PRECONCEPTIONAL COUNSELING AND PRENATAL CARE

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Dra. P.E. Armas-Contemplacion

Lecturer
TABLE OF CONTENTS
1. Pre-conceptional care (Page 1) RISK FACTORS
2. Risk Factors (Page 1) • Parental Age
3. Medical History (Page 2) • Maternal Height
4. Genetic Diseases (Page 2) • Maternal Weight
5. Reproductive History (Page 2)
6. Social History (Page 2) PARENTAL AGE
7. Prenatal Care (Page 2) MATERNAL AGE
8. Diagnosis of Pregnancy (Page 3) • Adolescent (<18y/o)
9. Ultrasonography (Page 5) o ↑ anemia, preterm delivery,
10. OB Score (Page 5) preeclampsia, STDs (sexually transmitted
11. Normal Pregnancy Duration (Page 5) infections/diseases)
12. Expected Date of Delivery (Page 5) o usually unplanned
13. Laboratory Test (Page 5)
14. Nutritional Counseling (Page 6) • After 35 years old
15. Common concerns (Page 6) o ↑ obstetrical complications
16. Summary (Page 8) o Gestational diabetes, hypertension
17. Past E (Page 9) o ↑ maternal mortality
o ↑ perinatal morbidity/mortality

PRE-CONCEPTIONAL CARE FETAL RISKS
• Set of interventions that aim to identify and modify • Indicated preterm delivery (HPN, diabetes)
biomedical, behavioral, and social risks to a woman’s • Spontaneous preterm delivery
health or pregnancy outcome through prevention and • Fetal growth disorders
management” • Fetal aneuploidy
• Pregnancies resulting from ART (multifetal
* Pre- Conceptional counseling is both for male and pregnancies, congenital malformations)
female.
PATERNAL AGE
GOALS • 40 years old
a. Improve knowledge, attitudes, and behaviors of • as the age of the father increases, the higher the
men and women related to pre-conceptional incidence of genetic diseases
health (the physician talks to both the husband
• ↑ genetic diseases (autosomal dominant
and wife)
mutations)
b. Assure that all women of childbearing age receive
o blood clotting factor disorders, von
preconceptional care services –
Willebrand disease, Huntington’s disease,
(1) evidence-based risk screening,
etc.
(2) health promotion,
(3) intervention – that will enable them to enter MATERNAL HEIGHT
pregnancy in optimal health • <5 ft. tall
c. Reduce risks indicated by a previous pregnancy o Congenital anomalies, premature
outcome through interconceptional interventions delivery, birth trauma, cesarean section
→ prevent/minimize recurrent adverse outcomes. due to contracted/smaller pelvis
d. Reduce the disparities in adverse pregnancy
outcomes.

Preconceptional Counseling and Prenatal Care
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 • During the pre-counseling period, female of
MATERNAL WEIGHT childbearing age who intends to get pregnant
I. OBESITY should be taking folic acid as a maintenance
• ↑ Gestational HPN/Pre-eclampsia • Folic Acid: 400-800 μg/day PO
• ↑ Gestational Diabetes or if given 3 months or earlier = good pregnancy
• ↑ Fetal Macrosomia
• ↑ Cesarean delivery 2. THALASSEMIAS
• Modest weight loss à better obstetric • Globin-chain synthesis disorders
outcome • most common single-gene disorders
worldwide (MUST KNOW)
II. UNDERNUTRION – FETAL EFFECTS • Endemic in Southeast Asian countries
• ↑ low birthweight babies • A history of anemia since birth warrants a
• ↑ glucose intolerance screening for thalassemia
• ↑ reactive airway disease
• ↑ HPN/dyslipidemia/coronary artery disease 3. PHENYLKETONURIA (NICE TO KNOW)
• Schizophrenia • Phenylalanine metabolism defect
• Fetus may be damaged by maternal disease
MEDICAL HISTORY • Unrestricted diet → abnormal ↑
1. DIABETES MELLITUS (MUST-KNOW!) phenylalanine → crosses the placenta →
o Goal: to achieve the lowest maternal damage to developing fetal organs (neural,
glycosylated hemoglobin (Hgb A1c) level cardiac)
without undue hypoglycemic risk o Goal: normalize phenylalanine
• ↑ 4x increase in fetal anomalies in hyperglycemic concentration 3 months BEFORE
states conception
• the most common problem with babies born with
diabetic mothers is fetal macrosomia (large REPRODUCTIVE HISTORY
babies around 4 kg) • Abnormal pregnancy outcomes
o Miscarriage, ectopic, recurrent pregnancy
2. EPILEPSY (NICE TO KNOW) loss
o Goal: to achieve seizure control with • Obstetrical complications
single-agent therapy which is non- o Pre-eclampsia, pre-term delivery,
teratogenic placental abruption, prior stillbirth
• increase 2-3x in infants with structural anomalies
• risk of seizure during pregnancy is decreased 50- SOCIAL HISTORY
70% if there were no seizure in the preceding year • smoking
• 1 year before pregnancy • alcoholic beverages – can pass through placenta
• recreational drugs
3. IMMUNIZATIONS • environmental exposures
• Contraindicated vaccines: • diet (pica, anorexia, bulimia)
o Measles, Mumps, Rubella, Varicella • exercise
o teratogenic • Intimate Partner Violence (IPV)
• Vaccines safe to give: o Physical, emotional or psychological and
o Tetanus, Influenza, Hepatitis B, acute or chronic violence
Pneumococcus, Rabies, Meningococcus o Use non-judgmental questions
o there is a specific age of gestation in o “deadma while showing compassion” is
which these vaccines are safe to give an art

GENETIC DISEASES PRENATAL CARE
1. NEURAL TUBE DEFECTS (MUST-KNOW) • COMPREHENSIVE ANTEPARTUM PROGRAM
• 0.9/1000 live births o coordinated approach to medical care
• 2nd most frequent structural fetal o continuous risk assessment
malformation (1st: cardiac disease)
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 o psychological support to the mother
o BEGINS before conception
o EXTENDS to the postpartum period (after
delivery) and interconceptional period
§ Meaning the whole life of the
patient (from reproductive age
until menopause) not only during
the time she gets pregnant

ADEQUACY OF PRENATAL CARE Figure 1. Areolar changes during pregnancy
• Kessner Index (Quantitative)
o timing of first prenatal visit 3. Skin changes
o number of visits • increased pigmentation (mostly in the abdomen) -
o length of gestation (pre-term, term, post- > caused by Estrogen
term) ex. abdominal striae
o Patients less than 20 weeks • Estrogen-containing OCP user are therefore at risk
o At least 6 checkups of Hyperpigmentation

BARRIERS IN PRENATAL CARE 4. Chloasma/Melasma
• late identification of pregnancy • mask of pregnancy
• lack of money or insurance • forehead/nasal bridge/cheekbones/neck
o Patients have HMO
• inability to obtain an appointment

GOALS OF PRENATAL CARE
• Define the health status of the mother and fetus
• Estimate the Gestational Age
• Initiate a plan for continuing obstetrical care

DIAGNOSIS OF PREGNANCY
1. Ammenorrhea Figure 2. Chloasma
• 10 days or more after the expected menses
(include formula) 5. Linea Nigra
• Implantation Bleed / “Pagbabawas” • midline of abdomen from the xiphoid to the
o Blastocyst Implantation in the Uterus = symphysis pubis
Vaginal Spotting
o Burrowed in Endometrium
• Rule out: Threatened abortion

2. Breast changes
• tenderness, paresthesia
• increase in size
• veins become visible
• nipples: larger, deeply pigmented, erectile
• areolae: broader, deeply pigmented
• All because of hormonal changes Figure 3. Linea Nigra

6. STRIAE GRAVIDARUM
• stretch marks, “kamot”
• separation of underlying collagen tissue

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 9. Uterine changes
• doughy, soft, elastic

HEGAR SIGN (NICE TO KNOW)
• softening of the isthmus (part proximal to the
cervix)

Figure 4. Striae Gravidarum

7. Spider telangiectasia
• ↑ estrogen
• ↑ vascularity = vascular stellate marks

Figure 7. Uterus

UTERINE SOUFFLE
• soft, blowing sound synchronous with the
maternal pulse
• loudest near the lower part of uterus (large vessels
at the lowest part of the uterus)
Figure 5. Spider Telangiectasia • passage of blood through the dilated uterine
vessels
8. Lower reproductive tract changes • check for the radial pulse of the mother
• CHADWICK SIGN
o vaginal mucosa appears dark-bluish red FUNIC SOUFFLE
and congested = vascular stellate marks • sharp, whistling sound synchronous with the fetal
o normal vagina is pinkish or heart tone
pinkish-red • rush of blood through the umbilical arteries
o increased cervical softening
o also increased in patients using How will you differentiate?
Oral Contraceptive Pills (OCPs)) • When you listen to the Fetal Heart Tone on the
o copious, tenacious cervical mucus (due to abdomen, use your other hand to palpate for the
progesterone) radial pulse.

• If you heard it at the same time - Uterine Souffle
***These are all INCONCLUSIVE. It will only give you clues
• If faster or slower - Funic Souffle
whether the patient is pregnant.

10. Fetal movement
• Quickening
o maternal perception of fetal movement
Primigravid: 18-20 weeks AOG
Multigravid: 16-18 weeks AOG
• It is earlier in multigravid because they’re used
to it.



Figure 6. Chadwick sign

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 11. Endocrine assay/ pregnancy test
OB SCORE
HUMAN CHORIONIC GONADOTROPIN (HCG)
• alpha (LH, FSH, TSH) and beta subunits 𝐺_𝑃_(𝑇𝑃𝐴𝐿)
• the beta subunit should be used to check for
pregnancy since the alpha subunit has similar G : Gravida (pregnancy irrespective of outcome)
structure found in LH, FSH and TSH P : Parity (completed pregnancy)
T : Term (≥37 wks)
Significance: P : Preterm (>20 to <37 wks)
Patients with irregular menstruation took a A : Abortion/Non-viable (≤20 wks) Ectopic Pregnancy
pregnancy test and had a weakly positive result L : ALive at Present Still Birth
(malabo yung isang linya pagpositive pregnancy
test) due to a Hormonal imbalance therefore it is
the alpha HCG detected not the beta HCG DEFINITION OF TERMS

• produced by the syncytiotrophoblast • NULLIGRAVID – not pregnant/never was
• prevents involution of the corpus luteum • GRAVIDA – pregnant now/was in the past,
o corpus luteum: principal site of irrespective of pregnancy outcome
progesterone formation during the first 6 o PRIMI: 1st pregnancy
weeks AOG (function replaced by placenta o MULTI: successive pregnancies
after 6 weeks) • NULLIPARA – never completed a pregnancy
o clinically manifested as a cyst in beyond 20 weeks
ultrasound, normal and not pathologic • PRIMI - delivered once to a fetus at 20 weeks or
• detected in maternal serum/urine: 8-9 days after more, regardless of the outcome
ovulation (3-4 weeks AOG) based on LNMP (Last • MULTI - 2 or more pregnancies delivered at 20
Normal Menstrual Period) ->the function of weeks or more; not increased to a higher number
pregnancy test in multifetal deliveries
• doubling time: 1.4 – 2 days • ABORTUS - 20 weeks or less = non-viable
o Meaning if today you get your patients • PARTURIENT – woman in labor
beta HCG value of 100, after 2 days the • PUERPERA – woman who had just given birth
value should be 200 and after another 2 • PRE-TERM - 20 weeks up to 36 6/7 weeks
days 400 and another 2 days 800 • TERM - 37 weeks to 42 weeks
• peak level: 60-70 days (8-10 weeks AOG) → • POST-TERM - > 42 weeks
declines → plateaus at around 16 weeks

NORMAL PREGNANCY DURATION
• Starts during the 1st day of the Last Normal
Menstrual Period (LNMP)
• 280 days = 40 weeks
• To confirm LNMP, check the menstrual history

EXPECTED DATE OF DELIVERY (EDD)
• Naegele Rule
EDD = LMP + 7 days – 3 months

Figure 8. HCG levels
• Trimesters
ULTRASONOGRAPHY • First Trimester: 14 weeks or less
• Gestational Sac: 4-5 weeks AOG transvaginal • Second Trimester: 14 1⁄7 to 28 6⁄7 weeks
• Yolk Sac: 5-6 weeks AOG • Third Trimester: 29 to 42 weeks
• Fetus: > 6 weeks AOG

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• Frequency of Prenatal Visits: • BMI
• 4-week intervals until 28 weeksà every
2 weeks until 36 weeks à weekly 𝐵𝑀𝐼= 𝑤𝑒𝑖𝑔ℎ𝑡 (𝑘𝑔)/ℎ𝑒𝑖𝑔ℎ𝑡 (𝑚𝑒𝑡𝑒𝑟𝑠)2

LABORATORY TEST Table 2. Nutritional requirements for pregnant and
• Complete Blood Count (CBC) lactating mothers
o For Anemia
• Blood Type with Rh Factor
o Always with Rh
o ABO incompatibility
o Rh (+) or (-) especially if with foreigner
partner
o Blood Transfusion
§ If patient delivers vaginally, you
are to lose half a liter of blood
§ If delivers operative by caesarean
section, you are to lose 1 liter of
blood
• Hepatitis B Serology
o Increase incidence in Philippines
o Can be inherited by baby à Liver Cancer
• Blood Sugar Test
o Endemic Diabetes
o FBS, OGCT, OGTT, Hba1c (FBS is more
reliable)
• VDRL/RPR (Syphilis)
• HIV
o Recommended as a universal request or
test
• Urinalysis/Urine Culture Barker hypothesis
o Untreated UTI à Sepsis secondary to • Whatever you are now, was determined when
neonatal pneumonia you were in your mother’s womb
• Papsmear • Fetal programming
o Done during the first prenatal check • Fetal health >>>> Adult morbidity &mortality
• Others
o Thalassemia – Electrophoresis COMMON CONCERNS
o Phenylketonuria – Phenylalanine 1. Employment
• in the absence of complications, may continue
NUTRITIONAL COUNSELING to work
Table 1. Body Mass Index Categories • Consider:
o Number of hours standing
o Intensity of physical and mental demands
o Environmental stressors

2. Exercise
• Maternal weight gain during pregnancy had a • thorough clinical evaluation (fatigue/injury)
POSITIVE correlation with birthweight • regular, moderate intensity, min. 30mins/day
• Severe nutritional deficiency → lighter, shorter, • avoid:
thinner babies o ↑ risk of falling
o abdominal trauma

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 • in the presence of pregnancy complications, • dental caries are NOT aggravated by pregnancy
limit physical activity/abstain from exercise • pregnancy is NOT a contraindication to dental X-
rays/treatment
3. Absolute contraindications
• Hemodynamically significant heart disease Why is the dentist hesitant?
• Restrictive lung disease They are afraid patient will bleed because during
• Incompetent cervix/cerclage pregnancy all blood vessels are engorged from
head to toe.
• Multiple gestation at risk for preterm labor

• Pregnancy-induced HPN
Usual DOC for bleeding: Tranexamic acid which is
• Placenta previa after 26 weeks AOG
contraindicated to pregnant patients
• Persistent 2nd or 3rd trimester bleeding
• Preterm labor during the current pregnancy
• Ruptured membranes 9. Caffeine
• diuretic (fluid, calcium)
4. Seafood consumption • spoils appetite
• excellent source of protein • mood swings
• low in saturated fats • interferes with iron absorption
• omega-3 fatty acids • Recommendations:
• consumption: maximum 6 ounces/week o < 300mg/day
• canned tuna: maximum 12 ounces/week (2 o three 5-oz cups of percolated coffee
servings)
CONTROVERSIAL DUE TO:
Note: Avoid Mercury-containing fish (shark, § miscarriage?
swordfish, king mackerel) § Fetal growth restriction?
§ preterm delivery?
5. Lead exposure § low birthweight?
• may cause gestational HPN § fetal diabetes?
• may lead to spontaneous abortion, low
birthweight, neurodevelopmental impairments 10. Nausea and vomiting
• associated with HCG levels
Lead Poisoning • stress, emotional tension
• 45 μg/dL → REFER! (MUST KNOW) • Recommendations:
o small meals, more frequent intervals
6. Automobile and air travel o stopping short of satiation
• use of seatbelt • HyperemesisGravidarum (MUST KNOW)
• periodic lower extremity movement o vomiting so severe that dehydration,
o risk for deep vein thrombosis electrolyte imbalance, acid-base
disturbances, starvation ketosis become
• hourly ambulation
serious problems
Note:

• up to 36 weeks AOG (- complications)
11. Backache
• infectious disease acquisition
• excessive strain, bending, lifting, walking
• Recommendations:
7. Coitus o squatting when reaching down
• healthy women: not harmful ***doing laundry example by doc
• Avoid Coitus in: o pillow as back support when sitting
o threatened abortion o Avoid high-heeled shoes
o preterm labor
o placenta previa 12. Varicosities
• increased lower extremity venous pressure
8. Dental care
• periodontal disease → preterm labor
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16. Sleep and fatigue
• soporific effect of progesterone
• ↑ AOG, ↓ sleep efficiency
• 3rd trimester
• ↑ awakenings
• ↓ deep sleep / REM sleep
• more likely to snore
• Recommendations:
o daytime naps
o sedatives
Figure 9. Varicose veins

17. Leukorrhea
• Recommendations: • ↑ vaginal discharge
o periodic rest o ↑ estrogen → ↑ mucus secretion by the
o leg elevation cervical glands
o elastic stocking o suspect vulvovaginal infections
o surgery (depends, weight the benefit and
the risks) 18. Cord blood banking
• Procedure:
13. Hemmorhoids o Once the baby is delivered, the OB-GYNE
• rectal vein varicosities will get samples of blood from the
• increased pelvic pressures umbilicus and place it in a very special
• Recommendations: and expensive bag and then store it in a
o hot sits bath cord blood bank. There is a monthly
o meds: stool-softening, topical storage fee.
anesthetics, rectal suppositories o If a child develops a problem, they get
o can you do hemorrhoidectomy (surgery) the stored cord blood and use it for stem
during pregnancy? – YES for as long you cell-related procedures.
can justify why • Public Bank - related or unrelated recipients
for donation

14. Heartburn • Private Bank – autologous use (among family
and relatives only)
• gastric content reflux into the lower esophagus

• upward displacement/compression of the
stomach by the uterus SUMMARY
• relaxation of the lower esophageal sphincter • Prenatal Care
• Recommendations: o Planned program of
o small, frequent meals § medical evaluation (thorough
o antacids history and physical examination)
o Avoid bending over, lying flat § management (diagnostics,
medications)
15. Pica and Ptyalism § observation (surveillance during
PNCUs)
• PICA
§ education (common concerns)
o strange craving for food
o directed toward making pregnancy,
o pagophagia: ice
labor, delivery and the postpartum
o amylophagia: starch
period safe and satisfying experience for
o geophagia: clay
the mother and her newborn
o spontaneous preterm birth

• PTYALISM

o profuse salivation

o recommendation is to take ice chips

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 REVIEW QUESTIONS (Past-E, Batch 2019) 8. A 22 y/o G1P0 came in for her first prenatal care. Last
1. Leopold’s Maneuver 3 revealed a hard, round, normal menstrual period was unrecalled. On physical
ballottable mass. This signifies a _______ presentation. examination, the uterine fundus was palpated at the
A. Breech level of the umbilicus. The estimated age of gestation
B. Cephalic is _______ weeks.
C. Shoulder A. 12
D. None of the choices are correct. B. 16
C. 20
2. The acceptable weight gain during pregnancy of a D. 24
patient who had a normal Body Mass Index prior to
pregnancy is _______ lbs. 9. Human Chorionic Gonadotropin (HCG) produced by
A. 15-25 syncytiotrophoblast reaches its peak level in the
B. 25-35 maternal serum at _______ weeks age of gestation.
C. 28-40 A. 4 – 6
D. 11-20 B. 8 – 10
C. 12 – 14
3. The following vaccines may be given during D. 16 – 18
pregnancy, EXCEPT:
A. Influenza 10. Folic Acid intake is recommended to prevent which
B. Rabies type of fetal malformation?
C. Tetanus-diphtheria-acellular pertussis (Tdap) A. Blood dyscrasias
D. Measles-Mumps-Rubella (MMR) B. Metabolic disorders
C. Cardiac anomaly
4. Quickening is usually perceived by a primigravid at D. Neural tube defects
_______ weeks age of gestation.
A. 12 – 14 11. The minimum recommended dosage of Folic Acid is
B. 18 – 20 _______ mg.
C. 14 – 16 A. 0.1
D. 16 – 18 B. 0.4
C. 1.0
5. At _______ weeks Age of Gestation, the fetus will be D. 4.0
visualized on TVS:
A. 3 For the next two items (Nos. 12 and 13)
B. 4 A 20 year old patient came in for consult with a positive
C. 5 Pregnancy Test. Her Last Normal Menstrual Period
D. 6 was on November 15, 2016.

6. The best time to document early pregnancy is to do 12 The Expected Date of Delivery is on _______.
a Pregnancy Test ______ days after the expected A. August 18, 2017
menses. B. August 22, 2017
A. 6 C. September 18, 2017
B. 8 D. September 22, 2107
C. 4
D. 10 13. The Age of Gestation is ______ weeks.
A. 17
7. Marks seen on the pregnant abdomen due to B. 17 1/7
separation of the underlying collagen tissue: C. 17 2/7
A. Linea nigra D. 17 3/7
B. Spider telangiectasia
C. Chloasma
D. Striae gravidarum

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 D. Stool softeners
For the next three items (Nos. 14-16).
A 40 y/o came in for her prenatal check-up. Her last For the next two items (Nos. 19-20).
normal menstrual period was on September 5, 2016. A 32 y/o pregnant patient came in with a chief
complaint of nausea and vomiting for one week, more
Obstetrical History revealed the following: severe towards the evening. She is a call center agent
G1: 1998, VSD, term, male, 7 lbs, hosp., (- who works from 10pm-6am. Her last normal
) complications, living; menstrual period was on January 9, 2017.
G2: 2002: CS sec to twins, 36 weeks, both males,
2kg/2.7kg, hosp, (-) complications, both living 19. Management may include the following, EXCEPT:
G3: 2005: repeat CS: term, female, 8 lbs, hosp, (- A. Give an anti-emetic
) complications, living B. Continue working on the same shift
G4: 2010: repeat CS, term, male, 7 lbs, (- C. Request for serum electrolytes
) complications, living D. Advise small, frequent feedings

14. Her Age of Gestation is _______ weeks. 20. The Age of Gestation is _______ weeks.
A. 27 A. 9
B. 27 2/7 B. 9 2/7
C. 27 4/7 C. 9 4/7
D. 27 6/7 D. 9 6/7

15. What is her OB Score? Answers: BBDBD – DDCBD – BBBBA - DCCBB
A. G4P4 (3205)
B. G4P4 (4004)
C. G4P5 (3205) REFERENCES
D. G4P4 (4005)
1. Powerpoint

2. Williams’ Obstetrics, 24th ed.
16. When is the Expected Date of Delivery?
3. Online References
A. June 8, 2017

B. July 9 2017
C. July 12, 2017 TRANSCRIBED BY:
D. June 12, 2017 1. Group 10B (Ileana, Lou, John, Grace, Emmanuel,
Louise)
2. Subtranshead: Tammy Resurreccion
For the next two items (Nos. 17-18).
A 25 y/o patient came in with a chief complaint of
constipation for the last 4 days. Her last normal
menstrual period was on August 25, 2016. Rectal
Examination revealed external hemorrhoids, 1.5 cm,
non-congested, non-thrombosed, no bleeding.

17. The Age of Gestation is _______ weeks.
A. 28
B. 28 4/7
C. 28 6/7
D. 28 2/7

18. The following may be advised at this time, EXCEPT:
A. Avoid prolonged standing
B. Hot sitz bath

C. Surgery

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