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Updated: Jan 26 2022

Prenatal Care

  • 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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