Key things:
<28 weeks: visits every 4 weeks
If antibody screen positive:
Order Anti-D titres
Consult Ob/Gyn/Perinatologist
Doppler to detect FHR starting at 10-12 weeks
Informal u/s at initial visit to measure CRL, especially if LMP uncertain
Formal US if first trimester bleeding
Formal US any time FH is >3cm discrepant from GA in weeks
Formal US at 18-20 weeks for anatomy screening
OGTT
1 hour GTT done at 26-28 weeks, earlier if risk factors for GDM (hx of GDM, FHx GDM, obesity, glucosuria, previous macrosomic infant)
If elevated, administer 3 hour GTT
Fasting, 1 hr, 2 hr, 3 hr cutoffs: (95, 180, 155, 140) or (105, 190, 165, 145)
If abnormal with normal fasting value: consult dietician for nutrition counselling and check FBGs
If abnormal, consider glyburide vs insulin
CBC at 28 weeks
Normal to have slightly elevated WBC
Dilutional anemia is normal--start FeSO4 and Colace when Hct<32%
Consider thalassemia if MCV is low--get iron studies, if not iron deficient get Hbg electrophoresis
Thrombocytopenia can be normal (nose bleeds, gums bleed with tooth brushing) but beware of HELLP syndrome, pre-eclampsia, especially if <100!
28-36 weeks: visits every 2 weeks
If Rh negative, give Rhogam 300 mcg IM at 28 weeks or any time she has vaginal/uterine bleeding during the pregnancy (See also: Screening and Treating Maternal/Fetal Rh Incompatibility and Alloimmunization)
>36 weeks: weekly visits
GBS at 35-37 weeks
Informal US to confirm presentation at 37 weeks
Confirm pregnancy
Urine hCG is as good as serum hCG. both can be positive 1 week after fertilization
Was the pregnancy planned?
Are you planning to carry the pregnancy?
Contraception
History
Previous care this pregnancy? Get records.
Dating
Pregnancy history and complications (HTN, DM, tears, bleeding, GBS, bad outcomes)
PMHx
HTN, DM, asthma, depression, bladder, kidney infections, bleeding/clotting problems, anesthesia problems, past surgeries (c/s, cervical procedures, abd/pelv surg)
Allergies (penicillin?)
Genetic history
Blood type (Rh?)
Are you safe in your current living situation?
Tobacco, EtOH, drugs
First visit
PE
Thyroid
Heart and lungs
Breast, teach BSA, discuss breastfeeding
Abdomen
Pelvic-GC/CT, pap, bimanual
Edema
U/S
Education
Prevention of
Listeriosis (wash produce and cutting boards with bleach, cook or freeze meats, no raw eggs or unpasteurized dairy)
Toxoplasmosis (gloves for changing cat litter or gardening)
CMV, varicella, parvo B19
Smoking, EtOH and drug abstinence
Seatbelt use
Sexual activity
Potential problems with work or hobbies
Safe medications
Prenatal vitamins
Gaviscon
Tylenol
Benadryl
Sudafed (if not hypertensive)
Tums
FeSO4
Colace
Acyclovir
Bactrim (but avoid in 3rd trimester)
Common medications
Macrodantin
First trimester-metrogel, monistat
After first trimester-flagyl, diflucan
Anti-emetics
Vistaril
Prozac and other SSRIs (avoid Paxil)
Diet
PNV with folic acid and iron
Limit caffeine to 500 mg/day
Avoid excessive fat soluble vitamins (AEDK)
Fish: avoid shark swordfish, king mackerel or tilefish
Limit shellfish and small oceanfish to 12 oz (2-3 servings/wk)
Limit other fish to 6oz (1 serving/wk)
Limit canned tuna to 6oz/wk
Wt-gain rec
25-35 pounds
15 pounds if obese (BMI>30)
40 pounds if underweight (BMI<20)
Exercise
Continuing at usual activity level is ok
Heart rate goal of 70% of 220-age (or 140 bpm)
New exercise programs should be limited to: walking, swimming, or other low-impactive activities
Avoid overheating (heat is a teratogen)
Avoid supine position
Avoid SCUBA, contact sports, skiing after 1st trimester
Work is okay, unless
Toxic exposures
Vaginal bleeding
Short or dilated cervix before 36 weeks
Uterine malformation
GHTN
FGR
Multiple gestation
Prior hx of preterm birth
Polyhydramnios
Unstable maternal disease
First trimester
Questions
Cramping or bleeding?
N/V?
If so, advise, small frequent meals
Soda crackers and 7up
Ginger
Sea-bands (acupressure)
Vitamin B6 and Unisom
Interventions
Influenza vaccine
Second trimester
Questions
Cramping or bleeding?
Fetal movement?
Interventions
Birthing classes
Preterm labor risks after viability
Influenza vaccine
Breastfeeding
Third trimester
Questions
Contractions, loss of fluid, or bleeding?
Fetal movement?
To discuss
Analgesia/anesthesia in labor
Operative vaginal delivery or c/s
Travel
Things to bring to hospital (i.e. car seat)
Fetal kick counts
Labour and delivery tour
Pediatrician options
If boy, circumcision
Post-partum contraception
Labs/Meds
G/C
DNA probe
Use first swab to clean mucus from os
Twirl second swab in os for at least 10 seconds
If positive, treat patient and partner, promote abstinence during treatment
If positive, do test for cure 4 weeks after tx
Pap
Liquid-based
Use broom, make at least 5 clockwise rotations against os. Push against bottom of vial, then push off head of broom into vial. Normal to have spotting afterward.
RPR
If reactive, check FTA-ABS; consult perinatologist.
Rubella
If non-immune, administer vaccine post-partum.
HBsAg
Can detect 1-12 weeks after exposure
Indicates recovery and immunity
HBeAg correlates with acute infection, may or may not be present in chronic infection
Acute infection is dx by IgM HBcAb, which is detectable at clinical onset and declines within 6mo
Chronic infection is dx by IgG HBcAb but no IgM HBcAb
If patient infected, notify peds
HIV
Notify patient that this is part of routine prenatal labs
Urine cx
Screen all patients
Treat if positive, then test of cure
Cystic Fibrosis (CF) carrier screening
Offer at pre-conception or new OB visit
If white, chance of being a carrier is 1 in 30. If both parents white, chance of affected baby is 1 in 3500. If both parents carriers, chance is 1 in 4.
Screen one partner first. If positive, screen the other.
Tests for 33 mutations on chr 7
AMA-women 35 or greater at time of delivery
Offer genetic counselling with possible diagnostic test (CVS or amniocentesis)
Offer MSS-quad screen or ulta-screen (but not if diagnostic test is done)
Was MS-AFP only, then was triple screen (MS-AFP plus estriol and hCG), now quad screen triple plus inhibin, newer are ultra screen and sequential screen.
Quad screen
Done between 15.0-20.9 weeks
Cannot be used for multiple gestations
Is a screening test only. If positive, need genetic counselling, high-res U/S, possible amniocentesis.
Detects 70-75% trisomy 21, 5% screen positive
Detects 60% trisomy 18, 0.2% screen positive (do not re-date since often growth restricted)
Detects 85% open NTD, 2-3% screen positive
Ultra-screen
Detects 90% trisomy 21, 5% screen positive
Still needs second trimester MS-AFP to detect open NTD
Can offer with multiple gestation (individual NTs)
Split the serum levels between fetuses
80% detection rate in a twin pregnancy
Is done between 11.1-13.9 weeks (CRL 45-84 mm)
Nuchal translucency by US
Free beta hCG and PAPP-A (preg.-assoc. plasma protein A) measured by dried blood from fingerstick at time of US
If positive: genetic counselling, high res U/S, possible CVS vs amnio.
Sequential screen
Part I: NT and free beta-hCG and PAPP-A (Ultra Screen)--detects 77% of Down Syndrome, 80% trisomy 18
Part II: Quad screen: detects 91% Down Syndrome, 90% trisomy 18 and 80% NTD
Group B Streptococcus (GBS)
Screen all patients at 35-36 weeks
Collect culture from lower vagina and anus (swab must go through sphincter)
If penicillin-allergic, ask for sensitivities with culture
Not necessary for scheduled C/S
If prior C/S
Document uterine scar
Discuss risks/benefits of VBAC vs repeat C/S
Have patient sign for consent for C/S or VBAC
If BP>140/90 or Protein >trace
Ask regarding sx of pre-eclampsia (h/a, visual changes, epigastric/RUQ pain, swelling.
Check pre-eclampsia labs
Consider 24 hour urine
Consider fetal monitoring on L&D
If any medical illness
Refer to perinatologist consult or care for maternal lupus, kidney disease, heart disease, HIV, other chronic disease, fetal anomalies, Rh isoimmunization, multiple gestation.
Also consider
Hep C antibody (if prior tattoos, IVDU, exposures)
PPD
Varicella antibody
TSH
Genetic counselling and directed testing if indicated by hx or PE (Ashkenazi Jew, AMA)
BV (not routine screen), but check and tx if present
PE, every visit
Fundal height
Fetal heart tones
Weight
BP
Urine dip (LE is normal, >trace protein is not)
Term
Start biweekly NSTs at 41 weeks
Consider IOL
IOL is not "post-dates" unless 42 weeks
Always recheck dating criteria at term
Post-partum checks
If vaginal delivery: two week visit--ask about ambulation, voiding, bowel movements, lochia, breastfeeding, contraception, pain, eating, depression
If c/s: one week visit--ask above plus check incision
Six week visits includes all of above plus breast exam and pap smear
Dr. Kwinter is a Cayman Family Doctor. He runs a Family Medicine Clinic at Cayman Medical in George Town, Grand Cayman, Cayman Islands.