OB

Revalida: 1st Prenatal Check Up

I. Chief complaint: Missed menses or (+) Pregnancy test

II. HPI & ROS
• Number of months of missed menses
• Number of times she took a pregnancy test & the result/s
• Investigate the signs, symptoms & dangers signs of pregnancy, note if positive or
negative

Presumptive symptoms Nausea +/- vomiting
(History) • Begins at 6w, peaks at 9-10w (corresponds to peak of
hCG secretion)
Disturbances in urination
• 2nd-3rd month while the uterus is still a pelvic organ
• Enlarging uterus puts pressure on urinary bladder
causing: Frequency, irritability, dribbling, nocturia
Fatigue
• Most noticeable during the 1st few weeks of pregnancy
• Due to an increased BMR
Maternal Perception of fetal movement (quickening)
• Primi: 18-20w
• Multi: 16-18w
Breast symptoms
• Estrogen: stimulates mammary duct system
• Progesterone: stimulates alveolar components
• Breast tenderness & engorgement (esp in early
pregnancy)
Presumptive signs Cessation of menstruation
(PE) • Corpus luteum (usually maintained by LH) does not
regress & continues to produce progesterone as it is
now maintained by embryonic hCG
• This will not allow the endometrium to be shed
Anatomical breast changes
• Breast enlargement & vascular engorgement
• Hyperpigmentation of the areola
• Nipples become larger
Chadwick’s sign (6w AOG)
• Purple/dark-bluish color of the vaginal mucosa due to
increased vascularity
Thermal signs
• Perceptible elevation of body temperature for longer
than 3 weeks due to the thermogenic effect of
progesterone
Skin pigmentation changes
• Due to an increase in estrogen and progesterone ->
stimulates Melanocyte Stimulating Hormone ->
hyperpigmentation: Chloasma or melasma
gravidarum (mask of pregnancy), linea nigra
• Due to the enlarging gravid uterus: striae gravidarum
Probable signs Abdominal enlargement (6w AOG onwards)
(PE) • Due to the enlarging gravid uterus
• Fundic height to be explained at the PE section
Hegar’s Sign (6-8w AOG)
• Softening of the uterine isthmus & fundus
Goodell’s Sign (4w AOG)
• Cyanosis of the cervix d/t increased vascularity

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 Softening of the cervix (6-8w AOG)
• Soft consistency = lips, d/t progesterone & estrogen
• Firm consistency = nasal cartilage (non-pregnant)
Crystallization of cervical mucus
• Beaded pattern of cervical mucus
• Progesterone decreases NaCl in mucus while Estrogen
increases it (ferning) à during pregnancy,
progesterone predominates à ferning is inhibited à
cervical mucus will crystallize (beaded pattern)
Braxton-Hicks Contractions (28w AOG)
• False labor pain: strong, palpable/visible, irregular
contractions of short duration
Ballotment (20w AOG)
• Indicates that the amniotic fluid volume is greater
than the fetal volume
• Internal ballotment: Insert IE fingers per vagina, other
hand exerts an upward pressure to the uterine
fundus, release fundus & you will feel a rounded
structure that will hit/bounce back on your finger
• External ballotment: examiner moves uterus from
side to side (with both palms on each side of uterus),
feels like something is floating/bouncing against the
palms
• Only a probable sign, since any intrauterine mass will
present with this finding
Outlining of the fetus
Positive pregnancy test (8-9d post-ovulation)
• Due to hCG detection
• Peak: 60-70d
• Nadir: 14-16w AOG
Positive signs Detection of fetal heart tone
(PE/Ancillaries) • TVS: 6-8 weeks, most accurate
• Doppler: 10-12 weeks
• Stethoscope: 18 weeks
Perception of fetal movement by the examiner (20w AOG)
US recognition of the embryo/fetus
• Gestational sac: 4-5 weeks
• Fetal heart beat: 6-8 weeks
• CRL predictive of gestational age up to 12 weeks
Danger signs of pregnancy Persistent headache – severe feature of pre-eclampsia
Blurring of vision – severe feature of pre-eclampsia
Persistent nausea and vomiting – may indicate GTD
Fever and chills – manifestations of infection
Dysuria – may signify UTI
Hypogastric pain – may signify preterm/premature
labor/abortion
Bloody vaginal discharge – may signify abortion/ectopic
pregnancy/labor/placenta previa/abruptio placenta
Watery vaginal discharge – may signify
preterm/premature/labor
Decreased fetal movement – may signify a hypoxic fetus
Edema of the hands and feet may signify pre-eclampsia

• Note if there is any cough, colds, exposure to radiation, if there are any other prenatal
check-ups from other hospital & reason for transfer
• Also take note of any viral exanthems/teratogen exposure, medications given

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II. Past Medical History
• Are there any chronic conditions or treatment for those conditions that may impact the
pregnancy? DM, HTN, HIV, PTB, Autoimmune diseases, Asthma, malignancy
• Previous illnesses, surgeries, blood transfusions, allergies

III. Family History
• Hereditary diseases that may impact the pregnancy or may be passed on to the fetus
• DM, HTN, Asthma, malignancy, heart disease

IV. Personal/Social History
• Smoking, alcohol, illicit drug use

V. Menstrual History
• MIDAS
• Menarche: Age at 1st menstruation
• Interval: 28-30 days (N: 28 + 7 days)
• Duration: 5-7 days (N: 4 – 7 days)
• Amount: 3-4 ppd, moderately soaked (MBL <80mL, Iron loss 13mg/cycle)
• Symptoms: (+) Dysmenorrhea Day 1 relieved by
• LMP: February 27, 2016
• PMP: January 28, 2016

VI. Sexual History
• Coitarche: Age at 1st sexual contact
• Sexual Partners: 2
• Symptoms: (-) dyspareunia, (-) post-coital bleeding
• Family planning method: Natural, barrier method, withdrawal, OCPs

VII. Obstetrics History
• GP(TPAL): Gravidity, Parity, (Term-Preterm-Abortion-Living)
• Also note date of deliveries, outcome, mode, complications
• Ex: G2P1 (1001)
DATE PREGNANCY LABORS PUERPERIUM
April 4, 2016 Live, term singleton NSD by an No
male BW 3.1kg, BL Obstetrician at complications
141cm USTH
If CS, note
indication.

VIII. Current Pregnancy
• Duration of pregnancy
o 280 days or 40 weeks from the 1st day of the LMP
o This corresponds to 10 units containing 28 days each
o Divided into 3 trimesters
§ 1st trimester: Up to 14w
§ 2nd trimester: Up to 28w
§ 3rd trimester: Up to 42w
• Estimation of the AOG: MUST BE IN WEEKS!
o 1st trimester ultrasound – most accurate method to estimate AOG
§ Example: US done Dec. 15, 2016 with an AOG of 8 weeks 2 days
• Convert weeks AOG to days
• 8 weeks x (7 days/1week) = 56 days + 2 days à 58 days
§ Date today: April 4, 2017
• Add the number of days that has passed from the US date to the
present date
• Dec: 16 + Jan: 31 + Feb: 28 + March: 31 + April: 4 = 110 days

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 • 58 days (Age indicated in the US) + 110 days (Number of days that
passed since the US)
• 58 + 110 = 168 days x (1week/7days) à 24 weeks AOG as of now
o LMP Method
§ LMP: January 4-8, 2017
§ Date today: April 7, 2017
Month Days
January 31 – 4 = 27
February 28
March 31
April 7
Add the number of days = 93 days
Divide by 7 to convert to weeks: 93/7 = 13.29 à 13-14w AOG by LMP
Use if US results are not yet available & menstrual cycle is regular
• Estimated Date of Delivery
o Naegle’s rule: provides an EDD, although not exact, we can expect delivery to be
+/- 2 weeks from this date
o EDD = -3mo or +9mo, then +7d from the 1st day of LMP
o LMP: January 4-8, 2017
o 01-04-17 (+9mo, +7days)
o EDD: 10-11-17 October 11, 2017

IX. Physical Examination
• Obtain the weight in pounds, height in cm. Compute BMI based on pre-pregnancy
weight
• Abdominal examination
o Inspection: Abdomen is flat/globular
o Auscultation: with Normoactive bowel sounds
o Percussion – please do not percuss pregnant patients
o Palpation
§ Fundic Height
§ Leopold’s Maneuver
§ FHT
• Fundic height (cm)
o Make sure that the bladder is empty! à Ihi po muna kayo
o Use a tape measure in cm and measure from the Upper border of the symphysis
pubis until the uterine fundus only in gravidas with >16-18w AOG
o Fundic height in cm is reflective of AOG during 16w/18w to 32w AOG
§ 20cm = 20 weeks AOG
o 12w – fundus is at the symphysis pubis
o 16-22w – growth is more rapid as uterus rises out of pelvis into the abdomen
o 20w – fundus is felt at the level of the umbilicus
o If uterine size is small for AOG
§ Erroneous dates of LMP
§ Transverse lie
§ IUGR/SGA
§ Oligohydramnios
§ Constitutionally small fetus
o If uterine size is large for AOG
§ Erroneous dates of LMP
§ Multifetal pregnancy
§ Molar pregnancy
§ LGA, constitutionally large fetus
§ Polyhydramnios

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 • Leopold’s maneuver
o Abdominal palpation which provides information on fetal position, presenting
part & engagement
o Only performed in the latter stages of gestation >28-30w AOG
Leopold’s Maneuver Determines
LM1: Fundic grip Fetal part occupying the fundus

LM1: Breech – if a large nodular mass
is palpated = buttocks

LM1: Cephalic – hard, freely movable,
ballotable part – fetal head at fundus
LM2: Umbilical Grip Position of the fetal back
Hard resistant convex structure –
fetal back
Numerous nodulations - fetal small
parts

LM2: FB Left or FB Right
LM3: Pawlik’s Grip Fetal part occupying the pelvic inlet

LM3: Cephalic – head is at the inlet

LM3: Breech – buttocks at the inlet

LM4: Pelvic Grip Determine whether head is
extended/flexed or whether
*only LM where the engagement has occurred
examiner faces the
mother’s feet LM4: Negative – fetal head is flexed,
this means engagement has not
occurred

• Fetal heart tone
o 6-8 weeks- could be detected by TVS
o 10-12 weeks- Doppler
o 18-20weeks- Stethoscope: Palpate the fetal back & place the bell of the
stethoscope over the FB and slightly place pressure on it
o Normal: 110-160bpm
• Breast examination
o Always perform!
o Respectfully ask the patient to remove clothing to expose both breasts
o Inspect à palpate outside going in à squeeze the nipples
o Normal: breasts are symmetric, skin colored, no dimpling, nipple not inverted,
no nipple retractions, no palpable masses & no nipple discharge
• Pelvic examination
o Inspect external genitalia for any local lesions that may be present or an
episiotomy scar
§ Normal: Pubic hair is coarse and thick, distributed in an inverted triangle
pattern. The labia majora is hyperpigmented and (not) coaptated. There
is a previous RMLE or ME wound. On palpation, there are no masses,
nor tenderness.
o Speculum examination
§ Describe the cervix and the vaginal discharge
§ Normal: Cervix is smooth, violaceous with minimal whitish non-foul
smelling discharge

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 o Internal examination:
§ Describe the cervix, uterus and adnexa
§ Normal: Cervix soft, long, closed; uterus enlarged to 2 months’ size, no
adnexal masses nor tenderness
§ Adnexae cannot be evaluated if uterus is 3 months’ size
§ If term: Cervix is soft, long, 1 cm dilated, (+) BOW, cephalic, station -3

X. Diagnosis
• G2P1 (1001), Pregnancy Uterine 13-14w AOG by LMP

XI. Labs/Ancillaries
• Transvaginal Ultrasound
o <12w AOG
o Requested to establish
§ Fetal aging & viability
§ Intrauterine pregnancy
• Fetal biometry if > 13w for fetal aging & viability
• Biophysical Profile if > 28w to assess fetal well-being
o AFI
o Fetal tone
o Fetal movement
o Fetal breathing
o FHR
• CBC
o Note for leukocytosis & pregnancy but mostly to assess physiologic anemia of
pregnancy
o 1st trimester: <11g/dl
o 2nd trimester: <10.5g/dl
o 3rd trimester: <11g/dl
o Quantify anemia if mild, moderate or severe
§ Mild: 9.5-10.5g/dl
§ Moderate: 8-9.4g/dl
§ Severe: 6.9-7.9g/dl
• Blood typing
o Just in case blood transfusion be needed during labor/delivery
o It is important to note maternal blood type to assess the possibility/risk for
developing hemolytic disease of the new born
• Urinalysis
o To assess for UTI as this may cause abortion/premature labor if left untreated
o Pus must be < 5/hpf, albumin (proteinuria is needed in the diagnosis of Pre-
eclampsia)
• HbSag
o Near term
o Hepatitis Virus is capable of crossing the placental barrier
o A reactive test may indicate the need for neonatal HB IgG
• VDRL/RPR: Near term
o For appropriate treatment to avoid vertical transmission of these diseases
• Pap Smear – baseline, but usually requested if a gravida presents with signs and
symptoms of cervical cancer (foul-smelling vaginal discharge, weight loss, post-coital
bleeding). This primarily detects premalignant lesions of the cervix as a screening tool
for cervical CA.
• HIV Screening – suggest to the patient as the Philippines has the highest rate of new HIV
cases recorded per day as compared to any other Asian country

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 • Diabetes Screening
o At the first prenatal visit, determine if the gravida is HIGH RISK or not based on
historical and pregnancy risk factors
Historical Risk Factors for the development of GDM
Past pregnancies Abnormal glucose tolerance
Macrosomia (BW > 8 lbs)
Congenital malformations
Recurrent abortions
Unexplained intrauterine death
Present pregnancy Family history (1st degree relation)
Maternal obesity (>180 lbs or BMI >27 kg/m2)
Drugs affecting CHO metabolism (steroids, beta agonists, etc.)
Age 25 years
Racial predilection
Obstetric/gynecologic Hydramnios
risk factors Macrosomic fetus
Fetal abnormality
Recurrent genital tract infections
PCOS

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XII. Plans
• Multivitamins tablet, 1 tab OD
• Folic Acid 1 tab OD
• Ferrous Sulfate 1 tab OD
• Milk 1 glass OD
• Follow up check-ups
o Non-high risk
§ 1st PNCU to 28w AOG: Every 4 weeks
§ 28-36w AOG: Every 2 weeks
§ 37w AOG onwards: Every week
o High risk
§ May vary depending on the disease
o Or anytime if with problems/danger signs of pregnancy
• Dietary prescription
o 2000 kcal/day, add 300 kcal/day in 2nd and 3rd trimester
§ Normal weight gain: 25-35lbs (1lb/week)
o Iron: 27mg/day of FeSO4, no supplementation during the 1st trimester
o Calcium 400-900mg, recommended to women with poor calcium intake & is
beneficial to those at risk of developing GHPN & Pre-eclampsia.
o Zinc 12mg/day, essential for enzymatic activity required for growth, brain dev’t,
sexual maturation & immune function
o Iodine 220mg/day – given due to the high prevalence of goiter
o Folate 350mcg/day – a deficiency of which is a contributing factor to anemia,
4mg/day if with history of NTDs as this prevents NTDs
• Common concerns of patients
o Air travel is safe up to 36 weeks AOG (ACOG)
o Periodontal disease has been linked to preterm labor but pregnancy is not a
contraindication to dental treatment/radiographs
o Caffeine intake should be <300mg/day: <3 5oz cups daily
o Immunizations
§ Tetanus toxoid
• Give if no/unknown history of immunization
• Give 3 doses starting at the 2nd trimester, 1 month apart and 3rd
dose can be given post-partum
• Tetanus toxoid more than 10 years ago, give 1 booster
§ Influenza Vaccine
• Can be safely given any time during pregnancy

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