[OBSTETRICS A] PRENATAL CARE

PRENATAL CARE  The consistency of a normal cervix in a non-

Aida V. San Jose, MD, FPOGS pregnant woman is like the consistency of the tip of
the nose,gravidarum
 Cloasma whereas orthe“mask
consistency of pregnant
of pregnancy”
DIAGNOSIS OF PREGNANCY cervix is like the buccal mucosa (soft).
 We need to know how to diagnose pregnancy first  Skin Changes
before we proceed with prenatal care.  Increased pigmentation
 Abdominal striae
SIGNS AND SYMPTOMS OF PREGNANCY  Striae can initially be pinkish but turns gray later on
 Cessation of Menses  Permanent  Can be an evidence that a woman has
 Not a reliable indication of pregnancy until 10 days or been pregnant though this is not a positive sign of
more after the time of expected onset of menstrual period pregnancy  Can also be seen in people with
 Most women with previous contact who have a few ascites, tumors of the abdomen
days of missed period will assume that they are
 Changes in the Uterus
pregnant.
 1st few weeks  Increased uterine size limited to AP
 A few days missed period is not a reliable indication diameter
of pregnancy until 10 days or more after the time of  6-8 weeks  Hegar sign (softening of isthmus)
expected onset of the menstrual period.
 Isthmus  Junction between the internal os and
 Changes in Cervical Mucus corpus of the uterus
FERN PATTERN BEADED PATTERN  If the patient is not pregnant  Isthmus is less than
 7th to 18th day of  After 21st day 1 cm
menstrual cycle  If the patient is pregnant  Isthmus becomes the
 Dependent on increased  Usually encountered lower uterine segment
concentration of sodium during pregnancy  Early in pregnancy, the isthmus can be so soft that
chloride sometimes it may be difficult to delineate 
 Presence of estrogen  Presence of Sometimes the corpus uteri and the cervix will feel
progesterone like they are separate organs because of the
softening of the uterus

 12 weeks  Uterus almost globular

 Uterus now becomes an abdominal organ after the

Photomicrograph of dried 12th week of gestation
Photomicrograph of
cervical mucus obtained  At 6 weeks  About the size of a small orange
cervical mucus obtained
from the cervical canal of  At 8 weeks  About the size of a big orange
on day 11 of the
a woman pregnant at 32  At 12 weeks  About the size of a grapefruit
menstrual cycle
to 33 weeks
 Uterine Souffle  Soft blowing sound synchronous with
 Fern Pattern = Leaf-like Pattern the maternal pulse
 Funic Souffle  Whistling sound synchronous with the
 It is unlikely that a patient is pregnant if you see this
fern-pattern on the cervical mucus. fetal pulse
 Changes in the Breasts
 Discoloration of Vaginal Mucosa  Characteristic during first pregnancy
 CHADWICK SIGN  Vaginal mucosa appears dark blue
and congested  In the subsequent pregnancies, the changes are not
that characteristic anymore
 Not a positive sign of pregnancy  Sometimes,
intake of oral contraceptive pills can bring about  Perception of Fetal Movement
this change  Quickening  Perception of fetal movements
 Changes in the Cervix  Primigravid: 18 – 20 weeks
 Increased softening as pregnancy advances  Multigravid: 16 – 18 weeks

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 [OBSTETRICS A] PRENATAL CARE

 Fetal Heart Action (110-160 bpm)  Nadir: 16 weeks

 17-19 weeks  Standard non-amplified stethoscope
 22nd week of gestation  By ordinary stethoscope,
you will hear the fetal heart sounds 100%
 10 weeks  Using doppler equipment
 5 weeks  Transvaginal
 Sounds Perceived by the Examiner other than the FHT
 Funic (Umbilical Cord) Souffle
- Rush of blood through the umbilical arteries
- Sharp, whistling sound synchronous with fetal pulse
 Uterine Souffle
- Produced by passage of blood through dilated uterine
vessels
- Soft blowing sound that is synchronous with maternal
pulse
 Sounds resulting from fetal movement
 Maternal pulse
 Sounds from maternal intestinal peristalsis
 False Positive
- In women with circulating factors in their serum that
may interact with the hCG antibody (eg. Heterophilic
antibodies)
 Women who are closely associated with animals
 POSITIVE Pregnancy Test WITHOUT Pregnancy
- Exogenous hCG injection for weight loss
- Renal failure with impaired hCG clearance
- Physiological pituitary hCG
- hCG producing tumors
 Some ovarian tumors can secrete hCG  Can
also give out a false positive test
ULTRASONIC RECOGNITION OF PREGNANCY
 4-5 weeks  Gestational sac by transabdominal UTZ
 Gestational Sac  First sonographic sign of pregnancy

 5-6 weeks  Yolk sac

PREGNANCY TEST
 6 weeks  Embryo with cardiac activity
 12 weeks  CRL is predictive of gestational age within 4
days

 CRL  Crown-rump length

 By 12 weeks, the measurement of the CRL is so
accurate in predicting the gestational age and EDC.

 HCG

 It is the presence if hCG in the urine or in the serum

that is the basis of pregnancy tests

 α-subunit is similar to: LH, FSH, TSH

 Prevents involution of the corpus luteum (principal site
of progesterone formation during the first 6 weeks)

 After 6 weeks, the placenta takes over the

production of progesterone  LUTEO-PLACENTAL
SHIFT

 Detectable in maternal plasma or urine by 8 – 9 days after

ovulation
 Doubling time: 1.4 – 2 days

 Doubling time usually happens during the Ectopic

Pregnancy

 Peak Levels: 60 - 70 days

 8th to 10th week of gestation

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 [OBSTETRICS A] PRENATAL CARE

INITIAL PRENATAL EVALUATION again in the again in the

3rd trimester 3rd trimester
Prenatal care should be initiated as soon as there is reasonable High risk
likelihood of pregnancy. women
should be
Chlamydial retested at
GOALS OF PRENATAL CARE Culture the
 To define the health status of the mother and fetus beginning of
the 3rd
 To estimate the gestational age of the fetus trimester
 To initiate a plan for continuing obstetrical care Williams:
High risk
women
TYPICAL COMPONENTS OF ROUTINE PRENATAL CARE should be
Hepatitis B screened at
15-20 24-28 29-41
First Visit Serology 1st prenatal
weeks weeks weeks visit and
HISTORY again in the
Complete 3rd trimester
Updated PPT: --
PHYSICAL EXAMINATION Williams:
Complete High risk
Blood women
Pressure should be
Maternal Test should screened at
HIV Serology
Weight be offered 1st prenatal
Pelvic/ visit and
Cervical Exam again in the
Fundic Height 3rd trimester
PPT: --
Fetal Heart
and Position Rectovaginal
culture
LABORATORY TESTS Group B should be
Hemoglobin & Streptococcus obtained
Hematocrit Culture between 35
Blood Type & and 37
Rh Factor weeks
Performed at
Antibody
28 weeks, if
Screen
indicated
Pap Smear
 Physical Examination  Should be complete, with
Screening special emphasis on the abdomen and the pelvis
Glucose
Tolerance Test
 Pelvic/Cervical Examination  Should tell us about the
First status of the cervix, size of the uterus, consistency of the
trimester uterus, adnexa
aneuploidy
Fetal screening  Patients who are at high risk for Gestational Diabetes
Test should
Aneuploidy may be
be offered Mellitus (GDM): Obese, history of DM, history of giving
Screening offered
between 11
birth to large babies, history of still birth, (+) glucosuria
and 14  We also request Glucose Tolerance Test during the 1st
weeks
visit
Neural Tube
Defect
Williams: -- Test should  If the patient has symptomatic bacteriuria  Request for
PPT:  be offered
Screening urine culture to confirm the diagnosis so we can treat the
Cystic Fibrosis Test should Test should
Screening be offered be offered patient accordingly to avoid the progression into an
Urine Protein upper urinary tract infection
Assessment
Urine Culture
 28-32nd week of Gestation  Increase in plasma volume
Rubella (About 55% increase)  Physiologic Hemodilution of
Serology Pregnancy  Increase circulating erythrocytes is not
High risk
women proportional with the increase plasma volume 
should be Request for repeat hemoglobin and hematocrit on the
Syphilis retested at
Serology the
28-32nd week of gestation regardless of whether the
beginning of patient is anemic or has normal hemoglobin and
the 3rd hematocrit count during the 1st trimester
trimester
High risk High risk  Hepatitis B Serology  Should be repeated at the time
women women of admission for delivery
Gonococcal should be should be
Culture screened at screened at
1st prenatal 1st prenatal
visit and visit and

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 [OBSTETRICS A] PRENATAL CARE

DEFINITIONS  Each trimester is comprised of 14 weeks

 Nulligravida  A woman who is not now and never has  Rationale for dividing it into 1st, 2nd and 3rd trimester
been pregnant  Some milestones or events can be particular to
 Gravida  A woman who is or has been pregnant, each of this trimesters
irrespective of the pregnancy outcome
 Nullipara  A woman who has never completed a
pregnancy beyond 20 weeks’ age of gestation HISTORY
 Primipara  A woman who has been delivered only once of  OBSTETRICAL HISTORY  Prior pregnancy complications
a fetus or fetuses born alive or dead with an estimated tend to recur in subsequent pregnancies
length of gestation of 20 or more weeks  MENSTRUAL HISTORY  Ovulatory cycles important for
 Multipara  Completed 2 or more pregnancies to 20 weeks accurate dating of pregnancy by history and PE
or more  OCP USE  Ovulation may not have resumed 2 weeks after
 Parity  Number of pregnancies reaching 20 weeks and not onset of the last withdrawal bleeding
by the number of fetuses delivered
- Same for singleton or multifetal delivery or delivery of a PSYCHOSOCIAL SCREENING
live or stillborn infant  Cigarette Smoking
 Adverse Outcomes
NORMAL PREGNANCY DURATION - Teratogenic effects
 Mean duration from last normal menstrual period - Spontaneous abortion
(Gestational Age or Menstrual Age): 280 days or 40 weeks  10 sticks per day  Can cause abortion
 Pregnancy usually lasts for 10 lunar months. Each - Low BW due to preterm delivery or fetal growth
lunar month consists of 28 days  28 x 10 = 280 days restriction
 Different from Ovulation Age or Embryonic Age - Fetal death, SIDS
- Placental abruptio, Placenta previa
 Expected date of delivery (Naegele’s Rule): LMP + 7 days
- PROM
then count back 3 months
 Pathophysiology for Adverse Pregnancy Effects
 Add 7 days to the 1st day of the last menstrual period - Fetal hypoxia
and count 3 months backward - Reduced uteroplacental blood flow
 Example: LMP = September 10 - Direct toxic effects of nicotine and other compounds in
 Count 3 months backward: August, July, June  smoke
June
 Add 7 days: 10 + 7 = 17  Alcohol and Illicit Drugs During Pregnancy
 Expected Date of Delivery: June 17  Ethanol  Potent teratogen and causes FETAL ALCOHOL
 You may also count 9 months backward or 9 months SYNDROME
forward  Fetal Alcohol Syndrome
- Growth restriction
“Easier” technique that I learned from my Nursing - Facial abnormalities
days: - CNS dysfunction
 Magic Formula: -3 +7 +1  Illicit Drugs
- Fetal growth restriction
- Low birth weight
- Drug withdrawal soon after birth

 Intimate Partner Violence Screening

 Pattern of assaultive and coercive behavior
 Includes: Physical injury, psychological abuse, sexual
assault, progressive isolation, stalking, deprivation,
intimidation, reproductive coercion
 Ovulatory Age or Fertilization Age  2 weeks short of the  Adverse Outcomes
menstrual age - Preterm delivery
 3 TRIMESTERS: - Fetal growth restriction
 1st Trimester: Extended through completion of 14 weeks - Perinatal death
 2nd Trimester: Through 28 weeks  Frequency of Screening
 3rd Trimester: 29th through 42nd weeks - First prenatal visit

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 [OBSTETRICS A] PRENATAL CARE

- 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

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 [OBSTETRICS A] PRENATAL CARE

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

ASSESSMENT OF GESTATIONAL AGE

 FUNDAL HEIGHT
 20 – 34 weeks
 Height of the fundus (cm) correlates with AOG in weeks
 Example: 26 weeks  Expect that the fundic height
will be 26cm
 If there is a discrepancy of about 3cm  Investigate
further
 Distance over the abdominal wall from the top of the
symphysis pubis to the top of the fundus
SUBSEQUENT PRENATAL VISITS  To avoid bias, get the measurement first in inches
 Every 4 weeks until 28 weeks  Then flip-over the tape measure to see what is
 Every 2 weeks until 36 weeks the corresponding value in cm
 Weekly thereafter
 Bladder must be emptied before making measurement
 Every 1-2 weeks interval for complicated pregnancies

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 [OBSTETRICS A] PRENATAL CARE

 A full bladder can add about 3cm to the fundic  Zinc

height  Selenium
 Vitamin A, B6, C and D
 FETAL HEART SOUNDS
 As early as 16 weeks RECOMMENDED DAILY ALLOWANCES
 Audible in all by 22 weeks  CALORIES
 10 weeks – Doppler  Requires 80,000 Kcal
 5 weeks – TVS  Increase intake of 100 – 300kcal/day
 ULTRASOUND  Protein is metabolized whenever caloric intake is
 If performed between 8 – 16 weeks was accurate by 2 days inadequate
for predicting the actual date at delivery
 This can deprive the growth and development of the
SUBSEQUENT LABORATORY TESTS fetus.
 Fetal aneuploidy at 11-14 weeks or 15-20 weeks
 Amniocentesis  PROTEIN
 High risk for developing fetal aneuploidy: Pregnant for  1000g deposited latter half of pregnancy= 5-6 g/day
the 1st time at the age of 35  Elderly primigravida  Most amino acids fall in maternal plasma
 Preferably supplied from animals
 NTD screening at 15-20 weeks
 Hemoglobin, hematocrit repeated at 28-32 weeks  Milk, dairy products, fish
 As well as Syphilis if prevalent
 HIV repeated before 36 weeks for high risk  MINERALS
 Hepatitis B retested at time of delivery if high risk  IRON
 Unsensitized Rh negative with antibody screen retesting at - 300 mg transferred to the fetus
28-29 weeks - 500 mg incorporated into maternal hemoglobin mass
 Group B streptococcal Infection  35 to 37th week - Iron requirement by mid-pregnancy = 7 mg/day
 Gestational Diabetes  OGTT on the 24th to 28 week - Recommended daily ferrous iron supplement = 27 mg
 Selected Genetic Screening
 Can be 27-30mg  Tablet of elemental iron
NUTRITION usually contains 30mg of iron
WEIGHT GAIN - Increase to 60 – 100 mg/day if:
 Large woman
 Twin fetuses
 Late iron supplementation
 Irregular intake
 Depressed hemoglobin levels
- Ingest at bedtime or on empty stomach facilitates
absorption and minimize adverse GI reaction
 Iron supplementation during the 1st semester = Not
usually recommended  May add up to the nausea
and vomiting felt by the pregnant woman
 May start during the 4th month of pregnancy
 CALCIUM
- 30 g is retained, most of which is deposited in the fetus
late in pregnancy
- There is increased absorption by the intestine and
progressive retention throughout pregnancy
 PHOSPHORUS
NUTRIENTS THAT CAN POTENTIALLY EXERT TOXIC EFFECTS - Plasma levels do not differ from pre-pregnancy levels
 ZINC
 Iron
- Recommended daily intake = 12 mg
 Iron supplementation is a must during pregnancy - ZINC DEFICIENCY
but it should be the recommended amount of  Poor appetite
supplementation only.  Suboptimal growth

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 [OBSTETRICS A] PRENATAL CARE

 Impaired wound healing  VITAMIN A

 Dwarfism and hypogonadism - Associated w/ birth defects at doses >10000IU/ day
 Acrodermatitis enteropathica - Isotretinoin is potent teratogen in humans
 IODINE - B-carotene has not been shown to produce vitamin A
- RDA 220 micrograms toxicity
- Use of Iodized salt, bread - Deficiency associated with increased risk of maternal
- Severe deficiency predispose endemic Cretinism anemia and preterm birth, severe with night blindness
 MAGNESIUM  VITAMIN B6
- Deficiency during pregnancy has not been recognized - Daily supplement of 2mg recommended for women at
 POTASSIUM high risk for inadequate nutrition
- Decreases by 0.5 mEq/L by mid-pregnancy - For nausea & vomiting
- Predisposed by prolonged nausea and vomiting  VITAMIN C
 SODIUM - RDA = 80 – 85 mg/day
- Increased total sodium accumulation - Maternal plasma level decline during pregnancy but
- Serum concentration is decreased due to expanded cord level is higher
plasma volume  VITAMIN B12
- Excretion unchanged - Decrease in normal pregnancy
 FLUORIDE - Occurs naturally in foods of animal origin
- Metabolism unchanged - Deficiency: Vegetarians, excessive vitamin C ingestion
- Supplementation not required  VITAMIN D
 CHROMIUM - Increases intestinal Calcium absorption
- Co-factor for insulin by facilitating attachment to - Promotes bone mineralization & growth
peripheral receptors - DEFICIENCY in women with limited sun exposure is
- No data suggesting supplementation is advisable for ordered skeletal homeostasis
pregnancy - Congenital rickets
 MANGANESE - Fractures in the newborn
- Co-factor for enzymes glycosyltransferase which are
necessary for synthesis of polysaccharides and
glycoproteins
 COPPER
- Marked increase in serum ceruloplasmin and plasma
coper during pregnancy
- Deficiency not documented in humans during
pregnancy
 SELENIUM
- Essential component of glutathione peroxidase which
catalyzes hydrogen peroxide to water
- Important defensive component against free radical
damage
- Severe Deficiency manifested by fatal cardiomyopathy
in children and women of childbearing age

 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

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 [OBSTETRICS A] PRENATAL CARE

COMMON CONCERNS  If mercury content of local fish unknown, consumption

 EMPLOYMENT should be limited to 6 oz/week
 Greater risk for preterm delivery with jobs that require
prolonged standing  LEAD SCREENING
 Occupational fatigue was associated with increased risk of  Exposure effects:
PPROM - Gestational HPN
 Adequate periods of rest should be provided during work - Spontaneous abortion
period - Low birth weight
 Women with uncomplicated pregnancies can continue to - Neurodevelopmental impairments in the newborn
work until onset of labor  Done if with identified risk factors

 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

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 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
 Result from congenital predisposition exaggerated by long
standing, pregnancy, and advancing age
 Femoral venous pressure increases as pregnancy
advances
 Advise periodic rest with elevation of the legs, elastic
stockings
 Surgical correction during pregnancy not advised
 CANDIDIASIS
 Asymptomatic colonization requires no treatment
 Extremely profuse, irritating vaginal discharge associated
with pruritic, tender, and edematous vulva
 Treat with miconazole, clotrimazole, and nystatin

 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

LEA THERESE R. PACIS 10


RECOMMENDATIONS FOR IMMUNIZATION DURING PREGNANCY
IMMUNOBIOLOGICAL INDICATIONS FOR IMMUNIZATION
DOSE SCHEDULE
AGENT DURING PREGNANCY
LIVE ATTENUATED VIRUS VACCINES
Contraindicated—see immune
Measles
globulins
Mumps Contraindicated
Contraindicated, but congenital
Rubella rubella syndrome has never been
described after vaccine
Poliomyelitis
Not routinely recommended for
 Oral = Live-
women in the United States,
attenuated
except women at increased risk of
 Injection =
exposure
Enhanced-potency
inactivated virus
Yellow fever Travel to high-risk areas
Contraindicated, but no adverse
Varicella
outcomes reported in pregnancy
Contraindicated in pregnant
Smallpox (Vaccinia) women and in their household
contacts
All pregnant women, regardless of
Influenza trimester during flu season
(November-March)
Indications for prophylaxis not
Rabies altered by pregnancy; each case
considered individually
Pre-exposure and post-exposure
Hepatitis B
for women at risk of infection
INACTIVATED BACTERIAL VACCINES
Indications not altered by
pregnancy. Recommended for
women with asplenia; metabolic,
Pneumococcus
renal, cardiac, or pulmonary
diseases; immunosuppression; or
smokers
Indications not altered by
pregnancy; vaccination
Meningococcus
recommended in unusual
outbreaks
Not recommended routinely
except for close, continued
Typhoid
exposure or travel to endemic
areas
Anthrax See text
[OBSTETRICS A] PRENATAL CARE
COMMENTS
Vaccinate susceptible women postpartum.
Single dose SC, preferably as MMR
Breast feeding is not a contraindication
Single dose SC, preferably as MMR Vaccinate susceptible women postpartum
Teratogenicity of vaccine is theoretical and
Single dose SC, preferably as MMR not confirmed to date; vaccinate
susceptible women postpartum
Primary: Two doses of enhanced-
potency inactivated virus SC at 4–
8 week intervals and a 3rd dose 6–
Vaccine indicated for susceptible women
12 months after 2nd dose
traveling in endemic areas or in other
high-risk situations
Immediate protection: One dose
oral polio vaccine (in outbreak
setting)
Limited theoretical risk outweighed by risk
Single dose SC
of yellow fever
Teratogenicity of vaccine is theoretical.
Two doses needed: 2nd dose
Vaccination of susceptible women should
given 4–8 weeks after 1st dose
be considered postpartum.
One dose SC, multiple pricks with
Only vaccine known to cause fetal harm
lancet
One dose IM every year Inactivated virus vaccine
Public health authorities to be
consulted for indications, dosage, Killed-virus vaccine
and route of administration
Used with hepatitis B immune globulin for
some exposures. Exposed newborn needs
Three-dose series IM at 0, 1, and 6
birth-dose vaccination and immune
months
globulin as soon as possible. All infants
should receive birth dose of vaccine
In adults, one dose only; consider
repeat dose in 6 years for high-risk Polyvalent polysaccharide vaccine
women
Antimicrobial prophylaxis if significant
One dose; tetravalent vaccine
exposure
Killed
Primary: 2 injections IM 4 weeks
Killed, injectable vaccine or live attenuated
apart
oral vaccine. Oral vaccine preferred
Booster: One dose; schedule not
yet determined
Preparation from cell-free filtrate of B.
Six-dose primary vaccination, then
anthracis. No dead or live bacteria.
annual booster vaccination
Teratogenicity of vaccine theoretical
LEA THERESE R. PACIS 11
 [OBSTETRICS A] PRENATAL CARE

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

Hello sa aking mga Pabebe Roomies: Nico and Pre <3

Thank you sa never ending support, lalo na ngayon na tinulugan niyo ko @.@

And shempre, hello to my What the F! family 

LEA THERESE R. PACIS 12