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Diagnosis
  • Symptoms of pregnancy
    • amenorrhea
    • urine frequency
    • breast engorgement
    • nausea
    • bluish discoloration of vagina, vulva, and cervix due to vascular congestion (Chadwick's sign)
    • softening of cervix
  • Urine Pregnancy Test (UPT)
    • detects hCG or B subunit
      • sensitive to 1-2 weeks
  • Ultrasound
    • most accurate method to detect fetal size
      • gestational Sac - 5 weeks
      • fetal image detected at 6-7 weeks
      • cardiac activity at 8 weeks
Initial Workup-First visit
  • Estimated date of confinement (EDC)
    • Nageles's Rule: LMP + 7 days - 3 mos + 1 yr
      • Ex.) LMP 4/19/12, EDC = 1/26/13
      • calculation based on regular 28 day cycle (only 20-25%)
    • sonogram estimation
      • crown-rump length (CRL)
      • biparietal diameter (BPD)
      • of note, sonogram estimation of EDC is more accurate earlier in pregnancy than later
  • Complete pelvic exam
    • estimate uterine size
    • PAP smear
    • cultures for gonorrhea and chlamydia
  • Labs
    • CBC
    • blood type with Rh status
    • urinalysis and culture
      • asymptomatic bacteriuria should be treated in pregnant women
      • can progress to pyelonephritis in pregnant women due to urinary stasis and ureteral dilation (right more than left)
    • RPR test for syphilis
    • Rubella titer 
      • if not already immune DO NOT VACCINATE
        • recall MMR is a live virus vaccine
    • TB skin testing
    • offer HIV/HBV antibody test 
    • sickle cell prep
    • TSH
      • hypothyroid women should have their dose of levothyroxine increased if found to be pregnant. During pregnancy, increased circulating levels of thyroxine-binding globulin (TBG) and increased plasma volume increase demand for T4
  • Genetic counseling indicated by history
  • Recommend 25-35 lb weight gain during pregnancy
  • Consider folate, iron & multivitamins
First Trimester
  • Visit every 4 weeks
  • Evaluate
    • weight gain / loss
    • BP
    • pedal edema
    • fundal height
    • urine dip for glucosuria and proteinuria
      • trace glucose is normal due to GFR
      • trace protein is not normal and should be evaluated
  • Cell-free fetal DNA 
    • non-invasive
    • very sensitive/specific
    • can order at 10 weeks or greater
    • can confirm with CVS or amniocentesis
  • Chorionic villus sampling (CVS)
    • definition
      • a procedure where small samples of placenta are acquired in order to
        • perform a prenatal genetic analysis (e.g., DNA analysis and cytogenetics)
    • CVS is typically performed between
      • 10 and 13 weeks of gestation
    • indications
      • maternal age is 35 years or older
      • prior child had a genetic disorder (e.g., Cystic fibrosis) and chromosomal abnormalities (e.g., Down syndrome)
      • parents are carriers of a genetic disorder
      • first trimester ultrasound examination suggests a congenital anomaly
      • abnormal aneuploidy screening result
    • risks
      • maternal alloimmunization (relative contraindication)
      • vertical transmission of infection (e.g., HIV)
    • complications
      • miscarriage
      • amniotic fluid leakage
 Estimate Gestational Age by Uterine Size
12 weeks At pubic symphysis
16 weeks Midway from symphysis to umbilicus
20 weeks At umbilicus
20-36 weeks Height (in cm) above pubic symphysis correlates with weeks of gestation
 
Second Trimester
  • Continue visits every 4 weeks
  • 15-18 weeks
    • offer triple marker screen (hCG, estriol, AFP)
      • used to detect neural tube defects or trisomies
  • 17 weeks 
    • document movement
    • amniocentesis if > 35 years old or history indicates
  • 24 weeks
    • glucose screening
  • 25 -28 weeks 
    • repeat Hct
Third Trimester
  • Every 4 weeks until week 28, then every two weeks, then every week after 36.
  • Routine third trimester tests
    • urine analysis  
    • blood glucose
  • Inquire about preterm labor symptoms
    • vaginal bleeding
    • contractions
    • rupture of membranes
  • 28-30 weeks
    • give RhoGAM if indicated
  • 28-32 weeks
    • mothers with pre-gestational diabetes should undergo twice weekly nonstress testing until delivery 
  • 35-37 weeks
    • screen for Streptococcus agalactiae (Group B Strep)
  • 36-40 weeks 
    • cervical chlamydia and gonorrhea cultures if indicated
 

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