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Prenatal Care

Prenatal Care. Ramiro. Objectives. To identify salient data in a mother who is coming in for first prenatal check-up To define prenatal care To list ways of determining age of pregnancy To list and justify tests done during prenatal check-ups

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Prenatal Care

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  1. Prenatal Care Ramiro

  2. Objectives • To identify salient data in a mother who is coming in for first prenatal check-up • To define prenatal care • To list ways of determining age of pregnancy • To list and justify tests done during prenatal check-ups • To list other facets of the prenatal check - up: • Social services • Nutritional counseling • Patient education • Psychological support

  3. Case

  4. General Data • JPS • 23 yo • Single • Filipino • Roman Catholic • Sampaloc, Manila

  5. Reason for Consult • First prenatal check-up

  6. Past Medical History • No hypertension • No diabetes mellitus • No thyroid disorder • No kidney disorder • No bronchial asthma • No cancer • No surgeries • No allergies • No blood transfusions

  7. Family Medical History • Pancreatic cancer, father, deceased • Hypertension, mother, living, age 54 • No diabetes mellitus • No bronchial asthma

  8. Personal and Social History • Social drinker, wine, Last on December 2009 • Previous smoker, 1 stick, last on 2007 • Single, unemployed, lives with common law husband

  9. Menstrual History • Menarche: age 11 • LMP: February 17, 2010 • PMP: January 2010 • Interval: monthly • Duration: 5 days • Amount: 3 ppd, fully soaked • No dysmenorrhea

  10. Gynecologic History: • Coitarche: age 16 • Sexual Partner: 1 • No dyspareunia • No vaginal discharge, no vaginal bleeding • No pap smear • Denied history of sexually transmitted infections • Denied use of any contraceptive methods: OCPs, IUDs, condoms

  11. Obstetric History • Ob Score: G1P0 • G1 – 2010 – present pregnancy

  12. Present Pregnancy • Menstrual Age: 19 6/7 w AOG • Sonar Age: 18 w AOG • Date of earliest sonogram: April 19, 2010 • 6 6/7 w AOG • Expected date of confinement: • By LMP: November 24, 2010 • By Ultrasound: December 7, 2010

  13. History • February 17, 2010 • April 17, 2010 • April 19, 2010 Last menstrual period Positive pregnancy test First transvaginal ultrasound (6 6/7 w AOG) SLMC-OB OPD

  14. Review of Systems • No fever, no headache, no weakness • No nausea, no vomiting • No blurring of vision • No cough, no colds • No difficulty of breathing • No chest pains, no palpitations

  15. Review of Systems • No constipation, no diarrhea • No dysuria, no frequency, no intermittency • No palpitations, no heat or cold intolerance, no tremors • No easy bruisability, no prolonged bleeding • No numbness

  16. Physical Examination • Conscious, coherent, ambulatory, not in cardio-respiratory distress • BP: 110/80mmHg • CR: 80/min, regular • RR: 20/min, regular • T: 37.7°C • Height: 5’4” • Pre-pregnancy weight: 124lbs • Pre-pregnancy BMI: 21.3 • Current weight: 132 • Current BMI: 22.7

  17. PE findings • Skin: Absent lesions • Eyes: Pale palpebral conjunctivae, anicteric sclerae, pupils briskly reactive to light (3 mm) • Neck: Supple neck, with no palpable neck mass, no neck vein engorgement • Lungs: Symmetrical chest expansion, no rib retractions, clear and equal breath sounds in all lung fields • Heart: Adynamic precordium, normal rate, regular rhythm, S1>S2 at apex, S2>S1 at base, no heaves, no murmurs • Full and equal pulses, no bipedal edema, no cyanosis

  18. Abdomen • Flat, soft, normoactive bowel sounds, non rigid, non-tender • FHT 150s

  19. External Pelvic Examination • No lesions, redness, excoriations, hyper/hypopigmentations

  20. Speculum Examination • Cervix: pink, smooth, no erosions, no masses, no lesions, no discharge

  21. Internal Examination • Vagina: admits two fingers • Cervix: firm, 3cm long, closed, posterior, no cervical motion tenderness, • Uterus; enlarged symmetrically to 18 weeks’ size, no tenderness • No adnexal mass or tenderness

  22. Assessment 23 yo G1P0 PU 19 6/7 w AOG by LMP 18 w AOG by USG

  23. Prenatal care

  24. Prenatal Care • Planned program of medical evaluation and management, observation, and education of the pregnant woman directed toward making pregnancy, labor, delivery and postpartum recovery a safe and satisfying experience

  25. Good prenatal care Good pregnancy outcome =

  26. Prenatal Care Program • Risk assessment • Medical care • Social services • Nutritional counseling • Patient education • Psychological support

  27. Estimation Of Pregnancy • Naegele’s Rule • Timing from ovulation • Timing from quickening • Height of fundus • Ultrasound

  28. Estimation Of Pregnancy • Naegele’s rule • EDC= LMP -3months + 7 days • Timing of Ovulation • If last ovulation is known, + 267 days

  29. Estimation Of Pregnancy • Height of the Fundus • Superior boarder of symphysis pubis and top of fundus by palpation measured off from a vertical line drawn at the level of the greatest thickness of the fundus.(tape meas in cm) • 12th wk :Symphysis pubis • 16th wk: Approx halfway bet symphysis and umbilicus • 20th wk: level of umbilicus • 36th wk: just below ensiform cartilage

  30. Estimation Of Pregnancy • Ultrasound: establish diagnosis of pregnancy, location, ovaries • 1st trim: CRL • 2nd trim: BPD • 3rd trim: ave of femur length, BPD, HC, AC • Timing of Quickening: perception of fetal movement • Multipara: 16- 18th wks • Primigravida: 18-20th wk • Not a primary method of assessing gestational age

  31. Obstetric History • Evidence of infertility • Previous pregnancies • Time in gestation when labor occurred • Duration • Type of delivery • Complications • Weight and sex of the baby • Postpartum course of both mother and fetus

  32. Physical Examination • Systematic: Vital signs, weight, heart, lungs, breast, abdomen, FHT, Fundic height, fetal lie, pelvic exam, internal exam, extremities, etc. • 1. Leopold’s Maneuver • 2. Pelvic Exam • 3. Rectal and Rectovaginal Exam

  33. Leopold’s Maneuvers • LM 1 - Fundal grip • “what fetal pole occupies the fundus?” • LM2 - Umbilical grip • “on which side is the fetal back?” • LM3- Pawlick’s grip • “what fetal part lies above the pelvic inlet?” • LM4 - Pelvic grip • “On which side is the cephalic prominence?”

  34. Pelvic Examination • Early months- establish the diagnosis of pregnancy or determine the presence or absence of uterine or adnexal pathology • 7th month AOG- evaluate and measure obstetric pelvis • Pelvic tissues are more relaxed • Pelvic cavity empty (uterus become abdominal organ) • Ischial spine and sacral promontory are more palpable

  35. Pelvic Examination • Cytologic screening for cervical CA • Digital exam: consistency, length, dilatation of cervix, presenting part • At 9th month AOG- weekly IE to monitor cervix

  36. Rectal and Rectovaginal Exam • Evaluate integrity of perineum and competence of rectal sphincter • Detect possible presence of rectocoele or extent if present. • Rule out pathologic conditions of rectum

  37. Routine Obstetric test • CBC: hematologic status, r/o anemia • Urinalysis, urine c & s: UTI, renal function • Blood group & Rh: blood type, Rh status & risk of isoimmunization • Pap smear: to detect cervical dysplasia/ CA • Rubella titer • HBsAg: detect carrier status, or active satatus • Serologic test for Syphilis (RPR, VDRL) • OGCT 28 wks

  38. Prenatal Instructions • Inform possible problems and discuss management • Begin antepartum educational program by means of personal interviews, reading materials and hospital classes. • Explain future visits • Discuss the economic aspect of pregnancy • Give instructions about diet, relaxation and sleep, bowel habits, exercise, bathing, recreation, sexual intercourse, smoking, drug and alcohol ingestion • Emphasize danger signals: vaginal bleeding, persistent vomiting, fever and chills, sudden escape of fluid from vagina, abdominal pain, swelling of face, blurring of vision, continuous headache

  39. Subsequent PNCU Frequency of visits • Monthly x 7 months • Every 2-3 weeks up to 36th week • Once a week until EDC • WHO (1994)- 4 visits minimum • 16 wks- screen and treat anemia and syphylis • 24-28 wks to 32 wks- screen for preeclampsia, multiple gestation, anemia • 36 wks- identify fetal lie/presentation

  40. Subsequent prenatal care • Maternal evaluation • Blood pressure • Weight change • Symptoms • Fundic height • Leopold’s maneuver • Vaginal examination • Fetal evaluation • Fetal heart tone • Size of fetus • Amount of amniotic fluid • Presenting part and station • Fetal activity Assess well-being of mother and fetus

  41. Maternal Evaluation • Blood pressure • Weight • Underweight < 19.9 Kg/m2 • Overweight > 26 Kg/m2 • BMI Weight gain • Under Weight <19.8 12.7-18.2 Kg • Normal 19.8-26.9 11.4 – 15.9 Kg • Overweight 26.1-29 6.8 -11.4 Kg • Obese >29 6.8 Kg • Twin Gestation 15.9-20.4 Kg ACOG- 10 to 12 kg (22 to 27 lb) weight gain

  42. Symptoms: Headache, nausea, vomiting, bleeding, dysuria, fluid from vagina • Fundic height • Abdominal Exam • Speculum Exam • Internal Exam • Rectovaginal Exam • Not done if with history of vaginal bleeding

  43. Fetal Evaluation • Fetal Heart Rate • Size of fetus, actual and rate of change • Amount of Amniotic fluid • Presenting part and station (late in pregnancy) • Fetal Activity

  44. Subsequent Laboratory tests • CBC: repeat at 28-32wks • Maternal serum alpha fetoprotein: 16-18wks • Elevated levels: neural tube defects, gastroschisis, omphalocoele • Low levels: Down syndrome • OGCT: 24-28wks

  45. Recommended dietary allowance • Levels of intake of energy and essential nutrients considered adequate to maintain heath and provide reasonable levels of reserves in body tissues • Calories: 300 kcal/ day (2nd-3rd trim); added maternal tissues and growth of fetus and placenta

  46. Protein: 15 gm/ day 1st, 2nd, 3rd; needed for tissue synthesis in the maternal and fetal compartments; • Carbohydrates: main source of energy, 150 gms for the 1st trim, 225 at the end of preg • Fats: most concentrated energy, 15-25 gms

  47. Vitamin and other supplementation • Iron: 41mg/d • 2nd trim: 79mg/Kg/d • 3rd trim: 114mg/Kg/d • To allow expansion of red cell mass • To provide needs of fetus and placenta

  48. Minerals • Calcium: structural element of bones and teeth, 900mg/d • Zinc: 12mg/d, for noral growt, sexual maturation, brain development and fxn, immune fxn • Iodine: 125mg/d • Iron: 41 mg/d replace bowel losses, allow expnsion of red cell mass, provide for the needs of fetus and placenta, given during the 2nd-3rd trim (deposition of iron in fetal and placenta tissues, increase in red cell mass proceed at a rapid rate • Phosphorus: for calcification of bones

  49. Vitamins • Folate 350mg/d, megaloblastic anemia • Vitamin A: 475 RE (retinol equivalent)/d; vision, growth, cellular differentiation & proliferation, • Vitamin B1 (thiamine): 1.3mg/d, aneuria, antineuritic • Vitamin B2 (riboflavin): 1.6mg/d, • Vitamin B6 (pyrodoxine): amino acid metabolism and protein synthesis, 1mg • Niacin: 21 mg/d • Vitamin C: ascorbic acid content of maternal blood decreases, while the fetal plasma values are higher 80mg/d

  50. General hygiene • Exercise: • aerobics: rhythmic, repetitive activities strenuous enough to demand increased oxygen to the ms, but not so strenuous enough that the demand exceeds the supply. Stimulates the heart, lungs, ms and jt activity, improves circulation, increases ms tone and strength • calisthenics: rhythmic light gymnastic movements that tone and develop ms and improve posture, relieves back ache • relaxation tech: breathing and concentration ex relax mind and body • Pelvic toning: Kegel exercise, tones the ms in the vaginal and perineal rea

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