Prenatal Care Flashcards
Initial Visit (between 6-12 weeks)
General
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
Initial Visit (between 6-12 weeks)
Labs
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
Initial Visit (between 6-12 weeks)
Immunizations
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)
Obstetric History
Determine gravity, parity, abortus
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
Gynecologic History
History of genital herpes → patients with genital HSV should
**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
OTC Pain relief during pregnancy
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)
EDD (Estimated Due Date)
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
purpose of initial Ultrasound
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
Ultrasound Screening in Pregnancy
Viability/NT/Anatomy/Cervical length/ Growth
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
Physical Exam in Pregnancy
Fundal Height
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
Physical Exam in Pregnancy
Leopold’s Maneuver
*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
Reasons for Abnormal Uterine Size
Causes of Oversized Uterus
Wrong dates
Polyhydramnios
Concealed/accidental hemorrhage
Twins
Tumors as fibroids and ovarian cysts
Fetal malformations as hydrocephalus
Reasons for Abnormal Uterine Size
Causes of Undersized Uterus
Wrong dates
Oligohydramnios
Fetal death
IUGR or small fetus
Malpresentation such as transverse lie
Nutrition in Pregnancy
Prenatal vitamin and mineral supplements/ protein
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
pregnancy folate prophylaxis
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
Recommend Pregnancy Weight Gain
Weight measurements should be taken at every antenatal visit
1 Kg to 2.2lbs
Pregnancy- What to Avoid
Foods
Deli meats (listeria)/ raw meat (salmonella, toxoplasmosis)
High mercury fish
Unpasteurized cheese
Pregnancy- What to Avoid
Smoking
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
Pregnancy- What to Avoid
Alcohol/FAS
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
Pregnancy Counseling
Sleep, work, and exercise
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
Pregnancy Counseling
Travel and sex
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
Genetic Carrier Screening
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
Old Prenatal Genetic Testing (during pregnancy)
Sequential Screen Labs (in pregnancy)
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)
Non-Invasive Prenatal Testing (NIPT) (Screening Test)
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
Invasive Prenatal Testing (Diagnostic Procedure)
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
Down Syndrome
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
Spina Bifida
Failure of spinal fusion
Malformation and protrusion of spinal cord
Can cause: Leg paralysis, bowel and bladder dysfunction
Prevention = folic acid supplementation
Subsequent Visits: Between 12-24 weeks
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
Common 2nd Trimester Issues/Complaints
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
Subsequent Visits: Between 24-28 weeks
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
Gestational Diabetes
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
Subsequent Visits: Between 28-36 weeks
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
Group B Streptococcus
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!
Subsequent Visits: Between 36+ weeks
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
Non-Stress Test
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
