1

Antepartum Care:Preconception and

Prenatal Care

Du Xue , PHDDepartment of Obstetrics & Gynecology General Hospital of TianJinMedical University

2

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.

3

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,

4

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

5

6

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.

7

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 ）

8

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

9

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

10

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

11

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

12

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

13

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

14

15

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.

16

Confirming Pregnancy and Determining viability

Pregnancy test Transvaginal ultrasonography Early pregnancy sign Physical examination

17

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.

18

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

19

20

21

22

23

Advice(1) :Alleviating unpleasant symptoms during pregnancy

Nausea and vomiting Heartburn Constipation Hemorrhoids Leg cramps Backaches

24

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.

25

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

26

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.

27

28

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

29

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

30

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

31

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)

32

33

lie Definition: --the relationship of the long axis of the

fetus to the long axis of the mother. Class: --Longitudinal --transverse --oblique

34

LieLongitudinal

35

LieTansverse

36

Presentation Definition: --the portion of the fetus that descends

first through the birth canal Class: --longitudinal ----head(cephalic presentation) ----breech(breech presentation) --Transverse ----shoulder

37

head breech shoulder

Presentation

38

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

39

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.

40

To determine which part of the fetus occupies the fundus

head(round,hard) breech(irregular,soft)

The procedure of Leopold maneuvers--1

41

To determine which side the fetal back lies

back(linear,firm) extemities(multiple

parts)

The procedure of Leopold maneuvers--2

42

To determine the presenting part(head, breech)

grasp the part using thumb and the finger, above the symphysis

)

The procedure of Leopold maneuvers--3

43

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

44

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]

45

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

46

47

48

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)

49

50

51

52

53

54

55

Biophysical profile test

NST Amniotic fluid Muscle movement Respiratory movement Fetal tone

56

57

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.

58

59

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

60