First Prenatal Visit

Lucas Phi, OMSIII LECOM

History Greeks – believed exercise during

pregnancy would birth stronger warriors

Romans – believed strong movements would induce rupture of membranes

1901 - prenatal care programs

1911 – first prenatal clinic, diagnosed and treated preeclampsia

Goals Identify risks and use appropriate

interventions

Evaluate health status of both mother and fetus via a thorough history and physical examination

Estimate gestational age

Build rapport and educate patient

When should the first visit be?

Ideally 6-8 weeks after missed menses

ASAP if there is no history of preconception visit

Patient History Demographics and personal information

Ethnicity – risk factors such as sickle cell for African American

Religion – restrictions such as denial of blood transfusion for Jehova’s Witness

Education – educational level and preferred language

Age – social issues (school or medical concerns)

Contact information

Menstrual history

Last menstrual period Estimated due date Estimated gestational age

Characteristics of cycle

Pregnancy History

Dates of deliveries

Types of Deliveries

Type of incision

Birth weight and age of past infants

Health status of children

Complications

Premature rupture of membranes

Preterm delivery

Incompetent cervix

Medical History

Diabetes

Chronic hypertension

Asthma

Cardiac disease

Hemoglobinopathies

Lupus

Thyroid disorders

Chronic hepatitis

Tuberculosis

Bleeding disorders

Chronic renal disease

Thromboembolic disorders

Surgical History

Abdominal/orthopedic procedures

History of ectopic pregnancy

History of uterine perforation or incision

Allergies

Social History

Support system

Domestic violence

Use of caffeine, tobacco, alcohol, illicit drugs

Employment

Nutritional status

Special diets

Diabetes

Phenylketonuria

Vegetarian

Current medications

Change contraindicated medications

Ex. Warfarin for heparain

OTC

Herbal Supplements

Genetic screen and infection history

Risk status evaluation

Modifiable risk factors of preterm labor

Work related exposure to infectious agents or chemicals

Infectious diseases

Hereditary disorders

OTC medications

Physical, emotional, or sexual abuse

Alcohol, tobacco, or substance abuse

Diabetes mellitus

Psychiatric disorders

Diagnosis of Pregnancy

>25 IU/L hCG in serum or urine

OTC pregnancy tests

History and physical exam

Amenorrhea, sexual activity, misuse or absence of contraception, early symptoms of pregnancy

Pelvic exam

Transvaginal ultrasonography – predicts viability of early pregnancies

Gestational sac seen at 5 weeks or hCG level of 1500 IU/L

Estimating Gestational Age

Naegele’s rule – used to find estimated date of confinement

First day of last menstrual period – 3 months + 1 year and 1 week

Ex. October 21, 2014 -> July 27, 2015 - GA would be 35 weeks

Ultrasound between 14-20 weeks

Used if last menstrual period is unknown or if patient has irregular cycles

Physical Examination

BMI – find appropriate weight gain in pregnancy

BP – establish baseline, check for chronic HTN

Heart and lungs – preexisting conditions

Thyroid – hypo/hyperthyroidism

Breasts – masses

Nipple abnormalities that would affect latching

Pelvis

Cervix

Anomalies, condylomata, neoplasia, infection

Consistency, length, motion tenderness

Uterus

Size, position, contour

Masses such as fibroids

Adnexa

Masses

Bony pelvis

Diagonal conjugate

Ischial spines

Sacral hollow

Arch of pubic symphysis

Ultrasound

Crown rump length at 7-10 weeks

Lab Testing WBC, hemoglobin, hematocrit, platelet count

Anemia or thalessemia

Syphilis

Rubella titer

Post partum immunization if negative

Hep B surface antigen

ABO, Rh

Antibodies

Rh negative retested at 26-28 weeks

TSH

Pap smear

HIV

Genetic screen

Tay-Sachs

Cystic fibrosis

Canavan disease (Ashkenazi)

α/βthalassemia

Sickle cell

Fragile X

Our clinic

Spinal muscular atrophy

Cystic fibrosis

Fragile X

Urine test

Leukocyte esterase – asymptomatic bacteruria

Diagnosed with a urine culture >100,000 per milliliter

Protein level – baseline

Culture and Infections

Chlamydia and Gonorrhea (high risk patients)

<25 years of age with past history or evidence of STD, new sexual partner within 3 months, or multiple sexual partners

Tuberculosis

PPD testing done in high risk areas

Patient Education General Information

Educational resources

Warning signs

Infection (fever, chills, dysuria, hematuria)

Threatened pregnancy loss (bleeding, cramping, passage of tissue)

OTC medications

Use of acetaminophen over NSAIDS

Weight gain

<19.8 BMI 30-40 lb

19.8-26 BMI 25-35 lb

26.1-29 BMI 15-25 lb

Obese 15 lb

Twins 40 lb or 10-15 lb more than single gestation

First 2 trimesters are just maternal changes

Fetal growth is most rapid in the third trimester

Weight gain should occur by 20-22 weeks

Excess weight gain

Increased risk of preterm delivery, low birth weight, macrosomia

Diet

300kcal above baseline

(Optimal body weight in kg * 35kcal) + 300 kcal

Vitamins – not necessary if patient has a balanced diet

Folate is the exception – 800-1,000 mg

Vitamin B12 and folate

Hemoglobinopathy, antiseizure medication, neural tube defects

Vitamin D

Most women have low levels

Minerals – supplementation is not needed in healthy women

Iron is the exception, requirement of 1g

Can supplement with 30 mg

Iron deficient require 60-120 mg

Also require 15 mg zinc and 2mg copper

Zinc – protects against intrauterine infection

Iodine

Caffeine – increased risk of miscarriage with >200mg/day (1-2 cups)

Seafood – limit to two servings per week of canned tuna, salmon, or shrimp

Avoid fish on higher tier of food chain

Exercise – encouraged ≥ 30 minutes a day

Low impact

Deep breathing may be difficult

Stop if fatigued or dizzy

Heartburn – enlarging uterus displaces stomach above esophageal sphincter

Constipation, diarrhea, gas – progesterone relaxes intestinal smooth muscle

Nausea and vomiting – also known as “morning sickness”

Starts week 6-8 and peaks at weeks 12-14

Eat ginger as well as smaller meals, avoid spicy food

Sleep disturbances

Nocturia, GERD, physical discomfort

Restless leg syndrome, caused by iron deficiency

Backache – hyperlordosis

Minimize standing time, rest often, and take acetaminophen

Exercises that help strengthen back and abdomen

Headaches – not uncommon during first trimester

Round ligament pain

Sharp bilateral, or unilateral groin pain

Pain remits by patient on both hands and knees with buttocks in the air

Emotional Changes

Increased psychological stress

May present with signs of atypical depression, or elevated stress and anxiety

Sexual Activity

Not restricted

Deep penetration may be more uncomfortable

Contraindication of membrane rupture and placenta previa

Forceful induction of air into vagina can cause air embolism

Employment

Avoid trauma

Avoid repetitive lifting or prolonged standing of >5 hours

Urinary frequency – uterus compresses the bladder

Travel

Walk for 10 minutes every 2 hours

Always use a seatbelt

Immunizations and precautions

Flu - recommended

TDAP – administered in third trimester

Listeria – avoid soft cheese and deli meat

Toxoplasmosis – avoid cats and uncooked meats

Parvovirus

CMV

Schedule next prenatal visit!

Thank you!

Bibliography Black, Ronald A., and Ashley D. Hill. "Over-the-Counter Medications in

Pregnancy." - American Family Physician. American Family Physician, 15 June 2013. Web. 22 June 2015.

Gibbs, Ronald S., and David N. Danforth. "Prenatal Care." Danforth's Obstetrics and Gynecology. Philadelphia: Lippincott Williams & Wilkins, 2008. N. pag. Print.

Hacker, Neville F., Joseph C. Gambone, and Calvin J. Hobel. "Prenatal Care." Hacker and Moore's Essentials of Obstetrics and Gynecology. Philadelphia, PA: Saunders/Elsevier, 2010. N. pag. Print.

Lockwood, Charles J., and Urania Magriples. "Initial Prenatal Assessment and First Trimester Prenatal Care." Uptodate. Wolters Kulwer, 18 June 2015. Web. 22 June 2015.

Phalen, Sharon T. "The Global Library of Women’s Medicine." The Prenatal Record and the Initial Prenatal Visit. The Global Library of Women's Medicine, 1 Jan. 2008. Web. 22 June 2015.

"Routine Prenatal Care." DynaMed. EbscoHost, 9 June 2015. Web. 22 June 2015.