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 Table 1. Information collected during counseling sessions that can

I. Preconceptional Care affect a future pregnancy. Adapted from lecturers powerpoint.
II. Diagnosis of Pregnancy Medical History Diabetes Mellitus
III. Initial Prenatal Care Seizure Disorder
IV. Nutrition Immunizations
V. Common Concerns Genetic Diseases Neural Tube Defects
VI. Vaccination Phenylketonuria
Thalassemia
No objectives were given. Reproductive History Infertility
Abnormal pregnancy
References (APA Bibliography format): outcomes
Lecturers powerpoint
Obstetrical complications
Williams Obstetrics 24th ed.
Parental Age Maternal
Legend: Italicized quoted from the lecturer; bold emphasis, Paternal
or from references Social History Drugs and smoking
Environmental exposure
I. PRECONCEPTIONAL CARE Diet
A. Preconceptional Care Exercise
Set of interventions that aim to identify and modify Screening Tests Hematological test
biochemical, behavioral, and social risks to a womans Diabetes, thyroid, cardiac,
health or pregnancy outcome through prevention and neurological
management
II. DIAGNOSIS OF PREGNANCY
B. Goals A. Signs and Symptoms
Improve knowledge, attitudes and behaviors of men Cessation of menses
and women related to preconceptional health o Abrupt cessation of menses in a woman with a
Assure that all women of childbearing age receive spontaneous, predictable cycle
preconceptional care services including evidence- o Not a reliable indication of pregnancy until 10 days
based risk screening, health promotion, and or more after the time of expected onset of menses
interventions that will enable them to enter pregnancy in o Occasionally, uterine bleeding suggestive of
optimal health menses may occur after conception during the first
Reduces risks indicated by a previous adverse half of pregnancy as a consequence of blastocyst
pregnancy outcome through interconceptional implantation
interventions to prevent or minimize recurrent adverse Changes in cervical mucus
outcomes o Beaded or cellular appearance of cervical mucus
Reduce the disparities in adverse pregnancy outcomes when spread on a glass slide
o Progesterone lowers sodium chloride concentration
C. Counselling Session = no crystallization = no fernlike pattern of mucus
Changes in the breasts
Gynecologists, internists, family practitioners, and
o Increase in size of breasts and nipples
pediatricians have the best opportunity to provide
o Nipples deeply pigmented, more erectile
preventive counseling during periodic health
o May also be seen in women taking estrogen-
maintenance examinations
containing contraceptives
Improve knowledge Includes information collection, Discoloration of the vaginal mucosa
which may be time consuming depending on the o Vaginal mucosa purplish, engorged (Chadwick
number and complexity of factors that require sign)
assessment (Williams 24th ed)
o Presumptive sign, not conclusive
Intake evaluation includes a thorough review of the Skin changes
medical, obstetrical, social, and family histories
o Increased pigmentation
These answers are reviewed with the couple to ensure o Abdominal striae
appropriate follow-up, including obtaining relevant Changes in the uterus
medical records o First weeks of pregnancy = Grows principally in
the anteroposterior diameter, feels doughy or
elastic
o 6-8 weeks = firm cervix, soft body, softened
isthmus (Hegars sign)
o 12 weeks = globular, 8 cm diameter

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 1

OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)
Changes in the cervix
o Increased softening as pregnancy advances
o Soft as lips of the mouth (in primigravidas)
o External cervical os and cervical canal may
become sufficiently patulous to admit a fingertip,
but the internal os should remain closed
FHT
o Ultrasonography by 5 weeks
o Doppler by 10 weeks
o Stethoscope by 17 weeks
Other sounds
o Fundic souffl sharp, whistling sound caused
by the rush of blood through umbilical arteries,
synchronous with fetal pulse
o Uterine souffl soft, blowing sound usually at
the lower portion of the uterus caused by passage
of blood through dilated uterine vessels,
synchronous with maternal pulse
o Fetal movements
o Intestinal peristalsis
Fetal movement perception
o by 20 weeks
16-18 weeks primigravids
18-20 weeks - multigravids
B. Pregnancy Tests (Williams, 24th ed.)
Detection of hCG in maternal blood and urine is the
basis for endocrine assays of pregnancy
hCG - glycoprotein with high carbohydrate content
Subtle hCG variants differ by their carbohydrate moieties
hCG is a heterodimer composed of two dissimilar
subunits, designated andwhich are non-covalently
linked
The -subunit is identical to those of luteinizing hormone
(LH), follicle-stimulating hormone (FSH), and thyroid-
stimulating hormone (TSH)
The -subunit is structurally distinct from LH, FSH, and
TSH
o With this recognition, antibodies were developed
with high specificity for the hCG -subunit
o This specificity allows its detection, and numerous
commercial immunoassays are available for
measuring serum and urine hCG levels
Measurement of -hCG
o Prevents involution of corpus luteum
o Produced by trophoblast cells
o Syncytiotrophoblast produce hCG in amounts
that increase exponentially during the first
trimester following implantation (Williams)
Detected in maternal plasma or urine 8 9 days after
ovulation
Doubling time = 1.4 2 days
Reach peak levels at 60 70 days
Nadir at 4 16 weeks
TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828)
Figure 1. Serum hCG levels increase from the day of implantation
and reach peak levels at 60 to 70 days. Thereafter, the concentration
declines slowly until a plateau is reached at approximately 16 weeks.
Adapted from Williams Obstetrics 24th Edition.
C. Ultrasonic Recognition
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
o The gestational sac is a small anechoic fluid
collection with the endometrial cavity (Williams
24th ed.)
Heart sound detectable by 6 weeks
o After 6 weeks, an embryo is seen as a linear
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 Goals of Prenatal 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 24th ed.)
Typical components of the initial visit are summarized in
the Table 1 in the appendix
B. Prenatal Record (Williams 24th ed.)
Use of a standardized record within a perinatal health-
care 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
C. Definition of Terms
Nulligravida
o Woman who is not now and has never been
pregnant
Gravida
o Woman who is or has been pregnant,
irrespective of the pregnancy outcome
o With the establishment of the first pregnancy,
she becomes primigravida (Williams)
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OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)

o With successive pregnancies, a multigravida o Discharges, dysuria, pruritus

(Williams) Sexual history
Nullipara o Coitarche, number of partners(and his/her
o Woman who has never completed a
previous partner),
pregnancy beyond 20 weeks gestation
o She may not have been pregnant or may have o Post-coital bleed, dyspareunia
had a spontaneous or elective abortion(s) or Contraceptive history
an ectopic pregnancy (Williams) o Use of steroidal contraceptives
Primipara Past Medical History
o Woman who has been delivered only once of a Social history
fetus or fetuses born dead or alive with an
o cigarette smoking, alcohol and illicit drug use
estimated length of gestation of 20 or more
weeks Cigarette smoking spontaneous
Multipara abortion, LBW, preterm delivery,
o Woman who has completed two pregnancies abruptio placenta
to 20 or more weeks. It is determined by the Fetal alcohol syndrome
number of pregnancies reaching 20 weeks, not o Domestic violence screening
by the number of fetuses delivered (The following sub-bullets are taken from Williams 24th Ed)
Pattern of assaultive and coercive
D. Normal Pregnancy Duration behaviour that may include:
Table 2. Duration of a normal pregnancy. Adapted from lecturers
Physical injury
powerpoint.
Normal duration of Psychological abuse
280 days or 40 weeks
pregnancy Sexual assault
Naegele Rule Plus 7 days, minus 3 months Progressive isolation
from the LMP Stalking
Gestational Age From the first day of the last Deprivation
menstrual period
Intimidation
Ovulatory 2 weeks shorter than the AOG
Reproductive coercion
Example of Naegele rule: If the last menstrual period
began September 10, the expected date of delivery is Recognized as a major public health
June 17 (Williams) problem
Gestational age assumes pregnancy to have begun With the possible exception
approximately 2 weeks before ovulation, which is not of preeclampsia, domestic
always the case (Williams) violence is more prevalent
Table 3. Division of a pregnancy into trimesters. Adapted from lecturers
than any major medical
powerpoint. condition detectable through
Trimesters routine prenatal screening
1st trimester Up to 14 weeks Intimate partner violence is
2nd trimester 14 to 28 weeks associated with an increased risk of
3rd trimester 28 to 42 weeks severe adverse perinatal outcomes
3 periods of 14 weeks each including
Clinical use of trimesters to describe a specific Preterm delivery
pregnancy is imprecise in modern obstetrics (Williams
24th ed.) Fetal-growth restriction
Weeks of gestation completed is the clinically Perinatal dreath
appropriate unit, as precise knowledge of fetal age is
imperative for ideal obstetrical management F. Physical Exam
Complete PE
E. History Fundic height
The same essentials go into appropriate history taking o Distance over the abdominal wall from the top of
from the pregnant woman as elsewhere in medicine.
the symphysis pubis to the top of the fundus
(Cunningham, 2014)
Queries regarding medical and surgical disorders, detailed o Bladder must be emptied before making the
information regarding previous pregnancies (Cunningham, measurement
2014) o Between 20-31 weeks, height of uterine fundus in
Menstrual history cm correlates closely with gestational age in
o regularity of menses weeks
Obstetric history used to monitor fetal growth and
o previous complications during pregnancy amniotic fluid volume (Cunningham,
Gynecologic history 2014)

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 3

OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)

Fetal Heart Sounds Table 2. Maternal conditions and related procedures. Adapted from
lecturers powerpoint.
o 16-19 weeks
(The following sub-bullets are taken from Williams 24th Ed) GDM Between 24-28 weeks; Earlier for those with
Normal FHR: 110-160 bpm high risk
Can be heard as early as:
6-7 weeks via real-time Chlamydial Screened during first prenatal visit for those
sonography Infection with high risk
10 weeks via Doppler ultrasound
16 weeks via standard non- Gonococcal Women with risk factors or symptoms cultured
amplified stethoscope Infection at an early prenatal visit and again in the 3 rd
Pelvic Exam trimester
o Speculum Exam
Speculum lubricated with warm water Fetal Detection in vaginal fluid used to forecast
Nabothian cysts may be noted Fibronectin preterm delivery in women with contractions
Pap smear
Cultures for Neisseria and Chlamydia if GBS Vaginal and rectal GBS cultures obtained
warranted Infection between 35 and 37 weeks
o Internal Exam
Consistency, length and dilatation of the IV. NUTRITION
cervix Recommended total weight gain:
Fetal presentation o Women carrying twins
35-45 lbs. (16-20 kg)
Bony architecture of the pelvis o Young adolescents (< 2 years after menarche)
Anomalies of the vagina and perineum Gains at the upper end of the range
o Examination of vulva and perianal region o Short women (< 62 in. or < 157 cm)
Cervical, vaginal and vulvar lesions further Gains at the lower end of the range
evaluated by colposcopy, biopsy, culture
or dark-field examination Table 3. BMI Classification and Recommended Total Weight Gain
o DRE over the Pregnancy. Adapted from the lecturers powerpoint.
Weight-for-height Category Recommended Total Weight
G. Subsequent visits Gain
Category BMI kg lb
Traditional Schedule of Visits LOW <19.8 12.5-18 28.40
o Monthly until 28 weeks NORMAL 19.8-26 11.5-16 25-35
o Every 2 weeks until 36 weeks HIGH 26-29 7-11.5 15-25
o Weekly >36 weeks OBESE >29 7 15

H. Prenatal Surveillance Table 4. Recommended dietary allowance during a pregnancy.

Adapted from lecturers powerpoint.
Fetal
CALORIES 100-300 kcal increases/day
o Heart rate PROTEIN Increased protein demands
o Size current and rate of change (5-6g/day)
o Amount of amniotic fluid IRON 7mg/day used during pregnancy
o Presenting part and station (late in pregnancy) 27mg.day recommended supplement after the
o Activity first 4 months
Maternal CALCIUM Increased calcium retention and intestinal
o Blood Pressure absorption during pregnancy
ZINC 12mg/day
o Weight
Increased birth weight and head circumference
Current and amount of change IODINE 220 ug
o Symptoms Deficiency leads to cretinism in the infants
o Fundic height FOLIC 4mg/day supplementation recommended during
o Vaginal exam ACID periconceptional period (before conception to the
late in pregnancy to confirm presenting first 3 months
part and determine station, estimation of Associated with neural tube defects
VITAMIN A Supplementation not recommended
pelvic capacity, and consistency,
10,000-50,000 IU daily may cause birth defects
effacement and dilatation of the cervix (as in Isotretinoin)
Vit. A deficiency cause maternal anemia and
I. Ancillary Procedures preterm birth

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 4

OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)

VITAMIN Decreased stores in pregnancy HEADACHE no cause, and treatment is symptomatic

B12 Strict vegetarians have very low levels May also be due to hypertensive disorders
VITAMIN B6 2mg/day recommended for those at risk for LEUKORRHEA Increased mucus secretion by cervical
inadequate nutrition (substance abuse, glands in response to hyperestrogenemia
adolescence, multifetal gestations) May be due to trichomonal or yeast
VITAMIN C 80-85mg/day, usually provided by regular diet BACTERIAL Maldistribution of normal vaginal flora
VITAMIN 12 Decreased stores in pregnancy VAGINOSIS Gardnerella vaginalis, Mobiluncus,
Strict vegetarians have very low levels Bacteroides species
Treatment reserved for those with fishy-
V. COMMON CONCERNS smelling discharge with Metronidazole
Table 5. Common concerns during pregnancy. Adapted from the 500 mg BID x 7 days
lecturers powerpoint. TRICHOMONIASIS
EXERCISE should be encouraged to engage in Foamy leucorrhea with pruritus and
regular, moderate-intensity physical irritation
activity 30 min or more each day Metronidazole 500 mg BID x 7 days
EMPLOYMENT women who work at jobs requiring CANDIDIASIS Asymptomatic infection requires no
prolonged standing are at greater risk for treatment
preterm delivery Miconazole, clotrimazole, nystatin
uncomplicated pregnancies can continue
to work until onset of labor VI. VACCINATION
4-6 weeks generally required before Table 6. Recommended vaccinations during pregnancy. Adapted from
return of physiological condition to normal the lecturers powerpoint.
TRAVEL can safely fly up to 36 weeks IMMUNOBIOLOGICAL INDICATIONS FOR DOSE
BATHING No contraindications AGENT IMMUNIZATION SCHEDULE
CLOTHING Avoid tight fitting clothes
DURING
BOWEL HABITS Constipation is common due to prolonged
PREGNANCY
transit time and compression of the bowel
by the uterus MMR Live vaccine Single dose
Hemorrhoids and prolapsed of the rectal contraindicated; SC
mucosa may occur Vaccinate
COITUS should be avoided susceptible women
DENTITION not a contraindication to dental treatment postpartum
CAFFEINE > 5 cups of coffee per day may increase Post exposure
risk for abortion prophylaxis for
MEDICATIONS drug that exerts a systemic effect in the measles given within
mother will cross the placenta to reach the 6 days of exposure
embryo and the fetus Polio (live attenuated) Indicated for Primary: Two
NAUSEA AND between the first and second missed susceptible women doses of
VOMITING menstrual period and may continue up to enhanced-
14-16 weeks potency
High levels of serum hCG inactivated virus
Small, frequent feedings SC at 4-8 week
intervals and 3rd
BACKACHE Increases as gestational age increases dose 6-12
Reduced by squatting rather than bending months after 2nd
over when reaching down, proving back dose
support with a pillow when sitting down Varicella Contraindicated, but Two doses
VARICOSITIES more prominent as pregnancy advances, no adverse needed: 2nd
as weight increases, and as the length of
outcomes reported dose 4-8
time spent upright is prolonged
HEMORRHOIDS increased pressure in the rectal veins due during pregnancy; weeks after
to obstruction of venous return by the vaccinate first dose
enlarging uterus postpartum
HEARTBURN upward displacement and compression of Immune globulin
the stomach by the uterus, combined with should be
relaxation of the lower esophageal considered for
sphincter exposed pregnant
PICA considered to be triggered by severe iron women to protect
deficiency against maternal
PTYALISM stimulation of salivary glands by ingestion infection;
of starch Influenza for women who will One dose IM
FATIGUE Remits spontaneously by the fourth month be pregnant during every year
of pregnancy the influenza season

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 5

OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)

Hepatitis B for those at risk for Three-dose

infection; series IM at 0,
Exposed newborn 1, and 6
needs birth dose months
vaccination and
immune globulin
ASAP

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.

IV. REVIEW QUESTIONS

1. Set of interventions that aim to identify and modify
biochemical, behavioral, and social risks to a womans
health or pregnancy outcome through prevention and
management
A. Prenatal Care
B. Pregnancy Test
C. Preconceptional Care
2. T/F: The fundic souffl 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.
3. What term best describes a woman who has never
completed a pregnancy beyond 20 weeks gestation?
A. Nullipara
B. Primipara
C. Multipara
4. 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 Answers: CFAA

END OF TRANS

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 6

OBSTETRICS: PRECONCEPTION AND PRENATAL CARE (2018B)

APPENDIX

Table 1. Typical components of routine prenatal care. Adapted from Lecturers Powerpoint

TRANSCRIBER: Trans Group 23 (SANTOS) EDITOR: Franco Sison IV (09175908828) 7