1. Pregnancy & Prenatal Care Jennifer McDonald DO

2. What is the purpose of prenatal care?

3. WHEN SHOULD PRENATAL CARE START?

4. History Routine prenatal care relatively new 1900 the nurses of the instructive nursing association in Boston began making house calls to pregnant mothers Noticed that complications were decreased. Ultimately practice adopted by physicians

5. IDEALLY, a woman planning to have a child should have a medical evaluation before she becomes pregnant The majority of pregnancies are unintended making pre-conceptual care challenging 25% of pregnancies worldwide will end in a termination

6. Why don’t women seek prenatal care?

7. Always Terminology Embryo (Greek “swelling within”) Fertilization thru 8 weeks Fetus (Latin “Offspring”) Beyond 8 weeks through delivery Neonatal period = birth until 28 days of life

8. Terminology Premature infant < 37 weeks gestation Post-mature infant > 42 weeks gestation Low birth weight < 2500 grams at birth Macrosomic infant > 4500 grams at birth Spontaneous Abortion = expulsion of an infant prior to 20 weeks of gestation Viability = 23-24 weeks gestation

9. Gravity & Parity Gravity = Total number of pregnancies Parity = Outcome of pregnancies Sometimes expressed as 4 digits Full term deliveries Preterm deliveries Abortions (spontaneous or elective) Living children A multiple birth is a single parous experience

10. Numbers Game Nulligravid = never been pregnant Primigravid = first pregnancy Multigravid = achieved previous pregnancies

11. Duration of Pregnancy Calculated from the first day of the last menstrual period (LMP) Average 280 days (40 weeks)

12. Numbers Game Naegele’s Rule EDC = LMP - 3 months + 7 days Example LMP 5/21 is due ??

13. Diagnosis of Pregnancy Presumptive Signs Probable Signs Positive Signs

14. Presumptive Secondary amenorrhea Nausea & vomiting Breast changes Skin changes (cholasma/linea nigra) Urinary frequency Fatigue Quickening (first perception of fetal movement)

15. Probable Signs Abdominal enlargement – uterus rises out of the pelvis at 12 weeks Braxton Hicks contractions Uterine souffle – rushing of maternal blood in placenta Goodell’s sign – softening of cervix 6-8 weeks Chadwick’s sign – bluish hue to cervix after 6 weeks Fetal movement – felt 18 to 20 weeks, earlier in multigravidas (14-16 weeks)

16. Positive Signs Fetal heart tones heard Identifiable with doppler after 10 weeks Fetus identified on ultrasound Palpation of the fetus (22 weeks) Positive hCG Now able to be identified up to 4 days before missed period

17. Estimating Gestational Age Uterus palpable at pubic symphysis at 8 weeks Rises out of pelvis at 12 weeks Mid to umbilicus at 15 weeks At umbilicus at 20 weeks Fundal height correlates with gestational age from 26-34 weeks

18. Fundal Height Measured from pubic symphysis to uterine fundus Should measure +/- 2 cm compared to weeks gestation

19. Ultrasound Early Landmarks 5 weeksChorionic sac; yolk sac 6 weeksYolk sac/embryo; cardiac activity 7 weeksEmbryonal movement 8 weeksExtremities visible Measurement < 12 weeks = crown rump length  hCG Levels GS = 1000-1200 Yolk sac = 7200 Embryo/cardiac activity = 10,800 Fetal loss rate after finding cardiac activity is 5%

20. Ultrasound - Accuracy 5 to 6 weeks+/- 4 days 7 to 11 weeks+/- 5 days 12 to 16 weeks+/- 7 days 17 to 26 weeks+/- 10 days 27-28 weeks+/- 2 weeks 29-40 weeks+/- 3 weeks

21. Ultrasound After 12 weeks Head circumference Biparietal diameter Femur length Abdominal circumference

22. The First Visit Present pregnancy Establish dating Previous pregnancy history Complications, routes of delivery, etc. Medical/Social history Surgical history Previous gyn surgery very important Family history

23. Teratogens Cigarette Smoking Only 20% of patients quit during pregnancy Low birth weight, increased risk of fetal death, placental abruption, placenta previa

24. Alcohol Exposure Alcohol crosses easily across the placenta One of leading causes of mental retardation Facial abnormalities Cardiovascular defects CNS dysfunction

25. Fetal Alcohol Syndrome (1) CNS dysfunction low intelligence microcephaly behavioral abnormalities (2) Growth restriction (3) Facial anomalies (4) Congenital heart defects Daily ETOH not as important as max concentration at critical periods

26. FAS 3 rd leading cause of birth defects

27. Significant Maternal Disorders Seizure disorders Pre-gestational diabetes Cardiac disease Psychiatric disorders Thyroid disease

28. Initial Routine Lab Evaluation CBC Blood type & antibody screen Rubella Hepatitis B RPR (serologic test for syphilis) HIV (not mandatory) Urinanalysis

29. Genetic Screening Advanced maternal age > 35 years old Cystic fibrosis screening Sickle cell screening Hemoglobinopathies TaySachs Ashkenazi Jewish (1 in 27 carriers) Baseline risk of major congential malformations is 3.4% Baseline risk for genetic disorders is 0.5%

30. Prenatal Diagnosis Chorionic villous sampling (CVS) Amniocentesis

31. Frequency of Visits Monthly until 30 weeks 30-36 weeks  every 2 weeks 36 weeks to delivery  every week Every visit: Weight/blood pressure Urine dip: protein/glucose Fetal heart tones/fundal height Labor symptoms/Hypertension symptoms

32. Other Testing Routine screening GC/chlamydia Pap smear Glucose challenge test 28 weeks 50 gram load/Not fasting/1 hour > 135 indicates need for 3 hour test Group B Strep (36 weeks)

33. Glucose Challenge Test Used for diagnosis when screening test (1 hour) abnormal Overnight fast/100 gram load Two or more abnormal values Fasting > 95 mg/dL 1 hour > 180 mg/dL 2 hour > 155 mg/dL 3 hour > 140 mg/dL

34. Rubella Infection can be communicated 7 days before and 4 days after rash appears If develops will be 2-3 weeks after exposure Rate of infection depends on trimester < 11 weeks = 90% chance congenital infection 11-12 weeks = 33% 13-14 weeks = 24% 15-16 weeks = 11% >16 weeks = Less than 1%

35. Vaccinations in Pregnancy Contraindicated measles mumps rubella yellow fever Case Dependent polio influenza rabies hepatitis A/B pnuemococcal tetanus toxoid

36. HIV Testing ACOG recommends testing for all pregnant women AZT in pregnancy and labor decreases transmission from 25% to 8% Scheduled C-section (before onset of labor) decreases transmission to 2% IV AZT 3 hours prior to c-section Avoid amniocentesis or other invasive procedures Viral load at baseline and every 3 months Breast feeding contraindicated

37. Group B Streptococcus Leading cause of life threatening perinatal infection 15-30% women asymptomatic carriers Early onset (80% within 6 hours of delivery) carries 6% chance neonatal mortality GBS bacturia on initial urinanalysis implies heavy bacterial load Routine screening perfomed 34-36 weeks Prophylaxis at delivery if positive

38. Quad Screen Screening for Down’s, neural tube defects, Trisomy 18 16-20 weeks 60-70%60%75-80% Detection with ultrasound