Download Routine Prenatal Care

Maternity Care I
By: Brittany Wyger, MD (PGY-III)
 Routine physical exam including pelvic exam at initial visit
 Detect reproductive tract abnormalities & screen for STI
 Maternal weight at all visits
 Height and weight at first visit to determine BMI
 Maternal BP at all visits
 Identify chronic HTN, preeclampsia or gestational
hypertension
 Fetal HR auscultation after 10-12 weeks with doppler
 Used to confirm viable fetus, HR range = 110-160
 Fundal height after 20 weeks
 Fundal height in cm should roughly equal gestational age in
weeks
 Fetal lie by 36 weeks
 Abdominal palpation with Leopold maneuvers
Calorie intake
 Most women require an additional 300-400 cal per day
Recommended weight gain for BMI
 Singleton pregnancy
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BMI <18.5 (underweight) — weight gain 28 to 40 lbs
BMI 18.5 to 24.9 (normal weight) — weight gain 25 to 35 lbs
BMI 25.0 to 29.9 (overweight) — weight gain 15 to 25 lbs
BMI ≥30.0 (obese) — weight gain 11 to 20 lbs
 Twin pregnancy
 BMI <18.5 (underweight) — no recommendation due to insufficient
data
 BMI 18.5 to 24.9 (normal weight) — weight gain 37 to 54 lbs
 BMI 25.0 to 29.9 (overweight) — weight gain 31 to 50 lbs
 BMI ≥30.0 (obese) — weight gain 25 to 42 lbs
 Evaluation for edema
 >1+ pitting edema after 12 hours bed rest or weight gain of 5 lb in 1
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week
 Occurs in 80% of pregant women and lacks specificity and
sensitivity in diagnosing preeclampsia
Urinalysis
 To evaluate for asymptomatic bacteriuria and protein
Pap smear should be offered
 Based on age (>21) and pap history
Oral exam
 Periodontal disease associated with increased risk of preterm birth
Dietary counseling and folic acid supplementation
 0.4mg daily recommended (4 weeks before conception ideally) to
help prevent neural tube defects
 If previous fetus with NTD or family history, 4mg recommended
daily
 Physical exam and counseling on prenatal topics
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pertinent to current gestational age of pregnancy
Urinalysis
Vital signs, height and weight
Doppler for fetal heart tones starting after week 10
Fundal height measurement after 20 weeks
Fetal lie by Leopold maneuvers after 36 weeks (you
can also do transabdominal US to confirm vertex
positioning)
Pelvic exam for cervical change and station after 36
weeks
 Urine pregnancy test to confirm pregnancy
 Pap smear only if age >21 and not current
 GC/Chlamydia genprobe
 USPSTF recommendation (2005)
 If <25 years old
 Engaging in high risk sexual behaviors (incl those living in high
prevalence areas…aka Louisiana), drug use, multiple partners, no
barrier contraception, incarcerated
 (if positive treat with Rocephin & Zithromax respectively)
 Wet prep only if they complain of discharge (if trich positive
treat with Flagyl)
 Pelvic exam
 Dating based on LMP (Naegle’s rule)
 LMP (1st day) + 1 year – 3 months + 7 days
 LMP- 07/23/2014, EDD- 04/30/2015
 Refer immediately for OB ultrasound to confirm gestational
age (earlier the US, the more accurate the dates)
 Prescribe prenatal vitamins, can also recommend
prenatal/ OB gummy vitamin if patient does not
tolerate regular prenatal vitamins
 Influenza vaccination (can be given in any
trimester)
 Genetic screen/ Risk assessment
 If high risk OB recommend referral to fetal-
maternal medicine, Dr. Rodts-Palenik
 Order OB panel labs
 CBC, CMP
 Urinalysis, Urine culture, UPT (treat asymptomatic
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bacteriuria in pregnancy)
RPR (treat with Penicillin G Benthazine)
HIV (antiretroviral therapy)
Rubella IgG (if non-immune, vaccinate after
delivery)
Hepatitis B surface antigen (treatment is active and
passive immunization of infant after delivery)
Antibody screen
ABO/Rh (if Rh- neg will need rhogam)
 Sickle cell screen (if African-American or
Caribbean descent)
 +/- Cystic Fibrosis screening
 Cervical cytology (as needed)
 HPV co-test
 <30 years of age- reflex (ASCUS) every 3 years
 >30 years of age- routine with pap every 5 years
 Maternal quad screen (16 weeks)
 If abnormal, patient may want further testing
(amniocentesis)
 Refer for OB ultrasound to assess fetal anatomy (18-20
weeks) and placental location
 Gestational diabetes screen (O’Sullivan)- 1 hour
GTT (50g oral glucose load)
 If CBS >140, recommend 3 hour GTT, if >190 skip 3hr
 3 hr GTT 1 hr<180, 2hr <155, 3hr <140
 Administer RhoGam if Rh negative patient (28
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weeks)
Repeat H&H to evaluate for anemia
STI testing if increased risk
Refer to OBGYN for BTL if requested by patient
(they must sign consent forms several weeks in
advance)
Tdap vaccination (28-32 weeks)
 Group B strep
 If positive, treat with intrapartum antibiotic prophylaxis
(PCN)
 Fax records to L&D
 Give patient pager number or cell number if you so
choose
 Counsel on labor & delivery preparation, where to go,
who to call, signs of labor etc.
 Induction of labor not recommened before 40 weeks
 If you and your patient choose induction, you must
speak with Dr. Madden ahead of time and reserve a
room in L&D (they usually need 1-2 days notice)
 L&D (318) 769-7030
 Clinic visits recommened every 4 weeks from intial
visit to 28 weeks gestation
 From 28-36 weeks recommend routine prenatal visits
every 2 weeks
 After 36 weeks recommend routine prenatal visits
weekly
 These are approximate and will change if patient is
high risk OB
 Artificial sweeteners
 Saccharin known to cross placenta and may remain in fetal
tissue
 Caffeine
 Limit to 150-300mg per day, high dose associated with
spontaneous abortion and low birth weight
 Dairy
 Avoid unpasteurized and soft cheeses (feta, brie, mexican
queso), risk of Toxoplasma and Listeria
 Deli foods
 Avoid deli metas, paté and meat spread, risk of Listeria
 Eggs
 Avoid raw eggs (ceasar salad, eggnog, raw cookie dough), risk
of Salmonella
 Seafood
 Avoid shark, swordfish, mackerel, tilefish, tuna steaks, raw fish
(sushi), shellfish
 Limit intake of other fish (incl canned tuna) to 12 oz per week
 Risk of Listeria, parasites, norovirus, organic pollutants
(polychlorinated biphenyls and dioxins), high mercury levels can
cause neurologic abnormalities in mother and fetus
 Herbal teas
 Avoid chamomile, licorice, peppermint, raspberry leaf
 Associated with uterine contraction, increased uterine blood flow,
spontaneous abortion
 Meat
 Avoid undercooked meat, risk of Listeria and Toxoplasma
 Excessive consumption of liver products can cause Vit A toxicity
 Leftovers
 Thoroughly reheat before eating, risk of Listeria
 Air travel
 Safe up to 36 weeks, long flights increased risk of DVT
 Consider the availability of medical resources at destination
 Breastfeeding
 Recommended as best feeding method
 Contraindicated in HIV, illicit drug use and certain medications
 Childbirth education
 Several childbirth classes are offered, increases maternal confidence
but does not change overall birth outcomes
 Exercise
 30 mins moderate exercise most days of the week recommended
 Avoid activities that put patient at risk for falls or abdominal trauma
 Fetal movement counts
 Not recommended, increases maternal anxiety
 Hair treatments
 Avoid during pregnancy, however not explicitly linked to
malformation
 Heavy metals
 Avoid because of potential for delayed fetal neurologic
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development
Herbal therapies
 Avoid ginko, ephedra & ginseng (known to be harmful to
fetus)
Hot tubs/ saunas
 Avoid in 1st trimester, heat exposure linked to NTD &
miscarriage
Labor & delivery
 What to do if membranes rupture, where to go, who to call,
pain management plan, support system during delivery
Medications & OTC
 Risk and benefits of medications
Radiation
 Avoid ionizing radiation (may affect fetal thyroid
development)
 Workplace issues
 Prolonged standing, exposure to certain chemicals or
radiation in the workplace
 Seat-belt use
 Use 3 point seatbelt with shoulder strap
 Sex
 May continue during pregnancy, contraindicated in
placenta previa
 Solvents
 Avoid exposure particularly in areas without adequate
ventilation, increase risk of miscarriage
Substance use
 Alcohol
 Screen pregnant women for alcohol use
 No amount of alcohol has been proven safe in pregnancy
 Fetal alcohol syndrome
 Tobacco
 Screen pregnant for tobacco use
 Offer smoking cessation counseling
 Increased risk of low birth weight
 Illicit drugs
 Inform pregnant women of potential adverse effects on
the fetus, detoxification programs, methadone therapy
in opiate addiction
 Accurate dating as early as possible in the pregnancy is
essential
 UPT usually positive within 1 week of missed menses
 Naegele’s rule
 LMP (1st day) + 1 year – 3 months + 7 days
 Ex: April 7, 2014 = LMP
EDD- January 14, 2015
 Early US can accurately date the pregnancy & evaluate
for multiple gestation
 Accurate within 4-7 days in 1st trimester, 10-14 days in 2nd
trimester, 21 days in 3rd trimester
 US performed at 18-20 weeks gestation for fetal
anatomic screening
 Risk of developing alloimmunization for an RhD
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negative woman carrying an RhD positive fetus is
approximately 1.5%
Risk reduced to 0.2% with RhoGam administration
RhoGam is Rh(D) immune globulin
ABO and Rh testing should be performed at initial
visit
Rh negative women should be given RhoGam
(300mcg) at 28 weeks and again within 72 hours of
delivery if infant has RhD-positive blood
 RhoGam should also be given if risk of fetal-maternal
transfusion is increased (CVS, amniocentesis, external
cephalic version, abdominal trauma, bleeding in 2nd or
3rd trimester)
 Alloimmunization is uncommon before 12 weeks
 Threatened early spontaneous abortion  RhoGam
50mcg
 Iron deficiency anemia
 Associated with increased risk of low birth
weight & preterm delivery
 All pregnant women should be screened at initial
visit and treated with supplemental iron if
indicated (in addition to prenatal vitamin)
 Pregnant women who do not respond to iron
supplementation within 4-6 weeks should be
evaluated for other conditions (malabsorption,
ongoing blood loss, thalassemia, other chronic
diseases)
 Most organizations recommend that all pregnant
women be offered screening
 Invasive genetic testing should be offered to
women >35 years of age
 Aneuploidy screening
 Nuchal translucency testing + serum testing (911 weeks gestation) and serum testing again (1519 weeks gestation)
 If screening test is positive, offer amniocentesis
(>15 weeks gestation) or chorionic villous sampling
(11-13 weeks gestation)
Prenatal Screening Tests for Down Syndrome
 First trimester screening
 Nuchal translucency, free β-hCG, PAPPA
(pregnancy associated plasma protein A),
maternal age
 Quadruple screening (second trimester)
 Unconjugated estriol, α-fetoprotein, free β-hCG,
inhibin A, maternal age
 Integrated screening (first and second trimesters)
 Nuchal translucency, PAPPA, α-fetoprotein,
unconjugated estriol, free β-hCG/total hCG,
inhibin A, maternal age
**Most common reason for false positive is incorrect EGA**
 Other screening tests offered to those with genetic
risks based on family history of the patient and her
partner
 Examples include:
 Cystic fibrosis
 Tay-sachs
 Canavan disease
 Sickle cell disease
 Thalassemias
 Affect 1.5 per 1,000 pregnancies
 Detected by testing maternal serum alpha-
fetoprotein levels (elevated MSAFP)
 Folic acid supplementation recommended early,
ideally prior to conception
 Folic acid 400mcg daily before pregnancy and
continued until 12 weeks gestation decreases the
rate of NTD by 75%
 For those on anti-seizure meds Valproate or
Carbamazepine  4mg folic acid per day recommended
 Measure TSH in women with history of thyroid
diease, Type-1 DM, other autoimmune diseases,
family history of autoimmune diseases or any
symptoms of thyroid disease
 Thyroid disease causes increased risk of pregnancy
loss, preeclampsia, low birth weight, thyroid
storm, prematurity and maternal CHF
 Women with hypothyroidism prior to pregnancy
will need increased doses of Synthroid
 Goal TSH <2.5 mIU
 Bacterial vaginosis
 Universal screening not recommended
 Rubella
 Screen for Rubella immunity at first visit, ideally should be before
conception (when vaccination is safe)
 Non-immune patient’s should be given MMR postpartum, MMR is
contraindicated during pregnancy but can be given during lactation
 Varicella
 Screen through maternal history
 Maternal varicella can cause congenital varicella syndrome (low birth
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weight, limb/ophthalmologic/neurologic abnormalities) and neonatal
varicella
Maternal shingles is not a risk (passive maternal immunity)
Some evidence to support serologic testing if unknown immunity
Non-immune women should receive vaccination postpartum and avoid
exposure during pregnancy
Varicella-zoster IG therapy may be given in the event of recent exposure
 Asymptomatic bacteriuria
>100,000 cfu of a single bacterial species, E.coli – most common
Complicates 2-7% of pregnancies
Screen at 11-16 weeks
If patient has sickle cell trait then screen q trimester
Treat to reduce risk of UTI, pyelonephritis and preterm labor
Treatment of choice- Cephalexin 250mg po QID x7d (ampicillin no
longer recommended due to high resistance rates)
 Repeat urine cx after therapy to ensure cure
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 Influenza
 Vaccinate for influenza including household contacts
 Can be given at any time during the pregnancy
 Tetanus and Pertussis
 Vaccinate at 27-36 weeks gestation for best antibody response and
passive immunity to the fetus
 Group B Streptococcus
 Screen at 35-37 weeks gestation
 Treat with intrapartum antibiotic prophylaxis (PCN,
Clindamycin (if PCN allergy and susceptible)), use
vancomycin if resistant to Clinda
 Treatment indicated also for anyone with GBS
bacteriuria at any stage of pregnancy or with
unknown GBS status and risk factors including:
preterm birth, ROM >18 hours or maternal fever
 Women with negative GBS Cx within 5 weeks of
delivery do not require Abx even if risk factors
develop (delivery <37 weeks, ROM >18 hrs,
intrapartum temp>100.4)
 Chlamydia- screening recommended
 Tx- Azithromycin, erythromycin, clindamycin
 Congenital eye infections, pneumonia, preterm birth
 Gonorrhea- screening based on personal or geographic risk
 Tx- Cefixime (Suprax), Ceftriaxone (Rocephin)
 Chorioamnionitis, preterm birth, low birth weight,
congenital eye infections
 HPV Condylomata- screening not indicated
 Tx- cryotherapy, trichloroacetic acid
 Vertical transmission, self-limited, usually minor
 Hep B- screening recommended
 Tx- active and passive immunization of the infant
 Vertical transmission
 HSV- screening not indicated, history should be asked
 Culture or PCR testing of lesions
 Tx- Acyclovir or Valacyclovir prophylaxis at 36 weeks for
HSV history, suppressive therapy recommended 36
weeksdelivery
 Vertical transmission risk, c-section for patient with
active lesions at delivery
 HIV- screening recommended
 Tx: Antiretroviral therapy
 Vertical transmission
 Syphilis- screening recommended
 RPR or VDRL
 Tx: Penicillin G benzathine
 Congenital syphillis
 Trichomonas- screening not indicated
 Tx- Metronidazole (Flagyl)
 Preterm birth, PROM, low birth weight
 Considered safe
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Amoxicillin
Ampicillin
Clindamycin
Erythromycin
Penicillin
Cephalosporins
 Typically avoid
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Tetracyclines
Nitrofurantoin*
Sulfonamides*
* Mixed evidence of potential birth defects per ACOG
 Gestational Diabetes
 Complicates 2-5% of pregnancies
 Associated with hypertensive disorders, macrosomia,
shoulder dystocia and c-section deliveries
 ACOG recommends screening early in pregnancy for
those at risk (hx of gestational DM, obesity or known
glucose intolerance) with HbA1C or fasting glucose
 All pregnant women should be screened at 24-28 weeks
with a 1 hour GTT (50g glucose load)
 Abnormal 1 hour GTT should be followed by a 3 hour
GTT (100g glucose load)
 Fasting glucose <95
 1 hr GTT 1 hr<140 (if >190 skip the 3hr GTT)
 3 hr GTT 1 hr<180, 2hr <155, 3hr <140
 Ectopic Pregnancy
 Risk factors:
 Previous ectopic pregnancy
 In utero DES exposure
 History of STI or infertility
 Current smoking
 Diagnosis:
 Abdominal pain & vaginal bleeding, approximately 7 weeks after
LMP
 US is diagnostic test of choice (no intrauterine gestational sac)
 Transabdominal US: β-hcg >3500
 Transvaginal US: β-hcg >1800
Ectopic Pregnancy
 Diagnostic curettage: used when β–hcg levels
falling or levels are elevated and US does not show
IUP
 If chorionic villi not detected, suspect ectopic pregnancy
 Decreasing β-hcg follow hcg titers
 Rising or stable + mass >4cm laparoscopy/laparotomy
 Rising or stable + mass <4cm Medical treatment
Ectopic Pregnancy
 Treatment:
 Hemodynamically unstable Laparotomy
 Stable patient/ Early diagnosis
 Laparoscopic salpingostomy
 Medical management with Methotrexate
 MTX contraindicated: Breastfeeding, immunodeficiency, liver
disease, blood dyscrasias, acute pulmonary disease, PUD, renal
disease
 Hypertension in Pregnancy
 BP measured at each clinic visit
 Counsel patients on warning signs of
preeclampsia
 Pts with chronic HTN or preeclampsia in
previous pregnancy should have baseline urine
protein
 Safe medications inlude: Methyldopa
(Aldomet), Nifedipine (Procardia) and Labetalol
(Trandate)
 Preterm Birth
 Before 37 weeks gestation
 >500,000 preterm births annually in the US
 Progesterone IM weekly from 16-37 weeks gestation
reduces preterm birth by 35% in women with hx of
PROM or spontaneous preterm labor
 Very expensive and hard to find at most pharmacies
 Cervical cerclage may reduce risk in women with
shortened cervical length with previous preterm
birth
 Posterm Pregnancy
 Decreased risk of perinatal death among women
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induced at 41 weeks vs expectant management
to 42 weeks gestation
Rate of meconium aspiration was lower with
induction but no difference in rate of c-section
delivery or operative vaginal delivery
Counsel patients on risks and benefits of both
options
Twice weekly NST and weekly AFI testing
Induction recommended if AFI <5mL or max
vertical pocket <2cm at term
Which one of the following is a standard component of
all prenatal visits? (check one)
A: Breast examination
B: Maternal weight measurement
C: Assessment of fetal lie
D: Pelvic examination
 B: Maternal weight measurement
All pregnant women should be screened for which one
of the following sexually transmitted infections?
(check one)
A: Hepatitis B virus
B: Gonorrhea
C: Herpes virus
D: Trichomonas
 A: Hepatitis B virus
Which one of the following vaccinations are safe to give
during pregnancy? (check all that apply)
A: Influenza
B: Diptheria & Tetanus
C: MMR
D: Varicella
E: BCG
 A: Influenza
 B: Diptheria & Tetanus
When should a healthy pregnant patient be screened for
gestational diabetes? (check one)
A: 10-14 weeks gestation
B: 16-20 weeks gestation
C: 24-28 weeks gestation
D: 30-34 weeks gestation
 C: 24-28 weeks gestation
How much folic acid supplemenation is recommended
for a patient with a family history of neural tube
defects? (check one)
A: 40mcg daily
B: 400mcg daily
C: 4mg daily
D: 40mg daily
 C: 4mg daily