1 57

C H A PT E R 9

P re n ata l Ca re

DIAGNOSIS OF PREGNANCY. . . . . . . . . . . . . . . . . . . . . . 1 58 Figure 9- 1 , 6 to 7 percent of women in this country have late

or no prenatal care. In 20 1 4, the percentages of non-Hispanic
I N ITIAL PRENATAL EVALUATION . . . . . . . . . . . . . . . . . . 1 59 white, Hispanic, and African-American women who received
SUBSEQUENT PRENATAL VISITS . . . . . . . . . . . . . . . . . . . 1 64 inadequate or no prenatal care were 4.3, 7 . 5 , and 9.7, respec­
tively (Child Trends, 20 1 5) .
N UTRITIONAL COUNSELING . . . . . . . . . . . . . . . . . . . . . . 1 65 he Centers for Disease Control and Prevention (CDC)
(2000) analyzed birth certificate data and found that half of
COMMON CONCERNS . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 70 women with delayed or no prenatal care wanted to begin care
earlier. Barriers to care varied by social and ethnic group, age,
and payment method. he most common reason cited was late
recognition of pregnancy by the patient. The second most com­
monly cited obstacle was lack of money or insurance. he third
was inability to obtain an appointment.
The borderline between health and disease is less distincty
marked during gestation, and therore, it accordingy • Prenatal Care Efectiveness
becomes necessary to keep pregnant patients under strict
Care designed during the early 1 900s focused on lowering the
supervision, and to be constanty on the alertor the appear­
extremely high maternal mortality rate. Prenatal care undoubt­
ance of untoward symptoms.
edly contributed to the dramatic decline in this mortality rate
-J. Whitridge Williams ( 1 903)
from 690 deaths per 1 00,000 births in 1 920 to 50 per 1 00 ,000

s emphasized above by Williams, prenatal care is important.

According to the merican Academy of Pediatrics and the Amer­ 8
ican College of Obstetricians and Gynecologists (20 1 7) a com­
prehensive antepartum program is deined as: "a coordinated
approach to medical care, continuous risk assessment, and
psychological support that optimally begins before conception
and extends throughout the postpartum period and intercon­
ceptional period. "
2 • Births in all states
• Births in states using the 1 989 birth certificate/revision
PRENATAL CARE IN THE U N ITED STATES Births in states using the 2003 birth certificate/revision
o ---�
•

Almost a century after its introduction, prenatal care has 1 990 1 993 1 996 1 999 2002 2005 2008 20 1 1 20 1 4
become one of the most frequently used health services in Year
the United States. In 200 1 , there were approximately 50 mil­ FIGURE 9-1 Percentage of birt h s to mothers who received late
lion prenatal visits. The median was 1 2. 3 visits per pregnancy, or no prenata l ca re-U n ited States, 1 990-20 1 4. (Data from Ch i ld
and many women had 1 7 or more visits. Still, as seen from Trends, 20 1 5.)
1 58 P reconceptional a n d P renatal Ca re

by 1 9 5 5 (Loudon, 1 992) . And, the low current maternal mor­ • Symptoms and Signs
tality rate of 10 to 1 5 per 1 00,000 is likely associated with Amenorrhea in a healthy reproductive-aged woman who previ­
the high utilization of this care (Xu, 20 1 0) . Indeed, data from ously has experienced spontaneous, cyclical, predictable men­
1 998 to 2005 from the Pregnancy \10rtality Surveillance Sys­
ses is highly suggestive of pregnancy. Menstrual cycles vary
tem identified a ivefold increased risk for maternal death in appreciably in length among women and even in the same
women who received no prenatal care (Berg, 20 1 0) . woman (Chap. 5, p. 8 1 ) . hus, amenorrhea is not a reliable
Other reports also attest t o prenatal care eicacy. I n a study pregnancy indicator until 1 0 days or more after expected
of almost 29 million births, the risk for preterm birth, still­ menses have passed. Occasionally, uterine bleeding that mim­
birth, early and late neonatal death, and infant death rose lin­ ics menstruation is noted after conception. During the irst
early with decreasing prenatal care (Partridge, 20 1 2) . Similarly, month of pregnancy, these episodes are likely the consequence
Leveno and associates (2009) found that a significant decline of blastocyst implantation. Still, irst-trimester bleeding should
in preterm births at Parkland Hospital correlated closely with generally prompt evaluation for an abnormal pregnancy.
increased use of prenatal care by medically indigent women. Of other symptoms, maternal perception of fetal move­
Moreover, National Center for Health Statistics data showed ment depends on factors such as parity and habitus. In gen­
that women with prenatal care had an overall stillbirth rate of eral, after a irst successful pregnancy, a woman may irst
2 . 7 per 1 000 compared with 1 4. 1 per 1 000 for women without
perceive fetal movements between 1 6 and 1 8 weeks' gestation.
this care (Vintzileos, 2002) . A primigravida may not appreciate fetal movements until
Evaluating the format of care, Ickovics and coworkers (20 1 6) approximately 2 weeks later. At about 20 weeks, depending
compared individual prenatal care and group prenatal care. he on maternal habitus, an examiner can begin to detect fetal
latter provided traditional pregnancy surveillance in a group set­ movements.
ting with special focus on support, education, and active health­ Of pregnancy signs, changes in the lower reproductive tract,
care participation. Women enrolled in group prenatal care had uterus, and breasts develop early. These are described in detail
significantly better pregnancy outcomes. Carter and colleagues in Chapter 4 (p. 49) .
(20 1 6) cited similar results. Childbirth education classes are also

• Pregnancy Tests
reported to result in better pregnancy outcomes (Afshar, 20 1 7) .
Adolescent pregnancies carry special risk, and guidelines have
been developed that focus on this subgroup (Fleming, 20 1 5) . Detection of hCG in maternal blood and urine is the basis for
Few data are available t o recommend the practice o f ofering endocrine assays of pregnancy. Syncytiotrophoblast produces
tangible incentives to improve prenatal care attendance (Till, hCG in amounts that increase exponentially during the irst
20 1 5) . trimester following implantation. A main function of hCG is
to prevent involution of the corpus luteum, which is the prin­
DIAGNOSIS OF PREGNANCY cipal site of progesterone formation during the irst 6 weeks of
pregnancy.
Pregnancy is usually identifi e d when a woman presents with With a sensitive test, the hormone can be detected in mater­
symptoms and possibly a positive home urine pregnancy test nal serum or urine by 8 to 9 days after ovulation. he doubling
result. Typically, these women receive conirmatory testing time of serum hCG concentration is 1 .4 to 2.0 days. As shown
of urine or blood for human chorionic gonadotropin (hCG ) . in Figure 9-2, serum levels range widely and increase from the
Further, presumptive signs or diagnostic indings of pregnancy day of implantation. They reach peak levels at 60 to 70 days.
may be found during examination. Sonography is often used, Thereafter, the concentration declines slowly until a plateau is
particularly if miscarriage or ectopic pregnancy is a concern. reached at approximately 16 weeks' gestation.

Measurement of hCG
his hormone is a glycoprotein
1 00,000
with high carbohydrate content.
50,000 he general structure of hCG is a

'
heterodimer composed of two dis­
E 1 0 ,000
5
similar subunits, designated a and

.
�, which are non covalently linked.
The a-subunit is identical to those
"
)
5000 of luteinizing hormone (LH), fol­
c licle-stimulating hormone (FSH),
and thyroid-stimulating hormone
(TSH), but the �-subunit is struc­
turally distinct among these. hus,
o 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 20 21 22 23 24 25 26 27 antibodies were developed with high
Weeks' gestation speciicity for the hCG �-subunit.
FIGURE 9-2 Mean concentration (95% CI) of h u m a n chorionic g o nadotro p i n (hCG) in serum of This speciicity allows its detec­
women throug hout norm a l preg n a n cy. tion, and numerous commercial
 Prenata l C a re 1 59

immunoassays are available for measuring serum and urine hCG

levels. Although each immunoassay detects a slightly diferent
mixture of hCG variants, its free subunits, or its metabolites,
all are appropriate for pregnancy testing (Braunstein, 20 1 4) .
Depending o n the assay used, the sensitivity for the laboratory
detection limit of hCG in serum is 1 .0 mIU/mL or even lower
(Wilcox, 200 1 ) .
False-positive hCG test results are rare (Braunstein, 2002) .
A few women have circulating serum factors that may bind
erroneously with the test antibody directed to hCG in a given
assay. The most common factors are heterophilic antibodies.
hese are produced by an individual and bind to the animal­
derived test antibodies used in a given immunoassay. Thus,
women who have worked closely with animals are more likely
to develop these antibodies, and alternative laboratory tech­
niques are available (American College of Obstetricians and
Gynecologists, 20 1 7a) . Elevated hCG levels may also reflect FIGURE 9-3 Tra n svag i n a l sonog ra m of a fi rst-tri mester i ntra u ter­
molar pregnancy and its associated cancers (Chap. 20, p. 39 1 ) . ine p reg n a ncy. The dou ble deci d u a l sign is noted su rrou n d i n g the
Other rare causes of positive assays without pregnancy are: ( 1 ) gestationa l sac a nd is defined by the decid u a parieta l i s (white aster­
exogenous hCG injection used for weight loss, (2) renal fail­ isk) a nd the decidua ca p s u l a ris (yellow asterisk). The a rrow notes the
yol k sac, a n d the crown-r u m p length of the embryo is ma rked with
ure with impaired hCG clearance, (3) physiological pituitary
mea s u r i n g ca l i pers. (Used with permission from Dr. Elysia Moschos.)
hCG, and (4) hCG-producing tumors that most commonly
originate from gastrointestinal sites, ovary, bladder, or lung
(Montagnana, 20 1 1 ) . gestational sac implants eccentrically in the endometrium,
whereas a pseudosac is seen in the midline of the endometrial
H o m e Preg na ncy Tests
cavity. Other potential indicators of early intrauterine preg­
Over-the-counter pregnancy test kits have been available since nancy are an anechoic center surrounded by a single echogenic
the early 1 970s, and millions are sold annually in the United rim-the intradecidual sign-or two concentric echogenic rings
States. More than 60 such tests are available in this country surrounding the gestational sac-the double decidual sin shown
(Grenache, 20 1 5) . Unfortunately, many of these are not as in Figure 9-3 . If sonography yields equivocal indings, the term
accurate as advertised Gohnson, 20 1 5) . For example, Cole and pregnancy of unknown location (PUL) is applied. In these cases,
associates (20 1 1 ) found that a detection limit of 1 2. 5 mIU/mL serial serum hCG levels and transvaginal sonograms can help
would be required to diagnose 9 5 percent of pregnancies at diferentiate a normal intrauterine pregnancy from an extra­
the time of missed menses, but they reported that only one uterine pregnancy or an early miscarriage (Chap. 1 9, p. 373) .
brand had this degree of sensitivity. Two other brands gave If the yolk sac-a brightly echogenic ring with an anechoic
false-positive or invalid results. In fact, with an hCG concentra­ center-is seen within the gestational sac, an intrauterine loca­
tion of 1 00 mIU/mL, clearly positive results were displayed by tion for the pregnancy is confi r med. The yolk sac can normally
only 44 percent of brands. Accordingly, only about 1 5 percent be seen by the middle of the ifth week. As shown in Figure 9-3,
of pregnancies could be diagnosed at the time of the missed after 6 weeks, an embryo is seen as a linear structure imme­
menses. Some manufacturers of even newer home urine assays diately adjacent to the yolk sac. Cardiac motion is typically
claim > 99-percent accuracy of tests done on the day of-and noted at this point. Up to 1 2 weeks' gestation, the crown-rump
some up to 4 days before-the expected day of menses. Again, length is predictive of gestational age within 4 days (Chap. 1 0,
careful analysis suggests that these assays are often not as sensi­ p. 1 83).
tive as advertised Gohnson, 20 1 5) .

• Sonographic Recognition of Pregnancy

IN ITIAL PRENATAL EVALUATION

Prenatal care is ideally initiated early. Major goals are to:

Transvaginal sonography has revolutionized early pregnancy
( 1 ) deine the health status of the mother and fetus, (2) estimate
imaging and is commonly used to accurately establish gesta­
the gestational age, and (3) initiate a plan for continued o bstet­
tional age and conirm pregnancy location. A gestational sac-a
rical care. Typical components of the initial visit are summa­
small anechoic luid collection within the endometrial cavity­
rized in Table 9- 1 . Subsequent care may range from relatively
is the irst sonographic evidence of pregnancy. It may be seen
infrequent routine visits to prompt hospitalization because of
with transvaginal sonography by 4 to 5 weeks' gestation. A luid
serious maternal or fetal disease.
collection, however, can also be seen within the endometrial

• Prenatal Record
cavity with an ectopic pregnancy and is termed a pseudogesta­
tional sac or pseudosac (Fig. 1 9-4, p. 375) . Thus, further evalu­
ation may be warranted if this is the only sonographic inding, Use of a standardized record within a perinatal health-care
particularly in a woman with pain or bleeding. A normal system greatly aids antepartum and intrapartum management.
1 60 P reconceptiona l a n d Prenata l Ca re

TABLE 9-1 . Typical Components of Routi n e P re nata l Care

Weeks
Text Referral Fi rst Visit 1 5-20 24-28 29-41
History
Complete Chap. 9, p. 1 6 1 •

U pdated • • •

Physica l exa m i nation

Com plete C h a p. 9, p. 1 63 •

B l ood pressu re Chap. 40, p. 7 1 1 • • • •

Maternal weig ht Cha p. 9, p. 1 65 • • • •

Pelvic/cervica l exa m i nation C h a p. 9, p. 1 63 •

F u n d a l h e i g ht Chap. 9, p. 1 64 • • • •

Feta l heart rate/feta l position Chap. 9, p. 1 65 • • • •

Laboratory tests
Hematocrit or h e m og l o b i n Chap. 56, p. 1 075 • •

B lood type a nd Rh factor Chap. 1 5, p. 30 1 •

A nti body screen C h a p. 1 5 , p. 30 1 • A

Pap s m e a r scree n i ng Chap. 63, p. 1 1 93 •

G l ucose to l e ra nce test Cha p. 5 7, p. 1 1 08 •

Feta l a n e u pl oidy scree n i n g Chap. 1 4, p. 2 7 8 B a a n d/o r 8

N e u ra l -t u be d efect scree n i ng C h a p. 1 4, p. 283 8
Cystic fi b rosis scree n i ng Chap. 1 4, p. 289 8 0r 8
U ri n e p rote i n assess ment C h a p. 4, p. 66 •

U ri n e cultu re Chap. 53, p. 1 026 •

R u bel l a serology Chap. 64, p. 1 2 1 5 •

0 0
Syph i l i s sero l ogy Chap. 65, p. 1 237 • C
Gonococca l scree n i ng Chap. 65, p. 1 23 9

0
C h l a myd i a l scree n i n g Chap. 6 5 , p . 1 240 • C

0
H epatiti s B serology Chap. 55, p. 1 064 •

H IV sero l ogy Chap. 65, p. 1 247 8

G ro u p B streptococcus c u l t u re Chap. 64, p. 1 220 E
Tuberc u l o s i s scree n i n g C h a p. 5 1 , p. 996

a F i rst-t ri m ester a n e u p l o i dy scree n i ng may be ofe red betwee n 1 1 a n d 1 4 wee ks.

A Performed at 28 weeks, if i n d i cated.
8 Test shou l d be ofered.

o H i g h- r i s k w o m e n s h o u l d be screened at t h e fi rst p re n ata l visit a n d aga i n i n t h e th i rd

C H i g h-risk wom e n s h o u l d be retested at the beg i n n i ng of t h e th i rd tri mester.

tri mester.
E Rectova g i n a l c u lt u re s h o u l d b e o bta i n ed between 35 a n d 3 7 weeks.
HIV h u ma n i m m u n od eficiency virus.
=

Standardizing documentation allows communication and care 2. Gravida-a woman who currently is pregnant or has been
continuity between providers and enables objective measures in the past, irrespective of the pregnancy outcome. With the
of care quality to be evaluated over time and across diferent establishment of the first pregnancy, she becomes a primi­
clinical settings (Gregory, 2006) . A prototype is provided by gravida, and with successive pregnancies, a multigravida.
the American Academy of Pediatrics and the American College 3. Nullpara-a woman who has never completed a pregnancy
of Obstetricians and Gynecologists (20 1 7) in their Guidelines beyond 20 weeks' gestation. She may not have been preg­
or Perinatal Care, 8th edition. nant or may have had a spontaneous or elective abortion(s)
or an ectopic pregnancy.
Defi n itions
4. Primipara-a woman who has been delivered only once of a
Several deinitions are pertinent to establishment of an accurate fetus or fetuses born alive or dead with an estimated length
prenatal record. of gestation of 20 or more weeks. In the past, a 500-g birth­
1 . Nulligravida-a woman who currently is not pregnant and weight threshold was used to define parity. his threshold is
has never been pregnant. now controversial because many states still use this weight to
 Prenata l Ca re 1 61

diferentiate a stillborn fetus from an abortus (Chap. 1 , p. 3) . whereas most women with hypertensive disorders due to preg­
However, the survival of neonates with birthweights < 500 g nancy are diagnosed during the third trimester.
is no longer uncommon. In modern obstetrics, the clinical use of trimesters to
5. Multpara-a woman who has completed two or more preg­ describe a speciic pregnancy is imprecise. For example , it is
nancies to 20 weeks' gestation or more. Parity is determined inappropriate in cases of uterine hemorrhage to categorize the
by the number of pregnancies reaching 20 weeks. It is not problem temporally as "third-trimester bleeding. " Appropriate
increased to a higher number if multiples are delivered in management for the mother and her fetus will vary remark­
a given pregnancy. Moreover, stillbirth does not lower this ably depending on whether bleeding begins early or late in the
number. In some locales, the obstetrical history is summa­ th ird trimester (Chap. 4 1 , p. 757) . Because precise knowledge
rized by a series of digits connected by dashes. hese refer of fetal age is imperative for ideal obstetrical management, the
to the number of term infants, preterm infants, abortuses clinically appropriate unit is weeks ofgestation complete. And
younger than 20 weeks, and children currently alive. For more recently, clinicians designate gestational age using com­
example, a woman who is para 2-1 -0-3 has had two term pleted weeks and days, for example, 3 3 4/7 weeks or 33 + 4, for
deliveries, one preterm delivery, no abortuses, and has three 33 completed weeks and 4 days.
living children. Because these are nonconventional, it is
helpful to speciy the outcome of any pregnancy that did not Previous a n d Cu rrent Hea lth Status
end normally. As elsewhere in medicine, history taking begins with queries
concerning medical or surgical disorders. Also, detailed infor­
N ormal Preg na ncy D u ration mation regarding previous pregnancies is essential as many
The normal duration of pregnancy calculated from the irst day obstetrical complications tend to recur in subsequent pregnan­
of the last normal menstrual period is very close to 280 days or cies. The menstrual and contraceptive histories are also impor­
40 weeks. In a study of 427, 5 8 1 singleton pregnancies from the tant. Gestational or menstrual age is the number of weeks since
Swedish Birth Registry, Bergsj0 and coworkers ( 1 990) found the onset of the last menstrual period in women with menstrual
that the mean pregnancy duration was 2 8 1 days with a standard cycles lasting 28 to 30 days. For those with irregular m enses,
deviation of 1 3 days. However, menstrual cycle length varies sonography in early pregnancy will clariy gestational age. Last,
among women and renders many of these calculations inac­ some methods of birth control favor ectopic implantation fol­
curate. This, combined with the frequent use of irst-trimester lowing method failure (Chap. 38, pp. 683 and 689) .
sonography, has changed the method of determining an accu­
Psychosocial Screening. The American Academy of Pediatrics
rate gestational age (Duryea, 20 1 5) .
and the American College of Obstetricians and Gynecologists
h e American College o f Obstetricians and Gynecologists
(20 1 7) defi n e psychosocial issues as nonbiomedical factors
(20 1 7e) , the American Institute of Ultrasound in Medicine,
that afect mental and physical well-being. Women should be
and the Society for Maternal-Fetal Medicine have concluded
screened regardless of social status, education level, race, or eth­
that irst-trimester ultrasound is the most accurate method to
nicity. Such screening should seek barriers to care, communica­
establish or reairm gestational age. For pregnancies conceived
tion obstacles, nutritional status, unstable housing, desire for
by assisted reproductive technology, embryo age or transfer
pregnancy, safety concerns that include intimate-partner vio­
date is used to assign gestational age. If available, the gesta­
lence, depression, stress, and use of substances such as tob acco,
tional ages calculated from the last menstrual period and from
alcohol, and illicit drugs. his screening is performed on a regu­
irst-trimester ultrasound are compared, and this estimated date
lar basis, at least once per trimester, to identiy important issues
of delivery is recorded. his is discussed in further detail in
and reduce adverse pregnancy outcomes. Coker and colleagues
Chapter 7 (p. 1 24) and in Table 1 0- 1 (p. 1 83) .
(20 1 2) compared pregnancy outcomes in women before and
A quick estimate of a pregnancy due date based on men­
after implementation of a universal psychosocial screening
strual data can be made as follows: add 7 days to the irst day of
program and found that screened women were less likely to
the last period and subtract 3 months. For example, if the irst
have preterm or low-birthweight newborns, as well as other
day of the last menses was October 5, the due date is 1 0-0 5
adverse outcomes. Speciic screens for depression are presented
minus 3 (months) plus 7 (days) = 7- 1 2, or July 1 2 of the
in Chapter 61 (p. 1 1 74) .
following year. his calculation is the Naegele rule (American
College of Obstetricians and Gynecologists, 20 1 7 e) .
Cigarette Smoking. Data on this practice have been included
on the birth certiicate since 1 9 89. The number of pregnant
Tri mesters women who smoke continues to decline. From 2000 to 2 0 1 0,
It has become customary to divide pregnancy into three equal the prevalences were 1 2 to 1 3 percent (Tong, 20 1 3) . Based
epochs or trimesters of approximately 3 calendar months. His­ on the Pregnancy Risk Assessment Monitoring System, these
torically, the irst trimester extends through completion of 1 4 women were more likely younger, had less education, and were
weeks, the second through 2 8 weeks, and the third includes the either Alaska Natives or American Indians (Centers for Disease
29th through 42nd weeks of pregnancy. Thus, there are three Control and Prevention, 20 1 3a) .
periods of 1 4 weeks each. Certain major obstetrical problems Numerous adverse outcomes have been linked to smoking
tend to cluster in each of these time periods. For example, most during pregnancy (U. S . D epartment of Health and H uman
spontaneous abortions take place during the irst trimester, S ervices, 2000) . Potential teratogenic efects are reviewed in
1 62 P reconcept i o n a l a n d P renatal Care

TABLE 9-2. Five A's of Smoking Cessation

A S K a bo ut s moking at the fi rst and s u bseq uent p renata l visi ts.

ADVI S E with clear, stro ng state me nts that expl a i n the risks of conti n ued smoking to the wom a n , fet u s, a n d newborn .
ASSESS the patient's wi l l i n g n ess to atte m pt cessation .
ASSIST with preg nancy-spec ific, self- h e l p smoking cessatio n mate r i a l s. Ofer a d i rect referra l to the sm oker's q u it l i ne
( 1 -800-Q U IT NOW) to p rovi d e o n g o i n g co u n se l i ng a n d s u pport.
ARRANGE to track smoking a b sti nence p rog ress at s u bseq uent vis its.

Ada pted from F io re, 2008.

Chapter 1 2 (p. 249) . Notable among these are greater rates of Surveillance System from 20 1 1 to 20 1 3 and estimated that
miscarriage, stillbirth, low birthweight, and preterm delivery 1 0 percent of pregnant women used alcohol. It is estimated that
(Man, 2006; Tong, 20 1 3) . here is also a twofold risk of 3.3 million women are at risk for such exposure (Green, 20 1 6) .
placenta previa, placental abruption, and premature mem­ h e American College o f Obstetricians and Gynecologists
brane rupture compared with nonsmokers. hus, the U.S. (20 1 6b) in collaboration with the CDC has developed the Fetal
Preventive Services Task Force recommends that clinicians Acohol Spectrum Disorders (FASD) Prevention Program, which
ofer counseling and efective intervention options to preg­ provides resources for providers and is available at: http://www.
nant smokers at the irst and subsequent prenatal visits (Siu, acog.org/ alcohol.
2 0 1 5 ) . Although beneits are greatest if smoking ceases early
in pregnancy or preferably preconceptionally, quitting at any Il licit Drugs. It is estimated that 1 0 percent of fetuses are exposed
stage of pregnancy can improve perinatal outcomes (Fiore, to one or more illicit drugs. Agents may include heroin and other
2008 ) . opiates, cocaine, amphetamines, barbiturates, and marijuana
Person-to-person psychosocial interventions are signiicantly (American Academy of Pediatrics, 20 1 7; merican College of
more successful in achieving smoking abstinence in pregnancy Obstetricians and Gynecologists, 20 1 5a, 20 1 7d) . As discussed in
than is simply advising the woman to quit (Fiore, 2008) . One Chapter 12 (p. 247), chronic use of most of these in large quan­
example is a brief counseling session covering the "5As" of tities is harmful to the fetus (Metz, 20 1 5) . Well-documented
smoking cessation (Table 9-2) . This approach can be accom­ sequelae include fetal-growth restriction, low birthweight, and
plished in 1 5 minutes or less and is efective when initiated by drug withdrawal soon ater birth. Adverse efects of marijuana
health-care providers (American College of Obstetricians and are less convincing. Women who use such drugs frequently do
Gynecologists, 20 1 7i) . not seek prenatal care, which in itself is associated with risks for
Behavioral interventions and nicotine replacement products preterm and low-birthweight newborns (EI-Mohandes, 2003;
are successful in reducing smoking rates (Patnode, 20 1 5) . hat Eriksen, 20 1 6) .
said, nicotine replacement has not been suiciently evaluated to For women who abuse heroin, methadone maintenance can
determine its efectiveness and safety in pregnancy. Trials evalu­ be initiated within a registered methadone treatment program
ating such therapy have yielded confl i cting evidence (Coleman, to reduce complications of illicit opioid use and narcotic with­
20 1 5 ; Pollak, 2007; Spindel, 20 1 6) . Two recent randomized drawal, to encourage prenatal care, and to avoid drug culture
trials also produced nonconclusive results. In the Smoking and risks (American College of Obstetricians and Gynecologists,
Nicotine in Pregnancy (SNAP) trial, Cooper and associates 20 1 7£) . Available programs can be found through the treatment
(20 1 4) reported a temporary cessation of smoking that may locator of the Substance Abuse and Mental Health Services
have been associated with improved infant development. In the Administration at ww.samhsa.gov. Methadone dosages usually
Study of Nicotine Patch in Pregnancy (SNIPP) trial, Berlin and are initiated at 1 0 to 30 mg daily and titrated as needed. In some
coworkers (20 1 4) found no diferences in smoking cessation women, careful methadone taper may be an appropriate option
rates or birthweights. (Stewart, 20 1 3) . Although less commonly used, buprenorphine
Because of limited available evidence to support pharma­ alone or in combination with naloxone may also be ofered and
cotherapy for smoking cessation in pregnancy, the American managed by physicians with specific credentialing.
College of Obstetricians and Gynecologists (20 1 7i) has recom­
mended that if nicotine replacement therapy is used, it should I ntimate-Partner Violence. his term refers to a pattern of
be done with close supervision and after careful consideration assault and coercive behavior that may include physical injury,
of the risks of smoking versus nicotine replacement. psychological abuse, sexual assault, progressive isolation, stalk­
ing, deprivation, intimidation, and reproductive coercion
Alcohol. Ethyl acohol or ethanol is a potent teratogen that causes (American College of Obstetricians and Gynecologists, 20 1 2) .

malities, and central nervous system dyunction. s discussed in

a etal syndrome characterized by growth restriction, acial abnor­ Such violence has been recognized as a major public health
problem. Unfortunately, most abused women continue to be
Chapter 1 2 (p. 239), women who are pregnant or consider­ victimized during pregnancy. With the possible exception of
ing pregnancy should abstain from using any alcoholic bever­ preeclampsia, domestic violence is more prevalent than any
ages. The CDC analyzed data from the Behavioral isk Factor major medical condition detectable through routine prenatal
 P renata l Ca re 1 63

screening (American Academy of Pediatrics and the Ameri­ the last menses. Uterine size similar to a small orange roughly
can College of Obstetricians and Gynecologists, 20 1 7) . The correlates with a 6-week gestation; a large orange, with an
prevalence during pregnancy is estimated to range between 4 8-week pregnancy; and a grapefruit, with one at 12 weeks
and 8 percent. Intimate-partner violence is associated with an (Margulies, 200 1 ) .
increased risk of several adverse perinatal outcomes including
preterm delivery, fetal-growth restriction, and perinatal death • Laboratory Tests
(Chap. 47, p. 925).
The American College of Obstetricians and Gynecologists Recommended routine tests at the first prenatal encounter

blood count, a determination of blood type with h status,

are listed in Table 9- 1 . Initial blood tests include a complete
(20 1 2) has provided methods for domestic violence screen­
ing and recommends their use at the irst prenatal visit, then
and an antibody screen. The Institute of Medicine recommends
again at least once per trimester, and again at the postpartum
universal human immunodeiciency virus (HIV) testing, with
visit. Such screening should be done privately and away from
patient notiication and right of refusal, as a routine part of pre­
family members and friends. Patient self-administered or com­
natal care. The CDC (Branson, 2006) as well as the American
puterized screenings appear to be as efective for disclosure
Academy of Pediatrics and the American College of Obstetri­
as clinician-directed interviews (Ahmad, 2009; Chen, 2007) .
cians and Gynecologists (20 1 6f, 20 1 7) continue to suppo rt this
Physicians should be familiar with state laws that may require
practice. If a woman declines testing, this is recorded in the
reporting of intimate-partner violence. Coordination with
prenatal record. All pregnant women are also screened for hepa­
social services can be invaluable in these cases. The National
titis B virus infection, syphilis, and immunity to rubella at the
Domestic Violence Hotline ( l -800-799-SAFE [7233] ) is a
initial visit. Based on their prospective investigation of 1 000
nonprofit telephone referral service that provides individualized
women, Murray and coworkers (2002) concluded that in the
information regarding city-speciic shelter locations, counseling
absence of hypertension, routine urinalysis beyond the irst pre­
resources, and legal advocacy.
natal visit was not necessary. A urine culture is recommended

• Clinical Evaluation
by most because treating bacteruria signiicantly reduces the
likelihood of developing symptomatic urinary tract infections
A thorough, general physical examination should be com­ in pregnancy (Chap. 53, p. 1 026) .
pleted at the initial prenatal encounter. Pelvic examination is Cervica l I nfectio n s
performed as part of this evaluation. he cervix is visualized
employing a speculum lubricated with warm water or water­ Chlamydia trachomatis is isolated from the cervix in 2 to 13 per­
based lubricant gel. Bluish-red passive hyperemia of the cer­ cent of pregnant women. he American Academy of Pediatrics
vix is characteristic, but not of itself diagnostic, of pregnancy. and the American College of Obstetricians and Gynecologists
Dilated, occluded cervical glands bulging beneath the ectocer­ (20 1 7) recommend that all women be screened for chlamydia
vical mucosa-nabothian cysts-may be prominent. he cervix during the irst prenatal visit, with additional third-trimester
is not normally dilated except at the external os. To identiy testing for those at increased risk. Risk factors include unmarried
cytological abnormalities, a Pap test is performed according to status, recent change in sexual partner or multiple concurrent
current guidelines noted in Chapter 63 (p. 1 1 93). Specimens partners, age younger than 25 years, inner-city residence, history
for identiication of Chlamydia trachomatis and Neisseria gonor­ or presence of other sexually transmitted diseases, and little or
rhoeae are also obtained when indicated. no prenatal care. For those testing positive, treatment described
Bimanual examination is completed by palpation, with spe­ in Chapter 65 (p. 1 240) is followed by a second testing-a test
cial attention given to the consistency, length, and dilatation ofcure-3 to 4 weeks after treatment completion.
of the cervix; to uterine and adnexal size; to the bony pelvic Neisseria gonorrhoeae typically causes lower genital tract
architecture; and to any vaginal or perineal anomalies. Later infection in pregnancy. It also may cause septic arthritis ( Bleich,
in pregnancy, fetal presentation often can also be determined. 20 1 2) . Risk factors for gonorrhea are similar to those for chla­
Lesions of the cevix, vagina, or vulva are further evaluated as mydial infection. The American Academy of Pediatrics and the
needed by colposcopy, biopsy, culture, or dark-field examina­ American College of Obstetricians and Gynecologists (20 1 7)
tion. The perianal region is visualized, and digital rectal exami­ recommend that pregnant women with risk factors or those liv­
nation performed as required for complaints of rectal pain, ing in an area of high N gonorrhoeae prevalence be screened at
bleeding, or mass. the initial prenatal visit and again in the third trimester. Treat­
ment is given for gonorrhea and simultaneously for possible
Gestationa l Age Assessment coexisting chlamydial infection (Chap. 65, p. 1 240) . Test of
cure is also recommended following treatment.
Precise knowledge of gestational age is one of the most impor­

• Pregnancy Risk Assessment

tant aspects of prenatal care because several pregnancy compli­
cations may develop for which optimal treatment will depend
on fetal age. As discussed earlier and in Chapter 7 (p. 1 24) , Many factors can adversely afect maternal and fetal well-being.
irst-trimester sonographic assessment is best correlated with Some are evident at conception, but many become apparent
menstrual history. That said, gestational age can also be esti­ during the course of pregnancy. The designation of "high-risk
mated with considerable precision by carefully performed clini­ pregnancy" is overly vague for an individual woman and prob­
cal uterine size examination that is coupled with knowledge of ably is best avoided if a more specific diagnosis can be assigned.
1 64 P reco n ceptiona l a n d P re natal Care

TABLE 9-3. Conditions for Which Materna l-Feta l Med icine Consu ltation May Be Beneficia l
Medical History and Cond itions
Card iac d isease-moderate to severe d i so rd ers
D i a betes m e l l itus with evid en ce of e n d-org a n da mage or u n contro i led hyperg lycemia
Fa m i l y o r perso n a l h i story of g e n etic a b n o rm a l ities
H em og lo b i nopathy
C h ro n i c hyperten s i o n if u ncontro l l ed or associated with ren a l r cardiac d i sease
Renal i ns ufici ency if a ssoci ated with sig n ificant prote i n u ria ( ::500 m g/24 h o u r), seru m
c reat i n i ne ::1 .5 m g/d L, or hyperten s i o n
P u l m o n a ry d i sease if seve re restrictive o r obstructive, i n c l u d i n g severe asthma
H u ma n i m m u n od eficiency virus i nfection
P rior p u l m o n a ry e m bo l u s or d ee p-ve i n t h rom bos is
Severe system ic d i sea se, i nc l u d i n g a utoi m m u n e con d itions
Ba riatric s u rg e ry
E p i lepsy if poorly contro l led or req u i res more t h a n one a nticonvu l s a nt
Cancer, espec i a l l y if t reatm e n t is i n d icated i n preg n a n cy
Obstetrical History and Conditions
CDE (Rh) o r other b lood g r o u p a l l oi m m u n ization (exc l u d i ng ABO, Lewis)
P rior or cu rrent feta l struct u ra l o r c h ro m osoma l a bn o rm a l ity
Des i re or need for prenata l d i a g n o s i s or feta l thera py
Perico nceptional expo s u re to known teratoge n s
I nfection w i t h or expo s u re to o rga n is m s that c a u s e congen ita l i nfection
H ig h e r-ord e r m u l tifeta l g estation
Severe d i sord e rs of a m n io n ic fl u i d vo l u me

Some common risk factors for which consultation is recom­ screened-were seen again at 26, 32, and 38 weeks. Compared
mended by the American Academy of Pediatrics and the Amer­ with routine prenatal care, which required a median of eight
ican College of Obstetricians and Gynecologists (20 1 7) are visits, the new model required a median of only ive. No dis­
shown in Table 9-3 . Some conditions may require the involve­ advantages were attributed to the regimen with fewer visits,
ment of a maternal-fetal medicine subspecialist, geneticist, and these indings were consistent with other randomized trials
pediatrician, anesthesiologist, or other medical specialist in the (Clement, 1 999; McDuie, 1 996) .
evaluation, counseling, and care of the woman and her fetus.

• Prenatal Surveillance
SU BSEQUENT PRENATAL VISITS
At each return visit, the well-being of mother and fetus are
hese are traditionally scheduled at 4-week intervals until 28 assessed (see Table 9- 1 ) . Fetal heart rate, growth, and activity
weeks, then every 2 weeks until 36 weeks, and weekly thereaf­ and amnionic fluid volume are evaluated. Maternal blood pres­
ter. Women with complicated pregnancies-for example, with sure and weight and their extent of change are examined. Symp­
twins or diabetes-often require return visits at 1 - to 2-week toms such as headache, altered vision, abdominal pain, nausea
intervals (Luke, 2003; Power, 20 1 3) . In 1 986, the Department and vomiting, bleeding, vaginal luid leakage, and dysuria are
of Health and Human Services convened an expert panel to sought. Mter 20 weeks' gestation, uterine examination mea­
review the content of prenatal care. his report was subsequently sures size from the symphysis to the fundus. In late pregnancy,
reevaluated and revised in 2005 (Gregory, 2006) . he panel vaginal examination often provides valuable information that
recommended, among other things, early and continuing risk includes conirmation of the presenting part and its station,
assessment that is patient speciic. It also endorsed lexibility in clinical estimation of pelvic capacity and configuration, amni­
clinical visit spacing; health promotion and education, includ­ onic luid volume adequacy, and cervical consistency, eface­
ing preconceptional care; medical and psychosocial interven­ ment, and dilatation (Chap. 22, p. 435) .
tions; standardized documentation; and expanded prenatal care
objectives-to include family health up to 1 year after birth. F u n d a l H e i g ht
he World Health Organization conducted a multicenter Between 20 and 34 weeks' gestation, the height of the uter­
randomized trial with almost 25 ,000 women comparing rou­ ine fundus measured in centimeters correlates closely with
tine prenatal care with an experimental model designed to gestational age in weeks Gimenez, 1 983) . his measurement is
minimize visits (Villar, 200 1 ) . In the new model, women were used to monitor fetal growth and amnionic fluid volume. It is
seen once in the irst trimester and screened for certain risks. measured along the abdominal wall from the top of the sym­
hose without anticipated complications-80 percent of those physis pubis to the top of the fundus. Importantly, the bladder
 P renata l Ca re 1 65

must be emptied before fundal measurement (Worthen, 1 980) . (American College of Obstetricians and Gynecologists, 20 1 6) .
Obesity or the presence of uterine masses such as leiomyomas Similarly, women who engage i n behaviors that place them at

of hospitalization for delivery. Women who are D (h) nega­

may also limit fundal height accuracy. Moreover, using fundal high risk for hepatitis B virus infection are retested at the time
height alone, fetal-growth restriction may be undiagnosed in
up to a third of cases (American College of Obstetricians and tive and are unsensitized should have an antibody screening
Gynecologists, 20 1 5 b; Haragan, 20 1 5) . test repeated at 28 to 29 weeks, and anti-D immunoglobulin is
given if they remain unsensitized (Chap. 1 5 , p. 305).
Feta l Heart Sou n d s
Instruments incorporating Doppler ultrasound are often used Gro u p B Streptococca l I nfection
to easily detect fetal heart action, and in the absence of maternal he CDC (20 1 0b) recommends that vaginal and rectal group B
obesity, heart sounds are almost always detectable by 1 0 weeks streptococcal (GBS) cultures be obtained in all women between
with such instruments (Chap. 1 0, p. 2 1 3) . he fetal heart rate 35 and 37 weeks' gestation, and the American College of Obste­
ranges from 1 1 0 to 1 60 beats per minute and is typically heard tricians and Gynecologists (20 1 6g) has endorsed this recom­
as a double sound. Using a standard nonampliied stethoscope, mendation. Intrapartum antimicrobial prophylaxis is provided
the fetal heart is audible by 20 weeks in 80 percent of women, to those whose culture results are positive. Women with GBS
and by 22 weeks, heart sounds are expected to be heard in bacteriuria or a previous infant with invasive disease are given
all (Herbert, 1 987) . Because the fetus moves freely in amni­ empirical intrapartum prophylaxis. Trials are in progress to test
onic fl u id, the site on the maternal abdomen where fetal heart an investigational vaccine (Donders, 20 1 6; Schrag, 20 1 6) . hese
sounds can be heard best will vary. infections are described further in Chapter 64 (p. 1 220) .
Additionally, with ultrasonic auscultation, one may hear
the unic soule, which is a sharp, whistling sound that is syn­ Gestation a l Dia betes
chronous with the fetal pulse. It is caused by the rush of blood All pregnant women are screened for gestational diabetes mel­
through the umbilical arteries and may not be heard consistently. litus, whether by history, clinical factors, or routine laboratory
In contrast, the uterine soule is a soft, blowing sound that is testing. Although laboratory testing between 24 and 28 weeks'
synchronous with the maternal pulse. It is produced by the pas­ gestation is the most sensitive approach, there may be pregnant
sage of blood through the dilated uterine vessels and is heard women at low risk who are less likely to beneit from testing
most distinctly near the lower portion of the uterus. (American College of Obstetricians and Gynecologists, 2 0 1 7c) .
Gestational diabetes is discussed in Chapter 57 (p. 1 1 07) .
Sonog ra phy
Sonography provides invaluable information regarding fetal N e u ra l -Tu be Defect a n d G e n etic Scree n i n g
anatomy, growth, and well-being, and most women in the Serum screening for neural-tube defects i s ofered at 1 5 to
United States have at least one prenatal sonographic exami­ 20 weeks. Fetal aneuploidy screening may be performed at 1 1
nation during pregnancy (American College of Obstetricians to 1 4 weeks' gestation and/or at 1 5 to 20 weeks, depending on
and Gynecologists, 20 1 6h) . Continuing trends suggest that the protocol selected (Rink, 20 1 6) . Additionally, screening for
the number of these examinations performed per pregnancy certain genetic abnormalities is ofered to women at increased
is increasing. Siddique and associates (2009) reported that the risk based on family history, ethnic or racial background, or
average number rose from 1 . 5 in 1 995 through 1 997 to 2.7 age (American College of Obstetricians and Gynecologists,
almost 10 years later. his trend was noted in both high- and 20 1 7h) . These are discussed in greater detail in Chapter 1 4
low-risk pregnancies. he actual clinical utility of this increased (p. 277) . Some examples include testing for Tay-Sachs disease
use in pregnancy has not been demonstrated, and it is unclear for persons of Eastern European Jewish or French Canadian
that the cost-benefi t ratio is justified (Washington State Health ancestry; � -thalassemia for those of Mediterranean, Southeast
Care Authority, 20 1 0) . The American College of Obstetricians Asian, Indian, Pakistani, or Mrican ancestry; a-thalassemia for
and Gynecologists (20 1 6h) has concluded that sonography individuals of Southeast Asian or Mrican ancestry; sickle-cell
should be performed only when there is a valid medical indica­ anemia for people of African, Mediterranean, Middle Eastern,
tion and under the lowest possible ultrasound exposure setting. Caribbean, Latin American, or Indian descent; and trisomy 2 1
The College further states that a physician is not obligated to for those with advanced maternal age.
perform sonography without a specific indication in a low-risk
patient, but that if she requests sonographic screening, it is rea­
N UTRITIONAL COU NSELING
sonable to honor her request.

• Weight Gain Recommendations

• Subsequent Laboratory Tests In 2009, the Institute of Medicine and National Research
If initial results were normal, most tests need not be repeated. Council revised guidelines for weight gain in pregnancy and
Hematocrit or hemoglobin determination, along with serology continued to stratiy suggested weight gain ranges based on
for syphilis if it is prevalent in the population, is repeated at 28 prepregnancy body mass index (BMI) (Table 9-4) . The new
to 32 weeks (Hollier, 2003; Kiss, 2004) . For women at increased guidelines included a specific, relatively narrow range of recom­
risk for HIV acquisition during pregnancy, repeat testing is rec­ mended weight gains for obese women. Also, the same recom­
ommended in the third trimester, preferably before 36 weeks mendations apply to adolescents, short women, and women of
1 66 P recon cepti o n a l a n d P renata l Care

economic, or political disaster, coincidental events have oten

TABLE 9-4. Reco m m endations for Total a n d Rate of
created many variables, the efects of which are not amenable to
We i g ht G a i n During Preg na ncy
quantiication. Some past experiences suggest, however, that in
Total Weight Weight Gain i n 2nd otherwise healthy women, a state of near starvation is required
Gai n Range and 3rd Tri mesters to establish clear diferences in pregnancy outcome.
Category (BMI) ( l b)a Mean in I b/wk (range) During the severe European winter of 1 944 to 1 945,
U nd e rwe i g h t 28-40 1 ( 1 - 1 .3) nutritional deprivation of known intensity prevailed in a well­
« 1 8.5) circumscribed area of The Netherlands occupied by the German
Normal wei g h t 25-35 1 (0.8- 1 ) military (Kyle, 2006) . At the lowest point during this Dutch
( 1 8.5-24.9) Hunger Winter, rations reached 450 kcal/d, with generalized
Ove rweig ht 1 5-25 0.6 (0.5-0.7) rather than selective malnutrition. Smith ( 1 947) analyzed the out­
(25 .0-29.9) comes of pregnancies that were in progress during this 6-month
Obese (::30.0) 1 1 -20 0.5 (0.4-0.6) famine. Median neonatal birthweights declined approximately
250 g and rose again ater food became available. This indicated
a E m p i rica l reco m me n d at i o n s for wei g h t g a i n i n twi n
that birthweight can be inluenced significantly by starvation
preg n a ncies i n cl ude: norma l BMI, 3 7-54 I b; ove rwe i g ht
during later pregnancy. he perinatal mortality rate, however,
wo men, 3 1 -5 0 I b; a n d o bese wom en, 25-42 l b.
was not altered. Moreover, the incidence of fetal malformations
B M I body mass i n d ex.
or preeclampsia did not rise signiicantly. Parenthetically, weight
=

Mod ifi ed from t h e I n st i tute of Med i c i n e a n d National

loss in obese women during pregnancy is also associated with an
Research Cou n c i l , 2009.
increased risk for low-birthweight neonates (Cox Bauer, 20 1 6) .
Evidence o f impaired brain development has been obtained
in some animal fetuses whose mothers had been subjected to
all racial and ethnic groups. The American College of Obstetri­ intense dietary deprivation. Subsequent intellectual develop­
cians and Gynecologists (20 1 6i) has endorsed these measures. ment was studied by Stein and associates ( 1 972) in young male
When the Institute of Medicine guidelines were formulated, adults whose mothers had been starved during pregnancy in
concern focused on low-birthweight newborns, however, cur­ the aforementioned Hunger Winter. The comprehensive study
rent emphasis is directed to the obesity epidemic (Catalano, was made possible because all males at age 1 9 underwent com­
2007) . This explains renewed interest in lower weight gains dur­ pulsory examination for military service. It was concluded that
ing pregnancy. Obesity is associated with significantly greater severe dietary deprivation during pregnancy caused no detect­
risks for gestational hypertension, preeclampsia, gestational dia­ able efects on subsequent mental performance.
betes, macrosomia, cesarean delivery, and other complications Several studies of the long-term consequences to this cohort
(Chap. 48, p. 939) . he risk appears "dose related" to prenatal of children born to nutritionally deprived women have been
weight gain. In a population-based cohort of more than 1 20,000 performed and have been reviewed by Kyle and Pichard (2006) .
obese pregnant women, those who gained <15 lb had the low­ Progeny deprived in mid to late pregnancy were lighter, shorter,
est rates of preeclampsia, large-for-gestational age neonates, and and thinner at birth, and they had a higher incidences of sub­
cesarean delivery (Kiel, 2007) . Among 1 00,000 women with sequent hypertension, reactive airway disease, dyslipidemia,
normal prepregnancy BMI, DeVader and colleagues (2007) diminished glucose tolerance, and coronary artery disease. Early
found that those who gained <25 Ib during pregnancy had pregnancy deprivation was associated with greater obesity rates
a lower risk for preeclampsia, failed induction, cephalopelvic in adult women but not men. Early starvation was also linked
disproportion, cesarean delivery, and large-for-gestational age to higher rates of central nervous system anomalies, schizophre­
neonates. his cohort, however, had an increased risk for small­ nia, and schizophrenia-spectrum personality disorders.
for-gestational age newborns. Lifestyle intervention during preg­ hese observations and others have led to the concept of
nancy can result in less weight gain (Sagedal, 20 1 7) . etal programming by which adult morbidity and mortality are
There i s irrefutable evidence that maternal weight gain dur­ related to fetal health. Known widely as the Barker hypothesis,
ing pregnancy inluences birthweight. Martin and cowork­ as promulgated by Barker and colleagues ( 1 989), this concept
ers (2009) studied this using birth certificate data for 2006. is discussed in Chapter 44 (p. 848).

• Weight Retention ater Pregnancy

Approximately 60 percent of women gained 26 Ib or more dur­
ing pregnancy, and maternal weight gain positively correlated
with birthweight. Nloreover, women with the greatest risk- Not all the weight gained during pregnancy is lost during and
1 4 percent-for delivering a newborn weighing < 2500 g were immediately after delivery. Schauberger and coworkers ( 1 992)
those with weight gain < 1 6 lb. Nearly 20 percent of births to studied prenatal and postpartum weights in 795 women.
women with such low weight gains were preterm. Their average weight gain was 28.6 Ib or 1 2.9 kg. As shown

• Severe Undernutrition
in Figure 9-4, most maternal weight loss was at delivery­
approximately 1 2 lb or 5 .4 kg-and in the ensuing 2 weeks­
Meaningful studies of nutrition in human pregnancy are approximately 9 Ib or 4 kg. An additional 5 . 5 lb or 2.5 kg was
exceedingly diicult to design because experimental dietary defi­ lost between 2 weeks and 6 months postpartum. Thus, average
ciency is not ethical. In those instances in which severe nutri­ retained pregnancy weight was 2 . 1 Ib or 1 kg. Excessive weight
tional deiciencies have been induced as a consequence of social, gain is manifest by accrual of fat and may be partially retained as
 P renata l Care 1 67

18
TABLE 9-5. Recommended Da i ly D i etary Al lowances for
16 P regnant and Lactat i n g Women

) 14 Pregnant Lactating
�
) 12 Fat-Soluble Vitam ins
Q
)
Vita m i n A 77O l1g 1 300 1g
E
10
Vita m i n Da 1 5 11g 1 5 11g
'w
�
>
8 Vita m i n E 1 5 mg 1 9 mg
6 Vita m i n Ka 9O 1g 90 1g

4 Water- Soluble Vita m i ns

2 Vita m i n C 85 mg 1 20 mg
Th ia m i n e 1 .4 mg 1 .4 mg
790 409
0 2 4 6 8 1 0 1 2 1 4 1 6 1 8 20 22 24 26
n = 6 1 8 31 3 554 222 483 Ri boflavi n 1 .4 mg 1 .6 mg
Time in weeks N ia c i n 1 8 mg 1 7 mg
Vita m i n B6 1 .9 mg 2 mg
FIGURE 9-4 C u m u lative wei g ht l oss from last a ntepa rtum visit
Fol ate 6OO 1g 5OO 1g
to 6 months postpa rt u m . *Sig n ificantly d ifferent from 2-week
weig ht loss; **S i g n ifica ntly d ifferent from 6-week weight loss. Vita m i n B 1 2 2.6 1g 2.8 1g
(Redrawn from Schau berg er CW, Rooney BL, Brimer LM: Factors M i nerals
that i nfl uence wei g ht loss in the puerperi u m . Obstet Gynecol

1 .5 9 1 .5 9
Ca l c i u ma 1 000 mg 1 000 mg
79:424, 1 992.)

4.7 9 5.1 9
Sod i u ma
Potassi u ma
I ro n 27 mg 9 mg
long-term fat (Berggren, 20 1 6; Widen, 20 1 5) . Overall, the more
Z i nc 1 1 mg 1 2 mg
weight that was gained during pregnancy, the more that was lost
I od i n e 220 -1g 29O -1g
postpartum. Interestingly, there is no relationship between pre­
Selen i u m 6O 1g 7O l1g
pregnancy BMI or prenatal weight gain and weight retention.

• Dietary Reference Intakes-Recommended 71 9 71 9

Other

1 75 9 21 0 9
P rote i n

28 9 29 9
Allowances Ca rbohyd rate
F i bera
Periodically, the Institute of Medicine (2006, 20 1 1 ) publishes
recommended dietary allowances, including those for pregnant aReco m mendations mea s u red a s adeq u ate i n ta ke.
or lactating women. The latest recommendations are summa­ F ro m the I n stitute of Medici n e, 2006, 20 1 1 .
rized in Table 9-5. Certain prenatal vitamin-mineral supple­
ments may lead to intakes well in excess of the recommended
allowances. Moreover, the use of excessive supplements, which pregnancy may be compensated in whole or in part by reduced
often are self-prescribed, has led to concern regarding nutrient physical activity (Hytten, 1 99 1 ) .

• Protein
toxicities during pregnancy. Those with potentialy toxic fects
include iron, zinc, selenium, and vitamins A, B6, C, and D.

• Calories
Protein requirements rise to meet the demands for growth and
remodeling of the fetus, placenta, uterus, and breasts, and for
As shown in Figure 9-5, pregnancy requires an additional
80,000 kcal, mostly during the last 20 weeks. To meet this
demand, a caloric increase of 1 00 to 300 kcal/d is recom­ 80 ,000
mended during pregnancy (American Academy of Pediatrics 70,000
and the American College of Obstetricians and Gynecologists, 60 ,000 Maintenance
20 1 7) . This greater intake, however, should not be divided
B
50, 000
equally during the course of pregnancy. The Institute of Medi­
�
)
40, 000
cine (2006) recommends adding 0, 340, and 452 kcal/d to the
30, 000
estimated nonpregnant energy requirements in the irst, second, Fat
and third trimesters, respectively. he addition of 1 000 kcal/d 20,000

...:;=,Protein
or more results in fat accrual Qebeile, 20 1 5) . 1 0 ,000
Calories are necessary for energy. Whenever caloric intake is
0 10 20 30 40
inadequate, protein is metabolized rather than being spared for
its vital role in fetal growth and development. Total physiologi­ Weeks of pregnancy
cal requirements during pregnancy are not necessarily the sum FIGURE 9-5 Cu m ulative kilocalories requ i red for pregnancy. (Redrawn
of ordinary nonpregnant requirements plus those speciic to from Cha m berlain G, Broug hton-Pipki n F (eds): Clinical P hysiology i n
pregnancy. For example, the additional energy required during Obstetrics, 3 rd ed. Oxford, Blackwell Science, 1 998.)
1 68 P reconceptional a n d P re nata l Ca re

increased maternal blood volume (Chap. 4, p. 5 5) . During the endemic cretinism, which is characterized by multiple severe neu­
second half of pregnancy, approximately 1 000 g of protein are rological defects. In parts of China and Africa where this condi­
deposited, amounting to 5 to 6 g/d (Hytten, 1 97 1 ) . To accom­ tion is common, iodide supplementation very early in pregnancy
plish this, protein intake that approximates 1 g/kg/d is recom­ prevents some cretinism cases (Cao, 1 994) . To obviate this, many
mended (see Table 9-5). Data suggest this should be doubled in prenatal supplements now contain various quantities of iodine.
late gestation (Stephens, 20 1 5) . Most amino-acid levels in mater­ Cacium is retained by the pregnant woman during gestation
nal plasma fall markedly, including ornithine, glycine, taurine, and approximates 30 g. Most of this is deposited in the fetus late
and proline (Hytten, 1 99 1 ) . Exceptions during pregnancy are in pregnancy (Pitkin, 1 985). his amount of calcium represents
glutamic acid and alanine, the concentrations of which rise. only approximately 2.5 percent of total maternal calcium, most

s another potential use, routine calcium supplementation to pre­

Preferably, most protein is supplied from animal sources, of which is in bone and can readily be mobilized for fetal growth.
such as meat, milk, eggs, cheese, poultry, and fish. hese fur­
nish amino acids in optimal combinations. Milk and dairy vent preeclampsia has not proved efective (Chap. 40, p. 727) .
products are considered nearly ideal sources of nutrients, espe­ Zinc deficiency if severe may lead to poor appetite, subopti­
cially protein and calcium, for pregnant or lactating women. mal growth, and impaired wound healing. During pregnancy,
Ingestion of specific ish and potential methylmercury toxicity the recommended daily intake approximates 1 2 mg. But, the
are discussed on page 1 70. safe level of zinc supplementation for pregnant women has not
been clearly established. Vegetarians have lower zinc intakes

• Minerals
(Foster, 20 1 5) . he bulk of studies support zinc supplementa­
tion only in zinc-deficient women in poor-resource countries
The intakes recommended by the Institute of Medicine (2006) (Nossier, 20 1 5 ; Ota, 20 1 5) .
for various minerals are listed in Table 9-5. With the exception Manesium deficiency as a consequence o f pregnancy has not
of iron and iodine, practically all diets that supply suicient been recognized. Undoubtedly, during prolonged illness with
calories for appropriate weight gain will contain enough miner­ no magnesium intake, the plasma level might become critically
als to prevent deiciency. low, as it would in the absence of pregnancy. We have observed
Iron requirements are greatly increased during pregnancy, magnesium deiciency during pregnancies in some with previous
and reasons for this are discussed in Chapter 4 (p. 58). Of the intestinal bypass surgery. As a preventive agent, Sibai and cowork­
approximately 300 mg of iron transferred to the fetus and pla­ ers ( 1 989) randomly assigned 400 normotensive primigravid
centa and the 500 mg incorporated into the expanding mater­ women to 365-mg elemental magnesium supplementation or
nal hemoglobin mass, nearly all is used after midpregnancy. placebo tablets from 1 3 to 24 weeks' gestation. Supplementation
During that time, iron requirements imposed by pregnancy did not improve any measures of pregnancy outcome.
and maternal excretion total approximately 7 mg/ d (Pritchard, Trace metals include copper, selenium, chromium, and
1 970) . Few women have suicient iron stores or dietary intake manganese, which all have important roles in certain enzyme
to supply this amount. Thus, the American Academy of Pedi­ functions. In general, most are provided by an average diet.
atrics and the American College of Obstetricians and Gyne­ Selenium deficiency is manifested by a frequently fatal cardio­
cologists (20 1 7) endorse the recommendation by the National myopathy in young children and reproductive-aged women.
Academy of Sciences that at least 27 mg of elemental iron be Conversely, selenium toxicity resulting from oversupplementa­
supplemented daily to pregnant women. his amount is con­ tion also has been observed. Selenium supplementation is not
tained in most prenatal vitamins. needed in American women.
Scott and coworkers ( 1 970) established that as little as Potassium concentrations in maternal plasma decline by
30 mg of elemental iron, supplied as ferrous gluconate, sulfate, approximately 0 . 5 mEq/L by midpregnancy (Brown, 1 986) .
or fumarate and taken daily throughout the latter half of preg­ Potassium deficiency develops in the same circumstances as in
nancy, provides suicient iron to meet pregnancy requirements nonpregnant individuals-a common example is hyperemesis
and protect preexisting iron stores. his amount will also pro­ gravidarum.
vide for iron requirements of lactation. he pregnant woman Fluoride metabolism is not altered appreciably during preg­
may benefi t from 60 to 1 00 mg of elemental iron per day if nancy (Maheshwari, 1 9 83) . Horowitz and Heifetz ( 1 967)
she is large, has a multifetal gestation, begins supplementation concluded that no additional ofspring beneits accrued from
late in pregnancy, takes iron irregularly, or has a somewhat maternal ingestion of luoridated water if the newborn ingested
depressed hemoglobin level. he woman who is overtly ane­ such water from birth. Sa Roriz Fonteles and associates (2005)
mic from iron deficiency responds well to oral supplementation studied microdrill biopsies of deciduous teeth and concluded
with iron salts. In response, serum ferritin levels rise more than that antenatal luoride provided no additional fluoride uptake
the hemoglobin concentration (Daru, 20 1 6) . compared with postnatal fluoride alone. Finally, supplemental
Iodine is also needed, and the recommended iodine allow­ luoride ingested by lactating women does not raise the luoride
ance is 220 Lg/d (see Table 9-5 ) . The use of iodized salt and concentration in breast milk (Ekstrand, 1 9 8 1 ) .
bread products is recommended during pregnancy to ofset the

• Vitamins
increased fetal requirements and maternal renal losses of iodine.
Despite this, iodine intake has declined substantially in the past
1 5 years, and in some areas it is probably inadequate (Casey, he increased requirements for most vitamins during preg­
20 1 7) . Severe maternal iodine deficiency predisposes ofspring to nancy shown in Table 9-5 usually are supplied by any general
 P re nata l C a re 1 69

diet that provides adequate calories and protein. he excep­ 1 978). Excessive ingestion of vitamin C also can lead to a
tion is folic acid during times of unusual requirements, such functional deiciency of vitamin B12. Although its role is still
as pregnancy complicated by protracted vomiting, hemo­ controversial, vitamin B I 2 deiciency preconceptionally, similar
lytic anemia, or multiple fetuses. hat said, in impoverished to folate, may elevate the risk of neural-tube defects (Molloy,
countries, routine multivitamin supplementation reduced the 2009) .
incidence of low-birthweight and growth-restricted fetuses, Vitamin B6, which is pyridoxine, does not require supple­
but did not alter preterm delivery or perinatal mortality rates mentation in most gravidas (Salam, 20 1 5) . For women at high
(Fawzi, 2007) . risk for inadequate nutrition, a daily 2-mg supplement is rec­
Folic acid supplementation in early pregnancy can lower ommended. As discussed on page 1 74, vitamin B6, when com­
neural-tube defect risks (Chap. 1 3, p. 270) . Namely, the CDC bined with the antihistamine doxylamine, is helpful in many
(2004) estimated that the number of afected pregnancies had cases of nausea and vomiting of pregnancy.
decreased from 4000 pregnancies per year to approximately Vitamin C allowances during pregnancy are 80 to 85 mg/ d­
3000 per year after mandatory fortiication of cereal products approximately 20 percent more than when nonpregnant (see
with folic acid in 1 998. Perhaps more than half of all neural­ Table 9-5) . A reasonable diet should readily provide this
tube defects can be prevented with daily intake of 400 �g of amount, and supplementation is not necessary (Rumbold,
folic acid throughout the periconceptional period. Evidence 20 1 5) . Maternal plasma levels decline during pregnancy,
also suggests that folate insuiciency has a global efect on brain whereas cord-blood levels are higher, a phenomenon observed
development (Ars, 20 1 6) . Putting 1 40 �g of folic acid into each with most water-soluble vitamins.
1 00 g of grain products may increase the folic acid intake of Vitamin D is a fat-soluble vitamin. After being metabolized
the average American woman of childbearing age by 1 00 �g/d. to its active form, it boosts the eiciency of intestinal calcium
Because nutritional sources alone are insuicient, however, absorption and promotes bone mineralization and growth.
folic acid supplementation is still recommended (American Unlike most vitamins that are obtained exclusively from dietary
College of Obstetricians and Gynecologists, 20 1 6e) . Likewise, intake, vitamin D is also synthesized endogenously with expo­
the U.S. Preventive Services Task Force (2009) recommends sure to sunlight. Vitamin D deiciency is common during preg­
that all women planning or capable of pregnancy take a daily nancy. his is especially true in high-risk groups such as women
supplement containing 400 to 800 �g of folic acid. with limited sun exposure, vegetarians, and ethnic minorities­
A woman with a prior child with a neural-tube defect can particularly those with darker skin (Bodnar, 2007) . Maternal
reduce the 2- to 5-percent recurrence risk by more than 70 deiciency can cause disordered skeletal homeostasis, congeni­
percent with a daily 4-mg folic acid supplement taken during tal rickets, and fractures in the newborn (American College of
the month before conception and during the first trimester. As Obstetricians and Gynecologists, 20 1 7k) . Vitamin D supple­
emphasized by the American Academy of Pediatrics and the mentation to women with asthma may decrease the likelihood
American College of Obstetricians and Gynecologists (20 1 7) , of childhood asthma in their fetuses (Litonjua, 20 1 6) . The Food
this dose should b e consumed as a separate supplement and not and Nutrition Board of the Institute of Medicine (20 1 1 ) estab­
as multivitamin tablets. This practice avoids excessive intake of lished that an adequate intake of vitamin D during pregnancy
fat-soluble vitamins. and lactation was 1 5 �g/d (600 IU/d) . In women suspected of
Vitamin A, although essential, has been associated with con­ having vitamin D deficiency, serum levels of 25-hydroxyvita­
geni tal malformations when taken in high doses (> 1 0,000 IU / d) min D can be obtained. Even then, the optimal levels in preg­
during pregnancy. These malformations are similar to those nancy have not been established (De-Regil, 20 1 6) .
produced by the vitamin A derivative isotretinoin (Accutane),
which is a potent teratogen (Chap. 1 2, p. 245 ) . Beta-carotene, • Pragmatic Nutritional Surveillance
the precursor of vitamin A found in fruits and vegetables, has
Although researchers continue to study the ideal nutritional
not been shown to produce vitamin A toxicity. Most prena­
regimen for the pregnant woman and her fetus, basic tenets for
tal vitamins contain vitamin A in doses considerably below
the clinician include:
the teratogenic threshold. Dietary intake of vitamin A in the
United States appears to be adequate, and additional supple­ 1 . Advise the pregnant woman to eat food types she wants in
mentation is not routinely recommended. In contrast, vitamin reasonable amounts and salted to taste.
A deiciency is an endemic nutritional problem in the develop­ 2. Ensure that food is amply available for socioeconomically
ing world (McCauley, 20 1 5) . Vitamin A deficiency, whether deprived women.
overt or subclinical, is associated with night blindness and with 3. Monitor weight gain, with a goal of approximately 2 5 to
an increased risk of maternal anemia and spontaneous preterm 3 5 lb in women with a normal BMI.
birth (West, 2003) . 4. Explore food intake by dietary recall periodically to discover
Vitamin BJ2 plasma levels drop in normal pregnancy, mostly the occasional nutritionally errant diet.
as a result of reduced plasma levels of their carrier proteins­ 5. Give tablets of simple iron salts that provide at least 27 mg
transcobalamins. Vitamin B J 2 occurs naturally only in foods of of elemental iron daily. Give folate supplementation before
animal origin, and strict vegetarians may give birth to neonates and in the early weeks of pregnancy. Provide iodine supple­
whose BI2 stores are low. Likewise, because breast milk of a mentation in areas of known dietary insuiciency.
vegetarian mother contains little vitamin B 1 2, the deiciency 6. Recheck the hematocrit or hemoglobin concentration at 28
may become profound in the breastfed infant (Higginbottom, to 32 weeks' gestation to detect signiicant anemia.
1 70 P reconce pti o n a l a n d P re nata l Ca re

TABLE 9-6. Some Contra i n d i catio ns to Exercise During P reg n a n cy

Sig n ifi ca nt card i ovasc u l a r or p u l m o na ry d i sease

S i g n ifi ca nt ri s k for p reterm labor: cerclage, m u ltifeta l gestation, s i g n ifi ca nt bleed i n g , t h reate ned preterm la bor, prematu rely
r u pt u red m e m b ra nes
Obstetrical com pl i cations: preecla m psia, p lacenta previa, a n e m i a, poorly contro l led d i abetes or epi lepsy, m o rb i d obesity,
feta l -g rowth restriction

S u m m a rized fro m America n Co l l ege of Obstet r i c i a n s a nd Gyn ecol og i sts, 201 7g.

COMMON CONCERNS recommending an exercise program. In the absence of contra­

indications listed in Table 9-6, pregnant women are encour­
• Employment aged to engage in regular, moderate-intensity physical activity
for at least 1 50 minutes each week. Each activity should be
More than half of the children in the United States are born
reviewed individually for its potential risk. Examples of safe
to working mothers. Federal law prohibits employers from
activities are walking, running, swimming, stationary cycling,
excluding women from job categories on the basis that they
and low-impact aerobics. However, they should refrain from
are or might become pregnant. he Family and Medical Leave
activities with a high risk of falling or abdominal trauma. Simi­
Act of 1 993 requires that covered employers must grant up to
larly, scuba diving is avoided because the fetus is at increased
1 2 work weeks of unpaid leave to an employee for the birth
risk for decompression sickness.
and care of a newborn child Qackson, 2 0 1 5). In the absence
In the setting of certain pregnancy complications, it is wise
of complications, most women can continue to work until the
to abstain from exercise and even limit physical activity. For
onset of labor (American Academy of Pediatrics and the Ameri­
example, some women with pregnancy-associated hypertensive
can College of Obstetricians and Gynecologists, 20 1 7) .
disorders, preterm labor, placenta previa, or severe cardiac or
Some types o f work, however, may increase pregnancy com­
pulmonary disease may gain from being sedentary. Also, those
plication risks. Mozurkewich and colleagues (2000) reviewed
with multiple or suspected growth-restricted fetuses may be
29 studies that involved more than 1 60,000 pregnancies. With
served by greater rest.
physically demanding work, women had 20- to 60-percent

• Seafood Consumption
higher rates of preterm birth, fetal-growth restriction, or ges­
tational hypertension. In a prospective study of more than 900
healthy nulliparas, women who worked had a ivefold risk of Fish are an excellent source of protein, are low in saturated
preeclampsia (Higgins, 2002) . Newman and coworkers (200 1 ) fats, and contain omega-3 fatty acids. The Avon Longitudinal
reported outcomes i n more than 2900 women with singleton Study of Parents and Children reported beneicial efects on
pregnancies. Occupational fatigue-estimated by the number of pregnancy outcomes in women who consumed 340 g or more
hours standing, intensity of physical and mental demands, and of seafood weekly (Hibbeln, 2007) . Because nearly all fish and
environmental stressors-was associated with an increased risk shellish contain trace amounts of mercury, pregnant and lac­
of preterm premature membrane rupture. For women reporting tating women are advised to avoid specific types of ish with
the highest degrees of fatigue, the risk was 7.4 percent. potentially high methylmercury levels. These include shark,
Thus, any occupation that subjects the gravida to severe swordfish, king mackerel, and tile fish. It is further recom­
physical strain should be avoided. Ideally, no work or play is mended that pregnant women ingest 8 to 1 2 ounces of fish
continued to the extent that undue fatigue develops. Adequate weely, but no more than 6 ounces of albacore or "white" tuna
periods of rest should be provided. It seems prudent to advise (U.S. Environmental Protection Agency, 20 1 4) . If the mercury
women with prior pregnancy complications that commonly content of locally caught fish is unknown, then overall fish con­
recur to minimize physical work. sumption should be limited to 6 ounces per week (American
Academy of Pediatrics and the American College of Obstetri­
• Exercise
cians and Gynecologists, 20 1 7) .

• Lead Screening
In general, pregnant women do not need to limit exercise, pro­
vided they do not become excessively fatigued or risk injury
(Davenport, 20 1 6) . Clapp and associates (2000) reported that Maternal lead exposure has been associated with several adverse
both placental size and birthweight were signiicantly greater maternal and fetal outcomes across a range of maternal blood
in women who exercised. Duncombe and coworkers (2006) lead levels (Taylor, 20 1 5) . These include gestational hyper­
reported similar findings in 1 48 women. In contrast, vfagann tension, miscarriage, low birthweight, and neurodevelopmen­
and colleagues (2002) prospectively analyzed exercise behavior tal impairments in exposed pregnancies (American College of
in 750 healthy women and found that working women who Obstetricians and Gynecologists, 20 1 6c) . The levels at which
exercised had smaller infants and more dysfunctional labors. these risks rise remains unclear. However, recognizing that such
The American College of Obstetricians and Gynecolo­ exposure remains a significant health issue for reproductive-aged
gists (20 1 7 g) advises a thorough clinical evaluation before women, the CDC (20 1 Oa) has issued guidance for screening
 P renata l Care 1 71

and managing exposed pregnant and lactating women. These as a result of air blown into the vagina during cunnilingus. Other
guidelines, which have been endorsed by the American College near-fatal cases have been described (Bernhardt, 1 988) .
of Obstetricians and Gynecologists (20 1 6c) , recommend blood
lead testing only if a risk factor is identified. If the levels are • Dental Care
> 5 /Lg1dL, then counseling is completed, and the lead source
Examination of the teeth is included in the prenatal examina­
is sought and removed. Subsequent blood levels are obtained.
tion, and good dental hygiene is encouraged. Indeed, periodon­
Blood lead levels >45 Lg/dL are consistent with lead poisoning,
tal disease has been linked to preterm labor. Unfortunately,
and women in this group may be candidates for chelation ther­
although its treatment improves dental health, it does not pre­
apy. Afected pregnancies are best managed in consultation with
vent preterm birth (Michalowicz, 2006). Dental caries are not
lead poisoning treatment experts. National and state resources
aggravated by pregnancy. Importantly, pregnancy is not a con­
are available at the CDC website: ww.cdc.gov/ncehllead/.
traindication to dental treatment including dental radiographs

• Automobile and Air Travel

(Giglio, 2009) .

Pregnant women are encouraged to wear properly positioned • Immunization

three-point restraints as protection against automobile crash
Current recommendations for immunization during pregnancy
injury (Chap. 47, p. 927) . The lap portion of the restraining
are summarized in Table 9-7. Well-publicized concerns regard­
belt is placed under the abdomen and across her upper thighs.
ing a causal link between childhood exposure to the thimerosal
The belt should be comfortably snug. The shoulder belt also is
preservative in some vaccines and neuropsychological disorders
irmly positioned between the breasts. Airbags should not be
have led to some parents to vaccine prohibition. Although con­
disabled for the pregnant woman.
troversy continues, these associations have proven groundless
In general, air travel in a properly pressurized aircraft has no
(Sugarman, 2007; Thompson, 2007; Tozzi, 2009) . Thus, many
harmful efect on pregnancy (Aerospace Medical Association,
vaccines may be used in pregnancy. The American College of
2003). Thus, in the absence of obstetrical or medical complica­
Obstetricians and Gynecologists (20 1 6b) stresses the impor­
tions, the American Academy of Pediatrics and the American
tance of integrating an efective vaccine strategy into the care
College of Obstetricians and Gynecologists (20 1 6a, 20 1 7) have
of both obstetrical and gynecological patients. The College fur­
concluded that pregnant women can safely ly up to 36 weeks'
ther emphasizes that information on the safety of vaccines given
gestation. It is recommended that pregnant women observe
during pregnancy is subject to change, and recommendations
the same precautions for air travel as the general population.
can be found on the CDC website at ww. cdc.gov/vaccines.
Seatbelts are used while seated. Periodic lower extremity move­
he frequency of pertussis infection has substantially risen in
ment and at least hourly ambulation help lower the venous
the United States. Young infants are at increased risk for death
thromboembolism threat. Signiicant risks with travel, espe­
from pertussis and are entirely dependent on passive immuniza­
cially international travel, are infectious disease acquisition and
tion from maternal antibodies until the infant vaccine series is
development of complications remote from adequate health­
initiated at age 2 months. For this reason, a three-agent tetanus
care resources (Ryan, 2002) .
toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)

• Coitus
vaccine is recommended and is safe for pregnant women (Cen­
ters for Disease Control and Prevention, 20 1 3b, 20 1 6; Mor­
In healthy pregnant women, sexual intercourse usually is not gan, 20 1 5) . However, as demonstrated by Healy and coworkers
harmul. Whenever miscarriage, placenta previa, or preterm labor (20 1 3) , maternal antipertussis antibodies are relatively short­
threatens, however, coitus is avoided. Nearly 1 0,000 women lived, and Tdap administration before pregnancy-or even in
enrolled in a prospective investigation by the Vaginal Infection the first half of the current pregnancy-is not likely to provide
and Prematurity Study Group were interviewed regarding sex­ a high level of newborn antibody protection. Thus, to maximize
ual activity (Read, 1 993) . hey reported a decreased frequency passive antibody transfer to the fetus, a dose of Tdap is ideally
of coitus with advancing gestation. By 36 weeks, 72 percent given to gravidas between 27 and 36 weeks' gestation (American
had intercourse less than once weekly. The decline is attributed College of Obstetricians and Gynecologists, 20 1 7j; Centers for
to lower desire and fear of harming the pregnancy (Bartellas, Disease Control and Prevention, 20 1 3b, 20 1 6) .
2000; Staruch, 20 1 6) . All women who will b e pregnant during inluenza season
Intercourse speciically late in pregnancy i s n o t harm­ should be ofered vaccination, regardless of gestational age.
ful. Grudzinskas and coworkers ( 1 979) noted no association hose with underlying medical conditions that increase the
between gestational age at delivery and coital frequency dur­ risk for infl u enza complications are provided the vaccine before
ing the last 4 weeks of pregnancy. Sayle and colleagues (200 1 ) lu season starts. In addition to maternal protection against
reported no increased-and actually a decreased-risk o f deliv­ infection, prenatal maternal vaccination in one study reduced
ery within 2 weeks of intercourse. Tan and associates (2007) the infant infl u enza incidence in the irst 6 months of life by
studied women scheduled for non urgent labor induction and 63 percent (Zaman, 2008) . Moreover, it reduced all febrile
found that spontaneous labor ensued at equal rates in groups respiratory illnesses in these infants by a third.
either participating in or abstaining from intercourse. Women who are susceptible to rubella during pregnancy
Oral-vaginal intercourse is occasionally hazardous. Aronson should receive measles, mumps, rubella (MMR) vaccination
and Nelson ( 1 967) described a fatal air embolism late in pregnancy postpartum. Although this vaccine is not recommended during
1 72 P reco n ce pti o n a l a n d P re nata l Care

TABLE 9-7. Reco m m endations for I m m u n ization D u ri n g Preg nancy

Ind ications for
I m munobiological Immunization During
Agent Pregnancy Dose Schedule Comments
Live Atten uated Virus Vacci nes
Measles Contra i n d icated-see Si ng le dose SCI prefera bly as MMRa Vacci nate suscepti ble women
i m m u ne g lobu l i ns postpartum . B reastfeedi ng is
not a co ntra i nd i cation
M u m ps Contra i n dicated Si n g le dose SCI prefera b ly as MMR Vacci nate susceptible women
postpartum
R u be l l a Contra i n d i cated, b u t Single dose SC, p refera bly as MMR Teratogenicity of vacci ne is
congen ita l rubella theoretical and not confi rmed
synd rome has never been to date; vacci nate susceptible
descri bed after vacci ne women postpart u m
Po! iomyel itis o ra l Not routi nely recom m ended P ri m a ry: Two doses of enha nced- Vacci ne i n d i cated for susceptible
= l ive for women i n the U n i ted pote ncy i nactivated v i ru s SC women t rave l i n g in endemic
atte nuated; States, except women at at 4- to 8-week i nte rva l s a n d a reas or i n other h i gh-risk
i njection = increased risk of expos u re b a 3 rd dose 6-1 2 months after situations
enha nced- 2nd dose
potency I m mediate protection: One dose
i nactivated vi rus o ra l po l i o vacci ne (in outbrea k
sett i ng)
Yel l ow fever Travel to h i g h-risk a reas Single dose SC L i m ited theoretical risk
outweig hed by risk of yel low
fever
Va ricella Contra i nd i cated, but no Two doses needed: 2nd dose Teratogenicity of vacci ne is
adverse outco mes reported g iven 4-8 weeks after 1 st dose theoretica l . Vacci nation of
in preg nancy susceptible women should be
considered postpa rtu m
Sma l l pox (vacci n ia) Contra i n d icated in p reg nant One dose SCI m u ltiple pricks with Only vacci n e known to ca use feta l
women a n d i n the i r lancet harm
household co ntacts
Other
I n fl uenza All preg nant women, One dose 1M every yea r I nactivated virus vacc i ne
rega rd l ess of tri mester
d u ri ng fl u season
(October -May)
Rabies I n d ications for prophylaxis not P u b l i c health a uthorities to be Ki l l ed-virus vaccine
altered by preg nancy; each consulted for i n d ications,
case considered i n d iv i d u a l ly dosage, a n d route of
a d m i n i stration
H u ma n Not recom mended Th ree-dose series 1M at 0, 1 , a n d Polyva lent vacci nes avai lable
pa p i l lomavirus 6 months conta i n i n g i nactivated v i rus.
No teratogenicity has been
observed
Hepatitis B P reexposure a n d Th ree-dose series 1M at 0 , 1 , a nd Used with hepatitis B i m m u ne
postexpos u re for women 6 months g lobu l i n for some exposures.
at risk of i nfection, e.g., Exposed newborn needs b i rth-
chronic l iver or kid ney dose vacci nation a nd i m mune
d isease g lobu l i n as soon as poss i ble.
All infa nts shou ld rece ive b i rth
dose of vacc i ne
He patiti s A P reexpos u re a n d Two-dose sched u l e 1M, 6 months I nactivated virus
postexposu re if at risk a part
(i nternational travel);
chronic Ii fer d i sease
 P re nata l Ca re 1 73

TABLE 9-7. Conti n ued

Indications for
Immunobiological Immunization During
Agent Preg nancy Dose Schedule Comments
I nactivated Bacterial Vacci nes
Pneu mococcu s I n d ications not altered by I n a d u lts, one dose o n ly; consider Polyva lent polysaccharide vacci ne;
preg nancy. Recommended repeat dose i n 6 yea rs for high­ safety in the fi rst tri mester has
for wo men with asplen i a; risk women not been eva l uated
metabol ic, renal, ca rd iac,
or p u l mona ry d i seases;
i m m u n osu ppression; or
smokers
Meni ngococcus I nd ications not a ltered by One dose; tetrava lent vacci ne: two A nt i m i crobial prophylaxis if
preg nancy; vacci nation doses for asplenia sign ificant exposu re
recom mended in u n us u a l
outbreaks
Typhoid Not recom mended rou t i nely Ki l led Ki l led, i njectable vacci ne or l ive
except for close, co nti n ued Primary: 2 i njections 1M 4 weeks atten u ated ora l vacci ne. O ral
expos u re or travel to a pa rt vacci ne preferred
endemic areas Booster: One dose; sched u l e not

Chapter 64 (p. 1 228)

yet determ i ned

of B an thracis. No dead or l ive

Anth rax S ix-dose primary vacci nation, then P repa ration from ce l l-free fi ltrate
a n n u a l booste r vacci nation
bacteria. Teratoge n icity of
vacci ne theoretica l
Toxoids
Teta n u s-d i p htheria­ Recommended in every P ri m a ry: Two doses 1 M at 1 -2 Com b i ned teta n u s-d i phtheria

between 27 and 36 weeks 6- 1 2 months ater the 2nd

ace l l u l a r pert u ss i s preg nancy, prefera b ly month i n terva l with 3 rd dose toxoids with ace l l u la r pert u ssis
(Tdap) (Tdap) p referred. U pdating
to max i m ize passive Booster: Single dose 1 M every i m m u n e status should be part
a nti body transfer 1 0 yea rs, as a pa rt of wou n d of a ntepa rtu m ca re
ca re if : 5 yea rs si nce last dose,
or once per preg nancy
Specific I m m une Globu l ins
Hepatitis B Postexposu re prophylaxis Depends on exposu re U s u a l ly g ive n with hepatitis B virus
(Chap. 5 5 , p. 1 064) vacci ne; exposed newborn
needs i m med i ate p ro phylaxis
Rabies Postexpos u re prophylaxis Half dose at i nj u ry site, half dose i n Used i n conj u nction with ra b i es
deltoid kil led-vi rus vacc i n e
Teta n u s Postexposu re prophylaxis One dose 1M Used i n conj u nction w i t h teta n u s
toxoid
Va ricella Should be considered for One dose 1 M with i n 96 hours of I n d i cated a l so for newborns or
exposed preg nant women expos u re women who deve loped va ricel la

2 days fol lowi n g d e l ive ry

to protect agai nst maternal, with i n 4 days before del ivery or
not congen ital, i nfecti o n
Standard I m m u n e Globu l i n s
Hepatitis A: Postexpos u re prophylaxis a n d 0.02 m Ukg 1 M i n one dose I m m u ne g lobu l i n s h o u l d be g iven

2 weeks o f expos u re; i nfants

Hepatitis A those a t h igh risk as soon as poss i b l e a n d with i n
virus vacci ne
shou l d be u sed born to women who a re
with hepatitis A i n c u bati n g the virus or a re
i m m u ne g lo b u l i n acutely i l l at del ivery s h o u l d
receive o n e dose of 0 . 5 m L as
soo n as poss i ble after b i rth

'Two doses n ecessa ry for students entering i nstitutions of h ig h er ed u cation, n ewly h i red medica l person nel, and t ravel a b road.
b l nactlvated pol io vacci n e recom mended for n on i m m u n ized a d u l ts at i n c reased risk.
10 = i nt radermal ly; 1 M i nt ra m u s c u l a rly; M M R meas l es, m u m ps, ru bel l a; PO o ra l ly; SC s u bcuta neou sly.
= = = =

F rom the Centers for Disease Control and P reve nt i o n, 20 1 1 ; Ki m, 2 0 1 6.

1 74 P reconceptio n a l a n d P re nata l Ca re

pregnancy, congenital rubella syndrome has never resulted from Heartburn is another common complaint of gravidas and
its inadvertent use. Breastfeeding is compatible with MMR vac­ is caused by gastric content reflux into the lower esophagus.
cination (Centers for Disease Control and Prevention, 20 1 l ) . The greater frequency of regurgitation during pregnancy most
likely results from upward displacement and compression of
• Cafeine the stomach by the uterus, combined with relaxation of the
lower esophageal sphincter. Avoiding bending over or lying flat
Whether adverse pregnancy outcomes are related to cafeine
is preventive. In most pregnant women, symptoms are mild
consumption is somewhat controversial. As summarized from
and relieved by a regimen of more frequent but smaller meals.
Chapter 1 8 (p. 348) , heavy intake of cofee each day-about
Antacids may provide considerable relief (Phupong, 20 1 5) .
five cups or 5 00 mg of cafeine-slightly raises the miscarriage
Specifically, aluminum hydroxide, magnesium trisilicate, or
risk. Studies of "moderate" intake-less than 200 mg daily­
magnesium hydroxide is given alone or in combination. Man­
did not fi n d a higher risk.
agement of heartburn or nausea that does not respond to sim­
It is unclear if cafeine consumption is associated with pre­
ple measures is discussed in Chapter 54 (p. 1 045) .
term birth or impaired fetal growth. Clausson and coworkers

• Pica and Ptyalism

(2002) found no association between moderate cafeine con­
sumption of less than 500 mg/d and low birthweight, fetal­
growth restriction, or preterm delivery. Bech and associates The craving of pregnant women for strange foods is termed
(2007) randomly assigned more than 1 200 pregnant women pica. Worldwide, its prevalence is estimated to be 30 percent
who drank at least three cups of cofee per day to cafein­ (Fawcett, 20 1 6) . At times, nonfoods such as ice-pagophagia,
ated versus decafeinated cofee. They found no diference in starch-amylophagia, or clay-geophagia may predominate.
birthweight or gestational age at delivery between groups. The This desire is considered by some to be triggered by severe iron
CARE Study Group (2008), however, evaluated 2635 low­ deficiency. Although such cravings usually abate after deficiency
risk pregnancies and reported a l .4-fold risk for fetal-growth correction, not all pregnant women with pica are iron deficient.
restriction among those whose daily cafeine consumption Indeed, if strange "foods" dominate the diet, iron deficiency
was > 200 mg/d compared with those who consumed < 1 00 will be aggravated or will develop eventually.
mg/d. he American College of Obstetricians and Gynecolo­ Patel and coworkers (2004) prospectively completed a
gists (20 1 6d) concludes that moderate consumption of caf­ dietary inventory on more than 3000 women during the sec­
feine-less than 200 mg/ d-does not appear to be associated ond trimester. The prevalence of pica was 4 percent. The most
with miscarriage or preterm birth, but that the relationship common nonfood items ingested were starch in 64 percent, dirt
between cafeine consumption and fetal-growth restriction in 14 percent, sourdough in 9 percent, and ice in 5 percent.
remains unsettled. The American Dietetic Association (2008) he prevalence of anemia was 1 5 percent in women with pica
recommends that cafeine intake during pregnancy be limited compared with 6 percent in those without it. Interestingly, the
to less than 300 mg/d, which approximates three 5 -oz cups of rate of spontaneous preterm birth before 35 weeks was twice as
percolated cofee. high in women with pica.
Women during pregnancy are occasionally distressed by
• Nausea and Heartburn profuse salivation p yalism . Although usually unexplained,
-

ptyalism sometimes appears to follow salivary gland stimula­

Nausea and vomiting are common complaints during the first
tion by the ingestion of starch.
half of pregnancy. These vary in severity and usually commence

• Headache or Backache
between the first and second missed menstrual period and con­
tinue until 1 4 to 1 6 weeks' gestation. Although nausea and
vomiting tend to be worse in the morning-thus erroneously At least 5 percent of pregnancies are estimated to be compli­
termed morning sickness-both symptoms frequently continue cated by new-onset or new-type headache (Spierings, 20 1 6) .
throughout the day. Lacroix and coworkers (2000) found that Common headaches are virtually universal. Acetaminophen is
nausea and vomiting were reported by three fourths of preg­ suitable for most of these, and an in-depth discussion is found
nant women and lasted an average of 35 days. Half had reliefby in Chapter 60 (p. 1 057) .
14 weeks, and 90 percent by 22 weeks. In 80 percent of these Low back pain to some extent is reported by nearly 70 per­
women, nausea lasted all day. cent of gravidas (Liddle, 20 1 5 ; Wang, 2004) . Minor degrees
Treatment of pregnancy-associated nausea and vomiting follow excessive strain or significant bending, lifting, or walk­
seldom provides complete relief, but symptoms can be mini­ ing. It can be reduced by squatting rather than bending when
mized. Eating small meals at frequent intervals is valuable. One reaching down, by using a back-support pillow when sitting,
systematic literature search reported that the herbal remedy and by avoiding high-heeled shoes. Back pain complaints
ginger was likely efective (Borrelli, 2005). Mild symptoms usu­ increase with progressing gestation and are more prevalent in
ally respond to vitamin BG given along with doxylamine, but obese women and those with a history of low back pain. In
some women require phenothiazine or H I -receptor blocking some cases, troublesome pain may persist for years after the
antiemetics (American College of Obstetricians and Gynecolo­ pregnancy (Noren, 2002).
gists, 2 0 1 5c) . In some with hyperemesis gravidarum, vomiting Severe back pain should not be attributed simply to preg­
is so severe that dehydration, electrolyte and acid-base distur­ nancy until a thorough orthopedic examination has been con­
bances, and starvation ketosis become serious problems. ducted. Severe pain has other uncommon causes that include
 P renata l Care 1 75

pregnancy-associated osteoporosis, disc disease, vertebral osteo­ sleep eiciency appears to progressively diminish as pregnancy
arthritis, or septic arthritis (Smith, 2008) . More commonly, advances. Wilson and associates (20 1 1 ) performed overnight
muscular spasm and tenderness are classiied clinically as acute polysomnography and observed that women in the third tri­
strain or ibrositis. Although evidence-based clinical research mester had poorer sleep eiciency, more awakenings, and less
directing care in pregnancy is limited, low back pain usually of both stage 4 (deep) and rapid-eye movement sleep. Women
responds well to analgesics, heat, and rest. Acetaminophen may in the irst trimester were also afected, but to a lesser extent.
be used chronically as needed. Nonsteroidal antiinlammatory Daytime naps and mild sedatives at bedtime such as diphen­
drugs may also be beneicial but are used only in short courses hydramine (Benadryl) can be helpful.
to avoid fetal efects (Chap. 1 2, p. 24 1 ) . Muscle relaxants
that include cyclobenzaprine or baclofen may be added when • Cord Blood Banking
needed. Once acute pain is improved, stabilizing and strength­
Since the irst successful cord blood transplantation in 1 988,
ening exercises provided by physical therapy help improve
more than 2 5,000 umbilical cord blood transplantations have
spine and hip stability, which is essential for the increased load
been performed to treat hemopoietic cancers and various genetic
of pregnancy. For some, a support belt that stabilizes the sacro­
conditions (Butler, 20 1 1 ) . There are two types of cord blood
iliac joint may be helpful (Gutke, 20 1 5) .
banks. Public banks promote allogeneic donation, for use by a

• Varicosities a n d Hemorrhoids
related or unrelated recipient, similar to blood product dona­
tion (Armson, 20 1 5) . Private banks were initially developed to
Venous leg varicosities have a congenital predisposition and store stem cells for future autologous use and charged fees for
accrue with advancing age. They can be aggravated by factors initial processing and annual storage. The American College of
that raise lower extremity venous pressures, such as an enlarg­ Obstetricians and Gynecologists (20 1 5d) has concluded that if a
ing uterus. Femoral venous pressures in the supine gravida woman requests information on umbilical cord banking, infor­
rise from 8 mm Hg in early pregnancy to 24 mm Hg at term. mation regarding advantages and disadvantages of public versus
Thus, leg varicosities typically worsen as pregnancy advances, private banking should be explained. Some states have passed
especially with prolonged standing. Symptoms vary from cos­ laws that require physicians to inform patients about cord blood
metic blemishes and mild discomfort at the end of the day to banking options. Importantly, few transplants have been per­
severe discomfort that requires prolonged rest with feet eleva­ formed by using cord blood stored in the absence of a known
tion. Treatment is generally limited to periodic rest with leg indication in the recipient (Screnci, 20 1 6) . The likelihood that
elevation, elastic stockings, or both. Surgical correction during cord blood would be used for the child or family member of
pregnancy generally is not advised, although rarely the symp­ the donor couple is considered remote, and it is recommended
toms may be so severe that injection, ligation, or even stripping that directed donation be considered when an immediate family
of the veins is necessary. member carries the diagnosis of a speciic condition known to be
Vulvar varicosities frequently coexist with leg varicosities, treatable by hemopoietic transplantation (Chap. 56, p. 1 075).
but they may appear without other venous pathology. Uncom­
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• Sleeping and Fatigue

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