PRENATAL CARE part 2

2013
weight (current and amount of change)
normal wt gain = 1lb/week

OVERVIEW
I.
II.
III.

High risk pregnancies

Subsequent prenatal visit
Nutrition

Symptoms
headache, altered vision, abdominal pain, N&V, bleeding,
vaginal fluid leakage and dysuria
Height of uterine fundus from top of symphysis (in cm)
Vaginal exam (late pregnancy)
a) confirmation of the presenting part and its station
b) clinical estimation of pelvic capacity and its general
configuration
clinical measurement of passage way
c) consistency, effacement and dilatation of cervix

HIGH RISK PREGNANCIES

A. MEDICAL HISTORY AND CONDITIONS
1) Asthma
2) Cardiac disease
3) Diabetes mellitus
4) Drugs & alcohol use
5) Epilepsy
6) Family history of genetic problems
7) Hemoglobinopathy (thalassemia)
8) Hypertension
9) History of pulmonary deep venous thrombosis (DVT)
10) Psychiatric illness
11) Coronary disease
12) Pulmonary disease
13) Renal disease

ASSESSMENT OF GESTATIONAL AGE

1. FUNDAL HEIGHT
height correlates with the AOG in weeks
measured from top of symphysis to the top of fundus
NOTE: empty bladder before measuring. Bladder and obesity affects
the height
Other independent way of determing AOG:
Quickening
Uterus become an abdominal oorgan at 12weeks

B. OBSTETRICAL HISTORY AND CONDITIONS

1) 35 y/o delivery
2) Prior cesarean section
Needs to undergo prenatal care in a hospital setting

2. FETAL HEART SOUND

16 - 19th week
20th week more audible

3) Incompetent cervix
4) Prior fetal structural or chromosomal abnormality
May have chance of recurrence
5)
6)
7)
8)

22nd week best

Prior neonatal death

Prior fetal death
Prior preterm delivery or preterm ruptured membranes
Prior low birth weight (<2500g)
DM patient have baby with birth weight & undergoes
hypoglycaemia after delivery

HR: 110-160bpm
NOTE: sounds like tickling WATCH under a pillow. Hindi CLOCK!
DROPPER US often used at 10th week
3. SONOGRAPHY
1st trimester part of aneuploidy screening
2nd trimester fetal anatomy
NOTE: note required pero kung mapilit kelangan mo irespeto yung
pasyente, magkakapera ka pa haha

9) Second-trimester pregnancy loss

10) Uterine leiomyomas or malformation
C. INITIAL LABORATORY TESTS
1) Human immunodeciency virus (HIV)
2) CDE (Rh) of other blood group isoimmunization (excluding ABO,
Lewis)
3) Initial examination condylomata
Wart lesions inside the vagina

SUBSEQUENT LAB TESTS

11-14th week and/or 15th week Fetal aneuploidy
15-20th week Neural tube defect
H/H, syphilis repeated at 28-32nd week if there are prevalent cases in the
population
Rh negative and unsensitized mothers are recommended to have repeat
antibody screening at 28-29th week with administration of RhoGam if
remain unsensitized

SUBSEQUENT PRENATAL VISITS

Traditional schedule for uncomplicated case
Every 4 weeks intervals from 1st trimester to 2nd trimester
Every 2 weeks until 36 weeks
Weekly from 36th week to term

before conception or during 1st or early 2nd trimesters

screening of Cystic fibrosis

For woman with complications, they are recommended to have 1-2weeks

intervals of visit
WHO trial (but not a trial anymore)
1st trimester if no risk factors subsequent visits
26, 32 & 38 weeks

A. GROUP B STREP INFECTION

vaginal and rectal 35-37th week
intrapartum antimicrobial prophylaxis for positive
empirical prophylaxis for GBS bacteriuria or previous infant
with invasive disease
B. GESTATIONAL DIABETES
all pregnant no exception
24-28th week most sensitive

PRENATAL SURVEILLANCE
FETAL evaluation:
heart rate
size
current and rate of change
assess fundic height
some women undergo diet because they dont want their
baby to be big (to avoid CS)

C. GONOCOCCAL INFECTION
same with Chlamydia
early prenatal visitor 3rd trimester
D. GENETIC DISEASES SCREENING
depends on ethnic or racial background

amniotic fluid volume

NUTRITION

presenting part and station (late pregnancy)

breeach presenting delivery
done on the time of pregnancy because breeach presentation
may be corrected preterm (pwede pa umikot ang baby)
fetal activity
diurnal
activity after eating (maternal)

RECOMMENDATIONS FOR WEIGHT GAIN:

Limited to 20lbs or 9.1kgs prevent gestational HPN and fetal macrosomia
(Mid 1900s)
25lbs or 11.4kgs prevent prenatal birth and fetal growth restriction
(1970s)
25-35lbs or 11.4-16kgs for women with normal BMI (1990s)
NOTE: weight gain depends on BMI. Influence birth weight

MATERNAL
blood pressure

Anak

ng Dilim

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PRENATAL CARE part 2

2013
D. PROTEINS
metabolized rather than spared
required for demands in fetal growth, remodelling, placenta, uterus,
breast as well as increased maternal blood volume
1000g are deposited during second half of pregnancy
Thus, 5-6g/day
Ornithine, glycine, taurine, proline
Glutamate and alanine
Milk and other dairy products are ideal sources for pregnant and
lactating women

E. MINERALS
All diets that supply sufficient calories will contain enough minerals to
prevent deficiency when iodized food are ingested
1) IRON
Needed during the 2nd trimester
Hematopoiesis occurs
27 mg per day Singleton
60 - 100 mg per day for:
a. Large women
b. Twin pregnancies
c. Anemia
2) CALCIUM
RDA 1000 to 1300 mg/day
For replenishment of bone calcium
Lesser chance of developing osteoporosis (esp. during
menopause)

OVERNUTRITION

3) ZINC

Maternal weight gain had a positive correlation with birthweight

women with weight gains < 16 lbs
greatest risk for delivering an infant weighing< 2500 g

RDA 12 mg
Deficiency may lead to:
a. Poor appetite
b. Suboptimal growth
c. Impaired wound healing

SEVERE UNDERNUTRITION
birthweight can be inuenced signicantly by starvation during later
pregnancy
The perinatal mortality
incidence of malformations signicantly increased
frequency of pregnancy toxemia
severe dietary deprivation during pregnancy caused no detectable effects
on subsequent mental performance
Progeny exposed in mid to late pregnancy dietary deprivation:
lighter, shorter, and thinner at birth
higher incidence of subsequent diminished glucose tolerance,
hypertension, reactive airway disease, dyslipidemia, and coronary
artery disease.
Early pregnancy exposure was associated with:
obesity in adult women but not men
central nervous system anomalies, schizophrenia, and
schizophrenia-spectrum personality disorders.

4) IODINE
RDA 200 ug
Deficiency may lead to:
a. Maternal subclinical hypothyroidism
b. Cretinism & neuro-development defects
Common among high-landers
5) MAGNESIUM
no known effect when deficient

6) MOST ARE PROVIDED BY BALANCED DIET

Cu, Se, Cr, Mn, K, F
7) OTHER VITAMINS

RECOMMENDED RANGES OF WEIGHT CHANGES (TABLE 8-7)

Normal: 25 35 lbs
Small built mother: 28 40 lbs
Obese mother: 15 25 lbs

THIAMINE (B1)
RDA 1.4 mg

EFFECTS OF NUTRITION

RIBOFLAVIN (B2)
RDA 1.4 mg

A. WEIGHT RETENTION AFTER PREGNANCY

Ave. wt. retention 3 lbs or 1.4 kgs
Prepregancy BMI or wt. gain weight retention
Breastfeeding-- weight retention
Therefore, Accruing weight with age = wt gain over time
Hindi kasi nageexercise

NIACIN
RDA 18 mg
PYRIDOXINE (B6)
RDA 1.9 mg
Combined with doxylamine (anti-histamine)
reduce vomiting, hyperemesis gravidarum
Avoid triggering factors like odor
Small frequent meals if gets nauseous easy

B. RECOMMENDED DIETARY ALLOWANCES

Vitamins & mineral with Potentially toxic effects in excess:
1. Fe
2. Se
3. Zn
4. Vitamins A, B6, C, & D
Excess in vit. A leads to a teratogenic effect
Ok lang hindi magbigay ng vitamins basta proper nutrition

FOLIC ACID (B9)

4 mg before and during the 1st trimester
70% reduction of B9 neural tube defects
NOTE: Drink folic acid even before they become pregnant &
continue till term but most important before pregnancy &
during 1st trimester
may stop giving after 1st trimester because organogenesis
is already done
no toxicity

C. CALORIES
Requires additional 80,000kcal
accumulated at last 20 weeks
Increase of 100-300kcal/day

Anak

ng Dilim

VITAMIN A
RDA 750 to 770 ug
Potentially teratogenic
Can be found in acne or dematologic meds
Isotretinoin, retinoic acid
topical preparations only reach the blood stream at minute
amounts, some tend to get stored in adipose tissue for as
long as 5 years
Deficiency may lead to:
a. Anemia
b. Spontaneous preterm birth

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PRENATAL CARE part 2

2013

CYANOCOBALAMIN (B12)
RDA 2.6 ug
Only present from animal sources
Deficiency neural tube defects
If vegetarian, give B12 supplements instead

CAFFEINE:
Caffeine intake < 300 mg daily or 1cup/day

NAUSEA & VOMITING

VITAMIN C
RDA 80 85 mg

Small frequent feedings

Mild: vit B6 and doxylamine
May also give phenothiazine or H1 receptor blocker
Hyperemesis gravidarum

PRAGMATIC NUTRITIONAL SURVEILLANCE

BACKACHE:
1) Eat what she wants in amounts she desires and salted to taste
Salted not for HPN
2) Ensure the availability of food
3) Monitor weight gain
25 - 35lbs in women with normal BMI
4) Periodically explore food intake
5) Give iron at least 27 mg, folate before and in the early weeks of
pregnancy
6) Recheck Hgb & Hct values at 28 to 32 weeks.

VARICOSITIES

May lead to DVT

Congenital predisposition
Can be present in the legs & perin
Exaggerated with:
Prolonged standing
Weight increase
Rx periodic rest with legs elevated & using stockings (special type)

COMMON CONCERNS

HAEMORRHOIDS

EMPLOYMENT

Varicosities of the rectal veins may first appear during pregnancy

because of increased venous pressure
Thrombosis of an external hemorrhoid can cause considerable pain, but
the clot usually can be evacuated by incising the vein wall under topical
anesthesia.

Avoid severe physical strain, relax relax din

Minimize physical work if with history of preterm labor

EXERCISE:

No limit provided that it is in moderation

Regular moderate intensity work put for 30 minutes
Exercise with a high risk of falling/abdominal trauma must be avoided
Scuba diving is NOT RECOMMENDED.
Due to N2 narcosis under the water
Low impact aerobics, exercises, walking

FISH CONSUMPTION:

Due to posture
Reduced w/ squatting than bending
Provide back support
Avoid high-heeled shoes

Avoid fish wi/ potentially methylmercury lvls (skin & belly fat of fish)
Not more than 12oz of canned tuna per week
Not more than-6oz of albacore/white tuna
Avoid bottom dweller fish because mercury gravitates towards the sea
floor
Attacks nerves
Tremors
Mercury in fluorescent lamps
LEDs now used & CFCs

TRAVEL:
A. Automobile:
Lap belt portion: under the abdomen and across the upper thighs
Shoulder belt between the breasts

HEARTBURN
Most common complaints of pregnant women
Low peristalsis due to pregnancy hormones
caused by reflux of gastric contents into the lower esophagus
relieved by a regimen of more frequent but smaller meals and avoidance
of bending over or lying flat
Antacids may provide considerable relief.
Aluminum hydroxide, magnesium trisilicate, or magnesium hydroxide
alone or in combination are given
Rx topical anesthetics, warms soaks, stool softeners, high fiber diet
Dont sit in the toilet kung hindi ka naman talaga natatae (feelingera)

PICA
Cravings of pregnant women for strange foods
craving for non-food:
Ice pagophagia
Starch amylophagia
Clay geophagia
* triggered by severe iron deficiency
NOTE: if strange foods dominate the diet, iron deficiency will be
aggravated or will develop eventually

PTYALISM

B. Air travel:
Safe to travel up to 36 weeks
Airline policy: no travelling if 7 months AOG

Excessive salivation
Stimulation of the salivary glands by the ingestion of starch

SLEEPING AND FATIGUE

COITUS
Generally safe (if no preterm labor)
Oral-vaginal intercourse causes air embolism from partner blowing air
inside vagina, thus harmful
Missionary nalang kasi hahaANO BAY YAN! haha

Due to the soporific effect of progesterone

Sleep efficiency is diminished because REM sleep is decreased and nonREM sleep prolonged thus pregnant have difficulty in sleeping
Rx daytime naps & mild sedative [diphenhydramine (Benadryl)]

LEUKORRHEA

DENTAL CARE

Excess white secretions

Majority of these in adult women are caused by bacterial vaginosis,
candidiasis, or trichomoniasis
May be normal in pregnancy (due to hyperestrogenemia)

Dental treatment not contraindicated in pregnancy

IMMUNIZATION:
CORD BLOOD BANKING
Vaccine
TT1
TT2
TT3
TT4
TT5

Anak

Minimum age/interval
As early as possible during pregnancy
At least 4 wks later
At least 6 mos. Later
At least 1 yr. later
At least 1 yr. later

ng Dilim

% protected
80
95
99
99

two types of cord blood banks:

1) Public banks
promote allogenic donation, for use by a related or
unrelated recipient, similar to blood product donation
2) Private Banks
were initially developed to store stem cells for future
autologous use, these banks charge fees for initial
processing and annual storage

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