Ramiro

ObjectivesTo identify salient data in a mother who is coming

in for first prenatal check-upTo define prenatal careTo list ways of determining age of pregnancyTo list and justify tests done during prenatal

check-upsTo list other facets of the prenatal check - up:

Social services Nutritional counseling Patient education Psychological support

General DataJPS23 yoSingle FilipinoRoman Catholic Sampaloc, Manila

Reason for ConsultFirst prenatal check-up

Past Medical HistoryNo hypertensionNo diabetes mellitusNo thyroid disorderNo kidney disorderNo bronchial asthmaNo cancerNo surgeriesNo allergiesNo blood transfusions

Family Medical HistoryPancreatic cancer, father, deceasedHypertension, mother, living, age 54No diabetes mellitusNo bronchial asthma

Personal and Social HistorySocial drinker, wine, Last on December 2009Previous smoker, 1 stick, last on 2007

Single, unemployed, lives with common law husband

Menstrual HistoryMenarche: age 11LMP: February 17, 2010PMP: January 2010Interval: monthlyDuration: 5 daysAmount: 3 ppd, fully soakedNo dysmenorrhea

Gynecologic History:Coitarche: age 16Sexual Partner: 1No dyspareuniaNo vaginal discharge, no vaginal bleedingNo pap smearDenied history of sexually transmitted

infectionsDenied use of any contraceptive methods:

OCPs, IUDs, condoms

Obstetric HistoryOb Score: G1P0

G1 – 2010 – present pregnancy

Present PregnancyMenstrual Age: 19 6/7 w AOGSonar Age: 18 w AOGDate of earliest sonogram: April 19, 2010

6 6/7 w AOG Expected date of confinement:

By LMP: November 24, 2010By Ultrasound: December 7, 2010

HistoryFebruary 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

Review of SystemsNo fever, no headache, no weaknessNo nausea, no vomitingNo blurring of visionNo cough, no coldsNo difficulty of breathingNo chest pains, no palpitations

Review of SystemsNo constipation, no diarrheaNo dysuria, no frequency, no intermittencyNo palpitations, no heat or cold intolerance,

no tremorsNo easy bruisability, no prolonged bleedingNo numbness

Physical ExaminationConscious, coherent,

ambulatory, not in cardio-respiratory distress

BP: 110/80mmHg CR: 80/min, regular

RR: 20/min, regular

T: 37.7°C

Height: 5’4”Pre-pregnancy

weight: 124lbsPre-pregnancy BMI:

21.3Current weight: 132Current BMI: 22.7

PE findingsSkin: Absent lesionsEyes: Pale palpebral conjunctivae, anicteric

sclerae, pupils briskly reactive to light (3 mm)Neck: Supple neck, with no palpable neck

mass, no neck vein engorgementLungs: 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

AbdomenFlat, soft, normoactive bowel sounds, non

rigid, non-tenderFHT 150s

External Pelvic ExaminationNo lesions, redness, excoriations,

hyper/hypopigmentations

Speculum ExaminationCervix: pink, smooth, no erosions, no masses,

no lesions, no discharge

Internal ExaminationVagina: admits two fingersCervix: firm, 3cm long, closed, posterior, no

cervical motion tenderness, Uterus; enlarged symmetrically to 18 weeks’

size, no tendernessNo adnexal mass or tenderness

23 yo G1P0PU 19 6/7 w AOG by LMP

18 w AOG by USG

Prenatal CarePlanned 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

Prenatal Care ProgramRisk assessmentMedical careSocial servicesNutritional counselingPatient educationPsychological support

Estimation Of PregnancyNaegele’s RuleTiming from ovulationTiming from quickeningHeight of fundusUltrasound

Estimation Of PregnancyNaegele’s rule

EDC= LMP -3months + 7 days

Timing of OvulationIf last ovulation is known, + 267 days

Estimation Of PregnancyHeight 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)

12th wk :Symphysis pubis

16th wk: Approx halfway bet symphysis and umbilicus

20th wk: level of umbilicus

36th wk: just below ensiform cartilage

Estimation Of PregnancyUltrasound: establish diagnosis of

pregnancy, location, ovaries1st trim: CRL2nd trim: BPD3rd trim: ave of femur length, BPD, HC, AC

Timing of Quickening: perception of fetal movementMultipara: 16- 18th wks Primigravida: 18-20th wkNot a primary method of assessing

gestational age

Obstetric HistoryEvidence of infertilityPrevious pregnancies

Time in gestation when labor occurredDurationType of deliveryComplicationsWeight and sex of the babyPostpartum course of both mother and

fetus

Physical ExaminationSystematic: Vital signs, weight, heart,

lungs, breast, abdomen, FHT, Fundic height, fetal lie, pelvic exam, internal exam, extremities, etc.

1. Leopold’s Maneuver2. Pelvic Exam3. Rectal and Rectovaginal Exam

Leopold’s ManeuversLM 1 - Fundal grip

“what fetal pole occupies the fundus?”LM2 - Umbilical grip

“on which side is the fetal back?”LM3- Pawlick’s grip

“what fetal part lies above the pelvic inlet?”LM4 - Pelvic grip

“On which side is the cephalic prominence?”

Pelvic ExaminationEarly months- establish the diagnosis of

pregnancy or determine the presence or absence of uterine or adnexal pathology

7th month AOG- evaluate and measure obstetric pelvisPelvic tissues are more relaxedPelvic cavity empty (uterus become abdominal

organ)Ischial spine and sacral promontory are more

palpable

Pelvic ExaminationCytologic screening for cervical CADigital exam: consistency, length,

dilatation of cervix, presenting part

At 9th month AOG- weekly IE to monitor cervix

Rectal and Rectovaginal ExamEvaluate integrity of perineum and

competence of rectal sphincterDetect possible presence of rectocoele or

extent if present. Rule out pathologic conditions of rectum

Routine Obstetric testCBC: hematologic status, r/o anemiaUrinalysis, urine c & s: UTI, renal functionBlood group & Rh: blood type, Rh status &

risk of isoimmunizationPap smear: to detect cervical dysplasia/ CARubella titerHBsAg: detect carrier status, or active

satatusSerologic test for Syphilis (RPR, VDRL)OGCT 28 wks

Prenatal Instructions1. Inform possible problems and discuss management2. Begin antepartum educational program by means of

personal interviews, reading materials and hospital classes.

3. Explain future visits4. Discuss the economic aspect of pregnancy5. 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

Subsequent PNCU Monthly x 7 monthsEvery 2-3 weeks up to 36th weekOnce 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

Subsequent prenatal careMaternal evaluation

Blood pressureWeight changeSymptomsFundic heightLeopold’s maneuverVaginal examination

Fetal evaluationFetal heart toneSize of fetusAmount of amniotic

fluidPresenting part and

stationFetal activity

Assess well-being of mother and fetus

Maternal EvaluationBlood pressureWeight

Underweight < 19.9 Kg/m2 Overweight > 26 Kg/m2

BMI Weight gain Under Weight<19.8 12.7-18.2 Kg Normal 19.8-26.9 11.4 – 15.9 Kg Overweight 26.1-29 6.8 -11.4 Kg Obese >29 6.8 Kg Twin Gestation 15.9-20.4 Kg

ACOG- 10 to 12 kg (22 to 27 lb) weight gain

Symptoms: Headache, nausea, vomiting, bleeding, dysuria, fluid from vagina

Fundic height Abdominal ExamSpeculum ExamInternal ExamRectovaginal Exam

Not done if with history of vaginal bleeding

Fetal EvaluationFetal Heart RateSize of fetus, actual and rate of changeAmount of Amniotic fluidPresenting part and station (late in

pregnancy)Fetal Activity

Subsequent Laboratory testsCBC: repeat at 28-32wksMaternal serum alpha fetoprotein: 16-18wks

Elevated levels: neural tube defects, gastroschisis, omphalocoele

Low levels: Down syndromeOGCT: 24-28wks

Recommended dietary allowanceLevels 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

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

Vitamin and other supplementationIron: 41mg/d

2nd trim: 79mg/Kg/d3rd trim: 114mg/Kg/d

To allow expansion of red cell massTo provide needs of fetus and placenta

MineralsCalcium: structural element of bones and teeth,

900mg/dZinc: 12mg/d, for noral growt, sexual maturation,

brain development and fxn, immune fxnIodine: 125mg/dIron: 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

VitaminsFolate 350mg/d, megaloblastic anemiaVitamin 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, 1mgNiacin: 21 mg/dVitamin C: ascorbic acid content of

maternal blood decreases, while the fetal plasma values are higher 80mg/d

General hygieneExercise:

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

BathingClothingBowel 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

Prenatal counselingSmoking: low birth weight infant, premature

labor, abruptio pacenta, bleeding and PROMCarbon monoxide and its fxnal inactivation of

fetal & maternal hgbVasoconstrictor effect of nicotine, inducing

placental abruptionReduced appetiteDecreased maternal plasma volume

Alcohol: Fetal alcohol syndrome (undersized, mental deficiency with multiple deformities

Common complaintsNausea and vomiting: 4th-12th, hormonal,

high levels of hCGBackpain: shifting center of gravityVaricosities: increased venous pressureHemorrhoids: 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

Common complaintsNausea and vomitingBackpainVaricositiesHemorrhoidsHeartburnLeukorrhea

Transvaginal ultrasoundSingle, live, intrauterine pregnancyYolk sac 3mmCRL 8.13mm (6 6/7 w AOG)FHB 125 bpmNo subchorionic bleedCervix is T shaped, closed, 2.8cm in length

April 19, 2010

Other LabsRPR non reactiveHBsAg non reactiveBlood type OFBS 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

PlanMultivitamins, FeSO4 one tablet once a dayMilk, one glass, two times a dayFor Rh typingFor pap smear on ff-up

Definition of termsGravidity: # 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

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