1. Prenatal Care
Obs &Gyn Department
D.M. O.U. Ivanova

2. Definitions
• It is a planed examination and observation
for the woman from conception till the birth .

3. Goals of antenatal care
• To reduce maternal and perinatal mortality and
morbidity rates.
• To improve the physical and mental health of
women and children.
• To prepare the woman for labor, lactation, and
care of her infant.
• To detect early and treat properly complicated
conditions that could endanger the life or impair
the health of the mother or the fetus.

4. Objectives
• Antenatal care support and encourage a
family’s healthy psychological adjustment to
childbearing
FACTORS AFFECTING MOTHERS
UTILIZATION OF ANTENATAL CARE
• Demographic and Biological Factors
• Socioeconomic Factors
• Psychosocial Factors
• Health Services Factors
• Environmental Factors

5. Assessment and physical
examination

6. RISK ASSESSMENT AT THE
PRECONCEPTION OFFICE
VISIT
• Age — As maternal age increases, the risk
of infertility, fetal aneuploidy, miscarriage,
gestational diabetes, preeclampsia, and
stillbirth also increases.
• Women should be aware of these risks and
the consequences of delaying conception
until they are in their 30s or 40s, and
consider this in their reproductive health
plans.

7. Medical history —is a good starting point for
discussing how pregnancy can affect maternal
health and the effect of maternal health and ehavior
on the fetus and pregnancy.
• Chronic medical problems
• Medications known to be teratogens
• Reproductive history
• Genetic conditions and family history
• Substance use, including nicotine-containing products, tetrahydrocannabinol
(THC), alcohol, opioids, and nonprescribed drugs
• Infectious diseases and vaccinations
• Nutrition, exercise, and weight management
• Environmental hazards and toxins (eg, nonuse of safety belts; exposure to
firearms, occupational hazards, infection)
• Social and mental health concerns (eg, depression, social support, intimate
partner violence, housing, food insecurity)

8. • During the firs visit, assessment and
physical examination must be completed.
Including:
history.
Physical examination.
Laboratory data.
Psychological assessment.
Nutritional assessment.

9. Personal and social history:
This include: woman’s name, age, occupation,
address, and phone number. Marital status,
duration of marriage, Religion, Nationality and
language, Housing and finance.

10. Menstrual history:
A compete menstrual history is important to establish the
estimated date of delivery. It includes:
- Last menstrual period (LMP).
- Age of menarche.
- Regularity and frequency of menstrual cycle.
- Contraception method.
- Expected date of delivery (EDD) is calculated as
followed:
1st day of LMP −3 months +7 days, and change the year.
Example: calculate EDD if LMP was august 30, 2007.
= June 6, 2008.

11. Current problems with pregnancy :
Ask the patient if she has any current problem, such as:
- Nausea & vomiting.
- Abdominal pain.
- Headache.
- Urinary complaints.
- Vaginal bleeding.
- Edema.
- Backache.
- Heartburn.
- Constipation.

12. • Obstetrical history:
This provides essential information about the previous
pregnancies that may alert the care provider to
possible problems in the present pregnancy. Which
includes:
 Gravida, abortion, and living children.
 Weight of infant at birth & length of gestation.
 Labor experience, type of delivery, location of birth,
and type of anesthesia.
 Maternal or infant complications.

13. • Medical and surgical history:
Chronic condition such as diabetes mellitus,
hypertension, and renal disease can affect the
outcome of the pregnancy and must be
investigated.
Prior operation, allergies, and medications
should be documented.
Previous operations such as cesarean section,
genital repair, and cervical cerclagc.
Accidents involving injury of the bony pelvis

14. • Family history:
Family history provides valuable information about
the general health of the family, and it may reveal
information about patters of genetic or congenital
anomalies.
Including:
- D.M.
- Hypertension.
- Heart disease.
- Cancer.
- Anemia.

15. Check for gestational diabetes.
ASK ABOUT
– Family history of diabetes &
history of obesity.
– Past pregnancy for difficult labor,
large babies, congenital
malformations and previous
unexplained fetal death.
LOOK FOR
– signs of maternal overweight or
obesity
– Polyhydramnios
– Signs of large baby or fetal
abnormality
– Vaginal infection.
Low Risk:
24-28 wks
High Risk:
Immediately,
any AOG

16. General Examination
It should be started from the moment the pregnant
woman walks into the examination room.
Examine general appearance:
• Observe the woman for stature or body build and
gait
• The face is observed for skin color as pallor and
pigmentation as chloasma.
• Observe the eyes for edema of the eyelids and
color of conjunctiva.

17. Vital signs:
 Blood pressure:
1. In late pregnancy, raised systolic pressure of 30 mm
Hg or raised diastolic pressure of 15 mm Hg above
the prepregnant state on at least two occasions of 6
or more hours apart indicates preeclampsia.
 Pulse:
The normal pulse rate = 60-90 BPM.
Tachycardia is associated with anxiety, hyperthyrodism,
or infection.

18.  Respiratory rate:
The normal is 16-24 BPM.
Tachypnea may indicate respiratory infection,
or cardiac disease.
 Temperature:
normal temperature during pregnancy is
36.2C to 37.6C.
Increased temperature suggests infection.

19. Cardiovascular system:
• Venous congestion:
Which can develop into varicosities, venous congestion
most commonly noted in the legs, vulva, and rectum.

20. • Height & weight:
An initial weight is needed to establish a baseline for
weight gain throughout pregnancy.
Preconception:
 Wt. lower than 45kg, or Ht. under 150 cm is associated
with preterm labor, and low birth weight infant.
 Wt. higher than 90 kg is associated with increased
incidence of gestational diabetes, pregnancy induced
hypertension, cesarean birth, and postpartum infection.
Recommendation for weight gain during pregnancy are
often made based on the woman’s body mass index.

21. Steps to Follow in Prenatal Care
1)IMMEDIATE ASSESSMENT for emergency signs.
Unconscious/Convulsing
Vaginal bleeding
Severe abdominal pain
Looks very ill
Severe headache with visual disturbance
Severe difficulty in breathing
Dangerous Fever
Severe vomiting
* Attend to sick woman quickly.

22. • Pelvic measurement:
The bony pelvis is evaluated early in the
pregnancy to determine whether the
diameters are adequate to permit vaginal
delivery.

23. • Contour of the abdominal wall is observed
for pendulous abdomen, lightening
protrusion of umbilicus and full bladder
Palpation
• The uterus will be palpable per abdomen after
the 12th week of gestation
Abdominal palpation includes
Estimation of the period of gestation. This is done
by determination of fundal height.

24. • Calculations:
• Calculation of gestation using fundal
height
– McDonald’s method: Measure from symphasis
pubis to top of fundus in cm.
– Gestation is measurement + or – 2 weeks

25. Laboratory data
Test Purpose
Blood group To determine blood type.
Hgb & Hct To detect anemia.
(RPR) rapid plasma reagin To screen for syphilis
Rubella To determine immunity
Urine analysis To detect infection or renal disease.
protein, glucose, and ketones
Papanicolaou (pap) test To screen for cervical cancer
Chlamydia To detect sexual transmitted disease.
Glucose To screen for gestational diabetes.
Stool analysis for ova and parasites
Hepitits B serface antigine To detect carrier status or active disease

26. Ultrasound
Is performed to:
• estimate the gestational age.
• Check amniotic fluid volume.
• Check the position of the placenta.
• Detect the multifetal pregnancy.
• The position of the baby.

27. • Fetal kick count:
• The pregnant woman reports at least 10
movements in 12 hours.
* Absence of fetal movements precedes
intrauterine fetal death by 48 hours.

28. Schedual of antenatal care:
• a medical check up every four weeks up
to 28 weeks gestation,
• every 2 weeks until 36 weeks of gestation
• visit each week until delivery
• More frequent visits may be required if
there are abnormalities or complications
or if danger signs arise during pregnancy

29. Genetic Screening
– Family history of genetic disorders?
– Previous fetus or child who was affected by a genetic
disorder?
– History of recurrent miscarriage?
• All women should be offered serum marker screening for
neural tube defects and trisomies 21 and 18
– Increased risk? amniocentesis or CVS may be offered
• Disease-specific screening should be offered to patients who
belong to an ethnic group with an increased incidence of a
recessive condition

30. Screening at 11-20 wks
10 12 14 16 18 20 wks
•Allows adjustment of age-related risk
• Nuchal plus biochemistry = Maternal Serum Screen
+Ultrasound

31. Fetal NT + Maternal age + ßhCG + PAPP-A at 11-14 wks
All
0
20
40
60
80
100
%
Ag
e
ßhCG PAPP-A
Detection Rate
30%
89%
72%
60%
Age
ßhCG
PAPP-A
Age
NT
Invasive
Testing
5%
Screening at 11-14 wks
Courtesy Dr J Johnson and the Fetal Medicine Foundation

32. Nuchal Translucency
• Gestation 11-14 wks
• CRL 45-84 mm
• Mid-sagittal view
• Image size >75%
• Neutral position
• Away from amnion
• Maximum lucency
• Calipers on-to-on
Courtesy Dr J Johnson and the Fetal Medicine Foundation

33. FETAL CENTRE
FETAL CENTRE
Fetal
Fetal Nuchal
Nuchal Translucency
Translucency

Chromosome abnormalities

Birth defects (cardiac, d.hernia)

Genetic syndromes

Increased mortality (> 3.5 mm)
Significance of increased nuchal fluid
Courtesy Dr J Johnson and the Fetal Medicine Foundation

34. Pathophysiology of increased
nuchal translucency
•Abnormal or delayed lymphatic development
• Venous congestion
• Cardiac failure
• Altered composition of extracellular matrix
• Failure of lymphatic drainage due to fetal
hypokinesia
• Fetal anemia or hypoproteinemia
• Congenital infection
Courtesy Dr J Johnson and the Fetal Medicine Foundation

35. First Trimester Biochemical Markers
PAPP-A: Pregnancy associated plasma protein A
•Produced by placental trophoblast
•Increases in 10-14 week period
•Lower in DS pregnancies (0.43 MOM)
•Associated with 42 % DR at 5% FPR.
Free - hCg: Free  subunit of human
chorionic gonadotrophin.
•Placental protein
•Decreases in T1 like total hGC
•Higher in DS pregnancies (1.79 MOM)
Courtesy Dr J Johnson and the Fetal Medicine Foundation
2-

36. MSS Limitations
 Sensitivity 70 %
 Specificity 95% ( False positive 5%)
Two reasons for a false positive:
 Wrong dates
 Twins

37. Ultrasound
 Ultrasound screening (detailed scan)
 18-20 weeks

38. INVASIVE TECHNIQUES FOR
EARLY PRENATAL TESTING
 Chorionic Villus Sampling
 Amniocentesis

39. Amniocentisis
 Performed at or more 15 weeks
 Takes 2-3 weeks for Karyotype
 Pregnancy loss risk 1/200
 Can get result of trisomies 13,18,21 and
Turners Syndrome X0 in 48 hours with
FISH (Florescent Insitu Hybridization)

40. Chorionic Villus Sampling
 Performed at 10-14 weeks
 Takes 2-3 weeks for the result
 Pregnancy loss rate 1/100
 Operator experience important
 Link to limb abnormalities (still
controversial)
 Placental mosaicism up to 3%, but little
effect on outcome

41. ANTENATAL CARE: Key Messages
 Reduced number of visits
 Provided by skilled birth attendant
 Screening and prevention of diseases that may
complicate pregnancy
 Preventive Measures: Tetanus immunization, iron
and folic acid supplementation
 Counseling on family planning, nutrition,
breastfeeding, and danger signs
 BIRTH PLAN: Birth preparedness and
complication readiness