Chapter 8. Prenatal Care

1. Chapter 8. Prenatal Care R3. Jeong Mi Byun

2. Overview of Prenatal Care Frequency distribution of the number of prenatal visits for the United States in 2001. 50million prenatal visits.- the median was 12.3 visits / pregnancy

3. Overview of Prenatal Care table 8-1 Obstetrical and Medical Risk Factors Detected During Prenatal Care in the United States in 2001

4. Overview of Prenatal Care Inadequate Prenatal Care • Reasons : varied by social and ethnic group, age, and method of payment • Not know pregnancy (m/c) • Lack of money or insurance • Inability to obtain an appointment • Kessner Index : for measuring the adequacy of prenatal care

5. Overview of Prenatal Care TABLE 8-2 Kessner Index Criteria • Kessner Index • incorporates information from three items recorded on the birth certificate • length of gestation • timing of the first prenatal care visit • number of visits • Limitation • measure the quantity of care but not the quality of care • not consider the relative risk of the mother • Useful measure of prenatal care • adequacy

6. Overview of Prenatal Care Effectiveness of Prenatal Care • No conclusive evidence that prenatal care improved birth outcome - Fiscella (1995) • Risk of preterm birth≥ (X 2) ↑↑: Prenatal care (-) - Herbst and associates (2003) • Cost effect : 1$ for prenatal care/ $1.49 in newborn and postpartum - Schramm(1992) • Rate of fetal death↓ - Vintzileos and colleagues(2002b) • Rate of neonatal death associated with several high-risk conditions (placenta previa, fetal growth restriction , and postterm pregnancy.) • Fewer preterm birth– Vintzileous and colleagues (2003) • Risk of pregnancy-related maternal death(X5)↓ -Harper and co-workers (2003 )

7. Organization of Prenatal Care • Definition “ a comprehensive antepartum care program that involves a coordinated approach to medical care and psychosocial support that optimally begins before conception and extends throughout the antepartum period” - the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002) • Comprehensive program I. Preconceptional care II. Prompt diagnosis of pregnancy III. Initial presentation for pregnancy care IV. Follow-up prenatal visits

8. Ι. Preconceptional care A comprehensive preconceptional care program has the potential to assist women by reducing risks, promoting healthy lifestyles, and improving readiness for pregnancy.

9. ΙΙ. Diagnosis of pregnancy 1. Signs and Symptoms 2. hCG • home urine pregnanacy test → confirmatory testing for hCG in urine or blood 3. Ultrasound

10. ΙΙ-1. Signs and Symptoms • Cessation of menses • Changes in cervical mucus • Change in the breast • Discoloration of the vaginal mucosa • Skin changes • Changes in the uterus • Changes in the cervix • Fetal heart action • Perception of fetal movements

11. ΙΙ-1. Signs and Symptoms Changes in cervical mucus Determined by cervical glandular response to hormonal action • Fernlike pattern : MCD 7th~18th day • Estrogen ( ↑↑↑ ) → cervical mucus is relatively rich in sodium chloride → crystallization of the mucus is dependent on an increased concentration of sodium chloride. • Beaded pattern : after MCD 21st day, during pregnancy • Progesterone (↑↑↑ ) → lower sodium chloride concentration

12. ΙΙ-1. Signs and Symptoms FIGURE 8-3Scanning electron microscopy of cervical mucus obtained on day 11 of the menstrual cycle. fernlike pattern (From Zaneveld and associates, 1975, with permission ) FIGURE 8-4Photomicrograph of dried cervical mucus obtained from the cervical canal of a woman pregnant at 32 to 33 weeks. The beaded pattern is characteristic of progesterone action of the endocervical gland mucus composition (Courtesy of Dr. J. C. Ullery)

13. ΙΙ-1. Signs and Symptoms Changes in the Breasts Anatomical changes in the breast, during the 1st pregnancy Discoloration of the Vaginal mucosa • Chadwick sign : dark bluish or purplish-red and congestion Skin Changes • Increased pigmentation, abdominal striae • Not just pregnancy – women taking estrogen-progestin contraception

14. ΙΙ-1. Signs and Symptoms Changes in the uterus • 12wks • body of the uterus – globular, • average uterine diameter : 8cm • Hegar sign • at about 6~8 weeks’ menstrual age, • on bimanual examination a firm cervix is felt which contrasts the now softer body of the uterus and compressible interposed softened isthmus. • The softening at the isthmus may be so marked that the cervix and the body of the uterus seem to be separate organs

15. ΙΙ-1. Signs and Symptoms Changes in the cervix softening Fetal heart action • 5weeks : real-time sonography vaginal probe • 10weeks : Doppler ultrasound • Mean of 17weeks ~19wks : auscultation Perception of fetal movement at or about 20weeks

16. ΙΙ-1. Signs and Symptoms Other sounds • The funic (umbilical cord) “souffle” • caused by the rush of blood through the umbilical arteries • sharp, whistling sound that is synchronous with the fetal pulse • The uterine “souffle” • soft, blowing sound • shynchronous with the maternal pulse • Produced by the passage of blood through the dilated uterine vessels • heard with any condition in which uterine blood flow is greatly increased, eg.) large uterine myomas, or ovarian tumors • Sounds resulting from fetal movement • Maternal pulse • Sounds from maternal intestinal peristalsis

17. ΙΙ-2. Chorionic Gonadotropin • glycoprotein with a high carbohydrate content • Heterodimer composed of two dissimilar subunits, designated α and β • α- subunit : similar to those of lutinizing hormone (LH), follicle-stimulating horrmoen (FSH), and thyroid-stimulalting hormone (TSH) • Prevents involution of the corpus luteum • Produced by trophoblast cells • Maternal plasma or urine by 8 ~9 days after ovulation • Doubling time of plasma hCG concentration : 1.4~2.0 days • Peak levels : at about 60~70 days • Declines slowly until a nadir is reached at about 14~16 weeks (fig 8-5)

18. ΙΙ-2. Chorionic Gonadotropin FIGURE 8-5 Mean concentration of chorionic gonadotropin(hCG) in serum of women throughout normal pregnancy. The free β-subunit of hCG is in low concentration throughout pregnancy. (Data fromAshitaka and colleagues, 1980;Selenkow and co-workers, 1971.)

19. ΙΙ-3. Ultrasonic Recognition of Pregnancy Transvaginal sonography Transabdominal sonography • Gestational sac : after 4~5weeks’ menstrual age ★all normal sacs should be visible : by 35 days • Heartbeat : after 6weeks ~12weeks : the CRL is predictive of gestational age within 4days FIGURE 8-6 Abdominal sonogram demonstrating a gestational sac at 4 to 5 weeks’ gestational (menstrual ) age. (Courtesy of Dr. Diane Twickler.)

20. ΙΙΙ. Initial Prenatal Evaluation Major goals 1. To define the health status of the mother and fetus 2. To estimate the gestational age of the fetus 3. To initiate a plan for continuing obstetrical care

21. ΙΙΙ. Initial Prenatal Evaluation Tab 8-3 Typical Compnents of Routine Prenatal Care

22. ΙΙΙ. Initial Prenatal Evaluation 1. Prenatal Record • Normal Pregnancy Duration • History 2. Psychosocial Screening • Cigarette smoking • Alcohol and Illicit Drugs during Pregnancy • Domestic Violence Screening 3. Physical Examination • Pelvic Examination 4. Laboratory Tests 5. High-Risk Pregnancies

23. ΙΙΙ-1. Prenatal Record Use of a standardized record within a perinatal health care system greatly facilitates antepartum and intrapartum management.

24. Definition

25. ΙΙΙ-1. Prenatal Record • Number of term infant-preterm infants-abortions-children currently alive eg) 6-1-2-6 Normal pregnancy Duration • Mean duration of pregnancy from the first day of the last normal menstrual period : 280 days or 40weeks • Expected date of delivery : LMP month - 3month / day + 7days (Naegele rule) eg) LMP : 9 / 10 → EDC : 6 / 17 • Gestational age or menstrual age from the first day of LMP : erroneously considered to have begun about 2 weeks before ovulation • Ovulatory age or fertilization age : typically 2weeks shorter

26. ΙΙΙ-1. Prenatal Record • Trimester : divide pregnancy into three equal trimester of approximately 3 calendar months • Precise knowledge of the age of the fetus is imperative for ideal obstetrical management • Gestational age using completed weeks and days eg) 33 3/7 weeks -> 33 completed weeks and 3days 42 weeks 14 weeks 28 weeks 1st trimester 2nd trimester 3rd trimester

27. ΙΙΙ-1. Prenatal Record History • Detailed information concerning past obstetrical history is crucial : many prior pregnancy complications tend to recur in subsequent pregnancies • Menstrual history : extremely important : Without a history of regular, predictable, cyclic, spontaneous menses that suggest ovulatory cycles, accurate dating of pregnancy by history and physical examination is difficult.

28. ΙΙΙ-2. Psychosocial Screening

29. ΙΙΙ-2. Psychosocial Screening Cigarette Smoking • Various adverse outcomes • spontaneous abortion, • low birthweight due to either preterm delivery or fetal growth restriction, • infant and fetal deaths, • placental abruption • Suggested pathophysiological mechanisms • increased fetal carboxyhemoglobin, • reduced uteroplacental blood flow, • fetal hypoxia

30. ΙΙΙ-2. Psychosocial Screening Cigarette Smoking Optimally, smokers should be treated before conception. - Wisborg and co-workers (2000)

31. ΙΙΙ-2. Psychosocial Screening Alcohol and Iilicit drugs during Pregnancy • Ethanol • potent teratogen • fetal alcohol syndrome : characterized by growth restriction, facial abnormalities, and central nervous system dysfunction • The Surgeon General recommends that women who are pregnant or considering pregnancy abstain from using any alcoholic beverages.

32. ΙΙΙ-2. Psychosocial Screening Alcohol and Iilicit drugs during Pregnancy • Chronic use of large quantities of illicit drugs, - opium derivatives, barbiturates, and amphetamines,… • fetal distress, • low birthweight, • and drug withdrawal soon after birth are well documented. • when women who use illicit drugs receive prenatal care, the risks for preterm birth and low birthweight are reduced. - El-Mohandes and associates (2003)

33. ΙΙΙ-2. Psychosocial Screening Domestic Violence Screening • refers to violence against adolescent and adult females within the context of family or intimate relationships. • Janssen and colleagues (2003) Survey (survey of 4750 women ) : found that 1.2 percent were exposed to physical violence by an intimate partner during pregnancy. • risk of antepartum hemorrhage and fetal growth restriction (X3) • risk of perinatal death. (X8)

34. ΙΙΙ-3. Physical Examination Pelvic Examination • Cervix : visualized employing a speculum lubricated with warm water. • Bluish-red passive hyperemia of the cervix • Nabothian cysts ☞ To identify cytological abnormalities • Pap smear • Specimens for identification of Neisseria gonorrhoeae and Chlamydia trachomatis are obtained if screening is indicated.

35. ΙΙΙ-3. Physical Examination • Palpation • consistency, length, and dilatation of the cervix • fetal presentation later in pregnancy • bony architecture of the pelvis • any anomalies of the vagina and perineum, including cystocele, rectocele, and relaxed or torn perineum. • The vulva and contiguous structures are carefully inspected. • All cervical, vaginal, and vulvar lesions are evaluated further by appropriate use of colposcopy, biopsy, culture, or dark-field examination. • digital rectal examination, visualized on the perianal region

36. ΙΙΙ-4. Laboratory Tests • human immunodeficiency virus (HIV) testing, with patient notification, as a routine part of prenatal testing.

37. ΙΙΙ-5. High-Risk Pregnancies • Some conditions may require the involvement of a maternal–fetal medicine subspecialist, geneticist, pediatrician, anesthesiologist, or other medical specialist in the evaluation, counseling, and care of the patient • Recommended Consultation for Risk Factors Identified in Early Pregnancy (table 8-5)

39. IV. Subsequent Prenatal Visits The timing of subsequent prenatal visits • ~ 28 weeks : intervals of 4 weeks • 28~ 36 weeks : every 2 weeks • > 36 weeks : weekly • with complicated pregnancies : often require return visits at 1- to 2-week intervals.

40. IV -1. Prenatal surveillance • At each return visit, steps are taken to determine the well-being of mother and fetus • Certain information is especially important. Ex) assessment of gestational age accurate measurement of blood pressure

41. IV -1. Prenatal surveillance Fetal • Heart rate(s) • Size—current and rate of change • Amount of amnionic fluid • Presenting part and station (late in pregnancy) • Activity

42. IV -1. Prenatal surveillance Maternal • Blood pressure : current and extent of change • Weight : current and amount of change • Symptoms : including headache, altered vision, abdominal pain, nausea and vomiting, bleeding, vaginal fluid leakage, and dysuria • Height in centimeters of uterine fundus from symphysis • Vaginal examination late in pregnancy often provides valuable information: • Confirmation of the presenting part • Station of the presenting part • Clinical estimation of pelvic capacity and its general configuration • Consistency, effacement, and dilatation of the cervix

43. IV -2. Assessment of Gestational Age • Precise knowledge of gestational age is important (because a number of pregnancy complications may develop for which optimal treatment will depend on fetal age. ) • performed clinical examination, coupled with knowledge of the time of onset of the last menstrual period. • Fundal Height • Fetal Heart sound • Ultrasound

44. IV -2. Assessment of Gestational Age Fundal Height • measured as the distance over the abdominal wall from the top of the symphysis pubis to the top of the fundus. • 20 ~ 31 weeks : the height of the uterine fundus, measured in centimeters, correlates closely with gestational age in weeks -Jimenez and co-workers, 1983 • essentially identical observations up to 34 weeks - Quaranta and associates (1981) and Calvert and colleagues (1982). cf) Obesity • The bladder must be emptied before making the measurement.

45. IV -2. Assessment of Gestational Age Fetal Heart Sounds • 16 ~ 19 weeks : auscultated with a DeLee fetal stethoscope.

46. IV -2. Assessment of Gestational Age Ultrasound • between 8 and 16 weeks slightly more accurate than LMP, for predicting the actual date of delivery - Taipale and Hiilesmaa (2001) • Routine ultrasound : notcurrentlyrecommended in low-risk pregnancies - by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2002).-

47. IV -3. Subsequent Laboratory Tests • initial results : normal → most tests need not be repeated (see Table 8–3). • 16 to 18 weeks : Maternal serum screening is recommended for detecting open neural- tube defects and some chromosomal anomalies • Hematocrit (or hemoglobin) • 28 to 32 weeks : syphilis serology if it is prevalent in the population, should be repeated (Hollier and co-workers; Kiss and colleagues, 2004). • Cystic fibrosis carrier screening • before conception or during the first or early second trimester. • Information about cystic fibrosis screening also should be provided to patients in other racial and ethnic groups who are at lower risk

48. Ancillary Prenatal Tests • Gestational Diabetes • Chlamydial Infection • Gonococcal Infection • Fetal Fibronectin • Group B Streptococcal (GBS) infection • Special Screening for Genetic Diseases

49. 1. Gestational Diabetes • Screened by history, clinical risk factors, or routine laboratory testing • GA 24 ~28 weeks

50. 2. Chlamydial Infection • women at high risk for C trachomatis infection : should be screened during the 1st prenatal visit • Risk factors • unmarried status • recent change in sexual partner or multiple concurrent partners • age under 25 years • inner-city residence • history or presence of other sexually transmitted diseases • little or no prenatal care • negative prenatal chlamydia or gonorrhea test : should not preclude postpartum screening