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HCG
- At least once per trimester Cyanotic, prior myocardial infarction, aortic stenosis,
- Postpartum pulmonary hypertension, Marfan syndrome, prosthetic
valve, American Heart Association class II or greater
PHYSICAL EXAMINATION Other
PELVIC EXAMINATION Diabetes mellitus
Speculum Exam Class A–C
Class D or greater
Before you start with the speculum exam, you start
Drug and alcohol use
examining the external genitalia If it is normal =
NEG (Normal External Genitalia) Proceed with Epilepsy (on medication)
introitus Family history of genetic problems (Down syndrome, Tay-
Sachs disease, phenylketonuria)
- Cervix Hemoglobinopathy (SS, SC, S-thalassemia)
Hyperemic, bluish-red Hypertension
Nabothian cysts Chronic, with renal or heart disease
Not normally dilated above the internal os Chronic, without renal or heart disease
Internal os may be somewhat open but should Prior pulmonary embolus or deep vein thrombosis
not be dilated above the internal os Psychiatric illness
Pulmonary disease
- Pap smear is obtained Severe obstructive or restrictive
- Specimen for N. gonorrhea and Chlamydia when Moderate
indicated Renal disease
Chronic, creatinine 3 mg/dL, ± hypertension
If the patient has muco-purulent discharge, collect Chronic, other
the specimen for gram staining Requirement for prolonged anticoagulation
Bimanual Examination Severe systemic disease
- Consistency, length, and dilatation of the cervix INITIAL LABORATORY TESTS
Human immunodeficiency virus (HIV)
Normal cervix before labor measures 2cm
Symptomatic or low CD4 count
If it is 1cm long = effacement is 50%
Other
If it is paper-thin = fully effaced cervix CDE (Rh) of other blood group isoimmunization (excluding
During labor, it is important to take not of the ABO, Lewis)
dilatation and effacement of the cervix Initial examination condylomata (extensive, covering vulva
- Uterine and adnexal size or vaginal opening)
- Bony architecture of the pelvis MEDICAL HISTORY AND CONDITIONS
- Fetal presentation later in pregnancy Drugs/alcohol use
Proteinuria (2+ on catheterized sample, unexplained by
During the latter part of pregnancy (2nd and 3rd
urinary infection)
trimester), you could already determine the
Pyelonephritis
presenting part, and sometimes even the fetal
Severe systemic disease that adversely affects pregnancy
presentation
OBSTETRICAL HISTORY AND CONDITIONS
- Anomalies of the vagina and perineum Blood pressure elevation (diastolic BP 90 mm Hg), no
- Vulvar inspection proteinuria
Fetal-growth restriction suspected
TYPICAL COMPONENTS OF ROUTINE PRENATAL CARE – Fetal abnormality suspected by sonography
Laboratory Tests (Refer to table on page 3) Anencephaly
Other
HIGH-RISK PREGNANCIES (23rd Edition of WILLIAMS) Fetal demise
RECOMMENDED CONSULTATION FOR RISK FACTORS Gestational age 41 weeks
IDENTIFIED IN EARLY PREGNANCY Herpes, active lesion at 36 weeks
MEDICAL HISTORY AND CONDITIONS Hydramnios or oligohydramnios by sonography
Asthma Hyperemesis, persistent, beyond first trimester
Symptomatic on medication Multifetal gestation
Severe (multiple hospitalizations) Preterm labor, threatened
Cardiac disease Premature rupture of membranes
Vaginal bleeding 14 weeks
EXAMINATION AND LABORATORY FINDINGS Monthly during the 1st 7 months 7 check-ups
Abnormal MSAFP (high or low)
Twice a week during the 8th month 2 check-ups
Abnormal Pap smear result
Weekly during the 9th month 4 check-ups
Anemia (hematocrit <28 percent, unresponsive to iron
Total of 13 check-ups
therapy)
According to WHO, there is no need for many check-ups
Condylomata (extensive, covering labia and vaginal
More of quality VS quantity of check-ups
opening)
HIV
Symptomatic or low CD4 count PRENATAL SURVEILLANCE
Other FETAL
CDE (Rh) or other blood group isoimmunization (excluding Heart rate
ABO, Lewis) Size – current and rate of change
Amount of amniotic fluid
PREGNANCY RISK ASSESSMENT (24th Edition of WILLIAMS) Presenting part and station
Activity
MATERNAL
Blood pressure
Weight
Symptoms (10 Danger Signals)
10 DANGER SIGNALS OF PREGNANCY:
1. Vaginal bleeding
2. Fever and chills
3. Passage of fluid from the vagina
4. Abdominal pain
5. Severe persistent headache and dizziness
6. Severe persistent vomiting
7. Swelling of hands and feet
8. Visual disturbances/Blurring of vision
9. Dysuria and burning sensation on urination
10. Marked change in the frequency of fetal
movement/absence of fetal movement
Fundic height
Vaginal examination
- Presenting part
- Station
- Pelvimetry
- Consistency, effacement and dilatation of the cervix
VITAMINS
FOLIC ACID
- Supplementation prevents NTD
Supplementation 1 month before conception and
during the early part of pregnancy Can prevent
NTD
- Daily intake of 400mcg throughout peri-conceptional
period
- Daily supplementation with 4mg folic acid decrease
recurrence rate of NTD by 70% if with prior child with
NTD
EXERCISE
Oxygen consumption, heart rate, stroke volume, and
cardiac output all increase
Pregnant women who exercised regularly had significantly
larger blood volumes
In the absence of contraindications, encourage regular,
moderate-intensity physical activity 30 min or more/day
Avoid scuba diving because fetus is at increased risk of
decompression sickness
Absolute Contraindications to Aerobic Exercise During
Pregnancy:
- Hemodynamically significant heart disease
- Restrictive lung disease
- Incompetent cervix/cerclage
- Multifetal gestation at risk for preterm labor
- Persistent second- or third-trimester bleeding
- Placenta previa after 26 weeks
- Preterm labor during the current pregnancy BATHING
- Ruptured membranes No contraindications
- Preeclampsia/pregnancy-induced hypertension
Relative Contraindications to Aerobic Exercise During CLOTHING
Pregnancy: Comfortable and non-constricting
- Severe anemia Well-fitting supporting brassiere
- Unevaluated maternal cardiac arrhythmia Avoid constricting leg wear
- Chronic bronchitis
- Poorly controlled type 1 diabetes BOWEL HABITS
- Extreme morbid obesity Constipation is common
- Extreme underweight (BMI <12) Prolonged transit time and compression of the lower
- History of extremely sedentary lifestyle bowel by the uterus or presenting part
- Fetal-growth restriction in current pregnancy Greater frequency of hemorrhoids
- Poorly controlled hypertension Bleeding and painful fissures of the rectal mucosa may
- Orthopedic limitations develop
- Poorly controlled seizure disorder Prevent constipation by sufficient amount of fluids and
- Poorly controlled hyperthyroidism daily exercise
- Heavy smoker
COITUS
FISH CONSUMPTION Not harmful in healthy pregnant women
Avoid shark, swordfish, king mackerel, tile fish
Ingest no more than 12 oz or 2 servings of canned May be contraindicated to women who have history
tuna/week; No more than 6 oz of albacore tuna of preterm labor, vaginal bleeding and frequent
vaginits
Tuna fish contains mercury
DENTITION
Dental carries are not aggravated by pregnancy
Pregnancy is not a contraindication for dental treatment Caused by reflux of gastric contents into the lower
esophagus
Dental x-ray is not contraindicated
From upward displacement and compression of the
stomach by the uterus, combined with relaxation of lower
CAFFEINE esophageal sphincter
No evidence that caffeine caused increased teratogenic or Give antacids, small frequent meals, avoid bending over
reproductive risk or lying flat
Only extremely high serum paraxanthine concentration
were associated with abortion (equivalent to >5 cups/day) PICA
Limit intake to 300 mg daily or three 5 oz cups coffee/day Has been considered to be triggered by severe iron
deficiency
Allowed: 200-300mg (3 cups) of caffeine daily 5 Rate of spontaneous preterm birth at less than 35 weeks
cups or more can be associated with abortion during was twice as high
the 1st trimester
FATIGUE
IMMUNIZATION Remits spontaneously by 4th month of pregnancy
Vaccines Contraindicated During Pregnancy May be due to soporific effect of progesterone
- MMR
- Yellow fever HEADACHE
- Varicella Treatment is symptomatic but should be investigated
- Small pox especially in late pregnancy
RECOMMENDATIONS FOR IMMUNIZATION DURING
PREGNANCY -- See table at the last page LEUKORRHEA
Increased mucus secretion by cervical glands in response
NAUSEA AND VOMITING to hyperestrogenemia
Commence between 1st and 2nd missed menses and
continue until 14 – 16 weeks BACTERIAL VAGINOSIS
Caused by high levels of serum B-hCG which is a surrogate Maldistribution of normal vaginal flora
for increasing estrogen levels Lactobacilli are decreased and overrepresented species
Advise small frequent feedings tend to be anaerobic bacteria
Associated with preterm birth
BACKACHE Metronidazole 500 mg BID x 7 days
Increased with duration of gestation
Prior low back pain and obesity are risk factors TRICHOMONIASIS
Squat rather than bend Foamy leukorrhea with pruritus and irritation
Provide back support avoid high heeled shoes Treat with Metronidazole
VARICOSITIES CANDIDIASIS
Result from congenital predisposition exaggerated by long Asymptomatic colonization requires no treatment
standing, pregnancy, and advancing age Extremely profuse, irritating vaginal discharge associated
Femoral venous pressure increases as pregnancy with pruritic, tender, and edematous vulva
advances Treat with miconazole, clotrimazole, and nystatin
Advise periodic rest with elevation of the legs, elastic
stockings
Surgical correction during pregnancy not advised
HEMORRHOIDS
Related to increased pressure in the rectal veins
Caused by obstruction of venous return by the large
uterus and by constipation
Advise topical anesthetics, warm soaks, and stool-
softening agents
HEARTBURN
TOXOIDS
Primary: Two doses IM at 1–2
month interval with 3rd dose 6–12 Combined tetanus-diphtheria toxoids
Lack of primary series, or no months after the 2nd preferred: adult tetanus-diphtheria
Tetanus-diphtheria
booster within past 10 years Booster: Single dose IM every 10 formulation. Updating immune status
years after completion of primary should be part of antepartum care
series
SPECIFIC IMMUNE GLOBULINS
Usually given with hepatitis B virus
Depends on exposure [see Chap.
Hepatitis B Postexposure prophylaxis vaccine; exposed newborn needs
50, Hepatitis B (HBV)]
immediate prophylaxis
Half dose at injury site, half dose Used in conjunction with rabies killed-virus
Rabies Postexposure prophylaxis
in deltoid vaccine
Tetanus Postexposure prophylaxis One dose IM Used in conjunction with tetanus toxoid
Indicated also for newborns or women
Should be considered for exposed
One dose IM within 96 hours of who developed varicella within 4 days
Varicella pregnant women to protect against
exposure before delivery or 2 days following
maternal, not congenital, infection
delivery
STANDARD IMMUNE GLOBULINS
Hepatitis A Immune globulin should be given as soon
as possible and within 2 weeks of
Hepatitis A virus Postexposure prophylaxis and high exposure; infants born to women who are
0.02 mL/kg IM in one dose
vaccine should be risk incubating the virus or are acutely ill at
used with hepatitis A delivery should receive one dose of 0.5 mL
immune globulin as soon as possible after birth