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Transcript of Prenatal Care
What labs should we order for prenatal patients?
What are the level A recommendations for dietary supplements/guidelines in pregancy?
What are the level B recommendations?
First Trimester Ultrasound
What are the important components of the physical exam for prenatal patients?
Which elements of the patients' history are important to obtain at the first OB visit?
What about all the rest?
True or false: systematic review of observational studies and randomized trials concluded that routine prenatal care improved outcomes?
Ryan Brang, MD, FAAFP
False! Although women in developed countries often have seven to 12 prenatal visits, a multinational trial showed that decreasing the visits to a minimum of four did not increase adverse outcomes, although it slightly decreased patient satisfaction.
While the number of visits doesn't seem to influence the outcome, the quality of the visit does.
Moreover, Randomized trials comparing routine prenatal care with enhanced prenatal care (eg, extra office visits, health education, home visits, telephone contact, psychosocial support) for women with high risk pregnancies by various criteria found enhanced care did not significantly improve outcome.
Prenatal care that is provided by a small team; is coordinated; and follows an evidence-based, informed process results in fewer prenatal admissions, improved prenatal education, and greater satisfaction with care.
Sonographic estimation of the EDD is mandatory when menses are irregular, the LMP is unknown or uncertain, if there is a discrepancy in the size of her uterus compared with the gestational age or in patients conceiving while taking OCPs.
What are the advantages of early US dating?
Ultrasound dating is considered accurate to within four to seven days in the first trimester, 10 to 14 days in the second trimester and 21 days in the third trimester.
Good evidence shows that early ultrasonography (before 14 weeks) accurately determines gestational age, decreases the need for labor induction after 41 weeks' gestation and detects multiple pregnancies.
Dating ultrasound ordered as "ULS OB<14 weeks, transvaginal if indicated." If this US is done in the first trimester and within 7 days of the patient's LMP, use the LMP. If it is more than 7 days off, use the ultrasound EDD for dating.
How do we manage initial OB dating for our practice?
How accurate is ultrasound dating?
When is an ultrasound necessary to determine the EDD?
Personal and demographic information
Past obstetrical history
Personal and family medical history
Past surgical history
Menstrual and gynecological history
Current pregnancy history
Once done, compile all this information for the problem list.
Height (to assess BMI)
Complete physical including pelvic exam
screen for reproductive tract abnormalities
screen for sexually transmitted infections
pap smear if indicated
Fetal heart auscultation
Pelvimetry is not useful
No evidence for a clinical breast exam
Routine fetal movement counting should be avoided
Blood type and antibody screen
Hct/Hgb and MCV
Immunity to varicella should be determined:
Diagnosis of varicella
Verification of history of varicella disease
Laboratory evidence of immunity
Women without evidence of immunity should avoid exposure and receive postpartum immunization
Will detect antibodies which may result in hemolytic disease of the newborn
Iron deficiency anemia is associated with increased risk of preterm labor, IUGR and perinatal depression. All women should be screened and treated with iron if low.
Every woman should have serologic testing for rubella at the first prenatal visit. If nonimmune, the patient should be counseled to avoid exposure and receive postpartum immunization
Women with untreated asymptomatic bacteriuria are at high risk of developing pyelonephritis
Untreated bacteriuria may be associated with an increased risk of preterm birth, low birth weight, and perinatal mortality.
Opt-out approach advantages:
Informed decision about continuing the pregnancy
Appropriate medical management for mother
Counseling for prevention of transmission to or identification of partner
Decreased perinatal transmission (antiretroviral therapy, C/S delivery, avoidance of breast feeding.
Recommended for all pregnant women to prevent perinatal transmission
Urine screening for proteinuria is useful as a baseline for comparison if assessment of renal function is performed later in pregnancy
Cost and morbidity associated with testing for syphilis are low and benefits of detection and treatment are high for both mom and child
All women should be screened at the first prenatal visit.
Nucleic acid amplification tests have high sensitivity and excellent specificity and are superior to culture.
Positive results need to be treated with a test-of-cure 4 weeks after treatment and retesting three to four months later.
Pregnant women who test positive are treated immediately and retested in three months. In addition, women at high risk for reinfection are retested in the third trimester to prevent maternal postnatal complications and gonococcal infection in the neonate.
Other screening for at-risk women:
Neurologic development may be adversely affected in children born to mothers with hypothyroidism, while maternal hyperthyroidism can lead to fetal and maternal complications.
Professional societies (eg, ACOG, the Endocrine Society, the American Thyroid Association [ATA]) recommend testing pregnant women for thyroid dysfunction if they have any of the following:
●Symptoms of thyroid disease
●Personal or family history of thyroid disease
●Characteristics that place them at high risk for overt hypothyroidism:
type 1 diabetes
history of head/neck radiation,
Herpes simplex virus
Sickle cell disease
The Dietary Guidelines Scientific Report estimated that 24 percent of United States pregnant women consume less than 800 mg/day.
For women with low baseline dietary calcium intake (particularly in non-United States populations), high-dose calcium supplementation may reduce the risk of developing a hypertensive disorder of pregnancy. Calcium supplementation does not appear to reduce this risk in healthy, nulliparous women in whom baseline dietary calcium intake is adequate.
Supplementation with 0.4 to 0.8 mg of folic acid should begin at least one month before conception.
Supplementation prevents neural tube defects.
Pregnant women should be screened for anemia and treated if necessary
Iron-deficiency anemia is associated with preterm delivery and low birth weight
Pregnant women in industrialized countries should limit vitamin A intake to less than than 5,000 IU per day.
Intake of more than 10,000 IU per day is associated with cranial-neural crest defects.
Moderate amounts are probably safe. Some guidelines recommend limiting consumption to 150 to 300 mg per day.
Observational studies show an association between high caffeine consumption and spontaneous abortion and low-birth-weight infants, though confounding is involved.
Pregnant women should avoid shark, swordfish, king mackerel, tilefish and tuna steaks.
Pregnant women should limit intake of other fish to 12 oz per week.
Exposure to high levels of mercury in fish can lead to neurologic abnormalities in women and their infants
Docusahexaenoic acid (DHA) is necessary for normal brain and retina development, though there is no clear evidence that supplements during pregnancy improve offspring neurodevelopment.
Women should avoid unpasteurized milk and milk products.
Due to the risk of contamination with Toxoplasma and Listeria based on case reports.
Pregnant women should avoid deli foods, pate and meat spreads.
Due to the risk of contamination of Listeria based on case reports.
There is the risk of Listeria contamination based on case reports for certain cheeses:
Due to the risk of contamination with Salmonella pregnant women should avoid raw eggs.
Case reports of intrauterine sepsis due to salmonellosis.
Foods containing raw eggs:
raw cookie dough
Liver and liver products should be eaten in moderation.
Excessive consumption could cause vitamin A toxicity.
Pregnant women should use caution when consuming foods and drinks containing saccharin, which is known to cross the placenta and may remain in fetal tissue.
Aspartame, sucralose and acesulfame-K are probably safe.
Women with phenylketonuria should limit aspartame.
Vitamin D supplementation can be considered in women with limited exposure to sunlight.
Rare, but has been linked to neonatal hypocalcemia and maternal osteomalacia.
High doses can be toxic.
2016 Cochrane review concluded "the evidence... remains unclear."
In a Cochrane review, vitamin C supplementation during pregnancy either alone or in combination with other supplements had no beneficial or harmful effects.
A Cochrane review showed that vitamin E supplementation during pregnancy in combination with vitamin C or other supplements or drugs does not improve outcomes of stillbirth, preterm birth, preeclampsia or low birth weight.
The CDC does not recommend fluoride supplementation during pregnancy because prenatal fluoride supplementation is not incorporated into primary teeth and does not reduce caries in offspring.
The benefits of fluoride occur almost entirely after tooth eruption as a direct topical effect on teeth; earlier hypotheses that ingested fluoride is systemically incorporated into developing tooth enamel have been largely discredited as a primary mechanism of fluoride action.
There is good evidence that postnatal exposure of newly erupted teeth to topical fluoride from water or dentifrice is efficacious.
Pregnant women should limit their consumption of herbal tea and other herbal products.
While herbal consumption is common in the U.S. (10% of pregnant women) there is minimal data and some herbals are considered unsafe in pregnancy.
In addition, makers of supplements are not required to prove efficacy, safety, or quality of a product before it is marketed and numerous recalls of supplements have taken place due to product alteration.
Seat belts and air bags
Pregnant women should continue wearing three-point seat belts during pregnancy. The lap belt is placed across the hips and below the uterus; the shoulder belt goes between the breasts and lateral to the uterus.
There is limited data regarding air bags. There is a trend toward increased preterm labor though not preterm birth with airbag use.
ACOG recommends wearing seatbelts and not turning off airbags.
Gestational weight gain
*Not evidence-based for class II and III obesity.
Air travel is generally considered safe for pregnant women until four weeks before the EDD.
Lengthy trips are associated with increased risk of VTE.
Pregnant women should avoid activities that put them at risk for falls or abdominal injuries.
Scuba diving during pregnancy is not recommended.
Exercise during pregnancy has minimal risks and demonstrated benefits for most pregnant women, including maintenance or improvement of physical fitness, control of gestational weight gain, reduction in low back pain, and possibly a reduction in risk of developing gestational diabetes or preeclampsia.
At least 30 minutes of moderate exercise on most days of the week is a reasonable activity level for most pregnant women.
Previously sedentary women should begin with 10 to 20 minutes of continuous low-intensity exercise three times per week, increasing the intensity, frequency, and duration gradually.
Although hair dyes and treatments have not been associated clearly with fetal malformation, exposure to these treatments should be avoided during early pregnancy.
Experimental animal studies showed risks of teratogenicity due to some of the chemicals found in hair products when used in very high doses. Human studies, however, show that exposure to these chemicals from hair dyes or hair products results in very limited systemic absorption, unless there are burns or abscesses on the scalp. Therefore, these chemicals are unlikely to reach the placenta in substantial amounts to cause harm to the unborn fetus.
Hot tubs, saunas, pools
Hot tubs and saunas probably should be avoided during the first trimester because maternal heat exposure has been associated with neural tube defects and miscarraige.
Swimming is good!
In the absence of pregnancy complications (eg, vaginal bleeding, ruptured membranes), there is insufficient evidence to recommend against sexual intercourse during pregnancy.
Alcohol, Drugs, Tobacco
Pregnant women are advised to consider postponing travel to areas with ongoing mosquito transmission of Zika virus. Women who must travel are advised to take precautions against mosquito bites including wearing long-sleeved shirts and pants, staying in places with air conditioning, sleeping under a mosquito net, and using approved insect repellant. In addition, pregnant women whose male partners have travelled to affected regions should abstain from sexual activity (vaginal, anal, and oral sex) or use condoms for the duration of the pregnancy.
Influenza vaccination is recommended for women who are or will be pregnant during the influenza season, regardless of stage of pregnancy.
Tetanus, diptheria, pertussis
These immunizations should be up-to-date. Tdap is administered in the third trimester of each pregnancy, regardless of prior vaccination.
Wash your hands and don't eat raw meat. Only weakly associated with cats.
Planned or unintended pregnancy
Potential barriers to care:
child care issues
mental health/level of stress- including depression screening