Prenatal Care
8-10
weeks- Typically first visit.
Remember: All residents need
to have an attending examine all First Obs for size, and all
Ob
pts need to be checked out with the attending
before the leave the clinic.
·
History:
Family or personal history of congenital diseases?
Prior baby with trisomy or neural tube defect?
Med problems (asthma, DM, HTN, psych, gyn infxns)?
Surgeries? Blood transfusion?
Past
OB
history
History of domestic violence?
·
Counseling:
No tobacco, Etoh, caffeine?, illicit drugs
Medications
Cat litter & raw meat – toxoplasmosis
Hot tubs & getting overheated in exercise
Diet – increase caloric intake by 300 calories a day
Prenatal
vitamins – 800 mcg folate/day recommended.
If
Prior NTD, 4mg/day. If DM or
Epilepsy, 1mg/day.
HIV test
Encourage moderate exercise
Offer flu vaccinations to women in their 2nd and 3rd
trimesters
Offer Hep B vaccinations to at-risk women
·
Exam:
General PE, Pap with GC/chlamydia, Sizing
·
Labs:
Blood type & Rh, RPR, Hep B, CBC, Rubella, HIV
Urine C&S
Chlamydia and Gonorrhea
10-12
weeks
·
Fetal heart tones w/ Doppler.
US if unable to obtain by 12wks.
16-20
weeks
·
Genetic counseling
·
Quadruple test:
MSAFP, HCG, inhibin and estriol. Recommended
between 16-18 weeks EGA, can do between 15-20 wks.
o
Neural tube defects—increased
MSAFP. If at increased risk (h/o
previous NTD, IDDM, valproic acid), offer amnio.
o
Down Syndrome—increased HCG,
decreased MSAFP and estriol. Many
false positives.
o
Trisomy 18—decrease in all
markers.
·
Amniocentesis—Offer to all women
who will be 35 by the time of delivery or women at increased risk.
·
Fetal movement by 20 weeks.
US the pt if not reported.
24-28
weeks
·
1 hour glucose tolerance test
(O’Sullivan or 1hr GTT)
If
positive (>140), obtain 3 hour GTT.
Fasting > 105 (if 105 or above refer to HROB)
1 hour > 190
2 hour > 165
3 hour > 145
If 2 or 3
elevated refer to HROB (High Risk OB clinic)
·
Repeat CBC
·
Rhogam—given in clinic.
If you have only one documentation of Rh status, repeat Rh and screen
prior to administering.
·
Tubal ligation?
Consent must be signed four weeks before expected delivery.
OB
doc generally has them call the
OB
clinic when they deliver to schedule this post-pardum.
All tubals done during C-sections have to go through a special approval
process.
·
Preterm labor precautions.
32-34
weeks
·
Discuss options for analgesia in
labor
·
Circumcision?
·
Birth control—give information on
options, make sure that consent is signed (if they are planning tubal ligation).
·
Reinforce preterm labor precautions
·
Fetal movement, fetal kick counts
·
Assess fetal position with
Leopold’s
34-36
weeks
·
GBS screening done
·
Fetal position
39-40
weeks
·
Answer questions about delivery
·
Discuss possibility of post dates
and protocol for induction
·
Evaluate cervix
>40
weeks
·
Patients should be referred to HROB
clinic at 41 2/7 weeks to evaluate for induction.
·
Patients >41 weeks need twice
weekly NST & weekly AFI.
Ongoing
Screening
·
Blood pressure
o
PIH—HTN > 20 weeks gestation.
o
Preeclampsia—SBP >140 or rise
of >30 mmHg systolic or DBP > 90 or rise > 15 mmHg diastolic.
Elevated BPs must be present >=2 separate occasions 6 hrs apart.
o
Severe preeclampsia—SBP > 160
or DBP > 110, proteinuria > 5g/24 hours (3+ to 4+), cerebral or visual
changes, epigastric pain, thrombocytopenia, olguria < 400ml/24h, pulmonary
edema, HELLP
o
Severe chronic HTN—risk of
abruption & preeclampsia
·
Weight
o
Normal wt gain is 25-35 pounds for
normal wt woman
o
Discourage wt loss in pregnancy
o
Weight gain of >3lbs/week is
concerning
·
Urine protein
·
Fundal height—after 20 weeks,
should correspond to week of gestation. Watch
for >3 cm difference.
·
Edema—dependent edema is normal
Edema
of face, greater than 5 pound weight gain in a week, pitting edema after 12 hours of rest are
concerning
Dating
a Pregnancy
·
Dating is crucial.
To date use LMP, sizing exam, doptones at 10-12 weeks, fetoscope at 20
weeks (U/S if needed)
·
Refer for U/S if pt presents >
20 weeks for care, if there is large discrepancy between size and “sure”
dates, or if one of the above milestones is not met.
·
If you have reliable sources of
dating, do not change the dates based on a late U/S if the original due date is
within the margin of error of the U/S.
1st
trimester U/S can be off by 1 week
2nd
trimester U/S can be off by 2 weeks
3rd
trimester U/S can be off by 3 weeks.
If LMP is sure
and U/S is within margin of error, use LMP
·
If more than one U/S has been
obtained, dating is based on the earliest U/S.
·
Uterine Size / Dates
o
7wk = egg
o
10wk = orange
o
12wk = grapefruit, above symphysis
o
20wk = fundus at umbilicus
o
20-36wk = fundal ht equals
gestational age within 2 weeks.
o
Doppler at 10-12wks
o
Fetoscope at 18-20wks
High
Risk
OB
Clinic
The following is a list of
patients who must be referred to HROB. Please
see HROB Policy and Procedure or Cindy Nicolay (our head clinic RN) for more
details.
·
U/S for dating pts who present >
20 weeks or who have abnormal AFP
·
PTL, HTN, Prior C-section, Breech
or transverse, Postdates, Pre-existing maternal diabetes, GDM, Anemia, History
of stillbirth, Genital herpes-primary outbreak in third trimester, Multiple
pregnancy, DVT and heparin therapy, Collagen vascular disease, Renal
insufficiency, Seizure disorder, Active thyroid disease, History of incompetent
cervix, Drug abuse/dependence, and inadequate fundal growth (no change in weight
for 2 consecutive visits, 3 cm difference between fundal height and date)
Treating
Common Infections in Pregnancy
·
UTI – 7 day regimen, needs Test
of Cure
Nitrofurantoin
SR (Macrobid)
TMP/SXT (Septra/Bactrim)-possible
teratogenicity 1st trimester; possible neonatal hyperbilirubinemia
near term
Cephalexin (Keflex)
Avoid
amoxicillin – high E. coli resistance (unless you have C/S)
·
Bacterial Vaginosis – Needs Test
of Cure (TOC) in 1 month
BV linked to
increased risk for PTL & endometritis
Metronidazole (Flagyl)
250 mg po tid x 7 days
Can use
metronidazole 0.75% gel (5g) intravaginally x 5 QHS
·
Trichomonas—metronidazole 2gm
single dose. Treat partner.
·
Vulvovaginal candidiasis—topical
azole creams only, for 7d
·
Chlamydia – needs TOC in 1 month.
Treat partner.
Azithromycin 1g
single dose or
Erythromycin
500 mg po qid x 7days or
Amoxicillin 500
mg po tid x 7 days
Screen high
risk women again in third trimester.
Do not use: tetracyclines or
fluorquinolones