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Ramiro. Objectives To identify salient data in a mother who is coming in for first prenatal check-up To define prenatal care To list ways of determining.

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Presentation on theme: "Ramiro. Objectives To identify salient data in a mother who is coming in for first prenatal check-up To define prenatal care To list ways of determining."— Presentation transcript:

1 Ramiro

2 Objectives To identify salient data in a mother who is coming in for first prenatal check-up To define prenatal care To list ways of determining age of pregnancy To list and justify tests done during prenatal check-ups To list other facets of the prenatal check - up: Social services Nutritional counseling Patient education Psychological support


4 General Data JPS 23 yo Single Filipino Roman Catholic Sampaloc, Manila

5 Reason for Consult First prenatal check-up

6 Past Medical History No hypertension No diabetes mellitus No thyroid disorder No kidney disorder No bronchial asthma No cancer No surgeries No allergies No blood transfusions

7 Family Medical History Pancreatic cancer, father, deceased Hypertension, mother, living, age 54 No diabetes mellitus No bronchial asthma

8 Personal and Social History Social drinker, wine, Last on December 2009 Previous smoker, 1 stick, last on 2007 Single, unemployed, lives with common law husband

9 Menstrual History Menarche: age 11 LMP: February 17, 2010 PMP: January 2010 Interval: monthly Duration: 5 days Amount: 3 ppd, fully soaked No dysmenorrhea

10 Gynecologic History: Coitarche: age 16 Sexual Partner: 1 No dyspareunia No vaginal discharge, no vaginal bleeding No pap smear Denied history of sexually transmitted infections Denied use of any contraceptive methods: OCPs, IUDs, condoms

11 Obstetric History Ob Score: G1P0 G1 – 2010 – present pregnancy

12 Present Pregnancy Menstrual Age: 19 6/7 w AOG Sonar Age: 18 w AOG Date of earliest sonogram: April 19, 2010 6 6/7 w AOG Expected date of confinement: By LMP: November 24, 2010 By Ultrasound: December 7, 2010

13 History February 17, 2010 April 17, 2010 April 19, 2010 Last menstrual period Positive pregnancy test First transvaginal ultrasound (6 6/7 w AOG) SLMC-OB OPD

14 Review of Systems No fever, no headache, no weakness No nausea, no vomiting No blurring of vision No cough, no colds No difficulty of breathing No chest pains, no palpitations

15 Review of Systems No constipation, no diarrhea No dysuria, no frequency, no intermittency No palpitations, no heat or cold intolerance, no tremors No easy bruisability, no prolonged bleeding No numbness

16 Physical Examination Conscious, coherent, ambulatory, not in cardio-respiratory distress BP: 110/80mmHg CR: 80/min, regular RR: 20/min, regular T: 37.7°C Height: 54 Pre-pregnancy weight: 124lbs Pre-pregnancy BMI: 21.3 Current weight: 132 Current BMI: 22.7

17 PE findings Skin: Absent lesions Eyes: Pale palpebral conjunctivae, anicteric sclerae, pupils briskly reactive to light (3 mm) Neck: Supple neck, with no palpable neck mass, no neck vein engorgement Lungs: Symmetrical chest expansion, no rib retractions, clear and equal breath sounds in all lung fields Heart: Adynamic precordium, normal rate, regular rhythm, S1>S2 at apex, S2>S1 at base, no heaves, no murmurs Full and equal pulses, no bipedal edema, no cyanosis

18 Abdomen Flat, soft, normoactive bowel sounds, non rigid, non- tender FHT 150s

19 External Pelvic Examination No lesions, redness, excoriations, hyper/hypopigmentations

20 Speculum Examination Cervix: pink, smooth, no erosions, no masses, no lesions, no discharge

21 Internal Examination Vagina: admits two fingers Cervix: firm, 3cm long, closed, posterior, no cervical motion tenderness, Uterus; enlarged symmetrically to 18 weeks size, no tenderness No adnexal mass or tenderness

22 23 yo G1P0 PU 19 6/7 w AOG by LMP 18 w AOG by USG


24 Prenatal Care Planned program of medical evaluation and management, observation, and education of the pregnant woman directed toward making pregnancy, labor, delivery and postpartum recovery a safe and satisfying experience


26 Prenatal Care Program Risk assessment Medical care Social services Nutritional counseling Patient education Psychological support

27 Estimation Of Pregnancy Naegeles Rule Timing from ovulation Timing from quickening Height of fundus Ultrasound

28 Estimation Of Pregnancy Naegeles rule EDC= LMP -3months + 7 days Timing of Ovulation If last ovulation is known, + 267 days

29 Estimation Of Pregnancy Height of the Fundus Superior boarder of symphysis pubis and top of fundus by palpation measured off from a vertical line drawn at the level of the greatest thickness of the fundus.(tape meas in cm) 12 th wk :Symphysis pubis 16 th wk: Approx halfway bet symphysis and umbilicus 20 th wk: level of umbilicus 36 th wk: just below ensiform cartilage

30 Estimation Of Pregnancy Ultrasound: establish diagnosis of pregnancy, location, ovaries 1 st trim: CRL 2 nd trim: BPD 3 rd trim: ave of femur length, BPD, HC, AC Timing of Quickening: perception of fetal movement Multipara: 16 - 18 th wks Primigravida: 18-20 th wk Not a primary method of assessing gestational age

31 Obstetric History Evidence of infertility Previous pregnancies Time in gestation when labor occurred Duration Type of delivery Complications Weight and sex of the baby Postpartum course of both mother and fetus

32 Physical Examination Systematic: Vital signs, weight, heart, lungs, breast, abdomen, FHT, Fundic height, fetal lie, pelvic exam, internal exam, extremities, etc. 1. Leopolds Maneuver 2. Pelvic Exam 3. Rectal and Rectovaginal Exam

33 Leopolds Maneuvers LM 1 - Fundal grip what fetal pole occupies the fundus? LM2 - Umbilical grip on which side is the fetal back? LM3- Pawlicks grip what fetal part lies above the pelvic inlet? LM4 - Pelvic grip On which side is the cephalic prominence?

34 Pelvic Examination Early months- establish the diagnosis of pregnancy or determine the presence or absence of uterine or adnexal pathology 7 th month AOG- evaluate and measure obstetric pelvis Pelvic tissues are more relaxed Pelvic cavity empty (uterus become abdominal organ) Ischial spine and sacral promontory are more palpable

35 Pelvic Examination Cytologic screening for cervical CA Digital exam: consistency, length, dilatation of cervix, presenting part At 9 th month AOG- weekly IE to monitor cervix

36 Rectal and Rectovaginal Exam Evaluate integrity of perineum and competence of rectal sphincter Detect possible presence of rectocoele or extent if present. Rule out pathologic conditions of rectum

37 Routine Obstetric test CBC: hematologic status, r/o anemia Urinalysis, urine c & s: UTI, renal function Blood group & Rh: blood type, Rh status & risk of isoimmunization Pap smear: to detect cervical dysplasia/ CA Rubella titer HBsAg: detect carrier status, or active satatus Serologic test for Syphilis (RPR, VDRL) OGCT 28 wks

38 Prenatal Instructions 1. Inform possible problems and discuss management 2. Begin antepartum educational program by means of personal interviews, reading materials and hospital classes. 3. Explain future visits 4. Discuss the economic aspect of pregnancy 5. Give instructions about diet, relaxation and sleep, bowel habits, exercise, bathing, recreation, sexual intercourse, smoking, drug and alcohol ingestion 6. Emphasize danger signals: vaginal bleeding, persistent vomiting, fever and chills, sudden escape of fluid from vagina, abdominal pain, swelling of face, blurring of vision, continuous headache

39 Subsequent PNCU Monthly x 7 months Every 2-3 weeks up to 36 th week Once a week until EDC WHO (1994)- 4 visits minimum 16 wks- screen and treat anemia and syphylis 24-28 wks to 32 wks- screen for preeclampsia, multiple gestation, anemia 36 wks- identify fetal lie/presentation Frequency of visits

40 Subsequent prenatal care Maternal evaluation Blood pressure Weight change Symptoms Fundic height Leopolds maneuver Vaginal examination Fetal evaluation Fetal heart tone Size of fetus Amount of amniotic fluid Presenting part and station Fetal activity Assess well-being of mother and fetus

41 Maternal Evaluation Blood pressure Weight Underweight< 19.9 Kg/m 2 Overweight> 26 Kg/m 2 BMIWeight gain Under Weight<19.812.7-18.2 Kg Normal19.8-26.911.4 – 15.9 Kg Overweight26.1-296.8 -11.4 Kg Obese>296.8 Kg Twin Gestation15.9-20.4 Kg ACOG- 10 to 12 kg (22 to 27 lb) weight gain

42 Symptoms: Headache, nausea, vomiting, bleeding, dysuria, fluid from vagina Fundic height Abdominal Exam Speculum Exam Internal Exam Rectovaginal Exam Not done if with history of vaginal bleeding

43 Fetal Evaluation Fetal Heart Rate Size of fetus, actual and rate of change Amount of Amniotic fluid Presenting part and station (late in pregnancy) Fetal Activity

44 Subsequent Laboratory tests CBC: repeat at 28-32wks Maternal serum alpha fetoprotein: 16-18wks Elevated levels: neural tube defects, gastroschisis, omphalocoele Low levels: Down syndrome OGCT: 24-28wks

45 Recommended dietary allowance Levels of intake of energy and essential nutrients considered adequate to maintain heath and provide reasonable levels of reserves in body tissues Calories: 300 kcal/ day (2nd-3rd trim); added maternal tissues and growth of fetus and placenta

46 Protein: 15 gm/ day 1st, 2nd, 3rd; needed for tissue synthesis in the maternal and fetal compartments; Carbohydrates: main source of energy, 150 gms for the 1st trim, 225 at the end of preg Fats: most concentrated energy, 15-25 gms

47 Vitamin and other supplementation Iron: 41mg/d 2 nd trim: 79mg/Kg/d 3 rd trim: 114mg/Kg/d To allow expansion of red cell mass To provide needs of fetus and placenta

48 Minerals Calcium: structural element of bones and teeth, 900mg/d Zinc: 12mg/d, for noral growt, sexual maturation, brain development and fxn, immune fxn Iodine: 125mg/d Iron: 41 mg/d replace bowel losses, allow expnsion of red cell mass, provide for the needs of fetus and placenta, given during the 2nd-3rd trim (deposition of iron in fetal and placenta tissues, increase in red cell mass proceed at a rapid rate Phosphorus: for calcification of bones

49 Vitamins Folate 350mg/d, megaloblastic anemia Vitamin A: 475 RE (retinol equivalent)/d; vision, growth, cellular differentiation & proliferation, Vitamin B1 (thiamine): 1.3mg/d, aneuria, antineuritic Vitamin B2 (riboflavin): 1.6mg/d, Vitamin B6 (pyrodoxine): amino acid metabolism and protein synthesis, 1mg Niacin: 21 mg/d Vitamin C: ascorbic acid content of maternal blood decreases, while the fetal plasma values are higher 80mg/d

50 General hygiene Exercise: aerobics: rhythmic, repetitive activities strenuous enough to demand increased oxygen to the ms, but not so strenuous enough that the demand exceeds the supply. Stimulates the heart, lungs, ms and jt activity, improves circulation, increases ms tone and strength calisthenics: rhythmic light gymnastic movements that tone and develop ms and improve posture, relieves back ache relaxation tech: breathing and concentration ex relax mind and body Pelvic toning: Kegel exercise, tones the ms in the vaginal and perineal rea

51 Bathing Clothing Bowel Habits: constipation, steroid induced suppresion of bowel motility and the compression of the intestines by the enlarging uterus, inc oral fluid intake, fruits, veg, milk of magnesia, stool softening agents

52 Prenatal counseling Smoking: low birth weight infant, premature labor, abruptio pacenta, bleeding and PROM Carbon monoxide and its fxnal inactivation of fetal & maternal hgb Vasoconstrictor effect of nicotine, inducing placental abruption Reduced appetite Decreased maternal plasma volume Alcohol: Fetal alcohol syndrome (undersized, mental deficiency with multiple deformities

53 Common complaints Nausea and vomiting: 4th-12th, hormonal, high levels of hCG Backpain: shifting center of gravity Varicosities: increased venous pressure Hemorrhoids: constipation & increased pressure in the rectal vein caused by obstruction of the venous return by the large uterus Leukorrhea: increased vaginal discharge, increased mucus formation by cervical gland

54 Common complaints Nausea and vomiting Backpain Varicosities Hemorrhoids Heartburn Leukorrhea


56 Transvaginal ultrasound Single, live, intrauterine pregnancy Yolk sac 3mm CRL 8.13mm (6 6/7 w AOG) FHB 125 bpm No subchorionic bleed Cervix is T shaped, closed, 2.8cm in length April 19, 2010

57 Other Labs RPR non reactive HBsAg non reactive Blood type O FBS 3.25 (3.89-5.84) UA pH 5, SG 1.010, 0 glucose, 0 albumin, WBC 3-5/hpf, RBC 0-2/hpf, few epithelial cells, few bacteria CBC: Hb 14, Hct 42, RBC 4.9, WBC 6, N 0.62, L 0.37, M 0.01 July 3, 2010

58 Plan Multivitamins, FeSO4 one tablet once a day Milk, one glass, two times a day For Rh typing For pap smear on ff-up

59 Definition of terms Gravidity: # of times the woman has gotten pregnant Parity: # of times a woman has delivered a viable fetus Primipara: a woman who has delivered only once of a fetus or fetuses which reachedviability Multipara: a woman who has completed two or more pregnancies to viability

60 Nulligravida: a woman who is not now or never has been pregnant. Gravida: a woman who is or has been pregnant irrespective of the pregnancy outcome. Nullipara: a woman who has never completed a pregnancy beyond the stage of viability or beyond an abortion. Parturient: a woman who is in labor Puerpera: woman who had just given birth Puerperium: time period from delivery of the infant and placenta to 6 weeks postpartum

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