Post on 13-May-2015
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Antepartum Care:Preconception and
Prenatal Care
Du Xue , PHDDepartment of Obstetrics & Gynecology General Hospital of TianJinMedical University
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The importance and definition of prenatal care
Provide ---health promotion ---risk reduction ---diease prevention Definition: Prenatal care should be a
continuation of preconception counseling, a physician-supervised program, provided for the pregnant women.
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The objective of prenatal care
to ensure every wanted pregnancy is given the maximal chance of culminate in the delivery of a healthy baby
without impairing the health of the mother.
to prevent and manage conditions that cause poor pregnancy outcomes.•Premature labor and delivery, intrauterine
growth retardation, birth defects, perinatal infections, post-term pregnancy
•hypertension, diabetes mellitus,
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The three basic Components of pregnant care
Early and continuing risk assessment ---a complete history ---a physical examination ---laboratory tests ---assessment of fetal growth and well-being Health promotion Medical and psychosocial interventions and follow-
up ---treatment of existing illness ---provision of resouces
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Regular visit schedule The first visit may be in preconception or
most commonly present to the clinician after missed menses.
Additional prenatal visit are routinely scheduled every 4 weeks until 28 week’s gestation,every 2 to 3 weeks until 36 week’s gestation, and then weekly until delivery.
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The first prenatal visit Thorough history→
A complete physical examination → routine test during pregnancy→ Confirming Pregnancy and Determining Viability→ Estimating Gestational age and Date of Confinement→ Advice(alleviating unpleasant
symptoms,nutritional,lifestyle,breast feeding ):→ Genetic Evaluation and Teratology ( omit )
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thorough history Medical history: (peripartum cardiomyopathy) Reproductive history:1. Previous pregnancy history(preterm birth, low
birth weight, pre-eclampsia, stillbirth, DM)2. Prior cesarean delivery circumstances(the cause of
cs,time ,fetal weight, et al.The mode of current pregnancy must be discussed).
Family history Genetic history:congenital anomalies of
newborn or mother Nutritional history Social history/psychosocial history
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Complete physical examination
Sign of normal pregnancy: systolic murmurs, exaggerated splitting S3 during
cardiac auscultation, linea nigra(pigmentation on midline of the lower abdomen), striae gravidarum on inspection of the skin
Breast examination:engorgement Pelvic examination: uterus is soft and enlarge slightly. Hegar’s sign
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Routine tests[1]
1. Complete blood count (anemia, leukemia and thrombocytopenia)
RBC COUNT and Hemoglobin and Hemotocrit WBC Platelet
2. Urinalysis and screen for bacteriuria (clean-catch midstream urine specimen)
protein, glucose, ketone body and et al. microscope examination (cast) other tests (bacterial culture or other methods)
3. Blood group, Rh factor, and antibody screen
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Routine tests[2]
4. TORCH rubella antibody titer toxoplasma cytomegaly virus herpes simplex virus and others
5. Serology test for syphilis6. hepatitis B surface antigen titer7. test for HIV8. Cervical cytology
Threaten abortion cervical carcinoma
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Commonly performed tests[1] blood glucose screen
to screening GDM 24-28 w for the first time 50g glucose load: 1 hour 7.8mmol/L
Glucose tolerance test > 30y, obesity, family history of DM, previous
birth of macrosomic, previous stillbirth infant, previous congenitally deformed infant, previous polyhydramnious, history of recurrent abortions, glycouria, previous gestational diabetes
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Commonly performed tests[2] AFP: serum а-fetoprotein (open neural tube defect) Ultrasonagraphy
to confirm the gestational week if last menstrual period is uncertain
To distinguish congenital anomalies 18-24 weeks(22w)
Screeniong for the down”s syndrome and congenital anomalies
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Estimating Gestational age and date of confinement
Accurate determination of gestational age is very important for the management of obstetric conditions such as preterm labor,IUGR,postdate pregnancy.
LMP:the first day of the last menstrual period
EDC:adding 9 months and 7 days to the LMP.
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Confirming Pregnancy and Determining viability
Pregnancy test Transvaginal ultrasonography Early pregnancy sign Physical examination
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Pregnancy test
Detects Human chorionic gonadotropin(hCG) in the serum or the urine.
first detectable 6 to 8 days after ovulation.1. less than 5 IU/L : negtive,2. above 25 IU/L :positive3. 6~24 IU/L : equivocal, again in 2 days. In the first 30 days of a normal gestation, the level of
hCG doubles every 2.2 days,but in patients whose pregnancies are destined to abort, the level of hCG rises more slowly,plateaus,or declines.
It’s important to differentiate a normal pregnancy from a nonviable abort or ectopic gestation.
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Transvaginal ultrasonography(1)
Relationship between ultrasonography and hCG Weeks---ultrasonography------hCG(IU/L) 5---------gestational sac------------1500 6---------fetal pole ------------------5200 7---------fetal cardiac motion-----17,500 probable embryonic demise : --gestational sac of 8 mm(mean sac diameter) without
a demonstrable yolk sac, --16mm without a demonstrable embryo, --or the absence of fetal cardiac motion in an embryo
with a crown-rump length of greater than 5 mm
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Advice(1) :Alleviating unpleasant symptoms during pregnancy
Nausea and vomiting Heartburn Constipation Hemorrhoids Leg cramps Backaches
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Advice (2):Nutritional counseling
BMI(Body mass index) =weight(kg)/height(m)2
BMI(before pregnancy) weight gained(pounds) <19.8(underweight) 28-40
19.8~26(normalweight) 25-35 > 26 (overweight) 15-25
Advice on nutrition --balanced for at least 3 months before conception. --obese is the great risk for obstetric complications, (e.g. GDM,PIH, femal macrosomia) Sudden weight gain in the third trimester is a warning
sign of impending pre-eclampsia.
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Inadequate weight gain or <10pounds at 28 weeks is associated with the risk of premature labor or IUGR
Vitamin and iron supplementation: --folic acid at least 0.4mg daily ( scrinanen 0.4mg,qd) --ferrous iron
non-anemia :30mg/d anemia patients:120mg/d for at least 6 weeks
--copper and zinc (for iron-taking anemic patients) --vitamin A (excessive is not benificial ) --calcium supplement
Advice (2):Nutritional counseling
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Advice (3):Lifestyle Exercise:beneficial, same level, avoid Aggressive
exercise Work: Avoid fatigue,Heavy forms or Stressful work
(risk of preterm delivery and poor fetal growth) Travel and change in residence: Avoid fatigue and
stress Sexual intercourse: second trimester pregnancy
except in patients at risk for abortion or preterm labor, or in patients with placenta previa.
Breast stimulation can induce uterine activity. Labor may follow coitus near term.
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Follow-up visits--Objectives To monitor the pregression of the
pregnancy To provide education and recommended
screening and interventions To assess the well-being of the fetus and
the mother To detect and treat medical and
psychsocial complications
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Follow-up visits(1)
History: --abnormal symptoms(preterm labor, pre-
eclampsia,labor near term) --fetal movements(>20w) --confirm gestational week PE: --Genenal examinations: ----Weight gain, ----Bp(systolic and diastolic) ----HR(arrythmia ,Atrial tachycardiac, Vetricular
premature contraction) ----Edema
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Follow-up visits(2)
--Abdomen examination(maneuvers of leopold) ---->28w ----Lie,positation,presentation ----uterine size Test: --blood rutine (Hb) --urine rutine(protein,glucose,ket) --universal Screening for GDM(24-28w) --repeated Test (sexually transmitted infections,
eg,syphilis) --screening for maternal clonization of Group B
streptococcus(35-37 w) --B ultrasonography and so on
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Fundus height from the symphysis pubis to the top of the
fundus The discrepancy of greater than 2 to 3cm
suggests a size-for-dates problem Multiple gestation (size at least 3 cm more
than expected for dates) Intrauterine growth retardation (size at least
3 cm less than expected for dates)
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lie Definition: --the relationship of the long axis of the
fetus to the long axis of the mother. Class: --Longitudinal --transverse --oblique
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LieLongitudinal
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LieTansverse
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Presentation Definition: --the portion of the fetus that descends
first through the birth canal Class: --longitudinal ----head(cephalic presentation) ----breech(breech presentation) --Transverse ----shoulder
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head breech shoulder
Presentation
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Position Definination --refers to the relationship of some definite part of the
fetus (the denominator ) to the maternal pelvis Denominator ----vertex ------------- occiput(O) --mentum(chin) ----breech------------- sacrum(S) ----Transverse-------- Scapula(Sc) Left or right Anterior, posterior, transverse (Occiput) Class ----LOA,LOP,LOT,ROA,ROP,ROT ----LMA,LMP,LMT,RMA,RMP,RMT ----LSA,LSP,LST,RSA,RSP,RST ----LScA,LScP,RScA,RScP
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Leopold maneuvers To determine the fetal location within
the uterus To be carried out at each visit during
the third trimester To identify an abnormal lie,
presentation, or position of the fetus.
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To determine which part of the fetus occupies the fundus
head(round,hard) breech(irregular,soft)
The procedure of Leopold maneuvers--1
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To determine which side the fetal back lies
back(linear,firm) extemities(multiple
parts)
The procedure of Leopold maneuvers--2
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To determine the presenting part(head, breech)
grasp the part using thumb and the finger, above the symphysis
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The procedure of Leopold maneuvers--3
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To determine the fetal head position (vertex)
place both hands on the lower abdomen above the inlet
press in the direction of the inlet
touch the occiput (extended) or brow(flexed)
The procedure of Leopold maneuvers--4
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Assessment of fetal well-being
Maternal assessment: fetal movement(3/h)
Nonstress test [learn on job] Ultrasonic assessment (real-time) Biophysical profile testing Contraction stress test [learn on
job]
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Nonstress test Fetal heart beat response to fetal motion (degree and
time) --Left lateral supine position --20 minutes Reactive --2 fetal motions --fetal heart rate acceleration >15 bpm -- acceleration >15 bpm for at least 15 senconds. --Basic fetal heart beat:120-160/min --Basic Fetal heart beat variation> 15 bpm
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Ultrasonic assessment To determine the adequary of the amniotic fluid AFI(the amniotic fluid index) ----represents the total of the linear measurements in
centimeter of the largest amniotic fluid pockets noted on the ultrasonic inspection of each of the four quadrants of the gestational sac ----Oligohydramnios: AFI less than 5 ----Polyhydramnios: AFI more than 23
Fetal breathing (30/10min) fetal movements(3/10min) Placenta maturation (calcification)
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Biophysical profile test
NST Amniotic fluid Muscle movement Respiratory movement Fetal tone
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Contraction stress test
To determine the uteroplacental function Definition: A diluted oxytocin is given to
establish at least 3 uterine contractions in 10 minutes
Positive: late decelerations with each contraction---delivered
Suspicious: only one deceleration is observed.
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Questions1. How to culculate EDC recording to LMP2. How to confirm pregnancy by test3. What is the procedure of Leopold
maneuvers4. How to assess NST/CST5. Which parameter the biophysical profile
test includes6. Definitions:
TORCH,Lie,Presentation,position
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