Updated: 12/31/2021

Prenatal Care

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  • Snapshot
    • A 26-year-old G1P0 woman presents to the obstetrician for her first prenatal visit. An ultrasound is performed (See image). She is estimated to be approximately 8 weeks gestation. She notes that she has experienced increased fatigue and occassional nausea but no major complaints. The patient is a recent immigrant from Mexico and has no immunization records with her and does not recall her vaccination history. She is sexually active with only her husband and has no history of sexually transmitted infections. The obstetrician takes a thorough medical history, performs a physical examination, informs her about the course of pregnancy, and explains details of the laboratory studies that will be performed at the current visit and subsequent visits.
  • Introduction
    • Overview
      • prenatal care helps to ensure the birth of a healthy baby while also maintaining a healthy pregnancy for the mother
        • accurate estimation of gestational age
        • identify pregnancies at ↑ risk for maternal or fetal morbidity/mortality
        • prevent morbidity during pregnancy
        • provide a transition to a healthy labor and birth
    • Timing
      • initial prenatal visit at 8-10 weeks of pregnancy
        • earlier if at risk for ectopic pregnancy
      • subsequent prenatal visits
        • every 4 weeks for the first 28 weeks
        • every 2-3 weeks until 36 weeks gestation
        • every week after 36 weeks gestation
    • Initial prenatal visit
      • assessment
        • initial history and physical exam
        • family medical history
        • genetic history
        • general examination to confirm pregnancy
        • assess for tobacco, alcohol, and/or drug use
        • screen for domestic violence
        • screen for depression
        • provide prescriptions for prenatal vitamins and iron supplementation
      • education/counseling
        • inform about expected course of pregnancy
        • discuss recommendation for 30 minutes of moderate-intensity exercise 5-7 days a week
          • avoid contact sports or activities with high fall risk
        • discuss routine lab studies and testing
        • discuss genetic counseling and prenatal diagnostic testing
          • cystic fibrosis carrier screening
          • hemoglobinopathy screening for individuals of African, Southeast Asian and Mediterranean descent
        • discuss high-risk conditions
      • routine lab/diagnostic studies
        • blood type and screen
        • complete blood count (CBC)
        • platelet count
        • hepatitis B surface antigen (HBsAg)
        • syphilis screening test
        • screening for gestational diabetes if at high risk
          • risk factors for gestational diabetes mellitus
            • pre-pregnancy BMI ≥ 30 kg/m
            • previous history of gestational diabetes
        • cervical cancer screening
          • Pap test
        • urine dipstick for protein and glucose levels
        • urine culture and sensitivity test
          • asymptomatic bacteriuria should be treated in pregnant women
        • chlamydia screening
        • gonorrhea screening for women at risk for sexually transmitted infections
          • risk factors for sexually transmitted infections
            • age < 25 years
            • previous sexually transmitted infection
            • new or multiple sex partners
            • inconsistent condom use
            • commercial sex work
        • rubella titer
          • if not already immune, do not administer vaccine during pregnancy
            • MMR (measles, mumps, and rubella) is a live vaccine
        • TSH
          • hypothyroid women should have their dose of levothyroxine increased if found to be pregnant
            • during pregnancy, ↑ circulating levels of thyroxine-binding globulin (TBG), and ↑ plasma volume ↑ demand for T4
        • inactivated influenza vaccination
    • Subsequent prenatal visits
      • every visit
        • vital signs
        • weight
        • fetal assessment, beginning after 10 weeks gestation
        • uterine size assessment (see Table below)
        • domestic violence screening
        • assessment of tobacco use and exposure
        • urine dipstick for protein and glucose levels
      • weeks 11-14 of pregnancy
        • education about breastfeeding
        • screening tests for aneuploidy
          • women with ↑ risk for aneuploidy
            • offer option of chorionic villus sampling or 2nd trimester amniocentesis
      • weeks 15-20 of pregnancy
        • anatomic survey ultrasound at 18-20 weeks
        • neural tube defect screening
          • maternal serum alpha-fetoprotein (MSAFP)
      • weeks 24-28 of pregnancy
        • repeat type and screen
          • if Rh negative, administer Rh immunoglobulin
        • screen for gestational diabetes
        • discuss postpartum contraception
      • weeks 32-34 of pregnancy
        • repeat testing for women at ↑ risk for sexually transmitted infections
          • syphilis, HIV, gonorrhea, and chlamydia
      • week 36 of pregnancy
        • determine fetal position
        • group B strep screening
      • week 38 of pregnancy
        • provide information about labor
        • discuss postpartum contraception again
      • > 41 weeks of pregnancy
        • discuss labor induction
    • Estimating 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
    • Timing of Major Prenatal Tests
      Prental Test

      Gestational Age (Weeks)

      Details of test

      First trimester screen

      11-14
      Ultrasound for nuchal translucency
      PAPP-A
       • ↓ levels are seen in chromosomal abnormalities
      hCG
      • ↑ levels are seen in chromosomal abnormalities
      Cell free fetal DNA

      ~10

      Analyze fetal DNA in maternal blood
      Screens for trisomies of 13, 18, and 21
      Positive test results should be followed by CVS or amniocentesis
      Chorionic villus sampling (CVS)

      11-14

       • Collect placental tissue to test for chromosomal and genetic abnormalities

      Quadruple screen

      16-18

      AFP, hCG, estriol, and inhibin
       • ↑ AFP = neural tube or abdominal wall defects
       • ↑ hCG and inhibin and↓ AFP and estriol = Down syndrome
       • ↓ AFP, hCG, and estriol = Edwards syndrome
      Amniocentesis

      15-20

      Collect amniotic fluid to diagnosis chromosomal abnormalities
      Glucose challenge test

      24-28

      1 hr glucose challenge test
      • If abnormal followed by glucose tolerance test
      Group B strep test

      35-37

      Swab the lower genital tract for colonization by GBS

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(M2.OB.17.4870) An 18-year-old G1P0 woman who is 10 weeks pregnant presents for her first prenatal visit. She reports nausea with occasional vomiting but denies bleeding, urinary symptoms, or abdominal pain. She just graduated high school and works at the local grocery store. She does not take any medications and has no known drug allergies. Physical examination is unremarkable. Initial laboratory studies reveal the following:

Serum:
Na+: 140 mEq/L
Cl-: 100 mEq/L
K+: 4.0 mEq/L
HCO3-: 24 mEq/L
BUN: 10 mg/dL
Glucose: 100 mg/dL
Creatinine: 1.0 mg/dL
Thyroid-stimulating hormone: 2.5 µU/mL
Ca2+: 9.5 mg/dL
AST: 25 U/L
ALT: 20 U/L

Leukocyte count: 10,000 cells/mm^3 with normal differential
Hemoglobin: 14 g/dL
Hematocrit: 42%
Platelet count: 200,000 /mm^3

Urine:
Epithelial cells: few
Glucose: negative
WBC: 20/hpf
Bacterial: > 100,000 cfu / E. coli pan-sensitive

What is the best next step in management?

QID: 109565
1

Observation and treatment if symptoms develop

2%

(1/51)

2

Nitrofurantoin for seven days

90%

(46/51)

3

Observation and repeat cultures in one week

2%

(1/51)

4

Nitrofurantoin for duration of pregnancy

2%

(1/51)

5

Levofloxacin for three days

4%

(2/51)

M 7 D

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(M2.OB.15.4672) A 33-year-old G1P0 at 32 weeks gestation presents to her OB/GYN for a prenatal check-up. Her medical history is significant for type II pregestational diabetes mellitus, which has been well-controlled with diet and insulin so far throughout her pregnancy. Which of the following is the recommended future follow-up for this patient?

QID: 107200
1

Ultrasound for fetal growth every week starting now until delivery

28%

(9/32)

2

Monitor fetal kick counts starting now until 40 weeks gestation

9%

(3/32)

3

Monthly nonstress test strating at 34 weeks gestation until delivery

6%

(2/32)

4

Monthly biophysical profile now until delivery

16%

(5/32)

5

Twice weekly nonstress test now until delivery

38%

(12/32)

M 8 E

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(M2.OB.15.4672) A 32-year-old G3P2 at 20 weeks gestation presents to her PCP with complaints of fatigue, chills, and decreased appetite for the past 5 days. Her pregnancy has been uncomplicated to-date, and she has been receiving regular prenatal care. The patient mentions that, in an attempt to increase nutrition for her fetus, she has been consuming increased amounts of dairy products in the past month. At 35 weeks gestation, the patient delivers an ill neonate with sepsis, pneumonia, and disseminated skin findings (Figure A). What is the appropriate action that the PCP should have taken after the patient’s initial presentation?

QID: 107192
FIGURES:
1

Supportive care with rest and hydration

0%

(0/24)

2

Blood and amniotic fluid cultures

33%

(8/24)

3

Vaginal and stool cultures

21%

(5/24)

4

Empiric ceftriaxone therapy

8%

(2/24)

5

Empiric ampicillin therapy

33%

(8/24)

M 6 E

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(M2.OB.15.4672) A 27-year-old G0P0 female presents to her OB/GYN for a preconception visit to seek advice before becoming pregnant. A detailed history reveals no prior medical or surgical history, and she appears to be in good health currently. Her vaccination history is up-to-date. She denies tobacco or recreational drug use and admits to drinking 2 glasses of wine per week. She states that she is looking to start trying to become pregnant within the next month, hopefully by the end of January. Which of the following is NOT recommended as a next step for this patient's preconception care?

QID: 107199
1

Begin 400 mcg folic acid supplementation

7%

(6/83)

2

Recommend inactivated influenza vaccination

2%

(2/83)

3

Obtain rubella titer

1%

(1/83)

4

Administer measles, mumps, rubella (MMR) vaccination

81%

(67/83)

5

Obtain varicella zoster titer

7%

(6/83)

M 8 E

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