Routine prenatal care
Posted by dkwinter

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

               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?
     Previous care this pregnancy? Get records.
     Pregnancy history and complications (HTN, DM, tears, bleeding, GBS, bad outcomes)
          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
          Heart and lungs
          Breast, teach BSA, discuss breastfeeding
          Pelvic-GC/CT, pap, bimanual
          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

          Sudafed (if not hypertensive)
          Bactrim (but avoid in 3rd trimester)
     Common medications
          First trimester-metrogel, monistat
          After first trimester-flagyl, diflucan
          Prozac and other SSRIs (avoid Paxil)
          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)
          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
          Multiple gestation
          Prior hx of preterm birth
          Unstable maternal disease
First trimester
          Cramping or bleeding?
               If so, advise, small frequent meals
               Soda crackers and 7up
               Sea-bands (acupressure)
               Vitamin B6 and Unisom
          Influenza vaccine

Second trimester
          Cramping or bleeding?
          Fetal movement?
          Birthing classes
          Preterm labor risks after viability
          Influenza vaccine
Third trimester
          Contractions, loss of fluid, or bleeding?
          Fetal movement?
     To discuss
          Analgesia/anesthesia in labor
          Operative vaginal delivery or c/s
          Things to bring to hospital (i.e. car seat)
          Fetal kick counts
          Labour and delivery tour
          Pediatrician options
          If boy, circumcision
          Post-partum contraception
               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
               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.
               If reactive, check FTA-ABS; consult perinatologist.
               If non-immune, administer vaccine post-partum.
               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
               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
                    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)
               Varicella antibody
               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
     Urine dip (LE is normal, >trace protein is not)
     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