Medical Archive

Introduction

Prenatal care in the United States

Diagnosis of pregnancy

Symptoms and signs

?? (???)	Sx: N/V, ????, ???, ?? (GA 16-18) Sign: ?? ?? 10?, beaded pattern of cervical mucus Discoloration of vaginal mucosa (Chadwick sign)
?? (???)	?? ??, ?? ??? ?? (softening), ???(ballottement), ?? ?? ??, ??&?? hCG
??	??? ?? : auscultation GA 17 (USG: GA 6, ??? GA 10) ?? ??: GA 20 ??/?? ??: USG, GA 5 (G-sac)
Breast	Tenderness, tingling
Skin	?? ??, striae
Uterus	??, ??, ????? ??(IVC ???)

Pregnancy tests

Sonographic recognition of pregnancy

Initial prenatal evaluation

Prenatal record

??	Gravida	Nulligravida
??	Parity	Nullipara	Primipara	Multipara
“????”	Term	Preterm	Abortus <20weeks	Alive

??: 20? ?, ????? ??. 20? ??? ????? parity+1

Clinical evaluation

Laboratory tests

Pregnancy risk assessment

Subsequent prenatal visits

Prenatal surveillance

Rh(D) type, antibody screen, Hb/Hct, MCV
HIV/VDRL/RPR, HBsAg
Rubella, varicella immunity
Pap test (if screening indicated)
Chlamydia PCR
Urine culture / urine protein

Subsequent laboratory tests

Timeline	Tests
?? ??	Maternal (BP, weight, fundal height, Contraction) Fetal (HR, movement, size, ??, ???, ???)
8-16?	??? ??. 10-12? ??? ??(CVS) GA ?10? & Age ?35: Cell-free fetal DNA testing. if abnormal, confirmed by CVS or amniocentesis
15-20?	Triple test, ????
24-28?	Hb/Hct, antibody screen if Rh(D) negative. GDM sreening (50g OGTT, 1hour)
28?	Rh(D)-negative with a negative antibody screen should receive anti-D immune globulin (Rhogam). Anti-D immune globulin should be given at 28-32 weeks gestation and again after delivery if the baby is Rh positive.
35-37?	GBS culture

• Quadruple test
  • 15~20?. MSAFP, hCG, uE3, inhibin
• Integrated screen
  • 15~20?. Quadruple test + NT by sono
• Chorionic villous sampling (CVS)
  • 10~12?. Fetal loss risk 2.5?, NTD? ? ? ??
• Amniocentesis
  • 16~18?. Fetal loss <1%. Twin? ?? Methylene blue? ??.
  • Indication
    • Age >35yr
    • Trisomy Hx
    • Recurrent abortion
• Cordocentesis
  • 20?~. Umbilical vein?? ??. ????, ???? ????? ?
• 50g OGTT
  • 24~28?

LMP ??? 280?, (?-3), (?+7) = ?????

?? ??
12?: pelvis? ??? pubic symphysis ???? ???
20?: ???? ???.
20~34?: fundal height(HOF)? ??. ?? cm? age in weeks? ??
??: ??? ??? HOF ?? ??.

AFP

• LOW
  • Obesity, DM, trisomy, fetal death, overestimated GA
  • USG? ???? ???. ????? amniocentesis? fetal blood? karyotyping
  • Down SD
    • hCG? inhibin ? MSAFP? uE3?
    • Sensitivity ~80%, false-positive rate ~5%
• HIGH
  • Multiple gestation, fetal death, underestimated GA
  • MSAFP cut-off? 2.5 MoM, Twin??? 3.5 MoM
    • 2.0 ??? ???? ???, standard USG ????? ??. 
    • ?? ??? or ? 2.5 ??? specialized USG (?? ??) ± amniocentesis

#?? ?? ?????? ?? ??? ???? 2? ? ?? triple test.

??	21	???, ??? ?? ? ?? ??? ??
????	18	??? ?, ???, choroid plexus cyst
???	13	????, ??? ?
??	X

# Preventing neonatal GBS infection

• Antenatal screening
  • Rectovaginal culture at 36-38 weeks gestation
  • Patients with this history do not require screening b/c they are presumed to be persistently and heavily colonized with GBS.
• Indications for intrapartum prophylaxis
  • GBS bacteriuria or GBS UTI in current pregnancy (regardless of treatment)
  • GBS-positive rectovaginal culture in current pregnancy
  • Unknown GBS status + any of the following:
    • <37 weeks gestation
    • Intrapartum fever
    • Rupture of membranes for ?18 hours
  • Prior infant with early-onset neonatal GBS infection
• Intrapartum prophylaxis
  1. IV penicillin
  2. Cefazolin

# High-risk STI screening

• High-risk patients
  • Age <25, Prior STI, high-risk sexual activity (eg, multiple partners, commercial sex work)
• Required screening
  • Performed at initial PNV & 3rd trimester
  • HIV, Syphilis, HBV, Gonorrhea, Chlamydia

Nutritional counseling

1. ?? ??? ??(BMI 20~26) 25-35lb ?? ?? ??
2. ii. Folic acid (Vit B9) –  ??? ?? ??? ??

1. ?? 1? ?~?? 1? ??
2. ?? ?? 0.4mg, ????? 4mg (Hx, FHx, ????, T1DM)
   (Serum ?? monitoring ???)
3. ?? – ??? ??? ??
   1. ?? ??? ?? 500mg
   2. ??/?? 300mg
   3. ?? 200mg

1. 2. ??? ?? ????? ?? 2??? ?? (? ?? N/V ??.) 
2. iv. Vit A derivative ? iso-tretinoin? teratogenic. Beta-carotene? ??

Weight gain recommendations

Category (BMI)	Total Weight Gain Range (lb)*	Weight Gain in 2nd and 3rd Trimesters Mean in lb/wk (range)
Underweight (<18.5)	28–40	1 (1–1.3)
Normal weight (18.5–24.9)	25–35	1 (0.8–1)
Overweight (25.0–29.9)	15–25	0.6 (0.5–0.7)
Obese (?30.0)	11–20	0.5 (0.4–0.6)

• Complications of inappropriate pregnancy weight gain
  • Excessive weight gain
    • GDM, fetal macrosomia, c-sec
  • Inadequate weight gain
    • FGR, preterm delivery

Severe undernutrition

Weight retention after pregnancy

Dietary reference intakes – recommended allowances

Common concerns

• ?? continue to work, 30? ??? ??? ??? O
• 1??? 2? ??? tuna? X
• 36???? air travel ????, ?? ??? ???
• ??? ???? – ?? ??

Measles, Mumps, Rubella, Varicella, Small pox (vaccinic)

Employment

Exercise

20-30 minutes of moderate intensity exercise on most or all days of the w eek is recommended.

Absolute contraindications

• At risk for preterm delivery
  • Amniotic fluid leak
  • Premature labor
  • Cervical insufficiency
  • Multiple gestation
  • Preeclampsia/gestational hypertension
• Have antepartum bleeding
  • Placenta abruption or previa
• Have an underlying medical condition that could be exacerbated by exercise.
  • Severe heart or lung disease

Unsafe activities

• Contact sports (eg, basketball, ice hockey, soccer)
• High fall risk (eg, downhill skiing, gymnastics, horseback riding)
• Scuba diving
• Hot yoga

Precautions

• Avoidance of dehydration, which can cause contractions
• Avoidance of prolonged periods of lying supine, which are associated with decreased venous return and placental perfusion.
• Patients should stop exercising if symptoms such as vaginal bleeding, leakage of fluid, contractions, or chest pain develop.

Seafood consumption

Lead screening

Automobile and air travel

Coitus

Dental care

Immunization

Vaccines during pregnancy

• Recommended
  • Tdap
    • Regardless of vaccine history, 3rd trimester is recommended for optimal antibody response.
    • Women who did not receive the Tdap during pregnancy should vaccinated in the immediate postpartum period.
  • Inactivated influenza
  • Rho(D) immunoglobulin
• Indicated for high-risk patients
  • Hepatitis B
  • Hepatitis A
  • Pneumococcus, Meningococcus, Haemophilus influenzae
  • Varicella-zoster immunoglobulin
• Contraindicated
  • HPV
  • MMR
  • Live attenuated influenza
  • Varicella
    • Postexposure prophylaxis – VZIG

Indications for prophylactic administration of RhoGAM

• At 28-32 weeks gestation
• <72 hours after feto-maternal blood mixing
  • Delivery of Rh(D)-positive infant
  • Spontaneous abortion, Ectopic pregnancy, Threatened abortion, H.mole, Chorionic villus sampling, amniocentesis
  • Abdominal trauma
  • 2nd- & 3rd- trimester bleeding
  • External cephalic version

Caffeine

Nausea and heartburn

Pica and ptyalism

Headache or backache

Varicosities and hemorrhoids

Sleeping and fatigue

Cord blood banking