGTT) (24-28 weeks AOG)– Rectovaginal culture of Group B Streptococcus (35-37
weeks AOG)
SPECIAL DIAGNOSTICS
• Electronic fetal surveillance– Non-stress test (NST)– Contraction stress test (CST)
• Ultrasound examination– Fetal biometry
• Crown-rump length, femur length• Biparietal diameter, head circumference
– Congenital anomaly scan– Biophysical profile (BPP)
• 5 variables: fetal tone, movement, breathing, amniotic fluid levels and NST
SUMMARY
• Prenatal care encompasses maternal and fetal health from pre-conception to delivery.
• History, physical examination, diagnostics and patient education form the tetrad of every prenatal care visit.
THANK YOU!Prenatal Care.