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
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
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
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
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.
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
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.
Folate leads to a decrease in homocysteine serum concentrations. Homocysteine in high levels is a known risk factor for cardiovascular disease and stroke.
average duration of pregnancy is about 280 days or 40 weeks counting from the first day of the last menstrual period . It is important to remember that due dates are not exact
hCG, is made in your body when a fertilized egg implants in the uterus. This usually happens about 6 days after conception
The gestational sac can be visualized as early as 4.5 weeks. It increases by about 1 mm per day
The mean gestational sac diameter (MGD) is an effective estimate of gestational age between 5 and 6 weeks, with an accuracy of about +/- 5 days. The yolk sac and embryo should be readily identified when the gestational sac reaches a certain size and the yolk sac is 20 mm in size or the fetal pole is 25 mm in size..
A careful review of the prenatal record should be supplemented by the patient interview with regard to recent illnesses and obstetrical complications.
Too high of a measurement and you could be having twins (or other fetal growth problems). Too low of a measurement and your baby could be having problems with fetal growth such as intrauterine growth restriction (IUGR).
One way to approximate a pregnancy&apos;s current gestational age is to use a tape measure to determine the distance from the pubic bone up over the top of the uterus to the very top.
The examiner uses the thumb the fingers of one hand in the suprapubic region (similar to palming a basketball) and attempts to move the presenting part from side to side. If little movement occurs or only the fetal neck is palpable the presenting part is engaged.
While facing the woman, palpate the woman&apos;s upper abdomen with both hands. A professional can often determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard, firm, round, and moves independently of the trunk.
2nd=the maneuver attempts to determine the location of the fetal back. Still facing the woman, the health care provider palpates the abdomen with gentle but also deep pressure using the palms of his or her hands.
3rd= provider attempts to determine what fetal part is lying above the inlet, or lower abdomen
4th:The fetal occipital prominence and flexion of the vertex is determined. If the fetal vertex is flexed, the cephalic prominence may be palpable on a same side as the fetal small parts. If a distinct cephalic prominence is noted on the same side as the spine and head the vertex is not very well flexed.
Amnio: results take 2wks.
Amnio: Mother&apos;s age of 35 or higher (because older mothers have a higher risk of Down&apos;s syndrome occurring in their babies)
Previous child with an inherited disorder
Family history of an inherited disorder
Abnormal findings on ultrasound
Abnormal findings on triple screen test (see below)
alpha-fetoprotein, a protein produced by the liver of the fetus
estriol, a pregnancy hormone
human chorionic gonadotropin (HCG), another pregnancy hormone
One important aspect of prenatal care is education of the pregnant woman about her pregnancy, danger signs, things she should do and things she should not do.
&lt;20: premature births, late prenatal care, low birth wt, uterine dysfx, fetal death or neonatal death
&gt;35: htn, DM- 6%, preeclampsia 9%, 14/1000 age 35-40