V Almost a century after its

introduction, prenatal care has become one

of the most frequently used health services in
the United States
V A planned program of medical evaluation and
management, observation, and education of
the pregnant woman directed toward making
pregnancy, labor, delivery and the
postpartum recovery a safe and satisfying
experience.
V áell-designed prenatal program should provide
the oppurtunities:
{ ’or the physician and the patient to become better
acquainted
{ ’or the physician to learn something about the
patientǯs emotional attitude toward pregnancy and
labor
{ ’or instruction of the patient and her husband in
optimal care for herself and the coming baby
V Àptimal instruction of the patient and her
husband in a prepared childbirth program
½
  
 
 
 

—
—

estational Hypertension


Diabetes

Anemia
—


Hydramnios/oligohydramnios


Lung Disease
enital Herpes

Chronic Hypertension
D(Rh) Sensitization
—
Cardiac disease


Renal Disease

Incompetent cervix

½
 
 
 
 Hemoglobinopathy
V Œaried by social and ethnic
group, age and method of payment
{ Late identification of pregnancy by the
patient Ȃ most common
{ Lack of money or insurance for such
care
{ Inability to obtain an appointment
V ºhe current low maternal mortality rate of
approximately  per , is likely
associated with the high utilization of
prenatal care
V Prenatal care was associated with
significantly lower rates of preterm births as
well as neonatal death associated with
several high-risk conditions that included
placenta previa, fetal-growth restriction, and
postterm pregnancy
V A comprehensive antepartum care program
involves a coordinated approach to medical
care and psychosocial support that optimally
begins before conception and extends
throughout the antepartum period
V ºhis comprehensive program includes:
{ () preconceptional care
{ (—) prompt diagnosis of pregnancy
{ () initial prenatal evaluation
{ ( ) follow-up prenatal visits
V ºhe diagnosis of pregnancy usually begins
when a woman presents with symptoms, and
possibly a positive home urine pregnancy test
result
V Sonography is often used, particularly in
those cases in which there is question about
pregnancy viability or location
V Cessation of menses
{ ºhe abrupt cessation of menstruation in a healthy
reproductive-aged woman who previously has
experienced spontaneous, cyclical, predictable
menses is highly suggestive of pregnancy
{ Amenorrhea is not a reliable indication of
pregnancy until  days or more after expected
menses onset. áhen a second menstrual period is
missed, the probability of pregnancy is much
greater
V Changes in Cervical Mucus
{ Mucus crystallization necessary for the production of the
fern pattern is dependent on an increased sodium chloride
concentration.
{ Cervical mucus is relatively rich in sodium chloride when
estrogen, but not progesterone, is being produced.
{ ’rom about the 7th to the th day of the menstrual
cycle, a fernlike pattern of dried cervical mucus is seen
{ After approximately the —st day, a different pattern
forms that gives a beaded or cellular appearance
V ÿreast Changes
{ Anatomical changes in the breasts that
accompany pregnancy are
characteristic during a first pregnancy
V Œaginal Mucosa
{ During pregnancy, the vaginal mucosa
usually appears dark bluish or purplish-
red and congested - the so-called
Ch
 
V Skin changes
{ Increased pigmentation and changes
in appearance of abdominal striae are
common to, but not diagnostic
of, pregnancy.
{ ºhey may be absent during
pregnancy, and they may be seen in
women taking estrogen-progestin
contraceptives
V Uterine changes
{ During the first few weeks of pregnancy, the
increase in uterine size is limited principally to the
anteroposterior diameter
{ ÿy — weeks, the body of the uterus is almost
globular, and an average uterine diameter of  cm
is attained.
{ At about  to  weeks' menstrual age, on
bimanual examination a firm cervix is felt which
contrasts the now softer fundus and compressible
interposed softened isthmus - the ¦ 
V Uterine changes
{ Uterine souffle Ȃ may be heard in the later months
of pregnancy, a soft blowing sounf that is
synchronous with the maternal pulse, produced
by passage of blood through the dilated uterine
vessels
{ ’unic souffle Ȃ sharp, whistling sound that is
synchronous eith the fetal pulse, caused by the
rush of blood through the umbilical arteries
V Cervical Changes
{ Increased cervical softening as pregnancy
advances
{ External cervical os and cervical canal may
become sufficienlty patulous to admit the
fingertip, however, the internal os should
remain close
V Perception of ’etal Movements
{ May first perceive fetal movements
between  and  weeks
{ A primigravida may not appreciate fetal
movements until approximately — weeks
later (-— weeks)
{ At approximately — weeks, depending on
maternal habitus, an examiner may begin
to detect fetal movements
V Pregnacy ºest
{ Detection of hC in maternal blood and urine
provides the basis for endocrine tests of
pregnancy
‰ HC is a glycoprotein woth a high carbohydrate content
‰ Composed of Ƚ and Ⱦ subunits
‰ Ƚ-subunit is identical to those in LH, ’SH and ºSH
‰ HC prevents the involution of the corpus luteum (principal site
of progesterone production for the first -weeks
V Pregnacy ºest
‰ áith sensitive test the
hormone can be detected
in maternal palsma or
urine by - days after
ovulation
‰ Doubling time = . Ȃ —
days
hCG ll  
h
‰ ’alse positive hC test
l

 
 h 
results are rare e.g. ll

h 
 
h
heterophilic antibodies  

 
 l ll
l


 
!
V A gestational sac may be demonstrated by
abdominal sonography after only to 
weeksǯ menstrual age.
V ÿy  days, a normal sac should be visible in
all women
V After  weeks, heart motion should be seen
V Up to — weeks, the crown-rump length is
predictive of gestational age within days
V Prenatal care should be initiated as soon
as there is a reasonable likelihood of
pregnancy. ºhe major goals are to:
{ Define the health status of the mother and
fetus
{ Estimate the gestational age
{ Initiate a plan for continuing obstetrical
care.
 áEEKS
’irst Œisit -— — -— —- 
¦

p Complete * A
p Updated * A * A * A
è 


  
p Complete * A
p ÿP * A * A * A * A
p Maternal * A * A * A * A
áeight
p Pelvic/Cervical * A
Exam
p ’undal Height * A * A * A * A
p ’etal Heart * A * A * A * A
Rate/Position
 áEEKS
’irst Œisit -— — -— —- 
ë 


p Hct or Hgb p A p A

p ÿlood type & Rh p A

factor
p Antibody screen p A 

p Pap smear p A
screen
p lucose p A
tolerance test
p ’etal Aneuploidy
ÿ   ÿ
Screening
p Xeural ºube
ÿ
defect screening
p Cystic ’ibrosis ÿ  ÿ
screeing
p Urine protein * A
assessment
 áEEKS
’irst Œisit -— — -— —- 
ë 

p Urine Culture * A
p Rubella * A
serology
p Syphilis * A 
serology
p onococcal ½ ½
culture
p Chlamydial p A 
culture
p Hepatitis ÿ p A
serology
p HIŒ serology ÿ
p roup ÿ strep

culture
V a Ȃ ’irst-trimester aneuploidy screening may be
offered between  and  weeks
V A Ȃ Performed at — weeks, if indicated
V ÿ Ȃ ºest should be offered
V C Ȃ High risk women should be retested at the
beginning of the third trimester
V D Ȃ High risk women should be screened at the first
prenatal visit and again in the third trimester
V E Ȃ Rectovaginal culture should be obtained
between  and 7 weeks
V Use of a standardized recod with a perinatal
healthcare system greatly aids antepartum
and intrapartum management.
V Standardizing documentation may allow
communication and continuity of care
between providers and enable objective
measures of care quality to be evaluated over
time and across different clinical setting.
V ºhere are several definitions pertinent to establishment of
an accurate prenatal record:
{ Xll 
"a woman who currently is not pregnant, nor
has she ever been pregnant
{ G 
" a woman who currently is pregnant or she has
been in the past, irrespective of the pregnancy outcome.
áith the establishment of the first pregnancy, she
becomes a  
and with successive pregnancies,
a l
 

{ Xll  "a woman who has never completed a pregnancy
beyond — weeks' gestation. She may or may not have
been pregnant or may have had a spontaneous or elective
abortion(s) or an ectopic pregancy
V ºhere are several definitions pertinent to establishment of
an accurate prenatal record:
{ è  "a woman who has been delivered only once of a fetus
or fetuses born alive or dead with an estimated length of
gestation of — or more weeks. In the past, a -g birthweight
threshold was used to define parity. ºhis threshold is no longer
as pertinent because of the survival of infants with birthweights
less than  g.
{ l
  "a woman who has completed two or more
pregnancies to — weeks or more. Parity is determined by the
number of pregnancies reaching — weeks and not by the
number of fetuses delivered. Parity is the same (para ) for a
singleton or multifetal delivery or delivery of a live or still born
infant
V In some locales, the obstetrical history is
summarized by a series of digits connected
by dashes. ºhese usually refer to the
V number of term infants, preterm infants,
abortus less than — weeks, and children
currently alive. (’-P-A-L)
V ºhe mean duration of pregnancy calculated from the first
day of the last normal menstrual period is very close to —
days, or  weeks
V u
 
 



h#




l

 


h


h


hl 
  l
 
 l

 
  $
h(Xaegeleǯs rule).
{ A u
u  

 u calculated in this way
erroneously assumes pregnancy to have begun approx. —
weeks before ovulation. Use to mark temporal events in
pregnancy
{ À  u   u employed by
embryologist and other reproductive biologist, which are
typically — weeks shorter.
V It has become customary to divide pregnancy
into three equal epochs of approx.  calendar
months. Historically, the first trimester
extends through completion of  weeks,
sthe second through — weeks, and the third
includes the —th through —nd weeks of
pregnancy.
V ºhus, there are three periods of  weeks
each
V Certain major obstetrical problems tend to cluster in
each of these time periods.
{ Most spontaneous abortions take place during the first
trimester
{ Most women with hypertensive disorders due to
pregnancy are diagnosed during the third trimester
V ÿecause precise knowledge of fetal age is
imperative for ideal obstetrical management, the
clinically appropriate unit is weeks of gestation
completed, and more recently, clinicians designate
gestational age using completed weeks and days.
V Detailed information concerning past obstetrical history is
crucial because many prior pregnancy complications tend to
recur in subsequent pregnancies
V ºhe  
 lh
is extremely important. ºhe woman
who spontaneously menstruates regularly every — days or
so is most likely to ovulate at midcycle. ºhus, the gestational
age (menstrual age) becomes simply the number of weeks
since the onset of the last menstrual period.
V áithout a history of regular, predictable, cyclic, spontaneous
menses that suggest ovulatory cycles, accurate dating of
pregnancy by history and physical examination is difficult.
V ºhe American College of Àbstetricians and
ynecologists advocate psychosocial screening at
least once each trimester to increase the likelihood
of identifying issues and reducing adverse
pregnancy outcomes.
V Screening ofr barriers to care includes lack
transportation,child care or family support; unstable
housing, unintended pregnancy, communication
barriers, nutritional problems, cigarette smoking,
subtance abuse, depression and safety concerns
that include domestic violence.
V Smoking results in unequivocal adverse
sequelae for pregnant women and their
fetuses.
V Xumerous adverse outcomes have been
linked to smoking during pregnancy
V ºhere is a twofold risk of placenta previa,
placental abruption and premature
membrane rupture compared with non-
smokers.
V ÿabies born to women who smoke are
approx. 
more likely to be born preterm,
weigh on average a half pound less, and are
up to three times more likely to die of SIDS.
{ Pathophysiological cause:
‰ ’etal hypoxia (increase carboxyhemoglobin)
‰ Reduced uteroplacental blood flow
‰ Direct toxic effects of nicotine and other compounds
V ºhe most successful efforts for smoking cessation
during pregnancy involve interventions that
emphasize how to stop.
V Àne example is a -step session lasting  minutes
or less in which the provider:
{ () about smoking status;
{ (—) 
those who smoke to stop;
{ () the willingness to quit within the next 
days;
{ ( ) 
interested patients by providing pregnancy-
specific self-help materials; and
{ ()  follow-up visits to track progress
V ºhe American College of Àbstetricians and
ynecologists (—b) has concluded that it is
reasonable to use nicotine medications
during pregnancy if prior nonpharmacological
attempts have failed
V Ethanol is a potent teratogen and causes the
fetal alcohol syndrome, which is
characterized by growth restriction, facial
abnormalities, and central nervous system
dysfunction
V áomen who are pregnant or considering
pregnancy should abstain from using any
alcoholic beverages
V It is estimated taht  percent of fetuses are
exposed to one or more illicit drug
V Agents may include heroin and other opiates,
cocaine, amphetamines, barbiturates and
marijuana
V áell documented sequelae inlcude fetal
distress, low birthweight, and drug
withdrawal soon afetr birth
V Unfortunately, most abused women contibue
to be victimized during pregnancy
V Domestic violence is more prevalent than any
major medical condition detectable through
routine prenatal screeining
V Intimate partner violence is associated with
an increase risk of a number of adverse
perinatal outcomes including preterm
delivery, fetal-growth restriction, and
perinatal death
V A thorough, general physical examination should be
completed at the initial prenatal encounter
V ºhe cervix is visualized employing a speculum lubricated
with warm water or water-based lubricant gel
V ÿluish-red passive hyperemia of the cervix is characteristic,
but not of itself diagnostic, of pregnancy
V Dilated, occluded cervical glands bulging beneath the
exocervical mucosa, so-called 
h  
 may be
prominent.
V ºhe cervix is not normally dilated above the level of the
internal os.
V Leopoldǯs Maneuver
{ LM  (’undal rip)
‰ áhat fetal pole or part occupies the fundus?
‰ ÿreech Ȃ irregular, nodular
‰ Cephalic Ȃ round
{ LM— ( Umbilical rip)
‰ áhich side is the fetal back?
‰ ÿack Ȃ linear, convex, bony ridge
‰ Small parts Ȃ numerous nodulation
V Leopoldǯs Maneuver
{ LM (Pawlikǯs rip)
‰ áhat fetal part lies abovbe the pelvic inlet?
‰ Head not engaged Ȃ round, ballotable, easily displaces
‰ Head engaged Ȃ felt as relatively fixed, knoblike part

{ LM (Pelvic rip)
‰ áhich side the cephalic prominence?
‰ Examiner faces the patientǯs feet and places one hand each on either side
of the lower pole of the uterus
´ Cephalic prominence
` Part of the fetus that prevents the deep descent with one hand
´ ’lexion Ȃ cephalic prominence same side as fetal parts
´ Extension Ȃ same side as the fetal back
V ºhere are many risk factors that can be
identified and given appropriate consideration
in pregnancy management
V 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

 
p Symptomatic on medication Àÿ
p Severe M’M
Cardiac Disease M’M
DM Àÿ or M’M
Epilepsy (on medication) Àÿ
Hypertension
p Chronic, with renal and heart disease M’M
p Chronic, without renal and heart disease Àÿ
Prior fetal death Àÿ
HIŒ/AIDS M’M
Multifetal gestation Àÿ
Preterm Labor, ºhreatened Àÿ
V ºraditionally, the timing of subsequent
prenatal visits has been scheduled at intervals
of weeks until — weeks, and then every —
weeks until  weeks, and weekly thereafter.
áomen with complicated pregnancies often
require return visits at - to —-week intervals.
V Routine prenatal care, required a median of 
visits
V At each return visit, steps are taken to
determine the well-being of mother and fetus
V Evaluation typically includes:
{ ’etal
‰ Heart rate(s)
‰ Size - current and rate of change
‰ Amount of amnionic fluid
‰ Presenting part and station (late in pregnancy)
‰ Activity
V Evaluation typically includes:
{ Maternal
‰ ÿlood pressure - current and extent of change
‰ áeight - 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
‰ Œaginal 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.
V Àne of the most important determinations at
prenatal examinations is assessment of fetal
age.
V Precise knowledge of gestational age is
important because a number of pregnancy
complications may develop for which optimal
treatment will depend on fetal age
V ÿetween — and  weeks, the height of the uterine fundus,
measured in centimeters, correlates closely with gestational
age in weeks
V ºhe fundal height should be measured as the distance over
the abdominal wall from the top of the symphysis pubis to the
top of the fundus.
{ —th week Ȃ above the symphisys pubis
{ th week Ȃ halfway between the symphysis pubis and the umbilicus
{ —th week Ȃ level of umbilicus
{ —th week Ȃ  cm above the umbilicus
{ th week Ȃ — cm below the xiphoid
{ th week Ȃ cm below the xiphoid
V hl




  
h 

V ºhe fetal heart can first be heard in most women between 
and  weeks when carefully auscultated with a non-amplified
stethoscope
V ºhe fetal heart rate now ranges from  to  bpm and is
heard as a double sound resembling the tick of a watch under
a pillow.
V Instruments incorporating Doppler Uº instruments are often
used to easily detect fetal heart action, almost always by 
weeks.
V Using real-time sonography with a vaginal transducer, fetal
cardiac activity can be seen as eraly as  menstrual weeks.
V All pregnant women should be screened for
gestational diabetes mellitus, whether by
history, clinical risk factors, or routine
laboratory testing.
V Although laboratory testing between — and
— weeks is the most sensitive approach, there
may be pregnant women at low risk who are
less likely to benefit from testing
V ºhe American Academy of Pediatrics and the
American College of Àbstetricians and
ynecologists (——) recommend that
pregnant women with risk factors or
symptoms be cultured for X h at an
early prenatal visit and again in the third
trimester.
V Risk factors for gonorrhea are similar for those
for chlamydia.
V Selected screening can be offered based on maternal age,
family history, or the ethnic or racial background of the couple
V Examples include testing for :
{ ºay-Sachs disease for people of Eastern European Jewish or
’rench Canadian ancestry;
{ Ⱦ-thalassemia for those of Mediterranean, Southeast Asian,
Indian, Pakistani, or African ancestry;
{ Ƚ-thalassemia for people of Southeast Asian or African
ancestry; and
{ Sickle- cell anemia for people of African, Mediterranean,
Middle Eastern, Caribbean, Latin American, or Indian
descent
V Recommended Ranges of áeight ain during Singleton
estations Stratified by Prepregnancy ÿody Mass Index
á  ¦       á   

Category ÿMI Kg Lb

Low <. —.- —- 

Xormal .-— .- —-

High —-— 7-. -—

Àbese >—
7


º  u    u
uu 
 
! 


  
   " "


 
    u
  
    u #   
! !$

 
    u
 
      u 
V Disadvantages of excessive maternal weight
gain and fetal macrosomia must be
considered
V Excessive weight gain - defined as more than
 lb - correlated closely with fetal
macrosomia
V Cohort studies of children born to
nutritionally deprived women have been
performed and were recently reviewed by
Kyle and Pichard.
V Progeny exposed in mid to late pregnancy
were lighter, shorter, and thinner at birth and
they had a higher incidence of subsequent
diminished glucose tolerance, hyeprtension,
reactive airway disease, dyslipidemia, and
coronary artery disease.
V Average total weight loss resulted in an average
retained pregnancy weight of  lb or . kg.
V Àverall, the more weight gained during pregnancy,
the more that was lost postpartum
V Interestingly, there is no relationship between
prepregnancy ÿMI or prenatal weight gain and
weight retention.
V Accruing weight with age rather than parity is
considered the main factor affecting weight gain
over time
V Periodically, the ’ood and Xutrition
ÿoard of the Institute of Medicine (—)
publishes recommended dietary
allowances, including those for pregnant
or lactating women


   !
"#ë ÿë
$%
%&
ŒIºAMIX A 7 Ɋg 77 Ɋg
ŒIºAMIX Da  Ɋg  Ɋg
ŒIºAMIX E  mg  mg
ŒIºAMIX K 7 Ɋg  Ɋg
á
 #ë ÿë

ŒIºAMIX C  mg  mg
ºHIAMIX . mg . mg
RÀÿÀ’LAŒIX . mg . mg
XIACIX  mg  mg
ŒIºAMIX ÿ . mg . mg
’ÀLAºE  Ɋg  Ɋg
ŒIºAMIX b— —. Ɋg —. Ɋg
’ % ’

&   ' 
 % (
   )
  *


   !

%&
ë
CALCIUMS  mg  mg
SÀDIUM . g . g
P˼ASSIUMS .7 g .7 g
IRÀX —7 mg —7 mg
IXC — mg  mg
IÀDIXE —— Ɋg —— Ɋg
SELEXIUM  Ɋg  Ɋg
#¦

PR˼EIX 7 g 7 g
CARÿÀHYDRAºE 7 g 7 g
’IÿERS — g — g

’ % ’

&   ' 
 % (
   )
  *

V Pregnancy requires an additional ,
kcal most are accumulated in the last —
weeks.
V ºo meet this demand a caloric increase
of  to  kcal per day is
recommended
V Added for the demands for growth and
remodeling of the fetus, placenta,
uterus and breast, as well as increase
maternal blood volume
V Most hould be supplied from animal
sources such as meat, milk, eggs,
cheese, poultry and fish, because they
furnish amino acids in optimal
combinations
V As little as  mg of elemental iron, supplied as
ferrous gluconate, sulfate or fumarate and taken daily
throughout the latter half of pregnancy, provides
sufficient iron to meet the requirments of pregnancy
and to protect preexisting iron stores.
V ºhe pregnant woman may benefit from  to  mg
of iron per day if she is large, has twin fetuses, begins
supplementation late in pregnancy, takes iron
irregularly, or has a somewhat depressed hemoglobin
level
V ºhe pregnant woman retains about  g
of calcium, most of which is deposited in
the fetus late in pregnancy
V ºhis amount of calcium represents only
about —. percent of total maternal
calcium, most of which is in bone, and
which can readily be mobilized for fetal
growth
V Severe zinc deficiency may lead to poor
appetite, suboptimal growth, and impaired
wound healing.
V Profound zinc deficiency may cause dwarfism
and hypogonadism
{ May also lead to a specific skin disorder,





h as the result of a
rare, severe congenital zinc deficiency
V Recommended daily intake during pregnancy
is about — mg
V ºhe use of iodized salt and bread products is
recommended during pregnancy to offset the
increased fetal requirements and maternal
renal losses
V Severe maternal iodine deficiency
predisposes offspring to endemic cretinism,
characterized by multiple severe neurological
defects
V More than half of neural tube defects can be
prevented with daily intake of  Ɋg of folic acid
throughout the periconceptional period
V ÿecause nutritional sources alone are insufficient,
however, folic acid supplementation is still
recommended
V A woman with a prior child with a neural-tibe defect
can reduce the —- percent recurrence risk by more
than 7
with daily -mg folic acid supplementrs
the month before conception and during the first
trimester.
V Dietary intake of vitamin A in the United
States appears to be adequate, and routine
supplementation during pregnancy is not
recommended
V A small number of case reports suggest an
association of birth defects with very high
doses during pregnancy, , to , IU
daily.
V ºhese malformations are similar to those
produced by the vitamin A derivative
isotretinoin (Accutane), which is a potent
teratogen in humans
V ÿeta-carotene, the precursor of vitamin A
found in fruits and vegetables, has not been
shown to produce vitamin A toxicity.
V ºhe level of vitamin ÿ— in maternal plasma
decreases variably in otherwise normal
pregnancies
V ºhis decrease is mostly from a reduction in
plasma transcobalamins and is thus
prevented only in part by supplementation.
V ’or women at high risk for inadequate
nutrition (e.g., substance abuse, adolescents,
and those with multifetal gestations), a daily
supplement containing — mg is
recommended.
V ºhe recommended dietary allowance for
vitamin C during pregnancy is  to 
mg/day, or about — percent more than when
nonpregnant
V A reasonable diet should readily provide this
amount.
V More than half of the children in the US are
born to working mothers
V ’ederal law prohibits from excluding women
from job categories on the basis that they are
or might become pregnant
V In the absence of complications, most
women can continue to work until the onset
of labor
V Àccupational fatigue, estimated by the number of
hours standing, intensity of physical and mental
demands, and environmental stressors, was
associated with an increased risk of preterm
membrane rupture
V ºhus, any occupation that subjects the pregnanct
woman to sever physicl strain should be avoided
V Adequate period of rest should be provided
V ºhe American College of Àbstetricians and
ynecologists advises a thorough clinical
evaluation be conducted before
recommending an exercise program.
V In the absence of contraindications, pregnant
women should be encouraged to engage in
regular, moderate-intensity physical activity
 minutes or more a day
V ÿ#ë 
&½ 
ë%$
#&%&½%%#& #

#ÿ%
'
%
½ %& è
&&
ÿ#ë 
#&%&½%%#& 
ë%$
#&%&½%%#&

U Hemodynamically significant heart U Severe anemia

disease
U Restrictive lung disease
U Incompetent cervix/ cerclage
U Multifetal gestation at risk for preterm
labor
U Persistent second-or third- trimester
bleeding
U Placenta previa afet — weeks
U Preterm labor during the current
pregnancy
U Ruptured membranes
U Preeclampsia/ pregnancy- induced
hypertension
U Unevaluated maternal cardiac arrythmia
U Chronic bronchitis
U Poorly controlled type  diabetes
U Extreme morbid obesity
U Extreme underweight (ÿMI <—)
U History of extremely sedentary lifestyle
U ’etal- growth restriction in current
pregnancy
U Poorly controlled hypertension
U Àrthopedic limitations
U Poorly controlled seizure disorder
U Poorly controlled hyperthyroidism
U Heavy smoker
V   (
{ Pregnant women should be encouraged to wear
properly positioned three-point restraints throughout
pregnancy while riding in automobiles.
{ ºhe lap belt portion of the restraining belt should be
placed under the woman's abdomen and across her
upper thighs.
{ ºhe belt should be as snug as comfortably possible.
{ ºhe shoulder belt also should be snugly applied and
positioned between the breasts
V    ( 
{ I ral, air trav l y t alt y a as ar f l
ff ct r a cy
{ Trav l i r rly r ss riz aircraft ff rs s al
risk, a i t a s c f st trical r ical
c licati s, t rica ll f O st tricia s a
Gy c l ists as c cl t at r a t ca
saf ly fly t  ks.
{ It is r c t at r a t s rv t
sa r ca ti s f r air trav l as t ral lati ,
i cl i ri ic v t ft l r xtr iti s,
a lati at l ast rly, a s f s at lts il
s at .
V It is generally accepted that in healthy
pregnant woman, sexual intercourse ussually
is not harmful.
V áhenever abortion or preterm labor
threatens, however, coitus should be avoided
V Intercourse late in pregnacy specifically has
not been found to be harmful
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MEASLES Contraindicated Single dose SC, preferably as Œaccinate susceptible women

MMRa postpartum. ÿreast feeding is
not a contraindication

M M
S Contraindicated Single dose SC, preferably as Œaccinate susceptible women

MMR postpartum

R ÿELLA Contraindicated, but congenital Single dose SC, preferably as ºeratogenicity of vaccine is
rubella syndrome has never MMR theoretical and not confirmed
been described after vaccine to date; vaccinate susceptible
women postpartum

ÀLIÀMYELIºIS ÀRAL= LIŒE Xot routinely recommended
rimary: ºwo doses of Œaccine indicated for
AººEXº
AºED; IXJECºIÀX= for women in the
nited States, enhanced-potency inactivated susceptible women traveling
EXHAXCED-
˼EXCY except women at increased risk virus SC at - week intervals
IXACºIŒAºED ŒIR
S for exposure and rd dose -— months after
—nd doses

ŒARICELLA Contraindicated, but not ºwo doses needed: —nd dose ºeratogenicity of vaccine is
adverse outcomes repoted in given - weeks after st dose theoretical. Œaccination of
pregnancy susceptible women should be
considered postpartum.
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b r s birth- s
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l b li as s as
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##  Indications not altered by In adults, one dose only; Polyvalent polysaccharide
pregnancy. Recommended consider repeat dose in  vaccine
for women with asplenia; years for high-rik women
metabolic, renal, cardiac, or
pulmonary diseases;
immunosuppression; or
smokers


&%&##  Indications not altered by Àne dose, tetravalent Antimicrobial prophylaxis if
pregnancy; vaccination vaccine significant exposure
recommended in unusual
outbreaks
¦è¦#%½ Xot recommended Killed Primary: — injections Killed, injectable vaccine or
IM weeks apart live attentuated oral vaccine.
ÿooster: Àne dose: Àral vaccine preferred.
scheduled
 #'#%½ %   
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& ½%è¦
% Lack of primary series, Primary: ºwo doses IM Combined tetanus-
or no booster within at -— month interval diptheria toxoids
pat  years with rd dose -— preferred: adults
months after the —nd tetanus-diptheria
ÿooster: Single dose IM formulation. Updating
every  years after immune status should
completion of primary be part of antepartum
series care.
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è ÿ Postexposure prophylaxis Depends on exposure Usually given with Hepa ÿ
virus vaccine; exposed
newborn needs immediate
prophylaxis
ÿ%
 Postexposure prophylaxis Half dose at injury site, half Used in conjugation with
dose in deltoid rabies killed- virus vaccine

&  Postexposure prophylaxis Àne dose IM Used in conjugation with
tetanus toxoid

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ëë Should be considered for Àne dose IM within  Indicated also for
exposed pregnant women hours of exposure newborns or women who
to protect against developed varicella within
maternal, not congenital, days before delivery or —
infection days following delivery
V In , the ’DA advised pregnant women to limit caffeine
intake.
V ºhe ’ourth International Caffeine áorkshop concluded
shortly thereafter that there was no evidence that caffeine
caused increased teratogenic or reproductiverisks
V In small laboratory animals, caffeine is not a teratogen, but if
given in massive doses it potentiates mutagenic effects of
radiation and some chemicals.
V ºhe American Dietetic Association (——) recommends that
caffeine intake during pregnancy be limited to less than 
mg daily, or about three, -oz cups of percolated coffee.
V ºhese are common complaints during the
first half of pregnancy.
V Although they tend to be worse in the
morning, thus, erroneously called   
   symptoms usually commence
between the first and second missed
menstrual period and continue until about 
to  weeks.
V Although nausea and vomiting tend to be
worse in the morning, they may continue
throughout the day.
V ’ortunately, the unpleasantness and
discomfort usually can be minimized. Eating
small feedings at more frequent intervals but
stopping short of satiation is of value. ºhe
smell of certain foods often precipitates or
aggravates the symptoms and should be
avoided.
V Low back pain to some extent is reported in nearly
7 percent of pregnant women
V Minor degrees follow excessive strain or fatigue and
excessive bending, lifting, or walking.
V ÿack pain can be reduced by having women squat
rather than bend over when reaching down,
providing back support with a pillow when sitting
down, and avoiding high-heeled shoes.
V ºhese enlarged veins generally result from
congenital predisposition and are exaggerated by
prolonged standing, pregnancy, and advancing age
V ÿecome more prominent as pregnancy advances, as
weight increases, and as the length of time spent
upright is prolonged.
V ºhe treatment of varicosities of the lower
extremities is generally limited to periodic rest with
elevation of the legs, elastic stockings, or both.
V Surgical correction is not advised
V ºheir development or aggravation during pregnancy
undoubtedly is related to increased pressure in the
rectal veins.
V ºhis is caused by obstruction of venous return by
the large uterus as well as by constipation during
pregnancy.
V Pain and swelling usually are relieved by topically
applied anesthetics, warm soaks, and stool-
softening agents.
V Àne of the most common complaints of pregnant women
and is caused by reflux of gastric contents into the lower
esophagus
V Most likely results from the upward displacement and
compression of the stomach by the uterus, combined with
relaxation of the lower esophageal sphincter
V Are relieved by a regimen of more frequent but smaller
meals and avoidance of bending over or lying flat.
V Antacid preparations may provide considerable relief.
V Aluminum hydroxide, magnesium trisilicate, or magnesium
hydroxide alone or in combination are given.
V ºhe cravings of pregnant women for strange foods
are termed pica
V ºhere has been considerable historical interest in
the cravings (pica) of pregnant women for strange
foods and, at times, nonfoods such as ice
(pagophagia), starch (amylophagia), or clay
(geophagia).
V ºhis desire has been considered by some to be
triggered by severe iron deficiency.
V áomen during pregnancy are
occasionally distressed by profuse
salivation.
V ºhe cause of this ptyalism sometimes
appears to be stimulation of the salivary
glands by the ingestion of starch.
V ÿeginning early in pregnancy, many women experience
fatigue and need increased amounts of sleep
V Likely due to soporific effect of progesterone
V ’atigue and nonrestful sleep may be exacerbated by
mornig sickness
V ÿy the late —nd trimester, total nocturnal sleep is
decerased, and women usuually begin to complain of
sleep distrubances
V ÿy the third trimester, nearly all women have altered
sleep
V Daytime naps and mild sedatives at bedtime such as
diphenhydramine are usually helpful
V Pregnant women commonly develop increased
vaginal discharge, which in many instances is not
pathological.
V Increased mucus secretion by cervical glands in
response to hyperestrogenemia is undoubtedly a
contributing factor.
V Àccasionally, troublesome leukorrhea is the result
of an infection caused by trichomonal or yeast
vulvovaginal infections.
V CordLife collects, processes and stores your baby's cord
blood stem cells which may later become potential source
material for lifesaving treatment.
V ºhere is only one chance to collect, which is at birth of your
baby.
V Cord blood has become a major source of stem cells for
transplantation worldwide and is used to treat over 
diseases, including certain cancers and bone marrow failure
syndromes, inborn errors of metabolism, blood disorders
and immunodeficiencies.
V Stem cells are also showing great promise in the treatment
of neural injury, diabetes, heart conditions.