Prenatal Care

Question 1

Initial Visit (between 6-12 weeks)

General

Answer 1

Full H&P including a detailed obstetrical, gynecological history
Perform viability ultrasound to determine EDD (estimated due date) & GA (gestational age)
Assess fetal heart tones with a doppler and fundal height with a tape measure
Heart Rate = 110-160bpm

Discuss a healthy, iron-rich diet, exercise, prenatal vitamins, the importance of oral hydration preferably with water, small frequent meals, and smoking/ETOH cessation

Discuss genetic screening & diagnosis options including non-invasive prenatal testing
Schedule ultrasounds (nuchal translucency and anatomy)

Patient is seen every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks. Then weekly until delivery

Viability ultrasound - looking for intrauterine pregnancy and FH

Question 2

Initial Visit (between 6-12 weeks)

Labs

Answer 2

Perform pap smear and gonorrhea/chlamydia collection

Labs: must check for syphilis (RPR or VDRL),
hepatitis B (HBsAg)

HIV (Repeat testing at 32-36 weeks)

CBC (baseline Hgb and Platelet counts)

Blood type and Antibody Screen (T&S)
ABO blood group, Rhesus D factor
If patient is Rh-negative, there is a risk for incompatibility
Antibody screening looks for many maternal antibodies that may attack fetal blood cells

Rubella and Varicella Antibody Titers
Non-immune individuals are at risk of giving birth to baby with congenital syndrome
MMR and Varicella vaccines contraindicated in pregnancy
If non-immune, counsel patient to avoid sick contacts
If pregnant person exposed to varicella, they can receive an immunoglobulin

Additional tests include:
Hemoglobin electrophoresis
Titers measles IgG, varicella IgG, rubella immunity

Urinalysis and urine culture (UA/ Ucx) - Treat asymptomatic UTIs (>100,000 CFUs of single pathogen)

PPD

Question 3

Initial Visit (between 6-12 weeks)

Immunizations

Answer 3

consider influenza vaccine if in season; pre/post-natal care is the perfect opportunity to complete health maintenance education and vaccinations
Tdap and Influenza recommended in every pregnancy
Additional vaccines may be indicated based on exposure level
Live vaccinations are NOT indicated (MMR, Varicella)

Question 4

Obstetric History

Determine gravity, parity, abortus

Answer 4

Gravid: Number of total pregnancies including current
Parity: Number of births

(TPAL) full term, premature, abortion/miscarriage, living children
Full term: 37- 42wks
Preterm: 20 wks - 36w6d
Abortion/Miscarriage: < 20 wks

Previous preterm deliveries carry higher risk of preterm delivery in this pregnancy

Procedures that required full-thickness incisions in the uterine fundus (ie abdominal myomectomy) = ↑ risk of uterine rupture with labor

Question 5

Gynecologic History

History of genital herpes → patients with genital HSV should

Answer 5

**Receive antiviral prophylaxis with acyclovir 400 mg PO TID starting around 36 weeks gestational age

Be evaluated specifically for any signs of active lesions (including on the cervix) at the onset of labor
Active lesions at the time of labor are a relative contraindication to vaginal delivery

Question 6

OTC Pain relief during pregnancy

Answer 6

Acetaminophen (Tylenol) is the safest option

NSAIDS can close the PDA (contraindicated in 3rd trimester, can consider if benefit outweighs risk in 1st and 2nd trimester)

Question 7

EDD (Estimated Due Date)

Answer 7

Establish an EDD (Estimated Due Date) at first visit

LMP - (last menstrual period) ask for the first day of last period

Naegele’s Rule for EDD: Calculated by adding 7 days to the first day of the LMP, subtracting 3 months and adding 1 year

Example: LMP was 1/12/2021, EDD is 10/19/2021

Question 8

purpose of initial Ultrasound

Answer 8

Confirm the pregnancy & viability
Confirm the fetal location (intrauterine pregnancy)
Most accurate due date (crown-rump length or CRL)
Number of fetuses & chorionicity in multiple gestations
Findings of abnormal uterine and adnexal masses

Question 9

Ultrasound Screening in Pregnancy

Viability/NT/Anatomy/Cervical length/ Growth

Answer 9

Viability US: Ultrasound at 8-12 weeks, first scan to determine the heart rate, placenta location, identify # of embryos

Nuchal Translucency (NT): 11-14 weeks. Measures fluid behind the fetus neck. Can identify certain birth defects, including cardiac and risk for Down Syndrome.

Anatomy US: 16-20 weeks. Check the entire anatomy of fetus, all organ development

Cervical Length: Measure length of cervix starting at 16 weeks, only indicated for those at risk of cervical shortening or cervical incompetence.
< 2.5cm = short cervix

Growth US: Measure areas of the body to determine estimated fetal weight. Occurs at anatomy scan and every 4-8 weeks depending on maternal conditions

Question 10

Physical Exam in Pregnancy

Fundal Height

Answer 10

Measure at every visit
20 weeks the uterus fundus = umbilicus
Grows 1cm per week until 40 weeks

*12 weeks at pubic symphysis
*16 weeks midway between pubic symphysis and umbilicus
*20 weeks at umbilicus
*20-36 weeks height in cm=gestational age
*After 36 weeks fetus descends into pelvis

Question 11

Physical Exam in Pregnancy

Leopold’s Maneuver

Answer 11

*Determines fetal position, done near end of pregnancy
*What is at the fundus
*Where is fetal back and small parts
*What is the presenting part
*Where is the cephalic prominence

Question 12

Reasons for Abnormal Uterine Size

Causes of Oversized Uterus

Answer 12

Wrong dates
Polyhydramnios
Concealed/accidental hemorrhage
Twins
Tumors as fibroids and ovarian cysts
Fetal malformations as hydrocephalus

Question 13

Reasons for Abnormal Uterine Size

Causes of Undersized Uterus

Answer 13

Wrong dates
Oligohydramnios
Fetal death
IUGR or small fetus
Malpresentation such as transverse lie

Question 14

Nutrition in Pregnancy

Prenatal vitamin and mineral supplements/ protein

Answer 14

Prenatal vitamin and mineral supplements
DHA
Folate (B9)/ Folic Acid (synthetic folate)
Iron

Protein:
Increased protein demands are needed for fetal, uterine, placental, breast growth and increased blood volume
Majority required from animal fat- meat, milk, eggs

Question 15

prophylaxis

Answer 15

Pregnancy Recommendations:
Universal prophylaxis: 0.4mg (400mcg) once daily
Recommended to start at minimum 1 month before conception to help prevent neural tube defects

High dose prophylaxis: 1-4mg
Recommended for individuals who are at higher risk of having fetal neural tube defects
Most important during the first trimester during organogenesis

Question 16

Recommend Pregnancy Weight Gain

Answer 16

Weight measurements should be taken at every antenatal visit

1 Kg to 2.2lbs

Question 17

Pregnancy- What to Avoid

Foods

Answer 17

Deli meats (listeria)/ raw meat (salmonella, toxoplasmosis)
High mercury fish
Unpasteurized cheese

Question 18

Pregnancy- What to Avoid

Smoking

Answer 18

Increases risk of low birth weight and fetal growth restriction
Increased risk of preterm labor and perinatal death
Carbon monoxide > vasoconstriction of the fetal vessels in the placenta > decreased placental perfusion

Question 19

Pregnancy- What to Avoid

Alcohol/FAS

Answer 19

Fetal alcohol syndrome (FAS) birth defect syndrome
Structural malformations (predominantly facial) (Microcephaly, short palpebral fissures, flat midface, underdeveloped philtrum, thin upper lip, low nasal bridge, epicanthal folds, minor ear anomalies, small teeth with faulty enamel, foreshortened nose, micrognathia)
Growth restriction
Neurologic abnormalities including mental retardation
Alcohol consumption during pregnancy generally >3oz/day, no lower limit

Question 20

Pregnancy Counseling

Sleep, work, and exercise

Answer 20

Sleep
Adequate rest about 8 hrs and 1-2 hrs in the afternoon is recommended

Exercise
Don’t limit exercise, continue doing what level you were doing pre-pregnancy (avoid contact sports)
Avoid starting new exercise regimens, walking is the best
Regular exercise improved metabolic efficiency (30 minutes most days)

Work
Any activity which causes severe physical strain should be avoided
Allow for adequate periods of rest when working

Question 21

Pregnancy Counseling

Travel and sex

Answer 21

Travel
No harmful effects of travel
If flight >6hrs, increase ambulation on plane, wear compression stockings to prevent DVT
Seat belts abdomen belt should be placed under abdomen and across thighs
Air travel safe up to 36 weeks (risk of labor or complications)

Sex
Safe in pregnancy, may result in some post-coital spotting
Coitus should be avoided in placenta previa, PROM, threatened preterm delivery
Intercourse in the last 4 weeks of pregnancy can increase likelihood of going into labor
Avoid Cat Litter - risk of toxoplasmosis transmission

Question 22

Genetic Carrier Screening

Answer 22

Blood or saliva testing prior to pregnancy for pregnant patient and partner. Checks for any autosomal recessive inherited disorders

Single Gene Autosomal recessive disorders
Able to test based on ethnicity that is most often affected, however these disorders are not restricted to these groups
Common: Tay Sachs (Eastern/Central European Jewish, French Canadian, Cajun), Fragile X, Cystic Fibrosis, Sickle Cell Disease (African descent)

Benefits:
Preconception identification of carriers of genetic disorders provides an opportunity for education regarding their risk of having an affected offspring, its prognosis, and their reproductive options.
Patient can consult with genetic counselor

Question 23

Old Prenatal Genetic Testing (during pregnancy)

Sequential Screen Labs (in pregnancy)

Answer 23

Triple screen (1st trimester): NT, bHCG, PAPP-A
Quad screen (2nd trimester): AFP, bHCG, Estriol, Inhibin A
Alpha fetoprotein: increased result suggests spina bifida, decreased result suggests trisomy 21 (Down Ayndrome)
Down syndrome marker results: bHCG high, INhibin A high, Estriol low, AFP low

PAPPA-A: pregnancy associated plasma protein, key regulator of insulin-like growth factor essential for normal fetal development. Low PAPP-A indicative of placental insufficiency (increased risk of preterm delivery, fetal growth restriction, stillbirth and hypertensive disorders)

Question 24

Non-Invasive Prenatal Testing (NIPT) (Screening Test)

Answer 24

cfDNA: Small amount of cell-free DNA released from placenta into the pregnant woman’s bloodstream.
10 weeks
Test for Trisomy 13, 18, 21 and number of sex chromosomes
Test 10-14 weeks pregnancy
Results return as “low risk” or “high risk” with percentages
Detection rate >98%

cfDNA- results can be inconclusive or abnormal if patient has higher BMI or on certain medications including lovenox
98% sensitive and specific

Question 25

Invasive Prenatal Testing (Diagnostic Procedure)

Answer 25

CVS: (Chorionic Villi Sampling) Needle aspiration procedure, small amount of cells taken from the placenta
Usually performed weeks 10-12
Amniocentesis: Needle aspiration procedure, cells taken from the amniotic sac
Can be performed as early as 16 weeks

Question 26

Down Syndrome

Answer 26

Trisomy 21
Most common genetic disorder

Defined by characteristic facial features
Epicanthal folds
Flat nasal bridge
folded/dysplastic ears
Furrowed tongue
Short neck
Narrow palate

Intellectual disability

About 50% risk of congenital heart defects
Atrioventricular septal defect
Ventricular septal defect
Atrial septal defect
Tetralogy of Fallot
Patent Ductus Arteriosus

Question 27

Spina Bifida

Answer 27

Failure of spinal fusion
Malformation and protrusion of spinal cord
Can cause: Leg paralysis, bowel and bladder dysfunction

Prevention = folic acid supplementation

Question 28

Question 29

Subsequent Visits: Between 12-24 weeks

Answer 29

Visits are monthly

Every visit:
Vital signs check (especially weight and BP)
Fetal heart rate check: bedside ultrasound (1st tri) or handheld doppler (2nd/3rd tri) (110-160bpm)
Fundal height starting 20 weeks - should be about equal to their gestational age in weeks
20 weeks = 20cm from pubic symphysis = at level of umbilicus

Ask:
Vaginal bleeding?
Loss of fluid?
Contractions?
Fetal movement? Usually 16 weeks in multiparous and 20 weeks in nulliparous

Second visit, usually 12-16 weeks (test serum MSAFP)
Third visit, usually 20 weeks + anatomy scan

Question 30

Common 2nd Trimester Issues/Complaints

Answer 30

Round ligament pain
Stretching, frequent position change, sleeping with a pillow between legs)

UTI’s
Dilated urinary tract increases risk, asymptomatic bacteriuria is treated if >100,000 CFUs

Yeast infections
immunosuppression, treat with Terconazole suppositories

Constipation
Colace 100mg BID, educate on increased fruits/vegetables, water, fiber-rich foods; if necessary, consider Miralax)

Iron-deficiency anemia
Ferrous sulfate with vitamin C supplementation

Question 31

Subsequent Visits: Between 24-28 weeks

Answer 31

Glucose screening 24-28 weeks

GCT: Glucose Challenge Test
Fasting not required
Drink 50g sugar beverage > test blood glucose 1 hr later
Elevated: > 135 or 140 → GTT
If results >200 → diagnostic

GTT: Glucose Tolerance Test
Test fasting glucose
Drink 100g sugar beverage
1 hr, 2hr, 3 hr labs
Positive is >2 values elevated

Offer Tdap
Passing immunity from mother to fetus for whooping cough (Pertussis)

Repeat CBC to check for anemia, thrombocytopenia
In Rh-Negative patients

Repeat antibody screening
Administer RhoGAM

Question 32

Gestational Diabetes

Answer 32

Why does this occur? Alternation in placental hormone and cortisol which can raise serum glucose. Rise in progesterone can also make patient insulin resistant

Risk factors: age over 35, obesity, prior history of GDM, history of stillbirth, PCOS, strong FH of diabetes

This test is measured around 24-48 weeks

Gestational diabetes occurs in 7% of pregnancies
If the initial screen is greater than 200 mg/dl after 1 hour, it is automatically considered gestational diabetes

Question 33

Subsequent Visits: Between 28-36 weeks

Answer 33

28+ weeks visits are every 2 weeks

32 weeks - offer Tdap vaccine to all patients (optimal timing for maternal antibodies before delivery)

35-37 weeks: GBS screening
Group B Strep Positive = Antibiotic prophylaxis while patients are in labor!
Recommended: Ampicillin 2g bolus > 1g every 4 hrs while in labor

40 weeks is the estimated due date, recommend IOL by 41+ weeks

Third Trimester:
Discuss contractions, leakage of fluid, vaginal bleeding (labor warning signs)
Repeat labs: CBC, HIV, Gonorrhea, Chlamydia
Every visit assess fetal position!
Explain fetal kick counts
Assure patient knows next steps/ when to call obstetrician

Question 34

Group B Streptococcus

Answer 34

Bacteria that can live in the vaginal/rectal flora
Newborn contraction of GBS during birth **increases risk of neonatal sepsis , meningitis, pneumonia **

Affects about 30% of women
Healthy normal bacteria in a non pregnant patient
Test in pregnancy due to the risk of transmission from vaginal flora to newborn during birth
Can be fatal to baby!

Question 35

Subsequent Visits: Between 36+ weeks

Answer 35

Ob/gyn visit weekly
Reiterate labor precautions
Monitor vitals, symptoms any indication patients need to be delivered sooner

Fetal position check
Head down (vertex/cephalic) = vaginal delivery candidate
Butt down (breech) = cesarean section candidate

Question 36

Non-Stress Test

Answer 36

Test for fetal well-being (Assess response of FHR to periods of fetal movement)
Most commonly performed antenatal testing
Low risk pregnancy- performed weekly after 40 weeks
High risk pregnancy: performed in the the late third trimester weekly/ biweekly

An evaluation of the FHR pattern in the absence of regular uterine contractions to determine fetal oxygenation, neurologic, and cardiac function
Based on premise that the normal fetus moves at various intervals; CNS and myocardium respond to FM with acceleration of FHR
Acceleration is a sign of fetal well-being

Interpret Fetal Heart Monitoring
NST reactive: two accelerations in FHR in a 20 minute period