PRENATAL AND

PRECONCEPTIONAL
CARE
PGI TALATTAD, KRENZ HARVEY
 Teratology,
Teratogens, and
Fetotoxic Agents
 TERATOLOGY
● The study of birth defects and their etiology
● Teratogen - any agent that acts during embryonic
or fetal development to produce a permanent
alteration of form or function.
● Hadegen- agent that interferes with normal
maturation and function of an organ.
● Trophogen is an agent that alters growth.
 Criteria for Determining
Teratogenicity
1. The abnormality has been completely characterized.
2. The agent must cross the placenta.
3. Exposure must occur during a critical developmental period.
a. The Preimplantation period is the 2 weeks between fertilization and
implantation and is known as the “all or none” period.
b. The Embryonic period extends from the second through the eighth
week post conception
c. The Fetal period, which is beyond 8 weeks post conception, is
characterized by continued maturation and functional development.
4. A biologically plausible association is supportive.
5. Epidemiological findings must be consistent.
6. The suspected teratogen causes a defect in animal studies.
 Studies in Pregnant Women
● Case Reports and Series (rare defect occurring after a
rare exposure.)
● Case-control Studies (efficient way to study rare
outcomes)
● Cohort Studies (cohorts of pregnant women who are
exposed or unexposed to a particular medication)
● Pregnancy Registries
 Presenting Risk Information
● Counseling should cover not only the embryonic and
fetal risks from drug exposure, but also the risks and/or
genetic implications of the condition or which the
drug is administered.
● Risks associated with not treating the condition also
are described.
● Even the manner in which information is presented
affects perception.
 COUNSELING FOR
MEDICATION EXPOSURE
Labeling Requirements
CATEGORY CHARACTERISTICS
Controlled human
A studies shows no risk

Animal studies OK no
B human data

Animal studies not OK

C no human data

Evidence for risk +++

D Benefits outweigh risk

Evidence for risk +++

X Risk outweigh benefits
TERATOGENIC AND FETOTOXIC
AGENTS
ALCOHOL
 Alcohol-Related Birth Defects
● Cardiac: atrial or ventricular septal defect, aberrant great vessels, conotruncal heart defects
● Skeletal: radioulnar synostosis, vertebral segmentation defects, joint contractures, scoliosis
● Renal: aplastic or hypoplastic kidneys, dysplastic kidneys, horseshoe kidney, ureteral duplication
● Eyes: strabismus, ptosis, retinal vascular abnormalities, optic nerve hypoplasia
● Ears: conductive or neurosensory hearing loss
Antiepileptic Medications
 Angiotensin Converting Enzyme
Inhibitors and Receptor Blocking Drugs
● Normal renal development depends on the fetal
renin-angiotensin system.
● ACE-inhibitor medication may cause fetal hypotension
and renal hypoperfusion, with subsequent ischemia and
anuria
● Reduced perfusion can result in fetal-growth restriction
and calvarium maldevelopment, and oligohydramnios
may lead to pulmonary hypoplasia and limb contractures
 Antifungal Medications
● Fluconazole = autosomal recessive
Antley-Bixler syndrome.
● Abnormalities include oral clets, abnormal
facies, and cardiac, skull, long-bone, and
joint abnormalities.
● Risk or tetralogy of Fallot following
exposure to low-dose fluconazole
 Anti Inflammatory Agents
Nonsteroidal Antiinflammatory Drugs
● They exert their effects by inhibiting prostaglandin synthesis.
● Indomethacin
○ may cause constriction of the fetal ductus arteriosus and subsequent
pulmonary hypertension
● Ibuprofen and aspirin
○ not a major risk factor for birth defects
● Aspirin,
○ a low dosage o 100 mg daily or less does not confer a greater risk
● Leflunomide
○ results in hydrocephalus, eye anomalies, skeletal anomalies, and
embryo death
 Antimicrobial and Antiviral
Drugs
Nitrofurantoin
● first-trimester = twofold risk of cleft lip
● contraindicated in glucose-6-phosphate dehydrogenase (G6PD) deficiency = risk for
hemolytic anemia and other hematologic abnormalities.
Sulfonamides
● contraindicated in pregnant women with known or suspected G6PD deficiency because of
risk or hemolytic anemia and other hematologic abnormalities.
Tetracyclines
● yellowish-brown discoloration of the deciduous teeth when used at 25 weeks’ gestation.
Ribavirin
● malformations include skull, palate, eye, skeleton, and gastrointestinal abnormalities
● Treated women must use two forms of contraception and have monthly pregnancy tests
while on therapy and or 6 months following drug discontinuation
 Antineoplastic Agents
Cyclophosphamide
● Pregnancy loss rates are greater, and reported
fetal,
● abnormalities include skeletal anomalies, limb
defects, cleft palate and eye abnormalities
Methotrexate
● potent teratogen
● Associated craniofacial abnormalities include
craniosynostosis with a “clover-leaf” skull, wide
nasal bridge, low-set ears, and micrognathia
● Exposure has also been linked to central nervous
system abnormalities, cardiac defects, and limb
anomalies
 Antineoplastic Agents
Tamoxifen
● Tamoxifen has been associated with malformations similar to those
caused by diethylstilbestrol (DES) exposure in rodents, including vaginal
adenosis
Trastuzumab
● not been associated with fetal malformations
Endothelin Receptor Antagonists
● Bosentan, ambrisentan, and macitentan are three endothelin-receptor
antagonists used to treat pulmonary arterial hypertension
● endothelin-receptor signaling pathway is important or neural-crest
development.
 Immunosuppressant
Medications
Corticosteroids
● Corticosteroids have been
associated with orofacial clefts in
animal studies, but the absolute
risk is small.
Mycophenolate Mofetil
● Mycophenolate embryopathy.
This includes microtia, auditory
canal atresia, clets, coloboma and
other eye anomalies, short fingers
with hypoplastic nails, and cardiac
defects
 Lead

● Lead crosses the placenta via passive diffusion.

● Prenatal lead exposure is associated with fetal-growth
impairment and with childhood neurodevelopmental delays.
 Mercury

● congenital Minamata disease—severe neurological

abnormalities rom methylmercury exposure in utero
● It crosses the placenta and can accumulate in the fetus.
 Psychiatric Medications
Antipsychotic Medications
● No antipsychotic medications are
considered teratogenic.
Lithium
● is medication has been associated
with Ebstein anomaly, a rare cardiac
abnormality
 Psychiatric Medications
Selective Serotonin- and Norepinephrine-reuptake Inhibitors
● Paroxetine, which has been associated with a slightly higher risk or cardiac
anomalies, particularly atrial and ventricular septal defects.
● Approximately 25 percent of neonates exposed to SSRIs in late pregnancy
manifest one or more nonspecific findings considered to represent poor
neonatal adaptation
● neonatal behavioral syndrome, findings can include jitteriness, irritability,
hyper- or hypotonia, feeding abnormalities, vomiting, hypoglycemia,
thermoregulatory instability, and respiratory abnormalities
 Retinoids

● inhibiting neural-crest cell

migration during embryogenesis,
they create a pattern of cranial
neural-crest defects—termed
retinoic acid embryopathy—that
involve the CNS, face, heart, and
thymus
 Thalidomide and Analogues

● The characteristic malformation is phocomelia—an

absence or underdevelopment of one or more long
bones.
● Cardiac defects, gastrointestinal abnormalities, external
ear and eye malformations, and other limb-reduction
defects also are common following thalidomide
exposure.
 Thyroid Medications
Methimazole
● 2-fold increased risk for aplasia cutis congenita, as well as choanal atresia
and esophageal atresia
● Aplasia cutis is a rare abnormality characterized by a full-thickness skin
defect, usually the scalp,

Radioiodine
● readily crosses the placenta and is concentrated in the fetal thyroid gland
by 12 weeks’ gestation.
● It may cause severe or irreversible fetal and neonatal hypothyroidism,
which can lead to decreased mental capacity and delayed skeletal
maturation.
 Warfarin
● Warfarin
embryopathy is
characterized by
stippled epiphyses
and nasal
hypoplasia
●
 Tobacco

● Cigarette smoke contains a complex mixture of nicotine,

cotinine, cyanide, thiocyanate, carbon monoxide, cadmium,
lead, and various hydrocarbons
● 1.5-fold risk For orofacial clefts
● The most prevalent obstetrical complication rom smoking is a
dose-dependent reduction in fetal growth.
Herbal Medicinal Products
 Drugs of Abuse
Cocaine
● most adverse outcomes result from its vasoconstrictive and hypertensive effects.
● Serious potential maternal complications are cerebrovascular hemorrhage, myocardial damage, and
placental abruption.
Marijuana
● Cannabinoids are not considered to be major teratogens, but they cross the placenta, and endogenous
cannabinoids play key roles in brain development.
Methamphetamine
● Methamphetamine is not considered teratogenic.
● Use in pregnancy is consistently associated with small-or-gestational age newborns, and children are at
risk or developmental delays and behavioral abnormalities.
Opioids - greater risk for spina bida, gastroschisis, and cardiac abnormalities with periconceptional opioid
exposure
Phencyclidine (PCP) - newborns, experience withdrawal symptoms characterized by tremors, jitteriness, and
irritability
Preconceptional
Counseling
 OBJECTIVES
1. Improve knowledge, attitudes, and behaviors of men and women
related to preconceptional health
2. Assure that all childbearing-aged women receive preconception care
services
3. Implement interconceptional interventions to prevent or minimize
recurrent adverse outcomes
4. Reduce the racial and socioeconomic disparities in adverse pregnancy
outcomes
 COUNSELING SESSION
● provide preventive counseling during periodic health maintenance
examinations.

The Fourth Trimester

● Designed to optimize postpartum care and provide contraceptive counseling,
it also sets the stage or any subsequent pregnancy and or the woman’s
long-term health.
MEDICAL
HISTORY
DIABETES MELLITUS
 DIABETES MELLITUS
● If a patient maintains glucose levels close to normal,
many of these complications can be avoided before
conception.
● Frequent use of teratogenic angiotensin-converting
enzyme inhibitors in this population.
● Preconceptional hemoglobin A1c level goal below 7
percent.
 EPILEPSY
● epilepsy conferred an elevated a priori risk for congenital malformations
● Polytherapy is associated with a higher malformation risk
● The American Academy of Neurology recommends consideration of anti
seizure medication discontinuation before pregnancy in suitable candidates
(Jeha, 2005). These include women who satisfy the following criteria:
1. have been seizure free or 2 to 5 years,
2. display a single seizure type,
3. have a normal neurological examination and normal intelligence, and
4. show electroencephalogram results that have normalized with
treatment.
● Women with seizures should be advised to take a daily 4-mg oral folic acid
supplement.
 Immunizations
● Vaccines that contain toxoids such as tetanus are suitable before or during
gestation.
● Killed bacteria or viruses—such as influenza, pneumococcus, hepatitis B,
meningococcus, and rabies vaccines—are not associated with adverse fetal
outcomes and are not contraindicated preconceptionally or during pregnancy.
● Conversely, live-virus vaccines are not recommended during pregnancy.
○ varicella-zoster,
○ measles,
○ mumps,
○ rubella,
○ polio,
○ chickenpox, and
○ yellow fever
GENETIC
DISEASES
 Family History

● Pedigree construction using the symbols

shown in Figure 9-2 is the most thorough
method or obtaining a family history as a
part of genetic screening.
 Neural Tube Defects
● The incidence of neural-tube defects (NTDs) is 0.9 per 1000 live
births
● 677C → T substitution in the gene that encodes
methylenetetrahydrofolate reductase.
● preconceptional folic acid therapy reduced the risk or a recurrent
NTD by 72 percent
● All women who may become pregnant are recommended to take
daily 400 to 800 μg of folic acid orally before conception and
through the first trimester
 Phenylketonuria
● The inherited defect in
phenylalanine metabolism
exemplifies diseases in which
the fetus may not be at risk to
inherit the disorder but may be
damaged by maternal disease.

● The target phenylalanine blood

concentration is 120 to 360
µmol/L
 Thalassemias
● most common single-gene
disorders worldwide
 Individuals of Eastern
European Jewish Descent
● Autosomal recessive disorders
○ Tay-Sachs disease
○ Gaucher disease,
○ cystic fibrosis,
○ Canavan disease,
○ familial dysautonomia,
○ mucolipidosis IV,
○ Niemann-Pick disease type A,
○ Fanconi anemia group C, and
○ Bloom syndrome
 REPRODUCTIVE HISTORY
● During preconceptional screening, information is sought regarding
infertility; abnormal pregnancy outcomes that may include
○ miscarriage,
○ ectopic pregnancy,
○ molar pregnancy, and
○ recurrent pregnancy loss; and
● obstetrical complications such as
○ cesarean delivery,
○ preeclampsia,
○ placental abruption, and
○ preterm delivery
 Maternal Age
Adolescents
● are at higher risk or anemia, preterm delivery, and preeclampsia
compared with women aged 20 to 35 years
● sexually transmitted diseases - higher during pregnancy
● rarely seek preconceptional counseling
After age 35
● more likely to request preconceptional counseling
● maternal mortality rate is higher in women aged 35 and older
● constituted 31 percent of maternal deaths
 Maternal Age
Maternal age-related risks primarily originate from
1. indicated preterm
2. delivery or maternal complications such as hypertension and
diabetes,
3. spontaneous preterm birth,
4. fetal-growth disorders related to chronic maternal disease or
multifetal gestation,
5. fetal aneuploidy, and
6. pregnancies resulting from assisted reproductive technology.
 Paternal Age

Advanced paternal age

● It is associated with a higher risk of preterm birth and new
autosomal-dominant mutations
● possible link between increasing paternal age and complex
neuropsychiatric conditions
 SOCIAL HISTORY
● Recreational Drugs and Smoking
● Environmental Exposures
● Diet
1. Pica is the craving or and consuming o ice, laundry starch, clay, dirt, or other non
food items.
2. Many vegetarian diets are protein deficient but can be corrected by increasing egg
and cheese consumption
3. Anorexia and bulimia raise maternal risks of nutritional deficiencies, electrolyte
disturbances, cardiac arrhythmias, and gastrointestinal pathology
● Exercise
● Intimate Partner Violence
● Lesbian, Gay, Bisexual, Transgender, and Queer Individuals
❖ higher incidences of obesity, tobacco and alcohol use, depression, diabetes, and low
parity compared with heterosexual women
Prenatal Care
 DIAGNOSIS OF PREGNANCY
● Women receive confirmatory testing of urine
or blood or human chorionic gonadotropin
(hCG)
● Sonography is often used, especially if
miscarriage or ectopic pregnancy is a concern.
Symptoms and Signs
● Amenorrhea in a healthy reproductive-aged
woman
● FETAL MOVEMENT (quickening)
○ Multigravid: 16-18 weeks
○ Nulligravid: 20 weeks
Pregnancy Tests
● hCG in maternal blood and urine
 DIAGNOSIS
OF
PREGNANCY
 False Positive PT

1. Exogenous hCG injection used for weight loss,

2. Renal failure with impaired hCG clearance,
3. Physiological pituitary hCG, and
4. hCG-producing tumors that most commonly originate rom
gastrointestinal sites, ovary, bladder, or lung
 Sonographic Recognition of
Pregnancy
Gestational Sac
● first sonographic evidence of pregnancy
● transvaginal sonography by 4 to 5 weeks of gestation
● implants eccentrically in the endometrium
Intradecidual Sign
● anechoic center surrounded by a single echogenic rim
Double Decidual Sign
● two concentric echogenic rings surrounding the gestational sac
Yolk Sac
● brightly echogenic ring with an anechoic center—is seen within the gestational
sac
● intrauterine location or the pregnancy is confirmed.
 INITIAL PRENATAL
EVALUATION
Major goals

1. Define the health status of the mother and fetus,

2. Estimate the gestational age, and

3. Initiate a plan or continued obstetrical care.

Definitions
Prenatal Record
 Normal Pregnancy Duration
● 280 days or 40 weeks
Naegele rule
● add 7 days to the first day of the last period and subtract 3 months
● For example, i the rst day of the last menses was October 5, the due date is
10-05 minus 3 (months) plus 7 (days)=7–12 or July 12 of the following year.
Trimesters
● first trimester- 1-14 weeks
○ spontaneous abortions take place
● the second- 15-28 weeks, and
● the third- 29-42 weeks.
○ women with hypertensive disorders due to pregnancy are diagnosed
● The fourth is the 12 weeks after delivery.
 Term Pregnancy Categories
(ACOG/SMFM: 'Term Pregnancy" is further classified into the following
categories)
● Early term: 37 weeks to 38 weeks and 6 days
● Full term: 39 weeks to 40 weeks and 6 days
● Late term: 41 weeks to 41 weeks and 6 days
● Postterm: ~42 weeks
Previous and Current Health
Status
 Psychosocial Screening

● at least once per trimester

● screened women were less likely to have preterm or
low-birth weight newborns, as well as other adverse
outcomes
 Cigarette Smoking
● Smoking is associated with subfertility.
Higher rates of
● miscarriage, stillbirth, low birthweight, and preterm delivery also are
linked to smoking during pregnancy
● Compared with nonsmokers, risks of placenta previa, placental
abruption, and premature membrane rupture are increased twofold.
 Intimate-Partner Violence
pattern of assault and coercive behavior that may include
1. physical injury,
2. psychological abuse,
3. sexual assault,
4. progressive isolation,
5. stalking,
6. deprivation,
7. intimidation, and
8. reproductive coercion.
● most abused women continue to be victimized during pregnancy
● IPV is associated with an increased risk of several adverse perinatal outcomes that
include preterm delivery, fetal-growth restriction, and perinatal death
● IPV screening -done at the first prenatal visit, again at least once per trimester, and again
at the postpartum visit.
 Gestational Age Assessment

● Menstrual history is best confirmed by first-trimester

sonography
Uterine size
● small orange - 6-week gestation;
● a large orange - 8-week pregnancy
● Grapefruit- 12 weeks
FUNDAL HEIGHT ASSESSMENT
 Clinical Evaluation
Pelvic Examination
● Bluish-red passive hyperemia of the cervix is characteristic- chadwick sign
● Dilated, occluded cervical glands bulging beneath the ectocervical mucosa -
nabothian cysts
● Pap test for cytological examination
● Specimen obtained for Chlamydia trachomatis and Neisseria gonorrhoeae
Bimanual examination
● completed by palpation
● Special attention is given to the consistency, length, and dilation of the cervix; to
uterine and adnexal size; to the bony pelvic architecture; and to any vaginal or
perineal anomalies.
Laboratory
Tests
 Cervical Infections
C. trachomatis
● all women be screened for chlamydia during the first prenatal visit, with
additional third-trimester testing or those at increased risk

● Risk factors include unmarried status, recent change in sexual partner or

multiple concurrent partners, age younger than 25 years, inner-city residence,
history or presence of other sexually transmitted diseases, and little or no
prenatal care.

N. gonorrhoeae

● causes cervicitis or urethritis in pregnancy

● Risk factors or gonorrhea are similar to those or chlamydial infection

Pregnancy Risk Assessment
SUBSEQUENT
PRENATAL
VISITS
1-28 weeks AOG
4-week intervals

28 -36 weeks AOG

2-weeks intervals

36 weeks - delivery
1-week interval
 Prenatal Surveillance
Fundal Height
● 20 and 34 weeks’ gestation, the height of the uterine fundus measured in
centimeters correlates closely with gestational age in weeks
● monitor fetal growth and amniotic uid volume
Fetal Heart Sounds
● Doppler - heart sounds are almost always detectable by 10 weeks
● 110 to 160 beats per minute and is typically heard as a double sound
● fetal heart is audible by 20 weeks in 80 percent of women
● 22 weeks, heart sounds are expected to be heard in all
Sonography
● At least one
● ALARA
 Subsequent Laboratory Tests
Group B Streptococcal Infection
● all women between 35 and 37 weeks’ gestation
● Women with GBS bacteriuria, preterm labor, or a previous infant with invasive
disease are given empirical intrapartum prophylaxis.
Gestational Diabetes
● All pregnant women are screened for gestational diabetes mellitus
● laboratory testing between 24 and 28 weeks of gestation is the most sensitive
approach
Genetic Screening
● Serum screening for fetal aneuploidy is routinely offered to all pregnant
women—in the rst trimester at 10 to 14 weeks, in the second trimester at 15 to
20 weeks, or as cell-free DNA screening at any point after 10 weeks
Laboratory
Tests
NUTRITIONAL COUNSELING
Weight Retention After
Pregnancy
 Dietary Reference
Intakes—Recommended Allowances
 Calories
● Pregnancy requires an additional 80,000 kcal, mostly during
the last 20 weeks.
● Caloric increase of 100 to 300 kcal/d is recommended
The Institute of Medicine (2006) recommends adding to the
estimated nonpregnant energy requirements:
● 0 kcal/d - first trimester
● 340 kcal/d - second trimester
● 452 kcal/d - third trimester
 Protein
● For growth and remodeling of the fetus, placenta, uterus,
and breasts, and or the expanded maternal blood volume.
● Preferably, most protein is supplied from animal sources,
such as meat, milk, eggs, cheese, poultry, and fish.
● Most amino-acid levels in maternal plasma fall markedly
● glutamic acid and alanine, the concentrations of which rise.
 Minerals
Iron
● 300 mg of iron transferred to the fetus
● 500 mg incorporated into the expanding maternal hemoglobin
mass
Iodine
● 220 µg/d
● Severe maternal iodine deficiency predisposes ospring to
endemic cretinism, which is characterized by multiple severe
neurological defects
Calcium
Zinc
● deficiency if severe may lead to poor appetite, suboptimal
growth, and impaired wound healing
● zinc-deficient women in poor-resource countries
VITAMIN
VITAMIN
 Vitamins
● Folic acid lower neural-tube defect risks
● Vitamin A Deficiency is associated with night blindness
and with an increased risk of maternal anemia and
spontaneous preterm birth
● Vitamin B12 deficiency is associated with neural-tube
defects
● Vitamin B6, supplementation not needed. + Doxylamine
helpful in many cases of nausea and vomiting of
pregnancy
● Vitamin C
● Vitamin D boosts the efficiency of intestinal calcium
absorption and promotes bone mineralization and growth.
Maternal deficiency can cause disordered skeletal
homeostasis, congenital rickets, and fractures in the
newborn
 Pragmatic Nutritional
Surveillance
1. Advise the pregnant woman to eat food types she wants in reasonable amounts and
salted to taste.

2. Ensure that food is amply available or socioeconomically deprived women.

3. Monitor weight gain and align goals with the Institute of Medicine recommendations.

4. Explore food intake by dietary recall periodically to discover the occasional nutritionally
errant diet.

5. Give tablets of simple iron salts that provide at least 30 mg of elemental iron daily. Give
folate supplementation before and in the early weeks of pregnancy. Provide iodine
supplementation in areas of known dietary insufficiency.

6. Recheck the hematocrit or hemoglobin concentration at 28 to 32 weeks’ gestation to

detect significant anemia
IMMUNIZATION
Immunization
 Thanks!
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