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1. The menstrual cycle can be considered a comprehensive physiological adaptation for potential pregnancy. 2. Normal menstrual cycles last 21–45 days (average 28 days), counted from the first day of menstrual bleeding. 3. Physiological adaptations of pregnancy affect most major organ systems including cardiac, renal, gastrointestinal, and endocrine systems.

1. Preconception counseling is medical evaluation and intervention performed prior to conception with the expectation that the course and outcome of subsequent pregnancies will be improved. 2. Preconception counseling and intervention may occur only in the context of care for other medical conditions. 3. Preconception counseling consists of three primary activities: (a) risk identification/ assessment, (b) patient education, and (c) risk intervention, when possible. 4. The postpartum period is often an ideal opportunity for preconception counseling for subsequent pregnancies.

1. Prenatal care is a process not an event. 2. Excellent prenatal care represents a partnership between the provider, the patient, and her family. 3. Key domains of intake information in prenatal care include pregnancy dating, baseline maternal health status, family health history, medical conditions impacted by pregnancy, medical conditions impacting pregnancy, and infection. 4. Key domains of information during follow-up visits include normal growth and development, medical and/or obstetrical complications of pregnancy, onset of labor.

1. All medications should be viewed with caution in pregnancy. 2. Management of medication use in pregnancy ideally begins with adequate preconception counseling and pre-pregnancy planning. 3. Medications used in pregnancy require clear identification of indication for use, duration of treatment, expected outcome, and signs or symptoms requiring early termination of their use. 4. When in doubt consultation with an expert in maternal-fetal medicine is strongly recommended.

1. Growth and development represent a complex interaction between genetic predisposition and environmental exposure. 2. Screening for genetic risk factors ideally begins in the preconception period.

1. Intrauterine growth restriction (IUGR) is defined as fetal weight below the 10th percentile and an abdominal girth below the 2.5 percentile. 2. Factors associated with IUGR can be categorized as fetal-genetic, uterineenvironmental, maternal, toxic exposures, and constitutional. 3. Complications associated with IUGR include early complications (increased mortality, pre-eclampsia, preterm labor, still birth) and late complications (learning, behavioral, and developmental abnormalities).

1. Preterm labor is uterine contractions resulting in progressive cervical change prior to 37 weeks gestation. Preterm delivery is delivery prior to 37 weeks gestation; low birthweight infants are those that weight less than 2500 g at delivery. 2. Prior to 34 weeks gestation, most patients should be considered for tocolysis; from 34 to 37 weeks gestation such decisions must be made on a case-by-case basis. 3. Complications associated with preterm delivery include increased perinatal mortality and complications of prematurity (including respiratory distress, gastrointestinal dysfunction, hemorrhage, and abnormalities of growth and development).

1. Premature rupture of membranes (PROM) is defined as rupture prior to the onset of labor. 2. Preterm premature rupture of membranes (PPROM) is defined as PROM occurring prior to 37 weeks gestation. 3. Rupture of membranes is followed by onset of labor within 24 hours in 90% of term patients and 50% of preterm patients. 4. PROM is associated with an increased risk of ascending infection. This risk increases with duration of rupture.

1. Evaluation of early pregnancy bleeding should focus initially on identification of ectopic pregnancy and spontaneous abortion. 2. The primary concern of initial management is assessment of hemodynamic stability and possible peritonitis. 3. Management of ectopic pregnancy is designed to (a) minimize maternal morbidity and mortality, (b) remove the ectopic pregnancy, and (c) maximize potential future fertility. 4. Management of possible spontaneous abortion begins with ruling out the possibility of ectopic pregnancy.

1. Initial assessment of late pregnancy bleeding is designed to identify potential placenta previa and abruptio placentae. 2. No manual or speculum examination should be performed until placenta previa has been ruled out. 3. Placenta previa is an absolute contraindication to vaginal delivery. 4. Placenta previa and abruptio placentae are obstetrical emergencies and require rapid assessment and management. 5. Initial management of placenta previa and abruptio placentae is directed toward ensuring hemodynamic stability and safe delivery.